Suspension of iOAT could lead to patients dying, lawyer argues during injunction hearing

‘iOAT is not just about treating someone’s severe opioid use disorder. It’s about addressing the broader health needs. It’s about finding a way to engage this patient in the health-care system,’ Nanda told the court.

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Patients who suffer from severe opioid use disorder could face irreparable harms including risk of death or sexual assault if a government-funded treatment program is halted next month, an Alberta court heard Wednesday.

Clinics in Calgary and Edmonton, which provide injectable opioid agonist treatment (iOAT), are slated to close in March following a decision by the United Conservative government, pending the outcome of a court challenge.

Shuttering those clinics would lead to “adverse health effects” for iOAT patients, who are likely to return to using street opioids, experience homelessness, contract sexually transmitted infections or lose access to primary care, argued Edmonton lawyer Avnish Nanda during Wednesday’s injunction hearing.

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The program has been described as a “last resort” for people with severe opioid addiction who have been unsuccessful with other forms of treatment such as methadone or suboxone.
Eleven iOAT patients with chronic opioid use disorder launched a legal challenge against the provincial government in September, alleging the decision to halt iOAT services violates their constitutional rights.

Justice Grant Dunlop reserved his decision Wednesday. His ruling is expected by the end of February, which will determine whether iOAT patients can continue receiving treatment until the lawsuit reaches a conclusion, even if the matter is still before the courts beyond March.

Nanda argued the pilot program, which launched in 2018 under the former NDP government, never explicitly stated an end date. He said they introduced iOAT with the intention of making it a permanent frontline treatment option.

The government’s counsel argued any perceived harm is speculative and the program was never guaranteed for an indefinite amount of time.

“iOAT is not just about treating someone’s severe opioid use disorder. It’s about addressing the broader health needs. It’s about finding a way to engage this patient in the health-care system,” Nanda told the court.

“If you remove any component to that, whether it’s wraparound services or injectable medication, it ceases to be iOAT.”

Nanda said the scope of an alternative program proposed by the government remains unknown.

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He cited a cross-examination of Mark Snaterse, executive director of addiction and mental health for Alberta Health Services, who compared iOAT to the “Cadillac model” of service and said alternatives would likely be of lesser quality.

“My concern here today is that, what if we get a vehicle that just has an engine but not the transmission? What if it has no doors?” Nanda said. “What if it has certain components, parts, of what iOAT is and Alberta claims it’s iOAT, but really it’s not?”

Nate Gartke, a lawyer representing the government, acknowledged “there will be some changes” in how the service is offered.

“The current model of iOAT clinics is … a Cadillac service. It’s the gold standard. It’s attempting to provide as many treatments as possible in one location,” Gartke told the court.

“Just because a Cadillac service is not being provided, (Snaterse) still does say that it will be ‘a very good car.’ We’re not going to be providing them a car that doesn’t have a transmission or windows. We’re going to be providing them with a fully functioning service.”

Lillian Riczu, co-counsel to Gartke, said the plaintiffs have a “weak and frivolous case.”

“There will be minimal variation in the delivery method, however the variation in the delivery does not result in any harm, let alone irreparable harm to the applicants,” said Riczu, adding the same suite of ancillary services will be available through the Opioid Dependency Program in Alberta.

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“Alberta’s evidence demonstrates that iOAT was a pilot study, it’s a controversial treatment and is only offered at a handful of jurisdictions around the world and in a limited number of Canadian cities.”

Nanda posed concerns about the government’s alternative treatment option, including whether there would be sufficient staffing, access to the same wraparound supports and trust in service providers.

There is no grant in place yet for the alternative service.

Patient says iOAT provided ‘hope for a better life’

One plaintiff testified the closure of iOAT is a “death sentence” for her.

She said program staff had become “the only real family” she’s ever known. Through iOAT, she stopped using street opioids, found housing and left sex work, which previously helped support her substance use.

The program gave her “hope for a better life,” she testified in an affidavit.

But its anticipated end forced her back to her previous lifestyle.

“I returned to street opioid use because I felt like the system had abandoned me again and I knew that without iOAT I had no other option to manage my opioid use disorder.”

She also returned to sex work.

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In December, she testified three men violently raped her and “dumped her in the snow.” She later tested positive for HIV at the iOAT clinic, which she believes is a result of the rape.

“I am so upset and angry with the government. It should be ashamed for what it is doing and the lives that are being ruined with the closure of iOAT,” she testified.

“The government gave us hope with iOAT, had us trust them, and now that has all been taken away, forcing us back into the streets with the violence and dangers we managed to avoid.”

She said the only reason she sought help after the December incident was because she trusts staff at iOAT and additional services were accessible at the Calgary clinic, such as the sexual transmitted infection screening.

Nanda said iOAT patients share similar stories to one another, including trauma endured prior to using opioids. He said many have a distrust of the health-care system due to prior circumstances.

“We’re really talking about the most vulnerable and marginalized group of opioid use disorder patients in Alberta,” he told the court. “It’s that only through iOAT they have aspirations, they have goals beyond the next time they use opioids. They’re talking about ambitions and plans and goals that they never thought possible.”

Nanda called the program a “one-stop shop” for medical care for patients.

“It’s the only effective treatment available and recognized for folks with severe opioid use disorder,” he said.

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The injunction hearing followed the release of a University of Calgary study this week which detailed the benefits of iOAT, according to 23 patient interviews.

Clients said the service “transformed” their lives, citing improved mental health, decreased reliance on street drugs, fewer withdrawal symptoms and an overall improvement to their quality of life.

Researcher Jennifer Jackson also highlighted other studies of similar programs in the Netherlands and B.C., which showed between 13 and 20 per cent of patients die when services are scrapped.

The province is already seeing record-high opioid-related deaths. A staggering 904 fatalities were recorded between January and October — marking the deadliest year on record with two months of data still undisclosed.

“The only reasonable, factual conclusion is that, at best, there is uncertainly about whether this is iOAT or it’s not iOAT,” Nanda told the court. “If that is the case, then the harms that I’ve described about relapse back to street opioid use all manifests.”

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