How should we handle the toxic drug-supply crisis? Experts weigh in.

When we debate things like safe supply, I think we stop having the conversation about what is actually the problem, which is that people never overdosed like this until we had a toxic drug supply. A policy change that we need to embrace is looking at legalization and regulation. This is what safe supply is ultimately doing.

The other thing that is really important in all of this is that for a lot of people who struggle around substance use, loss can be one of the bigger factors that drives them to use in particular ways. We are in a situation where we have whole families of people who have died, friends, and trying to live with that much grief and loss is a contributing factor for why people use in particular ways.

For me, harm reduction is a pragmatic approach. It’s not a left or right thing, but it’s being used as a political wedge. It’s very difficult to implement policies when there is a very hard drug-war narrative in the background and this idea that people just need to stop using drugs. Even in the face of this incredibly toxic supply, people are still using drugs. This speaks to how we need to move away from this kind of rhetoric and way of thinking because it’s not working. If we’re going to change the course of the crisis, then we need to implement policies that won’t kill people and stop spending money in ways that fund the drug war.

It comes down to what SAMHSA (Substance Abuse and Mental Health Services Administration, a branch of the U.S. Department of Health and Human Services) published and the CCSA (Canadian Centre on Substance Use and Addiction) had endorsed and recognized, and that’s a recovery-oriented system of care.

Basically, that means revamping our entire governmental approach to addiction from a top-down legislative process in which we accept that addiction is going to be a part of the criminal justice system, the education system, the community system and the health system. This would mean ensuring the minister in charge of Addiction and Mental Health actually has the ability to make changes at systemic levels. For example, providing treatment in jails; enhancing access to treatment across the country; providing supportive treatments inside of hospitals; making sure that we’re providing education in our education systems focusing on prevention; working with law enforcement to use them as part of the process of intervention; and access to treatment. We need to not just reactively deal with addiction and the overdose crisis, but proactively look at ways to prevent and improve access to care.

We should be trying to take a health approach and understand that addiction is a spectrum.

Right now, we have both harm-reduction services and recovery services that don’t have any medical staff working there. If we want to continue to break the stigma, that includes understanding addiction as a health disorder, it also means that you need health-care providers that are available for treatment and support.

Rather than trying to take a recovery approach or harm-reduction approach, we should be trying to take a health approach and understand that addiction is a spectrum. People who are suffering from addiction may be at one end of the spectrum, or they may just be people who use drugs at a completely opposite end of the spectrum. We really need to try to take an epidemiological and etiological approach from a health viewpoint, while shifting all levels of government to support them.

[Alberta’s] government is on the right track by developing the Compassionate Intervention Act. I just think it needs to be polished because many people call it forced treatment. Which it is not. It is actually the option for treatment.

I do get the harm-reduction approach, but that approach is just going to prolong the agony. I am obviously a recovery advocate. I am in recovery. I was homeless for seven years and addicted for 20 years to pharmaceuticals, alcohol and cocaine. My whole recovery journey has led me to this position as executive director of Oxford House. I definitely think recovery is the answer. How do we get people there is the big question, right?

I am not saying anything against the people [struggling with addiction] because I was one of those people. It is the addiction and the disconnect with self-love, self-esteem and self-care. I am a firm believer that all goes back to childhood trauma.

Abstinence is what is going to help save people’s lives.

There are gaps in the continuum of care. In Alberta, we are slowly filling them. We are the first licensed and government-supported pre-treatment housing organization in the country.

I think there needs to be an intervention for people to have medical detox for two weeks. Then once there is some clarity, offer them the opportunity to go into one of the recovery communities Alberta is developing for one year for free. Give them the option to get help. A lot will say no, but some will say yes. That is where I think the start has to happen.

I developed pre-treatment housing because you always hear about the waitlists for residential treatment. Now we have a licensed program with support in-house to bridge that gap between detox and treatment. We need these homes across the province and country. Medical detox should be mandated for people who cannot make that decision themselves. The bottom line is that abstinence is what is going to help save people’s lives.

To stop the mass deaths, we need mass low-barrier access to pharmaceutical versions of the drugs that are killing us. Anyone at risk needs access – that means people with habits but also weekend warriors.

Anyone at risk needs access – that means people with habits but also weekend warriors.

The provincial government needs to get on with that. The backlash against harm reduction, the moral panic about safe supply, and debates about mandatory treatment are all heading in the wrong direction – the graveyard. Time is running out because substances like benzos and xylazine are creeping into the street drug supply and making things more dangerous.

We are dying from an unregulated drug supply, created by prohibition. That shit needs to be replaced by a regulated drug supply.

The priority for the federal government, with urging from provincial governments, should be to regulate currently illegal substances.

Many years ago, a choice was made to go with a prohibition model and that wasn’t based on evidence at the time. In fact, a lot of it was based on racial stigma and discrimination. We now know that prohibition is not an effective approach to drug safety. That would be my No. 1 priority, but that’s going to be a longer-term project to shift our regulatory framework.

But what are the interim measures we have to take? At the provincial level, safer supply hasn’t really been scaled up. It’s not that easy to get a prescription but the public has this idea that hydromorphone is readily available, which isn’t the case across the provinces. Many programs have waitlists; there aren’t many safe-supply prescribers across the province; and we need additional medications that are aligned with what’s in the illicit market.

Municipalities also need to support those interventions. They mainly just need to not interfere by creating by-laws that are counterproductive to provincial initiatives, like decriminalization.

I also think there’s a really important role for treatment. We would never suggest for any other health-related issue that we would only supply one kind of medication. We don’t have to pit treatment and harm reduction against each other as if it’s only one or the other. With any health concern, there’s a range of interventions and some are better suited to some people over others.

Over the last 40 years, billions of dollars have gone into the war on drugs, and primarily enforcement-based strategies to keep illicit drugs out of the hands of our community members. But in fact, what we’ve seen is that drugs have become cheaper, more potent and more accessible. In terms of reducing the access to the illicit market, the so-called war on drugs has been an utter failure by any measure.

We have to think about the context of substance use in our society. Humans since time immemorial have used psychoactive substances for cultural and other purposes. Not all substance use is bad. There is a spectrum of substance use from beneficial use, like prescription-related use, recreational use of little or no harm, more risky use (e.g., driving under the influence of alcohol) and harmful use where substance use disorders develop.

In my local health authority, only 39 per cent of people that have died had an opioid-use disorder. That means the vast majority, 61 per cent, either had another type of substance-use disorder or they weren’t daily users. We also know that almost three quarters of people had contact with the health-care system three months or less before their death. What this tells me is that by solely focusing on those with opioid addiction, we’re missing 60 per cent plus of other folks by not offering adequate services. On top of that, when people do come into the health-care system, we’re not asking the right questions or offering support. People are still dying.

Overall, we don’t have a functioning substance-use system of care in Canada. We really need to build a full continuum of substance-use services that are really accessible for folks. It’s everything from harm reduction to treatment and recovery services, and everything in between.

We’re missing 60 per cent plus of folks by not offering adequate services.

A full continuum of care means primary prevention and health promotion interventions like school-based interventions; harm reduction services that recognize that individuals will use drugs and need support in making safer and healthier choices, as well as recovery-oriented programs and services. On the acute care end, that means withdrawal management, detox beds and stabilization. It is a false dichotomy to assume it’s either harm reduction or recovery, it’s both and more. It’s about building a comprehensive, evidence-based system of care. We also need to invest resources equivalent to the scope of the issue – this is the greatest public health emergency of our lifetimes.

Fundamentally, we need to take a public-health approach. What does an effective response look like? It is based on the expertise of people who use drugs and the best available data. Unfortunately, some provinces are withholding relevant information. Death data are being released only sporadically or not at all, and detailed information about who is most impacted, and where most of these deaths are occurring is rarely available. This makes it very difficult to target emergency response efforts and undermines public awareness of the magnitude of this crisis.

All provinces should be expanding access to interventions proven to save lives. This means implementing many more supervised consumption services (that include inhalation); and ensuring anyone seeking treatment has the full range of effective medication options, including injectable hydromorphone and diacetylmorphine, available to them. Naloxone should be widely available everywhere, with the nasal formulation covered by provincial drug plans for those who want it. A national policy of decriminalization would reduce the substantial harms of criminalization and encourage people to talk with others about their drug use and seek help when needed.

We should also accept that the unprecedented nature of this crisis means that strategies that have worked well in the past are unlikely to be enough now. We must be willing to try new approaches. Safer-supply programs are one example of a promising innovation.

Finally, it’s important to acknowledge that drug toxicity deaths are not equitably distributed. We know that in Alberta, for example, First Nations people are seven times more likely to die from drug toxicity than non-First Nations people (due to ongoing impact of colonization, racism and discrimination). Yet, we do not see commensurate funding for comprehensive overdose responses in these communities. This has to change. We also need meaningful investments in income support and permanent supportive housing to respond to increasing precarity in the wake of COVID-19, which is contributing to toxic drug morbidity and mortality in cities across Canada.

The toxic drug crisis is an alarming symptom of the many deeper issues we face in society today. Growing from shame, guilt, unworthiness, homelessness, trauma, loss of family, mental health, social inequities, stigma, racism, sexism, all wrapped into what we coin the neuro-bio- psychosocial package. And, like a weed, we are only too quick to want to dispose of and dehumanize addiction rather than understand, empathize and nourish the ground below which fosters the environment of health.

This toxic drug crisis is a plea for all of us to put aside our personal beliefs, politics and philosophies and reach to new challenges where we can look at the evidence and the significant health issues like other chronic illnesses.

While it is undeniably appealing to search for that one solution, addiction is such a complex, multi-layered, and all-around heavy-burdened illness that we must look beyond our own urge to touch the surface and rather sit in the mud and dig a little deeper. A pan-care continuum approach that not only throws out the life ring but advises on the state of the waters, provides life preservers, educates on the dangers of boating or swimming alone, offers courses on water safety and puts us all in the boat together is critical … and is it really such foreign of a concept?

While imminent drastic efforts and resources are imperative to save the lives of so many impacted by the toxic drug supply, we need to simultaneously invest in upstream energies. When we look to the research and efforts employed on the international scale, successes have been seen where multi-faced approaches were endorsed and supported by all sectors.