Don’t Damn the DAM

An open letter to the Canadian minister of health

Published on October 23, 2013by June H. Kim

Honourable Rona Ambrose:

Earlier this month, you moved to close the alleged “loophole” in the Special Access Programme, which was designed to give Canadians access to medications that are not otherwise approved for use in Canada, including the use of diacetylmorphine (DAM, or synthetic heroin) as a second-line treatment option for heroin dependence.

You frown upon the idea of your government fostering an addiction, yet the idea of a national lottery and a government-owned liquor monopoly does not seem to perturb you.

I understand that, as a political entity, you are indubitably swayed by political currents. However, I urge you to reconsider your stance, which I believe is misguided and unfounded. As the Federal Health Minister, is it not irresponsible to discount scientific evidence and the health of your constituents when making policy decisions?

If, however, you were simply unaware of the numerous studies that have assessed the use of DAM as a second-line treatment option for the subset of severely addicted individuals who do not respond to conventional approaches (e.g. methadone), please let me be the first to inform you.

First and foremost, while methadone has been an effective treatment option for many individuals, it is simply not an option for some. From a public health perspective, “it is predominantly the most difficult and problematic opiate users who cannot be attracted or retained into methadone treatment”.

In response to the need to find suitable secondary treatment options for these individuals, more than a half-dozen countries initiated clinical trials to test the effectiveness of heroin-assisted treatment (HAT) for these treatment non-responders. All of these trials, including the North American Opiate Medications Initiative (NAOMI)—conducted exclusively in Canada—demonstrated that HAT is a feasible, safe, and effective treatment option.

For these severely dependent individuals with the bleakest outlook, treatment benefits include substantial improvements in physical and mental health, reductions in illicit drug use, and withdrawal from participation in criminal activity and local drug scenes.

Furthermore, if it’s the price tag that is most disconcerting to you, a cost-benefit analysis of the Swiss trial has already shown the monetary savings conferred by HAT outweigh the financial cost of treatment.

Instead, as Health Minister, I’d be more concerned about the ethical implications of discontinuing a proven treatment option for some of your country’s most vulnerable patients. Please note that with the exception of Canada, all of the other countries with previous HAT trials have allowed patients to continue receiving treatment under “compassionate use”. In fact, HAT has become a staple of the treatment armamentarium in several of the HAT countries.

In these countries, krokodil exists only as a misspelling.

In conclusion, I urge you to reconsider closing this loophole. Treatment retention is critical for recovery. Do not give up on Canadians struggling with heroin dependence. Let the Special Access Programme serve its purpose. Let evidence drive health policy decisions, “not ideology and stigma”.


June H. Kim


Edited by Dana March