We must end the unwitnessed safe supply of opioids

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Mark Mallet has been working as a hospitalist in Victoria for the past decade.

I am a doctor, and I am a parent of teenagers, and I am watching a slow-moving tragedy unfold before my eyes in British Columbia. And I feel compelled to speak out about it.

As a doctor, I am bound by certain ethics and standards of practice. I am bound first and foremost to “do no harm.” I am also bound to provide evidence-based care to my patients. These are both virtues of the profession, guiding principles that ensure that patients are given the best available care, without being exposed to treatments that may harm them.

But sometimes, these two principles come into conflict.

That is what is happening with what I’ll call the unwitnessed safe supply of opioids in British Columbia, which is the prescribing of pharmaceutical-grade drugs that users are able to take home and use where and when they want, known as “carries.” (This is not to be confused with “witnessed” safe supply, which are drugs administered at a supervised site.) In both cases, the goal is to prevent users from having to use the toxic drugs available on the street.

Unwitnessed safe supply is causing immeasurable harm in unintended and deeply distressing ways, yet the program has continued because of a lack of evidence to “prove” this.

For now, all we have in the way of hard evidence is a mounting death toll. Last month, B.C. announced that illicit drug toxicity is now the leading cause of death amongst youth aged 10-18, overtaking both accidents and suicide. It is a statistic that is both horrifying and sobering. What we don’t have is clear evidence to explain why this is happening.

Instead, we have countless tragic anecdotes. As a doctor and as a parent, I hear story after story of how the province’s unwitnessed safe-supply program is drawing our young people into the dark world of the opioid epidemic. Every user has a story about the first opioid they tried, and for too many people, that opioid came from a pharmacy.

The problem is that for doctors, anecdotes are not considered good evidence. In fact, the term “anecdotal” is a derogatory term that is often used to dismiss evidence as something little better than hearsay, and certainly not worthy of changing clinical practice. Unless evidence is quantifiable and the data collected dispassionately, with large numbers of people, often over extended periods of time, doctors generally do not consider it to be evidence at all.

In this case, however, as the death toll continues to mount and our youth are literally dying while we wait for data, the anecdotes must be seen as evidence enough. The anecdotes are the evidence.

For instance:

I have a friend in Victoria whose 18-year-old daughter graduated during the COVID-19 pandemic. She went to a good high school and had the normal encounters at parties with the usual range of drugs and alcohol. After she graduated and the pandemic restrictions were lifted, she got a job in a café and took a year off school to get some experience and travel.

One night at a party, someone offered her a “Dilly.” They told her it would give her a great high. She tried it, and yes, it was a great high. And, as it turned out, it was also very cheap and easy to find, so she started using it on a semi-regular basis. Initially, she had no idea that the “Dilly” was in fact hydromorphone, a highly potent and highly addictive prescription opioid sold under the name Dilaudid. By the time she realized, it was too late. She was addicted.

What’s more, because Dilaudid is the drug handed out through the province’s “safe supply” program, my friend’s daughter thought they must be safe because they came in a blister pack from a pharmacy. But Dillies are far from safe, and the addiction they cause is just as powerful as the addiction to heroin or morphine or any other opioid.

More troubling still, when this 18-year-old went to seek help at a local addictions clinic, the first thing she was offered was a prescription for more Dilaudid so that she would be sure to have a continuing safe supply. She declined, saying her goal was to get off opioids rather than to continue using. So they gave her suboxone, which is a long-acting opioid agonist designed specifically to help people escape the wild highs and lows of opioid addiction. She is struggling, but she is stabilizing, at least for now.

Another teen in her circle was not so lucky: When he went to the same clinic for help with a Dilly addiction, and was similarly offered Dilaudid as a safe-supply option, he said yes. So now he is being given a handful of Dilaudid every day so that he can continue to get high “safely.”

Before we go further, let us understand what we are talking about when we use terms such as “unwitnessed safe supply” and “harm reduction.” In a nutshell, “harm reduction” refers to policies and programs that reduce the harms that stem from the use of drugs. It is a supportive, destigmatizing approach to drug addiction that includes safe-injection sites, providing free Naloxone kits and free needle exchanges. It is not necessarily about getting users off drugs, but rather about meeting them where they are in their journey and trying to keep them safe from harm. It is a mainstay of Canada’s collective strategy in dealing with the opioid crisis, and you’d be hard-pressed to find a doctor who doesn’t, in principle, believe in it. I certainly do.

“Unwitnessed” safe supply is a strategy that fits under the broad umbrella of harm reduction. While witnessed or supervised safe-supply programs have been around a decade or longer, “unwitnessed” safe supply is much newer, and much more controversial.

We have COVID-19 to thank for its existence.

When safe supply first arrived in Victoria in 2019, it was a very small program made available to only the most entrenched drug users. The drugs used were injectable Dilaudid or medical-grade heroin, and they had to be consumed in a witnessed setting, typically administered by a nurse. Users could get high, but they couldn’t take the drugs home with them. They certainly couldn’t sell them.

All that changed when COVID hit. Suddenly, B.C. policy makers felt compelled to rapidly transition to a program that allowed patients to take drugs home, so that they might get high while also self-isolating. It was an earnest effort to solve an unsolvable confluence of problems – the COVID-19 pandemic colliding with the drug-poisoning crisis.

As a result, it suddenly became common for users to be given 14 doses of eight-milligram Dilaudid – known as “Dilly-8s” or “Dillies” – to take home with them every day. Between March, 2020, and May, 2021, 4,537 British Columbians were prescribed safe-supply Dilaudid.

To put this in perspective, Dilaudid is a painkiller used for severe pain. It is four to five times more potent than morphine and 25-30 times more potent than codeine. After major surgery, a typical dose would be 1 to 2 mg every four hours. A single 8-mg dose would render many people unresponsive, and for some it would be enough to kill them. So 14 Dilly-8s a day is a lot.

The problem with these carries was not that the patients were taking large amounts of prescription painkillers. The problem was that a good number of them were not taking these prescription painkillers, for the simple reason that the Dilaudid wasn’t getting them high enough. The drugs on the street have become so potent that some users can down all 14 of their Dilly-8s at once and feel next to nothing.

So they were receiving their daily supply and then turning around and selling it in order to buy something better. Not everyone was doing this, but enough were doing it – and still are – that the street price of prescription-grade Dilaudid has cratered, making it one of the cheapest drugs you can find. A patient told me last week that it’s hardly even worth selling his Dillies any more because he can only get 25-50 cents a pill. That’s how saturated the streets are with Dilaudid – the law of supply and demand has driven the price of Dillies into the ground.

Where is all this cheap prescription Dilaudid ending up? That’s a good question, one that I’ve been asking some of my colleagues for the past two years. The truth is, no one has been tracking that, and therein lies the problem.

The assumption – and the hope – is that it’s ending up in the hands of other addicts and users already well entrenched in the opioid crisis. This was the assumption that underpinned the entire ethical review of the concept of safe supply that the B.C. government commissioned in 2020. In fact, the ethicist who wrote the report stated that, in view of the potentially deadly street supply of drugs, it would be unethical not to provide users with unwitnessed safe supply.

Although the ethics of the report may have been sound, the ethicist’s conclusion was based directly on the pivotal assumption that any drugs that were “diverted” – or sold to an unintended recipient – would only end up in the hands of another entrenched user. If that were the case, then diverted drugs would cause no harm.

Unfortunately, this assumption has proved to be catastrophically false.

If you ask teenagers kicking around Victoria, you’ll soon discover that Dilaudid has flooded the high schools and now commonly shows up at parties throughout the city. But be careful to use the right language. If you ask teens if they’ve heard of Dilaudid, you’ll be met with blank stares. If you ask about “Dillies,” however, it’s a different story. Of the teens I spoke to – even the ones who considered themselves savvy when it comes to street drugs – none of them even knew that the cute-sounding “Dillies” were in fact opioids.

Some prescribers have seen the dangers of the unwitnessed safe-supply program, and they’ve changed their practice. For instance, I spoke with one of the doctors at downtown Victoria’s Cool Aid Clinic, which services a large population of people who use drugs. The doctor said they have scaled back their prescribing of Dilaudid because they recognized a year ago that too much of it was being diverted, and they weren’t comfortable not knowing where it was ending up. They were hearing from local youth addictions counsellors that the numbers of teens seeking treatment for opioid-use disorder were way up, and they quickly recognized that the dangers of giving patients carries far outweighed the benefits.

So then why is the unwitnessed safe-supply program still running at all? If it began because of COVID-19 restrictions, why did it not end when the restrictions ended? The answer is complicated. Partly, it’s politics: There is a very vocal drug-advocacy lobby in B.C. that believes we can prescribe our way out of the drug-poisoning crisis. They believe that the only problem with safe supply is that there’s not enough of it. According to this way of thinking, we could prevent illicit-drug deaths entirely if only we could make hardcore opioids free and available to everyone who wants them. Only through mass availability of pharmaceutical-grade opioids can we prevent people from accessing the toxic street supply. Of course, this logic ignores the fact that mass availability inevitably leads to the creation of new addictions.

The more complicated part of the answer is that it is very difficult for doctors to stop prescribing opioids to patients who are dependent on them. If a doctor cuts off a patient’s supply of Dilaudid, that patient may very well turn to the toxic street supply, which in turn may kill them. That would be unethical.

So what doctors need is an “off-ramp”: an alternative to Dilaudid that isn’t easily diverted. Could this off-ramp be traditional opioid-agonist therapies such as methadone and suboxone, or something stronger, such as witnessed long-acting morphine or tamper-proof fentanyl patches? Absolutely. In many cases, doctors are already incorporating those changes into their prescribing habits, because they know that Dillies are creating new addicts.

Unfortunately, that on-the-ground experience is being countered by the drug-advocacy lobby. To them, the fact that January to July of this year set another provincial record for toxic-drug deaths – 1,455 – is just proof that we don’t yet have enough “safe” drugs on the street.

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As a doctor, I am being told that there is “no evidence” that unwitnessed safe-supply drugs are leading to overdose deaths, and “no evidence” that these drugs are ending up in schools. But as a father, I know this not to be true.

This brings me to an important nuance about the way doctors talk about evidence. When we say, “There is no evidence to support that,” we do not mean there is evidence to the contrary. We simply mean there is an absence of supporting evidence.

An “absence of evidence” could mean that no one has been collecting it. An “absence of evidence” could also just mean that public-health officials are failing to look for it in the right places. In British Columbia, when it comes to the whereabouts of all these diverted Dillies, both of these statements are sadly true.

For three years, we have been handing out literally thousands of Dillies a day, but we have not been tracking where they’re ending up. How many Dillies exactly? Precise numbers are hard to come by, but some simple back-of-the-napkin math says it’s in the tens of thousands of pills every day. In June of this year, there were approximately 4,619 people in B.C. being prescribed safe-supply opioids. For the vast majority of those people – 89 per cent as of May, 2021, the most recent date for which numbers are available – this means receiving Dilaudid.

In my experience as a hospitalist, almost everyone receiving safe-supply Dilaudid gets the maximum allowable number of pills – 14 Dilaudid 8-mg tablets – and they get them every day.

Put those numbers together and you have over 50,000 Dillies being dispensed daily in B.C. Even if we err on the side of caution and cut that number in half, that’s still 25,000 pills a day. Many of them are consumed by the intended recipient, but some are not.

Again, when it comes to the exact numbers of pills being diverted, no one is tracking that data, which is why some drug-advocacy groups can claim that Dilaudid diversion is not a problem, while doctors on the front lines know that it is.

Here are some other statistics that no one has been tracking: Where are the diverted Dillies going? Who is buying them? How many of them are ending up in high schools? Are they the gateway opioid that’s driving the increase in youth death rates? Unfortunately, because no one has been tracking any of that, we have no “evidence” showing that diverted Dilaudid is causing any problems whatsoever.

What we have been tracking, however, is death. To that end, B.C.’s Chief Coroner, Lisa Lapointe, stated in June that her office has seen no evidence of an increase in safe-supply drugs in the postmortem toxicology testing of people who have died of drug overdoses. This is no doubt true, but it is also incredibly unhelpful. People may start their long and arduous opioid journey with Dilaudid, but they rarely end with it. At some point along the line a number will graduate to fentanyl. That is what they die of, and that is what you’ll find in postmortem testing.

But the morgue is not where we should be looking if we want to know where all the Dilaudid is going. We should be talking to youth addictions counsellors, and to front-line prescribers who have changed their own practice guidelines based on what they see unfolding before their eyes. We should be talking to schools and to parents and to teenagers themselves.

Here is another anecdote:

Five months ago, I admitted a 35-year-old patient to the hospital. The young woman had a fentanyl addiction and a serious leg infection. She would need at least a week of intravenous antibiotics. During my time as her doctor, I asked about her journey with addiction. She told me that three years earlier she’d had a job and an apartment and a “normal life.” She had used the odd pill now and then, but rarely much more than a Tylenol No. 3 or a Xanax. But then COVID hit, and things weren’t easy. Someone offered her a Dilly, and she tried it. It made her feel good, and more Dillies were easy to find, so she began using them regularly.

What she didn’t know was how powerfully addictive these prescription opioids are, and once she realized she had a problem, she sought help. She found a doctor who treats addictions, and she was started on methadone, which, like suboxone, is a long-acting opioid agonist that prevents withdrawal but does not get users high. Her life started to stabilize.

But then, as sometimes happens, life threw her a curveball. She went through a personal crisis and wasn’t able to get to the pharmacy for her daily witnessed ingestion of methadone. Desperate to avoid the torture of withdrawal she knew was coming, she bought drugs off the street. That was her first taste of fentanyl, and, like so many people, she was hooked. By the time I met her, she had been smoking fentanyl multiple times a day for over a year. She was jobless and homeless. Her life was ruined.

Sadly, more and more tragic anecdotes are piling up. And more and more of these anecdotes begin with Dilaudid, the “safe supply” drug that has found its way onto the streets.

To be clear, I do not think that this was anyone’s intention. In fact, I doubt that policy makers and anyone upholding the success of the program are even weighing these issues in the balance. They are simply not aware. Or perhaps they are in denial, or possibly they are waiting for someone to conduct a long-term study, someone to supply them with better “evidence.” But frankly, we do not have the time to wait for better evidence.

The unwitnessed safe-supply program, whose stated intention is harm reduction, is in fact causing significant collateral harm. This reality undermines the ethical underpinning of the entire program. In its current form, the unwitnessed safe-supply program is medically unethical.

So what do we do now?

We now have three years of young people who have grown up through the pandemic, their experience of lockdowns and interrupted schooling making them perhaps more vulnerable than they otherwise would have been. They have emerged into a party scene that has access to government-supplied opioids. They are in danger of becoming the next generation of entrenched opioid users. Some of them already are.

What these kids need is immediate access to long-term treatment programs in their home communities, so that they can start their journeys to recovery. This needs to happen today. They need to get stabilized on long-acting opioid agonists such as suboxone or methadone, so that they can start to get their lives back together. And we need safe-supply drugs to revert back to what they were before COVID-19 turned everything upside down: a witnessed option for only the most entrenched drug users.

People are dying. Children are becoming addicted. Toxic drugs are the leading killer of teenagers in B.C.

To wait for more evidence than this would be negligent and absurd. In this case, the anecdotes are the evidence.

Shut the program down.