Safe Supply Saves Lives: a look beyond the deadly war on drugs

Part 1 of a 7-part series.

Introduction

Over 108,000 people died in the US last year from a drug overdose. British Columbia’s coroner data puts the sheer scale of the North American illicit drug overdose crisis into perspective: beginning around 2015, illicit drug deaths began towering over every other unnatural cause of death, including motor vehicle collision, suicide, homicide, and prescription medication overdose.¹ In this time period, fentanyl wholly replaced heroin and then some. Despite teenage illicit drug use in the US declining slightly from 2010 to 2021, annual teenage overdose deaths more than doubled from 518 to 1,146.² A mismatch between stagnant use and exponentially growing deaths indicates that overdoses are not an epidemic of Substance Use Disorder that treatment programs can prevent or overprescribing directly caused, they’re a crisis of worsening supply.

BC Coroner’s Service

What caused the spike in illicit drug deaths? If you ask the US government or Netflix, the answer will be a consistent narrative that “Big Pharma used greedy Doctors to push pills on random patients.” In the first bullet of the Department of Health and Human Services Opioid Epidemic webpage, pharmaceutical companies are called out for generating opioid addictions from the 1990s through the mid-2000s.³ Popular media has cemented this theory through dramatized shows like Hulu’s Dopesick and Netflix’s Painkiller, as well as docu-series such as Netflix’s The Pharmacist and HBO’s The Crime of the Century. Big Pharma’s deserved reputation makes the prescription addiction theory an easy pill to swallow. While this is the true story of how some individuals developed a Substance Use Disorder, it is not representative of the majority of people dying of a drug overdose in recent years. In 2013-2014, during the height of opioid prescriptions in the US, only 25% of people who had used prescription opioids for non-medical purposes had gotten them from a doctor, the remaining 75% were obtained from diverted supply, mostly from friends or family.⁴ It’s necessary to step back and recognize this drug overdose crisis is unique to the US and Canada: one in 3,050 Americans died of a drug overdose last year, compared to just one in 45,600 Germans,⁵ despite Germany having a higher rate of prescription opioid dispensing.⁶ This article will discuss the drug war policies that make the US and Canada’s overdose crisis unique, and the best practice alternatives in use globally.

After Perdue Pharmaceutical and the Sackler family’s coercive marketing tactics for OxyContin were exposed around 2010, the US moved to crack down on opioid prescriptions, declaring an “opioid epidemic.” The FDA quickly demanded tamper-proof pills that couldn’t be snorted or injected,⁷ pushing people to street drugs instead. CDC guidance issued in 2016 advised doctors to restrict opioid pain management to cancer and end-of-life care only while demanding specific dosages and durations.⁸ Doctors and insurers now push high doses of liver-havocking acetaminophen and dubious Chiropractic⁹ sessions instead.

The CDC proudly touts that prescribing rates have “improved” by being nearly halved from 2012 to 2020¹⁰ Overdose deaths have risen continuously in the same timeframe to an all-time high, from 41,340 in 2011 to over 108,000 in 2021. Under-prescribing pain medication in the wake of the Purdue scandal has had adverse effects, undermining physician discretion while suddenly disrupting effective chronic pain treatment for patients, transitioning many who legitimately need opioids to choose between debilitating pain, high-risk illicit self-medicating, or suicide.¹¹

It’s not just opioids anymore either. Among regular drug users, more concerning than fentanyl alone, which replaced heroin as the downer available, is the risk of mixed substances such as ‘benzodope’ (opioids mixed with benzodiazepines) and the growing prevalence of veterinary tranquilizer xylazine getting mixed in there. In BC, the 85% of fentanyl-related deaths greatly overlap with the 45% of cocaine-related, 41% of methamphetamine-related, and 13% of benzodiazepine-related deaths, indicating poly-substance deaths. In BC, the detection of ‘benzodope’ in deaths jumped to 52% by January 2022. Xylazine is suddenly showing up in as many as a third of overdose deaths in cities such as Philadelphia.¹² When opioids are pressed into pills with these non-opioids, not only are the respiratory depressant effects synergistic but the overdose from the non-opioid cannot be reversed with naloxone (Narcan), dealing a blow to our most immediate way to save lives. Methamphetamine and cocaine on their own do not cause a respiratory depression-type overdose, but in my community mental health work, we regularly see cases where individuals intending to consume uppers experience an opioid overdose from contaminants. As a result, uppers are becoming a lot more dangerous. Cocaine deaths rose dramatically, with 73% of them in the US involving opioids.¹³ If it sounds counterintuitive for dealers to intentionally contaminant uppers with downers, you might not be wrong: contamination could be an accident from shared processing surfaces.

Cocaine deaths are rising dramatically, and most of them are from opioid overdoses.

Media frequently uses tragedies of contamination to villanize fentanyl and indicate that people are only ever deceived into using it. Considering heroin has gone functionally extinct, this is just not true anymore. People who use drugs have adapted to the supply, and an ever-inconsistent cocktail containing fentanyl is intentionally consumed because it’s what’s available. In much of the US, that’s seen with “blues” – openly known by users as fentanyl and consumed by smoking, even though they’re pressed like 30mg oxycodone pills.

A Caricature of Evil Causes Panic

One such officer recounted to ABC7 a vivid memory of not being able to breathe.¹⁶

While the drug supply is a genuine and deadly crisis, the media still finds room to exaggerate with misinformation. Fear-mongering stories have dominated local news about police officers allegedly “overdosing” on the sight or touch of fentanyl and being revived with naloxone – despite the scientific impossibility of anything but a panic attack.¹⁷ In the most absurd counter-evidence of this copaganda, a medical worker accidentally spilled liquid fentanyl over a large area of their skin, including an open wound, and was observed to have no clinical effects.¹⁸

Peaking ahead of Halloween and the mid-term election this year, news stations panicked about how dealers must be marketing M30 pills to children as “rainbow fentanyl” when the Drug Enforcement Administration reportedly seized samples in other colors, combined with separate instances of traffickers caught hiding pills in candy packaging meant to evade customs.¹⁹ This is counterproductive: by no longer looking exactly like real oxycodone, a Google search description of a red or green M30 will make it clear to an unsuspecting user that it’s counterfeit, and no drug trafficker is giving trick-or-treaters hundreds of pills disguised as a box of Skittles. The media has painted police as putting their lives at risk to combat a caricature of evil, and this fear has done nothing to stop the growing death toll.

The hardline drug war policies the US has pursued in response to perceived opioid overprescribing have directly contributed to the toxicity of this supply. Fentanyl is a medication widely and safely prescribed in clinical settings for pain management. Opioids can have side effects when used chronically, namely constipation and dry mouth,²⁰ but the long-term health impacts pale in comparison to the risk of random death that pushing chronic pain patients into a criminalized market has created. The threat of fentanyl to users is not inherent to the drug, but in the inconsistent contents, dosage, and administration of street drugs. This paper will discuss that the only way to stop the deaths is by implementing public health-oriented and evidence-based harm reduction tactics, including a “safe supply” of regulated medications accessible enough to eliminate the illicit drug market.

What is Harm Reduction?

*UCSF Archives and Special Collections. BleachMan poster, San Francisco AIDS Foundation, 1988, AIDS History Project Ephemera Collection, MSS 2000-31.*

Harm reduction practices are interventions that reduce the risk of human behaviors, including drug use and sexual activity. Harm reduction was synthesized by activists scrambling to save lives amid the outbreak of HIV/AIDS and abandonment from institutions. Harm reductionists acknowledge that demanding abstinence is not a realistic or necessarily desirable demand, and it’s most effective to “meet people where they’re at” on practical ways to improve their health without moralizing their behavior. Strategies include:

Syringe exchange and pipe distribution programs to prevent transmission of HIV, Hepatitis C, other diseases, and development of abscesses.
Condoms to prevent STI transmission and unplanned pregnancy.
Medication-Assisted Treatment for Opioid Use Disorder such as Methadone and Suboxone.
Safe Supply programs that provide pharmaceutical-grade doses of the substances people are currently using, such as Heroin-Assisted Treatment.
Naloxone (Narcan) distribution and CPR/First Aid training to equip regular people with the ability to render lifesaving care.
Drug testing kits to see if a product is contaminated with unwanted substances before use.
Housing First and low-barrier shelter to meet people’s basic needs first regardless of current treatment participation.

In Supervised Consumption Sites like Vancouver’s InSite, participants have a sterile environment to use their own drugs, are provided medical intervention as needed, and have access to case management and treatment options. Despite an implicit threat made against Canadian sovereignty when Bush drug czar John Walters confronted Mayor Phillip Owen with 30 armed henchmen,²¹ InSite opened its doors in 2003 thanks to the efforts of the Vancouver Area Network of Drug Users (VANDU). In 19 years of operation, InSite has not had a single overdose death across its more than 3.6 million visits.²² Operated by multiservice non-profit PHS, InSite visitors are encouraged to engage in other services at their own pace, including the OnSite medically-supported detox and transitional housing program located in the same building.

Continue reading in Criminal Justice System Doubles Down on the War on Drugs

References

1
British Columbia Coroner’s Service, “Illicit Drug Toxicity Deaths in BC January 1, 2012 – August 31, 2022.” Accessed from: https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf
2
UCLA Health Newsroom. “Adolescent Drug Overdose Deaths Rose Exponentially for the First Time in History during the COVID Pandemic,” April 12, 2022. https://www.uclahealth.org/news/adolescent-drug-overdose-deaths-rose-exponentially-first.
3
Affairs (ASPA), Assistant Secretary of Public. “What Is the U.S. Opioid Epidemic?” Text. HHS.gov. https://plus.google.com/+HHS, October 27, 2021. https://www.hhs.gov/opioids/about-the-epidemic/index.html.
4
Rachel N. Lipari, Ph.D. and Arthur Hughes, M.S. “How People Obtain the Prescription Pain Relievers They Misuse.” Substance Abuse and Mental Health Services Administration, January 12, 2017. https://www.samhsa.gov/data/sites/default/files/report_2686/ShortReport-2686.html.
5
German Federal Government Commissioner for Addiction and Drug Issues. “1.826 Männer und Frauen in Deutschland 2021 an illegalen Drogen verstorben – Zahl erneut gestiegen,” May 16, 2022. https://www.bundesdrogenbeauftragter.de/presse/detail/1826-maenner-und-frauen-in-deutschland-2021-an-illegalen-drogen-verstorben-zahl-erneut-gestiegen/.
6
Richards GC, Aronson JK, Mahtani KR, Heneghan C. Global, regional, and national consumption of controlled opioids: a cross-sectional study of 214 countries and non-metropolitan territories. British Journal of Pain. 2022;16(1):34-40. doi:10.1177/20494637211013052
7
Jeffrey, Susan. “FDA Approves Tamper-Resistant Oxycodone.” Medscape, June 20, 2011. https://www.medscape.com/viewarticle/744935.
8
Deborah Dowell, MD, Tamara Haegerich, PhD, and Roger Chou, MD. “CDC Guideline for Prescribing Opioids for Chronic Pain.” MMWR. Recommendations and Reports 65 (March 18, 2016). https://doi.org/10.15585/mmwr.rr6501e1er.
9
Bev Schechtman [@ibdgirl76]. “Kaiser Is Sending These Letters. What I Want to Know Is If a CPP Is Abandoned or Forced off Meds, Do They Send a Letter of Concern Then Also? Or Is It Just Being on Rx Opioids That They Care about? Https://T.Co/Zsp4rBndai.” Twitter, September 24, 2022. https://twitter.com/ibdgirl76/status/1573610016468262913.
10
CDC Injury Center. “U.S. Opioid Dispensing Rate Maps | Drug Overdose,” November 10, 2021. https://www.cdc.gov/drugoverdose/rxrate-maps/index.html.
11
Barreveld, Antje M. “As a Pain Specialist, I May Have Caused More Harm by Underprescribing Opioids.” STAT (blog), April 12, 2022. https://www.statnews.com/2022/04/12/underprescribing-opioids-can-also-cause-harm/.
12
Kounang, Nadia. “How Xylazine, a Veterinary Tranquilizer, Is Making Overdoses Even Riskier.” CNN, March 17, 2022. https://www.cnn.com/2022/03/17/health/xylazine-tranq-overdose/index.html
13
The PEW Charitable Trust. “Opioid Overdose Crisis Compounded by Polysubstance Use,” October 8, 2020. https://pew.org/33DKphN.
14
DrugsData.org / Erowid Center. “Tan Powder (Juice WRLD) Sold as: Heroin ID: 13219,” June 13, 2022. https://drugsdata.org/view.php?id=13219.
15
DrugsData.org / Erowid Center. “M30 Sold as: Oxycodone ID: 12933,” May 30, 2022. https://www.drugsdata.org/view.php?id=12933.
16
ABC7. “Bodycam Video: San Diego Training Officer Saves Deputy’s Life after near-Fatal Fentanyl Exposure,” 2021. https://www.youtube.com/watch?v=VPZ6fDZUtGE.
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17
Moss, Michael J., Brandon J. Warrick, Lewis S. Nelson, Charles A. McKay, Pierre-André Dubé, Sophie Gosselin, Robert B. Palmer, and Andrew I. Stolbach. “ACMT and AACT Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders.” Journal of Medical Toxicology 13, no. 4 (December 2017): 347–51. https://doi.org/10.1007/s13181-017-0628-2.
18
Feldman, Ryan, and Benjamin W. Weston. “Accidental Occupational Exposure to a Large Volume of Liquid Fentanyl on a Compromised Skin Barrier with No Resultant Effect.” Prehospital and Disaster Medicine 37, no. 4 (August 2022): 550–52. https://doi.org/10.1017/S1049023X22000905.
19
Medrano, Kastalia. “‘Rainbow Fentanyl’ Is Probably a Good Thing, at This Point.” Filter (blog), September 23, 2022. https://filtermag.org/rainbow-fentanyl-dea-pills/.
20
Benyamin et al. “Opioid Complications and Side Effects.” Pain Physician 11, no. 2 Suppl (March 2008): S105-120. https://pubmed.ncbi.nlm.nih.gov/18443635/.
21
Smith, Alisa. “Vancouver’s Drug Experiment Winning Converts.” The Tyee, October 26, 2004. https://thetyee.ca/News/2004/10/26/VanDrugExpWinConverts/.
22
Vancouver Coastal Health. “Insite User Statistics,” July 2019. http://www.vch.ca/public-health/harm-reduction/supervised-consumption-sites/insite-user-statistics.

A sample of “heroin” powder tested from Massachusetts¹⁴	A Seattle sample of the M30 “blues”:¹⁵
Caffeine : 30.00 Fentanyl : 20.00 Xylazine : 20.00 Heroin : 15.00 Procaine : 15.00 Tetracaine : 15.00 4-Fluorofentanyl : 10.00 4-ANPP : 5.00 6-Monoacetylmorphine : 5.00 Despropionyl-4-fluorofentanyl : 5.00 4F-Phenethyl-4-ANPP : 2.50 6-Acetylcodeine : 1.00 Phenethyl 4-ANPP : 1.00	Acetaminophen : 4000 Fentanyl : 60 Metamizole OR 4-Methylaminoantipyrine : 20 4-ANPP : 4 Phenethyl 4-ANPP : 1