Five months after the pandemic forced the closing of his Saskatoon tattoo and piercing parlour, Sheldon Tarry found himself living in an encampment in Victoria’s Beacon Hill Park, at once fearing death and wanting to die.
At 54, he had lost his business, his home and his life’s savings. His left leg, ravaged by a car accident and resulting infection, would need to be amputated. And the opioid addiction he had struggled with off and on since a workplace accident many years ago was costing him $300 a day on the street, driving him to rob people at knifepoint out of desperation.
He knew each hit could be his last; he had overdosed before, and it terrified him. But at this point, he felt he had little to lose.
In September, an outreach worker approached Mr. Tarry in Victoria, where he had moved in hopes of starting over, to ask if he had enough to eat. It was a conversation that would ultimately lead to an unexpected offer: a free and legal supply of drugs.
The Public Health Agency of Canada calls the toxic drug crisis “one of the most serious public-health crises” in the country’s recent history. In 2020, as the pandemic curtailed harm reduction and social services, and disrupted global illicit drug supply chains, drug deaths shattered Canadian records. At least 5,233 people died from opioid-related toxicity last year, making it the deadliest year since national surveillance began in 2016, with months worth of data still to be counted.
The situation is only getting worse. Data obtained by The Globe and Mail show fentanyl – the powerful synthetic drug that is driving the surge in deaths – is showing up across Canada in extreme concentrations more frequently than ever before.
For several years, some prescribers in British Columbia have offered tablets of hydromorphone – a medication often used to treat moderate to severe pain from surgery, broken bones or cancer – as an alternative to street opioids, largely in a clinical setting. As the pandemic hit, the province expanded access and allowed for take-home doses.
In March of last year, 677 people in British Columbia were receiving hydromorphone. By December, there were 3,348 – a 395-per-cent increase. The province is now moving to expand prescribing access and developing provincial safe-supply guidance that could include dispensing other drugs, such as fentanyl, cocaine and injectable hydromorphone.
At its best, safe supply is seen as a critical intervention that directly addresses the deadly illicit drug supply – a step toward regulation – and helps connect vulnerable populations with health care and social supports.
At its worst, it’s an easy out for governments that have failed to meaningfully address bad drug policy, broken addiction treatment systems and the root causes of problematic drug use. Even in cities that are most accepting of the concept, the majority of prescribers don’t believe they should be the gatekeepers to a safer drug supply, hindering promised expansions by government.
It is an approach layered in politics. The federal Liberal government has called a safer drug supply a key priority in addressing the overdose crisis, directing $44.2-million so far to programs in B.C., Ontario, Quebec and New Brunswick. But provincial conservative governments have balked at the idea; Alberta’s United Conservative government quietly shut down community-based efforts to launch a single safe-supply program, according to people involved with the dealings.
As debate over safe supply continues, addictions physicians across Canada report soaring levels of opioid tolerance. Andrea Sereda, lead physician of the Safer Supply program at the London InterCommunity Health Centre in Ontario, says new patients coming onto her program in 2019 typically used between one-tenth and half a gram of fentanyl a day. Since early 2020, she says new intakes regularly use around 3.5 grams a day or more.
“I don’t know whether the drug ecosystem is going to crash and course-correct, but I can definitively say that the volume that people are using is profoundly more now than in 2019,” Dr. Sereda says. “We urgently need a rapid expansion of safer-supply programs to meet people where they are at in their drug use before that tolerance continues to go up. When people get to a certain tolerance, it’s harder to catch them with any substitution therapy – safer supply or otherwise.”
‘A population-level intervention’
Safe supply is predicated on the idea that by prescribing regulated medications, health care providers can cut or sever a patient’s reliance on toxic street drugs, thereby reducing overdose events and other related harms.
For illicit opioids such as heroin and fentanyl, the most common alternative are tablets of hydromorphone, which recipients can swallow whole or crush, cook and inject. A qualitative study of 42 participants in a hydromorphone program in Vancouver found that, after several months, the program significantly reduced participants’ illicit drug use and overdose risk and improved their overall health and well-being. Participants frequently accessed the program’s physicians and nurses to address issues such as wound care and pain treatment. They also reported a reduction in illegal or stigmatized forms of income generation, such as shoplifting and sex work.
“Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people’s use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality,” wrote the authors of the study, published this past October in the Journal of Urban Health.
Donald MacPherson, executive director of the Canadian Drug Policy Coalition, says the goal of addiction treatment is to have a functioning system in place so people can access help as soon as they want it. However, treatment is an intentional process that will only ever engage a small percentage of people who use drugs at any one time. “With a harm-reduction approach, you’re looking at more of a population-level intervention,” Mr. MacPherson says. “You’re actually trying to make it safe for every single person who, for whatever reason, is using drugs tonight – that they have a clean syringe, that they don’t get HIV or hepatitis C, that they have a safe supply and don’t get poisoned.”
When a Victoria-based AIDS service organization and peer-driven outreach group partnered last year to launch a safe-supply program, it quickly became clear they would have to offer more than just prescriptions. Some clients couldn’t fill them because they had never been connected to income assistance or the province’s drug plan; others were homeless and didn’t know how to apply for housing. Others still had health conditions such as HIV and hepatitis C that went untreated because they didn’t have primary care providers.
The team assembled a group of doctors, registered nurses, peer-outreach workers and systems navigators, launching as the Victoria SAFER Initiative in September. Since then, SAFER has helped people get government identification and make medical appointments, delivered meals, prescriptions and portable phone chargers, and conducted COVID-19 testing, isolating people when needed. And it has connected more than 100 people to pharmaceutical alternatives.
Corey Ranger, clinical nurse lead at SAFER, says the medication serves as a bridging point to connect clients to other forms of care. “Quite a few people we work with have been incredibly disconnected for a long time,” Mr. Ranger says. “It’s a bit of a snowball effect that starts with [hydromorphone] and ends with a whole myriad of other interventions that are patient-centred.”
When Mr. Ranger approached Mr. Tarry at Beacon Hill Park last fall, a conversation about the infection on Mr. Tarry’s leg ultimately resulted in connections to income assistance, PharmaCare and a prescription for hydromorphone. Those small tablets meant Mr. Tarry no longer woke up with his body twisted into knots, nauseous from withdrawal and ready to do anything to feel better.
He credits that prescription with keeping him from becoming another statistic in Canada’s toxic drug crisis. “If I didn’t have the prescription, I’d either be out hustling or panhandling or whatever, and then buying street drugs that are mainly fentanyl – and that scares me,” Mr. Tarry says during an interview near his tent, where he lived until recently with his nephew and a miniature Japanese Chin named Tuggs. “But they started coming around, got me onto the program, and that started the ball rolling.”
‘The chickens have come home to roost’
Proponents of safe supply say the matter is made urgent by the unprecedented toxicity of the illicit drug supply – namely fentanyl, a synthetic opioid many times stronger than heroin that is lethal in amounts the size of a few grains of salt.
Mr. Tarry attributes his only overdose to the drug. It was the summer of 2019, he was deep in withdrawal from illicit hydromorphone, and a friend offered up some fentanyl with a warning: “Just be careful with this stuff.”
Mr. Tarry cooked up a tiny pebble and injected. “Before I could even get the plunger out of my arm, I was gone,” he says. His nephew, who captured part of the overdose on his phone, later showed it to him to prove how serious the situation had been. “I was blue,” Mr. Tarry says. “Like a dark, hardcore blue.”
Back in 2012, fentanyl was detected in less than 5 per cent of overdose deaths in B.C.; in 2020, it was 84 per cent. In Ontario, fentanyl was a direct contributor to 87 per cent of overdose deaths. And it’s now turning up in potencies higher than ever before.
Conor King, an inspector with the Victoria Police Department and a career drug specialist, says seized fentanyl is typically between 2 per cent and 5 per cent pure, with the rest made up of fillers such as caffeine and sugar alcohol. In 2020, it was, on average, 10 per cent pure. Health Canada’s Drug Analysis Service, which tests drugs seized by law enforcement agencies, recorded just one fentanyl sample in 2019 with a concentration of more than 75 per cent. In 2020, it found 17.
“What we’re seeing is an increase in the purity of the fentanyl we’ve been seizing, leading me to believe that something really significant changed with respect to the toxicity of the fentanyl that’s generally being trafficked in Western Canada,” says Insp. King, whose department seized samples that reached 85-per-cent and 90-per-cent purity.
The high-concentration fentanyl is adulterated with other substances before being sold on the street and is not intended for direct consumption. “But the fact that the concentration of these bulk amounts is up to 90 per cent, that is new,” he says. “When we were seizing kilograms of fentanyl that were considered pure, pure was 30 or 40 or 50 per cent. Whoever is responsible for creating that [new] fentanyl, they really know what they’re doing.”
Postmortem toxicology results from B.C. have shown an increase in “extreme” fentanyl concentrations in overdose victims during the pandemic. From April to December, about 13 per cent of cases had concentrations exceeding 50 micrograms a litre, compared with 8 per cent from January to March, according to the BC Coroners Service.
Benzodiazepines, a class of drugs commonly used to treat anxiety and sleep disorders, are also regularly being detected in the illicit opioid supply. Combining opioids and benzodiazepines can lead to erratic behaviour, users remaining unconscious for hours and increased overdose risk. In B.C., testing on a subset of illicit drug deaths found benzodiazepines were detected in 15 per cent of samples in July, 2020, compared with 50 per cent five months later. In Ontario, benzodiazepines were detected in about one-third of drug deaths both before and during the pandemic.
In 1986, the cannabis activist Richard Cowan coined the term “the iron law of prohibition” to describe how harsher criminal penalties prompted traffickers to produce more potent forms of the substance to minimize volume and maximize profits.
“By continuing to support the policies of drug prohibition over the last 100 years, we’ve created a large, illegal unsafe drug supply controlled and distributed by transnational organized criminal networks,” says Mr. MacPherson of the Canadian Drug Policy Coalition. “The chickens have come home to roost. The policies we’ve supported for all these years have created this problem that we now have to deal with.”
An epidemic of drug overdoses has claimed more than 20,000 Canadians since 2016 — about the same number of victims as the coronavirus. In this interactive feature, Andrea Woo and Marcus Gee puts names and faces to those we lost.
First, do no harm
The discussion around safe supply comes as jurisdictions across Canada inch toward health-based approaches to substance use and away from punitive measures. Last July, the Canadian Association of Chiefs of Police called on Ottawa to decriminalize personal possession of illicit drugs, issuing a report that underscored how the criminal justice system has been ineffective in dealing with people battling addictions.
One month later, the Public Prosecution Service of Canada quietly updated its guidelines to direct prosecutors to focus on the most serious drug crimes and divert simple possession cases from the criminal justice system.
Vancouver is in formal discussions with Health Canada about decriminalizing on its own, while B.C. inquired this month about the possibility of doing so provincially. Cities including Victoria, Toronto and Montreal have asked Ottawa to take action federally.
But governments have been more cautious on the issue of expanding access to regulated substances. Some doctors have refused to prescribe for this purpose because they don’t feel it’s an appropriate intervention; others worry about liability or the lack of a broad body of evidence.
Vincent Lam is director of Toronto’s Coderix Medical Clinic, which offers traditional opioid agonist therapies such as methadone and buprenorphine-naloxone, as well as behavioural therapy, to treat addiction.
He’s supportive of newer therapies, such as injectable hydromorphone and heroin, that are administered in an observed setting and have been shown in clinical trials to be effective. But he’s troubled by the idea of freely prescribing high doses of opioids to people to do with as they please.
Dr. Lam says there’s little evidence to show that safe-supply programs reduce fentanyl overdoses, and adds that some people who inject fentanyl and receive much weaker hydromorphone tablets through these programs have sold them to get stronger drugs. That diversion increases the availability of hydromorphone on the street, lowering its price and increasing the risk to those who may have never been exposed to it before, he says.
“A lot of the things we do in medicine don’t have perfect evidence, and we have to make a judgment call,” Dr. Lam says. “But when we do that, we’re always carefully balancing potential benefits and potential harms. The difference here when we’re talking about what’s called ‘safe supply’ is that, in my view, a lot of the people who are potentially at risk are not the patients we’re having a discussion with.”
Julian Somers, a clinical psychologist, distinguished professor in the faculty of health sciences at Simon Fraser University and director of the Centre for Applied Research in Mental Health and Addiction, similarly rejects the concept.
“We’re talking about prescribing dangerous narcotics to people whose problem is their inability to control their use of dangerous narcotics,” he says. “That’s how it is – we can dress it up however we want.”
Kelsey Roden, a physician with the Victoria SAFER Initiative, emphasizes that safe supply is not treatment but harm reduction, and should be used with compassion and pragmatism in the context of dual health crises.
“I would ask other physicians to view it as an intervention we need to try to see if it will work,” Dr. Roden says. “Then we can use that data to make informed decisions around future prescribing.”
And while she does acknowledge that diversion of safe-supply drugs can happen, that could be seen as harm reduction – because the people accessing those pills are getting pharmaceutical-grade drugs that aren’t cut with fentanyl.
A tale of two provinces
Addictions physicians across Canada who spoke with The Globe say they observed patients’ opioid tolerances increase significantly over the past year, and that for safe supply to be effective, the alternatives must compete with what’s available on the street.
If hydromorphone tablets aren’t potent enough, people will supplement with illicit substances or sell their prescriptions on the street, as Dr. Lam has observed.
For this reason, B.C. has signed off on medications including powdered fentanyl, fentanyl patches, injectable and oral liquid morphine, injectable hydromorphone, oxycodone, Adderall XR and cocaine powder to be considered in its safe-supply guidance, according to documents obtained by The Globe.
“Our goal is to help break the reliance on dangerous, unpredictable street drugs, and that means prescribing pharmaceutical opioids that will address that problem for people and help to fully separate them from the toxic supply,” reads a statement from B.C.’s Ministry of Mental Health and Addictions provided to The Globe.
“We also recognize that people often use different kinds of drugs at the same time – not just opioids – so are carefully considering a range of medications to address that challenge as well.”
B.C. is now finalizing its guidance, which will determine which medications will be available and how they can be dispensed.
In September, Provincial Health Officer Bonnie Henry moved to allow registered nurses and psychiatric nurses to prescribe addiction treatment medications alongside physicians and nurse practitioners. A group of 30 nurses is expected to complete training and begin prescribing Suboxone this month, followed by safe-supply medications in the coming months.
Meanwhile, plans to produce a local supply of pharmaceutical-grade heroin – called diacetylmorphine – could be expedited to make it available to more people sooner.
The Globe reported in July that Martin Schechter, a professor in the school of population and public health at the University of British Columbia, and Perry Kendall, B.C.’s first provincial health officer, had launched a company to manufacture heroin, which would eliminate the high costs and regulatory barriers associated with importing the drug from Europe.
Dr. Schechter says he believes the company, called Fair Price Pharma Inc. (FPP), could have a licensed product available about 18 months after it raises startup funds. But given last year’s spike in overdoes deaths, he feels more urgent actions are needed.
FPP has launched a public-health division that can produce prescription-specific, prefilled syringes that can be ready in about three months. But this interim product is only good for 48 hours, Dr. Schechter says, which means it would only work in areas with enough uptake and where the medication could be delivered daily. The new product FPP hopes to manufacture would have a shelf life of about two years.
B.C.’s Minister of Mental Health and Addictions, Sheila Malcolmson, says the domestic supply of diacetylmorphine “may” be added to B.C.’s safe supply guidance when it becomes available.
One province over, Alberta’s UCP government has flatly rejected the idea of safe supply.
The Globe has learned that an Edmonton social-service provider partnered with Alberta Health Services, physician groups and regulatory bodies last year to apply for federal funding to run a safe-supply program. When it was approved, staffers from the province’s Ministry of Mental Health and Addictions “pressured” the groups to withdraw their application, according to two people with direct knowledge of the dealings.
They did, turning down $1-million over 10 months in federal funding for a safe-supply program. The Globe is not naming these sources because they fear retribution from the Alberta government.
Neither Jason Luan, Alberta’s associate minister of Mental Health and Addictions, nor Marshall Smith, his chief of staff, could be reached for interviews. Mr. Luan’s press secretary, Kassandra Kitz, said in an e-mail the minister “has been very clear on our position regarding a government supply of addictive drugs” and that the province would “not be considering safe supply as part of its recovery-oriented continuum of care.”
Asked whether the province either explicitly told or pressured the organizations not to run the program, Ms. Kitz said: “In no way did the Government of Alberta pressure or tell any organization that they could not proceed.”
Heather Sweet, Alberta’s NDP Mental Health and Addictions critic, points out the UCP has cancelled most harm-reduction programs, including a busy supervised consumption site in Lethbridge. “This government has chosen to take one stance, which is treatment, and it shouldn’t be one or the other,” Ms. Sweet says.
Federal Health Minister Patty Hajdu, who in August urged provincial and territorial health ministers to support safe supply, calls Alberta’s approach “unfortunate.”
“There are provinces that have been much more accepting of this approach and provinces like Alberta that have resolutely declared they are not interested in safe supply or harm reduction in general, which is unfortunate, because they’re seeing some of the highest rates of overdose in the country,” Ms. Hajdu said in an interview.
As for Mr. Tarry, a couple of months after outreach workers first approached him in Beacon Hill Park, he and his nephew moved away from the encampment, which he says was nothing but “drugs, stabbings and fights.” Initially, they set up in a quieter park, but soon a local non-profit offered to help put him up in a hotel temporarily.
Mr. Tarry says his goals now are to secure more permanent housing, get his leg amputated and replaced with a prosthetic, save up some money and get his tattoo and piercing business back up and running. He’s already bought the equipment, he says.
When it’s time for his medication, he extends an open palm to show a handful of blue and orange capsules, and little white tablets.
“This is something that gives you hope,” he says. “I don’t know how else to describe it.”
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