Bonnie Henry’s defiant challenge: “If not prescribed safer supply, then what?”
BC’s Provincial Health Officer, repudiated by the politicians, insists on going where the evidence leads her, urging consideration of non-prescribed alternatives to illicit drugs
An early morning earthquake rattled Victoria on July 11, just hours before Provincial Health Officer Bonnie Henry released her latest recommendations to confront BC’s continuing toxic drug crisis, now the province’s largest single cause of death.
Henry’s three-part special report included a searching review of alternatives to unregulated drugs, a broad overview of existing prescribed safer supply programs, and an unprecedented examination of the market effects of prescribed safer supply by US drug policy expert Jonathan Caulkins.
“The earth shook,” Henry joked to reporters as she tabled her proposal to explore the provision of non-prescribed “products of known quality, composition and purity” to people using illicit drugs.
The crashes that followed were the sounds of doors slamming in her face. The entire project proved politically dead on arrival.
There was “zero” chance the provincial government would implement such a proposal, said Premier David Eby. “It’s just non-negotiable.”
The government “will not go in this direction,” added Jennifer Whiteside, Minister of Mental Health and Addictions. “Dr. Henry is an important independent voice on public health issues in this province, and we respect her advice. However, this is a topic we do not agree on.”
Opposition leaders Kevin Falcon, of BC United, and John Rustad, of the Conservative Party of BC, both promised to fire Henry at the first opportunity.
The days when Henry, flanked by cabinet ministers, provided daily COVID-19 briefings to a rapt audience of reporters, was lionized in the New York Times, and was honoured with her own line of shoes are long gone. Now, politicians shoot her down within the hour.
But Henry’s careful research on prescribed safer supply -- the provision of opioid alternatives under medical supervision to about 4,500 British Columbians with opioid use disorders -- tackles some of the hottest issues in the field, including diversion of prescribed drugs, the complexities of prescribed supply, and the fact that such programs may never reach the tens of thousands of illicit drug users who do not have an addiction.
Prescribed safe supply, introduced in BC in March 2020 during the Covid-19 pandemic, does reduce fatal and non-fatal overdoses, according to early studies.
Yet few physicians are ready to take on the complex work of prescribing. The health care system is staggering under existing pressures, more access is required to additional alternative medications, treatment programs are inadequate, and the medical system puts up its own barriers in the form of screening and administrative costs. Henry does not believe prescribed safe supply can turn the tide.
If not prescribed safer supply, then what? The only route left, she argues, is the provision, somehow, of an unprescribed supply of defined composition, dose and purity from outside organized crime’s supply chain.
“To have a real impact on drug poisonings,” Henry says, “it is essential to name and address the underlying cause: drug prohibition and the resulting highly toxic unregulated drug supply. Drug prohibition – the system of laws and policies that constitute how Canada has regulated many psychoactive substances – restricts access to and criminalizes the production, possession and sale of certain drugs and substances . . .The manufacture, supply, and distribution of prohibited drugs has become the territory of organized crime, which has resulted in the creation of the toxic, unregulated drug supply.
“Ultimately, we cannot prescribe our way out of this crisis,” Henry concludes. “Finding new ways to enable access to alternatives to unregulated drugs will require bold conversations, system-level changes, and thinking outside of the constraints that have so far failed to turn this crisis around.”
Henry’s Conservative critics seized on this statement as proof of a push “toward legalization of illicit substances. . . (with) hard and dangerous drugs put in a store like cannabis.”
Legalization with regulation has been the route travelled to manage other addictions like alcohol, tobacco, cannabis and gambling. Fentanyl, however, is another story. This is one illicit market we seem happy to leave to transnational organized crime.
Henry’s report estimates at least 165,000 British Columbians, and perhaps as many as 225,000, access the illegal drug supply every year. Of those, an estimated 105,000 have an opioid use disorder.
The death toll, now about seven a day and totalling 14,000 since the declaration of a public health emergency in 2016, has reduced overall life expectancy in BC, especially for Indigenous men and women.
Fentanyl has been detected in 83 per cent of illicit drug deaths and is increasingly found in stimulants like cocaine and methamphetamine.
Harm reduction measures are inadequate. Treatment and recovery, critical as they are, will not ride to the rescue. Substance use disorders, Henry reminds us, “are chronic, relapsing medical conditions that are characterized by continued use of a substance despite experiencing negative impacts.”
The rates of new diagnoses of substance use disorders declined or remained stable between 2017 to 2022 while the death rate soared.
Henry’s sobering but inescapable conclusion: “treatment does not necessarily remove the risk of death due to the use of unregulated drugs . . . Increasing the number of treatment spaces or ‘beds’ for opioid or stimulant use disorder is unlikely, on its own, to substantially reduce the number of unregulated drug deaths.”
The crisis is deepening, prescribed safe supply is only a partial answer, treatment is not likely to reduce the death toll . . . what, if anything, can be done?
Henry’s first recommendation was to take action to maximize benefits and reduce the harms of prescribed safer supply, including (my emphasis) “consideration of expanded access to safe supply . . . substance use and recovery programs, mental health services, substance use treatment and recovery programs, mental health services and initiatives to address other social determinants of health (e.g. housing, food security).” Who could argue with that?
But if access to prescribed safer supply requires the diagnosis of a substance use disorder, tens of thousands of British Columbians using illicit drugs will remain at risk of injury or death.
A logical next step, Henry argued, is “enabling access to alternatives to unregulated drugs, providing people who use drugs with products of known quality, composition and purity.”
One possible avenue is tolerance of compassion clubs, like the one organized by Vancouver’s Drug Users Liberation Front, which acquired and tested opioids for sale to its members. (Two founders of DULF now face trafficking charges.)
“While there are no magic bullets for ending this crisis,” Henry writes, “enabling access to alternatives to unregulated drugs presents the best opportunity to address its fundamental driver—the highly toxic and unpredictable unregulated drug supply.
“Access to alternatives to unregulated drugs has been called for by people who use drugs, their families, public health officials, and other advocates for many years. And while BC has made important strides in offering prescribed alternatives, the ongoing high rate of death caused by the toxicity of the unregulated drug supply and the barriers inherent in enabling access to alternatives exclusively within the health-care system, shows that exploration of innovative, scalable, and thoughtfully designed non-prescribed approaches is urgently needed.”
The fact that a policy recommendation is politically impossible does not make it wrong.
Henry’s attack on prohibition, though it outraged opposition politicians, is mainstream thinking in global policy circles. Many British Columbians agree.
A 2023 poll found that most BC residents support safer supply as part of a continuum of services, with 63 per cent in support of programs “where alternatives to opioids can be prescribed.” One in five British Columbians knows of someone who died as the result of an overdose.
As the collapse of decriminalization demonstrated, however, public support for harm reduction measures has vaporized in the face of widespread street disorder and open drug use. That would be even more true for non-prescribed alternatives. But Henry’s job is to find a public health solution, not win an election.
The provision of a non-prescribed safer supply, whether by the government or some community organization like a compassion club, raises a host of new complications, none of which Henry shies away from. The risk of diversion of non-contaminated narcotics to the illicit market, where “clean” drugs command a premium, is just one of them.
The main barrier, as Henry argues, is the law, especially the Controlled Drugs and Substances Act and certain elements of the Food and Drugs Act. Another, clearly, is the criminal infrastructure controlling the current market, which stands ready to shoot anyone encroaching on market share. Prohibition is key to their business model.
As long as British Columbians believe that safer supply, prescribed or not, is more dangerous than the toxic drugs produced by criminal networks like the Hells Angels, the Brothers Keepers and all the rest, organized crime’s monopoly on the illicit drug market is safe.
The political counterattack against Henry’s report came so hard and fast that almost no one realized what she was doing: testing long-cherished beliefs, including her own, against the evidence. That should not be a firing offence.
What we’ve been doing up until now, including prescribed safe supply, has not worked or is not up to the task. Until drug users have a safer supply, they will continue to die. Henry has a suggestion. Do politicians have a better one?
How fentanyl cut the cost of “down” by as much as 90 per cent, and the premiums paid for “safer supply”
Expanding BC’s modest prescribed safe supply program could increase diversion of prescribed drugs to the illicit market, says a new study, but that may not be a bad thing if lives are saved and criminal activity declines.
In fact, the premium paid for opioids or “down” of defined purity, quality and dose confirms that people with substance use disorders would prefer a safer supply if it were available.
These assessments came in perhaps the most innovative paper released by Provincial Health Officer Bonnie Henry in her July 11 news conference, a White Paper Providing an Economic Framework for Thinking Through Possible Effects of Prescribed Safer Supply, by American drug policy expert Jonathan Caulkins.
Independently produced by Caulkins under a contract with the Provincial Health Office, which takes no position on his conclusions, the report marches through a complex series of thought experiments and economic analysis about how an expanded, prescribed safer supply might affect the market for illicit drugs.
Caulkins estimates the BC illegal market may be 30 to 50 times larger, in terms of morphine equivalence, than the amount distributed through prescribed safer supply. (About 4,500 people now receive prescribed supply, but at least 20,000 others are regular daily users of illicit fentanyl.)
Should a safer supply be free to users? If not, how much should they pay? What has the greatest impact on street prices? What might the premium be for diverted “safer” drugs in the illicit market? Caulkins considers all these issues.
One of his most startling comments comes in a footnote. Given that “points” (.1 of a gram) of opioid are approximately the same weight and sell for about the same price now as they did before fentanyl, then a shift from heroin at roughly 32 per cent purity, to fentanyl at 16 per cent represents a roughly ten-fold increase in morphine equivalent per bag, equivalent to a 90 per cent decline in the price.
This is the staggering impact of fentanyl: a massive reduction in the cost of the narcotic and a dramatic increase in the risk of death or near-fatal overdose. Most of that massive additional profit is taken by organized crime.
Since BC became the first jurisdiction in the world to launch a large-scale province-wide safer supply program in 2020, some lives have been saved, but the death count continues to rise.
“If BC’s safer supply experiment discovers for the world a new and better way to deal with substance use disorders and illegal markets, I will be delighted,” writes Caulkins. “If BC’s safer supply experiment backfires, I will not be surprised, and observers around the world look forward to learning from BC’s experiment. I sincerely hope it proves successful.”
How do the Alberta government’s drug actions stack up against ours? A comparison would be interesting. Dr. Henry is a thoughtful professional and her opinions and research should be considered.
No matter what happens, the politicians aren’t going to let this succeed, considering there’s an election coming up. It’s an easy target to sensationalize and gain political advantages over your opponents. I would rather trust her than a politician over direction of a health care policy.