Expansion of harm reduction and treatment beds help, physicians split on safe supply
Dave Keebler is a father, a son, a mentor, and an educator. He is also an ex-heroin addict.
Keebler spends his days working for SOLID Outreach in Victoria, assisting drug users with their mental health, and handing out clean needles. He also assists schools and teachers in the Greater Victoria area with kids who have drug addictions. He says that the province needs to make some whole-scale changes to how they handle drug addiction if the crisis is going to end.
“I think anything helps,” Keebler said about the government’s plans to decriminalize and create more treatment beds. “I just think they need to do way more. I think they need to put [in] way more money [and] way more time.”
The provincial government has committed to ending the overdose crisis through large investments in housing, safe consumption sites and mental health supports, more treatment beds at hospitals, and a promise to decriminalize personal possession of illicit substances such as cocaine and methamphetamine.
Experts like Bernie Pauly of the Canadian Institute for Substance Use Research (CISUR) say that the provincial government and the City of Vancouver are not going far enough in their plans to decriminalize and are pushing for the introduction of safe supply. They also say that there needs to be increased engagement with members of the drug-using community who say that they have been largely shut out of negotiations.
The consensus amongst both government officials and advocates is that the overdose crisis is likely to get worse before it gets better. They also see hope for a way out of the crisis through one simple idea: harm reduction. And time is of the essence as the COVID-19 pandemic has only served to worsen the crisis and leave people like Ellie Taylor of VANDU even more vulnerable.
A runaway train
According to a report by B.C.’s chief coroner Lisa Lapointe, 184 people died of overdose in the month of July alone.
Since it was declared an emergency in 2015, the overdose crisis has taken over 7 000 lives in the last six years. The crisis has only been exacerbated by the COVID-19 pandemic. Provincial health guidelines prompted the closure of safe consumption sites and mental health clinics — forcing many drug users to use alone at home for fear of stigma or prosecution if they use with friends or in public spaces.
Following a record-breaking year in 2020, overdose deaths have risen to even higher numbers in 2021. Over 1 000 people died in B.C. as a result of overdose in the first half of 2021, putting the province on pace to break last year’s record of 1 728.
Sandra Allison, medical officer for the central Vancouver Island region, says that Island Health has spent a significant amount of time over the past year working with drug users to help them use safely.
This spring, Island Health held an outreach campaign aimed at convincing men who use drugs to stop using alone. The campaign advertised tools and supports for using safely. It targeted males that use alone because 86 per cent of overdose victims within the past year were male, and because almost 60 per cent of all overdoses take place in private residences.
“I think the messages in the campaign speak for itself: that we know that men are using alone, and we value them, and we don’t want to lose [them],” Allison said.
She also said that one of the reasons people use alone is due to stigma. She says an integral part of their approaches reducing stigmas around drug use.
“Allowing people to talk about their pain and their coping behaviours in a manner that would put opioid use in the same realm as alcohol would be something that would be a safe and important thing for society to do,” she said.
Pauly says that while decriminalization will help, getting rid of the toxic drugs circulating on the street needs to be the number one priority.
“Decriminalization alone will help with stigma,” she said. “But it won’t change the fact that we have a toxic drug supply.”
What is harm reduction?
The central idea of harm reduction is pretty straightforward: reduce harm. For drug-using populations, harm reduction aims to reduce the key risks associated with substance use things like using alone and obtaining substances that may be laced with fentanyl or carfentanyl. By addressing these risks, the overall goal is to reduce death due to overdose.
Outreach workers who practice harm reduction focus on meeting people where they are at. For people who use substances, this means distributing safe supplies of illicit or controlled substances and providing information on safe substance use and where to get help. Harm reduction services also include drug checking, counselling, and providing take-home naloxone.
According to the National Harm Reduction Coalition, harm reduction differs from abstinence-based programs or prescriber-based models such as opioid agonist therapy (OAT) by acknowledging that illicit drug use is going to persist and involving people who use drugs in every aspect of the decision making process.
Pauly says it is critical that harm reduction practices be implemented if the province wishes to end the overdose crisis.
“Right now, we only have a prescriber-based model, but we need harm reduction-based models and models of community service, models of safer supply that are integrated with other health and social supports as well,” said Pauly. “So you have models that are going to be much more accessible.”
A prescriber-based model is the way most people receive medications. They schedule an appointment with a physician to discuss their symptoms or condition. The physician will then provide a diagnosis and, depending on what the problem is, provide a prescription or further course of action. If prescribed a medication, the patient will pick it up from a pharmacy and a pharmacist will provide further instructions and information on the medication.
This is a high-barrier approach that is inaccessible to many drug users. Harm reduction, by contrast, meets people where they are at without the need for a scheduled appointment or consultation from a physician.
Many organizations already offer harm reduction services throughout B.C. Outreach services such as AVI, SOLID, and VANDU offer sterilized needles, access to counselling, and free joints and cigarettes. For some people, that free joint or cigarette helps them get through their day without using. Drug checking projects like the Vancouver Island Drug Checking Project also practice harm reduction by providing anonymous checks of illicit drugs for harmful substances and relaying that information back to the user.
Decriminalization has long been a sought after aspect of harm reduction in B.C. In Portugal, the national government implemented decriminalization along with optional treatment programs and saw overdose deaths fall rapidly.
Although moving towards decriminalization is viewed as a positive step by advocates such as Taylor and Pauly, they say the imposition of thresholds and the lack of a plan for safe supply reduces the effectiveness of decriminalization and increases certain harms such as police discrimination.
Decriminalization and safe supply
In March, the City of Vancouver applied to the federal government for the decriminalization of small amounts of illicit substances meant for personal use. The provincial government followed up with their own application to span the whole of the province in July. Under Section 56 of the federal Illicit Drugs and Substances Act, the federal health minister can grant waivers of the act to provincial and municipal governments as well as health ministers.
In an emailed statement to the Martlet, the B.C. Ministry of Mental Health and Addictions says that they hope the move to decriminalize illicit drug possession for personal use will help to reduce the stigma and criminalization of drug users. They also recognize that there is a long way to go before the overdose crisis can be eliminated.
“Decriminalization is just one piece of a comprehensive response to the overdose crisis which includes services like overdose prevention sites, prescribed alternatives, and treatment and recovery options to help people in BC,” the Ministry said in the statement.
However, advocates say that B.C.’s decriminalization plan may have harmful side effects. Their approach uses thresholds for possession. For example, someone carrying any amount of cocaine above the threshold can still be criminally charged — whether that amount is one gram or 100 grams. The exact thresholds and amounts have yet to be determined, but the notion of thresholds for possession has advocates worried.
Although this is meant to punish dealers of illicit substances, Ellie Taylor of VANDU says that it ends up harming people who use drugs as many have addictions beyond threshold amounts. She adds that thresholds encourage random police checks of drug users.
Taylor also says that members of the drug-using community were not given a voice in the application for decriminalization by the City of Vancouver.
“They send off their request for the Vancouver Model,” said Taylor. “And they do all this without some of the most lived experience [of] drug users, which is us at VANDU.”
Along with decriminalization, the province has also expanded the amount of treatment beds available for those suffering from overdose or needing in-hospital treatment. In total, the province has promised to invest $938 million to combat the overdose crisis.
Measures included in this funding are expansions of OAT and safe consumption service, the training of nurses to deal with substance use related drug issues, and the creation of the lifeguard app which connects those who are overdosing to first responders.
The provincial budget, however, does not provide any funding for safe supply. Pauly says this is a mistake.
“It’s really a critical piece in a comprehensive approach,” said Pauly. “There’s been clear direction from people who use drugs, from families of people who use drugs, to people who work in harm reduction, to health care providers, who have all repeatedly said you need a regulated safe supply.”
Keebler says that at the end of the day, the key fight right now is ending stigma. He says that once that happens, harm reduction can follow.
“The only reason people are dying is because there’s somebody else looking over their shoulder and saying, you can’t do [drugs],” he said.
Allison says that stigma is preventing physicians from doing their jobs and, in the process, affecting the provision of supports people need.
“Stigma is absolutely getting in the way of providing social supports and appropriate health care for people who use opioids and illicit substances,” she said. “Broad acceptance of [safe supply is] reliant on people changing their minds about what we value.”
At the outset of the pandemic, Provincial Health Officer Dr. Bonnie Henry put forward the risk mitigation guidance waiver which allowed for broader measures to combat overdose through OAT and prescription of safe supply of certain illicit substances. Allison says that many physicians have been reluctant to offer those services due to a lack of training or misgivings about safe supply as a treatment method.
“There is a preconceived notion about what caring for people with substances might result in and so there’s a reluctance to have disruption in their practice,” said Allison. “I think that with supports and mentorship, a family doctor can very readily become a capable and confident prescriber for individuals who are trying to manage their substance use.”
While decriminalization is the keystone of the province’s plan to end the crisis, there are other avenues being explored such as OAT and mental health services that could provide further support to drug users.
Advocates are careful to warn that just like decriminalization, none of these solutions are a silver bullet.
A ‘holistic’ approach
In a typical work day, Taylor walks past members of the drug-using community congregating in alleyways or by convenience stores to catch up with friends and hopefully have a chance to discreetly use the drugs they have obtained.
Taylor paces over well trodden paths in the Downtown Eastside to supply people with joints, cigarettes, information regarding available support, and a person to speak to about what is going on in their lives.
All too often, Taylor sees police questioning drug users, confiscating their personal supply or arresting them for simple possession. She says this furthers the trauma and mental health crises many drug users already experience, and fails to provide a real solution to the overdose crisis.
“The majority of things [the police are] doing in the Downtown Eastside is taking people’s stuff, and giving them tickets,” Taylor told the Martlet. “What happens is the cops come up, [and strip] that person of their dignity.”
Allison, meanwhile, says that more mentorship needs to be given to physicians who are hesitant regarding safe supply and OAT — prescription opioids meant to reduce the chances of overdose. She also says that drug checking services, like the Vancouver Island Drug Checking Project, should be expanded.
Keebler has undergone OAT treatment and while he thinks that the program serves certain people well, there needs to be an expansion of the types of drugs offered. He says that the prescriber-based model and criminalization have at times led to people being admitted to medical care without access to the drugs they need, leading to withdrawal.
Pauly echoes Keebler’s call for more action and a more holistic approach.
“We started with naloxone, we expanded overdose prevention sites that were changes to the Good Samaritan Act so that police weren’t responding to calls,” she said. “But we have to do all of those things at once.”
In an email to the Martlet, the Ministry of Mental Health and Addictions said that decriminalization isn’t a solution on its own and that other actions such as treatment beds won’t complete the puzzle of ending the overdose crisis.
Taylor and Keebler say that more funding for harm reduction programs is critically needed as most outreach workers are either overworked or out of touch with what people need.
“Let’s stop playing system change and actually build the other solution,” said Taylor.
Worse before it gets better
Allison says the most likely scenario for the overdose crisis is that — despite the recent moves made by the government — it’ll get worse before it gets better.
“I think that we’ve got a lot of work to do in our communities to address [the crisis],” she said. “Everybody needs to have a better understanding of addiction and what we do as humans to cope with the stresses in our lives.”
She says that harm reduction can lower the number of deaths but wholescale decriminalization without threshold limits along with prevention centred on youth won’t end the crisis.
“I’m always interested in the prevention aspect and getting way upstream and trying to strengthen families in that first five years and to ensure that children are given that important opportunity to gain the most coping skills,” said Allison.
Pauly concurs and says that there is a long way to go before we see light at the end of the tunnel. She says that the need for a comprehensive response centred around harm reduction is needed now more than ever. This includes a concerted effort to implement safe supply.
“We’ve been in a declared public health emergency related to overdoses for over five years,” said Pauly. “While COVID numbers have been dropping, our overdose numbers have not been dropping, and it’s really been an ignored emergency.”
Taylor says that right now the most important and easiest thing for the average person to do is have compassion and empathy for those struggling with drug addiction.
“They always say you made a choice,” said Taylor. “But there are people who this is their survival — they have lost everything; they have nothing to work for — this is the one thing that brings them something and we need to keep that something alive.”
