Safe Supply Shortage

TELLING IT LIKE IT IS For the past six years, BC's chief coroner Lisa Lapointe has been making recommendations to the province about the actions needed to confront the deadly drug toxicity and poisoning crisis.

The numbers for 2021 are in. And the numbers are not good.

BC saw 2,224 suspected illegal drug toxicity deaths – the most ever recorded in a year and a 26 percent increase over the 1,767 deaths seen in 2020.

Lisa Lapointe says it's hard to think of anything else happening in this province resulting in the deaths of six or seven people every single day that would not elicit a massive, coordinated response.

Lapointe is BC's Chief Coroner, and she is speaking to her most recent report Illicit Drug Toxicity Deaths in BC January 1, 2011 – December 31, 2021 released this February. Her reports have become grim, annual reminders not only of failed drug prohibition policies, but of the institutional inertia and shortage of political will that continues to protract the crisis.

The COVID-19 pandemic has shown British Columbians what a robust response to a public health emergency can look like, with provincial testing, provincial vaccination sites and provincial data. But none of this has been brought to bear on the opioid crisis even though toxic drug deaths in BC have far outpaced those from COVID-19. Poisoned opioids and other drugs killed 3,000 people in BC between January 2020 and July 2021, compared to the 1,800 who died from COVID-19 in the same period.

The crisis is national in scope. Some 25,000 Canadians have died from unintentional toxic drug poisoning since 2016 – an average of 19 Canadians died every day in 2021 according to the Public Health Agency of Canada, and there are no signs that 2022 will be any different.

In her role, Lapointe oversees the independent investigations of approximately 10,000 deaths reported to the Coroners Service annually, including all children's deaths, and deaths reviewed at inquest. Coroners establish the circumstances of unexpected deaths for the public record and may make recommendations to prevent similar deaths in the future.

The chief coroner has the discretion to establish death review panels to review the facts and circumstances of deaths and provide advice on medical, legal, social welfare and other matters that impact public health. In the wake of February's grim drug toxicity report, Lapointe convened a panel of subject matter experts to provide advice and recommendations on how to stem the unrelenting death rate. The panel's report, A Review of Illicit Drug Toxicity Deaths, was released in March and is the second such report since the public health crisis was declared in 2016. The first Death Review Panel report was published in 2018. 

The latest report contains several findings and recommendations (see sidebar: The Deadliest Year Ever), which Lapointe has forwarded to relevant ministries and organizations.

Update Magazine sat down with Lapointe to discuss the report and her views on the crisis.

UPDATE The Death Review Panel findings show that deaths are increasing both in number and in rate and the drug supply has become increasingly toxic. What explains the persistence of toxic supply and deaths? How does this make you feel considering the significant efforts to expand harm reduction services and options over the past six years?

LAPOINTE The numbers of people dying is truly heartbreaking. As coroners we are very close to this crisis. Our coroners go to the scene of death. They examine the person who died. They talk to the family members at the scene. Then they follow up with the family members calling them to ask what happened and to share information. So, it's very personal to those working in the Coroners Service.

It's also heartbreaking for families and communities. And it's not just families. It's friends, co-workers and friends of friends that are suffering when someone dies.

Most of the people who die have had long-term substance dependencies and not as many casual users die. Which makes sense because the more often you use, the more you are at risk from the toxic market.

A challenge we are facing has been the increasing toxicity of drugs over time. In 2012, when somebody purchased heroin, it was heroin and normally, if somebody purchased what they felt was cocaine, it was cocaine.

Then fentanyl arrived, which is much cheaper to manufacture. But then people started becoming accustomed to fentanyl. However, we now see fentanyl in more extreme concentrations, making it much riskier to use. And now we are finding increasingly benzodiazepine in the drugs today, which, as a sedative and not an opioid, does not respond to naloxone.

The unpredictability of the drug supply is a huge, huge factor. It really means that people can't protect themselves very easily unless there are substantial drug checking services, which there aren't, there are some. Overdose prevention sites are extremely valuable. But not every community has one. Or if it does, it's maybe not where people want to go. Someone living in a suburban neighborhood may not want to go to a different area of town to use their substance. We need more drug checking, more overdose prevention sites.

I know efforts are underway to initiate safe supply, but it is still extremely limited across the province. A few hundred people can access safe supply and there are estimates that there are 200,000 substance-dependent, opioid-dependent people in our province. So the access to safe supply is really, really minimal.

And treatment and recovery options are, again, very, very minimal. Few physicians are willing to prescribe a supply. There are long waits for publicly available treatment. Private options are out of the reach of many people and we don't have data to know if they work because there are no reporting requirements. Something my office has been asking for since the previous Death Review Panel back in 2018 is regulations around treatment and recovery services, and making sure there are reporting requirements so we have some sense that what's happening out there is evidence-based and actually effective.

There are still so many service gaps. As long as these gaps remain while we have an increasingly toxic drug market, people are going to continue to die, and that's what we have been seeing over the past six or seven years.

UPDATE BC could become the first province to decriminalize personal possession of some illegal substances. Instead of arresting people, or seizing their drugs, law enforcement would direct people who use substances to health and social service resources. But some critics and advocates say BC's proposal and submission to the federal government won't solve the deadly problem. They argue the 4.5-gram limit is too low. Many people carry multiple days' worth of substances with them that would tip them easily over the total limit. The City of Vancouver's proposal, which also contains quantity limits, has received similar criticism. Is the quantity-limit approach to decriminalization the way to go?

LAPOINTE I do feel very strongly, as do members of the death panel, that we need to be listening to the people who are directly impacted and who have lived experience. It seems very logical to me that we would permit people to carry substances they are going to consume or that a family member or friend is going to consume. I know there are concerns about trafficking, but trafficking is an offence, and that is not going to change. So, no matter what a person is carrying, if they are trafficking, they still are liable to sanction.

The assumption has been if somebody is carrying over a certain amount [they are a trafficker]. Law enforcement all have different ideas – and that's one of the challenges. We do hear from some of the major police departments like Vancouver and Victoria about how they don't arrest people for possession. And we know from Federal Crown direction is that they will not prosecute for possession. But, in smaller communities, we hear loud and clear that people are often stopped, and their substances are taken away no matter how much they have. And, even in Vancouver and Victoria, currently it is not lawful to have controlled drugs in your possession and they will be taken away.

I think we need to be really clear that if people have drugs that they are using for their personal use, then just because the quantity is more than a police officer might feel comfortable with, doesn't mean they are trafficking. I don't think that it is reasonable to assume they are, or that it is even lawful. That's where the line is. Is it for personal use or are they trafficking? And the line shouldn't be an amount, it should be active evidence of trafficking.

UPDATE Interms of greater action on safe supply, last year the province issued a directive expanding programs to provide users with safe, non-poisoned drugs, and where nurses could prescribe "pharmaceutical alternatives." Some critics, including nurses, have said it is too restrictive and it does not include access to heroin. Community advocates have also said the province is not moving fast enough on the safe-supply front. Is access to pharmaceutical alternatives safer supply?

LAPOINTE Yes, absolutely.

There are varying definitions of safe supply and there are some who say safe supply is people being able to access a drug of their choice when they need it. While others are saying it's broader, that it includes access when needed in addition to receiving opioid agonist therapy, or being treated for substance dependency.

The real focus needs to be acknowledging that substance use is a choice for many people. Sometimes it becomes a dependency. Sometimes it becomes a disorder. But in any of those cases, ensuring that people have access to safe regulated drugs is the only way that we are going to prevent the number of deaths we are seeing.

Currently, access is only by prescription and it clearly needs to be broadened. The Death Review Panel was pretty explicit about that. There needs to be much greater access to safe supply much more quickly across the province. That's the only thing that is going to prevent these deaths because the illicit drug market is toxic. We know there is no quality control. Clearly, it's a profit driven market.

Safe supply is ensuring that people can access the drug they need and that it's regulated and safe – whether they are looking for treatment or whether they are looking for personal use. And, as the panel pointed out, there will probably need to be more models. A prescriber-only model is probably not going to be sufficient to meet everybody's needs.

UPDATE Discussion about the drug toxicity crisis almost always leads to a discussion about addiction, substance use disorder and the need for treatment.  But most people who use drugs are not addicted, and are not needing prescriptions. They don't want to have contact with the health-care system. They just want to purchase some cocaine on a Friday evening after work just like somebody else might want to go get a six-pack. Are policy makers too focused on treatment at the expense of analyzing the broader toxicity crisis?

LAPOINTE As a coroner service, the population we encounter most often are people who are substance-dependent because they are more at risk. But clearly, if we want to keep people alive, then we need to ensure that the drugs that the people are accessing are safe. Whatever they might be accessing them for, because as long as we allow the illicit market to flourish and be this sole provider of these substances, then lives are at risk. If we want to keep people alive then all substances need to be regulated and safe. What does that regulation look like? That's a policy issue. How substances are dispensed to people is another question. But that is what will keep people alive.

For decades we have been socialized into believing that drugs are bad and people who use drugs are bad, and the stigma associated with that is going to take time to undo. But so many people are recognizing now that drugs can be used safely if there are safe drugs. Make sure the drug is safe.

UPDATE You and the Death Review Panel have reported that deaths are occurring throughout the province, yet so much of the focus and coverage of the crisis quickly turns to Vancouver's Downtown East Side. This community needs significant mental health support and treatment, but does this clarify or obscure the nature of the crisis? Adjusted for population, death rates in rural and northern BC are almost double the death rate of Vancouver. How do you deal with this challenge?

LAPOINTE It's frustrating because it reinforces this idea among many that "that's not me" and that it only concerns other people who are using drugs. And my family and my community are not at risk. In fact, we know that every community in the province is at risk and many, many family members are at risk. The fallback notion that it's a Downtown Eastside problem is really unfortunate. It is people from all walks of life and, as you know, we often see media images of somebody using intravenous drugs in a lane. That is a stereotype and it's so inaccurate. Many, many people struggle with substance use.

UPDATE The Death Review Panel recommends developing a Comprehensive Continuum of Substance Use Care. However, the panel also noted that the majority of those who died had accessed the health care system recently and many for a reason related to substance use and or mental health. That's concerning. Do you think that there were unrealized possibilities in that encounter that might have resulted in a different outcome for the person using drugs?

LAPOINTE The panel didn't go into it, but certainly we coroners hear often from families that there is still a great deal of stigma, even in the health-care system, towards people who come in having suffered an adverse drug event or who are known to be substance-dependent.

One of the hopes of decriminalization is that, over time, that stigma around drug use – it's illegal and therefore people who use drugs are criminals and therefore they are bad people – will go away.

But also, a real frustration for medical practitioners is not having resources available. We've heard from practitioners who've treated someone who's suffered an adverse drug event or come in for another reason, and they're really motivated to access safe supply or some kind of treatment program. But there are huge gaps in available services, no options for them and nowhere to refer them because anything publicly funded is so oversubscribed that we'll put you on a list and hope that sometime in the next few weeks we'll be able to link you up with a safe supply or get you into a treatment or a detox program.

The panel also identified the importance of having a consistent assessment protocol so everybody is really clear that, when somebody comes in, medical practitioners are able to assess their dependency, where they are in their journey, what they might need, and then have evidence-based options in terms of referring them. That currently just doesn't exist. It's a huge gap.

And we know that medical practitioners are like everybody else. Sometimes they don't want to treat somebody experiencing substance use. They are nervous about how it might reflect on their practice. My read on the panel's recommendations is that this is about making substance use a health-care issue that has all of the same training and protocols as any other health-care issue. When someone comes in with certain symptoms, we go through the options, there's a protocol assessment, and depending on what the protocol says, this is how they are treated. And currently that just doesn't exist.

For so long the investment and energy has been focused on law enforcement and it hasn't been directed to providing support for people who are substance dependent.

UPDATE The Death Review Panel recommends rapidly expanding the safer drug supply throughout the province and in all communities, including rural, remote and Indigenous communities. Where will the supply come from? Could there possibly be a recommendation about how to access that supply?

LAPOINTE It's really going to be up to the folks that the panel's recommendations were directed to: the Ministry of Mental Health and Addictions, the Ministry of Health and the CEO's of the health authorities. They need to look at available models and see how quickly we can ramp this up in terms of meeting the needs of as many people as possible.

We know there have been some groups like the Vancouver Area Network of Drug Users and others that have been purchasing substances on the internet and having them tested and then providing them to substance users.  So, we know that it's possible to get substances on a large scale and it is possible to distribute them.

The panel drew a lot of parallels to the COVID crisis, noting how that was a crisis which presented new obstacles weekly, but there was an ability to be flexible and say we want to reduce harm, we want to save lives, and what do we need to do? Something else has come up, what do we need to do now?

What came through loud and clear in the panel's report was that this is a crisis. We are losing thousands of people. We will soon probably hit 10,000 deaths since the public health emergency was declared in 2016 – and we know that it was declared because of the growing number of deaths before that. So, in a crisis, you respond by doing what needs to be done to prevent the deaths and prevent the harm.

I do hear the colleges saying we need to evaluate, and we need to take time. Ideally, it would be a slower process. But, in a crisis, there isn't a lot of time with six or seven people dying every single day – so it's about reducing the harm and trying to fix supply for as many people as quickly as possible.

And it means moving from the traditional law enforcement model – which has not been effective – to a medical model. Or perhaps it's a compassion club model. Maybe that's the recommendation that needs to come back, with the recognition that the health-care system can't possibly facilitate all of this. Maybe we need a broader model and make some recommendations to government about how that might look. Like government liquor and cannabis stores – who knows? Maybe that's what it is. But it's about getting those minds to the table and asking, how do we quickly put together something that is really meaningful to prevent death?

I'm so appreciative of the work that nurses do, and the nurse practitioners in particular right now, around safe supply because what I've heard is that where many of the physicians are unwilling, the nurse practitioners are stepping up and ensuring that safe supply is available, and sometimes being criticized for it. We all know that this is a change that will happen over time and there's a certain nervousness around it, in particular with some of the regulators. It takes courage and I appreciate that nurses have the best interests of their patients at heart.•

UPDATE (Spring 2022)