By Adam Zivo
May 9, 2023
Source: National Post
Photo Source: Unsplash,
Opioids Series: Diversion
In this special report, columnist Adam Zivo details how drugs handed out for free are being sold on the black market to fund fentanyl addictions
Measuring diversion
To date, very little research has been done to measure the scale of diversion or its negative community impacts. In some cases, researchers allege that their attempts to study the issue have been actively hindered. In the absence of a formal investigation, current evidence is generally anecdotal.
Numerous addiction physicians acknowledged the dangers of generalizing from anecdotal evidence, but said that the problems they’ve observed are so overwhelming that it’s glaringly obvious that diversion is systemic. Their concerns, however, seem to be backed up by at least one indicator: market prices.
In cities where safer supply programs are active, experts say that the street price of hydromorphone has plummeted, suggesting an avalanche of new supply.
According to Dr. Koivu, the street price of an 8-mg hydromorphone tablet in London was approximately $20 when safer supply first launched. Today, she says it’s $2. “It’s now cheaper to buy than a tallboy beer,” she said, exasperated.
Dr. Red, a B.C.-based addiction physician, observed a similar price collapse in Vancouver. Before safer supply, 8-mg hydromorphone tablets sold for $10 in the DTES. Now the doctor’s patients say that street prices range from 50 cents to $1.
Dr. Yellow, another B.C.-based addiction physician, had slightly different, more granular numbers for Vancouver. The doctor claimed that an 8-mg tablet was $8 before safer supply, then dropped to $4 after Vancouver launched hydromorphone vending machines in early 2020. After safer supply was further expanded, prices allegedly dropped to between 25 and 33 cents per tablet.
Dr. Vincent Lam, the medical director of Coderix Addiction Therapy, provided insight into the situation in downtown Toronto. According to his patients, 8-mg hydromorphone tablets that used to go for $20 on the street now sell for between $2 and $5, and sometimes as little as $1.
Dr. Indigo, an addiction physician from Ottawa, said that before safer supply launched in that city, most opioid diversion involved Hydromorph Contin — a long-acting version of hydromorphone. Dr. Indigo estimated that 24-mg capsules of the drug, which were likely originally prescribed for pain relief, would sell for between $20 and $30.
After safer supply launched, Dr. Indigo saw Hydromorph Contin use almost disappear. The drug was replaced by 8-mg hydromorphone tablets that patients said were bought for about $2 apiece. Adjusting for different pill strengths, that translates to a 70-80 per cent reduction in black market opioid prices.
Several addiction physicians said that street prices for hydromorphone are also correlated with proximity to safer supply dispensaries — the farther away a neighbourhood or city is from safer supply sites, the more expensive black market hydromorphone seems to be.
According to Dr. Blue, another B.C.-based addiction physician, anyone in downtown Vancouver who is paying more than $1 per tablet is “getting ripped off,” but in Surrey, B.C., a suburb that is somewhat removed from the DTES safer supply cluster, hydromorphone tablets sell for $1 to $5 a pill.
I emailed several police departments regarding safer supply and hydromorphone prices. The Ottawa Police Service did not reply to my questions, while the London Police Service said that it doesn’t “have anyone available to speak to this.”
The Toronto Police Service vaguely answered: “It’s possible that street prices have dropped recently, but we wouldn’t be able to say with any certainty that it’s related to the safer supply diversion.”
The Hamilton Police Service claimed that the price of hydromorphone “has stayed the same as always — $1 per mg essentially.” That would put the price of an 8-mg tablet at $8, contradicting the price ranges identified by six different addiction physicians across Canada.
The Vancouver Police Department said that it doesn’t “have too much information” on the topic, as it focuses on harder drugs that are more strongly associated with overdose deaths. According to the department, because Vancouver police officers engage with only a small number of hydromorphone cases a year, they don’t have enough data to confidently report prices.
However, Vancouver police said they are aware of safer supply diversion, as the issue is “being raised as a concern in discussions with health and community partners.”
Collapsing prices would be unsurprising considering the astonishing number of pills being distributed. Several physicians claimed that safer supply patients were receiving upwards of 20-30 tablets a day.
These assessments are consistent with safer supply protocols published by the Parkdale Queen West Community Health Centre in Toronto, which states that patients may receive up to 24 8-mg hydromorphone tablets daily.
These pills are not typically consumed by the handful. According to the addiction physicians I interviewed, a single 8-mg hydromorphone tablet is more than enough to severely intoxicate, hospitalize and in some cases even kill an individual who is inexperienced with opioids.
A sign stating “No More Drug War, End Overdose Deaths Now!” outside a Street Health location in Toronto, April 13, 2023. PHOTO BY PETER. J. THOMPSON/NATIONAL POST
Dr. Lori Regenstreif, a Hamilton-based addiction physician, expressed frustration at safer supply’s lack of barriers and accountability. “You don’t have to prove anything. You can just go in and say that you’ve overdosed on fentanyl in the last few months,” she said.
While price shifts are useful for demonstrating the existence of widespread diversion, it also helps that patients openly tell physicians that this is happening. Dr. Lam, who believes the term “safer supply” is misleading and prefers the term “public supply of addictive drugs” (PSADs), said, “Anecdotally, it’s very common for my patients to tell me that they know people who sold most, if not all, of their prescriptions for PSADs. Unfortunately, that means that the hydromorphone is going somewhere else.”
“Everybody that I talk to who is being prescribed this is telling me this,” said Dr. Green. “I meet people in my office that buy large amounts of it and then ship it off to Saskatchewan, Manitoba and the United States, where it’s much more valuable.”
Dr. Red also noted that, “I have patients who actually work in the DTES and report that they see it happening. We see people driving down to the corner of Main and Hastings, obviously not locals, exchanging money for tablets.”
According to Dr. Regenstreif, some of her patients made an effort to consume hydromorphone, but were unable to “dissolve that many tablets in a spoon and cook and inject it all — it was too high a volume.” Those patients ultimately sold their tablets to purchase fentanyl, she says.
Doctors can sometimes detect diversion by testing urine for fentanyl and hydromorphone. However, there are limits to this method.
Detecting hydromorphone doesn’t necessarily rule out diversion, as some patients intentionally consume some of their hydromorphone, while selling the rest, to pass urine tests. Meanwhile, if there is fentanyl in a patient’s urine, that doesn’t necessarily mean that it was funded by selling safer supply drugs.
It’s now cheaper to buy than a tallboy beer DR. SHARON KOIVU
In a 2020 podcast interview, Dr. Mark Tyndall, one of Canada’s earliest safer supply advocates, said that he had tested the urine of 15 patients who were on safer supply and found that 90 per cent still used fentanyl.
When Dr. Green prescribed hydromorphone to an opioid addict for the first and only time, the patient returned two weeks later with an inexplicable $200 in his wallet. The doctor ordered a urine test, which showed no hydromorphone in his system.
Though urine tests help catch diversion, several addiction physicians said that safer supply advocates often oppose them, arguing that such tests stigmatize addiction and infringe on drug users’ human rights. “As far as I know, they don’t usually test urine, as that’s considered to be oppressive,” said Dr. Regenstreif.
Prescription labels have also been used to track diversion. In March, the Nanaimo Area Public Safety Association claimed that it had found more than 80 prescription labels discarded near a downtown pharmacy, most of which were for hydromorphone.
Collen Middleton, the organization’s chair, expressed concern about safer supply being sold to purchase fentanyl and ultimately ending up in the hands of high schoolers. Similarly, a representative from the Nanaimo Network of Drug Users said that the system is broken and estimated that up to 80 per cent of safer supply drugs in Nanaimo, B.C., are currently being diverted.
Prescription labels can also show that hydromorphone is ending up in communities far away from prescribers. Dr. Violet, a B.C.-based physician, said that their clinic sometimes receives calls from concerned pharmacists in Ontario who have come across hydromorphone packages that obviously originate from the West Coast.
Individuals seeking hydromorphone have allegedly gone to Ontario pharmacies and, in the process of explaining what drug they want, presented pharmacists with packages of prescription hydromorphone. The pharmacists then noticed that the individuals’ names didn’t match the prescriptions attached to the packages and were able to trace them back to Dr. Violet’s clinic.
Dr. Violet said that diversion is “incredibly dangerous” and lamented the fact that these drugs are not tracked and that there are no provincial programs dedicated to monitoring the harms of safer supply, including diversion.
Several addiction physicians also said they were disturbed by the predatory and violent social dynamics associated with diversion. According to Dr. Koivu, some vulnerable patients who receive safer supply are compelled to hand over their hydromorphone to others, such as abusive spouses and pimps.
Dr. Jennifer Brasch, an addiction psychiatrist who was president of the Canadian Society of Addiction Medicine from 2020-2022, said that there is a real risk that vulnerable patients are being “forced into falsely telling their doctor that they need an increased dose, so part of it could be diverted to other markets.”
Dealers often harass drug users and pressure them into handing over their safer supply. Some users are also pressured into securing as much safer supply as possible to divert to the black market. In this way, safer supply finances drug dealers and allows them to make money in a whole new way.
These dynamics have been noted by some safer supply programs. For example, a 2021 report published by LIHC noted that, “Both clients of the SOS program and people not on the program described situations where women in abusive or coercive relationships were forced to give portions of their prescriptions to their partners.”
This same report also recognized that diversion was a significant issue and quoted one program participant as saying, “They get their medication and just trade it for what they need and want. Basically, that’s the bottom line, that’s all it is, and those are the people that are taking it to an advantage, and it’s giving us who need it a bad name.”
Recovery advocates concerned, too
In January, Global News reported that recovery experts had learned that youth in Vancouver were likely diverting opioid drugs dispensed from the city’s three MySafe vending machines.
According to the Last Door Recovery Society, youth had specifically mentioned to the organization’s staff that they were travelling to downtown Vancouver to purchase safer supply opioids.
In response, MySafe said that its machines were secure and that they only dispense opioids upon conducting a biometric scan, which confirms the identity of the recipient. The company said that patients undergo “a full medical and social assessment, which includes current drug use patterns and their risk of overdose,” and told the Vancouver Sun that, “From what we have observed, any diversion is to a friend or partner who is drug sick.”
Yet the security of these vending machines is irrelevant if it doesn’t prevent safer supply patients from reselling opioids to youth. The claim that diverted hydromorphone only goes to friends or sick partners starkly contradicts what the physicians I interviewed are saying.
To get more insight into diversion, I spoke with Giuseppe Ganci, a recovery advocate with a 30-year history of drug use. Ganci is the director of community development at the Last Door Recovery Society, the chair of the Recovery Capital Conference of Canada (the nation’s largest recovery-oriented event) and the chair of Clean Sober and Proud, which provides sober events and addiction services to the LGBTQ community.
Through his work, Ganci has met hundreds of people who are either currently struggling with addiction or are in recovery. Based on his experiences, he believes diversion is ubiquitous.
“One-hundred per cent of all of the people I’ve met who are on safer supply sell their safer supply. I’ve never met anybody who’s taken all of it,” he said. “They may take their safer supply as a bridge, until they get their drug of choice, but nobody that I know, in the history of me meeting people — well, they all sell and divert it.”
Ganci criticized safer supply’s “patriarchal” assumption that addicts who want to consume fentanyl can be dissuaded by providing them with a less potent, government-sponsored substitute.
From his perspective, this assumption fails to account for the fact that drug users know how to rationally pursue their goals. If their goal is to consume a specific substance, such as fentanyl, they will lie and resell drugs to acquire it — it’s the rational means to an irrational end.
In other words, safer supply relies on the infantilizing belief that drug users have no agency over their lives and lack the intelligence to exploit the system to get what they want.
Ganci’s anger towards the safer supply program is palpable. “I know a story of this one person who literally would pick up his dirty heroin pills (hydromorphone), leave, walk a block and sell it to the local gang. It’s a business and a system. It’s just the way it is here in British Columbia,” he said.
Sabotaging recovery
Decades of addiction research shows that if you increase the availability of a drug, decrease its cost and reduce the perception of how harmful it is, use of that drug will go up and addiction will increase.
Safer supply drugs are no different, which is why the hydromorphone flooding into communities across Canada is already destroying lives. The effect has been particularly pronounced among youth and people who are trying to recover from addiction.
Several physicians I spoke with said that they are seeing a rising tide of young people requesting help with hydromorphone tablet dependence. For example, at least three physicians, representing three different outpatient clinics in B.C., directly reported to Dr. Red that they are witnessing increased hydromorphone addiction among youth. The issue has not been limited to the West Coast, as physicians in Ontario say they are witnessing a similar trend.
According to these physicians, youth generally understand the grave risks of using fentanyl and are therefore unlikely to experiment with it. However, because hydromorphone is prescribed by a doctor and marketed as “safe,” young people severely underestimate its dangers and are more likely to try it.
However, for a teenager who has never used opiates before, an 8-mg dose of hydromorphone, which is four times the dose typically prescribed in a hospital setting, is not actually safe. Even one tablet can be dangerous, particularly if mixed with alcohol.
“I started seeing a real shift in the people that I was seeing. Much younger populations. Young people who this was now an early drug in what they were using,” said Dr. Koivu, noting that, from her understanding, youth typically experiment with hydromorphone after trying ecstasy and magic mushrooms.
Safer supply has also been ruinous for recovery-oriented treatments, such as OAT.
“Safer supply is very attractive to people with opioid use disorder. Unlike OAT, people experience euphoria when taking hydromorphone, and they can generate income by selling hydromorphone to others. This causes some patients to refuse OAT or to drop out of OAT, even though they were doing well on OAT,” said Dr. Kahan.
Dr. Koivu has also interacted with former OAT patients who destabilized because of safer supply. Many explicitly told her that they wanted to divert free drugs to the black market.
Even individuals who have completed OAT and are sober are at risk. At Dr. Green’s practice, half of the people being initiated into OAT “either relapsed due to safer supply or initiated an opioid use disorder because of it.”
Dr. Indigo said that, in Ottawa, drug dealers are aggressively marketing diverted hydromorphone to recovering addicts. Patients would allegedly tell the doctor that, “There’s tablets in my building and I can’t get away from them.” Many patients who were stable on OAT and not using drugs consequently relapsed. Some of them thought that they could “just have one or two,” but were quickly hooked back into addiction.
Homelessness and infections
Dr. Koivu said that several patients voluntarily left their homes to move into tents located in a parking lot near a pharmacy that dispenses safer supply drugs. They wanted to be close to the action — to buy hydromorphone early in the morning, when it was cheapest on the black market, for consumption and profitable resale. She is now convinced that safer supply exacerbates homelessness.
A person leans against a needle drop box on Dundas Street at Sherbourne Street in Toronto, Thursday April 13, 2023. PHOTO BY PETER J. THOMPSON/NATIONAL POST
Given that many of her patients got addicted to hydromorphone and then graduated to fentanyl use, Dr. Koivu suspects that safer supply is also exacerbating the fentanyl crisis. And she is not the only one who feels this way.
Dr. Lam similarly stated that, based on his experiences, safer supply appears to lead to more fentanyl addiction. “I hear from patients, all the time, that they don’t really understand the rationale behind safer supply. They don’t really see it helping people in their community. In fact, they find it harmful,” he said.
It was common knowledge among the addiction physicians and pharmacists I interviewed that, although hydromorphone tablets are meant for oral consumption, they are commonly crushed, cooked and injected.
Injecting hydromorphone is pervasive enough that clinician resources have been dedicated to addressing it. Dr. Regenstreif said that many safer supply programs even provide “recipes” for preparing and injecting different versions of hydromorphone.
I hear from patients, all the time, that they don’t really understand the rationale behind safer supply... In fact, they find it harmful DR. VINCENT LAM
The problem, though, is that the tablets aren’t sterile and include materials that aren’t safe for intravenous use. According to several addiction physicians, injecting them can lead to horrific infections that disfigure patients and cost tens of thousands of dollars, and weeks of hospital stays, to treat.
Both Dr. Koivu and Dr. Regenstreif, who work in different cities (London and Hamilton, Ont.), said that these infections have led to paralysis, leaving patients paraplegic or quadriplegic. Both doctors flagged spine and heart-valve infections as a particular concern. Spinal abscesses are said to be especially excruciating.
Though the timing of these infections suggest that they are caused by hydromorphone injection, validating that relationship can be difficult. Other possible causes have to be ruled out. People struggling with addiction often abuse several different kinds of drugs at a time, and infections can sometimes happen just by sticking a needle in your arm.
However, during the OxyContin crisis, Dr. Koivu produced research showing that injecting Hydromorph Contin is associated with increased heart-valve and HIV infections (HIV was caused by the act of injection, not the Hydromorph Contin itself). As such, at least some of the suspected dangers of injecting hydromorphone are backed up by formal research.
For Dr. Regenstreif, the most important issue is that hydromorphone is a short-acting opioid whose effects last only three to four hours, which allegedly leads users to inject the drug four to six times a day. She is concerned that, by prioritizing a short-acting opioid like hydromorphone, safer supply encourages drug users to inject with unnecessary frequency. The goal should be to get patients onto long-acting opioids that reduce injections, she said.
Erasure of harms
Last December, Health Minister Carolyn Bennett in an opinion article for the National Post, praised safer supply and defended the federal government’s commitment to the program. In Bennett’s fairy-tale world, there are no concerns about diversion, rising addictions or debilitating infections.
The minister also skipped over the fact that, according to the government’s own research, many participants of safer supply programs continue to abuse fentanyl because hydromorphone doesn’t get them high.
Bennett cited the LIHC safer supply pilot project in London as a “particularly notable” example of success. According to the health minister, the program has seen zero overdose deaths.
Yet Dr. Koivu says she has had patients who were enrolled in the LIHC safer supply program and ended up dying of overdoses. Their exclusion from official statistics has made her deeply concerned about the quality of data being provided to the government — did this data fully capture what was happening to program participants? “The patients I watched suffering have to matter. Their lives and experiences are important, but I feel that they have been erased,” she said.
Several addiction physicians expressed concerns that the LIHC program was measuring outcomes in insufficient ways. For example, LIHC’s evaluation reports rely on self-reported data to measure outcomes (i.e. client surveys and focus groups), but self-reported data is often unreliable because respondents can easily misrepresent their experiences.
I emailed a list of questions to LIHC inquiring about what measures they employ to address the weaknesses of self-reported data. The organization did not directly answer these questions, but instead sent a study, published last September in the Canadian Medical Association Journal, which showed positive outcomes and relied on data drawn from Ontario’s administrative health databases.
However, LIHC’s safer supply program doesn’t just provide free hydromorphone — it also gives patients comprehensive wrap-around supports. That includes an array of health and social services, as well as access to an interdisciplinary team that provides counselling, housing support and social services.
The study provided no evidence showing that the provision of hydromorphone, and not the plethora of accompanying supports, were the cause of positive outcomes.
Interviewed addiction physicians said that this kind of oversight, wherein the benefits of wraparound supports appear to be misattributed to safer supply drugs, is common in the harm reduction world.
“The quality of the science is very poor,” said Dr. Regenstreif, who also noted that the LIHC evaluations showed that some patients had dropped out of the program, but that no information was given about what happened to them. By failing to investigate these outcomes, safer supply programs can misleadingly reduce their death count — patients don’t die, they just disappear.
Letters and messages of encouragement seen on the wall of an opiate addiction clinic. PHOTO BY PETER J. THOMPSON/NATIONAL POST
Dr. Regenstreif said that, in general, many drug-related deaths are simply not counted if they are caused by something other than an overdose.
“If you’re injecting fentanyl and then get a heart infection, or you die of something else related to drug injection while in hospital, that doesn’t get counted as a coroner’s case,” she said. “It’s not necessarily considered a drug-related death. It’s not being included with the overdose numbers. And the epidemiologists don’t seem to be aware of this.”
Dr. Kahan also pointed out that safer supply research typically compares program recipients to individuals who have received no treatment at all. However, the norm in health-care research is to compare new treatments to standard care — in this case, that means recovery-oriented programs, such as OAT.
It isn’t enough to show that safer supply is better than doing nothing — it needs to be better than existing options. By not making these comparisons, Dr. Kahan argued that advocates were exaggerating the benefits of safer supply while minimizing the harms.
“The type of studies they (safer supply advocates) are doing are the weakest. The bottom line is that they’re not comparing — this is the unethical part — they’re not comparing hydromorphone programs to the standard of care, which is methadone or buprenorphine. That would be more ethical,” said Dr. Regenstreif.
At least four addiction physicians I spoke to, including some familiar with B.C., have witnessed, first-hand, that evidence which contradicts the narrative around safer supply is often dismissed.
In some cases, doctors say they are pressure to ignore harms. Dr. Regenstreif described being left out of important meetings, research activities and conversations after raising concerns about safer supply.
Dr. Violet used to work at a B.C.-based institution that is associated with safer supply. As an addiction physician with a research background, the doctor asked to analyze the institute’s safer supply data, in order to track unintended consequences and potential harms.
“The request was met with hostility. They set up meetings with other stakeholders and I very quickly got the sense that this was not welcomed,” said Dr. Violet. The institution refused to share its data, the doctor says, and claimed that it already had plans to measure the potential harms of safer supply, but could not describe what those plans were.
There was a “very clear warning” that Dr. Violet’s job security was at risk by pursuing research that could reflect poorly on safer supply. “It was quite clear to me that they did not want any outsiders to take part in their work. I’m not the only physician whose interest in this area has been met with opposition and challenges,” said Dr. Violet.
After that incident, Dr. Violet found work elsewhere.
Government inaction
What are Canadian government bodies doing about diversion? As it turns out, very little.
I emailed a list of diversion-related questions to Health Canada, B.C.’s Ministry of Mental Health and Addictions and Ontario’s Ministry of Health. Among my questions, I asked whether they were aware that: i) hydromorphone street prices had collapsed since safer supply was implemented; and ii) that some addiction clinics were seeing increased admissions relating to diverted hydromorphone.
MySafe Verified Identity Dispensers. PHOTO BY THE CANADIAN PRESS/HO, DISPENSION INDUSTRIES INC.
The Ontario government didn’t answer my questions, despite promising that it would. Staff eventually stopped responding to my emails. However, both the B.C. government and Health Canada replied. Neither answered my two simple yes-or-no questions, either ignoring or deflecting them.
Health Canada claimed that I should speak with provincial authorities about changes in demand for addiction services — i.e., rising hydromorphone addictions — as provincial governments are responsible for providing said services.
It was a strange response. Health Canada evangelizes safer supply and claims that one of the program’s main benefits is reduced use of street-acquired substances. It seems that the agency feels that it has the authority to make positive claims about safer supply’s impact on drug consumption, but, when asked about negative outcomes, tries to say that is the provinces that know best.
When asked what it was doing to prevent hydromorphone diversion, Health Canada couldn’t provide anything that resembles a credible plan.
The agency said that doctors are required to protect against the loss or theft of drugs and, relatedly, should report any such incidents. However, loss and theft from health-care providers is not the issue here, as diversion occurs after safer supply drugs are dispensed to a patient.
Safer supply is very attractive to people with opioid use disorder DR. MELDON KAHAN
Health Canada also said that health-care practitioners can help prevent diversion by crushing hydromorphone tablets before providing them to patients. While this makes hydromorphone slightly less convenient to sell, it’s hard to see how this would make any meaningful impact on diversion as users already crush their pills for intravenous injection.
Finally, Health Canada said that doctors may test urine to detect diversion. However, as mentioned earlier, drug users can easily circumvent this by consuming some of their hydromorphone and selling the rest, and many “low barrier” safer supply settings discourage urine testing.
Health Canada didn’t mention any additional anti-diversion measures in its email, but said that it will “monitor and assess available information” and “take appropriate action where necessary.”
I emailed Health Canada’s response to over 10 addiction physicians. Those who replied were uniformly critical of the agency’s recommendations, which they called “inadequate” and “puzzling.” According to Dr. Lam, Health Canada seemed to be “significantly out of touch with the realities of opioid use disorder and the market for illicit substances, which is concerning.”
To Health Canada’s credit, at least it drafted a personalized response. When B.C.’s Ministry of Mental Health and Addictions replied, it simply referred me to two documents produced by the BCCSU.
The first document was an updated version of the BCCSU’s risk mitigation guidelines (the document which helped expand safer supply in 2020). Yet it barely mentions diversion, with only a brief mention of how doctors should conduct regular evaluations of patients and reconsider “take-home” safer supply if diversion appears to be happening. This, of course, fails to address “low barrier” programs that dispense hydromorphone in large quantities while minimizing doctor interactions and oversight.
The second BCCSU document (“Opioid Use Disorder: Practice Update”) mentioned the word “diversion” exactly twice throughout 33 pages, and even then it was only briefly listed in brackets as a “potential” risk. The document made no significant attempt to inform readers of the dangers of diversion or provide credible strategies to mitigate it.
As the BCCSU currently recommends that Canada explore decriminalizing diversion, the topic’s near-total absence from the organization’s literature is perhaps unsurprising. In a 2021 study into diverted prescription opioids, the BCCSU recommended that “the decriminalization of the possession and trafficking of diverted prescription opioids should be explored.”
Several addiction physicians I spoke with said that both they and their colleagues who work on the front lines generally believe that the BCCSU’s guidelines, which are tremendously influential in Canadian addiction policymaking, fail to address the potential risks or harms of safer supply.
Echoing his colleagues, Dr. Kahan said that, “Health Canada and B.C. government, researchers, public health officials and harm-reduction advocates have ignored these concerns and given funding and uncritical support for safer supply.”
When I emailed the BCCSU a list of questions about diversion, they sent me the same documents that the Ministry of Mental Health and Addictions had cited, along with three recent studies that had been authored by BCCSU researchers.
The addiction physicians I have spoken with have consistently claimed that the BCCSU uses inadequate research to support safer supply. This includes three former BCCSU staff members who spoke on a condition of anonymity, for fear of career repercussions.
The pro safer supply research
The first study provided by the BCCSU suggests that the diversion of pharmaceutical opioids is associated with a 30 per cent reduction in fentanyl exposure. The study was published in 2021 and relied on data gathered in Vancouver between 2016 and 2018. Yet this was before federally approved safer supply programs began operating in that city; at the time, access to these drugs was very limited and generally required supervised consumption.
By omitting this context, the BCCSU seemed to be using its study to imply that safer supply hydromorphone diversion reduces fentanyl use. This conflates traditional opioid diversion (the resale of opioids prescribed in limited amounts to treat pain) with safer supply diversion (the resale of opioids freely distributed to illicit drug users).
The two phenomena are incomparable. The supply chains are different, as are the underlying social dynamics. When the street price of opioids goes down by over 80 per cent, as allegedly happened after safer supply was introduced to Vancouver, that matters.
The other two papers provided by the BCCSU were both published in 2021 and relied on qualitative data. In other words, they are rooted in descriptions and language, such as interviews and written observations. These studies are, by their very nature, more subjective and difficult to generalize from than quantitative studies that crunch hard numerical data.
While qualitative studies can be useful in some cases, addiction physicians, such as Dr. Regenstreif, stressed that health-care experts consider these types of studies, on their own, to be among the lowest-quality research one can produce. The fact that the BCCSU’s research on safer supply diversion was limited to two such studies is concerning.
Each study simply interviewed a cohort of Vancouver drug users about safer supply and then framed their responses as an objective assessment of what diversion dynamics are actually like. Predictably, the drug users gave relatively rosy assessments of their own behaviour and glossed over the harms observed by front-line addiction physicians.
Upon reading the BCCSU’s research, I couldn’t help but recall what Giuseppe Ganci told me:
“As people who are in addiction, we lie to get what we want — to get more. And so I will say anything to anybody that’s asking me any type of research question to make sure that I get that safer supply, so I can just divert it to other people and sell them to make money.”
In addition to sending these three studies, the BCCSU claimed that, “At this point there is no evidence demonstrating a rise in hydromorphone dependence arising from safer supply provision.” The BCCSU said in an email that, although there was a 19.2 per cent increase in diagnosed opioid use disorders between September 2018 and September 2020, “whether diversion is a factor is not known.”
There’s no way of capturing if kids are being addicted. There’s no system in place, unless they die. Then you know GIUSEPPE GANCI
When Ganci heard this, he was furious. “That’s absolutely ridiculous,” he said. However, after a moment of reflection, he made an interesting point.
According to Ganci, youth who develop opioid addictions typically take years to seek treatment. Since safer supply was only scaled up in 2020, it would make sense that there may be a delay in official statistics on diversion-related addictions and overdoses. Such a delay could also be exacerbated by Canada’s failing health-care system, which has made it more difficult for people to access doctors and seek treatment.
This problem could be compounded by the fact that Canadian pediatric hospitals are typically unfamiliar with managing opioid misuse in minors. According to Dr. Regenstreif, “Youth are often discharged without their opioid use being addressed, even after an overdose. This is true for most hospitals.”
Ganci added that “low-barrier” safer supply programs distribute hydromorphone without checking IDs, or even confirming whether someone is using a fake name, making it impossible to track many safer supply recipients and draw connections to future addiction disorders and overdoses.
“There’s no way of capturing if kids are being addicted. There’s no system in place, unless they die. Then you know,” said Ganci.
Romanticizing diversion
In April 2022, the National Safer Supply Community of Practice (NSSCP) published a document, “Reframing Diversion for Health Care Providers,” which was designed to convince health-care providers that diversion is not actually harmful and that it shouldn’t be an obstacle to prescribing safer supply.
The NCCSP is a “knowledge exchange initiative” created through a partnership between the LIHC (which runs the London safer supply pilot project) and the Canadian Association of People Who Use Drugs, a drug user advocacy group. Yet the “Reframing Diversion” document doesn’t disclose that it has any relationship with either of these two organizations, despite being sponsored by them.
The NSSCP glossed over the harms witnessed by front-line addiction physicians and portrayed diversion as “compassionate sharing” and “mutual aid” that funds basic needs. Doctors are told to “appreciate the benefits of diverting prescribed medications,” and not to portray the practice as harmful or reckless.
The document even celebrates the uncontrolled flood of diverted opioids into Canadian communities, which it says has the “benefit” of creating “barrier-free” access to opioids for more people and, in turn, could lead to “normalizing and destigmatizing drug use.”
The NSSCP concluded that diversion should be rebranded as a “protective practice” and that doctors who suspect patients are diverting drugs should not restrict access, as that could create distrust, “damage patient-doctor relationships” and infringe upon patients’ “freedom and agency to self-regulate their own consumption.”
Needles on the sidewalk outside of a downtown Toronto safe injection site. PHOTO BY DAVE ABEL/POSTMEDIA/FILE
Many addiction physicians find this attempted rebrand to be outrageous. “That’s a narrative that I don’t see. The narrative I see is significantly different,” said Dr. Koivu, who is particularly concerned about the prevalence of coerced diversion. When pimps and abusive spouses threaten vulnerable people into acquiring as much hydromorphone as possible for resale, that hardly looks like “compassionate sharing,” she said.
The NSSCP’s arguments also rely on the assumption that diverted opioids ultimately end up being consumed by people who want safer supply but simply can’t access it, which isn’t necessarily the case.
While diversion could theoretically be acceptable if it displaces fentanyl use, in reality, it appears that safer supply drugs are primarily diverted to people who are not fentanyl users and who may be developing opioid addictions due to hydromorphone. In this sense, diversion is not a “protective practice” — it’s drug dealing that targets youth and recovering addicts.
As a recovery expert who has witnessed countless relapses, Ganci called the romanticization of diversion “disgusting” and “completely irresponsible.” Dr. Brasch was similarly blunt and said, “I don’t prescribe medication with the expectation that anyone but the person I’ve prescribed it for will take it.”
The fact that Ottawa funds the LIHC’s safer supply program, and that the “Reframing Diversion” document was produced “through a financial contribution from Health Canada,” suggests to me and some experts that the federal government is financing material that encourages opioid diversion, despite claiming that it doesn’t condone the practice.
“Health Canada is talking out of both sides of their mouth. On one hand, they are frowning on the diversion of opioids and other controlled substances. Meanwhile, they are giving millions of dollars to the doctors and programs that are literally encouraging this and enabling the practice,” said Dr. Regenstreif.
Several people I interviewed said that the “Reframing Diversion” document appears to be part of a larger campaign to win the support of health-care providers.
Though Health Canada’s funding has established safer supply programs throughout the country, they can only serve a limited number of people. For safer supply to be widely available, thousands of unaffiliated health-care providers throughout Canada need to be convinced that prescribing safer supply is helpful and safe.
According to numerous addiction physicians, health-care providers have generally been skeptical of safer supply, so the program’s uptake has been low. As the NSSCP document recognizes, concerns about diversion contribute to that resistance. The success of Canadian safer supply is thus dependent on the fabrication of an alternate reality where diversion is not destructive.
Bullying and Censorship
When Dr. Julian Somers, director of Simon Fraser University’s Centre for Applied Research in Mental Health and Addiction (CARMHA), was commissioned by Alberta’s Ministry of Health to conduct a rapid review of safer supply research in 2022, his team found that there was no credible evidence that safer supply works.
The rapid review discovered that, despite this lack of evidence, many of the reviewed research publications “advocated for ‘safe supply,’ often forcefully, but without defining the term or addressing fundamental details such as eligibility, estimated costs, and responsibility for adverse consequences.”
Dr. Somers and his team concluded that safer supply is “a human experiment that conflicts with the ethical principles of physicians, clinical psychologists and other regulated health professionals.”
Dr. Somers was subsequently subjected to a retaliatory campaign. First, the BCCSU drafted an evaluation deeming his review to be of “critically low-quality.” A close reading of the evaluation suggests that many of the accusations made within it do not hold up.
For example, the BCCSU claimed that Dr. Somers was not following best research practices, but, in support of this claim, cited a research paper which suggested the exact opposite. The organization also alleged that Dr. Somers’ review had missed a “considerable body of evidence” supporting safer supply, but failed to provide any details as to what, exactly, was missing. Upon reviewing a list of 173 BCCSU-affiliated publications, which the organization published in tandem with its critique of Dr. Somers, I was unable to find this “considerable body of evidence.”
Shortly afterwards, a group of 53 safer supply advocates drafted a public letter condemning Dr. Somers’ report. The letter did not disclose that over half of its signatories were authors of the very studies that Somers had critiqued. Approximately a third of the signatories were connected to the BCCSU.
The letter was subsequently spotlighted by several media outlets, who also failed to flag this potential conflict of interest. This took a sledgehammer to Dr. Somers’ credibility and gave the impression that there was widespread, organic opposition to Dr. Somers’ research, when, in reality, pushback seemed to be coming from a small, interconnected and organized group.
When Dr. Somers tried to present his findings at a conference later that year, the BCCSU contacted the conference’s organizers and pushed to deplatform him, stressing, once again, that his work was of “critically low-quality.”
These kinds of attacks had a chilling effect on other critics. Many of the addiction physicians who refused to be named for this story specifically cited Dr. Somers’ experiences as a concern.
Dr. Brasch almost didn’t agree to be interviewed for this story out of fear of harassment and character assassination, but ultimately agreed to speak to me because she wanted to defend Dr. Somers, who she felt was conducting “interesting and important and sensitive work,” and “used good methodologies that could be replicated.”
She felt that Dr. Somers was being targeted by “unsubstantiated criticisms” and that safer supply critics were being “bullied into silence.”
As the former president of the Canadian Society of Addiction Medicine, Dr. Brasch regularly engages with addiction physicians across the country. She said that the majority of Canadian addiction medicine practitioners appear to be “somewhere between uncomfortable to reluctant” regarding safer supply.
At the Canadian Society of Addiction Medicine’s conference last autumn, she alleges that most attendees were skeptical of the safer supply program — an assessment that was corroborated by other interviewees.
Meanwhile, when Dr. Koivu began speaking up about the negative effects of safer supply, she said she was harassed and accused of fear-mongering and lying. She no longer feels completely safe sharing her views. “I was verbally attacked for just saying what I was seeing. I have never felt that in my entire medical career,” she said.
Dr. Koivu said that at least 50 physicians have privately voiced concerns to her about safer supply and added that, if she were to factor in other health-care providers, such as nurses, “that number would be much higher.”
Dr. Lam has also received substantial pushback for his outspoken criticism of safer supply, but said that he is lucky to work in an independent clinic that gives him more freedom to speak his mind. He said he has been privately contacted by at least 10 colleagues who are concerned about safer supply but were afraid to speak up due to bullying and intimidation.
According to Dr. Lam, it’s “paradoxic” that the dominant public narrative around safer supply is positive, because, in his experience, skepticism is the mainstream position within addiction medicine.
In contrast to the others, Dr. Kahan said that he did not personally feel that he had been censored, but noted that it is “quite problematic” that safer supply advocates appear to have “complete domination” over the media coverage, which is “absolutely, blanket 100 per cent in favour of safer supply.” He was concerned that critics of safer supply are “not even interviewed or asked to comment.”
Several addiction physicians said that online harassment, particularly on Twitter, has created an environment of fear and censorship. Safer supply advocates allegedly swarm anyone who tries to speak out against their chosen policies.
On Twitter, these same activists have also repeatedly tried to discredit stories about hydromorphone diversion as “fake news.” For example, Zoe Dodd, from the Toronto Overdose Prevention Society, claimed that the Last Door Recovery Society is part of the “alt right” and is lying about youth accessing hydromorphone.
Many safer supply advocates have even argued that it is beneficial for youth to access diverted opioids.
Matthew Elrod, a Victoria-based drug policy activist, suggested on Twitter that concerns about youth accessing diverted opioids constitutes a “moral panic,” comparing it to the backlash against distributing free condoms. Ian Cromwell, a safer supply advocate who received approximately 30,000 votes in Vancouver’s municipal election last year, also compared easy access to opioids to providing condoms to youth.
Karen Ward, an active drug user who has been contracted as an addiction policy adviser by the City of Vancouver, said that it was “pro-death” to raise concerns about youth accessing diverted opioids. Ward even threatened to sue Last Door Recovery for “defamation” for speaking up about youth accessing diverted opioids.
OxyContin crisis 2.0
Several addiction physicians compared the safer supply program to the OxyContin crisis of the 1990s and 2000s, when Purdue Pharma aggressively promoted a powerful opioid as an empathic solution to pain management.
“The words that were used were that people who were suffering needed our compassion and care, and we could give them a better life if we gave them more opioids. And that culture led to people prescribing more, as was promoted by Purdue. It was certainly embraced by a lot of the medical profession. This led to a lot of opioids being on the street, which led, essentially, to the crisis that became the opioid crisis,” said Dr. Koivu.
The OxyContin-induced opioid epidemic would ultimately lead to the deaths of hundreds of thousands of people throughout North America, including thousands of Canadians — sometimes directly, via prescription opioid overdoses, and sometimes indirectly, by fostering addictions to more deadly street drugs.
It was later discovered that Purdue Pharma misrepresented the dangers of OxyContin and paid doctors kickbacks. In 2020, after years of litigation, the company pled guilty to federal charges in the United States for conspiring to defraud the U.S. and violating anti-kickback statutes.
In the U.S. Department of Justice’s subsequent news release, then-acting U.S. Attorney for New Jersey Rachael Honig stated that Purdue Pharma “marketed and sold its dangerous opioid products to health-care providers, even though it had reason to believe those providers were diverting them to abusers.… The company lied to the Drug Enforcement Administration about steps it had taken to prevent such diversion, fraudulently increasing the amount of its products it was permitted to sell.”
The similarities with Canada’s safer supply program are uncanny. In both cases, one sees diversion being minimized and doctors being incentivised to flood communities with opioids. The main difference is that, with safer supply, the drug pushers are not pharmaceutical executives, but the government.
Over the past few years, multiple class action lawsuits have been settled throughout North America, with multibillion-dollar payouts, for the very same behaviours and harms that are now being reproduced by safer supply.
In fact, in 2018, the B.C. government launched a class action lawsuit against Purdue Pharma Canada on behalf of all of Canada’s federal, provincial and territorial governments. The lawsuit alleged that Purdue downplayed the risks of its opioids, especially regarding their addictiveness, and thereby exacerbated a drug crisis that has since killed thousands.
Purdue Pharma Canada eventually conceded to a $150 million settlement. The B.C. government is now determining how to best distribute these funds to fight the opioid epidemic, while simultaneously flooding communities with opioids just as Purdue Pharma once did.
There are other troubling implications to consider, as well. Throughout the OxyContin crisis, the cost of purchasing opioids for black market resale was typically paid for by the individuals who were being prescribed the drugs. In contrast, safer supply uses taxpayer dollars to flood communities with opioids — funds that, in a better world, would’ve been invested in evidence-based problems that actually reduce, rather than exacerbate, addiction.
When governments fail to do their jobs, grassroots voices have to step in. While this was possible during the OxyContin crisis, those who speak out about safer supply risk career suicide.
“I was pretty critical of Purdue very early on in the opioid crisis and gave talks criticizing Purdue before it was trendy. People questioned whether I felt that put me at risk, and I was never at risk. Now people are at risk to come forward and at risk of being bullied,” said Dr. Koivu.
Replace safer supply
Since safer supply was ramped up in 2020, opioid deaths have only gone up. Safer supply advocates often say that this is because safer supply programs haven’t been widely deployed yet and remain somewhat niche. They argue that rising overdoses are not evidence of the program’s failure, but rather a sign that Canada needs to dramatically expand safer supply as quickly as possible.
Yet safer supply has already created immense harms despite its limited availability. Expanding the program would likely be catastrophic. Canada’s opioid crisis is killing thousands of people a year. Pretending that safer supply works won’t save lives and will only create more addiction.
Perhaps there is a role in this country for more responsible models of safer supply, akin to what is done in Switzerland, where consumption is generally supervised. Experimenting with such a system, however, should not draw resources away from other interventions that have much stronger evidence of success.
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