Canada is reaching the limits of a drug policy centred on harm reduction — a philosophy that aims to limit the harms of substance use without insisting on abstinence. Despite the creation of over 40 supervised consumption sites, opioid overdose deaths have remained staggeringly high: more than 10,300 Canadians lost their lives to an opioid overdose between January 2016 and September 2018, the Public Health Agency of Canada recently reported.

Even ardent supporters of the policy acknowledge current measures are ineffective in an environment contaminated by fentanyl. In the Globe and Mail, public health physicians Mark Tyndall and Benedikt Fischer said, “Standard ‘harm reduction’ interventions — for example, naloxone programs or supervised consumption facilities — even if greatly expanded, are unlikely to substantially reduce the overdose toll in an environment of a toxic drug supply.”

Yet, rather than question the effectiveness of the underlying harm reduction strategy, activists and public health authorities are calling for more extreme measures. Beyond needle exchanges and supervised injection sites, proponents now seek to establish what they term a safe supply of pharmaceutical-grade opioids for dependent users at risk of overdose.

In this vein, public health authorities are increasing the number of patients eligible for injectable opioid agonist treatment, the practice of administering injections of heroin or hydromorphone multiple times daily to dependent patients. In May 2019, Health Canada formally approved injectable hydromorphone as a treatment for opioid use disorder, and clinics offering the therapy are now operational in British Columbia, Alberta and Ontario. The British Columbia Centre for Substance Use has proposed the formation of a “heroin compassion club,” where drug users can purchase heroin directly from the government at a reduced cost. The 2019 federal budget has allocated $30.5 million over the next five years specifically to develop further safe-supply interventions.

Yet the direct delivery of highly potent prescription-grade opioids to those who struggle with an opioid use disorder should raise serious concerns. The movement to establish a so-called safe supply is increasingly dictated by activists who present harm reduction as the solution to the epidemic. Proponents have failed to address significant safety and ethical concerns.

A central claim among safe-supply advocates is that the provisioning of a regulated supply of opioids will save lives by decreasing the user’s reliance on illicit fentanyl. The North American Opiate Medication Initiative (NAOMI) and the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), both completed in Vancouver, BC, are the two studies most frequently cited as evidence justifying broader use of injectable opioid agonist therapy and safe-supply interventions.

Yet NAOMI simply concluded that prescription heroin, when compared with standard methadone protocols, reduced illicit opioid use and health care costs while increasing what’s called treatment retention (the unsurprising finding that a patient who struggles with a heroin addiction is more likely to return to the clinic if offered heroin). SALOME compared injectable hydromorphone with prescription heroin and found hydromorphone was equal to heroin as a treatment. Neither study demonstrated a statistically significant decrease in opioid-related mortality nor complete cessation of illicit drug use among participants.

Furthermore, NAOMI and SALOME were both completed before 2013 — a time when fentanyl was relatively absent from the drug supply. In 2013, fentanyl was detected in 15 percent of opioid overdose deaths in British Columbia; by 2018, that number had increased to 87 percent.

A recent study published in JAMA Psychiatry by Dr. William Honer and six other researchers calls into question the effectiveness of substitution therapy in the era of fentanyl. The study of 103 patients from Vancouver’s Downtown Eastside treated with various opioid replacements (including hydromorphone and heroin) found that over 50 percent tested positive for fentanyl in their urine after five months, at the study’s conclusion. Some patients reported actively seeking out fentanyl for its potency. This is unsurprising given that addiction’s defining feature is that of gradual tolerance and escalation.

Even assuming perfect adherence to the prescribed heroin or hydromorphone regimens, thorny ethical questions remain with safe-supply interventions. One can reasonably question where exactly the treatment lies in injectable opioid agonist treatment. Does this treatment empower patients?

Source: Shutterstock, by Darwin Brandis

Harm reduction interventions are frequently presented as temporary stepping stones toward more meaningful therapies. However, this claim contrasts with frank discussions among addiction physicians who favour a harm reduction approach. “People have these unrealistic expectations like, if we allow [drug users] to go to a supervised injection site, we need to get them hooked up with care, and then we need to get them abstinent and recovered,” Tyndall has stated elsewhere. “That so rarely happens to people that I don’t have those expectations anymore. I want to keep people alive and relatively healthy and hope for the best.”

A similar sentiment is echoed by Vancouver addiction physician Dr. Keith Ahamad. When faced with criticism that injectable heroin might simply be enabling drug use, he responds: “I’m not feeding their addiction, I’m treating their addiction. By prescribing heroin to a heroin addict, if I’m able to eliminate crime, if we’re able to eliminate human suffering, if we’re able to eliminate all the expensive health care costs associated with illicit heroin use, then we’ve achieved our objective of treating their addiction.”

Tyndall’s and Ahamad’s statements contradict the belief held by many caring Canadians that harm reduction is a stepping stone toward full recovery. Under the harm reduction paradigm, individuals are considered “treated” if they remain alive and are not actively committing crimes or using health care resources. This approach compromises the potential of the drug user, who is now viewed as a liability to be managed rather than an individual with potential gifts to offer.

That many severely addicted individuals across Canada are in pain is undeniable, but to believe that a heroin maintenance regimen can eliminate suffering is absurd. Past traumas and personal demons frequently lie at the root of addiction and should not be glazed over with opioids. To think otherwise is to accept the drug user’s self-destructive coping strategy as legitimate.

Activists and drug policy leaders, in their zeal to undermine the previous “war on drugs” or the criminal justice approach to addiction, are unwittingly creating a prison system of their own: a mental prison of perpetual, state-sponsored drug use.

We should also question to what extent individuals are able to meaningfully direct their lives while dependent on a clinic three times daily. Even the comparatively less restrictive methadone has earned the title of “liquid handcuffs” among certain patients: it requires a daily trip to the pharmacy so the medication can be taken in front of a witness. While proponents describe injectable opioid agonist therapy as a transformative liberation from the daily struggle of finding one’s next fix, the new regimen is hardly better. Tyndall highlights the boredom and the substantial restriction the treatment places on one’s freedom; he notes that “you have to stay there for 45 minutes after injection. So that’s basically your whole life. It’s three times a day, and most people don’t travel far from the clinic. So they just mill around outside.” Milling around hardly connotes a life of purpose and engagement.

Activists and drug policy leaders, in their zeal to undermine the previous “war on drugs” or the criminal justice approach to addiction, are unwittingly creating a prison system of their own: a mental prison of perpetual, state-sponsored drug use. This prison is even more insidious because it purports to offer treatment while keeping patients trapped in their addiction.

How, then, can we bring freedom from drug addiction to our most marginalized? How can we foster agency, self-esteem and a sense of purpose critical to lasting recovery?

Portugal’s success in combating its own opioid epidemic in the 1990s is instructive. Harm reduction played a comparatively minor role; Portugal did not feature a single supervised consumption facility until mid-2018. Instead, the country decriminalized the possession of small amounts of substances in 2001 and established local drug dissuasion commissions. Instead of criminal penalties, drug users would be ordered to appear before an interdisciplinary panel often composed of an addiction counsellor, a physician and a lawyer. Supported by a massive increase in funding, the panels aggressively direct drug users towards meaningful treatment and recovery programs. In 1999, Portugal had 6,040 people enrolled in rehabilitation facilities; by 2008, the number had increased to nearly 26,000.

Rehabilitation, abstinence and social integration have always been the core guiding principles underlying Portugal’s strategy. In addition to funding up to three years of therapeutic community involvement, the government will generously subsidize programs for re-entry into the workforce. The approach has been remarkably successful. The Portuguese Ministry of Health estimates the number of heroin users has decreased to 50,000 in 2018 from 100,000 in 1999.

Those who struggle with opioid addiction must be treated with compassion, dignity and respect. Above all, the treatment we provide must offer hope for their future. Canada should follow Portugal’s lead in constructing a recovery-oriented system. It is time for us to rethink the value of harm reduction.

Photo: Shutterstock, by Victor Moussa

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Jeremy Devine
Jeremy Devine is a psychiatry resident at McMaster University. He has a long-standing interest in addiction and drug policy.

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