Packets of drugs tested for contaminants are sorted for distribution in Downtown Eastside of Vancouver, on Jan. 31, 2023.JENNIFER GAUTHIER/Reuters
A panel of experts in B.C. has concluded that it is ethically defensible to provide prescribed opioids to drug users to save lives, even when some of those pills are being diverted and could create new addictions.
This is not a theoretical debate. The findings are meant to shape policy in British Columbia, the first province in the country to introduce prescribed opioids for people with addictions, where public-health officials are now recommending that B.C. expand the range of drugs available to include smokable fentanyl and other substances.
The utilitarian argument goes like this: providing prescribed, regulated alternatives to street drugs reduces harms for those at high risk of overdose or death. Therefore, the benefits of lives saved outweigh the potential for harm to the broader population if some of those drugs are diverted, shared or sold on the street, according to B.C.’s health ethics advisory team.
The flaw with this argument is government is being asked to make a decision without a clear understanding of the risks of diversion. The measure of potential harm to individuals is uncertain because there are limited data, and no definitive verdict on whether diversion is increasing youth addiction. More certainty is needed before broadening the scope of this experiment.
As concerns have grown about the province’s other major drug trial – decriminalization – the government must consider how much risk the broader population will accept without eroding public support for harm reduction measures.
In early 2021, after the pandemic had exacerbated the toxic drug crisis, the government rapidly expanded access to a modest program that provided hydromorphone to drug users (but consumed in front of a medical professional) as an alternative to increasingly deadly opioids bought on the street. The key change: allow patients to take their prescribed pills away to consume elsewhere. It created an opportunity for those drugs to be sold on the street.
That emergency measure has become the status quo; the question before government now is how it evolves to meet changing needs.
B.C. Provincial Health Officer Bonnie Henry, in a report released Feb. 1, found the evidence for prescribed supply is largely positive, but noted that there is not enough information yet for the policy to be described as “evidence-based.”
As part of the review, Dr. Henry commissioned the health ethics advisory team and consulted broadly with clinicians, researchers and people who use drugs. “When harms to individuals are certain, severe or irreversible, there is ethical justification to implement effective interventions that reduce or eliminate those harms even when it means there may be some uncertain harms to individuals,” the ethical analysis concludes.
The problem is, such a determination can only be made with clear evidence in hand, points out Professor Kerry Bowman, bioethicist at the University of Toronto. “Good ethics are grounded in good science, and good science is grounded in good data.”
Dr. Henry’s review did not find that evidence. She noted that the benefits of prescribed alternatives as a medical intervention is reaching less than 4 per cent of the 115,000 people in B.C. who have a diagnosed opioid-use disorder. She expressed several concerns: the program can increase availability of opioids for youth; normalization of this access leads to risky use; and it reduces incentives for recovery. Any new medications that could become available under the program should require “witnessed dosing” as a default, to reduce the risk of diversion.
She called on the government do to more to investigate the potential for harm at the population level, but B.C.’s track record on public reporting on the effects of decriminalization does not foster confidence in its commitment to such monitoring. Jennifer Whiteside, B.C.’s Minister for Mental Health and Addictions, is reviewing Dr. Henry’s recommendations and the findings of the medical ethics panel.
There is urgency to respond to the escalating toxic drug crisis that is now killing an average of seven British Columbians each day, but public-health officials have not made the case for expanding the program. Indeed, there should be an evaluation – based on the speedy assembly of data – as to whether all dispensed opioids should be consumed under observation by health care workers.