This February, B.C pledged to reintroduce witnessed dosing to its controversial safer supply program.

Safer supply programs provide prescription opioids to people who use drugs. Witnessed dosing requires patients to consume those prescribed opioids under the supervision of a health-care professional, rather than taking their drugs offsite.

The province said it was reintroducing witnessed dosing to “prevent the diversion of prescribed opioids and hold bad actors accountable.”

But experts are saying the government’s interim guidelines, released April 29, are fundamentally flawed.

“These guidelines — just as any guidelines for safer supply — do not align with addiction medicine best practices, period,” said Dr. Leonara Regenstreif, a primary care physician specializing in substance use disorders. Regenstreif is a founding member of Addiction Medicine Canada, an advocacy group that represents 23 addiction specialists.

Addiction physician Dr. Michael Lester, who is also a founding member of the group, goes further.

“Tweaking a treatment protocol that should not have been implemented in the first place without prior adequate study is not much of an advancement,” he said.

Witnessed dosing

Initially, B.C.’s safer supply program was generally administered through witnessed dosing. But in 2020, to facilitate access amidst pandemic restrictions, the province moved to “take-home dosing,” allowing patients to take their prescription opioids offsite.

After pandemic restrictions were lifted, the province did not initially return to witnessed dosing. Rather, it did so only recently, after a bombshell government report alleged more than 60 B.C. pharmacies were boosting sales by encouraging patients to fill unnecessary opioid prescriptions. This incentivized patients to sell their medications on the black market.

B.C.’s interim guidelines, developed by the BC Centre on Substance Use at the government’s request, now require all new safer supply patients to begin with witnessed dosing.

But for existing patients, the guidelines say prescribers have discretion to determine whether to require witnessed dosing. The guidelines define an existing patient as someone who was dispensed prescription opioids within the past 30 days.

The guidelines say exemptions to witnessed dosing are permitted under “extraordinary circumstances,” where witnessed dosing could destabilize the patient or where a prescriber uses “best clinical judgment” and determines diversion risk is “very low.”

Holes

Clinicians say the guidelines are deliberately vague.

Regenstreif described them as “wordy, deliberately confusing.” They enable prescribers to carry on as before, she says.

Lester agrees. Prescribers would be in compliance with these guidelines even if “none of their patients are transferred to witnessed dosing,” he said.

In his view, the guidelines will fail to meet their goal of curbing diversion.

And without witnessed dosing, diversion is nearly impossible to detect. “A patient can take one dose a day and sell seven — and this would be impossible to detect through urine testing,” Lester said.

He also says the guidelines do not remove the incentive for patients to sell their drugs to others. He cites estimates from Addiction Medicine Canada that clients can earn up to $20,000 annually by selling part of their prescribed supply.

“[Prescribed safer supply] can function as a form of basic income — except that the community is being flooded with addictive and dangerous opioids,” Lester said.

Regenstreif warns that patients who had been diverting may now receive unnecessarily high doses. “Now you’re going to give people a high dose of opioids who don’t take opioids,” she said.

She also says the guidelines leave out important details on adjusting doses for patients who do shift from take-home to witnessed dosing.

“If a doctor followed [the guidelines] to the word, and the patient followed it to the word, the patient would go into withdrawal,” she said.

The guidelines assume patients will swallow their pills under supervision, but many crush and inject them instead, Regenstreif says. Because swallowing is less potent, a higher dose may be needed.

“None of that is accounted for in this document,” she said.

Survival strategy

Some harm reduction advocates oppose a return to witnessed dosing, saying it will deter people from accessing a regulated drug supply.

Some also view diversion as a life-saving practice.

Diversion is “a harm reduction practice rooted in mutual aid,” says a 2022 document developed by the National Safer Supply Community of Practice, a group of clinicians and harm reduction advocates.

The group supports take-home dosing as part of a broader strategy to improve access to safer supply medications. In their document, they say barriers to accessing safer supply programs necessitate diversion among people who use drugs — and that the benefits of diversion outweigh the risks.

However, the risks — and harms — of diversion are mounting.

People can quickly develop a tolerance to “safer” opioids and then transition to more dangerous substances. Some B.C. teenagers have said the prescription opioid Dilaudid was a stepping stone to them using fentanyl. In some cases, diversion of these drugs has led to fatal overdoses.

More recently, a Nanaimo man was sentenced to prison for running a highly organized drug operation that trafficked diverted safer supply opioids. He exchanged fentanyl and other illicit drugs for prescription pills obtained from participants in B.C.’s safer supply program.

Recovery

Lester, of Addiction Medicine Canada, believes clinical discretion has gone too far. He says take-home dosing should be eliminated.

“Best practices in addiction medicine assume physicians prescribing is based on sound and thorough research, and ensuring that their prescribing does not cause harm to the broader community, as well as the patient,” he said.

“[Safer supply] for opioids fails in both these regards.”

He also says safer supply should only be offered as a short-term bridge to patients being started on proven treatments like buprenorphine or methadone, which help reduce drug cravings and manage withdrawal symptoms.

B.C.’s witnessed dosing guidelines say prescribers can discuss such treatment options with patients. However, the guidelines remain neutral on whether safer supply is intended as a transitional step toward longer-term treatment.

Regenstreif says this neutrality undermines care.

“[M]ost patients I’ve seen with opioid use disorder don’t want to have [this disorder],” she said. “They would rather be able to set goals and do other things.”

Oversight gaps

Currently, about 3,900 people in B.C. participate in the safer supply program — down from 5,200 in March 2023.

The B.C. government has not provided data on how many have been transitioned to witnessed dosing. Investigative journalist Rob Shaw recently reported that these data do not exist.

“The government … confirmed recently they don’t have any mechanism to track which ‘safe supply’ participants are witnessed and which [are] not,” said Elenore Sturko, a Conservative MLA for Surrey-Cloverdale, who has been a vocal critic of safer supply.

“Without a public report and accountability there can be no confidence.”

The BC Centre on Substance Use, which developed the interim guidelines, says it does not oversee policy decisions or data tracking. It referred Canadian Affairs’ questions to B.C.’s Ministry of Health, which has yet to clarify whether it will track and publish transition data. The ministry did not respond to requests for comment by deadline.

B.C. has also not indicated when or whether it will release final guidelines.

Regenstreif says the flawed guidelines mean many people may be misinformed, discouraged or unsupported when trying to reduce their drug use and recover.

“We’re not listening to people with lived experience of recovery,” she said.

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.