Eris Nyx has been on British Columbia’s safe supply since the B.C. Centre on Substance Use (BCCSU) rolled out guidelines for prescribers in the spring of 2020.
The guidelines that have become informally known as the first iteration of B.C.’s “safe supply” were – at least in name – what many drug policy reform advocates like Nyx had been demanding for decades. But the availability of prescription alternatives to illicit street drugs has been riddled with issues that Nyx says signal how out of touch policies are with the reality faced by people who use drugs. “I’m on the safe supply (program), I still use illicit street drugs,” Nyx says. “It’s not really safe supply.”
Those wishing to access safe supply in B.C. – defined as “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market” – over this past year have been met with a number of obstacles: no existing connections within the medical system; doctors refusing to prescribe safe supply; or access limited to alternatives that fail to meet their needs.
Nyx is an organizer with the Drug User Liberation Front, a group that independently purchased and gave away tested and clearly labelled meth, cocaine, and heroin at two events over the last year. The group did so in part to demonstrate what Nyx says a safe drug supply initiative should look like.
“If you’re someone who is smoking crystal meth every day, you can’t smoke extended-release Dexedrine. Dilaudid is not the same thing as heroin, certainly not the same thing as fentanyl,” says Nyx. “The reason it’s ineffective isn’t because safe supply as a concept doesn’t work; it’s because you’re not giving people what they want, so of course they’re going to divert their drug use.”
Between January 2016 and December 2020, 21,174 people in Canada died from opioid toxicity, with 5,148 toxic drug supply deaths occurring during the beginning months of the pandemic, an 89 per cent increase from the same time last year. B.C., Alberta and Ontario are the provinces with the highest total numbers of toxic drug-related deaths.
To deal with the scourge, B.C. announced on July 15 that it would expand its safe supply initiative. It will focus on expanding the availability of opioids for the first phase, which proposes $22.6 million over the next three years to expand existing health authority programs, fund new service hubs and outreach teams and supplement federally funded programs. The expansion will still operate under existing federal restrictions set out by the Controlled Drugs and Substances Act and still requires a prescription to access.
According to B.C.’s minister of health and addictions, Sheila Malcolmson, fentanyl has been included to adapt to the potency of the illicit drug market. “Once fully implemented, more people who use illicit drugs can be prescribed a broader range of safer alternatives,” Malcolmson said.
The cost of prescriptions will be covered by B.C.’s PharmaCare system. Certain programs and clinicians can now also prescribe fentanyl in the form of patches as well as in tablet form.
The province says it is still looking into options to provide diacetylmorphine, or prescription heroin. Diacetylmorphine has had success in a number of studies in Europe and Canada, but when asked why the drug wouldn’t be included in the expansion, the province pointed to a lack of available supply within the country.
For now, the expansion does not include any new options for the safer supply of stimulants, but the province says it will look into doing so in the future. B.C. coroner reports show that in 2020, cocaine was present in 49 per cent of toxic drug-related deaths and methamphetamines in 39 per cent of drug-related deaths, a 208 per cent increase from 2012.
B.C. is the first province in Canada to invest in a safe supply program of this scale, but critics warn that many of the existing barriers will persist despite the recent announcement.
A look back on B.C.’s safe supply
On March 26, 2020, the British Columbia Centre on Substance Use (BCCSU) released new interim clinical guidance for health-care providers to support people who use drugs in response to the COVID-19 pandemic isolation protocols, also known as the risk-mitigation guidelines.
“The whole early outlook on safe supply was this weird linkage to COVID-19 and for prescribing practices to be framed under the context of withdrawal management and keeping people from getting dope sick,” says registered nurse Corey Ranger. Ranger is also the coordinator with Victoria’s SAFER Initiative, a federally funded safer supply project operated by AVI Health and Community Services.
SAFER launched in July of 2020 and is based on a flexible harm-reduction model with practices shaped by feedback provided by people in the community who use drugs. The program is unique in that it offers Oxycodone, a smokable prescription alternative to street opioids not included in the BCCSU’s risk-mitigation guidelines, even though it is widely regarded as a safer supply alternative. “The people who are dying the most by overdose right now in Canada are smoking those drugs and we’re only creating options that can be injected in some way, shape or form that may be generating further harm,” Ranger explains.
The risk-mitigation guidelines were not meant to provide a safe supply of drugs for regular use but to help those who use drugs avoid withdrawal while social distancing, not as a true-to-name safe drug supply.
Ranger says that a program designed only to prevent withdrawal isn’t really a safe supply program. People who use drugs do so for a number of reasons, not only to avoid the effects of withdrawal. A recent report released by SAFER Victoria surveyed people with lived experience with drug use and asked what would make safe supply work effectively. The report highlights six key responses, with one emphasizing appropriate dosing that helps them function and maintain a quality of life as defined by the service user – not based on withdrawal management.
Ranger says another key access issue has to do with the medical, prescriber-based model that the province’s wider “safe supply” system operates under.
Many people who use drugs may not have existing connections within the medical system – something that is not uncommon in a province where an estimated 18.2 per cent of residents do not have a family doctor. Those who do have contact within the health system may be met with clinicians who are unwilling to prescribe safe supply.
Despite recent changes, the safe supply expansion will still rely on prescribers to act as gatekeepers. Ranger says this means that many of the existing obstacles to safe supply will remain. “The majority of [safe supply is] still being delivered through the lens of addiction medicine,” he says. “To be perfectly frank, those institutions are rife with paternalism, control, and surveillance of people and lots of hoops for folks to jump through. That makes the program either super inaccessible or have very low capacity to take people on.”
“B.C. announced that it would expand its safe supply initiative, but critics warn that many existing barriers will persist.”
According to B.C.’s provincial health minister, Bonnie Henry, approximately 6,000 people have accessed some form of safe supply over the past year. But there are upwards of 75,000 people in the province who have been diagnosed with an opioid-use disorder. This number doesn’t include those who may use illicit substances recreationally or those who primarily use stimulants.
Hesitancy to prescribe safe supply to patients is in part fuelled by drug use stigma. “There’s a general systemic belief that people who use drugs aren’t deserving. We know those are stereotypes and are not accurate reflections … but those act as barriers,” says researcher, registered nurse and University of Victoria professor Bernie Pauly. “That stigma exists in the health-care system even though we have very clear professional [anti-discrimination] guidelines.”
Reports of inconsistent access across the province have been widespread.
“A lot of prescribing is happening in major centres; it’s not happening in other centres. Systemically, there’s a lot of stigma around drug use,” says Pauly. “We see this with all kinds of services, especially in more rural areas of B.C.”
In an effort to remedy access issues, in September 2020, Henry authorized a public health order giving nurses the ability to prescribe safe supply. The order aimed to remove barriers to access created by a shortage of physicians as well as prescriber reluctance, especially in areas outside of major cities.
But nurses were only allowed to prescribe opioid agonist therapies (or OAT’s), such as suboxone, not “safe supply” itself or prescription alternatives to illicit street drugs.
“When we first started hearing the prescribing was going to be limited to one type of opioid agonist therapy and not inclusive of all pharmaceuticals, it became very apparent that this wasn’t going to be the panacea for safe supply,” says Ranger.
The expansion also didn’t address the bottleneck that was forming in the province, according to Ranger. “Ultimately, nurses, whether they can prescribe or not, aren’t going to be the ones that are going to resolve the overdose crisis. All that’s going to do is create more opportunities for individual prescriber gatekeeping within the institution that is nursing,” Ranger says. “And (nursing’s) regulatory colleges are probably more restrictive than that of the physicians, and we’re already struggling with physicians feeling unable or unsupported to prescribe safe supply.”
“We need regulation, we need public health approaches”
Without the explicit endorsement of safe supply prescribing from the B.C. College of Physicians and Surgeons, doctors will continue to be hesitant to prescribe these drugs – not only due to stigma but also out of fear of professional repercussions, says UBC professor and former executive director of the BC Centre for Disease Control Mark Tyndall. “There still hasn’t been an endorsement from the College of Physicians, so physicians still feel like they’re taking a risk by writing these prescriptions.”
Tyndall is also the creator of the MySafe project, a series of dispensing machines that distribute a safe drug supply to those who have a prescription. The project launched in 2017 and now has several sites across the country aiming to address issues related to access. Currently the project only has about 20 people registered in its system in Vancouver.
“I expect someday I’m going to get a letter from the college saying that my Dilaudid prescribing is out of keeping with standards … that’s what other doctors have had done to them, so I suspect I’m on the watch list,” says Tyndall.
Projects like MySafe could be one alternative for those who are currently required to have regular interactions with pharmacists. Someone with a prescription for safer prescribed alternatives or certain OATs may find themselves going to a pharmacy or clinic as many as three times a day for supervised dosing.
For now, one of the core concerns remains the same – it’s still operating within a prescriber-based model. “These drugs are treated extremely strictly so the College of Pharmacy and the College of Physicians really look very seriously at prescribing practices,” says Tyndall.
To adequately respond to the overdose crisis, Tyndall says we have to start treating it like the public health crisis that it is.
“People are buying really deadly drugs on the street and they need an alternative, and that can’t be done through doctor’s prescriptions,” says Tyndall. “If there was poisoning from any other thing we’d quickly go in and take those that poison off the market and if people were needing it, then we give them an alternative.”
The inclusion of options like fentanyl is a positive one, but ultimately the recent changes aren’t reflective of the urgency of the toxic drug supply crisis – something Henry acknowledged at the press conference. “It’s taken obviously far too long for us to pull this together, but the last 18 months has been a really challenging time for all of us and no more so than for people who use drugs; it’s an important piece in our tool box that’s going to help get us through this next phase,” said Henry.
Ranger adds that flexible models like Victoria’s SAFER Initiative are going to continue to be useful for providing clinical guidance and empowering other programs to engage in more patient-centered prescribing practices, but that there are limits to what these programs will accomplish.
“It’s always too little too late … We are at the worst iteration of the overdose crisis today. The medicalized model is one option, and it’s an option that needs to be there – but we need more accessible options that don’t involve medical gatekeeping. We need regulation, we need public health approaches,” says Ranger. “As long as we’re continuing to criminalize people who use some drugs versus people who use other drugs … we’re never going to see a truly accessible safe supply, nor will we see the end of stigma or the overdose crisis.”
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