"IF IT'S SO AVAILABLE WHY ARE PEOPLE DYING MORE THAN EVER?"

I saw a “safe supply” rally yesterday in Victoria. And I read this article about it this morning, titled “BC mother runs across province for safe drug supply.” It reads, in part:

“I want them to provide safe drug supply, I want them to stop people dying,” Michalofsky says. On Thursday, Michalofsky began the final leg of her journey on Vancouver Island and will be running from Nanaimo to Victoria over the next several days. She stopped at a safe-supply rally at Maffeo Sutton Park in Nanaimo. Running 30 kilometres a day, her journey began last month in Nelson, B.C. "That's where my son died. That's where he grew up," she says.

Michalofsky's son Aubrey died last August at the age of 25 from a toxic drug overdose. She believes he would still be alive if he had access to a safe drug supply. She finally met with the province, and she said they agreed that there needs to be more safe supply. "But they couldn't tell me why it wasn't being rolled out," Michalofsky adds. … Michalofsky wonders where people can access this safe supply. "If it's so available why are people dying more than ever?"

The video accompanying the article shares words from another advocate, from Moms Stop the Harm, who argues that “safe supply is not about providing drugs to people, it’s about having prescription drugs supplied in a safe way.”

Well, I remain very confused about all of this. And, seemingly, the more information I have the more confused I get.

DOES ANY OF THAT MAKE SENSE?

The most obvious and uncontroversial problem with the above is that safe supply, and our harm reduction strategies more generally, are most definitely not about offering prescription pharmaceuticals to users. For decades now, advocates such as The Canadian Association of People Who Use Drugs (CAPUD) have pushed for regulated supplies of whatever substances folks feel they need. CAPUD is very clear when they define safe supply as “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.” A list of such substances, obviously, would exclude effectively nothing we think of as a drug. More explicit, according to these experts and their “safe supply concept document”, upon which the City of Vancouver based its current safe supply strategy, in addition to prescription pharmaceutical alternatives, the drugs to be made available include substances such as heroin, cocaine, crystal meth, MDMA, and LSD. And that is just what we have seen in practice. The unofficial safe supply of these substances has been purchased on the dark web, tested, and not prescribed by a doctor but distributed freely by advocacy groups such as the Vancouver Area Network of Drug Users and the Drug User Liberation Front, whose demands are in line with CAPUD's:

• All levels of government must immediately fund programs for safe and accessible supplies of all drugs, including cocaine, heroin, and crystal meth, by directly listening to user groups and people who use drugs.

• All levels of government must immediately develop an accessible legal framework that decriminalizes, licenses, funds, and provides facility spaces for heroin, cocaine, and methamphetamine compassion clubs.

  
  

Unsurprisingly, the government-run version of safe supply has offered the same. And now everyone is getting in on it, apparently. Awesome.

THERE ISN'T A PROBLEM WITH PRESCRIPTIONS, THERE ARE MANY

Even if the plan was only prescription pharmaceuticals and only by way of a doctor or pharmacist, which it is clearly and definitely not, a whole range of problems remain:

A) Prescription and over-the-counter pharmaceuticals (such as: morphine [Kadian, Avinza], codeine, hydrocodone [Vicodin], hydromorphone [Dilaudid], oxycodone [OxyContin, Percocet], oxymorphone [Opana], fentanyl, and others) are what kicked off and sustain this multi-decade, multinational drug addiction, overdose, and death crisis that has already taken more than 600,000 lives — a number expected to double before the decade is out. One may question the logic and ethics of encouraging all of that. I mean, what would you call continuing to send trainloads of money, untold millions of taxpayer dollars, to those drug companies (as well as doctors, nurses, dentists, pharmacists, pain clinics, legislators, and criminals) who created and profited from this tragedy and continue to do so, and all for the manifest purpose of acquiring more of the exact same? I call that encouragement. I also call that insane.

B) We've known since the 1950s that there are considerable risks posed by opioids and that those are likely far greater than any benefits when used for non-malignant conditions. Oh, and not only do these substances have a long list of adverse side effects and contraindications but any list of possible issues will include significant risk of dependence, addiction, overdose, and death. The United States, for example, has sustained around 14,000 annual prescription opioid overdose deaths for nearly two decades, commonly beating out annual non-prescription heroin overdoses. Does putting more of that on the street sound like an overdose reduction strategy?

C) Providing alternatives to illicit, tainted drugs has taken place for quite some time. Methadone and buprenorphine have been long used as opioid substitution treatment all over North America. Those efforts have always been plagued with reports of devastating side effects and poor retention, not rousing success.

D) Long ago, Canada expanded injectable hydromorphone as a treatment for opioid addiction. Those programs have proven to be unsuitable for many people who use opioids and particularly the vulnerable population of most concern (folks difficult to keep engaged with the healthcare system) and even just those who simply do not inject their drugs. More than that, those programs are difficult to scale up and implement outside of major cities, due to the significant resource capacity required; which is exactly where, in remote Nelson BC, the man in the above story died and where, per capita, the worst of the problem exists.

E) Significant efforts have been made to improve the uptake of medication-based treatments in Appalachia, at the heart of the opioid crisis in the US. Those efforts have included almost tripling the allowable physician prescription limits of buprenorphine and significantly increasing access. Studies have shown those interventions remain largely underutilized. So, in that light, what is the argument or evidence for BC having the exact opposite response? I've never heard and cannot find one.

F) There is no reason whatsoever to believe providing access to regulated, prescription substances will reduce the availability or use of the unregulated, toxic, illicit supplies; and, thus, as noted above, no reason to suspect this will decrease the risk of overdose and death. What should be most obvious to advocates is that the full-scale War on Drugs (with SWAT teams in military assault vehicles busting down peoples’ doors at 2am followed by judges delivering sentences of life behind bars for as little as minor possession), totally failed to even slow down, never mind curb, international smuggling, homegrown production, and open use of illicit drugs. Fact. Also, since decriminalization and then the full legalization of cannabis here in Canada — the only similar example we have to safe supply — international and illicit sources have remained as popular as ever, dampened little by our legal, local production and distribution. To be clear, surveys post-legalization have shown the majority of British Columbians who consume cannabis and related products choosing NOT to buy from legal, provincially-authorized and regulated cannabis dealers, favouring black market options instead. Users cite cost (illegal options often being half the price of legal), convenience, and familiarity with the product. This is how people reason and should surprise no one.

G) Similarly, the publicly-funded provision of crack and ecstasy will not help the majority of users and the kinds of tragic deaths we read about in these news articles; at least, not without being more readily available than coca-cola and lottery tickets. In Aubrey Michalofsky’s small, remote town of Nelson, for example, organizations such as ANKORS have offered all varieties of harm reduction information, tools, and services since 2016. Those services include: free drug checking and mobile drug checking; clean needles, pipes, foil kits, and snorting kits; disinfectants and sharps disposal containers; naloxone anti-overdose kits and a monitored safe consumption site; as well as a positive, judgment-free peer network for users. There is no evidence this victim of tainted drugs took advantage of any of that, all at his doorstep or a call away, or the many in-person, virtual, and mail-in services offered by the province and so many other organizations. And without being a full-on addict and actively engaged in an intervention program, rather than a casual user, it's highly unlikely he would have gotten a prescription for "safe" drugs.

So what is the reason to suspect any of this or similar alternatives can and will work? And what is the profound counter-evidence to the local precedent of ever-increasing “harm reduction” strongly correlating with ever-increasing harm? (When we bring in a vaccine campaign to fight tuberculosis or drunk driving education programs to address driving impairment fatalities we don't EVER see incidences double and then double again and then once more the following year. Something is amiss here, and more than the tainted drugs...) Is there good reason to believe safe supply will be anything more than an extraordinarily costly experiment resulting in more needless deaths of the most vulnerable among us? And does any of this discussion appear to do so much as recognize the wide variety of drug use, including folks who use illicit substances not being interested in treatment or those for whom traditional forms of treatment are not suitable? I don’t know and can’t find those arguments or independent research findings for any of the above. Still, Michalofsky’s mother and others like her tell us that not enough was done while her son was alive and the situation today remains profoundly insufficient. So, it seems worth spelling out what the recent history and current scenario with safe supply looks like, exactly.

CURRENT POLICY

The present safe supply strategy has been in the works for decades and was implemented on the down-low by advocates like Michalofsky for years through “compassion clubs”, so called, and supervised consumption sites. From there, safe supply was officially adopted as a matter of policy by the City of Vancouver back in 2019. (That year there were 987 illicit drug toxicity deaths.) The first pilot project was introduced the same year and has continually expanded since. And in less than a year, in March of 2020, at the start of the pandemic, provincial authorities made “prescribed safer supply medications” available as part of their holistic emergency measures to prevent deaths. BC’s Minister of Mental Health and Addictions, Judy Darcy, announced that the province was eliminating all the barriers possible by offering virtual prescriptions as well as home drug delivery for users. Later that same year, the provincial health officer, Dr Bonnie Henry, issued a public health order proposing to:

• Dramatically increase eligibility criteria to prioritize reducing overdose events and deaths, and reach individuals with opioid-use disorder, other substance-use disorders or individuals with a history of accessing the toxic street drug supply who are at high risk of overdose and other drug-related harms;

• Carefully expand the types of medications that can be prescribed and dispensed by doctors, pharmacists and nurses;

• Increase access points to allow for dispensing medications from health authorities and community pharmacies

  
  

(Just months later the province tallied 1,774 illicit drug toxicity deaths for the year 2020.) By March of 2021, the province was spending $3.5 million to provide more opioid vending machines (the first of which was installed by the MySafe program back in 2017). These machines were implemented as “a cheap and scalable” alternative to the safe injection sites that require interaction and supervision, allowing participants to “access a safer drug without fear, shame and stigma, and without contact with anyone.” From there, in July of 2021, the province announced it was directing $22.6 million to health authorities to further expand the safe supply program. (With that, the total number of illicit drug toxicity deaths for 2021 hit 2,306, more than ten times the already-high numbers recorded prior to 2012). And, of course, all along local governments and advocacy groups pushed the federal government for BC’s exemption from the national Controlled Drugs and Substances Act. That exemption was approved and announced in May of 2022. (And by the end of the year we learned the death toll for 2022 was 2,272). More recently, it was announced the provincial budget for 2023 includes an additional $1 billion for the provisioning of safe supply, other harm reduction programs, as well as treatment options.

So, all of the above was in play before the safe supply rally I saw the other day in Victoria. And all of it came prior to and was searchable for those reporting on it. And yet all of this isn't just missed or disregarded but all the efforts to date are said to leave everyone wanting. I, for one, wonder what the ask is, then? Should all of the most addictive drugs known be produced locally and handed out like cocktail weenies by a pharmacist in a white coat in the deli section of every grocery store, liquor store, gas station, high school campus, and college dorm in the province? How else would you get these substances into the hands of every person who would pop a pill at a party one time or who don't have immediate, in-the-room access to drug testing — you know, folks just like Michalofsky's son, Aubrey? To do MORE would require nurses slipping prescription MDMA and Heroin into the pockets of unsuspecting pedestrians and incorporating prescription benzodiazepines and government-approved "clean crack" into the junk mail circulation at Canada Post. What else would do it? What is their solution? Well, other than providing more drugs and in far larger quantities (a demonstrably terrible idea that has only and will only kill more people), these advocates don't say. So, are there working models out there for preventing drug deaths? Could it be that there's a very simple and obvious answer to Michalofsky’s question, "If it's so available why are people dying more than ever?"

PROVEN SOLUTIONS

As I’ve noted in the past, Portugal remains the world’s leading model and the only place anyone ever references as an example of working policies. So, what did Portugal do? Portugal DID NOT bring in any of the “harm reduction” strategies we have in BC (above getting folks into counselling, rehab, and off of drugs.) They NEVER HAD safe injection sites or needle exchanges for users and they certainly didn't bring in a “safe supply” program, either. In fact, Portugal has never even distributed naloxone anti-overdose kits outside of medical settings. (Here in Victoria the little black pouches swing from many people’s backpacks, bicycles, and strollers, are affixed to fences and benches in public spaces, are available in cafes and stores all over town, and can be found in fire trucks, police cars, and city vehicles as well.) Too, on the road to becoming a model for the world, Portugal never legalized any drugs. So, in Portugal it IS NOT legal to produce, transport, sell, purchase, or use any of the many substances widely available throughout BC. The Portuguese only decriminalized drugs as an attempt to destigmatize drug addiction. This model ensures there are no criminal penalties for users in possession of or consuming drugs and the social costs are minimized. However, that doesn’t mean there’s an absence of severe consequences or strong state coercion. For instance, drug producers and pushers still receive criminal punishments and users have a whole suite of non-criminal repercussions, any one of which may be considered as bad or worse than jail. Once they’ve encountered police or social services, for instance, as an alternative to a criminal court, users are made to sit before a commission. That commission has powers to restrict user’s freedom of movement, limiting travel and even preventing users from entering certain neighbourhoods or businesses if those places are seen to be problematic. They can also restrict freedom of association by preventing users interacting with certain persons deemed to be enabling their use of illegal substances. Too, commissions are free to seize and sell drug users' personal possessions if fines and fees for services are not paid and, more than that, these bodies are even able to end non-compliant users' access to social services and welfare funds. The carrot offered to prevent some of these sticks from being applied to users is the users' “voluntary” rehabilitation. So, you see, there is simply no option for a person with a drug problem in Portugal to avoid coercion into their drug-use cessation system. So, again, what has all of Portugal’s illegality, harm acceptance, and coercion done for them? Well, as we all know, they are the world’s glowing example for how to end your nation's drug crisis.

And yet, apparently, everything I have written here is — according to every local authority, including the province’s health officer, chief coroner, independent representative for children and youth, and deputy medical officer for the First Nations Health Authority — wild misinformation erroneously politicizing the debate on safer supply. (But I, like others I'm sure, take that criticism lightly as this comes from the same health authorities that rejected an evidence-based approach to the pandemic, became the laughingstock of the world's scientific and engineering communities, and gifted us one of the worst outcomes in the country and on the planet.)

YOU'RE RIGHT, WE NEED TO STOP KILLING PEOPLE

Sadly, I don't think you have to go as far as I have here. I don't think we need to review dozens of policy statements and research papers and news reports. It's simply unethical to identify that someone has had their health or life deranged by addiction and then procure and provide them with the very substances that hold them there and promise to make things worse. If your brother comes to you, explaining that he has lost job, his wife and kids and all his friends, sold his truck, his television and the rest of his belongings, accidentally burned down his townhouse, got into a terrible accident and now needs his leg amputated due to lack of treatment and subsequent infection — and that all this came about because of his addiction to alcohol, prescription opioids, crystal meth, or all of the above; and then he explains the only reason he's telling you any of this is that he needs more of what he needs... and your response is something other than immediately coercing him into some form of institutionalized treatment (exactly what happens to anyone who has people around them who care for them) but instead to provision him with everything he wants, then you are less an advocate or caregiver and closer to a monster. Despite the insistence from provincial health authorities, advocates, and my own friends, I remain unable to see how it could be otherwise.