No, BC isn't hyperfocused on safe supply
No, BC isn't hyperfocused on safe supply
Right-wing actors have latched onto the government's lip service to safe supply to claim it has a singular focus on the policy. But it doesn't, and it never has.
Depending on whom you ask, BC’s drug policy has either been hyperfocused on safe supply, or it hasn’t scratched the surface.
Or, I guess, if you want to ask the BC government, you’ll get some mealy-mouthed middle ground about how they’ve totally done safe supply but they’re Learning and Doing Better.
In the former case, you’ve got the likes of BC United leader Kevin Falcon, quoted in the Vancouver Sun as saying the government needs to move away from its “complete focus” on publicly supplied drugs. The choice by Falcon to call it “publicly supplied drugs” is in itself an interesting one. It’s part of an ideological push away from the term “safe supply,” but it also obscures differences between opioid agonist therapy (OAT) drugs like methadone or suboxone and safe supply drugs like hydromorphone or fentanyl.
In a recent debate with BC Greens leader Sonia Furstenau on This is Vancolour, Falcon similarly said, albeit with stronger language, that the government has “lost the plot” and that it’s “all about providing publicly supplied addictive drugs” to keep people breathing, adding we’re “not getting improved outcomes.”
Writing in the Toronto Sun, Brian Lilley noted BC’s drug policy has failed, as the province is on track for another grim record of overdose deaths. (According to the most recent stats from the BC Coroners Service, 1,228 people dead from unregulated drugs in the first six months of the year.) Instead, he’s pushing the approach taken in Alberta.
This comes in the context of record-high opioid deaths in Alberta earlier this year (something that was predicted by fellow Substacker Euan Thomson). In April, 179 people died from opioids in that province, higher than any other month before it. And this is purely based on an initial count. Thomson notes these numbers tend to increase about 10%, meaning this figure could climb up closer to the 200 mark.
Lilley writes: “If rising deaths in Alberta mean they should be reconsidering their recovery-focused program, doesn’t that mean that BC’s rising deaths should mean that their drug liberalization policies should be reconsidered?”
And he is awfully close to touching on something.
What the budget does (and doesn’t) tell us
In that exact same Vancouver Sun article where Falcon complains of a “complete focus” on safe supply, readers are treated to a bit of reality.
The 2023 budget included a $1-billion increase to spending in the area of mental health, addictions and substance use, something the BC NDP called the “largest investment in mental health and addictions services in BC history,” according to the article.
In the second paragraph, we get some details on that figure: $586 million is earmarked for treatment and recovery beds, including 190 new free treatment beds.
In the next paragraph, we learn that $184 million is targeted at “safe supply, enhanced prevention and intervention services for children, and the expansion of a program that matches healthcare workers and advocates with police responding to mental health calls.”
To put it another way, the funding going to recovery is nearly three times the funding for safe supply… and a bunch of other stuff. This is a frustrating reality of budget reading—we’re never given line items; we only get the numbers broken down in the ways the government cares to break them down for us.
As a result, we get to compare apples to a fruit basket.
But even this is better than most budgets. Last year’s budget makes no such distinction in how much funding goes to treatment and recovery and how much goes to safe supply or harm reduction, outside increasing complex care housing, nor does 2019’s budget. And the 2020 budget hardly bothers to mention the toxic drug crisis at all, save a mention of it in setting up the money laundering inquiry. The 2021 budget is a bit weirder, referencing $133 million over three years for “treatment and recovery services” and $152 million for “opioid use disorder treatment” without defining the distinction between the two—though we’ll get to a few details in the latter figure shortly.
Breaking down the numbers
The BC government provided somewhat more of a breakdown of the 2023 budget figures in an emailed statement recently. Of the $184-million figure, $68 million is going towards expanding access to prescribed safer supply (PSS), while another $85.5 million is going towards OAT and injectable OAT (iOAT). The latter is another version of safe supply in that it it is intended not to provide relatively low-potency drugs, like methadone, but should ostensibly match what the drug user is getting on the streets. But it’s highly controlled in a therapeutic setting, where PSS, which can be prescribed by a doctor, is intended just to separate drug users from the toxic illicit supply. (Thanks to my friend Tyson Singh, a social worker in the DTES, for helping to disentangle, somewhat, iOAT and PSS.)
The government didn’t break down the price tags on OAT and iOAT, but it’s doubtful that iOAT is much more than a fraction of that funding given how many people are able to access each of them.
The government’s statement also provided some background on previous years. This includes, in 2021, $132 million that went towards the treatment and recovery industry compared to $45 million over three years to “accelerate responses to the overdose emergency, including expanding access to safer supply” and $22.6 million towards prescribed safer supply. You’ll note $45 million and $22.6 million don’t add up to the Exactly how much of that $45 million goes towards safer supply and how much goes towards other harm reduction services isn’t clear.
For 2022, the statement only notes $144.5 million committed to the treatment and recovery industry.
It is worth noting that hydromorphone prescriptions through PSS ballooned from 557 people in February 2020 to 3,899 in May 2021, according to the Pathway to Hope progress report. This, mind you, was still only a fraction of the over 24,000 on OAT as of March 2021, according to the same report. The BC government recently indicated 34,500 people accessed OAT in the 2021/22 fiscal year, while CBC reported the hydromorph figure is now closer to 5,000. (Fun fact, the ministry aimed to have the number of patients on OAT up to 58,000 by 2020/21.)
The government funds 3,260 treatment beds in BC as of September last year, according to a statement the ministry sent me in January. This is certainly a small number and something that should be expanded so those who want to access recovery beds can access them. And while it seems smaller than the number of people accessing PSS, we need to keep in mind that one treatment bed ostensibly treats far more people than a single prescription.
Addiction treatment vs. reducing deaths
The Ministry of Mental Health and Addictions service plans offer some further indication of the ministry’s priorities. Since 2019, they’ve had some version of the same two goals, each with two objectives. Goal 1: Respond to overdose deaths. Goal 2: Provide a system of mental health and addictions care. But the goals are hardly about access to safe supply. You’ll see maybe one mention of safe supply or iOAT. You’ll see several more mentions of treatment or recovery, but the measures of success for Goal 1, until 2022, have mostly focused on take-home naloxone distribution and OAT.
As of last year, another measure has been included under treatment: wait times to access recovery beds. That was pegged at a baseline of 29.5 days in this year’s budget. But even this measure of success isn’t part of the goal to improve access to addictions care. It’s under Goal 1.
Notably, none of the measures of success is reducing deaths. Or reducing overdoses. Or improving access to safe supply.
The BC government’s model of responding to the masses of people dying from an unregulated drug supply to date can largely be characterized as one of addictions treatment. It’s in the continued funding of inpatient recovery spaces with little regulation or monitoring to ensure its efficacy and in its heavy reliance on OAT. And it’s in premier David Eby’s on-again-off-again flirtation with involuntary care, a policy that is linked to increased likelihoods of dying and little increased likelihood of recovery.
BC’s approach to safe supply, with only a few exceptions, is also largely within a treatment framework, despite 13% of those who died between August 2017 and July 2021 only using drugs “occasionally/infrequently,” according to the BC Coroners Service’s death panel report, published in March last year. (Thanks to Karen Ward for re-upping that figure recently.)
Treatment-oriented safe supply is great for those who can use it—and for those who can keep up with the demands of the treatment it involves—but while people with substance use disorders make up about three-quarters of those who are dying, the crisis of thousands of people dying every year from drugs is one of an unregulated supply—not addiction.
Government-fuelled misperceptions
The BC government has its own role in this misperception that it is seriously engaged in providing access to safe supply. For years, they’ve touted their safe supply programs, even when those programs were more a series of disconnected pilot projects than a coherent program. I’ve sat through countless press conferences on the monthly coroners stats where successive mental health and addictions ministers have touted their commitment to safe supply, often to the incredulity of reporters.
Lilley is right that the government in BC needs to change its approach. The number of people dying does, indeed, display a catastrophic policy failure. But despite his and others’ beliefs to the contrary, it isn’t because of an over-reliance on safe supply.
OAT, while very useful to many people who use drugs, isn’t particularly adapted to an age where people’s tolerances are dictated by the power of fentanyl. Naloxone, while extremely useful in reversing opioid poisonings, doesn’t do anything about the increasing encroachment of benzodiazepines and tranq in the supply.
And the government’s messaging on this hasn’t just given ammunition to bad-faith arguments that safe supply doesn’t work to reduce deaths; it has fuelled misleading commentary on the diversion of hydromorphone into street-level drug markets.
Folks like far right media personalities Adam Zivo and Aaron Gunn, and Alberta premier Danielle Smith claim hydromorphone diversion is causing a whole new crisis, but that likely isn’t true. At least, it’s likely untrue that safe supply is doing much to increase the availability of hydromorph, also known by its brand name, Dilaudid, and often referred to as dillies, available on the streets.
It’s highly likely some hydromorph is being diverted from safe supply programs. But as Zivo mentions in his 10,000-word National Post screed, a study showed people accessing diverted opioids were 30% less likely to be exposed to fentanyl. Zivo characterizes this as a flawed study because it was before the drug was made all that widely available for safe supply. But it’s an ill-thought argument—dillies have been widely available for cheap in the DTES since long before the government ever remotely considered safe supply.
In 2018/19 alone, before safe supply was scaled up in the pandemic, there were more than 80,000 people receiving hydromorphone prescriptions. But when Zivo and others talk of diversion, they hardly even need to say “safe supply”—they just assume that’s where it’s coming from. And they get away with it because the province has talked a far bigger game than it plays on safe supply.
But if Zivo and Gunn and Smith, all of whom have cited diversion as a reason to oppose safe supply, want to limit diversion, there’s an easy way to do that: give people the drug they’re actually looking for.
Hell, Zivo links to a good source on this, too. This time, it’s a Health Canada report on safe supply pilot programs. He characterizes the report as federal government staff acknowledging (but ignoring, to his mind) the issue of diversion, but he ignores a whole lot to get to that point.
He acknowledges comments about fentanyl skewing people’s tolerance levels but ignores others about there being few programs for fentanyl safe supply—that is, there are few actual safe supply programs that are intended to provide a safer supply of the drugs people are actually using.
And he ignores the glowing reviews from people for whom hydromorphone is enough. Here’s a screenshot of those reviews:
Addressing today’s reality
So it’s true: the BC government does need to change its tack. That can very much include investing in recovery spaces—but even those are riddled with their own problems and lack any substantial level of oversight.
But to cut down on deaths, it needs to increase access to safe supply, as many experts have been begging for for years. It needs to give people a safe supply of the drugs of their choice, rather than making them choose between something that won’t address their cravings and the tainted street supply.
Hydromorphone as a treatment-oriented safe supply option is great for some, and it would have been far better for far more people a decade ago. In fact, hydromorphone as safe supply is a concept that was devised in the Vancouver context way back in the late 2000s, ahead of the SALOME trial, as an alternative to heroin due to challenges obtaining heroin to treat opioid use disorder.
But in today’s environment, it seems to be more akin today for many opioid users to what methadone was to heroin users in the mid-2010s. It addresses withdrawal symptoms but doesn’t offer the high they get from fentanyl—a high many people need to be able to just face every day and potentially address other factors in their opioid use disorder, like poverty, joblessness, houselessness, etc. And it does nothing to help people who use any number of drugs recreationally, from opioids to cocaine to whatever else, who are also dying from this toxic street supply.