Don't buy the snake oil

ChatBox AI image created by me

I generally stay out of the fray when it comes to commentary on politicking, so much of which is about as reliable as a snake-oil pitch.

But having caught Pierre Poilievre’s promise of addiction treatment for 50,000 Canadians, paid out of the money that will be saved when safe-supply programs are cut, I just can’t let that blatantly misleading statement stand unchallenged.

First, let’s start with safe supply. That’s the term used for when people are able to swap out their completely unregulated opioid-based street drugs for a prescription opioid from a health professional. It’s the most obvious immediate strategy to stop a toxic drug crisis that has killed 50,000+ Canadians – more than a quarter of them in BC - in the decade since the anesthetic fentanyl began dominating the street drug market.

That Poilievre actually thinks there’s enough money in the country’s teeny-weeny safe-supply response to pay for a major expansion of treatment beds and the cost of putting people into them for three, four or more times through – totally predictable with a relapsing health condition – well, that’s the first glaring sign that this promise is pure snake oil.

Here in BC, we have an estimated 100,000-125,000 people with opioid use disorder. A mere 4,600 of them are on the safe-supply program that BC launched at the start of the pandemic. That’s four per cent of the people who could actually benefit from safe supply.

Elsewhere in Canada, 10 other cities launched pilot safer-supply programs during the pandemic, nine of them in Ontario and one in Fredericton, NB. Federal funding ran out for most of them already.

In the few short years since, the mercurial public mood has shifted toward a view of safe supply as having “failed,” even though it actually barely got a start. So good luck grabbing all that big money invested in safe supply into treatment, Mr. Poilievre.

What really gets me with stuff like this is that a politician's comments are rarely challenged by reporters, leaving the public to assume that there really is some massive government investment in safe supply that can be transferred over to treatment.

I figure that whichever party ends up elected at the end of this month, we’ll get a few more treatment beds. That’s a good thing, because we really need them, along with government funding to support people accessing those beds without having to come up with tens of thousands of dollars multiple times to buy their way into a largely private system of care.

But any new beds will barely make a dint on the actual issues that are troubling the public - one of which is an unregulated drug supply managed in the shadows by international drug cartels that is killing their children, grandchildren, employees, partners, siblings and neighbours; and the other being a multi-faceted crisis of poverty, homelessness and mental illness manifesting ever more ferociously on the streets of our communities.

Substance use is definitely layered into that latter problem. But the main driver of the tragedy unfolding on our streets is poverty, mental illness and a housing crisis. Until we deal with those underlying causes, we’re going to be living with the soul-searing visibility of enormous suffering no matter how many treatment beds come into play.

Safe supply is an easy scapegoat for politicians, I suspect because we’ve been convinced over many decades to view the kind of drugs that end up on our streets as evil. BC’s tiny safe supply program was dealt a very hard blow recently when Premier David Eby got fussed about the supply being diverted into the illicit market, and withdrew people’s right to take their prescription drugs in the privacy of their own home.

Picture how that would go for whatever prescription drugs you might be taking, if suddenly you had to visit your local pharmacy twice a day, within their operating hours, to take your heart drugs, for instance, or use your asthma puffer.

Your job, your family time, your recreation activities – all of that would have to fit around getting yourself to the pharmacy twice a day, every day, to swallow your pills or inject your insulin in front of a health professional. How long would it take any of us to be looking for alternatives on the black market to spare us such misery?

Yes, diversion happens. An issue with safe supply is that it decrees what drugs you can swap onto, and fentanyl isn’t one of them. So some people on safe supply sell whatever drug they’ve been given to get the money for the fentanyl that they actually want.

You can look at that as a failure, I suppose. But toxic substances laced with unknown quantities of fentanyl and fentanyl analogs are now the No. 1 cause of death for British Columbians ages 10 to 59, exacting a massive impact on our collective productivity that is second only to cancer. What could possibly be a bigger failure than that?

So now let’s consider treatment as a “cure” for that failure, as Poilievre wants us to do.

First, the obvious: Many of the people dead in the toxic drug crisis weren’t in need of treatment. They were just average people using drugs for fun – not aberrant behaviour in a country where three-quarters of us consume alcohol regularly. They died because a toxic drug supply doesn’t differentiate between whether you’re a first-time user or an “addict.”

Then there’s also this tricky truth: Treatment for any chronic, relapsing condition is a long, hard slog. Whether it’s Type II diabetes, hypertension, or this thing we call addiction, 40-60 per cent of people will relapse after treatment. They will need many passes through treatment to reach a state of recovery, and some will never get there. Getting to where we need to be in terms of quick access to treatment is going to be expensive, just as it is for any other long-term health care interventions.

People using opioids are particularly vulnerable to dying during a relapse, as their tolerance falls significantly after a period of abstinence. Add in that little ongoing problem of a toxic drug supply - any hope of accessing safe supply during a relapse having evaporated under Poilievre’s plan - and it’s clear that expanding treatment alone will not get us out of this crisis.

And one more tricky truth: Treatment for this thing we call addiction is almost completely owned by the private sector – and increasingly, by multinational corporations and private-equity firms interested in consolidating many small community treatment centres into one big entity that will attract investors. (As is happening with veterinary services, lab services, mental health services, employment training, etc.)

Treatment for substance use problems is outside of the Canada Health Act. Private treatment centres are free to set their own rates and their own methods. If they report on their effectiveness at all, the data collection stops the moment a person leaves the centre. A person could relapse within hours of “graduating” and still be counted as a success.

The lack of transparency and absence of meaningful data collection leaves us with scarce knowledge to prove or disprove the effectiveness of any treatment approach. Nobody can actually say what’s working, or what happens once someone leaves a treatment facility in a state of abstinence and walks out into the big world where all their troubles await.

We simply don’t know how many times people relapse, because we don’t measure or track. We don’t know how long an individual stays abstinent after a round of treatment. There are no national standards for treatment. No followup.

So yes, let’s talk treatment. It’s a pillar of any health-care approach, as is access to regulated medications. But please don’t buy the snake oil.

Health authority's detox rules block access for street users

We met over coffee last week, each with our own reasons for being there.
I was there to find out why the region’s new 14-bed detox unit is virtually unavailable to people from the street community. He wanted to know why the media always fixate on the negative.
We talked for an hour and a half. I’m not sure that either of us fully understood the other one’s points by the end of it all. But at least we heard each other out, and I appreciated his frankness.
As the director of addiction services for the Vancouver Island Health Authority, Dr. Laurence Bosley is an important man when it comes to addressing some of the immense problems on our streets.
Addiction certainly isn’t the only reason why people end up homelessness. But it’s a major reason for why they get stuck out there. So when the health authority opens a new detox with policies that essentially exclude most of the several hundred people with addictions on our streets, I’d like to understand why.
But first to Dr. Bosley’s point about the media, because I do get what he means. We desperately needed the new detox and seven “stabilization” beds that opened this month, and it’s a beautiful facility in a time of scarce resource.
So I understand Bosley’s unhappiness at having media hone in on two “negative” angles on the story: That the facility isn’t available for stimulant users (people addicted to cocaine or crystal meth); and that it goes against the health authority’s own addiction-treatment policy by prohibiting smoking anywhere on site.
But like I told an audience of young activists at the youth-organized Change Conference this past weekend, you don’t fix a hole in the roof by talking about the 90 per cent of it that isn’t leaking. We won’t address what’s wrong in this world without talking about the problems.
Detox is the first step in getting out from under an addiction. It’s essentially five to seven days of care and prescription-drug therapy to help people through the most immediate withdrawal effects of whatever drug they were using.
Bosley rightly notes that it’s a pretty minor step, all things considered. But it’s the first one nonetheless. None of the steps that come after - treatment; spiritual healing; finding new ways to cope; drug-free housing; new friends and places to go; the hard, hard work of staying sober - can begin without detox.
So when policies at the new detox shut out the most prominently addicted people in our region, that’s one heck of a leak in the roof. The dominant drugs on the street right now are crack cocaine and crystal meth, so the no-stimulants rule alone has huge implications. But add in the no-smoking policy for a population for whom tobacco is the sole saving grace of life, and you’ve shut out the people who most need the help.
Bosley applies a cost-benefit analysis to the issue. The health authority has a limited amount of money to spend, and unrelenting demand for all its services. It’s making choices all the time in terms of who’s getting care.
On the detox front, Bosley points out that withdrawing from heroin or alcohol can kill you, and must be done under medical supervision. Withdrawing from cocaine or crystal meth is unpleasant, but not life-threatening. VIHA’s mandate is to provide medical care, not to give away expensive beds to people who really just need a place to lie down and sweat it out.
Except people on the street don’t have a place to lie down. No bed to sleep in for five straight days, that’s for sure. No way to get away from the sellers and the users. No place to detox, and thus no way to even begin the long journey out of addiction.
Bosley also notes that it makes little sense to give someone who’s homeless a detox bed for five nights and then just release them back to the streets. On that point we definitely agree. He wonders if we try too hard to “cure” everyone, when some people’s problems simply may not be curable.
I would argue that we’ve barely tried at all in terms of the street community. The significant successes of the three VIHA-led integrated outreach teams in keeping people supported and housed this past year underline how much can be accomplished when we do get down to the business of dealing with people’s real needs.
As for smoking, Bosley says he can’t believe anyone is surprised at that decision: “That’s just good clinical care.” I guess I see it as picking your battles. What good can come of denying people care for their addiction just because they can’t quit smoking?