Addictions
Addiction experts demand witnessed dosing guidelines after pharmacy scam exposed
By Alexandra Keeler
The move follows explosive revelations that more than 60 B.C. pharmacies were allegedly participating in a scheme to overbill the government under its safer supply program. The scheme involved pharmacies incentivizing clients to fill prescriptions they did not require by offering them cash or rewards. Some of those clients then sold the drugs on the black market.
An addiction medicine advocacy group is urging B.C. to promptly issue new guidelines for witnessed dosing of drugs dispensed under the province’s controversial safer supply program.
In a March 24 letter to B.C.’s health minister, Addiction Medicine Canada criticized the BC Centre on Substance Use for dragging its feet on delivering the guidelines and downplaying the harms of prescription opioids.
The centre, a government-funded research hub, was tasked by the B.C. government with developing the guidelines after B.C. pledged in February to return to witnessed dosing. The government’s promise followed revelations that many B.C. pharmacies were exploiting rules permitting patients to take safer supply opioids home with them, leading to abuse of the program.
“I think this is just a delay,” said Dr. Jenny Melamed, a Surrey-based family physician and addiction specialist who signed the Addiction Medicine Canada letter. But she urged the centre to act promptly to release new guidelines.
“We’re doing harm and we cannot just leave people where they are.”
Addiction Medicine Canada’s letter also includes recommendations for moving clients off addictive opioids altogether.
“We should go back to evidence-based medicine, where we have medications that work for people in addiction,” said Melamed.
‘Best for patients’
On Feb. 19, the B.C. government said it would return to a witnessed dosing model. This model — which had been in place prior to the pandemic — will require safer supply participants to take prescribed opioids under the supervision of health-care professionals.
The move follows explosive revelations that more than 60 B.C. pharmacies were allegedly participating in a scheme to overbill the government under its safer supply program. The scheme involved pharmacies incentivizing clients to fill prescriptions they did not require by offering them cash or rewards. Some of those clients then sold the drugs on the black market.
In its Feb. 19 announcement, the province said new participants in the safer supply program would immediately be subject to the witnessed dosing requirement. For existing clients of the program, new guidelines would be forthcoming.
“The Ministry will work with the BC Centre on Substance Use to rapidly develop clinical guidelines to support prescribers that also takes into account what’s best for patients and their safety,” Kendra Wong, a spokesperson for B.C.’s health ministry, told Canadian Affairs in an emailed statement on Feb. 27.
More than a month later, addiction specialists are still waiting.
According to Addiction Medicine Canada’s letter, the BC Centre on Substance Use posed “fundamental questions” to the B.C. government, potentially causing the delay.
“We’re stuck in a place where the government publicly has said it’s told BCCSU to make guidance, and BCCSU has said it’s waiting for government to tell them what to do,” Melamed told Canadian Affairs.
This lag has frustrated addiction specialists, who argue the lack of clear guidance is impeding the transition to witnessed dosing and jeopardizing patient care. They warn that permitting take-home drugs leads to more diversion onto the streets, putting individuals at greater risk.
“Diversion of prescribed alternatives expands the number of people using opioids, and dying from hydromorphone and fentanyl use,” reads the letter, which was also co-signed by Dr. Robert Cooper and Dr. Michael Lester. The doctors are founding board members of Addiction Medicine Canada, a nonprofit that advises on addiction medicine and advocates for research-based treatment options.
“We have had people come in [to our clinic] and say they’ve accessed hydromorphone on the street and now they would like us to continue [prescribing] it,” Melamed told Canadian Affairs.
A spokesperson for the BC Centre on Substance Use declined to comment, referring Canadian Affairs to the Ministry of Health. The ministry was unable to provide comment by the publication deadline.
Big challenges
Under the witnessed dosing model, doctors, nurses and pharmacists will oversee consumption of opioids such as hydromorphone, methadone and morphine in clinics or pharmacies.
The shift back to witnessed dosing will place significant demands on pharmacists and patients. In April 2024, an estimated 4,400 people participated in B.C.’s safer supply program.
Chris Chiew, vice president of pharmacy and health-care innovation at the pharmacy chain London Drugs, told Canadian Affairs that the chain’s pharmacists will supervise consumption in semi-private booths.
Nathan Wong, a B.C.-based pharmacist who left the profession in 2024, fears witnessed dosing will overwhelm already overburdened pharmacists, creating new barriers to care.
“One of the biggest challenges of the retail pharmacy model is that there is a tension between making commercial profit, and being able to spend the necessary time with the patient to do a good and thorough job,” he said.
“Pharmacists often feel rushed to check prescriptions, and may not have the time to perform detailed patient counselling.”
Others say the return to witnessed dosing could create serious challenges for individuals who do not live close to health-care providers.
Shelley Singer, a resident of Cowichan Bay, B.C., on Vancouver Island, says it was difficult to make multiple, daily visits to a pharmacy each day when her daughter was placed on witnessed dosing years ago.
“It was ridiculous,” said Singer, whose local pharmacy is a 15-minute drive from her home. As a retiree, she was able to drive her daughter to the pharmacy twice a day for her doses. But she worries about patients who do not have that kind of support.
“I don’t believe witnessed supply is the way to go,” said Singer, who credits safer supply with saving her daughter’s life.
Melamed notes that not all safer supply medications require witnessed dosing.
“Methadone is under witness dosing because you start low and go slow, and then it’s based on a contingency management program,” she said. “When the urine shows evidence of no other drug, when the person is stable, [they can] take it at home.”
She also noted that Suboxone, a daily medication that prevents opioid highs, reduces cravings and alleviates withdrawal, does not require strict supervision.
Kendra Wong, of the B.C. health ministry, told Canadian Affairs that long-acting medications such as methadone and buprenorphine could be reintroduced to help reduce the strain on health-care professionals and patients.
“There are medications available through the [safer supply] program that have to be taken less often than others — some as far apart as every two to three days,” said Wong.
“Clinicians may choose to transition patients to those medications so that they have to come in less regularly.”
Such an approach would align with Addiction Medicine Canada’s recommendations to the ministry.
The group says it supports supervised dosing of hydromorphone as a short-term solution to prevent diversion. But Melamed said the long-term goal of any addiction treatment program should be to reduce users’ reliance on opioids.
The group recommends combining safer supply hydromorphone with opioid agonist therapies. These therapies use controlled medications to reduce withdrawal symptoms, cravings and some of the risks associated with addiction.
They also recommend limiting unsupervised hydromorphone to a maximum of five 8 mg tablets a day — down from the 30 tablets currently permitted with take-home supplies. And they recommend that doses be tapered over time.
“This protocol is being used with success by clinicians in B.C. and elsewhere,” the letter says.
“Please ensure that the administrative delay of the implementation of your new policy is not used to continue to harm the public.”
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
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A Canadian poll finds that racial minorities don’t believe drug enforcement is bigoted.
By Adam Zivo
[This article was originally published in City Journal, a public policy magazine and website published by the Manhattan Institute for Policy Research]
Is drug prohibition racist? Many left-wing institutions seem to think so. But their argument is historically illiterate—and it contradicts recent polling data, too, which show that minorities overwhelmingly reject that view.
Policies and laws are tools to establish order. Like any tool, they can be abused. The first drug laws in North America, dating back to the late nineteenth and early twentieth centuries, arguably fixated on opium as a legal pretext to harass Asian immigrants, for example. But no reasonable person would argue that laws against home invasion, murder, or theft are “racist” because they have been misapplied in past cases. Absent supporting evidence, leaping from “this tool is sometimes used in racist ways” to “this tool is essentially racist” is kindergarten-level reasoning.
Yet this is precisely what institutions and activist groups throughout the Western world have done. The Drug Policy Alliance, a U.S.-based organization, suggests that drug prohibition is rooted in “racism and fear.” Harm Reduction International, a British NGO, argues for legalization on the grounds that drug prohibition entrenches “racialized hierarchies, which were established under colonial control and continue to dominate today.” In Canada, where I live, the top public health official in British Columbia, our most drug-permissive province, released a pro-legalization report last summer claiming that prohibition is “based on a history of racism, white supremacy, paternalism, colonialism, classism and human rights violations.”
These claims ignore how drug prohibition has been and remains popular in many non-European societies. Sharia law has banned the use of mind-altering substances since the seventh century. When Indigenous leaders negotiated treaties with Canadian colonists in the late 1800s, they asked for “the exclusion of fire water (whiskey)” from their communities. That same century, China’s Qing Empire banned opium amid a national addiction crisis. “Opium is a poison, undermining our good customs and morality,” the Daoguang emperor wrote in an 1810 edict.
Today, Asian and Muslim jurisdictions impose much stiffer penalties on drug offenders than do Western nations. In countries like China, Saudi Arabia, Iran, Singapore, and Thailand, addicts and traffickers are given lengthy prison sentences or executed. Meantime, in Canada and the United States, de facto decriminalization has left urban cores littered with syringes and shrouded in clouds of meth.
The anti-drug backlash building in North America appears to be spearheaded by racial minorities. When Chesa Boudin, San Francisco’s former district attorney, was recalled in 2022, support for his ouster was highest among Asian voters. Last fall, 73 percent of Latinos backed California’s Proposition 36, which heightened penalties for drug crimes, while only 58 percent of white respondents did.
In Canada, the first signs of a parallel trend emerged during Vancouver’s 2022 municipal election, where an apparent surge in Chinese Canadian support helped install a slate of pro-police candidates. Then, in British Columbia’s provincial election last autumn, nonwhite voters strongly preferred the BC Conservatives, who campaigned on stricter drug laws. And in last month’s federal election, within both Vancouver and Toronto’s metropolitan areas, tough-on-crime conservatives received considerable support from South Asian communities.
These are all strong indicators that racial minorities do not, in fact, universally favor drug legalization. But their small population share means there is relatively little polling data to measure their preferences. Since only 7.6 percent of Americans are Asian, for example, a poll of 1,000 randomly selected people will yield an average of only 76 Asian respondents—too small a sample from which to draw meaningful conclusions. You can overcome this barrier by commissioning very large polls, but that’s expensive.
Nonetheless, last autumn, the Centre for Responsible Drug Policy (a nonprofit I founded and operate) did just that. In partnership with the Macdonald-Laurier Institute, we contracted Mainstreet Research to ask over 12,000 British Columbians: “Do you agree or disagree that criminalizing drugs is racist?”
The results undermine progressives’ assumptions. Only 26 percent of nonwhite respondents agreed (either strongly or weakly) that drug criminalization is racist, while over twice as many (56 percent) disagreed. The share of nonwhite respondents who strongly disagreed was three times larger than the share that strongly agreed (43.2 percent versus 14.3 percent). These results are fairly conclusive for this jurisdiction, given the poll’s sample size of 2,233 nonwhite respondents and a margin of error of 2 percent.
Notably, Indigenous respondents seemed to be the most anti-drug ethnic group: only 20 percent agreed (weakly or strongly) with the “criminalization is racist” narrative, while 61 percent disagreed. Once again, those who disagreed were much more vehement than those who agreed. With a sample size of 399 respondents, the margin of error here (5 percent) is too small to confound these dramatic results.
We saw similar outcomes for other minority groups, such as South Asians, Southeast Asians, Latinos, and blacks. While Middle Eastern respondents also seemed to follow this trend, the poll included too few of them to draw definitive conclusions. Only East Asians were divided on the issue, though a clear majority still disagreed that criminalization is racist.
As this poll was limited to British Columbian respondents, our findings cannot necessarily be assumed to hold throughout Canada and the United States. But since the province is arguably the most drug-permissive jurisdiction within the two countries, these results could represent the ceiling of pro-drug, anti-criminalization attitudes among minority communities.
Legalization proponents and their progressive allies take pride in being “anti-racist.” Our polling, however, suggests that they are not listening to the communities they profess to care about.
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By Adam Zivo
Harm-reduction activists claim evidence supports “safer supply,” but their studies don’t back that up.
Canada, where I call home, is the only jurisdiction in the world that hands out free addictive drugs to addicts. Under the “safer-supply” policy, Canadian health authorities distribute hydromorphone—an opioid as potent as heroin—as well as, to a lesser degree, oxycodone, pharmaceutical fentanyl, and mild stimulants. These drugs are provided at no cost and, until recently, rarely had to be consumed under medical supervision.
Some American harm-reduction activists claim that Canada’s experience—and studies of it—prove that safer supply saves lives. In reality, the studies they cite are deeply flawed. They rely on weak methodologies, including biased interviews and self-reported surveys, and fail to isolate the effects of safer supply from those of other interventions. U.S. policymakers should not let such shaky evidence justify similarly misguided policies at home.
Canada piloted safer supply in 2016 with no evidence that it worked. Some clinical trials suggested that administering pharmaceutical-grade heroin under careful medical supervision could stabilize severely addicted drug users. But advocates took this evidence and claimed that it supported their safer-supply experiment, despite crucial dissimilarities—the most important being the lack of witnessed consumption.
Over the following years, radical activist-scholars produced numerous evaluations and studies declaring that safer supply “saves lives” and improves recipients’ quality of life. As Canada expanded program access nationwide in 2020, policymakers latched on to this “evidence-based” experiment, condemning critics as anti-science.
This evidence is predominantly composed of qualitative studies, which rely not on data but on interviews with safer-supply recipients and providers. The interviewees naturally say that the program is wonderful and has few downsides. Advocates then frame these responses as objective evidence of success.
Notably, the studies never reach out to those who might provide negative evaluations of safer supply—doctors, addicts uninvolved with these programs, or individuals newly in recovery. Addiction experts throughout Canada have dismissed these studies as glorified customer testimonials.
Some studies involve surveys, converting patient responses into quantitative data that can be statistically analyzed. For example, the London InterCommunity Health Centre (LIHC), one of Canada’s leading safer-supply prescribers, publishes survey-based evaluations that claim approximately half of its patients reduced their fentanyl consumption after enrollment. This quantitative method does not change the unreliability of self-reported data, however, and there’s nothing that keeps patients from giving false answers if it suits their interests.
A 2024 study conducted by Brian Conway, director of Vancouver’s Infectious Disease Centre, indirectly validated these criticisms. The study distributed surveys to 50 of his safer-supply patients and then collected urine samples immediately afterward. Conway discovered that, while only 4 percent of these patients self-reported diverting (selling or trading) all their safer-supply hydromorphone, 24 percent had no hydromorphone in their urine. That suggests a significant portion of patients lied on their surveys.
A few studies use administrative health data to show that enrollment in federally funded safer-supply programs correlates with improved health outcomes. But these studies make no effort to determine whether the free drugs themselves are responsible. The real driver could be the extensive wraparound services the programs offer, such as housing assistance and access to primary care. It’s like giving an obese man a personal trainer and a daily slice of cake—and then, when he loses weight, crediting the cake.
Last year, the British Columbia Centre for Disease Control (BCCDC) published a study in the British Medical Journal examining the health data of 5,882 drug users over an 18-month period between 2020 and 2021. The study found that individuals who received safer-supply opioids were 61 percent less likely to die over the following week than those who didn’t. This number rose to 91 percent for those receiving safer-supply opioids for four or more days in a single week.
Encouraging, right? But not so fast. When a team of seven addiction physicians reviewed the study, they discovered that the researchers misrepresented their data. Safer-supply patients are often co-prescribed traditional addiction medications, such as methadone and Suboxone, that have long been proven to reduce overdoses and deaths (these medications are often referred to as opioid agonist therapy, or OAT). The study data showed that safer-supply patients who did not also receive OAT medications were just as likely to die as those who did not get safer supply. In other words, the benefits that the BCCDC researchers touted were likely driven primarily by OAT, not safer supply.
The study data also showed no significant mortality reductions after one year of accessing safer supply. One wonders why the researchers chose to fixate on the one-week follow-up numbers.
Most recently, a study published in JAMA Health Forum found that, between 2020 and 2022, British Columbia’s safer-supply policy was associated with a 33 percent increase in opioid hospitalizations and no change to drug-related mortality. The researchers arrived at this conclusion by comparing the province’s publicly available health data with data from a control group made up of a handful of other Canadian provinces. The study raised further doubts about safer supply’s scientific basis.
Over the past two years, Canadian policymakers have openly, if reluctantly, acknowledged that safer supply is not as well-supported as they once claimed. British Columbia’s 2023 safer supply fentanyl protocols clearly state, for example, that “there is no evidence available supporting this intervention, safety data, or established best practices for when and how to provide it.” Similarly, the province’s top doctor released a report in early 2024 admitting that the experiment is “not fully evidence based.” Just last autumn, the Canadian Research Initiative in Substance Matters acknowledged in a major presentation that safer supply is supported by “essentially low-level evidence.”
This about-face has been hastened by investigative media reports confirming that safer-supply drugs were being diverted to the black market, enriching organized crime and corrupt pharmacies in the process. Public support for the policy has apparently declined, as once-taboo criticism becomes normalized among Canadian politicians and commentators. The Canadian federal government has now quietly defunded its safer-supply programs (though independent prescribers still operate), while British Columbia mandated earlier this year that all safer-supply drugs be consumed under supervision.
Harm-reduction activists nonetheless maintain that the blowback against safer supply represents a “moral panic,” and that politics is overriding evidence-based policymaking. “Safer supply saves lives! Follow the science!” they insist. International policymakers, especially in the United States, should see through these misrepresentations.
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