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Injectable opioid agonist treatment (iOAT) with pharmaceutical-grade heroin (diacetylmorphine) or high-dose IV HM has emerged as an evidence-based treatment for select individuals with OUD, shown to reduce non-prescribed opioid use and associated crime, overdose risk, and medical consequences of unsafe injection practices [4]. While iOAT may serve as a means to engage individuals in substance use treatment who may otherwise not have been able or willing to do so, community-based iOAT is only available in a few jurisdictions in Canada. Limiting factors relate to the high cost of service delivery as well as regulatory and governmental restrictions, which have remained relatively unchanged despite growing calls for iOAT expansion. Given the pressing need for expansion of safer alternatives to the illicit drug supply given mounting overdose deaths, support for safer supply prescribing as a harm reduction measure has grown; the province of British Columbia recently released guidelines for such prescribing and several safer supply programs have been federally funded in Canada [6, 7]. It is therefore likely that growing numbers of individuals who use prescribed opioids by injection may be seen in the hospital setting.
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The use of high-dose IV HM in hospital does warrant careful consideration and appreciation of potential associated risks. While there are published iOAT guidelines for the outpatient setting, there are no guidelines to support the management of inpatient IV HM, which makes implementation more challenging for providers unfamiliar with this treatment [4]. There is the potential for iatrogenic overdose, although this could be mitigated by post-dose monitoring and cautious titration within the constraints of possible nursing assessment. There may be concerns that high-dose IV HM may reduce engagement in evidence-based OAT treatment and increase overdose risk as it cannot be continued on discharge in the majority of cases. However, some PWUD will choose not to use OAT regardless or wish to remain in a safer supply program. Offering such a strategy in this circumstance alongside the full spectrum of addiction care and OAT respects individual autonomy and the rights of PWUD from a harm-reduction perspective.
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