When Portugal decriminalized drug possession, it had 60 therapeutic communities and zero drug consumption sites. The BC government has introduced no therapeutic communities and over 50 consumption sites.
I’ve had the professional privilege to focus on substance use and addiction for nearly four decades, working in hospitals and clinics, training practitioners, and investigating ways of helping people and improving services.
A major focus of my work has involved helping people who live in poverty. I led two of the world’s largest randomized trials comparing different services for people who live homeless with addictions alongside other mental illnesses.
For 20 years I led research on interventions that help people who experience addiction and involvement with the criminal justice system. I also ran a program of work to improve primary healthcare for substance use in urban, rural, and remote parts of Canada.
For more than a decade, British Columbians have experienced a severe increase in harms linked to substance use. Drug poisonings are now the leading cause of death among people aged 10-59. Involuntary hospitalizations for addiction have more than doubled and our prisons are increasingly used to detain people diagnosed with addictions and surviving from the proceeds of crime. About two-thirds of the people younger than 19 who died from drug poisoning received care from B.C.’s Ministry for Children and Family Development.
Nearly a year-and-a-half ago, the provincial government, with Health Canada approval, began a three-year pilot decriminalization program. Both levels of government gambled that decriminalizing drug possession and providing pharmaceutical forms of addictive drugs – so-called “safe supply” – would diminish the overdose crisis.
It’s not working.
The Stanford-Lancet Commission and others, including my team, specifically advised against these policies.
The North American opioid crisis spanning from the late 1990s showed that increasing the supply of opioids in society tends to increase the rate of drug-related risks including addiction. And from decades of research we know that implementing decriminalization without robust safeguards is likely to expand harms to individuals and communities rather than reduce them.
Reforms ran counter to BC government policies
It’s been my privilege to support governments, including B.C.’s, in the improvement of public policies and services. In 2021, B.C. Premier David Eby – then Attorney General and Housing minister – asked me to brief deputy ministers on evidence related to province’s worsening crisis of addiction, homelessness, and crime.
The briefing highlighted peer-reviewed research describing of British Columbians’ needs, gaps in services, and reforms shown to be effective internationally and within B.C. I summarized results from my team’s work, spanning more than 20 years following tens of thousands of individuals as they interacted with healthcare, housing and justice sectors in B.C. And I also outlined our latest government-approved work using cross-ministry data to evaluate COVID’s impacts.
My team’s recommendations included several reforms to improve the effectiveness of publicly funded resources addressing substance use, homelessness, and mental illness. We also recommended evaluating new public programs and comparing outcomes against benchmarks for improvement established by published research.
One week after my briefing, the provincial government ordered Simon Fraser University to destroy our team’s entire database and related capabilities.
One week after my briefing, the provincial government ordered Simon Fraser University to destroy our team’s entire database.
Who orders scientists to destroy decades of research? And why eliminate an already agreed upon plan to evaluate the performance of public services?
Unbeknownst to my team and me, our research and recommendations ran counter to government programs that were being ramped up, including prescribing addictive drugs (“safe supply”), and concentrating people in hotels, shelters and congregate housing facilities rather than providing independent supported housing in healthy communities.
The pushback to our proposal was unprecedented, but three years later, our recommendations stand.
The suggestions laid out below are strongly supported by international and locally derived evidence. They address substance use and mental illness generally, and have specific urgency for those at greatest risk.
Support services need to be regulated and standardized
Services need to follow protocols that have been proven to be effective.
People with complex needs require 24/7 community-based teams. Those with less complex needs require dedicated case management. B.C.’s patchwork of shelters, encampments, and low-barrier buildings needs to be replaced with a province-wide portfolio of dispersed housing and priority needs to be placed on building relationships with landlords and employers.
B.C.’s patchwork of shelters, encampments, and low-barrier buildings needs to be replaced with a province-wide portfolio of dispersed housing.
Standards have already been developed to train and support professionals in the delivery of effective care. And professionals around B.C. have confirmed their desire to provide better services.
In 2021, 12 not-for-profit organizations and Simon Fraser University jointly submitted a fully budgeted and scientifically grounded proposal to B.C.’s ministers of Housing and Mental Health and Addiction. The proposal called for standardized and regulated services in several regions of B.C., matching services to clear evidence of community-based need.
Even though the proposal was ignored, these reforms can still be implemented anytime.
Justice sector reforms can reduce crime
Prioritizing preventative and voluntary forms of intervention doesn’t eliminate the need for our justice system.
The neglect of current and previous provincial governments has caused large numbers of people to enter conditions of despair and survival that escalate to repeated criminal activities such as theft and breaches of court orders.
Fortunately, our justice system has already proven capable of reducing crime while promoting employment, social reintegration and improved wellness. Recovery can begin while serving time in custody, as practiced in Alberta.
In B.C., peer-reviewed research confirms the effectiveness of interventions involving the judiciary, including community court and drug treatment court. These programs require similar resources to voluntary interventions, including healthy dispersed housing and support finding or regaining employment.
Police play vital roles in prevention through school liaison programs, surveillance of ports, and reducing illicit trafficking including novel classes of drugs and their precursors.
Prosecutors and courts are essential to reducing illicit drug sales and money laundering. And intelligence operations are integral in understanding how foreign governments use drugs to destabilize adversaries with weak anti-drug regimes.
Collaborative mental health care needed
Family physicians and other primary care providers need coordinated support from mental health, substance use, vocational & housing services.
Federally funded initiatives have confirmed the feasibility and effectiveness of integrated approaches to delivering mental health care in Canada. Collaborative care results in better patient outcomes and vastly improved morale among service providers.
The magnitude of dysfunction in our health sector breeds cynicism and despair among professionals and patients alike.
When delivered in isolation, prescribed medications such as methadone and other opioids can cause more harm than good. Working collaboratively requires sharing information and dividing responsibilities in an organized manner.
The fragmentation that many B.C. health professionals experience is particularly detrimental to addressing substance use and mental health, and erodes the performance of our entire healthcare sector.
Among nearly 4,000 people hospitalized for addiction and mental illness in Vancouver, nearly one in five were discharged to no fixed address after 3 weeks in care, and they were likely to be readmitted. The magnitude of dysfunction in our health sector breeds cynicism and despair among professionals and patients alike.
Services need to be transparent and measured
For nearly 20 years, B.C. had one of the world’s best information systems regarding substance use, mental illness, crime, and homelessness. Data from the ministries responsible for health, justice, and social services were integrated and used to monitor meaningful population changes over time and assess the effectiveness of publicly funded interventions and policies.
Dozens of peer reviewed publications are based on B.C.’s information system, showing achievable levels of improvement that could be used as benchmarks.
The current provincial government erred when it hastily ordered the destruction of this public resource. It should be re-established.
Hub for mental health and addictions care needed
When the global movement to deinstitutionalize mental healthcare reached B.C., the public was assured that Riverview Hospital would be replaced by more effective interventions that would be provided early and close to home.
Decades later, we need to make good on that promise and the lands where Riverview Hospital once operated can play a crucial role in that transformation.
A home base of operations will be required to create a new system of care. The provincial government and Kwikwetlam Band have discussed redeveloping the former Riverview lands as a new community built in the spirit of reconciliation.
Now known as Sumiqwuela, the new community would foremost be a beautiful place to live. But Sumiqwuela could also be one of the world’s leading communities for promoting mental health and providing training for professionals both on site and remotely. It could deliver best practices to local residents and serve as a hub of expertise for family members and professionals across B.C.
Sumiqwuela could also be one of the world’s leading communities for promoting mental health.
Accredited post-secondary programs could provide training to health professionals in team-based outpatient mental health care at Sumiqwuela. Additional programs could provide remote instruction and supervision, continuously raising the standard of care.
We cannot expect changes in practice without changing how practitioners are educated and supported.
This vision for Sumiqwuela acknowledges the crucial role that Riverview Hospital played in the last century of mental healthcare and would exemplify the transition to community-based mental healthcare for the next century.
Therapeutic communities must be geared to social integration
Portugal achieved its famous reversal of street drug use and addiction between 2000 and 2010 through a firm commitment to social reintegration. The country’s national drug strategy states: “Strictly speaking, there is no such thing as treatment without social reintegration”.
To help achieve this, over 60 therapeutic communities provided structured supports to help people successfully transition into healthy neighbourhoods with meaningful work. Portugal’s commitment to social reintegration meant that they did not require a single drug consumption site. By contrast, the current B.C. government has created no therapeutic communities and over 50 consumption sites.
Employment has a powerful impact on mental health and protection against relapse – two-thirds of fatal drug poisonings in B.C. involved people who were unemployed; most were young.
Employment has a powerful impact on mental health and protection against relapse.
Curricula for therapeutic communities in B.C. could be developed with major employers in industries such as construction and resource stewardship, ensuring graduates are positioned and provided a warm hand-off into sustainable, in-demand jobs.
The suffering that leads to addictive drug use is arguably the major crisis of our generation. The above recommendations are proven feasible and effective to reduce risk and promote wellness. And evidence confirms that we don’t need to spend more. We need to spend differently.
There are incredibly uplifting and inspirational lessons from research on substance use and mental illness over the past several decades. It is well past time for British Columbians to benefit from them.