Advocates tout safe supply for drug users, but Nova Scotia doctors aren't convinced

This is Part 1 of a two-part series on the relatively new harm reduction technique in addiction medicine known as safe supply. Some doctors and researchers say, since the pandemic, safe supply has begun to demonstrate its effectiveness. While it is becoming increasingly available across the country, few Nova Scotians have access.

Jane was a health-care worker who got a back injury and was prescribed an opioid painkiller. That was the start of her descent into addiction.

After the prescription ended, Jane spent 10 years seeking the drug on the street. She got into conflict with the law and experienced an overdose.

"My life was good, you know, married and had three children and working a job I loved and that all just slowly slipped away when my addiction came. It destroyed a lot of relationships, all the relationships in my life and financially drained me and the depression began and it's been a long, long road for the last decade."

Since January, Jane has been prescribed the drug she became addicted to, under the relatively new harm reduction technique known as safe supply.

It's controversial among doctors because patients are being prescribed alcohol, cocaine, heroin and opioids to keep them from going into withdrawal.

Proponents say patients are no longer consumed by the need to seek drugs and are less frequently involved in crime or dangerous activities to get them. They can also focus on other aspects of their lives, such as work or housing.

Toxic street drug deaths

Safe supply is also touted as a way to reduce illness or death from toxic street drugs that are increasingly laced with the powerful opioid fentanyl.

Last year, 39 Nova Scotians died of confirmed or probable opioid toxicity. So far this year, 38 have died.

Critics say safe supply is a dangerous practice that could harm patients and make doctors liable.

Jane, one of the few people in Cape Breton being prescribed a safe supply, said for her, it is the only thing that's worked.

"It's completely changed my life, one-eighty," said Jane, not her real name. "It's finally made me have hope for the future. I feel healthier. I gained weight. I started building back relationships, with my daughter especially. My first grandchild's going to be born in November and it's the first Christmas I'm looking forward to in a long, long time."

CBC News is not using her real name, because she is worried about people targeting her to get drugs illegally.

Jane said now, she doesn't have to worry about the quality of drug she's taking.

"The past few years, fentanyl has become so rampant around here and slowly I've seen my circle of friends start to go one by one and it was scary," said Jane.

"I did overdose. One time I was on life support for five days from opiates and toxic supply. I'm not sure exactly what was in it, but I know it was scary."

Other therapies didn't work

Jane tried opiate replacement therapy, also known as opioid agonist therapy, which substitutes the addictive drugs with methadone or buprenorphine — drugs that reduce cravings and withdrawal symptoms.

However, for a variety of reasons, that didn't work for her.

"With this new program and my doctor [it's] amazing. She listens to me. She doesn't judge me. She helps me and that's the difference, I think."

Safe supply is far from common, in part because it's relatively new and has only become more accepted since the pandemic.

In 2020, doctors found they needed to prescribe alcohol and harder drugs for some patients in isolation who would otherwise be out on the streets spreading COVID-19 while seeking drugs for their addiction.

New research was just published in June titled "COVID just kind of opened a can of whoop-ass: The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada."

One of the authors, Gillian Kolla of the Canadian Institute for Substance Use Research at the University of Victoria in British Columbia, said the increase in safe supply resulted in new data that bolsters research and provides the evidence many doctors say they need showing that the "emerging and novel" technique saves lives and improves patient outcomes.

"When you are receiving a known dose of a pharmaceutical opioid, you know exactly what that medication is, you know exactly the concentration, the quantity that is in what you're being prescribed," she said. "That is a very, very different situation than when we leave people using the unregulated market where you don't actually know the composition of the drugs that you're taking, number one, or the potency of the drug, either.

"In the papers that have been published so far, overwhelmingly people who use drugs who are in safer supply programs tell us that these programs are saving their lives, that they're experiencing fewer overdoses, that they're reducing their reliance on the unregulated drug supply, that they feel like they're more stable in their lives and that they're able to actually focus on other aspects of their lives," she said.

Advocates for the drug community in Cape Breton say there is only one local doctor prescribing safe supply to a couple of patients. That doctor did not respond to a request for an interview.

Dr. Mike Gniewek, a family physician with the North End Community Health Centre in Halifax and the centre's Mobile Outreach Street Health unit, prescribes safe supply to patients who need it as one method of treatment under the broad umbrella of harm reduction.

He said there are fewer than five doctors in the province doing it, but he also said that is bound to change as more doctors realize the benefits for some patients and the community at large.

Safe supply improves people's health by reducing reliance on the toxic street supply and allows people to avoid criminal activity and direct their limited resources toward food and housing instead of illicit drugs, he said.

"The framework of the pandemic certainly created comfort for a lot of us with saying OK, the purpose is to keep people in isolation, so there's definitely a benefit of giving a safe supply in this case so that we don't spread COVID, but when you remove COVID from the equation and you look at all of the other positives that I highlighted, the positive things are still there," Gniewek said.

"The opioid epidemic has existed without significant action for a long time and so it's funny how a different pandemic has kind of brought attention onto this already existing problem."

Two models of delivery

There are essentially two models of safe supply in Canada. One is the clinical model practiced by Gniewek and others, where a patient visits a doctor or nurse practitioner and is given a prescription that a pharmacy fills. The patient can then take the medication at home or at one of Nova Scotia's two safe consumption sites.

That's the model preferred by the Ally Centre of Cape Breton, which has a safe consumption site and wants to offer safe supply, but has been unable to find a doctor who will regularly prescribe it.

The other model is known as peer-led and low-barrier, because the prescription is dispensed by a vending machine under a pilot program known as MySafe.

That's the model being pursued by CAPED — the Cape Breton Association of People Empowering Drug Users, which is run by people with lived experience in drug addiction.

Health Canada funded five of the machines through Dr. Mark Tyndall, a professor at the University of British Columbia and an infectious disease specialist who spent much of his career working with drug users in Vancouver.

Tyndall said he got tired of seeing people show up at safe injection sites, only to overdose on the unregulated street supply. After being revived, he said, they sometimes ended up dead after taking toxic street drugs when the site was closed.

Tyndall was approached by the Dartmouth vending machine company Dispension and they came up with a system for delivering safe doses of the opioid painkiller hydromorphone, also called Dilaudid.

Tyndall said since 2019, before the pandemic, four of the machines have been operating in Vancouver and Victoria.

He had been working with CAPED to put one in Cape Breton, but the group was unable to get a doctor or nurse practitioner to prescribe for the program .

'It's been a hard road'

Tyndall said he had also been in talks with a group in London, Ont., but they also had trouble finding a prescriber and he is now hoping to get the fifth going in Winnipeg.

"It's been a hard road as far as getting these things up and running, mostly finding prescribers, and so up until ... a month or two ago, I was the prescriber," he said.

"I was prescribing to about 100 people for these four machines and then I was able to find some other people to do it finally, so I'm no longer prescribing."

It has been an uphill battle convincing others the machines are a good solution, Tyndall said.

Supervised injection sites require more infrastructure and more people to operate, whereas the machines are more economical and efficient, he said.

"This idea that you'd get [drugs] from a machine kind of freaked people out and they were quite worried about the colleges [of physicians and surgeons] and the college of pharmacists, who kind of try and keep track of every pill, [but] we've shown that it's secure," Tyndall said.

"My records are just as good as they would [be] through a pharmacy. Every pill that comes out of that machine is counted and we keep track of it right to the minute.

"In the three years of the machine, there's never even been an attempt to steal anything or break into it. It doesn't make any sense that people would. If you want to steal drugs from people, it's way easier to find a stoned person on the street with a pocket full of heroin than it is to break into the machine."

He has also been able to trust the patients to use the system honestly, Tyndall said.

"There's absolutely nothing to stop them from selling those drugs, but why would they? I mean, people are in the program because they don't want to buy fentanyl on the street anymore."

'Only ethical response'

A few of those pills may be diverted to the streets, he said, but that means someone is not getting a sketchy and possibly toxic dose.

Despite its novelty, safe supply will eventually become more common, Tyndall said.

"It's a long haul. I've seen harm reduction go from giving out needles to supervised injection sites, widespread methadone programs and safe supply is kind of a new idea and it won't happen quickly.

"To me, it's the only ethical response. If people are using these drugs and addicted to these drugs, we've created an environment that really is killing people."

TOMORROW:
A Cape Breton doctor says safe supply is still too new and dangerous for patients and the regulatory environment is not supportive of physicians using it as a treatment. Meanwhile, Doctors Nova Scotia says it is starting to work on a harm reduction strategy that includes safe supply. And advocates in Cape Breton say they have all the elements in place to offer safe supply — if they can only convince a doctor to prescribe.

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