Nora Volkow, Director of the National Institute on Drug Abuse, on May 4, in Washington.Jacquelyn Martin/The Associated Press
Nora Volkow, the director of the U.S. National Institute on Drug Abuse, was in Vancouver on Friday to deliver a keynote speech for the 30th anniversary of the BC Centre for Excellence in HIV/AIDS (BC-CfE).
The Globe and Mail spoke with Dr. Volkow after she toured the organization’s Hope to Health Research and Innovation Centre in the city’s Downtown Eastside, and Insite, North America’s first supervised consumption site, now 20 years old.
The Hope to Health centre, opened in late 2019, offers primary care as well as eye care, supervised consumption services and pharmaceutical alternatives to illicit drugs (commonly referred to as safer supply). It recently received city approval to pilot a six-booth smoking and inhalation room that is expected to be operational later this summer.
Tell me about your tour this morning.
What was particularly noteworthy about Hope to Health is how it has grown from a concept that I had heard [BC-CfE executive director Dr. Julio Montaner] express to a real brick-and-mortar place where people are being treated. I also thought it was amazing that he is able to provide health care to this population that otherwise would not be seen by anyone, or tested. The fact that it’s so easygoing, they can come in and have their blood work done, have a physical exam, have treatments done if they need it, it’s amazing.
When I went to visit Insite, what was remarkable to see was how committed the staff is, to make people feel comfortable. People were coming in, they knew them by name, the staff was excited to see them. That is not a given for people who are socially isolated, who are so discriminated against, to have a warm hand and someone who cares for them. It can make a huge difference.
Some critics of supervised consumption sites feel that these facilities enable drug use.
There is no evidence that a facility like this promotes drug use. That argument, people that think that way, are very difficult to change because it’s sort of a prejudice that relates to the lack of insight on what it is to be addicted. Harm reduction is a valid intervention, because people will take drugs whether you have harm reduction or not. What you are doing is saving an individual’s life, and by keeping them alive, you have an opportunity to bring them into treatment and recovery, which is what everyone, ideally, would like to see. But if someone overdoses and dies, that’s the end of that narrative.
The other argument, the one that is made by public-health experts, is, “okay, we all have a limited set of resources that we need to invest in ways that get the most benefit. Do we invest in these, or other interventions that could have greater impact?” In my view, that could absolutely be a valid criticism in a scenario where you have very few overdoses, to have all that infrastructure. But in a situation like here in East Vancouver, or Kensington in Philadelphia, you can see how it is definitely a good strategy to invest in harm reduction practices.
I’m curious of your thoughts on safer supply, a relatively new and small-scale intervention here in Canada where some people at high risk of overdose from illicit drugs are given pharmaceutical alternatives.
I have not seen sufficient data to help me determine whether this could be beneficial. I was very intrigued because there was one program that gives the person very high doses of fentanyl. If you’re getting these doses, do you decrease the risk of overdose and death? There’s no data. I suspect that individuals that are taking [illicit] fentanyl at extremely high rates and frequency with very risky behaviours, with no support systems, may be able to be stabilized if they get [pharmaceutical-grade] fentanyl, but I’d like to see the data and see what those dynamics are. I suspect that the data will show that it depends on the characteristics of the individual, because it’s not like any one single intervention is going to show benefit for everyone.
I would love to have these individuals followed with wireless technologies to see oxygen content, to see blood pressure, to see sleep patterns. That would allow us to ask whether the safer fentanyl leads to more stable physiological parameters. With wearables, we, in principle, could do that.
Do you feel that the North American response to the overdose crisis is commensurate to the magnitude of the problem?
No. Look at the amount of money and attention that went into addressing the COVID pandemic. It is absolutely unlike what we’re doing with the overdose crisis. Look what happened: You could go and get your COVID vaccines anywhere you wanted, for free. In the U.S., people are not getting [medications for opioid use] buprenorphine or methadone because insurance isn’t paying for it. [COVID-19 medication] Paxlovid, free. There is a huge difference between one and the other. Addiction is not considered a disease on the same level as other diseases like diabetes or hypertension or cancer, where people are willing to pay so much more.
What’s the biggest obstacle to the implementation of meaningful solutions?
Stigma. We’re not willing to put the level of resources that are necessary. There are absolutely evidence-based solutions that, if they were scaled up, would have a significantly large impact, but they’re not.
What are those solutions?
We should have health care providers screening and treating for substance-use disorders. In the U.S., physicians make much more money treating other diseases, so they are not incentivized. I would also want to have documentation of standards and outcomes in health care so that one can evaluate whether a particular treatment program actually results in best outcomes or not. We do not have a system that monitors for quality of treatment in substance-use disorder.
I would also put a big emphasis on prevention. If you look at the factors that increase your risk, it’s the social determinants of health. Adverse childhood experiences can dramatically increase the risk for substance use. Also, prevention interventions for adults that give them opportunities to get out of situations where they feel helpless and hopeless. That may mean retraining them, re-educating them, giving them job opportunities and social support.
We should also be training physicians so that they can play an important role in prevention, starting by doing screening for preaddiction, so that you can then have interventions that prevent them from escalating into severe substance-use disorder.
This Q&A has been edited for length and clarity.