How safe supply of drugs is saving lives and destigmatizing substance use
Judy Darcy, B.C.’s minister of mental health and addictions, announced last March that physicians could prescribe pharmaceutical alternatives to street drugs for people who use substances. In September, Dr. Bonnie Henry, B.C.’s provincial health officer, passed an order allowing registered nurses and registered psychiatric nurses to prescribe controlled substances in an attempt to increase access to a safer supply after a record-breaking number of drug toxicity deaths over the summer. One factor that contributed to this surge of deaths is an extremely toxic and illegally produced drug supply with high fentanyl concentrations in all illicit substances. This is in part due to border closures shutting off supply chains.
A safe supply could help lower the number of deaths connected with a poisoned drug supply and curtail this public health emergency that has been raging since 2016. Readers may be cautious to hear phrases such as “prescription heroin,” which is why it’s important for all to know about the life-saving benefits of this supply and ways in which we’re still falling short.
What is safe supply?
Safe supply is defined by the Canadian Association of People who Use Drugs (CAPUD) as “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.”
Safe supply falls under the harm reduction umbrella, as it reduces the harms and risks associated with illicit drug use. It’s a way for people to access their drug of choice without having to worry about what else it may be laced with. The current distribution model for safe supply includes access to both opioids and stimulants, among others.
These prescription alternatives to street drugs should not be mistaken for the prescription of substitution treatments, like methadone or Suboxone, which are given to those wishing to taper off their substance use. Although these drugs must also be prescribed by a clinician, they do not contain the same mind-altering properties of recreational drugs that people who use substances desire. The alternatives approved last year in March are for people who are not yet able or willing to stop their drug use for a variety of reasons, and the substitution treatments are for those who want to stop using illicit substances but need to slowly wean their body off.
What’s good about a safe supply?
Fewer overdoses:
The main objective and benefit of a safe supply is to save lives.
“We often hear this crisis referred to as an overdose crisis, but really, we are in a drug poisoning crisis,” stated the Safe Supply Statement approved by Vancouver City Council.
Street drugs can be poisoned with fentanyl, carfentanil, and benzodiazepines, among other contaminants. Drug-checking sites in Vancouver revealed that most of the drugs sold on the street were not what the buyer thought they were and most contained unexpected substances like fentanyl and benzodiazepines. An analysis done by the Canadian Centre on Substance Use and Addiction found that 36 per cent of people who tested positive for fentanyl in urine screenings did not know that they had consumed the drug. Fentanyl was found in 91 per cent of all opiates and in 10 per cent of all stimulants sold on the street in B.C., higher than the national average.
A safe supply provides a consistent and regulated alternative to street drugs for people who use substances both regularly and occasionally. These alternatives will save lives and reduce overdoses, as people know exactly what they are getting every time.
Less police intervention:
A regulated drug supply will reduce the likelihood of people being unjustly criminalized for their substance use. This includes a reduction in the rates of incarceration due to drug possession, as well as mitigating the traumas of confinement associated with prison. Dr. Bonnie Henry continues to advocate for the decriminalization of the possession of illicit drugs in order to reduce the stigma associated with drug use and reduce harm. Providing a non-toxic safe supply could lead to redirecting resources from law enforcement to health and social services. A disproportionate number of illicit drug users are Indigenous youth and adults, a population that already faces extreme amounts of police brutality and discrimination.
More stability in the lives of people who use drugs:
Quite often, people rely on survival crimes like personal property theft and sex work to finance their drug habits. These illegal activities could be reduced if they’re given non-toxic substances provided by a service like B.C. PharmaCare.
Access to a regular safe supply eliminates the need for people who use illicit substances to engage in the underground economy to finance their illicit substance use on a daily basis. This ensures that people can focus on other activities that improve their health and well-being.
This new-found stability in the lives of people who use substances may even lead to more people seeking addiction treatment and recovery, as it helps people stay alive long enough to make that decision. Access to a safe supply will allow people who used to spend their days financing and finding illicit drugs to work on tasks like finding stable housing and addressing other pressing needs in their lives.
“The lived experience of buying and selling illicit drugs every day sets you up for criminalization, stigma — it basically controls your life, and you’re left to the whims of the illicit market,” says Jordan Westfall, president of the Canadian Association for Safe Supply. “[Safe supply] provides safety for people who are normally obtaining drugs in an illicit market which is totally unpredictable. [A safe supply] is predictable for people — they know the potency; they know the dosage.”
Less COVID-19 risk:
It stands to reason that when people who use substances have access to a safe supply, they’re able to shelter more effectively because they’re not on the street financing or purchasing drugs, thereby lessening their risk of COVID-19 exposure. The more someone has to hustle every day, the bigger their social bubble will be. This is especially true for street-entrenched people who already have an extremely difficult time isolating.
Cost effective:
With a safe supply, the rates of overdose, police intervention, incarceration, and disease transmission will decrease, and so will the amount of taxpayer money spent on those issues. Some may argue that the government should divert this money into recovery and treatment programs instead of supporting people’s drug habits. However, forced abstinence does not work. Despite the fact that evidence shows that relying on conventional treatment and recovery models doesn’t work for everyone, many governments continue to rely on them and therefore fail to adequately respond to the overdose crisis. If people had access to a safe and regulated drug supply, there would be less need for many other harm reduction services, like safe consumption sites, drug checking, and naloxone distribution.
Increased bridges to health care:
Safe supply programs foster positive relationships between people who use substances and service providers and create connections that promote trust and better health outcomes. Access to a safe supply provides people with connections to ongoing care, treatment, and support for those who need it most. An upcoming, updated policy directive for prescribers and health authorities will encourage clinicians to work with people who use substances to reach their individual goals and to support them in accessing further harm reduction services, addiction counselling, mental health supports, and recovery treatment.
Less withdrawal:
Dr. Henry noted withdrawal to be a factor in the increased number of overdose deaths since the onset of COVID-19. With a consistent source of regulated and safe substances, people with substance use disorders are less likely to experience painful withdrawal symptoms, cravings, and dope sickness while self-isolating or in quarantine. When someone who uses substances on a regular basis takes a break from using, their tolerance decreases rapidly, therefore making them highly susceptible to overdose the next time they consume drugs. With regular access to a safe supply we can prevent overdose deaths due to drug tolerance fluctuation.
Catalyst for change in drug policy and destigmatization of substance use:
CAPUD noted in their safe supply concept document that “Safe supply is the next step in the construction of a human rights based drug policy framework, whereas harm reduction is a humane response to deal with the outcomes of inhumane policy.” Substance use is not something that should be criminalized, and our drug policy must be morally neutral. Providing a safe supply is a solution that works toward removing the criminalized context of drug use.
“I think you need to have both decriminalization and safe supply because even if people aren’t criminalized if they have to rely on illicit drugs, they have to rely on [drugs that contain] fentanyl which increases the likelihood of overdosing,” says Westfall. “[A safe supply] can be seen as a step toward decriminalization, but it’s actually more immediate because it doesn’t require any legal change.”
What can still be improved?
Engaging people who are disconnected from the health-care system:
Access to this safe supply involves first being diagnosed by a health-care provider to determine what kind of substance user someone is, followed by visiting the pharmacy every day to get a refill of their prescription, unless their pharmacy offers delivery. These prescriptions are dispensed on a much more frequent basis than your typical prescription because of their ability to be abused or sold on the black market. People living in shelters or on the street may find it difficult to go to a pharmacy every day and may even be unwilling to see a physician due to past trauma and discrimination within the health-care system. Furthermore, people living in remote and rural communities may struggle to find a doctor willing to prescribe these substances.
Westfall suggested a greater telehealth aspect for prescribing safe supply. Telehealth is accessing a doctor through a video or phone appointment, something already being done in some walk-in clinics. As well, Westfall stressed the importance of an improved plan to reach out to people in these rural areas where substance use is still so stigmatized that those who need safe supply may be unwilling to ask for it.
CAPUD suggested that drugs could be dispensed at licensed entertainment venues, dispensaries, and shops without requiring a prescription for purchase. This could be a way to make the safe supply more accessible to those who are disconnected or chose not to enter the health-care system. In the same way that alcohol is sold in stores, bars, and restaurants and how cannabis is sold in dispensaries, we could provide heroin, fentanyl, MDMA, cocaine, hallucinogenic mushrooms, and all other substances to patrons through a dignified, low-barrier pathway.
It would also need to take into account that some settings are more appropriate to offer certain substances than others. For example, “club drugs” like MDMA and LSD would be more suitable to distribute at nightclubs and similar venues. However, drugs that impose a greater health risk to users like heroin and methamphetamine need to be paired with a strong informed consent component so people know exactly what they’re receiving and what health risks are involved.
Expectation that people enter treatment and/or prescriber hesitancy:
Some prescribers may be uncomfortable prescribing a safe supply and encourage their patients to access substitution treatments or recovery-based treatments instead. It is difficult for many people who use drugs in B.C. to find a doctor outside of the Downtown Eastside of Vancouver with a harm-reduction mindset that will be willing to prescribe them what they need. Some users who are currently accessing these prescriptions are continually pressured by their doctors to taper off their dosage and face stigma at the pharmacy.
Physicians must be better educated about the root causes of substance use and treat their patients in a non-judgmental, trauma-informed manner. Clinicians need to realize that some of their patients may not be ready or willing to give up their substance use, and they must be willing to offer every support possible to reduce the harm of consuming illicit substances. This is especially true for people who use stimulants, such as cocaine and methamphetamine, as there is a common misconception that the only recovery available for a stimulant addiction is through behavioural or psychosocial treatment rather than through FDA-approved medications or health care.
Ensure equitable access to safe supply:
Currently, those who qualify for safe supply are people who are at risk of contracting COVID-19 and at a high risk of overdosing or withdrawal. Dr. Henry ordered that only those who are diagnosed as having a problematic substance use condition or substance use disorder can be prescribed these regulated substances. However, Dr. Christy Sutherland, medical director of the Portland Hotel Society, said that 60 per cent of opioid fatalities in Vancouver were not daily opioid users. Therefore, the current model of allowing only those who are diagnosed with substance use disorder to have access to a safe supply is not effective in reaching many people who are at risk of overdose. Even so, it is estimated that just four per cent of people who meet the criteria for opioid dependence are being prescribed a safe supply. In order for this safe supply program to be effective, it needs to be highly accessible and low-barrier for all people who use substances to access as easily as they could access illicit substances on the street.
The current pharmaceutical substances being prescribed are not effective:
Under the new guidelines put in place in March, doctors are now prescribing drugs like hydromorphone to treat heroin addiction — except it’s nowhere near as strong as the heroin people are used to, leading people to go after illicit street drugs again or to stockpile their prescription to sell. Kali Sedgemore, executive director of the Coalition of Peers Dismantling the Drug War, advocates for safe supply to also include illicit street drugs that have been drug tested. People who use substances will not seek out a safe supply unless it offers what they seek in the illicit market, like similar strength of the drug or the mode of consumption.
“The price of Dilaudid has plummeted on the street because so many people are selling their prescribed pills to buy street shit,” says Westfall. “That proves that for one thing, fentanyl tolerance is pretty strong, and the doses people are getting prescribed are not strong enough. I think we need to [prescribe] the higher dose injectable opioids. They’re safer to use as long as you know your tolerance.”
The company Fair Priced Pharma is planning to produce injectable heroin that could be a viable alternative to the oral tablets currently being prescribed by doctors under the risk mitigation guidelines. The only injectable option available through PharmaCare is currently through B.C.’s injectable Opioid Agonist Treatment (iOAT) program. Switzerland’s Heroin-Assisted Treatment (HAT) trials started in 1994 and showed tremendously positive health outcomes for those involved in treatment.
The safe supply program is still in its pilot-project stage, and therefore some bumps in the road are to be expected. Giving a safe supply to people who use stimulants and opioids is a necessary step in the fight against the dual public health crises we find ourselves in: the opioid crisis and COVID-19.
However, the program needs to have a lower barrier in order to reach people most at risk of overdose, and this can be achieved through consulting people who use drugs themselves in program development. Westfall noted that the provincial government must diversify whom it consults in policy-making — peers of drug users, advocates for safe supply, companies like Fair Priced Pharma, researchers in the field — to get a fresh perspective on ways efficiency can be improved.
Although this harm reduction service does not treat the root causes or trauma associated with substance use, it will save lives. Over 1,500 British Columbians lost their lives to drug toxicity in 2020. With equitable access to a safe supply we might be able to reverse this trend.
(Halacious/Unsplash)
Andrea Sadowski is working towards her BA in Global Development Studies, with a minor in anthropology and Mennonite studies. When she's not sitting in front of her computer, Andrea enjoys climbing mountains, sleeping outside, cooking delicious plant-based food, talking to animals, and dismantling the patriarchy.
