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Comment: Prescribed safer supply needs more research

Systematic evaluation of potential unintended consequences needed to make sure program is not doing more harm than good

I would like to thank Dr. Bonnie Henry, B.C.’s chief medical officer, for her courageous and honest examination of the thorny issue of Prescribed Safer Supply (PSS).

Although Henry recommended cautious expansion of the program to include a wider range of prescribed alternatives, it is worth highlighting three of her conclusions which should give us pause when considering further expansion, as they clearly indicate that we are jumping the gun.

First, Henry reviewed the evidence behind PSS, and concluded that the total body of evidence is “quite limited.” In fact, it is “not at this point strong enough for this intervention to be described as fully evidence-based.”

The significance of this finding cannot be overstated.

PSS advocates — and in particular those who favour PSS expansion — have repeatedly claimed that their argument is based on “evidence,” and that opposition to expanded PSS is little more than “fear-mongering.”

The truth is that much of the evidence behind PSS is weak or inadequate, and Henry has confirmed that with her report.

Even a recent much-cited study in the British Medical Journal, which showed that drug users have a lower chance of death in the seven days after receiving PSS, is underwhelming. As any doctor will tell you, one-week mortality benefit — while positive — is never used as a measure of a treatment’s success.

People care about patients being alive one or two years down the road, not one week.

The second important conclusion that Henry came to was that the potential harms of PSS are manifold.

These include “diversion to non-intended populations, expanded access and availability of opioids for youth, and normalization of this access leading to risky use, and reduced incentives for recovery … and uncertainty over long-term population-level effects (e.g., increasing the prevalence of substance use disorders).”

This admission of safe supply’s vast potential for harm is stunning, particularly when one considers that some physicians — myself included — who have warned of the potential dangers of the unwitnessed PSS program, have been accused of “moral panic” and of blatantly politicizing the issue.

In truth, we have been standing by our duty to do no harm, by considering all those who may be negatively impacted by the unwitnessed PSS program.

Henry’s admission of the program’s potential harms is gratifying, but it is also unsettling.

Perhaps most unsettling is Henry’s third significant finding: that research into these potential harms is virtually nonexistent. “Some diversion is occurring; however, the extent and impacts are unknown.”

Although there is a team evaluating the efficacy of PSS itself, “systematic evaluation of potential unintended consequences is outside the scope of the current evaluation.”

This is a shocking reversal of what we have been told for years. In May 2023, for example, chief coroner Lisa Lapointe assured British Columbians that authorities are “closely monitoring, continually, for any and all trends that may impact public safety.”

That same month, Lapointe also referred to concerns about PSS diversion as an urban myth.

It is staggering to learn the truth: that not only is diversion a very real problem, it is also not being monitored at all.

Given this lack of oversight, it is not surprising that stories of real harm happening to real people because of diverted PSS drugs are easily dismissed as “anecdotal.” It is impossible for anecdotes to rise to the level of evidence if no one is systematically collecting data.

Together, these three findings in Henry’s comprehensive report should make all of us take a step back and look carefully at what we are doing.

It is virtually unheard of for a potentially dangerous medical intervention to be expanded beyond a pilot project without significant evidence showing efficacy, and similarly significant evidence showing an absence of harm.

When it comes to PSS, we have neither.

What we need urgently is not expansion of the safe supply program, but more research. I say this as a supporter of the concept of PSS in general, but only if safety is a priority.

COVID-19 forced the province to roll out PSS in great haste in March 2020, and in those frantic first few months, a lack of evidence was perhaps understandable. But the program has been running for almost four years. We should be drowning in evidence by now.

Until such time as we have strong data showing both efficacy and absence of harm, PSS must remain tightly controlled, rigorously monitored, and meticulously documented.

Rather than expand the program, we should enact every safeguard possible to ensure the program is not doing more harm than good.

Finally, we must all remember that to demand evidence is not fearmongering, it is not politicizing, and it has nothing to do with moral panic; to demand evidence is, in fact, the very basis of scientific inquiry.

As a physician and a citizen of British Columbia, it is not only my right to demand such ­evidence; it is my responsibility.

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