Dr. Jennifer Jackson on injectable opioid agonist treatment in Alberta
By Krishna Shetye, March 8 2021—
In a recent news release, the Faculty of Nursing at the University of Calgary revealed that a two-year injectable opioid agonist treatment (iOAT) program was successful in suppressing life-threatening opioid withdrawal symptoms. The program involves a regimen of injections of hydromorphone “2-3 times a day with a liquid medication being taken as well at the end of the day,” according to Dr. Jennifer Jackson, an assistant professor in the UCalgary Faculty of Nursing in an interview with the Gauntlet.
Jackson compared this treatment to the likes of kidney dialysis, where patients receive medication indefinitely, based on their varied responses. The professor also emphasized that, “people do not get high from these injections. They avoid the physical symptoms of withdrawal which can actually kill them.” Sobriety is not a necessary end goal of the iOAT program, which aims to simply improve the wellbeing of its patients, in addition to providing financial and housing assistance.
No current Alberta Health Services (AHS) addiction services provide the same intensity of treatment as the iOAT program according to Jackson. However, it was announced that the program would be shut down on March 31 by the provincial government despite offered funding from the federal government to continue the program.
This announcement triggered a hard-fought legal battle to keep the program running for current participants whose survival depended on the treatment. The instrumental leader of the suit against the provincial government was pro bono lawyer Avnish Nanda, who filed an injunction on behalf of participants.
The roster of participants taking this action against the province includes a wide demographic of Albertans, including some who had suffered traumatic injuries and childhood sexual abuse. Jackson applauded the courage of participants who testified, in order to demonstrate the necessity of the treatment.
“The clients showed a tremendous amount of bravery. They had to put their deeply personal stories in the public domain. Given that addiction is so heavily stigmatized in today’s society, this was no ordinary feat,” she said.
To counter, the provincial government insisted “that the patients, many of whom were experiencing homelessness, pay the province $20,000 to cover the legal costs for AHS,” said Jackson.
Speaking to the “unnecessary cruelty,” of the government policy, Jackson said that “for many of the participants, the iOAT program brought the first hope for stability in 20-30 years. They should not be fighting for a life sustaining service, they have enough on their plate.”
Originally, the government planned on transferring iOAT patients to the opioid dependency program, or OPD. The program’s use of methadone rather than hydromorphone injections and plans to inject patients at a lesser frequency concerned Jackson, who believed the use of methadone in these severe situations would not match up to the level of care and support given to the patients.
“Looking at this from a liberatarian perspective, forcing people into a detox center where they can’t leave of free will is restricting their freedom and furthering the stigma against opioid addicts,” said Jackson.
Services provided by the iOAT program would be near impossible to replicate in a generic government setting according to Jackson.
“We even give our patients a guaranteed meal a day. By taking away all these supports and services and making a pharmacist at a general store inject these medications, the facilitation of the program will not be clear cut and specialized to patients,” she said.
Concern for the fragile stability of iOAT patients was rampant amongst program staff and participants, according to Jackson, in the face of several international studies which showed that switching to methadone injections will result in 20-30 per cent of patients dying in the first year.
“It’s hard for me to understand as a nurse, because [the iOAT] program gives good clinical and social results. There is less crime, less unemployment and globally, the programs are shown to be cost effective,” said Jackson.
Unfortunately, the injunction was rejected on Feb. 25, 2021, jeopardizing the future of the iOAT program. Jackson believes that the statement from the presiding judge, Justice Grant Dunlop, clearly demonstrated a stigma based decision rather than an evidence based one. Dunlop maintained that plaintiffs did not demonstrate that “they will suffer irreparable harm,” or “death or serious health consequences” if the program were to shut down.
In an unexpected twist — a mere 5 days later on March 2 — the Alberta government awarded a $6 million dollar grant to the program, allowing its continuation for two years. According to Jackson, this decision was revealed only a few hours after Nanda filed an appeal.
One of the caveats of the grant is that the iOAT program will be administered under the ODP program with another being that no new patients will be offered the treatment. However the staff, facilitators and services will remain the same, offering stability to the 88 patients currently within the program.
“The fact that we have two years of funding in place now, means that our clients can focus on building their lives, engaging with treatment and getting the support they need without the fear of these services being taken from them at any given moment. It is a huge relief,” said Jackson.
The conclusion to this draining battle for the lives of opioid addicts was successful but bittersweet. Tragically, the risk of lost access to treatment drove multiple iOAT patients to leave the program to seek street opioids. One such patient died by accidental overdose, a death that was understandable but unnecessary according to Jackson.
“It was a huge amount of unnecessary stress and it ultimately contributed to one person’s death, nevermind the long term harms caused to other patients. Our clients are resilient but they still should have never been put through this ordeal in the first place,” she said.
Although this is a major win for the iOAT patients, Jackson says there is much more work to be done.
“The challenge is not yet over. We still need to consider how we can reach those who are outside of Calgary and Edmonton who need our services, amongst other goals,” she said.
Currently, the program is closed to new participants who are plentiful in the face of the opioid crisis in Calgary that “has taken more lives than the COVID-19 pandemic,” according to Jackson. However, after additional review the government can potentially amend the policy to open the treatment to more Albertans.
This case, while avoidable, was crucial in demonstrating the dangers of stigma based decisions, especially when the subsequent policies mean the difference between life and death.
In the uphill battle to increase access to treatment and destigmatize opioid addiction, Jackson hopes “that with my research and the courageous work of the patients, we will at least raise awareness about this issue. And I sincerely hope the provincial government will take a long hard look at these policies and at themselves asking: How are we treating our fellow humans?”
More information on the iOAT program is available online.