Full Comment - Best of 2023： Canada’s great addictive hard-drug giveaway experiment somehow goes awry

00:00:00.000 throughout 2023 we spoke to a range of guests and a range of topics from the absurd

00:00:11.180 the chinese spy balloons taking over the skies above canada the light-hearted why did taylor

00:00:16.940 swift's tickets cost so much to go see her in concert to well the absolute deadly the wars in

00:00:23.160 both ukraine and israel hello my name is brian lily host of the full comment podcast i'd like

00:00:28.260 to thank you for the time that you've given us over the last year as we take our break over

00:00:32.500 christmas and new year we want to bring you some of the best episodes of the year episodes that

00:00:37.380 touched a nerve episodes that sparked conversation one of those happened back in june when we spoke

00:00:44.220 to dr sharon koivu she is someone who supports the idea of harm reduction when it comes to dealing

00:00:49.760 with addictions she is someone who has advocated for and run such programs but now she is being

00:00:55.920 targeted by many of her own colleagues because she speaks out against the idea of safe supply

00:01:00.840 she has watched the programs grow in her hometown of london ontario she has seen the negative impacts

00:01:08.860 that it has on society that neither researchers nor the government will put forward as hard evidence

00:01:15.200 and a reason that maybe we should hit pause on this this is a conversation we had back in june that i

00:01:21.940 think still stands up today i hope you enjoy and please remember you can go back and listen to any

00:01:27.620 of the episodes you've missed throughout the year and always share them with your friends please enjoy

00:01:32.780 doctor thanks for the time thank you for having me it's a tough issue because you've got a lot of

00:01:40.540 different aspects at play here you've got moral aspects people will have strong views on the morality

00:01:47.580 of hard drugs or how we treat them there are the medical issues there are economic issues um such as

00:01:56.120 do we have enough money to pay for um the drugs for all the addicts in the country how would you

00:02:03.920 describe where what we're doing in terms of experiments like what you've had out in london what

00:02:09.080 we're having in vancouver and what we may soon be having here in toronto

00:02:12.640 i think that what you've said calling an experiment is exactly what's happening that we are having an

00:02:21.940 experiment without really having the parameters that we normally use to both run an experiment and

00:02:29.700 to monitor the effects or the harms of an experiment um and i think specifically that when you're

00:02:37.140 referring to safe or safer supply um it is an experiment it sounds good on paper obviously we

00:02:47.020 don't want people to be dying from toxic fentanyl but i think that it's we have to look at what

00:02:54.720 happens once we introduce more drugs into a community when we introduce more drugs into a community

00:03:01.280 we have found in the past that that actually increases the number of people that are going

00:03:07.100 to be using them that is essentially what happened during the opioid crisis that we sometimes talk about

00:03:13.380 as the purdue opioid crisis more drugs were being prescribed more drugs were being diverted and used by

00:03:21.140 other people who weren't prescribed those drugs and that led to our opioid crisis now we're kind of using

00:03:30.240 that and calling it a treatment plan i also want to say that when we first started using that in

00:03:38.440 london we did not have a toxic fentanyl problem we were actually using safe supply specifically to help

00:03:47.780 street level workers at risk um at risk of infection who were using a similar drug called hydromorph

00:03:56.680 content and we were trying to protect them from street work by giving them dilaudid and i think that

00:04:03.820 that what we found that is positive is that if you give people health care and social services you will get an

00:04:14.780 improvement if you offer comprehensive um care for people's hiv a place they can come in a non-judgmental way

00:04:25.760 you will get improvement but what i don't feel we've shown is that we will continue that improvement

00:04:34.420 for people who are using fentanyl which is a very very very different drug and more importantly

00:04:40.160 whatever we're doing anything we have to be so careful that it's not causing harms to the people in the

00:04:47.440 program and to people outside of the program and to the community and that's where i feel we haven't

00:04:55.160 done our due diligence in this program you described an awful lot of wraparound services as they're often

00:05:02.980 called um yes by the politicians i talked to about this you know health care um perhaps housing other

00:05:10.100 uh other supports my big issue with this and i i i can be reluctantly convinced to go in the direction

00:05:20.860 of harm reduction and safe supply if there are supports but my problem with this is we keep

00:05:27.600 adding in okay well we'll do harm reduction we'll do safe supply we'll do this but there's no supports

00:05:33.680 uh or not enough supports there isn't treatment enough treatment for people that would like it

00:05:40.800 there's not enough housing um and so we are in in my view and you could tell me if i'm way off base

00:05:48.820 it seems like we're saying okay we've got all these people on the streets let's give them what

00:05:55.260 they need in terms of drugs but not what they need in terms of anything else actually i think that's a

00:06:01.140 really good point and that's a really important way of of describing it because harm reduction when we

00:06:07.720 really started embracing that it was a pillar of drug strategy and there were four pillars in that drug

00:06:14.100 strategy and those pillars are prevention treatment harm reduction and enforcement and i think that we've

00:06:22.640 put we recognized that compared to perhaps other countries we weren't doing enough in harm reduction

00:06:30.620 and now we've put emphasis in harm reduction and taken away any we've taken away supports for prevention

00:06:40.840 prevention and treatment and enforcement and specifically prevention we know from our all evidence and

00:06:49.780 our data for tobacco for example that the most important way to prevent is to decrease access

00:06:56.000 and part of that is to also increase the cost that's why to pay for cigarettes most of the money is tax

00:07:04.580 and that's to make it less accessible more expensive less likely for youth to be using it but now we have a

00:07:12.500 program in which diversion is happening making it very much more accessible and more accessible for

00:07:19.800 anyone in the community to be using something that's extremely dangerous and we're actually labeling it

00:07:27.120 as safe so it's danger it's danger for addiction it's danger for overdose it's danger to the community it's

00:07:36.180 danger as a stepping stone to fentanyl it's danger potentially in injecting a pill that was designed

00:07:44.560 to be swallowed and perhaps causing severe infections as i'm seeing we're calling something safe and having it an

00:07:53.660 extremely inexpensive um market so we're now having it out on the streets without can i can i interrupt

00:08:03.300 for a second because you said something at the beginning that i want you to define for us because

00:08:08.660 it relates to everything that you're talking about here you said we have diversion now what's diversion

00:08:14.560 in this safer supply discussion diversion which is sometimes talked to about as being kind of enhancing the

00:08:22.380 illicit opiate market it's when you prescribe a pill or have a prescription that you give to some

00:08:29.280 someone with the intent that they take it but the person that receives the prescription gets that

00:08:36.140 filled and then sells their drug diversion can include being selling your drug um having it stolen from you

00:08:46.160 or having violence where you have to give it up because you're at risk of being hurt and i believe all of

00:08:54.020 those happen so when we prescribe for safe supply it is not witnessed it is not a we are not witnessing all of

00:09:02.900 the doses most places aren't witnessing it's not like some of the pharmacies where people used to go and get

00:09:08.120 a methadone right when when you start on methadone you have to have it witnessed when you start on suboxone which is a

00:09:17.320 amazing opiate agonist therapy that is not getting nearly enough attention when you start on these things we witness

00:09:25.660 them we make sure you're tolerating them we make sure that this is the dose that your body needs and that you can handle

00:09:33.800 and that is safe for you then once you're stable we look at giving you what's called take-home doses that is not

00:09:43.780 happening in the programs that are using dilaudid or hydromorphone as a met as a way of dealing with people with an

00:09:52.760 opioid addiction so they're given an amount without an assessment as to whether that amount is safe for them to take what

00:10:00.800 what they need and as people ask for higher doses we are not checking to make sure that that dose is

00:10:10.740 actually appropriate for them and i'm seeing that working in the hospital that's an extremely stressful

00:10:18.740 situation for the physicians and health care staff because we'll have people come in prescribed

00:10:25.220 20 sometimes even as many as 40 dilaudid 8 milligram pills in a day so hydromorphone 8 milligrams in a day

00:10:35.220 they'll get 40 pills and then we find that to keep them safe not in withdrawal and not overly sedated

00:10:44.400 they take much less than that 50 percent 25 often it's even less than that so i've got one person who

00:10:51.920 was prescribed 40 pills and is stable on equivalent of nine pills in a day if we started them back on the 40

00:11:00.120 pills in a day um right away and they took them or we change it into a method where you know we're giving

00:11:07.260 it by injection we could actually be creating toxicity so we know that those people are not tolerating

00:11:14.300 that dose we know that they're not checked to make sure they're tolerating that dose

00:11:18.240 which is further evidence that they're selling their dose so this was raised last week and i know

00:11:28.360 that you spoke to adam zivio for his piece in the national post i know the global news in vancouver

00:11:34.100 went out on the streets and they were buying up pills the supporters just still said this isn't true

00:11:41.620 it doesn't happen i mean uh there was clear video evidence within half an hour the global news crew

00:11:49.540 on camera had a fistful of pills um so is it widely known within the research community that this

00:12:00.460 does happen and is it just political activists say trying to protect a program they don't want

00:12:07.100 criticize saying it doesn't i cannot imagine how people don't see that it is being diverted

00:12:16.320 in so many ways i lived within a kilometer of where um the safer supply is prescribed in london i

00:12:25.860 actually moved there um to be a an urban physician living where people are and in in addition i was moving

00:12:34.900 there to support a supervised consumption site which might have been built there and i wanted

00:12:39.540 to be able to be supporting it both as a physician hearing from people telling me they were buying

00:12:46.920 diverted drugs and from people who were actually telling me they were selling diverted drugs i had

00:12:53.340 people who we had stable on methadone and stable on suboxone that told me they were going to go on safe

00:12:59.560 supply so that they could get the income associated with selling their drugs and that that was too much

00:13:06.000 of an incentive for them to be able to to stay on methadone or suboxone wow but living in the community

00:13:13.660 i also saw it we developed encampments behind the pharmacy that had much of the diversion i lived there

00:13:24.900 i would go and walk and talk to people i was well known and well um people weren't hiding from me so

00:13:32.960 when i'd go there i'd talk to people i would actually see people involved in selling their drugs

00:13:38.680 um i'd see people living in encampments and tell me that it's cheaper to get the dilaudid near the source

00:13:47.440 of the diversion near the source where people get their their prescription filled and sell it right away

00:13:53.540 it's cheaper there so people were telling me that do i did i bring a camera with me and record it that

00:14:01.760 wouldn't you know it didn't occur to me that that would be something that would be necessary in the

00:14:06.400 future and but it was as i say it was i brought that to the attention of the group that was prescribing

00:14:14.100 um and i brought it to many attention at many levels when i was literally seeing it also we were

00:14:22.700 seeing things the evidence of of an increase in crime in the community that things like bicycles

00:14:28.860 being stolen people having you know their um pipes broken to get the copper off of pipes those sorts of

00:14:36.520 things are much more prevalent crime in that community against businesses that you know that didn't used to

00:14:43.140 happen i have family living in an area that social economically is the same that was not experiencing

00:14:51.140 the same issues that i was seeing in the neighborhood that's right near where where this

00:14:57.520 program was initiated i also have certainly seen younger people i have lots of what they tell me are

00:15:08.100 just anecdotes of younger people who are telling me that they're accessing diverted drug well they're

00:15:14.160 saying they're getting drugs from safer supply they don't use the word diverted are these uh younger

00:15:19.880 people are they you know high school kids that that's how they're getting into drugs or they were

00:15:25.940 already on something and decided to move to this i think that in high school there are definitely people

00:15:33.500 that will experiment with drugs when my kids were in high school it was not uncommon to see kids

00:15:39.300 experimenting with ecstasy um mushrooms even perhaps crystal meth what's changed from what i can tell

00:15:49.660 from speaking to parents who have kids in high school from speaking to the young people that i'm seeing

00:15:56.040 is that now it is more accessible to be able to get diverted so dilaudid diverted drugs opioids at the high

00:16:08.800 school level i don't think necessarily that means people in the program are going to the high schools

00:16:14.000 i think that as i mentioned i've known of people that have lived in encampments that actually moved

00:16:20.880 there not to use the drugs but to to get them and then sell them out elsewhere once things are diverted

00:16:28.440 you don't have a control of where they go as i mentioned as long as things are cheap and accessible

00:16:36.320 it does mean there's going to be an increase in the market it's going to be an increase in the people

00:16:41.860 that can access those pills i cannot give a number of how many people in high school have access to

00:16:49.340 to diverted dilaudid i can say that i'm hearing that repeatedly i'm seeing that in patients that i'm

00:16:56.860 seeing and i'm seeing that in stories of violence and that really really really scares me because i think

00:17:04.920 that now you know when you're experimenting in high school and you experiment with something like ecstasy

00:17:11.240 three years later you can choose not to be using that when you experiment at any time in your life

00:17:17.860 with something that is this addictive then your chances of becoming addicted to it are extremely high

00:17:25.080 compared to some of the other recreational drugs and that as people start using something like

00:17:33.620 hydromorphone once you become addicted that means your body becomes needing it you that becomes your

00:17:39.660 normal you need that there's changes in your brain at a neuro biochemical level and you need that drug

00:17:45.640 to feel normal without it you go into withdrawal so you have to seek it but you're also seeking

00:17:51.500 something we call euphoria so the high and if you try to seek a higher high a better high then you'll go

00:17:58.000 to a stronger drug such as fentanyl and fentanyl and so people are stepping from one to the other

00:18:05.520 yes that that is what i'm seeing so i say you know over and over again when i'm seeing young

00:18:12.580 people in the hospital they tell me this as their story this is their journey is that they've started

00:18:20.080 with hydromorphone and those who've moved on most started with it in addition as i mentioned we

00:18:27.260 didn't see fentanyl in the community be at in 2016 when this the program started now i feel i agree with

00:18:37.040 with the article in the national post that it's promoting fentanyl to come here but either way it's

00:18:44.120 not stopping it so if you think of an amount of fentanyl that is going to be toxic and that it's going to harm

00:18:52.280 people that will not decrease by adding drugs to your community so somebody dying from fentanyl

00:19:01.800 the numbers won't change if anything i do think it's attracting the fentanyl market and people will

00:19:07.880 use and move up but it doesn't do anything to address that there's fentanyl here it won't adding

00:19:16.120 something to other people won't address that somebody could die from from fentanyl so it doesn't

00:19:23.600 save lives in numbers it might change who dies but it's not going to save lives it will just

00:19:32.180 to me it reminds me of the old um trolley um ethical dilemma um in reverse so there's a common ethical

00:19:42.360 dilemma where a trolley is going towards one person and you sorry trolley is going towards many people

00:19:50.740 and you can pull the switch and it could go to just one person and it's going to run over those people

00:19:56.700 and cause their death to me i feel like what we're seeing is the trolley is heading to one person and

00:20:02.400 we're pulling a switch and heading the trolley towards many in the trolley the trolley is fentanyl and

00:20:09.200 we're putting more people on the track it is possible that we can help that one person but i

00:20:16.760 would say that at the risk of harm to many and i would say that there are better safer ways to help

00:20:25.060 that person this isn't the only way we can help a person develop um leave their addiction or go into

00:20:35.160 recovery even if we're looking at meeting people where they are and trying to provide care where

00:20:40.820 they are i feel like we're forgetting about the other people that are being harmed focusing on that

00:20:48.820 person and also forgetting that there are other very evidence-based treatments and things that we

00:20:54.780 need to be doing and enhancing and enhancing people shouldn't just have access to comprehensive

00:21:03.400 health care if they're in the program people in a methadone clinic or the suboxone you know rapid

00:21:11.040 access addiction medical clinic do not have the same access to care that you get if you're in the safe

00:21:18.360 supply program because the safe supply program is is connected to the community health center and the

00:21:25.460 others aren't so we've we've haven't set up anything like a fair kind of way of assessing it because

00:21:32.960 we've we've attached health care that we know is beneficial to people and we've haven't provided

00:21:41.340 that for other people in other programs all right we need to take a quick break here dr koivu but when

00:21:48.560 we come back i do want to ask you where do we go what are the steps that we can take because there

00:21:54.320 is no doubt that there is an addictions problem i just there are steps being taken i'm just not sure

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00:23:36.580 opioids you know there was an opioid problem before fentanyl but everything has been made worse by

00:23:43.860 fentanyl uh and you know doctor i cover all kinds of issues uh in my career as a columnist and and i can

00:23:53.140 tell you that all the major issues that toronto is facing right now i think whether we're talking about

00:23:58.160 addictions mental health homelessness crime grime in the streets there is a connection back to fentanyl

00:24:04.580 um because it drives the crime it drives the shootings it is a valuable stash that people will

00:24:12.260 kill to protect uh all of these things and in fentanyl has just spread across the country over

00:24:18.260 the last few years you mentioned it wasn't there in 2016 when you started this safe supply program in

00:24:23.900 london um but it's there now and it is a scourge but how do we how do we respond you say that there

00:24:34.140 are better evidence-based treatment programs um you know when the government was asked about

00:24:39.660 the issue of safer supply last week they said we stand with the science um that seems to be their

00:24:46.440 their answer to a lot of things we stand with the science as if there's only one and and they have it

00:24:52.040 and it's in a nice little box over here and they're going to protect it um science is constantly

00:24:57.680 changing evolving people experiment people look at results are we looking at results or are we

00:25:05.000 wedded to a new religion i think that's a very good question i think that i think there's

00:25:12.320 stories there are anecdotal evidence of some benefit from

00:25:18.920 um from safer supply and those stories have been published and we're calling those stories evidence

00:25:27.100 unfortunately my stories i haven't published so they're not evidence i think that we have to look

00:25:34.820 at what's happening and be aware the people in the community are seeing what's happening and we have

00:25:41.320 to look at whether it's really making the difference that we are hoping it will make is it actually

00:25:47.160 decreasing overall overdose deaths is there a connection to increasing fentanyl is there a

00:25:55.140 connection to people living in encampments to get diverted drugs are more people developing an

00:26:02.300 addiction are younger people developing an addiction i was recently told by a local politician that until

00:26:09.260 those are there that they're not changing there's the federal government won't change their stand and i guess

00:26:14.900 i'd be saying those are exactly the things that you need to be following if you're going to be

00:26:21.100 implementing this program as a physician i am legally responsible and and have to if i see harms i'm legally

00:26:29.880 required to to report the harms that i'm seeing in no other scenario have i been told that i also have to

00:26:38.980 prove those harms so i think we need to be having a much better surveillance for the harms that many

00:26:48.140 of us believe are associated with the program as i say it's not normally up to me to prove

00:26:55.780 that i'm you know that it's the version is a problem we know that from lots and lots of evidence in

00:27:03.660 all sorts of um other data the diversion of opioids is a problem it increases people that are taking it

00:27:10.360 and increases the risk of of anyone becoming addicted that's not new we have to be looking at

00:27:16.400 that data we also have evidence of an increase in use in london we have to be looking at that data

00:27:22.900 but i also think we're focusing so much on safe supply at the expense of of so many other programs

00:27:32.060 even at the expense of other harm reduction programs i absolutely support the merit of a

00:27:39.340 supervised injection site it will help people who go and doesn't cause harm to someone else so when

00:27:47.560 i'm looking at whether harm reduction is effective i want to make sure we're meeting people where they

00:27:53.100 are it has to be one strategy in the four pillars of drug strategy it can't stand alone it needs to be

00:28:01.820 connected and interconnected and needs to be available and we need to be making sure that

00:28:08.260 anything we pick is not having unintended side effects and unintended harms what are the other

00:28:15.520 pillars in the four pillars okay the pillars are prevention the most important probably i mean we like

00:28:21.520 to say all of them are important prevention the most important aspects in prevention are access and cost

00:28:27.440 and health we need to be looking at the social determinants of health that can cause people to seek

00:28:35.880 out drugs so we're looking at things like child abuse trauma poverty homelessness focusing on things that

00:28:45.980 help people before they're going to be seeking a drug for addiction are extremely important we need to be

00:28:55.060 putting much prevention seems to have been forgotten and our need to be putting more emphasis on

00:29:04.600 prevention is absolutely crucial so prevention is one another is treatment and we have significant

00:29:13.400 evidence that when people can access treatment that they can have improvements in their health we have that

00:29:21.460 with opioid agonist therapy including methadone we have a newer medication suboxone and which also comes in a one

00:29:29.580 once a month form called sublicade we have significant evidence that when people go on opioid agonist therapy in a

00:29:39.000 clinical setting that we can they can have improvement in health outcomes we have not done anything to compare

00:29:45.820 those settings to people who are getting um health care and wraparound services that aren't available

00:29:53.740 at those settings we also have had significant restrictions on on um with making sure we witness doses to prevent

00:30:02.820 diversion i think we've done a fairly good job of that and we've lost sight of why we did that in the first place

00:30:10.060 suboxone is a very much safer drug to be having um to be taking it helps withdrawal and it prevent it

00:30:19.280 decreases the risk of an overdose um we need to be focusing on a treatment that will actually um help

00:30:28.900 people move on well yeah i want to ask you about treatment because one of my colleagues was interviewing

00:30:35.000 someone in the public health field and they asked about treatment and proactively offering addicts

00:30:42.480 treatment at places like safe injection sites and the response that she got was offering someone

00:30:49.200 treatment would be judgmental on their lifestyle it and it flabbergasted it flabbergasted me um is that a

00:30:57.160 a common view among some people in the public health community or is that was that person an outlier

00:31:05.300 i i don't know that i certainly have heard that view before i don't know whether i could say it's common

00:31:13.300 i do know that people working for example in a supervised injection site want to make sure that they're not

00:31:20.320 coming across as judgmental and initially in london we had a um problem with um an hiv outbreak

00:31:30.200 and um we were able to show that that was related to how people were people were injecting a long

00:31:37.180 acting form of hydromorph cotton and um that if they were reusing the filter or selling the filter or

00:31:44.860 sharing the filter then that was spreading um hiv and it was also contributing to a heart valve

00:31:51.280 infection we had to work with the supervised injection site to get them to feel comfortable

00:31:57.480 teaching people how to use the equipment properly because of this fear of interfering with their

00:32:05.700 relationship but we were able to do that i also know that the supervised injection site here

00:32:11.500 traditionally has worked with other treatment facilities as being able to provide information

00:32:19.640 for people to be able to get treatment i think that that is something that's really important so i i

00:32:26.500 have heard that view i don't support it i think that absolutely at a supervised injection site you have

00:32:34.600 part of harm reduction is to meet people at where they're at with stepwise approach to what their

00:32:44.920 recovery is going to look like knowing that for some people that's not going to be abstinence but also

00:32:50.920 providing the knowledge and the accessibility to ways that they can move on into recovery and abstinence

00:32:58.200 how the neurobiochemical effects of opioids will affect people's ability to function in society when

00:33:10.000 they're when they have a high level of use being able to get on something like methadone and suboxone

00:33:17.520 will actually take away that euphoria and have neurochemical changes that will cause improvement staying on

00:33:24.940 something like dilaudid or hydromorphone will not allow neurochemical changes that it basically stays

00:33:31.820 in the addictive phase so offering treatments that help you get out of being in an addictive phase are

00:33:39.720 important and they're important that harm reduction in harm reduction one of the pillars isn't working as a

00:33:47.320 silo it's working in collaboration with treatment in collaboration with prevention and we're

00:33:54.820 all working together if we're working in silos we're not going to be able to address this crisis

00:33:59.600 so we've got prevention we've got treatment and then my apologies for interrupting you but i had to

00:34:05.000 ask that question what are the other two pillars then okay the other pillar is harm reduction so that is a

00:34:10.020 pillar um and the other pillar that we refer to is enforcement as in law enforcement as in law enforcement

00:34:19.200 yes so traditionally and this is even work out of vancouver when we've looked at other places such as in

00:34:27.200 switzerland where they have been able to have a decrease in addiction opioid use and have been quite

00:34:34.940 successful they have used all four pillars effectively and the fourth pillar is one that

00:34:42.260 um is has less discussion but it is about protecting even the people using against crime so it's about

00:34:54.140 recognizing that there are um people selling that we have to you know that those trafficking those

00:35:02.160 dealing um you know making sure that there is protection of people from those people making sure that

00:35:09.720 this can't get to high school so it shouldn't be up to me saying i'm seeing it in high school students

00:35:15.460 it should be an enforcement issue that it's not getting there and we need to be recognizing that

00:35:22.580 but we seem to be forgetting not only pillar four but pillars one and two and focusing on pillar three

00:35:28.540 i think absolutely i i feel like we've we we were under funding or under recognizing the importance of

00:35:36.660 pillar three harm reduction and now we've overcompensated by putting so much of our

00:35:43.940 attention on that pillar at the expense of really important services that offer the other pillars

00:35:53.080 and that's i think why it's not working you can't you know a building is going to fall down if you only have

00:36:00.240 one pillar we know you need four we're putting everything into one and hoping things work at the

00:36:08.240 expense of services that are about treatment as i say our treatment you know the rapid access addiction

00:36:14.740 medical clinic is not is finally open four days a week it's not even open five um the amount of

00:36:21.700 availability is still low and it's not connected to other health care programs in the way that the

00:36:29.440 supervised injection or sorry and what the way that the safe supply is so i feel absolutely we've we've

00:36:36.600 focused on a pillar that we neglected and now we've overcompensated by having it as our sole focus

00:36:44.000 we need to be stepping back recognizing what we're doing and looking at all four pillars and making sure that

00:36:52.920 we're adequately funding adequately promoting and adequately using all four pillars to have an effective

00:37:00.640 drug strategy i'm glad to hear somebody who works in the field expressing this like i said to you earlier

00:37:08.440 i can be reluctantly convinced of of moving in harm reduction if other supports are there but they don't appear

00:37:16.980 to be and when i point out things like after um british columbia decriminalized all our drugs at the end of january

00:37:24.020 um i pointed out in a recent column that within less than two months they were having record numbers

00:37:31.860 double their previous high of uh overdose calls on the downtown east side and the response from supporters

00:37:39.760 was well why do you want people to die i don't want people to die this is supposed to be the point but

00:37:45.420 decriminalizing all the drugs without other guardrails in place you know two months in and things are getting

00:37:53.260 dramatically worse shouldn't we be measuring that shouldn't we be taking note wondering okay are we

00:38:00.360 missing a step here i agree with you my expertise i will say is not in enforcement but i will say that

00:38:08.200 from looking at the pillars and being involved in these for years enforcement was an important pillar

00:38:13.900 even things you know now people can carry their fentanyl i don't know i mean i understand not wanting

00:38:21.240 to criminalize people for their addiction absolutely that is something i completely support but i also know

00:38:28.280 that previously if you were walking and you were found with fentanyl it was taken away now you have the

00:38:34.340 opportunity to use it and have an overdose from the fentanyl that used to be taken away from you

00:38:39.980 so part of being able to get better includes as mentioned lack of access so the access has absolutely

00:38:49.320 increased and this again decreases prevention and increases access um i do not i i strongly don't feel

00:38:58.840 people should be criminalized and jailed for their addiction but we also then have to be looking at

00:39:04.760 what does that mean when we um move forward and if if what we're seeing with decriminalization

00:39:11.720 is that there's more trafficking that there's more use of the fentanyl that more people are going to

00:39:16.900 overdose with the fentanyl fentanyl because they're very comfortable walking around with it it's not taken

00:39:22.380 away from them we have to be evaluating that we you know if we're going to make a change whether

00:39:27.460 it's decriminalization or adding safe supply they need to be there needs to be surveillance and there

00:39:34.300 needs to be monitoring and those who are saying we're seeing problems shouldn't be told well you

00:39:40.120 haven't proved it really the onus should be on the those changes to prove they're safe to prove the

00:39:47.040 to the community thalidomide is very effective at decreasing nausea in pregnancy if all you're going to

00:39:55.120 look at is the benefit then thalidomide is an effective drug at decreasing nausea that can

00:40:02.280 lead to you becoming dehydrated which is a medical problem in pregnancy we were able to connect it to

00:40:08.320 the harms and determine that the harms made it something that we wouldn't accept the benefits and

00:40:15.160 i think we have to be doing the same with anything where we're looking at it doesn't mean there are no

00:40:20.160 benefits we have to be looking at what the harms are and the surveillance of the harms shouldn't just

00:40:27.240 be up to people saying these are concerning i'm seeing them we need to be doing accurate surveillance

00:40:33.780 of the harms and then following up with what that looks like are we really getting an improvement in

00:40:39.560 overdose deaths if it's not then maybe that's not the direction we should be taking what i see is it's

00:40:45.640 not and we're doubling down on on continuing the same path as opposed to re-evaluating whether what

00:40:53.720 we're doing is effective in the first place you were recently uh profiled in london free press because

00:41:00.980 you're not used to being a person of controversy um what what was that like you know you you generally

00:41:08.840 you know i'm sure you've um you know been in the media in the past um and and probably at times

00:41:14.440 with controversy given that you your support of safe injection sites and and that has been a

00:41:19.360 controversial issue over the years but having um being part of a a national debate um was probably

00:41:28.460 a bit of a shock to you wasn't it oh absolutely i've tended to be somebody who's fairly private and

00:41:34.440 fairly um i don't seek attention i don't like being the center of attention but i also believe

00:41:43.920 that it is my duty as a physician as a person that when i'm seeing something i i believe is harmful

00:41:51.460 i have to speak up i don't believe that i have a choice in that i believe that i need to speak up

00:41:57.800 and express concerns that i have about harm and i've done that in other scenarios in other situations

00:42:04.900 this one and to be honest when i first was speaking to the national you know the reporter at the

00:42:10.900 national post i really wasn't expecting that that was in february i believe that i i was well i didn't

00:42:17.600 ever speak with him i just answered questions he emailed i really had no um thought that i my opinions

00:42:26.980 would become controversial or at the center of a controversy i've been stating them for a long time

00:42:32.620 i've been publicly stating them for a long time um but now that other people are listening to them

00:42:39.000 they have become more contentious um i believe that i'm a have seen harm and i believe it's my

00:42:47.600 moral responsibility to identify it and i am willing to accept that there are going to be people who are

00:42:56.500 going to be adamantly adamantly disagree with with what i'm seeing because they're not seeing it

00:43:02.060 if you're not in the hospital seeing these people who are suffering from the infections

00:43:07.980 you can't tell me i'm not seeing it and if you're not living in the community you can't tell me you're

00:43:13.820 not you know that and not seeing those things i'm seeing them and i'm reporting are we measuring them

00:43:19.840 though no are we studying this properly and measuring outcomes no no no and and then that's a problem

00:43:26.400 absolutely uh you know and and um i think there's when i look at some place like vancouver for example

00:43:35.960 there's so much happening now that it's harder to prove links to anything when i first started

00:43:41.840 seeing infections in london fentanyl wasn't here and it was easy to say fentanyl wasn't the cause

00:43:49.400 it's harder for me to prove that now because fentanyl is here and that so many people are

00:43:55.940 using more than one thing and i've had that pointed out to me that i can't prove it because people are

00:44:01.540 now using multiple drugs or they started with dilaudid they've moved to fentanyl by the time they get

00:44:06.860 their infection from the dilaudid they are now using fentanyl how do i prove it it's going to take

00:44:12.860 rigorous study to prove it but i also don't know of any study that really proves that injecting

00:44:18.940 a pharmaceutical a pill designed to be swallowed is safe and in any type of rigorous manner that

00:44:25.800 would normally be associated with scientific research it's challenging but i would say that

00:44:32.400 the onus should be on those doing so you know the surveillance should be on health canada the

00:44:39.120 surveillance should be i've which i've sent um reports to health canada of people with um who

00:44:46.100 have told me they're injecting dilaudid and have developed spine infections one had a paraplegia

00:44:52.740 meaning so they couldn't walk another one was paralyzed from the neck down from a an abscess in

00:44:58.580 the higher up in the spine i'm reporting those um it's we it's it's more challenging now than it was

00:45:08.120 when i started and yes people are using multiple things but to be able to say that injecting a pill

00:45:15.560 is safe i don't know of any study that actually shows that and i think that's important before you

00:45:21.780 start saying something is safe to inject there really needs to be a study that shows that it's safe

00:45:27.360 it shouldn't be up to people in the community to say okay i can guarantee they're not using anything

00:45:32.000 else or there can't be any other explanation for the infection we haven't proved that it's safe to

00:45:37.300 inject we haven't proved if and that is a major issue that you're you're facing is that people

00:45:43.680 are taking these pills yes and they're crushing them down and inject yeah absolutely that they're

00:45:48.520 because it gives gives them a better high yes yes it gives them and and often that's essentially

00:45:53.860 what they're used to do and they're they're used you know their addiction well most people start

00:46:00.580 when they do start they start swallowing pills but to get a better a bigger high you

00:46:06.780 it you get a quicker euphoria a quicker high through injection so injection tends to be a step when people

00:46:15.220 have developed an addiction things i'm glad i'm not fully aware the program itself essentially encourages

00:46:26.440 it people to be injecting a pill and and i would say isn't really giving enough um informed consent

00:46:34.880 about dangers if they don't believe those dangers exist they're certainly not reporting it to people

00:46:41.420 but i think that the danger of crushing a pill that's designed to swallow and injecting it

00:46:47.480 is very real and it it's you know the thing it's not the hydromorphone in the pill that's that

00:46:53.720 would be causing damage it would be other things that are in the pill that would cause damage um

00:46:59.340 far you know in the bloodstream that can lead to an infection um but a pill isn't designed to be put

00:47:06.560 into your bloodstream it's designed to be swallowed and i think before we are giving a pill to inject

00:47:13.660 we should have studies that show it's safe if statistically it's now hard in a place like vancouver to show

00:47:20.680 that there's an increase in infections from injecting a pill it's because there's so many people who are

00:47:26.160 injecting and it becomes much more complicated i can say when it was more simple here i felt very much

00:47:34.840 like i could see a link do i have have i been able to prove that link i think that the thought as i say

00:47:42.820 the thought that that um injecting something designed for swallowing um is likely to cause harm

00:47:51.500 we we have never studied that it doesn't cause harm dr koivy thanks so much for the time and uh

00:47:59.460 and your wisdom and experience and um i hope the discussion keeps going thank you very much for having

00:48:04.820 me full comment is a post media podcast my name is brian lily your host this episode was produced by

00:48:11.500 andre prue with theme music by bryce hall kevin liban is the executive producer you can subscribe

00:48:16.880 to full comment on apple podcast google spotify listen on the app your alexa enabled device and

00:48:22.960 of course give us a rating or leave a review and tell your friends about this by sharing it

00:48:27.980 on social media thanks for listening until next time i'm brian lily

00:48:32.040 thank you

00:48:35.420 very much

00:48:36.660 very much

00:48:38.820 next time i'm back

00:48:41.600 you

00:48:43.140 yeah

Full Comment - January 01, 2024

Best of 2023： Canada’s great addictive hard-drug giveaway experiment somehow goes awry

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