Providing safer opioids to people who use drugs is the opposite of “giving up” on them
As unprecedented numbers of Canadians are dying from the greatest drug toxicity crisis in our history, British Columbia is expanding harm reduction services for people who use opioids. This will include, in coming months, a pilot program that uses dispensing machines to distribute safer pharmaceutical-grade opioids to drug users. Some in the medical community have criticized B.C.’s plan, arguing that public health leaders are “giving up on addicts” and opting to “just keep them on drugs.” Canadians must understand that both science and epidemiology rebut these views. In responding to the opioid crisis, B.C. hasn’t given up on anyone.
Rising mortality in B.C. is not associated with rising drug use, per se, but with the prevalence of toxic and cheap synthetic opioids like fentanyl and its analogs. From 2012 to 2017, the number of unintentional illicit drug overdose deaths in B.C. surged from 202 to 1,422 annually, while during this same period the number of these deaths involving fentanyl increased from 12 to 1,156 per year—a staggering jump from four percent to 81 percent of cases. By providing a safer supply of drugs, B.C. is preventing more of these tragic overdose deaths from happening.
Decades of scientific evidence demonstrate that harm reduction measures improve health outcomes for people who use substances. Programs like naloxone distribution, needle exchange, supervised injection facilities and methadone treatment have been shown to more than recover their costs in health department savings, and to improve public health and social order. They also increase the likelihood that people who use drugs will seek out treatment. Patients who attended Vancouver’s Insite, for instance, were 30 percent more likely to attend substance use treatment than those who did not.
Offering safer opioids by no means takes away from addiction treatment or prevention. In other words, public health authorities do not need to choose between prevention of substance use and prevention of harms from substance use. A key tenet of harm reduction is to provide people who engage in risky behaviours access to additional recovery services by meeting them where they are first and then determining their needs. As Dr. Mark Tyndall, executive director of the B.C. Centre for Disease Control, puts it, “You cannot get someone into rehabilitation when they’re dead.” As a non-judgmental intervention, harm reduction connects marginalized individuals with broader health care, thereby enabling health and social systems to begin addressing risk factors for substance use and poor health such as homelessness, mental illness and trauma. Even with an inclusive ethos, though, rehabilitation and prevention measures take months or even years to realize an effect.
In any chronic health condition—whether diabetes, arthritis or opioid addiction—multiple treatment options should be available. Thankfully, we have strong evidence demonstrating cost-effective benefits from “conventional” treatments for addiction, like methadone and buprenorphine/naloxone (Suboxone) maintenance therapy, as well as from structured slow-release morphine maintenance, supervised injectable diacetylmorphine (pharmaceutical heroin) and hydromorphone therapies. If these services cannot reach everyone who may benefit, B.C’s idea of lower-threshold access to pharmaceutical opioids follows the proven logic of harm reduction.
Tyndall concedes that distributing safer opioids may leave one feeling uneasy, particularly given the dominant narrative that the crisis is rooted in the way physicians have prescribed opioids in recent decades. B.C. plans to mitigate public health risk by distributing hydromorphone pills through the dispensing machines, which will use biometric data to identify patients, ensuring that medications are securely dispensed to authorized users. Individuals would be assessed, registered and issued a card to access two or three pills up to three times per day, thereby reducing the risk of theft for purposes of diversion. All things considered, these dispensers are less traditional vending machines, as characterized in the media, and more high security ATM-like machines. If successful, this program could offer a way forward not just for those struggling in Vancouver’s Downtown Eastside—which, in truth, is likely Canada’s safest place to overdose—but also in under-resourced communities increasingly affected by the crisis.
In public health emergencies involving novel hazards, authorities necessarily find themselves having to mobilize quickly to develop pragmatic interventions with the best possible, and often less than perfect, evidence. This crisis is no different. Providing safer opioids to those at highest risk of deadly overdoses has the potential to connect patients to life-saving services, decrease the spread of more toxic opioids, curtail social dysfunction and reduce the transmission of infectious diseases. If it takes an innovation like a hydromorphone-dispensing machine to make even a small difference, then so be it. Importantly, these interventions also send a message to those struggling with substance use: We haven’t given up on you.
Max Deschner is a medical student at the University of Ottawa. Jonathan Gravel is an epidemiologist and a family medicine resident physician at the University of Toronto. The authors thank Dr. Mark Tyndall and Dr. Hakique Virani for their insights.