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A user displays their 'safe supply' of opioid alternative Dilaudid, provided by the local health unit as a pharmaceutical alternative to deadly street drugs, in the downtown eastside of Vancouver, on April 6, 2020.

JESSE WINTER/Reuters

Corey Ranger had just taken a leave from his regular nursing duties to provide full-time health care at a growing homeless encampment in Victoria when the B.C. government opened the door to “safe supply” for drug users.

The provincial announcement in late March meant that people at risk of overdose could now be prescribed a take-home supply of a pharmaceutical alternative to deadly street drugs – a move spurred by heightened overdose risks associated with the COVID-19 pandemic.

At the Topaz Park encampment, Mr. Ranger, a registered nurse with AVI Health and Community Services and the Victoria Inner City COVID Response team, added another task to his long list of duties. On top of wound care, overdose reversals and COVID-19 screening, he would inquire if campers wanted, and qualified for, safe supply – also referred to in some government literature as “pandemic prescribing for risk mitigation.”

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If so, he would then contact their primary health care providers.

“I remember calling this guy and he laughed at me: ‘I’m a recovery doctor, not a Dilaudid doctor,’ ” Mr. Ranger recalled. Dilauded is a trade name for hydromorphone, an opioid that can be prescribed as a replacement for heroin or fentanyl.

“Okay, what do we do now?” Mr. Ranger said of hearing the response.

The green light to prescribe a safer supply, made possible by changes to the federal Controlled Drugs and Substances Act and provincial prescribing guidelines, was heralded by drug-policy experts as a significant step toward tackling an overdose crisis that has killed thousands largely because of a highly contaminated illicit drug supply.

But the rollout has been halting. A reluctance by many physicians and nurse practitioners to prescribe, in part because of liability concerns, means people who could benefit from these regulated medications have no way of accessing them.

In the two months since the announcement, about 450 people are confirmed to have been prescribed pharmaceutical alternatives to illicit drugs under the new guidance, according to health-authority data. Of those, roughly 400 are in the Vancouver Coastal Health region and 50 in the Island Health region, while the northern, Interior and Fraser health authorities did not provide The Globe and Mail with any numbers.

PharmaNet, the database that records every prescription dispensed in community pharmacies, shows that 1,294 people were prescribed hydromorphone in April, a 91-per-cent increase from the 677 in March; but the province is still parsing the data to determine if the increase is related to uptake of the guidance.

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Ashley Heaslip, an inner city family doctor and medical lead at PHS Community Services Society, said that the guidance on pandemic prescribing – released in March by the BC Centre on Substance Use (BCCSU) – is not yet supported by a broad body of evidence.

“We’re trying to develop that evidence as we go by integrating research and evaluation with programs that are able to provide safer supply prescriptions to individuals," she said.

That puts prescribers on a cautious path as they navigate a novel safe-supply program, with some unsure about the impact on patient safety.

"We want to be part of reducing harm,” Dr. Heaslip said. “That’s the oath we take: ‘First, do no harm.’ It’s at the forefront of any prescriber’s mind to weigh those risks and benefits with any prescription.”

The guidance being directed at physicians also means that a person’s ability to access a safer supply hinges on regular contact with a physician or nurse practitioner.

“So if you don’t have somebody that you can see, who is able to see you in an ongoing way, who feels that it’s appropriate and is comfortable with utilizing the guidance in their own practice, then you don’t have access to this,” Dr. Heaslip said.

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Mr. Ranger said the predicament shows that it is untenable for individual prescribers to serve as the entry points to a safer drug supply. His efforts to connect people at Topaz Park to safer medications required intensive, patient-by-patient advocacy; the person whose recovery doctor laughed at the idea ultimately ended up switching doctors. The effort took about a full day, in all.

“There needs to be a more as-needed type delivery model, where people can go to a consumption site and access a safe supply of drugs, use it while being monitored and not be bogged down by all of the medicalization and barriers that exist in the current guidelines,” Mr. Ranger said.

(Topaz Park was cleared this week as the B.C. government moved to transition campers indoors.)

Dr. Heaslip called the guidance on pandemic prescribing “an amazing first step in a really important direction,” and said the next step will be to develop community-based models to facilitate broader rollout.

Guy Felicella, a peer clinical advisor at the BCCSU, said addictions physicians and inner city doctors may be more open to prescribing a safer supply. But others have told him directly that they are worried about liability, and losing their licences.

“Their training doesn’t allow them to think outside of their scope. They are focused solely on risk aversion," Mr. Felicella said. “What they don’t understand is that by not doing it, they are causing that individual more risks.”

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While it is understandable that prescribers would first want to see a robust body of evidence, B.C.'s current climate, with its dual public health emergencies, does not allow for that, he said.

"You can’t wait for evidence because people die. It’s like fighting a forest fire: Let’s see which way the wind’s blowing before we do anything.”

Mr. Felicella called on the College of Physicians and Surgeons of B.C. to issue a memo to prescribers on the matter.

Reached for comment, spokeswoman Susan Prins said the college does not have expertise on developing novel courses of treatment for addiction, nor does it advocate for one type over another.

“The expectation of any agency that develops clinical guidelines is that they also make available clear directions for use, standards, mentoring and teaching to ensure the end user, in this case a prescriber, is confident in the treatment before administering it,” she wrote in an e-mail.

In a statement provided by the Ministry of Mental Health and Addictions and attributed to Minister Judy Darcy, Ms. Darcy says the safe-supply guidelines were released as soon as possible to keep people safe during the COVID-19 pandemic and that the ministry is listening to feedback from the front lines to update the guidance and develop new models as needed.

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“We know that overdose prevention and supervised consumption sites can offer people a safe, judgment-free place to connect with care including medication-assisted treatments,” the statement read. “We’re looking at how we can continue to build upon these kinds of models and others to make it easier for more people to find a treatment plan that will work for them.”

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