You gotta have faith to believe in ‘safe supply’

“It will replace fentanyl. No it won’t. It is safe. No it isn’t.”

––Addictions physician

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It’s official. Public health policymaking has become a faith-based pursuit. 

British Columbian and Canadian government elected and senior public health officials are such fervent believers in the gospel of “safer supply,” they preach unproven benefits as truth, embrace self-reporting by drug users as hard scientific evidence, and dismiss warnings from addictions specialists as mere anecdote.

Fixated on the contamination of street drugs as the root evil, safer supply advocates have one enemy in their sights – the unregulated drug market – and they are locked in a pitched battle to out-pharmaceutical it.

Just as bygone conservative governments were determined to enforce and prosecute the illicit drug market into submission, today’s officials are bent on replacing it.

Welcome to the War on Drugs 2.0: The Surrender (of your critical thinking).

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Rather than focusing on medically sound addiction treatment and recovery measures that have helped countless people around the world climb out of their addictions, our public health policymakers are single-mindedly expanding an unproven pharmaceutical intervention no other country in the world is doing – the public supply of addictive drugs (PSAD), euphemistically known as safe, or safer, supply. 

Adherents call the program innovative. Extreme situations call for extreme solutions, they say, and with 20 people a day dying in Canada (six of those people in B.C.), we need to be daring and think outside-of-the-box.

That might make sense if it worked. But it doesn’t.

Addictions physicians say PSAD/safe supply is failing their patients and creating new opioid dependencies in people who weren’t previously addicted.

Rather than heed warnings from medical professionals on the frontlines and halting or pausing the program to investigate, our elected and public officials are doubling down.

‘The whole drug policy is flawed’

“The whole drug policy is flawed, not just because policy for the whole province seems to be driven largely by people working with the community of the Downtown Eastside, but because there is a resistance to investing in anything beyond harm reduction and safer supply,” said a Lower Mainland addictions physician who requested anonymity after he and his family were personally and professionally attacked when he previously publicly criticized the program.  

“What we’ve been seeing is a whole cohort of people brain-damaged who won’t ever go back to work. And the solution for these people who are cognitively not capable of making great decisions is what?”

“The only solution anyone has is, ‘Well, let’s just give them more drugs.’”

Safe supply 101

The public supply of addictive drugs (PSAD) are fast-acting pharmaceuticals prescribed to people with severe addictions in the hopes they will stop using unregulated street drugs and therefore not overdose. The drugs intoxicate the user and are consumed unsupervised.

Hydromorphone is the main drug, although fentanyl, cocaine and methamphetamine-type stimulants are also offered in some locations.

Fourteen months after the program was introduced in B.C. 8,400 people had been dispensed safe supply pharmaceuticals 257,000 times. Within two years, 14,000 people had been prescribed PSAD/safe supply in the province.

Primarily available in tablet form known as ‘dillies,’ after the brand name Dilaudid (made by Purdue Pharmaceuticals), hydromorphone delivers a euphoric high indistinguishable from heroin. It is five times stronger than morphine and three times more potent than oxycodone (OxyContin, also courtesy of Purdue), the drug that fueled an historically unprecdented level of opioid addictions in North America (more on this later).

PSAD is sometimes conflated with opioid agonist therapy (OAT), but the two are worlds apart in intent and effect.

OAT pharmaceuticals, mainly methadone and buprenorphrine (Suboxone), are slow-acting opioids that ward off cravings and withdrawal and are consumed in a clinical setting until the patient is stabilized. They do not get the patient ‘high.’

Where safer supply is experimental, OAT is the decades-long, worldwide gold standard in opioid treatment assisting an untold number of people regain stability and achieve abstinence.

PSAD/ safe supply on the other hand, has no off-ramp to recovery. No helping hand to ease the burden of addiction or guide the user to another level of care while empowering them to improve.

That’s not even an intention. According to safe supply advocates, the problem is not people’s death grip addiction to drugs and it isn’t that they need treatment – that would be too stigmatizing to say – it’s that people are using the wrong severely addictive drugs.

Government officials blame all drug overdose deaths on the “unregulated toxic drug market,” as if ingesting methamphetamines and fentanyl is otherwise healthy. Public health representatives plead with drug users to stop buying illicit drugs, with their unknown potencies and smorgasborg of contaminants, and switch to the free, state-sanctioned pharmaceuticals, which are also addictive, but less likely to kill a person in one sitting.

“As though the best we can do for these people is provide them with heroin three times a day, and essentially ignore their housing and unemployment,” says clinical psychologist and SFU distinguished professor, Dr. Julian Somers.

Such is the low bar of PSAD/safe supply.

The root causes of addiction aren’t addressed. Personal responsibility is neither encouraged nor supported, and above all, no one has to say the obvious – that regardless of the toxicity of the unregulated street contaminants, self-administering a drug 100 times stronger than morphine (fentanyl) is a very bad and dangerous idea. 

‘Pharmacological sedation of poverty’

According to the brilliant analysis of the North American opioid crisis by the Stanford-Lancet commission, “care providers should also consider that many patients with [opioid use disorder] have serious, unaddressed psychiatric, medical, family, employment, and housing issues that medication alone will not solve…”

The commission further cautions “… [opioids] should not be used as an informal system of pharmacological sedation of poverty.”

If you’re a doctor, nurse, airline pilot, or public servant who develops an addiction, you’re offered high-quality treatment that takes into account the whole person and all the influences fuelling your addiction. If you’re living with people who use drugs, you’re relocated. If you need mental health counselling, you get it.

Crucially, you must refrain from doing drugs while in treatment and your urine is tested to prove it.

“Amazingly, overwhelmingly, people respond well to this. They keep their jobs and comply with the program,” said SFU psychologist and professor, Somers, whose team has amassed a vast body of research exploring the compounding effects of homelessness, addiction, mental illness, criminality and unemployment.

By contrast, impoverished people without a job and resources get none of this care. They aren’t separated from other drug users and their unemployment isn’t addressed. Two thirds of those who’ve died of drug overdoses in B.C. were unemployed.

Instead, they are only given the one thing pilots, doctors and nurses are not allowed to have – more addictive drugs.

“And somehow, we’re being told that this is how we reduce stigma,” Somers said.

“It is, in fact, how you practice stigma. You couldn’t have a clearer example in health care of stigma.”

Dreaming of the promised land: legalization of all drugs

Our provincial and federal officials pay disingenuous lip service to the concept of a balanced, multi-pillared drug strategy of prevention, harm reduction, treatment and enforcement, even going so far as pretending they’re emulating successful multi-pillared drug programs in Portugal, Germany, Switzerland and elsewhere.

In actuality, they are hurtling headlong into a safe supply model without physician gatekeepers on a trajectory towards the ultimate harm reduction legacy – the legalization of all illicit drugs.

For the most zealous safe supply adherents, legalization is the promised land, a near-ecstatic state where heroin, methamphetamine, cocaine and fentanyl are as accessible as beer, stigma is erased, drug use is normalized, and the illicit trade, magically vanquished.

According to this utopian dream and counter to logic and all evidence about human nature to the contrary, everyone with crippling, brain-injuring addictions will carefully and responsibly ingest their severely addictive “safe” drugs, overdoses will diminish and drug diversion will cease. No one will buy street drugs or sell their publicly supplied psychoactive drugs for profit, and the real kicker, illegal drug traders will concede defeat and bow out of the market.

A sensible compromise

“In the long term, would [legalization] be a way to counter the toxic street drugs and to take that business away from organized crime? Absolutely,” said B.C. Provincial Health Officer Dr. Bonnie Henry at a press conference in June.

When hard drugs are unregulated, they’re highly toxic and harmful, she said. Alternatively, promoting drugs like alcohol was, can also be damaging. “So we need a spot somewhere in the middle.”

Easy retail access to meth, crack and powder cocaine, fentanyl and heroin is apparently Henry’s idea of a sensible compromise.

“In the long term, would [legalization] be a way … to take that business away from organized crime? Absolutely.”

Bonnie Henry

“I would say that the experiment, or what we’re doing with legalization and regulation of cannabis, fits into that, where you have enough controls, and you have enough regulation, but you also have monitoring and safety of the product,” Henry said. 

Two hits of heroin, a chunk of crystal meth and some fentanyl gummies, please.

How can that be safe? 

“It’s not safe!” one addictions physician exploded.

“But it fits the business model,” he said. “The ultimate goal is legalization of all drugs. It’s not decriminalization. It’s legalization of all drugs for profit.”

Former federal Minister of Mental Health and Addictions, Carolyn Bennett, the ostensible lead on Canada’s drug strategy, concurred.

Responding in federal parliament to Conservative Party of Canada Opposition Leader, Pierre Poilievre, who has promised to scrap safer supply if elected next term, Bennett said, “We have to move to a safer supply of drugs, as we have with alcohol, cannabis and the other ways people actually use substances to numb their pain.”

So, the offiical Canadian health strategy is not to support people to heal their pain and master their addictions, but to just give them easier access to what’s killing them?

The most immediate problem with PSAD/safe supply, according to Henry, is not a lack of evidence it works, but that not enough people have access. The medical prescriber model may not be the best delivery mechanism for the program, she said, because “it puts a lot of pressure on clinicians” and “it’s very difficult to scale up.”

Translation: physicians and nurse practitioners don’t believe in the PSAD program and are not signing up in droves to prescribe it. 

Henry’s office is looking at other models “to support people having access,” she said.

Someone is not being forthright

All of which flies in the face of what B.C. Premier David Eby told the legislature this spring.

“We’re trying to get a physician between them and a street-level dealer, to keep them alive so that they can get into treatment,” Eby said, responding to a question on safe supply from BC United Opposition Leader Kevin Falcon.  

Eby was either oblivious to Henry and Bennett’s plan for a non-prescriber model aimed at legalization, or he was masking his awareness and his government’s intention to do so. By keeping his comments strictly to the safer supply program as it currently exists, he sidestepped any pending non-prescriber shift and longer-term legalization goal.

Same goes for the astonishment and outrage expressed by the Premier and Public Safety Minister Mike Farnworth in March when they learned Health Canada had granted a B.C. cannabis company licence to possess, produce, sell, and distribute cocaine.

BC United’s Falcon called it “legalizing cocaine trafficking, full stop.” Farnworth and Eby were stern and unequivocal. Commercialization of hard drugs was not on the table.

Except now, it is?

Also, does Eby really think the program is stopping people from using street drugs, reducing overdoses and progressing them into treatment? 

Has no one told him the program isn’t working?

Because his addictions minister knows there’s no data supporting those outcomes. 

In fact, data is an issue across the board at B.C.’s Mental Health and Addictions Ministry.

When BC United Opposition critic for addictions, Elenore Sturko, asked for “the exact metrics” used to determine ministry services were “effective and responsive” as advertised, Addictions Minister Jennifer Whiteside was stumped.

“I’m not sure any jurisdiction has really developed a good set of metrics yet for gathering evidence and for determining outcomes,” Whiteside said.

Seven years into a public health emergency, with untold billions sunk into harm reduction, and who knows how much of that towards the experimental safe supply program, and they haven’t even developed metrics for gathering data?!

Teeing up the non-medical model

And before the Premier launches into another prescribers-put-the-‘safe’-in-safe-supply speech, he should probably check in with his addictions minister. Whiteside might want to inform her boss about the “non-prescriber” safe supply co-op pilot project her ministry and his government are quietly backing.

For the lay crowd out there, non-prescriber safe supply is also known as individuals without medical degrees handing out severely addictive drugs to people with crippling addictions. In some countries, these people are called drug dealers. In B.C., because they are doing the government’s good work, they will no doubt adopt a warmer, more opaque, morale-boosting title.

The BC Centre for Substance Use (BCCSU), the public health agency affiliated with many of the province’s safe supply affirmation studies, will co-lead the non-prescriber project with the Fraser and Vancouver Coastal Health authorities, assuming Health Canada approves it.

Members of the province’s politically favoured drug users groups will likely be involved, such as those a BCCSU sociologist recently enthused about as “some really interesting community based models that are moving forward.” Namely, government-condoned drug user groups that buy cocaine, meth and heroin off the dark web, test for contamination, then repackage and disperse to members and other drug user groups in B.C. 

All of which might dovetail nicely with recent federal funding from the Substance Use and Addictions Program (SUAP) that promised to increase community groups’ involvement with the safer supply program. So far, SUAP, a kind of harm reduction slush fund, has meted out nearly $500 million, with a substantial portion directed at the advocacy, practice, marketing and distribution of PSAD/safe supply.

But don’t expect any metrics on outcomes from the federal government either.

Now for some hard truths.

One (very big) problem: safe supply doesn’t work

Safer supply was introduced to do two things: replace illicit drugs, namely fentanyl, and reduce overdoses. 

After seven years operating in Ontario and three years in B.C., program clinicians have been unable to generate proof the program does either.

“There is no clear evidence that it actually reduces overdoses and deaths,” wrote addictions physician, Dr. Vincent Lam in a highly nuanced Globe and Mail OpEd on February 3.

Lam is medical director of Coderix Medical Clinic, an addictions clinic in Toronto. He’s also co-editor of an opioid agonist therapy (OAT) prescriber’s guide and a Giller Prize-winning novelist whose latest book, On the Ravine, follows an addictions physician and one of his OAT patients as she struggles to get in front of her addictions.

“When front-line clinicians like me are seeing new cases of opioid-use disorder instigated by hydromorphone diverted from PSAD programs, we have to ask … how many other lives will we unintentionally harm by increasing the market supply of opioids, despite attaching the label ‘safe’?” Lam asked.

“For the past few years, we’ve been told that the data is emerging,” said Dr. Nickie Mathew, an addictions psychiatrist at Coquitlam’s Red Fish Health Centre, which treats people with some of the most complex mental health and addictions issues in the province.

“In comparison, if we look at COVID trials … in seven months, they were able to come up with a randomized control trial to show that, hey, these vaccines work. In three years, we still haven’t had that [for safer supply],” Mathew said during a Vancouver Coastal Health Authority seminar on the reluctance of doctors to prescribe safe supply.

A clinical psychiatrist with the University of British Columbia, Mathew was an author/contributor to B.C.’s opioid use disorder treatment guidelines and injectable opioid agonist therapy (iOAT) guidance. He is medical director of complex concurrent disorders at B.C.’s Provincial Health Services Authority.

Instead of verifiable evidence, study-after-study by government-funded PSAD/safe supply researchers purport a range of benefits from the program, but the methods and results fall apart under scientific scrutiny. 

“The evaluators of safe supply often seem to be people who are advocates of safe supply, who have been saying that this works before they’ve even done the studies,” said Mathew.

Participants are selected for success (a scientific no-no); program drop-outs aren’t counted (which embellishes successes); other factors enhancing outcomes aren’t considered or revealed (access to primary health care, simultaneous participation in other therapies); ongoing illicit drug use isn’t monitored (some researchers worried that asking for regular urine tests to determine illicit drug use might upset patients or cause them to exit the program), and there is no control group (no one to compare participant outcomes against), among other shortfalls. 

As well, harms are not quantified (including drug diversion risks) and most studies rely heavily or solely on self-reporting.

This seems obvious, but apparently needs saying, so again from the Stanford-Lancet commission, any drug approval processes should consider “the risk of a drug being misused” and include “pragmatic clinical trials on the risks and benefits of opioids.”

Neither are happening in B.C. or Canada as far as safe supply goes.

Another inconvenient truth: safe supply is being diverted

Lam, Mathew, and others are far from alone in what they’re seeing. More and more frontline physicians are risking their reputations to speak publicly, or approaching journalists off-the-record to say what one team of scientists got lambasted for concluding last year – PSAD/safer supply has no proven benefits.

Also, it’s damaging people.

Medical clinicians say hydromorphone, the main drug in the program, doesn’t satisfy patient cravings, get them high, or ward off withdrawal. So patients are taking their free government-supplied drugs and selling them to buy the illicit fentanyl safe supply is meant to replace.

The original hydromorphone prescriptions, marketed on the street under the guise of being safe, are ending up in the hands of other people, creating dangerous new opioid addictions where previously there were none. One addictions physician reported diverted hydromorphone from B.C.’s safe supply program is circulating in Alberta’s illicit street drug trade.

“Most of the way I’m able to get dope at the moment is by selling my [hydromorphone] pills.” 

21-year-old female safe supply patient

“Many, if not all of my patients … have told me that really, they don’t feel the hydromorphone when they use it. It’s not adequate to meet their opioid requirements. So therefore, they’re not using it,” addictions psychiatrist Dr. Pouya Azar told physicians during a recent professional development seminar on safe supply. 

The problem with opioids is, the more you use, the more you need to use as your tolerance increases, until a higher level of intoxication is required to get high and hold excruciating withdrawal pain at bay.

Azar is a UBC clinical instructor and Vancouver General Hospital specialist in complex care and addictions with expertise in fentanyl and solving complicated treatment challenges. He also has community practice in the Downtown Eastside, Vancouver.

‘John’ (not his real name) is one of his patients.

Next problem: PSAD/safe supply causes new addictions 

Soon after Azar learned his patients were selling their hydromorphone, he observed another distressing pattern that hadn’t existed a year prior – the emergence of new onset hydromorphone use disorder.

And it was showing up in people not usually associated with fentanyl use – suburban teenagers, university students, and young professionals.

“I’ve had patients overdose [from hydromorphone] and I’ve had patients then make the jump to fentanyl, so you have new onset hydromorphone use disorder, leading to new onset fentanyl use disorder,” he said. 

“How frequently this is happening? I don’t know.”

Our government officials should want to know. If they did, they’d investigate. “They don’t want to know,” said one addictions physician.

‘Lily’ is another patient of Azar’s.

Sacrifices are inevitable on the altar of safe supply

B.C.’s top health officer, Henry, said she is not seeing physicians’ “dramatic stories” in public health data. “We can’t make our policy and change things based on individual stories or anecdotes. We need to have the data behind it.”

Unless it’s stories about safe supply, then the entire country’s drug policy can be based on anecdotes, because the PSAD/safe supply program relies on unproven benefits, no matter how earnestly advocates present it as “emerging evidence.”

According to B.C.’s Chief Coroner Lisa Lapointe, all criticisms of PSAD/safe supply and reports of drug diversion are politically motivated or fear tactics.

“Physicians are afraid that if they prescribe and it’s diverted to an opioid naive user, they may become opioid dependent and they may die,” Lapointe told a BCCSU-sponsored conference in the spring. “And I understand that. But that may happen to some people [Lapointe’s emphasis]. But the fact is six people are dying every single day of every single week, of every single month, for the last two-and-a-bit years.”

Which falsely presents PSAD/safer supply as a successful remedy against fatal overdose. And it accepts as inevitable a tenet held by program believers: sacrifices are inevitable on the altar of safe supply; their personal ruin is the price they must pay.

“The urban myth now is that people are picking up their safer supply and selling it to youth and now youth are becoming opioid-dependent and youth are dying as a result of diverted supply,” said Lapointe. “And it’s not true.”

Deja vu, Purdue

For some addictions specialists, the safe supply situation strikes eerily similar to the prescription opioid crisis that began in the 1990s and peaked in 2012 when medical practitioners in Canada and the U.S. wrote a mind-blowing 275 million opioid prescriptions.

Just as the oxycodone crisis spun out-of-control under the noses of prescribers, legislators, and public health officials, some addictions physicians worry the harms of PSAD/safer supply are being ignored while a new wave of dangerous opioid addictions are being bred.

When B.C. Opposition Leader Falcon pointed out the similarities between the government’s public supply of addictive drugs and the Purdue Pharma-propelled opioid addiction catastrophe, Premier Eby dismissed the comparison as “despicable.”

“The key difference in Purdue Pharma is that physicians were encouraged to prescribe, as painkillers, opioids to people who had never used opioids before as it it’s as safe as Tylenol,” whereas PSAD/safer supply is for people already diagnosed with opioid use disorder, Eby responded.

Which ignores the diversion issues and the strangely duplicitous relationship B.C. has struck with the pharmaceutical company it literally just finished suing.

The ink had barely dried on the 2018 law suit launched by the B.C. government against Purdue Pharma Canada alleging deceptive marketing practices causing opioid addictions and overdoses related to oxycodone (OxyContin), when the province introduced its own addictive drug program featuring Purdue Pharma’s even more potent and addictive hydromorphone formula, Dilaudid.

Purdue settled the lawsuit against B.C. last year (after the federal, provincial and territorial governments joined the case) for $150 million, while having made an unknown amount selling Dilaudid and other drugs to our governments in the meantime.

Safe supply is a failed experiment, move on

“[PSAD/safe supply] is an ongoing experiment which really has not delivered the outcomes that were hoped for,” Toronto addictions physician, Lam, told CBC TV in May.

“At what point do we say that this … is not an experiment that should continue any further?”

Vincent Lam

Lam said Canada needs a national standard of care that includes OAT medication treatment with methadone and buprenorphine and slow-release oral morphine, along with counseling, residential treatment, access to education, income support, and housing.

“All of these ingredients are tremendously important if people are going to live the kinds of lives they want to live,” he said.

Time to face facts

Our government officials need to wake up from their PSAD/safer supply fever dream and face facts.

It’s. Not. Working.

While the B.C. and federal governments wax heartfelt about a multi-pillared drug strategy, they have instead erected a one-legged monument to safe supply and the 40,000 Canadians and 13,000 British Columbians who have died of drug overdose since 2016 needed more. Everyone struggling to live another day with their addictions, needs more.

Even if B.C.’s much ballyhooed $1 billion investment in treatment and addiction services gets done, it’s not enough. A significant portion will shore up existing harm reduction services, with only 195 new treatment and recovery beds anticipated over the next three years.

B.C. needs to stop talking about this really great system of care they’re going to build one day and follow the Canadian leader in this area: the Alberta government.

Alberta is constructing a province-wide “recovery-oriented” mental health and addictions system of care. And they’re going big, complete with therapeutic living units in jails (recommended to the B.C. government, but as yet undone) and addiction recovery communities throughout the province, which are best practices and a staple of Portugal’s drug strategy. And like Portugal, the recognized world leader in public drug addictions care, Alberta doesn’t have safe supply.

If logic doesn’t resonate, maybe fear will.

Because one day soon the wrong person’s daughter or brother will die because of safe supply. And that surviving loved one will have the tenacity and means to correct that harrowing injustice on behalf of all those lost souls who could not.

Then the so-called safe supply program will really hit the fan.

And the B.C. and federal governments will be faced with a problem they can’t ignore or pretend away, when their faith is tested in a court of law.

Note: Thank you to the psychologists, medical doctors, psychiatrists and other addictions specialists who contributed on and off-the-record to this column.