People march to remember those who died during the overdose crisis and to call for a safe supply of illicit drugs on International Overdose Awareness Day, in Vancouver, on Aug. 31, 2021.DARRYL DYCK/The Canadian Press
British Columbia clinicians who prescribe drug users pharmaceutical alternatives to deadly street drugs have expressed a range of concerns with the safer-supply program, from limited medication options and inadequate social supports to fears that the very drugs they’re prescribing could fuel new cases of substance-use disorder.
The feedback is contained in a draft report obtained by The Globe and Mail as part of Provincial Health Officer Bonnie Henry’s review of the B.C. program. The document – the product of a summer’s worth of consultations between Dr. Henry and physicians, nurse practitioners, researchers and people who use drugs – captures the distress felt by clinicians as they navigate the province’s most contentious response to one of its worst public-health crises, and the frustration of drug users who feel their lives hang in the balance.
Many of the review’s themes were echoed in a separate report from the BC Coroners Service, which was released Wednesday. The coroner’s expert panel recommended the province dramatically expand access to the safer-supply program by removing the need for prescriptions, which the government promptly rejected.
B.C. originally introduced safer supply three years ago, in the early days of COVID-19, so that people could reduce risk of withdrawal while complying with pandemic safety measures. The program has continued. The intervention – which is not treatment, but harm reduction – is predicated on the idea that by prescribing regulated medications, health care providers can sever or lessen a patient’s reliance on unpredictably toxic street drugs, thereby reducing overdoses and other related harms.
About six people die in B.C. each day from an illicit drug supply that has been supplanted with fentanyl, benzodiazepines, tranquilizers and other substances. More than 13,000 people have died since 2016.
The coroner’s report noted that around 225,000 people in the province use illicit substances, while about 100,000 have been diagnosed with an opioid-use disorder. Data provided by B.C.’s Ministry of Mental Health and Addictions show that 4,476 people were prescribed an opioid medication as part of the province’s safer-supply program in July, up from the 1,432 in December, 2020.
Safer supply has become a political flashpoint, with federal Conservative Party Leader Pierre Poilievre alleging that medication from these programs – which also exist in Manitoba, Ontario and Quebec – are “flooding the streets.”
The BC Coroners Service says there is no evidence that drugs prescribed under the program have contributed to overdose deaths, while data from the BC Centre for Disease Control do not indicate any increase in new opioid-use disorder diagnoses (though new cases can be a lagging indicator, with problems not being known for a year or more). B.C.’s Ministry of Mental Health and Addictions said preliminary findings from the program’s early years have found a 61-per-cent reduction in all-cause mortality among people receiving at least one prescription.
Dr. Henry announced the review in June, primarily in response to concerns raised about the prescribing of hydromorphone. Typically used to treat moderate to severe pain, the opioid is the most commonly prescribed medication in the program, with nearly 90 per cent of people receiving it at least once in July, according to government figures.
Feedback was collected through video conferences, roundtables and online surveys; the draft document does not state how many people participated in all.
The report notes the goal of the review is to support prescribers and people who use drugs by ensuring that the program “meets the needs of people at risk of harm or death due to the toxic illicit drug supply, while also taking into account the health and safety of people who do not use drugs.”
The majority of clinicians agreed that prescribed safer supply is a necessary intervention in the context of the continuing toxic drug emergency, the review found. Some spoke of it stabilizing clients, helping to retain them in drug-treatment programs and engage them in other health care.
But some were concerned about the “exit strategy” for those on the program, noting the dearth of social supports needed for long-term stability. Some expressed “significant moral distress when providing care to vulnerable clients with limited guidance,” the report said, and feeling ill-equipped to balance the risks of the illicit drug supply against those of high-dose prescribing.
Others still worried about opioids from the program being diverted to the black market, where they could fall into the hands of new users, or where their increased availability would make them cheaper and more appealing to young people. These worries were amplified by the fact that prescribers’ names are on the medication bottles, “establishing a clear line of responsibility for the medication and any potential harms it may cause if diverted,” the report said.
In an interview with The Globe in September, Dr. Henry said she was soliciting province-wide feedback to guide how the safer-supply program should proceed, and had also commissioned the BC Provincial Health Ethics Advisory Team to weigh risks, benefits and challenges of the program to individuals and communities.
At the same time, Dr. Henry’s office is preparing a separate report looking at a range of safer-supply models, including ones that would not require clinicians to prescribe these medications to patients individually.
“Government right now is looking at medical models, and that’s what my advice to them will be about,” Dr. Henry told The Globe in September. “But I believe we really need to look at the broader impact of what we’re seeing in the toxic drug supply right now and further the discussion on both medical and non-medical models.”
The draft report does not include recommendations. The final version is expected in coming weeks.
Respondents told Dr. Henry that while these medications can promote short-term stability, there are significant gaps in B.C.’s system of care impeding long-term stability. Connecting patients to detox or addiction treatment was described as a “labour intensive and often futile process;” there are limited supports for people once they are released from treatment; and connecting patients to housing is “nearly impossible,” they said.
“One clinician reflected that while [prescribed safer supply] is helpful for keeping people alive, it was questionable whether it could help them achieve the ultimate goal of improving their quality of life,” the review said.
Drug users described extended wait times between detox and treatment, long wait lists for treatment beds, poor discharge practices and inequitable access to mental health care.
“One participant shared that the root cause of their substance use is trauma and post-traumatic stress disorder; however, they have been unable to see a psychologist or psychiatrist to receive appropriate care for these underlying conditions,” the review said.
Doctors have said that a novel response to a runaway crisis requires careful monitoring and adjustments, and that the politicization of the issue has been distracting and unhelpful.
Nick Baldwin, a family and addiction medicine physician in Kelowna, said concerns about diversion pose a tough dilemma for clinicians.
“I’ve felt terrible when I’ve written a prescription for safer supply because I’m worried about what’s going to happen to it, and I’ve felt terrible when I’ve said ‘no’ to someone who’s asked for it because I’m worried about what’s going to happen to them,” he said.
Diversion is attributed in part to issues with hydromorphone, which is weaker than the fentanyl that has flooded the illicit supply and is akin to “bringing a knife to a gun fight,” one clinician said in the report. This mismatch, particularly for clients living in poverty, can create an incentive to sell their medication, clinicians told Dr. Henry.
Others reported that clients benefited from hydromorphone, reducing or ending illicit drug use and securing employment. Some said hydromorphone was effective when used to supplement traditional medications for opioid-use disorder, such as methadone and Suboxone; others felt that it may be a useful short-term tool but failed to see long-term benefits. While perspectives on hydromorphone prescribing were mixed, there was “overwhelming opposition” to ending it without other effective options in place, the review said.
The review also examined concerns that current options within the safer-supply program do not suit all patients. Stronger opioids, for example, are more likely to be effective but remain harder to access. Powdered fentanyl – a more flexible formulation that can be smoked, snorted or injected – is currently only offered at a few programs in Vancouver. It is not covered by the province’s publicly funded drug plan, which makes it an expensive option, and some cities don’t have pharmacies that will compound the drug.
In northern B.C., some clinicians noted that practitioners providing pharmaceutical alternatives are in the minority, and that people seeking prescribed safer supply are turned away “every day,” highlighting regional disparities.
Tracey Day, clinical director of substance-use and addiction services at Carrier Sekani Family Services in Prince George, echoed these sentiments and added that limitations in funding, infrastructure and access to medications also pose considerable barriers. In the North, 82 per cent of drug deaths in August were from inhalation, but Prince George doesn’t have an overdose prevention site that accommodates smoking, and clinicians can’t access inhalable medications such as compounded fentanyl, Dr. Day said.
Among other feedback, clinicians said they wanted more access to monitoring and evaluation data, as well as clearer and objective clinical guidance. They also sought more support from their regulatory colleges, citing perceived disapproval in relation to prescribing safer supply as “a key source of anxiety.”
Both drug users and clinicians called for a more appropriate name for the intervention, finding “safer supply” to be inaccurate and confusing.
Dr. Baldwin, the addition medicine physician in Kelowna, said that given the urgency of the situation and the need for a radical and novel approach, leaders should acknowledge the paucity of evidence for this intervention and the limitations of their knowledge as they navigate uncharted waters.
He called for more transparency in how government is going to monitor benefits and harms, as well as how it might change course if needed.
“We need to be open to the idea that we might get it wrong,” he said. “There needs to be a lot of humility about it.”