We appreciate the authors’ commentaries (Carroll, 2020; del Pozo & Rawson, 2020; Lembke, 2020) engaging with our perspective article (Bonn et al., 2020) in the September 2020 issue of the Journal of Studies on Alcohol and Drugs on the potential roles for drug decriminalization and safe supply in response to the syndemic of HIV, hepatitis C, overdose, and COVID-19 among people who use drugs (PWUD). They have each raised some commonly expressed concerns regarding the relative benefits and risks of safe supply; however, considering the life-or-death importance of this topic, we feel it is necessary to address these arguments head-on.
Here, we discuss how the crisis has changed over the last 20 years and how the urgent responses we detailed are desperately needed. We push back on the idea that harm reduction implementation needs to be done in a piecemeal way and that only certain types of treatment should be used. Last, we discuss the importance of implementing a range of responses that address the needs of PWUD.
In their commentary, Lembke (2020) wrote, “The expanded use of controlled prescription drugs should not occur in the absence of reliable evidence to support it, lest we find ourselves in a worse drug crisis than we’re already in” (p. 565). North America has been in an accelerating overdose crisis since long before the COVID-19 pandemic, but the response to COVID-19 has exacerbated harmful structural factors. Before the pandemic there was already a triple wave to the overdose crisis: first related to prescription opioid pills (Wave 1), then heroin (Wave 2), and then synthetic opioids, including fentanyl and fentanyl analogues (Wave 3; Ciccarone, 2019). With most overdose deaths now involving fentanyl or fentanyl analogues, we are in an unprecedented mass drug poisoning crisis that has taken the lives of more than 70,000 Americans a year over the last multiple years (Stephenson, 2020), with an additional 17,000 Canadian lives since 2016 (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2020). With most overdose deaths involving synthetic opioids, traditional forms of treatment are not as effective as they once were. We need new strategies to reduce overdose deaths in this crisis. Now, with the public health restrictions of COVID-19 that promote self-isolation, arguably we have entered the fourth and most deadly wave of this overdose crisis. Pragmatic and innovative measures are needed if we truly want to reduce overdose deaths and improve the quality of the lives of PWUD (Tyndall, 2018).
Lembke (2020) also wrote, “. . . there is limited evidence in North American populations for using hydromorphone (Dilaudid), methylphenidate (Ritalin), or diacetylmorphine (heroin) to target addiction, dependence, or problematic use” (p. 564). We argue that this is untrue. Diacetylmorphine and hydromorphone were shown to be safe and effective opioid agonist therapies (OAT) in two randomized controlled trials conducted in Canada—the North America Opiate Medication Initiative (NAOMI; Oviedo-Joekes, 2009) and the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME; Boyd et al., 2017; Oviedo-Joekes 2016). Recent research, also based in Canada, highlights how hydromorphone tablets are effective for PWUD as a safe supply of drugs compared with illicit fentanyl (Ivsins et al., 2020a, 2020b). As for methylphenidate, prescription psychostimulants are emerging as a treatment for stimulant use disorders (Tardelli et al., 2020). However, the safe supply intervention is not addiction treatment but rather a direct response to the poisoned drug supply. Additionally, we do know that people who receive a safe supply are more likely to engage in treatment, creating more opportunities to reduce harm and to improve their quality of life (Ivsins et al., 2020b). Moreover, currently fentanyl-assisted treatment programs are being implemented in Vancouver in response to the overdose crisis (Bardwell et al., 2019).
Carroll (2020) wrote that “Treatment is the ultimate safe supply” (p. 561). Although we absolutely agree that access should be expanded for lifesaving addiction treatments (including OAT and psychosocial treatments), we urgently need a direct response that will reduce exposure to the toxic illicit drug supply (Nordt et al., 2018). It is clear that forced treatment is not effective (Pilarinos et al., 2020) and that PWUD should not be forced into treatment or to take traditional OAT medication. In addition to being ineffective, it is actually harmful when abstinence-based approaches lead to loss of tolerance and increased risk of overdose death (Pauly et al, 2018). del Pozo and Rawson (2020) argue that we should make more widely available buprenorphine (an opioid that is a partial agonist at the mu receptor and therefore associated with less respiratory depression and overdose risk) as an initial step toward safe supply. Although we certainly agree with their suggestion to “recast buprenorphine as a non–treatment-based overdose prophylaxis and distribute it widely among the populations at the greatest risk” (p. 563), we strongly believe that this is not enough. Although more PWUD may eventually use buprenorphine, in the short term, it will never replace the self-medicating properties and euphoria sought out by most PWUD (Chilcoat et al., 2019). In addition, research from Switzerland where access to multiple pharmacological treatments (including methadone, buprenorphine, slow-release oral morphine, and diacetylmorphine) is readily available suggests that increased buprenorphine prescribing alone is unlikely to meet the needs of PWUD, with a strong trend to preference for full mu agonists (Nordt et al., 2018). To compete with the poisoned illicit drug supply, we must provide substances that PWUD are seeking and wanting to use. If not, it doesn’t matter what treatments are available, and this is a matter of life and death.
It is extremely challenging for public health policy makers and clinicians to think beyond traditional treatment strategies and embrace new ways to reduce the death and suffering associated with prohibition and criminalization that has led directly to a toxic and unpredictable illicit drug supply. We absolutely need to improve quality and access to addiction treatment and harm reduction services, but we argue that this is not enough. If we don’t start to act with progressive solutions based in compassion and pragmatism, people will continue to suffer from the deadly syndemic of overdose, HIV, hepatitis C, and COVID-19.
The authors acknowledge that this work was done on the unceded and traditional land of the indigenous people of Canada, specifically the Mohawk, Ojibwe, Algonquin, Mi’kmaq, Musqueam, Squamish, and Tsleil-Waututh Nations.
We acknowledge Dr. Gillian Kolla, Dr. Ryan McNeil, and Candis Lepage, M.Sc., for their contributions in helping us respond to this review.
Matthew Bonn reports personal fees from AbbVie, a pharmaceutical research and development company, and grants and personal fees from Gilead Sciences, a research-based biopharmaceutical company, outside of the submitted work. Sofia Bartlett has participated in Advisory Board Programs and received speakers’ honoraria from Gilead Sciences, outside of the submitted work (all personal fees given as unrestricted donations to the British Columbia Centre for Disease Control Foundation for Public Health). The other authors have no conflicts to declare.
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