NPs in Canada Can Now Prescribe Pharmaceutical Heroin

In response to it’s growing national opioid crisis, nurse practitioners in Canada have recently been given authority under an amendment to the Controlled Drugs and Substance Act (CDSA) to prescribe pharmaceutical grade heroin to their patients, as well as have been given authority to more easily prescribe methadone. 

The change stems from a guideline that was released earlier in the year by the Canadian Research Initiative in Substance Misuse, which included suggestions on how to better manage opioid-use disorders. The hope is that the changes in legislation will allow greater healthcare access for Canadians in need of medication assisted treatment for addiction as well as reduce the number of opioid related deaths. So what exactly does the new legislation mean for NPs in Canada and could the legalization of heroin happen in the US?

What specific changes were made to the CDSA?

Under the previous legislation, Canadian practitioners were required to apply for an exemption from federal law in order to be allowed to prescribe, administer, sell or provide methadone. Only physicians were authorized to prescribe pharmaceutical heroin, or diacetylmorphine, in a hospital setting in order to treat pain.

The new changes made to the Controlled Drugs and Substance Act (CDSA) allow NPs in the provinces of Nova Scotia, New Brunswick, Newfoundland and Labrador, Manitoba, Alberta and British Columbia to be able to prescribe methadone without having to apply for an exemption. As one of its revisions, diacetylmorphine (heroin) is no longer excluded from the list of controlled substances that NPs can prescribe to patients.

Are there any regulations for NPs when prescribing methadone and diacetylmorphine (heroin)?

Currently, there is no new legal requirement for NPs to complete specific education in order for to prescribe either medication, however all of previous requirements to prescribe methadone and controlled substances are still in effect. Just as before, only NPs who have successfully completed College approved controlled substances education are allowed to prescribe controlled substances in Canada, including methadone and now diacetylmorphine.

Some provinces, like British Columbia, do require NPs to meet other specific requirements to prescribe opioid agonist treatment. All NPs in Canada are also still expected to meet the accountabilities outlined by their provinces’ practice standards for nurses and have to act responsibly when determining which is the best treatment option for patients in need of opioid intervention.

How are the changes expected to improve the opioid crisis in Canada?

While it is still recommended in Canada that suboxone be the first medication used to help those addicted to powerful narcotics (since it is considered to have safer side effects than both diacetylmorphine and methadone), proponents of the change felt that the previous restrictions on methadone and pharmaceutical heroin made it more difficult for Canadian practitioners to offer these medications to their patients as an alternative to other opioid disorder treatments like suboxone and buprenorphine, which can be ineffective for some patients. Proponents also felt that other barriers discouraged opioid dependant patients from continuing with their medication assisted treatment plan. For example, not only was it difficult to find a practitioner who could prescribe methadone, but because pharmaceutical heroin could only be administered in a hospital setting, people who needed more than one dose of the drug per day were unable to make multiple trips per day to the hospital for such.

Health Minister Ginette Petitpas Taylor said earlier in the year when announcing the changes to come that because health care practitioners will be able to prescribe and administer methadone without an exemption from federal law, more family physicians and general practitioners will offer medication assisted treatment for patients addicted to opioids as part of their services. As a result, people suffering from addiction have more options on where to go for treatment. They can either go to their family doctor discretely or to a treatment facilities or substance use disorder clinics. Nevertheless, they’ll have more access to help and better treatment options.

Only time will tell if the number of opioid related deaths will decrease as a result of the new legislation. While improving access is a welcome news to proponents of the changes, Petitpas Taylor also recognizes that stigma is a huge barrier for patients when seeking the treatment that they need. As such, the Canadian federal government will allocate $18.7 million towards an education campaign to fight stigmas as well as has allocated more other funds towards the different factors that contribute to the crisis.

The opioid crisis in America

Like it’s neighbor to the north, America’s opioid epidemic also continues to rise. According to the CDC, more than 42,000 people died from opioid drug overdoses in 2016. Currently however, only one-third of specialty addiction treatment programs in the US offer medication-assisted therapy to patients suffering from opioid addiction. In October 2017, President Trump declared the opioid epidemic in America a public health emergency and freed up some federal grant funds for the states to direct toward the crisis as well as loosened restrictions on access to treatment. In addition, a presidential commission has recommended other policies, including immediately establishing and funding a federal incentive to enhance access to medication assisted treatment.

So far, it doesn’t seem that diacetylmorphine (heroin) will be approved by the FDA for use in treating opioid addictions in the U.S. While the FDA has approved methadone, naltrexone and buprenorphine for treating opioid use disorder, a barrier to effective treatment with these medications is that they require a commitment to consistent and constant administration. The FDA did recently approve a one-month injectable version of buprenorphine which could make adherence easier, especially for patients in more rural areas. Earlier this year the FDA also said it expects to roll out guidance on expanded access to medication-assisted treatment by encouraging the development of longer-acting formulations of the current therapies such as other injectable forms of the drug. The FDA will issue guidance around studies that have evaluated the effectiveness of medication-assisted treatment in the hopes that it will correct misconceptions around such treatments for opioid use disorder.