Canadian Vending Machine To Dispense Hydromorphone

 

 

 

 

Last month the Washington Post newspaper reported that British Columbia officials plan to set up three vending machines to dispense hydromorphone to people with opioid use disorder.

Canada has struggled with opioid overdose deaths just like the U.S., and they declared their opioid use disorder public health emergency in 2016. Projected data from 2017 estimates four thousand Canadians died from opioid use disorder that year. (In the U.S., an estimated sixty-four thousand people died from overdoses in 2016.) The extremely potent drug fentanyl has been detected in around 83% of the Canadian overdoses.

In British Columbia, overdose death rates last year were estimated at 30 per 100,000 people, which is roughly the same as in Rhode Island. (Our highest state, West Virginia, had around 52 per 100,000).

I’ve blogged before about Vancouver’s heroin-assisted therapy (HAT). In a blog in 2013, I described results of trials in Vancouver and Montreal where pharmaceutical-grade heroin was provided, in specialized facilities, to people with opioid use disorder. Medical personnel were on site at the facilities in case of overdose, and new needles and equipment were provided to participants.

Vancouver’s results showed better retention in treatment with heroin-maintenance therapy (HAT) than patients enrolled in traditional medication-assisted treatment with methadone. Participants had lower rates of use for other illicit drugs, and lower rates of participation in criminal activities than patients not in any treatment. Overall, these programs reached a subset of people with opioid use disorder who would not consider more traditional treatments with methadone or buprenorphine.

These HAT programs work in urban settings, where people can come to a centralized facility manned with trained personnel. Logistically, this sort of facility is more difficult in more rural areas. Plus, since there’s no drug company manufacturing heroin, scientists had the idea of vending machines pre-set to deliver doses of pharmaceutical-grade, immediate release hydromorphone tablets. This medication would not be as hard to obtain for patients in the treatment program.

These machines will be set up to release two or three hydromorphone pills three times per day. The cost per patient would be around $3 per day.

This idea was based on a study published in 2016 in the Journal of the American Medical Association Psychiatry by Oviedo-Jones et al., that showed supervised injection of hydromorphone was non-inferior to supervised injection of heroin.

Pharmaceutical-grade hydromorphone reduces the risk of fatal overdose death from heroin, which is often cut with substances that can be lethal, like fentanyl. Plus, non-drug substances are frequently added to heroin to make the product go farther, exposing users to all sorts of contaminants.

Canada already has vending machines to dispense clean needles to drug users, so this idea takes the concept a step farther. I didn’t realize it, but while researching this article, I found that some cities in the U.S. also have clean needle vending machines. I think this is a wonderful idea, based on science that shows access to clean needles reduces spread of infectious diseases.

Of course, hydromorphone vending machines raised concerns. Law enforcement worried that the machines could be tampered with, and the hydromorphone stolen. Other people worry this medication could be sold on the black market. But the machines are supposedly difficult to break, more like ATMs than typical vending machines, and the small amounts dispensed each day per person are thought to make it less likely to sell these pills.

In Canada, harm reduction ideas do not cause the pearl-clutching outrage we tend to have in the U.S. Can you imagine a proposal in some state legislature for a vending machine to dispense hydromorphone? It probably would not be given a hearing.

In fact, we’ve taken the opposite route in the U.S. The pharmaceutical opioid oxymorphone, in the brand formulation Opana ER, was taken off the market because so many people were injecting it. In my area, six month ago, most new patients I admitted into treatment were using Opana as their main opioid drug. Over the past month, that has changed. Now, most patients are using heroin.

This has happened all over the U.S. – declining availability of prescription opioids fueled the sharp increase in heroin use, and with it, heroin overdose deaths.

I suspect Canada will see fewer heroin overdose deaths in areas with hydromorphone vending machines, but I’m not fully sold on their idea. I worry the medication dispensed by these machines may be diverted to new users, creating new cases of opioid use disorder. In the U.S., the increased access and availability of opioids starting twenty years ago was associated with increased rates of opioid use disorder, and got us into our present mess. Before I endorse the vending machine idea, I need research showing it won’t cause unintended harm.

I’m sure British Columbia health officials will track data that will show if this vending machine concept will work to reduce deaths. It’s an interesting concept, and we have a front row seat to watch what happens with our neighbors to the north.

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6 responses to this post.

  1. Posted by Kenneth Gaughran on February 4, 2018 at 8:18 pm

    Great Article. I think we need to realize that drug addiction was never about supply and all about treating an inner insult. Any step that mitigates the 800 pound gorilla,”shame” and doesn’t center around “tough love” and instead shows “collective empathy” that harm reduction does is a positive

    Reply

  2. Posted by Craig on February 5, 2018 at 4:44 pm

    I love this idea,why can’t we here in USA be like our much smarter northern neighbors,people are gonna use herion and die,period,no stopping that,but I really like this idea

    Reply

  3. Posted by Cindy on February 5, 2018 at 4:57 pm

    so does this mean anyone can go to the “atm” and order themselves a dose of dilaudid? How will the machine identify a person and know that they have received their daily allotment?

    Reply

  4. Posted by Scott on February 7, 2018 at 12:27 pm

    I actually think this is a fantastic idea. I can only hope it proves a success and more countries follow suit. We live in a very unusual period in our history. Drug use has only been illegal for the last 100 or so years out of many millennia of human history.

    Realistically, expecting humans to abstain from drugs (except the accepted few: alcohol, tobacco, caffeine etc.) is a ridiculous idea. Pretty much all the dangers of drug use are caused by their legal status: unknown dosages; unknown content; contaminants; high prices etc.

    If people could be supplied with drugs that they knew were 100% pure, the dosages were accurate, and the prices reasonable, they could live quite happily on them forever.

    There are notable exceptions (in my mind): tobacco, alcohol & methamphetamine. These drugs are harmful to humans in recreational quantities. Most (all?) other drugs are not. I need to be clear that I am specifically excluding “Research Chemical (RCs)” from this statement. However, RCs are only necessary in a prohibitionist society. Remove prohibition and people will take ketamine, not methoxetamine. They will take LSD, not NBOMe.

    By supplying addicts who live in a society of adulterated Heroin with Fentanyl mixers with pure hydromorphone we are saving lives. Even if more people become addicted, the overall harm to society is significantly reduced.

    I am a recovered Heroin user, on Suboxone. If I could get pure Opioids for a fair price I’d go right back on them, which is a GOOD THING. Opioids resolved 30 years of untreatable mental illness for me, they cured my alcoholism, and they also improved my performance as an employee and a parent (maintained for many years). On Suboxone I am free of Heroin but back to my previous life. The ONLY reason I am off them is the price, which is unsustainable.

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  5. Reblogged this on My Sharing Blog.

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  6. Posted by Eric M on April 30, 2018 at 4:04 am

    I like the vending machine idea. I think diversion is most common in populations that need to find a way to find their addiction. Diverting to “friends” just to be popular doesn’t strike me as a big market as none of the opioid use disorder people I know ever do that – they charge even their best friends if they need to fund other things. And the amounts dispensed don’t seem high enough to support multiple regular users.

    Reply

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