‘Mythconceptions’ of safer supply and legalization of hard drugs

Written By Keith Norbury

Shortly after announcing her pending retirement as B.C.’s Chief Coroner, Lisa Lapointe slammed the provincial government for not heeding her recent recommendation to expand the controversial safer supply program to a non-medical model. She even wondered if anyone in government had read her November report.

The BC Coroner’s death review panel report recommends safer supply of hard drugs like fentanyl, cocaine and meth be available without prescription — including licensing non-medical agencies to distribute drugs — in an effort to reduce B.C.’s escalating drug deaths. 

Exactly who these “agencies” would be, her report doesn’t state. But Provincial Health Officer Dr. Bonnie Henry released a safer supply review last month that recommended overdose prevention and safe consumption sites as possible venues for non-prescribed addictive drugs. Like Lapointe, Henry’s review also recommended dramatic expansion of the program across B.C.

Both Lapointe and Henry have publicly supported the ultimate goal of full-on legalization of all drugs and a state-sanctioned version of cannabis compassion clubs as a possible delivery model. 

BC Chief Coroner Lisa Lapointe on Nov. 1, 2023, recommends an expansion of safer supply to allow access to pharmaceutical opioids and stimulants without a prescription. [Image BC Government]

Originally introduced in March 2020 as a pandemic measure to give people diagnosed with substance use disorder access to opioids and stimulants when opioid agonist therapy (OAT) didn’t work, safer supply evolved to include everyone with a diagnosis regardless of whether they’d tried OAT. Recently, both the chief coroner and the province’s top health officer went further, worrying that recreational users without a diagnosis are also at risk from the unregulated street drugs and should have access to safer supply.

The coroner’s report even notes that the unregulated drug supply “is a particularly significant concern for people who have never previously used opioids.” Anyone reading that might wonder when safer supply will expand to be available for anyone who wants to use hard drugs. Then again, that would be legalization.

It’s likely that members of the provincial cabinet did read Lapointe’s report and realized that “safer supply” had jumped the shark, given the swift pushback her recommendation met from both the premier and his addictions minister.

“Non-prescription models for the delivery of pharmaceutical alternatives are not under consideration,” Jennifer Whiteside told reporters minutes after Lapointe announced her recommendation for non-medical safer supply. In response to Henry’s review, Whiteside steered away from allowing access to pharmaceutical-grade opioids and stimulants without medical oversight, but agreed with expanding prescribed safer supply, touting it as “a part of a substance use continuum of care.”  

Safer supply tunnel vision

While Lapointe’s report calls the crisis “complex” with “no simple solutions,” she and other drug-user advocates have seized upon safer supply as just such a simplistic solution. They have tunnel vision about safer supply.

The aim of safer supply is to stop the use of street drugs and to save lives. It has the support of groups like Moms Stop the Harm, who believe that if only their children had access to “safe” versions of the drugs they’d be alive today. As a consequence, any questioning, concerns or skepticism about safer supply is treated as tantamount to not caring that people die.

That’s not the case. Skeptics of widespread safer supply and/or the legalization of hard drugs are concerned the program is not achieving its objectives and that unintended consequences of expanding those measures will result in potentially even more deaths than the present toll. That’s because neither approach has been tested anywhere else in the world, let alone been successful or rolled out on the scale Lapointe and Henry are now proposing.

On Feb. 1, BC Provincial Health Officer Dr. Bonnie Henry released a safer supply review that recommends expanding the program to include access to medical-grade stimulants and opioids without a prescription. [Photo BC Government]

Ideally, the government would pause safer supply until credible medical studies could demonstrate the program’s efficacy or not. And since it is theoretically possible for social scientists to model a range of drug policy options, including legalization and safer opioid supply, to explore potential outcomes, perhaps the provincial government can commission such models. It might also pay careful attention to the unexpected consequences that worry critics, and advocates of safer supply seem to be willfully ignoring or dismissing.

Meanwhile, in their support of safer supply and legalization, Lapointe, Henry, and other advocates seem to have accepted uncritically a range of significant “mythconceptions.”

Myth #1: Contamination is the main cause of deaths

Mythconception #1: Drug users are dying mainly because the illegal supply is contaminated. That presumes that drug users are, for example, ingesting fentanyl when they mean to take heroin. The premier himself has voiced this concern.

“That is 10-year-old information if you’re thinking that fentanyl is an adulterant in the drug supply,” Fred Cameron of the drug-user advocacy group SOLID, said in 2022. “That’s the drug of choice out on the street.”

The toxic drug explanation further falters in cases where users are knowingly ingesting multiple substances simultaneously. A recent New York Times piece cited studies showing that 70 to 80 per cent of people addicted to opioids are purposely taking several substances, such as meth. 

2018-2019 survey in B.C. found that nearly half of opioid users also simultaneously take another drug, usually meth. That report also noted that “the frequency of reported opioid and stimulant overdose in the past six months was higher among those that used crystal meth.” As well, in the last couple years, people are deliberately taking benzodiazepines along with fentanyl. Toxicology from 2023, found benzos in 40 per cent of B.C. drug overdose deaths and fentanyl in 85 per cent.

Simon Fraser University addictions expert Julian Somers has long characterized the drug death crisis in B.C. as a poly-drug crisis, not a toxic drug crisis.

In February 2022, the Stanford-Lancet Commission expressed similar skepticism about safer supply in its report on the opioid crisis.

So, it’s not at all clear how legalizing hard drugs such as fentanyl, meth, and cocaine is going to prevent drug users from mixing those substances with predictably tragic results.

Myth #2: Drugs aren’t bad

Mythconception #2: Hard drugs, such as opiates, aren’t so bad.

While Henry and Lapointe have conceded that hard drugs themselves can do harm, not all drug-user advocates are so constrained. Retired SFU professor Bruce Alexander, whose Rat Park experiments have influenced modern thinking about addiction, actually has called heroin a safe drug. Kurt Lock, a research coordinator with Vancouver’s Crosstown Clinic, reportedly said at least twice that heroin isn’t bad for you.

Other medical sources disagree. It’s also easy to find research that links opiate use with cancer.

Injecting and smoking opioids and stimulants can cause a host of health issues. [Photo Samoa Police]

That’s not to say that legal drugs — alcohol, tobacco, and cannabis — are good for you, either.

Myth #3: Alcohol poisoning deaths are common

But it’s mythconception #3 to argue, as safer supply advocates have, that people often overdose and die on alcohol.

Figures from the early 2000s, which were posted on UVic’s website, showed about 20 alcohol poisoning deaths per year in B.C. That’s a fraction of the 2,000 or more annual deaths from hard-drug overdoses (or toxic drugs deaths, as drug-use advocates call them). And many more people drink booze than partake of hard drugs.

When comparing substances, two rules need to be kept in mind: what are the similarities and what are the differences?

Tobacco and alcohol typically take a long time — up to many decades — to kill a user. One would be hard-pressed to find a case of anyone actually overdosing on tobacco.

Myth #4: Drugs are like liquor

Related to that is mythconception #4: The toxic nature of the hard drug supply mirrors the tainted liquor that killed people during Prohibition.

In the U.S., roughly about 1,000 people died per year at time when the country’s population was around 100 million. Compare that to the recent annual death toll from hard drugs in the U.S., which is about 75,000 people, or around 20,000 cases per 100 million. Also the U.S. government itself deliberately poisoned alcohol to discourage drinking!

Myth #5: Prohibition failed

That leads to mythconception #5: Prohibition was a failure.

German Lopez, now with the New York Times, revisited that received wisdom in a 2019 Vox article. His conclusion was that the deaths attributed to alcohol — including domestic violence, car crashes and other accidents; and the carnage inflicted by gangsters — actually decreased during Prohibition.

Alcohol consumption dropped way down during prohibition. Bootlegged alcohol is poured out under watchful eyes in Canada, circa 1920. [Photo Société des alcools du Québec]

Prohibition was doomed because it was extremely unpopular. Then, as now, about half of North American adults like to have a drink now and then. That was enough political pressure to convince politicians to repeal prohibition.

Something similar played out with cannabis, although it was a longer struggle. Pot is popular enough that Canada finally legalized it for recreational purposes in 2018.

Whereas a large proportion of Canadians now support legalization of booze and pot, recent polls indicate that less than 10 per cent favour legalization of hard drugs. They might see merit in decriminalization; they’re willing to endorse supervised consumption sites; they’re also supportive of prescribed safer supply. But they’re leery about legalization.

Myth #6: Legalization won’t increase use

Mythconception #6: Legalization of hard drugs won’t cause an uptick in their use.

The Canadian government compiled statistics on cannabis use in the early days of legalization. Most notably, the proportion of Canadians 15 and older who used cannabis increased by nearly two per cent from 2018 to 2019, after cannabis was legalized. (That was about 600,000 more cannabis users.) That isn’t to say that legalizing heroin will have a similar effect. But policy makers might want to investigate that prospect before venturing down that path.

Prevention is supposed to be one of the vaunted four pillars for addressing substance use disorder. The others are treatment, enforcement, and harm reduction. 

An element of prevention is education. If your slogan is “safer,” that’s sending a message to the public that it’s perfectly fine to do the drugs.

It would be as if the tobacco industry promoted a safer cigarette. Oh wait, that did happen. Remember that movie, The Insider, about the tobacco industry whistleblower, played by Russell Crowe? Jeffrey Wigand, the man Crowe portrayed, was working on research to develop a safer cigarette.

More recently, vaping has emerged as a safer alternative to cigarettes. As a smoking-cessation therapy, vaping delivers nicotine without all the nastiness of tobacco smoke. Were vaping made available only by prescription to help smokers quit, it would have done a great deal of good.

Unfortunately, vaping became commercialized and fell into the clutches of marketers who made it appealing to non-smokers. Medical opinions are mixed on whether that is also leading to a resurgence of cigarette smoking. Nicotine itself isn’t harmless, though, particularly for young brains.

It’s also passing strange that tactics successfully employed to curb smoking and its harms are now considered off-limits in the fight against the harms of hard drugs.

Myth #7: Destigmatizing drug use is a good idea

So, mythconception #7 is that stigmatizing drug use is a bad thing and won’t work.

One aim of decriminalization is to avoid stigmatizing drug users. Somehow it’s also come to mean destigmatizing drug use itself.

Our society has had pretty good success stigmatizing tobacco smoking. Smoking in restaurants and bars was banned a few decades ago — something that was controversial at the time. It has since been extended to most public places, indoors and outdoors, to the point where smokers have become pariahs.

Bottom line, stigmatizing behaviours – not people – works.

One other thing that can be said of nicotine addicts, though, is that they’re high-functioning. They won’t nod off at work or behind the wheel of a car due to smoking.

Myth #8: Severe addiction doesn’t impair function

Mythconception #8, though, is of the high-functioning opiate addict, meth addict, or alcoholic. 

Substance use disorder is “uncontrolled substance use despite harmful consequences.” It damages relationships with friends and family; it impairs the ability to dance and sing, to play sports, to do anything requiring sustained concentration.

It’s particularly problematic in the workplace. Ideally, you don’t want to fire someone for an addiction. But you also don’t want your pilot, surgeon or school bus driver (or the mechanic servicing its brakes), to be high or pass out on the job.

Myth #9: Trade workers most disproportionately affected

Mythconception #9 is that people who work in the trades are most susceptible to opioid deaths. 

The BC Building Trades website still has a post that claims half of all opioid deaths in the province are among workers in the construction trades. But that is based upon a faulty interpretation of a coroner’s estimate, which itself was based upon a flawed analysis.

That mythconception, though, still drives a narrative that anybody can die from the illicit toxic drug supply and therefore the province must make safer versions of those drugs available to anybody, anywhere on demand. And the only sure way to do that is to legalize those drugs and make them as accessible as candy in a drug store, as Bruce Alexander proposes.

B.C. has done such a poor job on the prevention side when it comes to opiates that so far this millennium the proportion of opioid users in the province has doubled from about one per cent in 2000 to two per cent two decades later. In 2000, Portugal also had about one per cent of its population taking opioids. But it enacted sweeping reforms that reduced that proportion to about 0.3 per cent.

Had B.C. similarly reduced its proportion of opioid users, the province would have about one-sixth as many users today as in 2000. And, since you can’t die from opioid use if you don’t use opioids, the death toll would also be a sixth of what it is today. Instead of six or seven deaths a day, B.C. would have about one a day. That’s still tragic but in such a scenario would the call for safer supply be nearly as loud or taken as seriously?

The most radical — and consequently the most publicized — feature of Portugal’s drug strategy was its decriminalization of hard drugs, but it is a singular aspect of a multi-pronged program that includes prevention, treatment, social reintegration, harm reduction and dissuasion.

Myth #10: Decriminalization alone will reduce overdoses deaths

Mythconception #10: Decriminalization on its own will work similar wonders here. 

B.C. ignored that Portugal also put in place supports such as housing and addictions treatment, to help drug users turn their lives around. Another key part of the program is its administrative tribunals that act as an inducement. Drug users who run afoul of the law are given a choice: submit to treatment or feel the full effects of the law the next time you encounter legal trouble.

Drug user advocates consider that sort of carrot-and-stick approach to be too coercive.

It should be noted that Portugal has even had setbacks with its program in recent years. The lesson from that is that addiction is a really wicked problem; even if something has been working, it can stop working, especially if complacency sets in.

Other significant mythconceptions include: opioid addiction is just a disease like diabetes; someone cannot quit drugs until they have an epiphany, even if it takes decades; the only people an addict will heed are other addicts or reformed addicts; hard drug users are the best judges of their drug use; since morphine and fentanyl are used therapeutically, they’re OK for recreational use; safer supply hasn’t worked because it needs to be applied far more broadly; safer supply diversion isn’t a problem; legalizing drugs will cause the cartels and the dark web to close their operations.

Until drug researchers can devise and test convincing models that address those and other mythconceptions, and clinicians can show that vastly widening safer supply, or legalizing hard drugs, won’t inadvertently lead to more hard-drug addiction and deaths, the B.C. government would be wise to tread cautiously.