B.C. to provide regulated substances under safe supply directive to mitigate drug overdoses

British Columbia will require all health authorities to develop programs that provide pharmaceutical-grade opioids, stimulants and other addictive substances to street-drug users, under a policy directive on safe supply aimed at curbing overdose deaths.

However, the medications to be offered, and who will receive them, will still be at the discretion of individual programs and clinicians – one of the principal barriers to expanding access. And they can only be offered in certain “programmatic” or clinical settings, according to the policy directive.

The document, which was obtained by The Globe and Mail, reveals that the provincial government recognizes that providing drug users with regulated versions of street drugs such as fentanyl, cocaine, and methamphetamine can reduce deaths and other drug-related harms. But the government is reluctant to expand access quickly, the document suggests.

“Health system partners” consulted for the policy development also expressed “significant reservations” about such an approach, according to the document. Some said prescribing drugs for harm-reduction purposes was not part of their training and that prescribing potentially dangerous substances such as opioids must be done with care and be guided by clear evidence.

“Some key partners, including some prescribers, have expressed reservations about the approach outlined in this document, and others have noted that an approach that begins with programmatic settings will not provide broad access for people who use substances,” the document says. “We recognize that we have been unable to address all concerns, but we also recognize that we must start somewhere.”

The province’s safe supply plan will be rolled out in phases, programs will be required to develop clinical protocols and continuing evaluation will guide future steps. Safe supply programs operated by health authorities, as well as those funded through Health Canada grants, will be required to offer alternative drugs in either a setting created specifically for the provision of safe supply or a similar health clinic.

Prescribed safe supply drugs such as fentanyl patches or tablets and injectable hydromorphone – as well as related pharmacy services – will be covered under PharmaCare, the province’s drug plan. Stimulants are expected to be added at a later date.

Clients will not have to engage in treatment if they do not wish to do so.

Prescribers that have offered safe supply drugs under Risk Mitigation in the Context of Dual Public Health Emergencies – a similar but separate piece of safe supply guidance specific to substance use during the pandemic – will be permitted to continue doing so.

The new policy is expected to be released publicly later this week.

Minister of Mental Health and Addictions Sheila Malcolmson was not available for an interview before the release of the policy. The College of Physicians and Surgeons of British Columbia (CPSBC) said registrar Heidi Oetter was not available for an interview and did not respond when asked when she would be.

Safe supply is predicated on the idea that, by prescribing pharmaceutical-grade versions of illicit drugs, health care providers can lower or sever a patient’s reliance on the unsafe black-market supply, thereby reducing the number of overdose events and other related harms.

Proponents say safe supply is not treatment, but rather a harm-reduction strategy made urgently necessary by an increasingly volatile illicit drug supply and record-shattering numbers of overdose deaths. The powerful synthetic opioid fentanyl has been detected in 85 per cent of drug deaths this year, up from 5 per cent in 2012, and postmortem toxicology results show a growing percentage with “extreme” fentanyl concentrations during the pandemic.

Further testing on a subset of drug deaths shows that benzodiazepines – a class of drugs commonly used to treat sleep and anxiety disorders, but which increase the risk of overdose and death when combined with opioids – were detected in 60 per cent of samples in May, up from 15 per cent last July.

More than 7,586 people have died from illicit drug toxicity in B.C. since 2016, the year the province declared a public-health emergency because of a surge in overdose deaths. Five or six people are still dying every day.

Donald MacPherson, executive director of the Canadian Drug Policy Coalition, said the health authority mandate and low-threshold access outlined in the policy directive are good, but they’re not enough.

“This is a world-class disaster that’s unfolding, and you don’t respond to a disaster with small increments every eight or 12 months,” he said.

Mr. MacPherson said the urgency and mobilization seen during the pandemic should be applied to the toxic-drug crisis, with public-health clinics, pharmacies and other frontline organizations working to quickly connect people at risk of overdose with pharmaceutical alternatives.

He also said the directive does not provide for the use of diacetylmorphine (heroin), a drug that has been prescribed for decades in parts of Europe and has been available in a very limited capacity in B.C. since 2005.

“That is astounding to me, that the most obvious substance, with a 30-year evidence base to consider, is not being used when you have a program in your province already,” he said.

Jenny McDougall, who advocates for safe supply and opioid agonist therapy with the non-profit Coalition of Substance Users of the North, called the policy “a start.” She is pleased to see a few more medications being made available for safe supply, but said it was “disgraceful” that health authorities have to be mandated to support the programs.

Ms. McDougall said she has heard from physicians who refuse to prescribe for this purpose, citing worries such as drug diversion and being audited by the CPSBC.

“The doctors up here don’t want any part of it,” she said. “I believe if there was direction from the [college], there would be a little bit less of a problem.”

Jordan Westfall, co-founder and president of the Canadian Association for Safe Supply, said he is hopeful the directive will encourage some expansion, but cautioned that regional approaches could also mean inequitable access across the province.

“This is supposed to be a provincial document, but it’s more so like the province setting out some basic parameters and letting each region do [what they want],” he said.

Preliminary evaluations from risk-mitigation prescribing in B.C. show that 6,498 people were given pharmaceutical alternatives between March 27, 2020, and Feb. 28, 2021. Opioids were dispensed to 3,771 people (58 per cent), stimulants to 1,220 (18.8 per cent), alcohol withdrawal management medications to 1,431 (22 per cent) and benzodiazepines to 784 (12.1 per cent). (Some received more than one type of drug.)

Eighty-two people in the group died during that period, with seven receiving medications on the day they died. But of the 45 deaths in which the cause was specified, none was due to illicit drug toxicity. The cause of death was not available for the remaining 37 (45 per cent) because of a delay in vital statistics data.

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