Expanding prescribed safer-supply drugs to include injectable heroin and smokeable fentanyl — as recommended by the provincial health officer — may sound controversial, but it’s a practical public-health measure, says an Island Health drug expert.
Dr. Randal Mason, regional medical director for the health authority’s Addiction Medicine and Substance Use program, said there’s a “huge gap” between the potency of the hydromorphone tablets prescribed as part of B.C.’s safer-supply program and the toxic fentanyl people are buying on the streets.
Mason said hydromorphone can help an intermittent opioid user or someone with a lower opioid tolerance, but for those with a “high degree of dependence and tolerance,” options such as fentanyl and diacetylmorphine — heroin — need to be considered.
If not for the high cost, many drug users he’s talked to “would certainly use heroin” over illicit opioids because the effects last longer, he said.
The recommendation about expanding safer-supply drugs was included in Dr. Bonnie Henry’s 96-page experts review, released last week, aimed at maximizing the benefits of prescribed safer supply and mitigating potential harms. The toxic-drug crisis saw a record 2,511 deaths last year.
Of the 115,000 people diagnosed with opioid use dependence in the province, about 4,331 use prescribed pharmaceutical alternatives such as hydromorphone, while another 24,370 use prescribed opioid agonist therapies (OATs), including methadone and suboxone and slow-release morphine called Kadian. About a fifth of those on OATs live on Vancouver Island.
Some critics including physicians have complained about prescribed hydromorphone pills from the safer-supply drug program, introduced in 2020, ending up being sold for cheap on the street, including to youth, something the review acknowledges.
Under the current program, the review says, initial daily dosages of four to 12 eight-milligram hydromorphone pills were found to be inadequate for many people who use drugs. In some cases, the dosage had to be increased to 16 to 40 tablets per day.
A non-drug-user would typically be prescribed one quarter or half a pill every six hours for pain.
“For those who have been using fentanyl, their tolerance is such that even maximal doses of Dilaudid (hydromorphone) have little effect except withdrawal management,” says the review. “This leads people to continue to use street fentanyl, as the Dilaudids do not approximate the effect they get from fentanyl.”
Henry said the expanded supply would at first be prescribed by a clinician and consumed in a supervised health-care setting, but could later expand to a non-prescription model, where the drugs are consumed in a non-medical setting once a strong relationship between a client and clinician is established.
Premier David Eby has said physician oversight for safer supply is needed.
The Opposition BC United also wants all safer-supply drug consumption done by prescription and witnessed so the drugs don’t leave the health-care setting.
Mason said there are several barriers — from geography to discrimination and fear of the medical system — preventing people from accessing the province’s safer-supply program, but he doesn’t see the province moving in the direction of an unprescribed non-medical model in the near future.
The health authority is, however, trying to better match people with pharmaceutical alternatives such as fentanyl patches and fentanyl tablets as part of the prescribed alternatives program.
James Sarasin of SOLID Outreach Society, a peer-based organization in Victoria that helps to reduce harms from substance use, said “once people get on fentanyl, nothing else does it for them.”
“Once you do fentanyl for a long time, your body kind of needs that,” said Sarasin, who was on the streets six years ago until he was successful in recovery.
Sarasin said his own 67-year-old mother fatally overdosed last year, but could have been on the fentanyl patch if she was able to access that program.
Access to the limited safer-supply program is a huge barrier, he said, adding his mother was self-medicating on street drugs until her death.
While there are no centralized or health authority waitlists for prescribed alternatives, the Ministry for Mental Health and Addictions says it is aware that some programs have reported patient waitlists to access prescribed alternatives.
“Individual programs and clinicians are responsible for managing waitlists and are encouraged to report increasing patient need to health authorities so they can be addressed,” the ministry said in a statement.
It did not offer a reason for the backlog, though a physician shortage and the reluctance of some prescribers to offer safer supply have previously been cited.
Safer-supply participants do not need to be diagnosed with opioid-use disorder to access the prescribed alternatives, the ministry said, given the majority of users of street drugs are not diagnosed.
Mental Heath and Addictions Minister Jennifer Whiteside last week said the government’s focus is on improving the current prescribed safer-supply system, pointing to a study published in the British Medical Journal that found fewer deaths amongst those receiving the current prescribed safer supply.
The paper, whose authors included University of Victoria researcher Bernie Pauly, concluded safer supply in B.C. between 2020-2021 was associated with reduced mortality from overdoses and other causes.
Henry’s recommendation for the expansion of safe supply drugs was couched in the context of expanded access to substance-use treatment and recovery programs, mental-health services, and initiatives to address other social determinants of health, including more supportive and affordable housing for youth and adults.
The provincial health officer’s review noted recovery means different things for different people — anything from abstinence to maintenance on pharmaceutical alternatives so they are able to care for themselves, work or care for a family.
Island Health says it’s looking at integrating addictions and substance-use care into every aspect of health care, from maternity and primary care to long-term care, and is looking at virtual models as one way of better connecting people who use drugs to health-care clinicians, including doctors, nurse practitioners and nurses.
“We need to separate people from that toxic street supply,” said Mason. “We want to do everything we can to give people an option that is safer to reduce the risk of harm regardless of the substances that they are exposed to.”
