TOXICOLOGY QUESTION OF THE WEEK
JANUARY 13, 2022
Should the government dispense drugs in safe places?
(Disclosure: This Question is a bit longer)
The article from the New York Times [CLICK TO READ] discusses Canada’s legal fentanyl dispensary (safe place) to address harm reduction (death) from overdoses. European countries have used this harm-reduction approach for decades. The first legalized injection site opened in Berne Switzerland in 1986. Some US cities have legal injection sites, i.e., New York City where injection sites are privately run. Rhode Island is the first state to legalize supervised injection sites.
But this is a controversial approach. As the overdose death count in British Columbia is high (>1827 in the first 10 months of 2022) conservative Canadian politicians say harm reduction with safe places only allows “taxpayer-funded drugs to be given to addicts”.
The clients for the harm reduction program are required to have a diagnosis of substance use disorder and have tried other treatments, so this is a small group. Similar programs have been tried in LA, Seattle, and Portland. Critics of the program attribute the increase in OD and crime in these cities to the harm reduction program. But ODs have been increasing rapidly since the pandemic began and no city has been spared making it difficult to attribute causation to safe places.
There is also a Vancouver pilot program where alternatives to drugs that people access on the street are prescribed i.e. if you use meth, Adderall is prescribed. Heroin and fentanyl are prescribed thru federally funded pilot projects. A federal law that criminalizes these substances will be suspended at the end of January 2023. Less than 2.5 gm in possession will not lead to arrest. One of the goals is to reduce stigmata and reallocate police resources. (Critics say the 2.5 g limit is not big enough-most would use twice that amount in one day requiring multiple meets with dealers.)
But there is significant opposition to the program. The documentary “Vancouver is Dying” has been viewed more than 2.4 million times on U-Tube. The documentary starts with a walk down streets with many homeless people followed by views of real-time crime. It goes on to talk with police and citizens who offer the following views: robberies and assaults against police officers are up 21%; violent offenders are being released; harm reduction is helping everyone get high; free drugs override the treatment; drug abuse is more visible. (I did not think the documentary demonstrated the loss of public safety was caused by drug policies. It was based on a few statistics but primarily opinions.)
Canadian doctors have been critical of safe supply policies. Physicians prescribing alternatives (prescribing hydromorphone as an alternative to fentanyl) might increase the availability on the street by using fentanyl and selling hydromorphone (diversion). The role of physicians in the health care system changes by prescribing these drugs. Although there is little objective evidence that a safe supply decreases fentanyl usage or death, physicians in Switzerland and the Netherlands have been prescribing heroin since the 1990s with documented benefits regarding housing stability and employment.
Vancouver advocates for safe places say the policy isn’t going far enough to make a difference. Crime occurs when attempts are made to access drugs. Although the same number of people are using substances, the substances are more lethal (fentanyl and carfentanil). Substances enter Canada and are cut to make the most profit. There hasn’t been enough focus on the supply and support needed in other social services.
The different approaches between states and countries reflect the differing attitudes toward addiction. I asked Saralyn Williams, Professor of Emergency Medicine, Medicine, and Pediatrics (and Attending Toxicologist) to comment on this Question. Her comment- This is such a hard subject as there seems to be so little data on what works to 1)reduce mortality from inadvertent overdose vs 2) reduce mortality and morbidity from complications (including societal) of injectable drug use. I guess the viewpoint depends on how harm reduction is defined.
Next week, Reid Finlayson, Professor of Psychiatry and Behavioral Sciences, VUMC, will address issues regarding the stigmata of addiction and why we should be approaching the treatment of addiction in a different manner.
Question submitted by Donna Seger MD
I am interested in any questions you would like answered in the Question of the Week. Please email me with any suggestions at donna.seger@vumc.org.
DONNA SEGER, MD Professor Emerita Department of Medicine VUMC
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