What might we learn if we listened?

Image by Couleur: Pixabay

Nobody knows the challenges of getting out from under harmful substance use like someone who has actually done it. The third event in the Peers Victoria speaker series on the toxic drug crisis brought together a powerful panel of six past and present substance users to talk about their journeys with frankness, wisdom and so much insight. (I was the lead organizer of the series.)

But while we've got a complete video of the event, it's a rare devotee of the subject who would watch the whole thing, clocking in at over two hours. So I made a "greatest hits" compilation, if you will - 40 minutes all in, with clips reordered and with a bit of categorization that helps bring more focus to the panelists' comments. 

Here it is for your viewing pleasure. If you have people in your circle who are still saying stupid nonsense about substance users not wanting recovery sufficiently or being content to exist in a state of oblivion, please share it with them. 

What kind of systems for substance disorders might we have if we just listened to the people who have already been through this toughest of life challenges? 

As these six voices remind us, of course, we would be foolish to just listen to ONE voice when designing approaches (Marshall Smith, you're on my mind). The path to healing is so very distinct and different for each person, and the underlying pain and trauma that lead up to harmful substance use are highly individual as well. But if we genuinely wanted to address this crisis, the experts are all around us. 

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.

One more walk down the road to failure

Sunil Kargwal, Pixabay

Thank you to long-time community organizer Ann Livingston for pointing me to this 17-year-old blog post that takes us back to 1950s Vancouver to remind us that there's nothing new about the strategies being talked about now to improve health care for people who use substances - or the political tactics used to block those efforts.

The Community Chest and Council, the forerunner to the United Way, struck a Narcotics Committee in 1952 to examine the problem. The Committee recommended a comprehensive drug strategy that included rehab centres, educational campaigns, and stiffer penalties for traffickers. But what really stirred debate was its proposal for clinics that would provide maintenance-level doses of heroin to addicts.

The drug clinic scheme was intended to “maintain a constant check on the number of addicts in any community. It would also protect the life of the addict and support him as a useful member of society. This existence would hasten his rehabilitation, or at least reduce the amount of his addiction since many of the stresses in the addict’s life would be reduced.” What’s regarded today as the novel philosophy of harm reduction was simple pragmatism in 1952.

Both the Province and Sun newspapers printed the Community Chest’s report along with gushing editorials endorsing its recommendations. The Sun noted that Vancouver alone had four times as many addicts as all of Britain, leaving “little doubt that the European system of cheap drugs and medical treatment is infinitely superior to our faltering system of straight police suppression.” The editor agreed that the Community Chest’s plan would eliminate the illegal drug trade by “destroying its root – the fabulous underworld profit in drugs.”

The Community Chest anticipated resistance to the drug clinics, predicting they would be “violently opposed by those who profit from drug trafficking and one should expect opposition and interference from such criminals.” Stiff opposition did kill the clinic plan, but it came from the government rather than criminals.

Soon enough, the government of the day was promoting involuntary care. What is now Matsqui Institution was in fact purpose-built in 1966 for the forced treatment of men and women using heroin. But they built it so it could be repurposed as a prison just in case - a good move, as it turns out, because the forced-treatment project was deemed a failure a mere three years later and Matsqui became just another jail. 

The John Howard Society also reported “a radical upswing in addict deaths in BC” since Matsqui opened. [The JHS's] Mervyn Davis explained that it was probably “the result of increasing police pressure on the drug market, which usually results in inferior drugs and a wider variety of potentially dangerous drugs – such as barbiturates – being used as a substitute for heroin.”

 But hey, 20 times is the charm, right? With more than 17,000 dead just since BC declared a state of emergency almost nine years ago and such a long, long history of abject failure on this issue, you'd think we might be ready for something new. Nope. We're pulling back even farther, leaving politicians, police and hysterical media pundits to continue calling the shots on a massive public health crisis. 

Watch this segment on moral panic from the Peers Victoria speaker series on the toxic drug crisis that just wrapped this week. There's the conversation we need to be having.