Martin Schechter at the facility where he works as an epidemiologist to produce diacetylmorphine as a response to the toxic drug supply.Paige Taylor White/The Globe and Mail
A former public health professor and a former provincial health officer have started offering an inhalable form of pharmaceutical heroin for the treatment of opioid use disorder in British Columbia.
Martin Schechter, professor emeritus at the University of B.C.’s school of population and public health, and Perry Kendall, B.C.’s longest-serving provincial health officer, launched FP Pharma Inc. (also called Fair Price Pharma) in 2020 with the goal of expanding access to the treatment option.
They recently completed construction of a Vancouver manufacturing facility built to Health Canada specifications and received authorization to import diacetylmorphine, the active pharmaceutical ingredient in heroin, from a European manufacturer. Through a sister pharmacy, they are compounding an inhalable version for a handful of patients who are being prescribed at a local health centre.
Their company is also working through additional federal requirements that would allow it to manufacture the drug – a step that could open the door to pharmaceutical heroin’s inclusion in provincial drug formularies.
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“The medication that we’re bringing forth has been used in Europe very successfully for more than 20 years, so there is a ton of clinical experience. We know all about the safety and effectiveness of it,” Dr. Schechter said.
“The government has said it wants to focus on evidence-based treatments. This is exactly what they’ve been asking for.”
Opioid agonist therapy, or OAT, uses prescribed, long-acting opioid medications – commonly methadone or buprenorphine-naloxone (Suboxone) – to reduce cravings, prevent withdrawal symptoms and stabilize patients. It is the most evidence-based treatment for opioid addiction.
Prescribed heroin, also called heroin-assisted treatment, has been used for decades in several European countries as an OAT option for people who have not benefited from standard treatments. It was first trialled in 1994 in Switzerland, where it was formally adopted into clinical practice in 2011. The Netherlands, Germany and Denmark have also incorporated it into their national health programs, while Spain, Norway, Belgium, England, Luxembourg and Scotland offer it in trials or limited programs.
A machine that puts diacetylmorphine capsules into packaging at the facility in Vancouver. Producing legal heroin is being used as a response to the toxic drug supply.Paige Taylor White/The Globe and Mail
Canada trialled heroin-assisted treatment with injectable diacetylmorphine from 2005 to 2008. The North American Opiate Medication Initiative (NAOMI) was a randomized controlled trial that involved 251 participants in Vancouver and Montreal and compared methadone with prescribed heroin.
After one year, 67 per cent of those on heroin-assisted treatment had reduced drug use or other illegal activities, compared with 48 per cent on methadone. Retention was also higher, with 88 per cent of those receiving heroin remaining in treatment, compared with 48 per cent on methadone. Participants reported improved physical and mental health, repaired relationships and greater stability.
When the NAOMI trial concluded, a B.C. Supreme Court ruling allowed some patients to continue receiving prescribed heroin. However, regulatory barriers and high costs limited the program’s expansion.
Meanwhile, the drug landscape has changed significantly. As fentanyl swept the illicit drug supply, smoking far surpassed injection as the dominant mode of consumption in B.C. In 2016, 36 per cent of illicit drug deaths involved injection and 29 per cent smoking; this January, 11 per cent involved injection compared with 73 per cent smoking.
At the same time, use of conventional OAT medications has declined. Data from the BC Centre for Disease Control show that about 11,100 people in the province were dispensed methadone in January, down 28 per cent from six years earlier. Roughly 6,300 people were on Suboxone at any given time over the same period.
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Keeping patients on these medications has been a persistent challenge. A 2024 JAMA study of more than 30,000 first-time OAT recipients in B.C. found that 55 per cent discontinued methadone and 76 per cent stopped Suboxone after three months. At two years, 82 and 89 per cent had stopped treatment. The study concluded that clinical guidelines must be reconsidered to prevent treatment dropout.
Research has shown that diacetylmorphine’s rapid onset and euphoric effect may better engage patients who have not benefitted from the slower, steadier effects of conventional options.
Fair Price Pharma pivoted to inhalable diacetylmorphine from injectable to reflect the shift in drug use. Dr. Schechter said the medication, offered in a form that reflects how drugs are now most commonly used, could attract people into recovery.
“We know from our research that when you stabilize a patient with something like diacetylmorphine, they are more likely to want to enter into recovery voluntarily – and they’re also far more likely to succeed in recovery,” he said.
The two men bring deep expertise to the issue. Dr. Schechter, a former Canada Research Chair in HIV/AIDS and urban population health, served as principal investigator of NAOMI, which was the first prescribed-heroin trial in North America. Dr. Kendall’s five-decade public health career included overseeing the opening of Insite, North America’s first supervised drug-use site, and declaring a public health emergency in response to the toxic drug crisis in April, 2016. Both are members of the Order of Canada and the Order of B.C.
Prescribed heroin, also called heroin-assisted treatment, has been used for decades in several European countries as an OAT option for people who have not benefited from standard treatments. A machine that puts diacetylmorphine capsules into packaging at the facility in Vancouver.Paige Taylor White/The Globe and Mail
As illicit fentanyl deaths surged over the past 10 years, Ottawa moved to ease access to diacetylmorphine. In 2019, Health Canada designated it a drug for an urgent public health need, simplifying importation for opioid addiction treatment. The following year, then-federal health minister Patty Hajdu wrote to provincial and territorial counterparts, highlighting international evidence of its effectiveness for patients who had not benefitted from conventional therapies.
Scott MacDonald, former physician lead at Vancouver’s Providence Crosstown Clinic – the first clinic to prescribe heroin outside of the clinical trial, in 2014 – said it is “patently obvious” the drug should be incorporated into treatment.
“It’s an urgent public health need, and has been since 2016,” he told The Globe and Mail this month.
Fair Price Pharma’s manufacturing facility is a former bank located in a neighbourhood dotted with small shops and restaurants, its unassuming exterior belying the extensive construction that has gone into meeting strict requirements for safety, quality control and licensing.
Stainless-steel industrial blenders, capsule fillers and blister packaging machines are secured in restricted areas where air pressure, temperature and humidity are tightly controlled. Staff enter through a gowning area where they wash their hands and don protective equipment, and exit through a decontamination vestibule where a fine mist clears away potential residue.
Sample capsules that are used to hold diacetylmorphine.Paige Taylor White/The Globe and Mail
The inhalable diacetylmorphine is compounded, filled into capsules of varying doses and sealed into blister packs of five.
Under provincial pharmacy rules, the company is able to compound the medication for specific patients in B.C. If Health Canada authorizes it for sale, the drug will receive a Drug Identification Number, allowing it to be marketed across the country. Canada’s Drug Agency would then review it for clinical benefits, risks and cost‑effectiveness, and make recommendations to public drug plans.
A 2022 review of opioid agonist therapies by the pan-Canadian health organization mentioned a “relative benefit in the clinical effectiveness of heroin-assisted treatment” compared with methadone.
Asked whether it would consider adding inhalable diacetylmorphine to its formulary, B.C.’s Ministry of Health said that it’s aware of emerging discussions about new approaches to OAT.
“At this time, there are no approved proposals or decisions, and any consideration of new treatment options would require further evidence and formal evaluation,” the ministry said in a statement provided to The Globe by communications manager Layma Maslova.
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Two health authorities have expressed interest in piloting the option should it get provincial approval.
Patricia Daly, vice-president of public health and chief medical health officer for Vancouver Coastal Health, said there are an estimated 19,000 people in the region with opioid use disorder. Of those, data show that upward of 85 per cent have tried OAT at some point, but only 24 per cent continued for a year or more.
“That signals to me that they want to be treated, but the treatments aren’t working well, for whatever reason,” she said. “So we need to look at other treatment options.”
Réka Gustafson, vice-president of population and public health and chief medical health officer at Island Health, similarly mentioned the need to explore all evidence-based treatment options that may help improve retention.
“Opioid agonist therapy is the one evidence-based treatment for people with opiate use disorder,” she said. “It’s not a question of belief or philosophy. It’s a question of how we treat conditions that people have, with medications that have been proven to either reduce their symptoms, maintain their health or prolong their lives.”