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Reckless: British Columbia’s “safe supply” fentanyl tablet experiment

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9 minute read

From the MacDonald Laurier Institute

By Adam Zivo

While safer supply sounds nice in theory, addiction experts have found that drug users are reselling (“diverting”) a significant portion of their free hydromorphone on the black market to purchase harder substances. This has fuelled new addictions while generating handsome profits for organized crime.

Adam Zivo reviews the latest drug protocols adopted by the BC government and reports on their alarming lack of evidence and accountability.

British Columbia’s new drug protocols allow doctors throughout the province to prescribe “safer supply” drugs in a reckless manner.

In a new report titled Reckless: British Columbia’s “safe supply” fentanyl tablet experiment, Adam Zivo reviews the newest drug protocols adopted by the BC government, documenting the evolution of “safe supply” opioid programs in Canada since 2020. Zivo reports on the concerning lack of evidence behind the protocols, how they undermine recovery, drive diversion to the black market, and ruin the lives of young Canadians.

The new protocols not only avoid any requirement for drug users to first try evidence-based recovery programs before receiving high-potency opioids, but also allow minors to receive them, with no reference to the rights and roles of parents or even a minimum age for safer supply clients.

Of deep concern is also the BC government’s approach of continually increasing access to “safe” opioids despite openly admitting that there is no evidence of proven benefits or safety. The protocols also require that clients be told that their access to free fentanyl and sufentanil will almost certainly be cut off if they are hospitalized, or if they attend withdrawal management or substance use treatment facilities.

Zivo explains: “The prospect of free fentanyl and sufentanil creates powerful incentives to sign away one’s rights to evidence based treatment, so the province is essentially exploiting clients’ addictions so that it can experiment on them without taking legal responsibility for potential harms.”

Zivo adds that “one can reasonably expect that a significant portion of the fentanyl tablets being distributed by the BC government will end up being traded or resold on the black market,” explaining how mass diversion is already a major issue for weaker “safer supply” opioids like hydromorphone.

While addiction experts have been overwhelmingly critical of unsupervised safer supply, Zivo notes that many believe that the solution is not to abolish but to reform the program so that drugs can be provided more responsibly. By receiving safer supply as a temporary intervention, addicted users can transition to recovery-oriented treatments such as opioid agonist therapy (OAT.)

“It would not take much to reshape BC’s safer supply fentanyl and sufentanil programs into something more responsible and genuinely safe,” concludes Zivo. “There is nothing preventing the province from redesigning safer supply as a recovery-oriented intervention.”

To learn more, read the full paper here:

PDF of paper

Executive Summary

This past August, British Columbia’s government quietly launched new protocols that allow doctors to prescribe “safer supply” fentanyl tablets and liquid sufentanil. Fentanyl is at least 10 times stronger than hydromorphone and sufentanil, which is derived from fentanyl, is a further 5 to 10 times more potent than its parent drug. While in theory these drugs could save lives if provisioned cautiously, the way the province has chosen to distribute these dangerous opioids is nothing short of reckless.

There is evidence to support the use of opioid agonist therapy (“OAT”) medications, such as methadone, buprenorphine, and slow release oral morphine in addiction treatment, but the government’s new protocols extrapolate OAT-related evidence to support “safer supply” fentanyl even though the two therapies have little in common. In fact, the government’s protocols stress that providing safer supply fentanyl or sufentanil is “not a treatment for opioid use disorder” and that “there is no evidence available supporting this intervention, safety data, or established best practices for when and how to provide it.” It is deeply concerning that the BC government has, over the past several years, significantly increased access to “safe” fentanyl and sufentanil despite openly admitting that there is no evidence showing that these interventions provide any benefits and can be implemented safely.

“Safer supply” programs claim to reduce overdoses and deaths by providing free pharmaceutical-grade drugs as alternatives to potentially tainted illicit substances. While safer supply sounds nice in theory, addiction experts have found that drug users are reselling (“diverting”) a significant portion of their free hydromorphone on the black market to purchase harder substances. This has fuelled new addictions while generating handsome profits for organized crime. Some patients have even been coerced into securing safer supply they didn’t need. Pimps and abusive partners pressure vulnerable women into securing as much hydromorphone as possible for black market resale. Other vulnerable patients, such as the geriatric and disabled, have been robbed of their safer supply outside of pharmacies.

There are other issues with the protocols, too. They require that clients be told that their access to free fentanyl and sufentanil will almost certainly be cut off if they are hospitalized, or if they attend withdrawal management or substance use treatment facilities. This creates powerful disincentives for drug users to seek life-saving health care. Further, none of the safer supply protocols by the British Columbia Centre on Substance Use (BCCSU) discuss the rights and roles of the parents of minors struggling with addiction. It appears that health care providers can give fentanyl and sufentanil to minors regardless of whether parents are aware of, or consent to, this intervention. The protocols do not specify a minimum age for safer supply clients.

It would not take much to reshape BC’s safer supply fentanyl and sufentanil programs into something more responsible and genuinely safe. There is nothing preventing the province from redesigning safer supply as a recovery-oriented intervention. Experts argue that safer supply could be helpful if used as a temporary intervention that helps severely-addicted users make the transition to recovery-oriented treatments, such as OAT.

There is also nothing stopping the province from fixing many of the issues with the safer supply program – including lax safeguards for youth. Any safer supply model must require supervised consumption. It is the absence of this supervision that has enabled the mass diversion of safer supply drugs onto the black market.

Governments have a duty to provide evidence-based treatment to vulnerable citizens and consider collateral harms to others. Rather than fulfil this duty, the BC government is committing to risky and highly experimental interventions that lack an appropriate evidence base.

Adam Zivo is a freelance writer and political analyst best known for his weekly columns in the National Post. He holds a Master of Public Policy from the Munk School of Global Affairs and Public Policy and recently founded the Centre for Responsible Drug Policy, a nonprofit advocacy organization.

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Addictions

Leading addiction doctor warns of Canada’s ‘safer supply’ disaster

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A man considers using a prescription opioid. Credit: Dreamstime

By Liam Hunt

Addiction physician Dr. Sharon Koivu has seen the effects of safer supply programs in her clinical practice and personal life — and is sounding the alarm

Dr. Sharon Koivu, an addiction physician and parent, believes her son might not have survived to adulthood if Canada’s “safer supply” programs had been in effect during his adolescence.

Having worked on the front lines of Ontario’s opioid crisis, she views these programs as a catastrophic failure.

In an extended interview, Koivu explained the unintended consequences of these programs, which offer free tablets of hydromorphone — an opioid about as strong as heroin – to vulnerable patients with a history of addiction. While advocates of safer supply claim it mitigates the use of more dangerous illicit substances, there is evidence that most users divert — that is, sell or trade — their hydromorphone to acquire stronger substances.

Safer supply was first piloted in London, Ont., in 2016, before being widely expanded across Canada in 2020 with the help of generous federal grants. While the program looked good on paper, Koivu, who provides comprehensive addiction consultation services at a London-based hospital, saw a different reality: her patients were destabilizing, relapsing and fatally overdosing because of safer supply.

Koivu says that “one hundred percent” of her colleagues working in addiction medicine have noticed safer supply diversion. Some patients have told her they have been threatened with violence if they do not procure and divert these drugs. She estimates that, because of safer supply, tens of thousands of diverted hydromorphone pills — also known as “Dilaudid,” “dillies” or “D8s” — are flooding into Canadian streets every day.

For context, just two or three of these pills, if snorted, are enough to induce an overdose in a new user.

This influx has caused the drug’s street price to crash by as much as 95 per cent. While 8-milligram hydromorphone pills used to sell for $20 each several years ago, they can now be bought for as little as a dollar or two. These rock-bottom prices have ignited a new wave of addictions and relapses, and lured opioid-naive individuals into experimenting with what is essentially pharmaceutical heroin.

Koivu estimates that 80 per cent of her opioid-using patients now take diverted hydromorphone.

“The biggest harm is that we’ve turned on the tap and we’ve made everything cheap, which is leading to a large increase in the number of people becoming addicted and suffering,” she said.

“It is the most serious issue that I’ve seen in my lifetime.”

Safer supply programs seem to regularly overprescribe opioids without considering patients’ actual needs, Koivu says. Patients have come into her hospital with prescriptions that provide 40 eight-milligram hydromorphone pills a day, even though they can only tolerate 10 pills.

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‘That attraction is horrific’

Throughout the first few decades of Koivu’s career, almost “everyone” in her patient pool developed addictions due to childhood traumas or from mishandling opioids prescribed for chronic pain.

Since the advent of safer supply, the origins of new opioid addictions have shifted toward social or recreational exposure. Concerningly, this exposure often occurs in patients’ adolescent years.

“I’m seeing an increase in youth becoming addicted,” said Koivu, who has had patients as young as 15 tell her their addictions began through diverted hydromorphone.

“Almost everyone I see who’s started since 2018 started recreationally. It started as something that was at a party. It’s now a recreational drug at the youth level.”

Parents often seem completely unaware of the problem. Some have told Koivu they overheard their children discussing the availability of “D8s” at their highschools, only to later realize — when it was too late — they were referring to opioids.

“You can’t walk into your house with a six-pack of beer. If you’re smoking weed, people can smell it. But you can walk into your house with a lot of [tablets] in your pocket. So, it’s cheap, really easy to hide, and is even called ‘safe’ by the government. I think that attraction is horrific.”

“Our youth are dying at a higher rate … and we have a lot more hydromorphone found in [their bodies] at the time of death.”

While safer supply programs claim to make communities safer, Koivu’s lived experiences suggest the opposite. She used to reside in London’s Old East Village, where the city’s first safer supply program opened in 2016, but moved away after watching her neighbourhood deteriorate from widespread crime, overdoses and drug trafficking.

“I moved there to support a supervised injection site,” said Koivu. “Then I watched that community drastically change when safer supply was implemented. … I would go for walks and directly see diversion taking place. Homelessness is very complicated, but this has absolutely fueled it in ways that are unconscionable.”

Dr. Sharon Koivu

Koivu characterizes the evidentiary standards used by advocates of safer supply as “deeply problematic.” She says many of the studies supporting safer supply are qualitative — meaning they rely on interviews — and use anecdotal data from patients who have a vested interest in perpetuating the program.

While Koivu has been blowing the whistle on safer supply programs for years, her concerns largely went unnoticed until recently. She has faced years of harassment and denigration for her views.

“When I came to say I’m concerned about what I’m seeing: the infections, the suffering, the encampments … I was literally told that I was lying,” she said.

Last month, the London Police Service provided the National Post with data showing that annual hydromorphone seizures increased by 3,000 per cent after access to safer supply was significantly expanded in 2020. The newspaper has since raised questions about why this data was not released earlier and whether the police stonewalled attempts to investigate the issue.

Koivu considers herself a lifelong progressive and has historically supported the New Democratic Party. But she is concerned many left-leaning politicians have ignored criticism of safer supply. Many seemingly believe that opposition to it is inherently conservative.

“I went to a hearing in Ottawa of a standing committee to talk about addiction,” she said. “We had five minutes to give a talk, and then two hours to answer questions, [but] I didn’t receive any questions from the NDP or the Liberals.”

Although Koivu believes safe supply can play a role in the continuum of care for opioid addiction, she says it must be executed in a meticulous manner that prevents diversion and emphasizes pathways to recovery.

“It needs to be part of a comprehensive strategy to help people get their lives back. And right now, it’s not.”

Above all, it is Koivu’s experience as a mother that drives her to criticize safer supply. One of her sons struggled with opioid addiction as a young adult. Although he eventually recovered, the experience could have killed him.

“Had this program been around … my family could have been another statistic from an opioid death. That drives me. Because it’s very real, and it’s very personal.”

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Addictions

Opioid seizures exploded by 3,000% in Ontario city after “safer supply” experiment

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A London police drug seizure in April included 9,298 Dilaudid eight milligram tablets.

By Matthew Hannick

Doctors and journalists wondering why local police failed to disclose concerning statistic to public sooner

Nigel Stuckey saved more lives during the last five years of his policing career than the previous three decades combined. “Every time you go back to the street, it has a different flavour,” said Stuckey, a former sergeant with the London Police Service (LPS) who retired in 2022. “As a frontline police officer, you are constantly going to overdoses in the city. I’ve administered Narcan to multiple people, and this is just something that never existed before.”

Stuckey first noticed a dramatic increase in overdoses and drug-related crimes occurring throughout his city – London, Ontario – in 2019. While the reasons behind this increase were initially unclear, recent data released by the LPS suggest that “safer supply” programs may be contributing to the problem.

Safer supply programs aim to save lives by providing drug users with pharmaceutical-grade alternatives to the untested street supply. That typically means distributing hydromorphone, a heroin-strength opioid, as an alternative to illicit fentanyl. However, addiction experts say the program is having the opposite effect, as many people who are enrolled in safer supply programs are illegally selling or trading their prescribed hydromorphone on the black market, a practice known as “diversion.”

Harm reduction advocates claim that safer supply diversion is not a significant issue, but according to an investigation into London Police Services (LPS) seizure data by journalist Adam Zivo, the number of hydromorphone tablets seized in London increased by 3,000 per cent after access to safer supply was greatly expanded in 2020.

In 2019, the LPS seized fewer than 1,000 hydromorphone tablets. This number jumped significantly in 2020 and continued to rise afterwards, reaching 30,000 tablet seizures last year – an unprecedented amount. The London police estimate that last year’s record will be met or exceeded by the end of 2024.

Doctors have said that this is only representative of a small fraction of what is actually out there, and that just 3-4 of these pills, if snorted, are enough to induce an overdose in a new user.

Some people are wondering why this data wasn’t released months, if not years, earlier.

Dr. Sharon Koivu, a London-based addiction physician, was among the first to recognize the harms of safer supply and has been warning the public about widespread diversion for years. Based on her clinical experiences, she believes that diverted safer supply hydromorphone is causing new addictions and falling into the hands of youth.

When Koivu tried to speak out against safer supply and call attention to diversion and an overall lack of program transparency, she was bullied and told that the suffering she was witnessing didn’t exist. This harassment was so severe that her mental health deteriorated and she worried about whether her career had been irreversibly damaged – yet the London police had quietly possessed data showing that she was right all along.

“It’s become an ideological thing,” she said. “People seem to have doubled down on the information they have. They don’t want to hear from someone who has information and concerns that don’t align with their, I’m going to say, ideology – because it’s not science.”

News of skyrocketing hydromorphone seizures might have remained hidden from the public had it not been for a major bust earlier this year.

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On April 12, the London police announced a drug seizure which included 9,298 hydromorphone eight-milligram tablets. When Zivo inquired into this seizure, he received no answers to his questions for almost two months. He says that he was “stonewalled” and that the police seemed unwilling to release key data until it became impossible for them not to.

Zivo found it particularly concerning that the 2019-2023 hydromorphone seizure data was not released earlier. “Journalists and addiction physicians have been trying to raise the alarm about this issue for years,” he said, “but have been called liars, grifters and fearmongers, despite the fact that data validating their concerns existed and was held by the London Police Service.”

Stuckey, who now works as a documentary filmmaker covering London’s homelessness, addiction and mental health crisis, had a similar experience when he queried the LPS about the 9,290 hydromorphone pills seized this April.

Despite multiple requests for information about a possible connection to safer supply, the police service did not get back to him. He expressed frustration at the police’s unresponsiveness and worried that a lack of government transparency is endangering both the general public and law enforcement officers.

“Members of the London Police Service are being put in harm’s way dealing with organized crime and firearms to take drugs off the street, which were provided by the federal government. It’s absolute lunacy that we are paying one branch of government to rid a problem that was created by another branch of government,” said Stuckey.

It would be deeply concerning if the LPS knowingly withheld data pertaining to safer supply diversion. Not only has the failure to publish such data hindered informed public debate and policy development, it has also compromised the safety of the very communities which police are tasked with protecting.

According to Zivo, safer supply programs have benefitted from the silence of powerful institutions like the LPS. He said that, as there seems to be significant institutional resistance to acknowledging the community harms of safer supply, then more attention and trust should be given to local grassroots-level addiction medicine practitioners “who are bravely testifying to what they are seeing in their clinics.”

However, Dr. Koivu thinks that “the tide is turning” and that more people are beginning to understand the harms of safer supply

“I think it’s unfortunate that this data wasn’t made available sooner, when it was relevant to the funding of these programs and the changes we’re seeing in the city. The police need to be accountable for that. I really don’t understand their rationale for not addressing this” she said. “They hung me out to dry while knowing that what I was saying was accurate. If the police are afraid to come forward, no wonder physicians are afraid to come forward, too.”

A guest post by
Matthew
Matthew Hanick is a journalist living in Toronto.
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