A Victoria hospitalist is warning that if the province opens up access to a greater variety of highly addictive and potent opioids without a prescription or supervision, new addictions will occur “on a massive scale.”
Dr. Mark Mallet was reacting to a call by chief coroner Lisa Lapointe this month for prescription-free access to a wider array of quality controlled opioids and stimulants to reduce illicit drug overdose deaths.
The recommendation is based on the advice of a B.C. Coroner Service 21-member death review panel in a report released Nov. 1.
Unregulated-drug toxicity is the leading cause of death in B.C. for those ages 10 to 59, accounting for more deaths than homicides, suicides, accidents and natural disease combined, according to the coroners service.
About 225,000 people in B.C. use unregulated drugs, including 100,000 who have an opioid-use disorder, prompting calls for increased access to a safer drug supply to prevent people from being poisoned by the toxic illicit-drug supply.
Now in its eighth year, the toxic-drug overdose crisis has claimed more than 13,000 lives.
The safer-supply program sees physicians prescribe pharmaceutical alternatives to illicit drugs — most often hydromorphone, which goes by the brand name Dilaudid.
But advocates says it’s reaching only a fraction of drug users, due to a lack of access — especially in rural settings — as well as physicians’ reluctance to prescribe safer-supply drugs for fear they’ll end up on the street, because Dilaudid is regarded as a weak substitute for fentanyl, the drug to which most are addicted.
Only about 5,000 people are prescribed safer- supply alternatives in any given month, according to the panel’s report, while about six people in B.C. die of toxic drug poisonings each day.
The death review panel’s recommendation that community groups distribute regulated opioids and stimulants without a prescription was immediately rejected by Mental Health and Addictions Minister Jennifer Whiteside.
But provincial health officer Dr. Bonnie Henry has yet to file her own report on alternatives to the toxic drug supply. Depending on her recommendations — due to be submitted to government in the next few weeks — the debate will likely continue.
Mallet, who supports harm-reduction measures, says without oversight, drugs handed out as part of the safer-supply program will continue ending up in the wrong hands, “destabilizing people who had been on the road to recovery.” He and other critics say users are selling their allotment of Dilaudid on the street for cheap —about $2 a pill — to buy stronger drugs, such as fentanyl.
Dilaudid pills, called Dillies, are also ending up in high schools, says Mallet, where they’re “creating new addictions amongst our most vulnerable youth.”
The Victoria hospitalist points to a Sept. 23 open letter from 17 addictions specialists in Canada —including Dr. Robert Cooper, who served on the board of the Canadian Society of Addiction Medicine, as well as Dr. Paul Farnan, a clinical associate professor in the department of family practice at UBC.
“We are regularly seeing and hearing in our practices that diverted hydromorphone is causing harm to both adults and children,” the letter says. “We call on the government to ensure that all hydromorphone prescribed to people with opioid addiction is provided in a supervised fashion or that funding be ceased.”
But harm-reduction drug researchers argue it’s the toxic supply and not addictions that are killing people who use drugs.
Bernie Pauly, a University of Victoria nursing professor and scientist with the Canadian Institute on Substance Use Research, says the backlash against safer supply has resulted in a clear decline in prescribing.
“We are hearing from communities that people are being reduced or cut off,” Pauly said in an email. “This is extremely concerning, as now less than five per cent of the population diagnosed with a substance-use disorder have access to a life-saving intervention.”
Pauly argues that access to safer supply without prescription is needed, as those without a substance-use disorder diagnosis but accessing the illicit market remain at high risk of overdose.
As for prescribers who want to be part of the program, there’s not a lot of support by way of education, training or infrastructure, she said.
In July 2020, the Canadian Association of Chiefs of Police expressed support for evidence-based medical treatment that included safe supply.
Victoria Police Staff Sgt. Connor King said that based on his experience, Dilaudid is not the drug most people want and so the pills “are indeed being sold illegally.”
But various prescription drugs have been sold on the streets for decades, said King, a court-certified expert witness on the trafficking of fentanyl, heroin, oxycodone, cocaine, and methamphetamine. “There has always been Dilaudid and oxycodone and other powerful opioids in the teen environment in high school and university campuses.”
In addition, King said, “when I look at the coroner data, we’re not seeing a link between safer-supply drugs and lethal overdoses.”
King called diversion of safe supply a “small piece” of an “enormous picture,” as illicit drugs flow into B.C. via organized crime. Fentanyl coming into the province is highly toxic and deadly, and methamphetamines manufactured in Mexico and shipped or smuggled across the U.S.-Canada border are plentiful, powerful and cheap, he said.
“There has never been greater availability of cheaper drugs that are more toxic than the situation we face right now,” he said. “And none of that has anything to do with prescribed or safer-supply drugs.”
Police efforts will never be able to match organized crime’s ability to bring in drugs, King said. “These drugs are coming in too quickly and in such a way that is impossible for us to stop the arrival.”
Police have focused their efforts on a small number of drug dealers and organized-crime groups and look to health providers to deal with the health and mental-health aspects of addiction and toxic drug poisonings.
“I’m a fan of looking for alternate ways for people to access drugs that are going to keep them alive, but I leave that to the medical community to sort out,” said King.
If the government’s goal is to move people away from toxic illicit street drugs to a government-controlled safe supply, King said, the program is “likely going to have to change so it meets the person’s addiction needs.”