Full Comment - Canada’s great addictive hard-drug giveaway experiment somehow goes awry

00:00:00.000 addiction and mental health they go hand in hand and they're issues that are talked about

00:00:09.500 constantly now in provincial legislatures federal parliament in mayoral elections like we're having

00:00:15.820 in toronto right now and in the media it's worse than it's ever been it seems that's the layman's

00:00:23.200 look anyway you walk the streets of toronto and you will see people suffering from addictions

00:00:27.960 you walk the streets of smaller towns that didn't used to deal with this sort of problem in the same

00:00:33.640 way and you see the issues that you used to just see in the big cities hi i'm brian lily host of the

00:00:40.280 full comment podcast and we're going to delve into the issue of addictions safer supply how we're

00:00:46.180 handling this as a society and as a country before we get to our next guest though i do want to remind

00:00:51.260 you that you can subscribe to full comment on spotify on apple on google podcast amazon any

00:00:57.860 of the platforms that you listen to please hit subscribe and perhaps leave a review share it on

00:01:02.720 social media now are we headed in the right direction we are definitely going in a direction

00:01:09.620 we're going in a liberalization direction when it comes to dealing with hard drugs we have fully

00:01:15.980 embraced harm reduction now we are embracing in some areas safer supply but is it the right move

00:01:23.220 now dr sharon koivu is an addictions physician who works at a hospital in london ontario and has

00:01:29.500 been studying this issue for some time and she joins me now uh doctor thanks for the time

00:01:34.100 thank you for having me it's a tough issue because you've got a lot of different aspects at play here

00:01:41.940 you've got moral aspects people will have strong views on the morality of hard drugs or how we treat

00:01:49.440 them there are the medical issues there are economic issues um such as do we have enough

00:01:57.100 money to pay for um the drugs for all the addicts in the country how would you describe where what

00:02:05.020 we're doing in terms of experiments like what you've had out in london what we're having in

00:02:09.940 vancouver and what we may soon be having here in toronto

00:02:12.380 i think that what you've said calling an experiment is exactly what's happening that we

00:02:20.880 are having an experiment without really having the parameters that we normally use to both run an

00:02:28.380 experiment and to monitor the effects or the harms of an experiment um and i think specifically that when

00:02:36.700 you're referring to safe or safer supply um it is an experiment it sounds good on paper obviously we

00:02:46.760 don't want people to be dying from toxic fentanyl but i think that it's we have to look at what happens

00:02:55.180 once we introduce more drugs into a community when we introduce more drugs into a community we have found

00:03:02.480 in the past that that actually increases the number of people that are going to be using them

00:03:07.680 that is essentially what happened during the opioid crisis that we sometimes talk about as the purdue

00:03:13.840 opioid crisis more drugs were being prescribed more drugs were being diverted and used by other people who

00:03:21.640 weren't prescribed those drugs and that led to our opioid crisis now we're kind of using that and calling it

00:03:31.600 a treatment plan i also want to say that when we first started using that in london we did not have

00:03:40.260 a toxic fentanyl problem we were actually using safe supply specifically to help street level workers

00:03:48.860 at risk um at risk of infection who were using a similar drug called hydromorph content and we were

00:03:57.940 trying to protect them from street work by giving them dilaudid and i think that that what we found

00:04:05.240 that is positive is that if you give people health care and social services you will get an improvement

00:04:15.040 if you offer comprehensive um care for people's hiv a place they can come in a non-judgmental way

00:04:25.480 you will get improvement but what i don't feel we've shown is that we will continue that improvement

00:04:34.140 for people who are using fentanyl which is a very very very different drug and more importantly

00:04:39.880 with ever we're doing anything we have to be so careful that it's not causing harms to the people

00:04:46.680 in the program and to people outside of the program and to the community and that's where i feel we

00:04:54.460 haven't done our due diligence in this program you described an awful lot of wraparound services

00:05:01.300 as they're often called um yes by the politicians i talked to about this you know health care um perhaps

00:05:08.980 housing other uh other supports my big issue with this and i i i can be reluctantly convinced to go in

00:05:20.140 the direction of harm reduction and safe supply if there are supports but my problem with this is we

00:05:26.960 keep adding in okay well we'll do harm reduction we'll do safe supply we'll do this but there's no

00:05:32.900 supports uh or not enough supports there isn't treatment enough treatment for people that would like

00:05:40.340 it 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

00:05:48.560 it seems like we're saying okay we've got all these people on the streets let's give them what

00:05:54.980 they need in terms of drugs but not what they need in terms of anything else actually i think that's a

00:06:00.860 really good point and that's a really important way of of describing it because harm reduction when we

00:06:07.460 really started embracing that it was a pillar of drug strategy and there were four pillars in that drug

00:06:13.840 strategy and those pillars are prevention treatment harm reduction and enforcement and i think that

00:06:21.900 we've put we recognized that compared to perhaps other countries we weren't doing enough in harm

00:06:29.940 reduction and now we've put emphasis in harm reduction and taken away any we've taken away supports

00:06:39.220 for prevention and treatment and enforcement and specifically prevention we know from our all

00:06:48.240 evidence and our data for tobacco for example that the most important way to prevent is to decrease

00:06:55.080 access and part of that is to also increase the cost that's why to pay for cigarettes most of the money

00:07:03.560 is tax and that's to make it less accessible more expensive less likely for youth to be using it but now we

00:07:11.880 have a program in which diversion is happening making it very much more accessible and more accessible for

00:07:19.520 anyone in the community to be using something that's extremely dangerous and we're actually labeling it as safe

00:07:27.680 so it's danger it's danger for addiction it's danger for overdose it's danger to the community it's

00:07:35.920 danger as a stepping stone to fentanyl it's danger potentially in injecting a pill that was designed to be

00:07:44.640 swallowed and perhaps causing severe infections as i'm seeing we're calling something safe and having it an

00:07:53.380 extremely inexpensive um market so we're now having it out on the streets without it can i can i interrupt

00:08:03.000 for a second because you said something at the beginning that i want you to define for us because

00:08:08.380 it relates to everything that you're talking about here you said we have diversion now what's diversion

00:08:14.280 in this safer supply discussion diversion which is sometimes talked to about as being kind of enhancing the

00:08:22.100 illicit opioid market it's when you prescribe a pill or have a prescription that you give to some

00:08:29.020 someone with the intent that they take it but the person that receives the prescription gets that filled and then

00:08:37.640 sells their drug diversion can include being selling your drug um having it stolen from you or having violence

00:08:47.280 where you have to give it up because you're at risk of being hurt and i believe all of those happen so

00:08:54.840 when we prescribe for safe supply it is not witnessed it is not a we are not witnessing all of the doses most

00:09:03.660 places aren't witnessing it's not like some of the pharmacies where people used to go and get a methadone

00:09:08.200 right when when you start on methadone you have to have it witnessed when you start on suboxone which

00:09:16.480 is a amazing opioid agonist therapy that is not getting nearly enough attention when you start on

00:09:24.060 these things we witness them we make sure you're tolerating them we make sure that this is the dose that

00:09:31.340 your body needs and that you can handle and that is safe for you then once you're stable we look at

00:09:39.780 giving you what's called take-home doses that is not happening in the programs that are using

00:09:47.440 dilaudid or hydromorphone as a met as a way of dealing with people with an opioid addiction so they're

00:09:54.220 given an amount without an assessment as to whether that amount is safe for them to take

00:10:00.080 what they need and as people ask for higher doses we are not checking to make sure that that dose is

00:10:10.480 actually appropriate for them and i'm seeing that working in the hospital that's an extremely

00:10:17.660 stressful situation for the physicians and health care staff because we'll have people come in

00:10:24.080 prescribed 20 sometimes even as many as 40 dilaudid 8 milligram pills in a day so hydromorphone 8

00:10:34.100 milligrams in a day they'll get 40 pills and then we find that to keep them safe not in withdrawal

00:10:41.920 and not overly sedated they take much less than that 50 25 often it's even less than that so i've got

00:10:50.940 one person who has prescribed 40 pills and is stable on equivalent of nine pills in a day if we started

00:10:58.660 them back on the 40 pills in a day um right away and they took them or we change it into a method where

00:11:06.240 you know we're giving it by injection we could actually be creating toxicity so we know that those

00:11:12.520 people are not tolerating that dose we know that they're not checked to make sure they're tolerating

00:11:17.460 that dose which is further evidence that they're selling their dose so this was raised last week

00:11:25.980 and uh i i know that you spoke to adam zivio for his piece in the national post i know the global news

00:11:33.040 in vancouver went out on the streets and they were buying up pills the supporters just still said this

00:11:40.740 isn't true it doesn't happen i mean uh there was clear video evidence within half an hour the global

00:11:48.460 news crew on camera had a fistful of pills um so is it widely known within the research community that

00:11:59.940 this does happen and is it just political activists saying trying to protect a program they don't want

00:12:06.840 criticize saying it doesn't i cannot imagine how people don't see that it is being diverted

00:12:16.040 in so many ways i lived within a kilometer of where um the safer supply is prescribed in london i actually

00:12:26.000 moved there um to be a an urban physician living where people are and in in addition i was moving there to

00:12:35.000 support a supervised consumption site which might have been built there and i wanted to be able to

00:12:39.900 be supporting it both as a physician hearing from people telling me they were buying diverted drugs

00:12:47.620 and from people who were actually telling me they were selling diverted drugs i had people who we had

00:12:53.940 stable on methadone and stable on suboxone that told me they were going to go on safe supply

00:12:59.780 so that they could get the income associated with selling their drugs and that that was too much of

00:13:05.880 an incentive for them to be able to to stay on methadone or suboxone wow but living in the community

00:13:13.400 i also saw it we developed encampments behind the pharmacy that had much of the diversion i lived there

00:13:24.640 i would go and walk and talk to people i was well known and well um people weren't hiding from me so

00:13:32.680 when i'd go there i'd talk to people i would actually see people involved in selling their drugs

00:13:38.400 um i'd see people living in encampments and tell me that it's cheaper to get the dilaudid near the source

00:13:47.160 of the diversion near the source where people get their their prescription filled and sell it right away

00:13:53.280 it's cheaper there so people were telling me that do i did i bring a camera with me and record it that

00:14:01.500 wouldn't you know it didn't occur to me that that would be something that would be necessary in the

00:14:06.120 future and but it was as i say it was i brought that to the attention of the group that was prescribing

00:14:13.820 um and i brought it to many attention at many levels when i was literally seeing it also we were

00:14:22.440 seeing things the evidence of of an increasing crime in the community that things like bicycles

00:14:28.580 being stolen people having you know their um pipes broken to get the copper off of pipes those sorts of

00:14:36.240 things are much more prevalent crime in that community against businesses that you know that didn't used to

00:14:42.880 happen i have family living in an area that social economically is the same that was not experiencing

00:14:50.860 the same issues that i was seeing in the neighborhood that's right near where where this

00:14:57.260 program was initiated i also have certainly seen younger people i have lots of what they tell me are just

00:15:08.040 anecdotes of younger people who are telling me that they're accessing diverted drug well they're saying

00:15:14.140 they're getting drugs from safer supply they don't use the word diverted are these uh younger people are

00:15:20.120 they you know high school kids that that's how they're getting into drugs or they were already

00:15:26.260 on something and decided to move to this i think that in high school there are definitely people that

00:15:33.460 will experiment with drugs when my kids were in high school it was not uncommon to see kids experimenting

00:15:39.740 with ecstasy um mushrooms even perhaps crystal meth what's changed from what i can tell from speaking

00:15:50.040 to parents who have kids in high school from speaking to the young people that i'm seeing

00:15:55.860 is that now it is more accessible to be able to get diverted so dilaudid diverted drugs opioids at the high

00:16:08.540 school level i don't think necessarily that means people in the program are going to the high schools

00:16:13.780 i think that as i mentioned i've known of people that have lived in encampments that actually moved

00:16:20.600 there not to use the drugs but to to get them and then sell them else elsewhere once things are

00:16:27.740 diverted you don't have a control of where they go as i mentioned as long as things are cheap and

00:16:35.460 accessible it does mean there's going to be an increase in the market it's going to be an increase in the

00:16:41.300 people that can access those pills i cannot give a number of how many people in high school have

00:16:48.320 access to to diverted dilaudid i can say that i'm hearing that repeatedly i'm seeing that in patients

00:16:56.200 that i'm seeing and i'm seeing that in stories of violence and that really really really scares me

00:17:02.860 because i think that now you know when you're experimenting in high school and you experiment with

00:17:09.920 something like ecstasy three years later you can choose not to be using that when you experiment

00:17:15.660 at any time in your life with something that is this addictive then your chances of becoming addicted

00:17:22.620 to it are extremely high compared to some of the other recreational drugs and that as people start

00:17:31.180 using something like hydromorphone once you become addicted that means your body becomes needing it

00:17:38.060 you that becomes your normal you need that there's changes in your brain at a neurobiochemical level and

00:17:44.400 you need that drug to feel normal without it you go into withdrawal so you have to seek it but you're

00:17:50.520 also seeking something we call euphoria so the high and if you try to seek a higher high a better high

00:17:56.780 then you'll go to a stronger drug such as fentanyl and fentanyl and so people are stepping from one to

00:18:04.820 the other yes that that is what i'm seeing so i say you know over and over again when i'm seeing young

00:18:12.300 people in the hospital they tell me this as their story this is their journey is that they've started

00:18:19.820 with hydromorphone and those who've moved on most started with it in addition as i mentioned we

00:18:26.960 didn't see fentanyl in the community be at in 2016 when this the program started now i feel i agree with

00:18:36.760 with the article in the national post that it's promoting fentanyl to come here but either way it's

00:18:43.840 not stopping it so if you think of an amount of fentanyl that is going to be toxic and that it's

00:18:51.280 going to harm people that will not decrease by adding drugs to your community so somebody dying

00:19:00.640 from fentanyl the numbers won't change if anything i do think it's attracting the fentanyl market and

00:19:07.080 people will use and move up but it doesn't do anything to address that there's fentanyl here

00:19:14.320 it won't adding something to other people won't address that somebody could die from from fentanyl so

00:19:22.840 it doesn't save lives in numbers it might change who dies but it's not going to save lives it will

00:19:31.600 just to me it reminds me of the old um trolley um ethical dilemma um in reverse so there's a

00:19:41.020 common ethical dilemma where a trolley is going towards one person and you sorry trolley is going

00:19:49.120 towards many people and you can pull the switch and it could go to just one person and it's going to

00:19:55.560 run over those people and cause their death to me i feel like what we're seeing is the trolley is heading

00:20:00.520 to one person and we're pulling a switch and heading the trolley towards many in the trolley the

00:20:07.400 trolley is fentanyl and we're putting more people on the track it is possible that we can help that one

00:20:14.960 person but i would say that at the risk of harm to many and i would say that there are better safer ways

00:20:23.720 to help that person this isn't the only way we can help a person develop um

00:20:31.300 leave their addiction or go into recovery even if we're looking at meeting people where they are

00:20:38.380 and trying to provide care where they are i feel like we're forgetting about the other people that

00:20:46.320 are being harmed focusing on that person and also forgetting that there are other

00:20:51.280 very evidence-based treatments and things that we need to be doing and enhancing and enhancing

00:20:57.880 people shouldn't just have access to comprehensive health care if they're in the program people in

00:21:07.140 a methadone clinic or the suboxone you know rapid access addiction medical clinic do not have the same

00:21:14.440 access to care that you get if you're in the safe supply program because the safe supply program is

00:21:21.640 connected to the community health center and the others aren't so we've we've haven't set up anything

00:21:29.580 like a fair kind of way of assessing it because we've we've attached health care that we know is

00:21:35.680 beneficial to people and we've haven't provided that for other people in other programs all right

00:21:44.940 we need to take a quick break here dr koivu but when we come back i do want to ask you where do we go

00:21:51.140 what are the steps that we can take because there is no doubt that there is an addictions problem

00:21:56.880 i just there are steps being taken i'm just not sure they're working back in a moment

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00:23:34.800 addictions and even opioids you know there was an opioid problem before fentanyl but everything has been

00:23:42.520 been made worse by fentanyl uh and you know doctor i cover all kinds of issues uh in my career as a

00:23:51.220 columnist and and i can tell you that all the major issues that toronto's facing right now i think whether

00:23:57.140 we're talking about addictions mental health homelessness crime grime in the streets there is a

00:24:03.160 connection back to fentanyl um because it drives the crime it drives the shootings it is a valuable stash

00:24:11.180 that people will kill to protect uh all of these things in in fentanyl has just spread across the

00:24:17.540 country over the last few years you mentioned it wasn't there in 2016 when you started this safe supply

00:24:23.000 program in london um but it's there now and it is a scourge but how do we how do we respond you say

00:24:33.500 that there are better evidence-based treatment programs um you know when the government was asked

00:24:39.120 about the issue of safer supply last week they said we stand with the science um that seems to be their

00:24:46.160 their answer to a lot of things we stand with the science as if there's only one and and they have it

00:24:51.780 it's in a nice little box over here and they're going to protect it um science is constantly changing

00:24:57.960 evolving people experiment people look at results are we looking at results or are we wedded to a new

00:25:06.160 religion i think that's a very good question i think that i think there's stories there are anecdotal

00:25:15.720 evidence of some benefit from um from safer supply and those stories have been published and we're

00:25:25.280 calling those stories evidence unfortunately my stories i haven't published so they're not evidence

00:25:31.680 i think that we have to look at what's happening and be aware the people in the community are seeing

00:25:38.800 what's happening and we have to look at whether it's really making the difference that we are hoping it

00:25:45.040 is it actually decreasing overall overdose deaths is there a connection to increasing fentanyl is there

00:25:54.700 a connection to people living in encampments to get diverted drugs are more people developing an

00:26:02.040 addiction are younger people developing an addiction i was recently told by a local politician that until

00:26:09.000 those are there that they're not changing there's the federal government won't change their stand and i guess

00:26:14.620 i'd be saying those are exactly the things that you need to be following if you're going to be

00:26:20.820 implementing this program as a physician i am legally responsible and and have to if i see harms i'm legally

00:26:29.600 required to to report the harms that i'm seeing in no other scenario have i been told that i also have to

00:26:38.720 prove those harms so i think we need to be having a much better surveillance for the harms that many

00:26:47.860 of us believe are associated with the program as i say it's not normally up to me to prove

00:26:55.500 that i'm you know that it's the version is a problem we know that from lots and lots of evidence in

00:27:03.380 all sorts of um other data the diversion of opioids is a problem it increases people that are taking it

00:27:10.080 and increases the risk of of anyone becoming addicted that's not new we have to be looking at

00:27:16.140 that data we also have evidence of an increase in use in london we have to be looking at that data

00:27:22.620 but i also think we're focusing so much on safe supply at the expense of of so many other programs

00:27:31.780 even at the expense of other harm reduction programs i absolutely support the merit of a

00:27:39.080 supervised injection site it will help people who go and doesn't cause harm to someone else so when

00:27:47.280 i'm looking at whether harm reduction is effective i want to make sure we're meeting people where they

00:27:52.820 are it has to be one strategy in the four pillars of drug strategy it can't stand alone it needs to be

00:28:01.540 connected and interconnected and needs to be available and we need to be making sure that

00:28:07.980 anything we pick is not having unintended side effects and unintended harms what are the other

00:28:15.240 pillars in the four pillars okay the pillars are prevention the most important probably i mean we like

00:28:21.240 to say all of them are important prevention the most important aspects in prevention are access and cost

00:28:27.180 and health we need to be looking at the social determinants of health that can cause people to seek

00:28:35.600 out drugs so we're looking at things like child abuse trauma poverty homelessness focusing on things that

00:28:45.720 help people before they're going to be seeking a drug for addiction are extremely important we need to be

00:28:54.780 putting much prevention seems to have been forgotten and our need to be putting more emphasis on

00:29:04.320 prevention is absolutely crucial so prevention is one another is treatment and we have significant

00:29:13.120 evidence that when people can access treatment that they can have improvements in their health we have that

00:29:21.180 with opioid agonist therapy including methadone we have a newer medication suboxone and which also comes in a one

00:29:29.320 once a month form called sublicade we have significant evidence that when people go on opioid agonist therapy in a

00:29:38.740 clinical setting that we can they can have improvement in health outcomes we have not done anything to compare

00:29:45.540 those settings to people who are getting um health care and wraparound services that aren't available

00:29:53.440 at those settings we also have had significant restrictions on on um with making sure we witness doses to prevent

00:30:02.560 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

00:30:09.800 suboxone is a very much safer drug to be having um to be taking it helps withdrawal and it prevent it

00:30:19.000 decreases the risk of an overdose um we need to be focusing on a treatment that will actually um help

00:30:28.660 people move on well yeah i want to ask you about treatment because one of my colleagues was interviewing

00:30:34.740 someone in the public health field and they asked about treatment and proactively offering addicts

00:30:42.200 treatment at places like safe injection sites and the response that she got was offering someone

00:30:48.920 treatment would be judgmental on their lifestyle it and it flabbergasted it flabbergasted me um is that a

00:30:56.880 a common view among some people in the public health community or is that was that person an outlier

00:31:05.040 i i don't know that i certainly have heard that view before i don't know whether i could say it's

00:31:12.540 common i do know that people working for example in a supervised injection site want to make sure that

00:31:19.640 they're not coming across as judgmental and initially in london we had a um problem with um an hiv outbreak

00:31:29.920 and um we were able to show that that was related to how people were people were injecting a long

00:31:36.900 acting form of hydromorph cotton and um that if they were reusing the filter or selling the filter or

00:31:44.580 sharing the filter then that was spreading um hiv and it was also contributing to a heart valve

00:31:51.000 infection we had to work with the supervised injection site to get them to feel comfortable

00:31:57.220 teaching people how to use the equipment properly because of this fear of interfering with their

00:32:05.420 relationship but we were able to do that i also know that the supervised injection site here

00:32:11.240 traditionally has worked with other treatment facilities as being able to provide information

00:32:19.380 for people to be able to get treatment i think that that is something that's really important so i i

00:32:26.240 have heard that view i don't support it i think that absolutely at a supervised injection site you have

00:32:34.340 part of harm reduction is to meet people at where they're at with stepwise approach to what their

00:32:44.660 recovery is going to look like knowing that for some people that's not going to be abstinence but also

00:32:50.660 providing the knowledge and the accessibility to ways that they can move on into recovery and abstinence

00:32:57.920 how the neurobiochemical effects of opioids will affect people's ability to function in society when

00:33:09.740 they're when they have a high level of use being able to get on something like methadone and suboxone

00:33:17.260 will actually take away that euphoria and have neurochemical changes that will cause improvement staying on

00:33:24.660 something like dilaudid or hydromorphone will not allow neurochemical changes that it basically stays

00:33:31.540 in the addictive phase so offering treatments that help you get out of being in an addictive phase are

00:33:39.440 important and they're important that harm reduction in harm reduction one of the pillars isn't working as a

00:33:47.040 silo it's working in collaboration with treatment in collaboration with prevention and we're

00:33:54.540 all working together if we're working in silos we're not going to be able to address this crisis

00:33:59.320 so we've got prevention we've got treatment and then my apologies for interrupting you but i had to

00:34:04.720 ask that question what are the other two pillars then okay the other pillar is harm reduction so that is a

00:34:09.760 pillar um and the other pillar that we refer to is enforcement as in law enforcement as in law enforcement

00:34:18.920 yes so traditionally and this is even work out of vancouver when we've looked at other places such as in

00:34:26.940 switzerland where they have been able to have a decrease in addiction opioid use and have been quite

00:34:34.680 successful they have used all four pillars effectively and the fourth pillar is one that

00:34:42.020 um is has less discussion but it is about protecting even the people using against crime so it's about

00:34:53.860 recognizing that there are um people selling that we have to you know that those trafficking those

00:35:01.880 dealing um you know making sure that there is protection of people from those people making sure that

00:35:09.440 this can't get to high school so it shouldn't be up to me saying i'm seeing it in high school students

00:35:15.180 it should be an enforcement issue that it's not getting there and we need to be recognizing that

00:35:22.300 but we seem to be forgetting not only pillar four but pillars one and two and focusing on pillar three

00:35:28.260 i think absolutely i i feel like we've we we were under funding or under recognizing the importance of

00:35:36.400 pillar three harm reduction and now we've overcompensated by putting so much of our attention

00:35:44.040 on that pillar at the expense of really important services that offer the other pillars and that's

00:35:54.860 i think why it's not working you can't you know a building is going to fall down if you only have

00:35:59.980 one pillar we know you need four we're putting everything into one and hoping things work at

00:36:07.780 the expense of services that are about treatment as i say our treatment you know the rapid access

00:36:14.040 addiction medical clinic is not is finally open four days a week it's not even open five

00:36:18.620 um the amount of availability is still low and it's not connected to other health care programs in the

00:36:28.600 way that the supervised injection or sorry and what the way that the safe supply is so i feel absolutely

00:36:35.440 we've we've focused on a pillar that we neglected and now we've overcompensated by having it as our sole

00:36:43.160 focus we need to be stepping back recognizing what we're doing and looking at all four pillars and making

00:36:52.060 sure that we're adequately funding adequately promoting and adequately using all four pillars

00:36:58.900 to have an effective drug strategy i'm glad to hear somebody who works in the field expressing this

00:37:06.200 like i said to you earlier i can be reluctantly convinced of of moving in harm reduction if other

00:37:13.460 supports are there but they don't appear to be and when i point out things like after um british

00:37:20.340 columbia decriminalized all our drugs at the end of january um i pointed out in a recent column that

00:37:27.020 within less than two months they were having record numbers double their previous high of uh overdose

00:37:35.860 calls on the downtown east side and the response from supporters was well why do you want people to die

00:37:41.200 i don't want people to die this is supposed to be the point but decriminalizing all the drugs without

00:37:47.360 other guardrails in place you know two months in and things are getting dramatically worse

00:37:54.000 shouldn't we be measuring that shouldn't we be taking note wondering okay are we missing a step here

00:38:01.240 i agree with you my expertise i will say is not in enforcement but i will say that from looking at the

00:38:08.820 pillars and being involved in these for years enforcement was an important pillar even things you know

00:38:15.380 now people can carry their fentanyl i don't know i mean i understand not wanting to criminalize people

00:38:22.080 for their addiction absolutely that is something i completely support but i also know that previously

00:38:28.980 if you were walking and you were found with fentanyl it was taken away now you have the opportunity

00:38:34.540 to use it and have an overdose from the fentanyl that used to be taken away from you so part of being

00:38:41.820 being able to get better includes as mentioned lack of access so the access is absolutely increased

00:38:49.820 and this again decreases prevention and increases access um i do not i i strongly don't feel people

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

00:39:05.120 mean when we um move forward and if if what we're seeing with decriminalization is that there's more

00:39:13.000 trafficking that there's more use of the fentanyl that more people are going to overdose with the

00:39:17.420 fentanyl because they're very comfortable walking around with it it's not taken away from them we have to

00:39:23.380 be evaluating that we you know if we're going to make a change whether it's decriminalization or adding

00:39:29.500 safe supply they need to be there needs to be surveillance and there needs to be monitoring

00:39:35.120 and those who are saying we're seeing problems shouldn't be told well you haven't proved it

00:39:40.860 really the onus should be on the those changes to prove they're safe to prove the to the community

00:39:47.680 thalidomide is very effective at decreasing nausea in pregnancy if all you're going to look at is the

00:39:55.520 benefit then thalidomide is an effective drug at decreasing um nausea that can lead to you becoming

00:40:03.060 dehydrated which is a medical problem in pregnancy we were able to connect it to the harms and determine

00:40:09.280 that the harms made it something that we wouldn't accept the benefits and i think we have to be doing

00:40:16.100 the same with anything where we're looking at it doesn't mean there are no benefits we have to be

00:40:21.840 looking at what the harms are and the surveillance of the harms shouldn't just be up to people saying

00:40:28.280 these are concerning i'm seeing them we need to be doing accurate surveillance of the harms and then

00:40:35.620 following up with what that looks like are we really getting an improvement in overdose deaths if it's not

00:40:40.840 then maybe that's not the direction we should be taking what i see is it's not and we're doubling down on

00:40:47.000 on continuing the same path as opposed to re-evaluating whether what we're doing is

00:40:54.040 effective in the first place you were recently uh profiled in london free press because you're not

00:41:01.040 used to being a person of controversy um what what was that like you know you you generally uh you know

00:41:09.340 i'm sure you've um you know been in the media in the past um and and probably at times with controversy

00:41:14.880 given that you your support of safe injection sites and and that has been a controversial issue over

00:41:20.100 the years but having um being part of a a national debate um was probably a bit of a shock to you

00:41:29.240 wasn't it oh absolutely i've tended to be somebody who's fairly private and fairly um i don't seek

00:41:37.640 attention i don't like being in the center of attention but i also believe that it is my duty

00:41:45.780 as a physician as a person that when i'm seeing something i i believe is harmful i have to speak up

00:41:52.660 i don't believe that i have a choice in that i believe that i need to speak up and express concerns

00:42:00.060 that i have about harm and i've done that in other scenarios in other situations this one and to be

00:42:06.820 honest when i first was speaking to the national you know the reporter at the national post i really

00:42:12.320 wasn't expecting that that was in february i believe that i i was well i didn't ever speak with

00:42:17.920 him i just answered questions he emailed i really had no um thought that i my opinions would become

00:42:27.540 controversial or at the center of a controversy i've been stating them for a long time i've been

00:42:32.940 publicly stating them for a long time um but now that other people are listening to them they

00:42:38.900 have become more contentious um i believe that i'm a have seen harm and i believe it's my moral

00:42:47.780 responsibility to identify it and i am willing to accept that there are going to be people who are

00:42:56.240 going to be adamantly adamantly disagree with with what i'm seeing because they're not seeing it

00:43:01.780 if you're not in the hospital seeing these people who are suffering from the infections

00:43:07.720 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

00:43:13.560 not you know that and not seeing those things i'm seeing them and i'm reporting are we measuring them

00:43:19.560 though no are no are we studying this properly and measuring outcomes no no no and and then that's a

00:43:25.860 problem absolutely you know and and um i think there's when i look at some place like vancouver

00:43:35.020 for example there's so much happening now that it's harder to prove links to anything when i first

00:43:41.100 started seeing infections in london fentanyl wasn't here and it was easy to say fentanyl wasn't the cause

00:43:49.140 it's harder for me to prove that now because fentanyl is here and that so many people are

00:43:55.680 using more than one thing and i've had that pointed out to me that i can't prove it because people are

00:44:01.280 now using multiple drugs or they started with dilaudid they've moved to fentanyl by the time they get

00:44:06.580 their infection from the dilaudid they are now using fentanyl how do i prove it it's going to take

00:44:12.580 rigorous study to prove it but i also don't know of any study that really proves that injecting

00:44:18.680 a pharmaceutical a pill designed to be swallowed is safe and in any type of rigorous manner that

00:44:25.540 would normally be associated with scientific research it's challenging but i would say that

00:44:32.120 the onus should be on those doing so you know the surveillance should be on health canada the

00:44:38.840 surveillance should be i've which i've sent um reports to health canada of people with um who

00:44:45.820 have told me they're injecting dilaudid and have developed spine infections one had a paraplegia

00:44:52.460 meaning so they couldn't walk another one was paralyzed from the neck down from a an abscess in

00:44:58.300 the higher up in the spine i'm reporting those um it's we it's it's more challenging now than it was

00:45:07.840 when i started and yes people are using multiple things but to be able to say that injecting a pill

00:45:15.280 is safe i don't know of any study that actually shows that and i think that's important before you

00:45:21.500 start saying something is safe to inject there really needs to be a study that shows that it's safe

00:45:27.100 it shouldn't be up to people in the community to say okay i can guarantee they're not using anything

00:45:31.740 else or there can't be any other explanation for the infection we haven't proved that it's safe to

00:45:37.040 inject we haven't proved if and that is a major issue that you're you're facing is that people

00:45:43.420 are taking these pills yes and they're crushing them down and inject yeah absolutely that they're

00:45:48.240 because it gives gives them a better high yes yes it gives them and and often that's essentially what

00:45:53.980 they're used to do and they're they're used you know their addiction well most people start when

00:46:00.840 they do start they start swallowing pills but to get a better a bigger high you it it you'll get a

00:46:09.440 quicker euphoria a quicker high through injection so injection tends to be a step when people have

00:46:15.140 developed an addiction things i'm glad i'm not fully aware the program itself essentially encourages it

00:46:26.500 people to be injecting a pill and and i would say isn't really giving enough um informed consent

00:46:34.620 about dangers if they don't believe those dangers exist they're certainly not reporting it to people

00:46:41.160 but i think that the danger of crushing a pill that's designed to swallow and injecting it

00:46:47.220 is very real and it it's you know the thing it's not the hydromorphone in the pill that's that would

00:46:53.560 be causing damage it would be other things that are in the pill that would cause damage um far you

00:46:59.860 know in the bloodstream that can lead to an infection um but a pill isn't designed to be put into your

00:47:06.720 bloodstream it's designed to be swallowed and i think before we are giving a pill to inject we should

00:47:13.900 have studies that show it's safe if statistically it's now hard in a place like vancouver to show that

00:47:20.580 there's an increase in infections from injecting a pill it's because there's so many people who are

00:47:25.880 injecting and it becomes much more complicated i can say when it was more simple here i felt very much

00:47:34.560 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

00:47:42.560 the thought that that um injecting something designed for swallowing um is likely to cause harm

00:47:51.240 we we have never studied that it doesn't cause harm dr koivy thanks so much for the time and uh

00:47:59.180 and your wisdom and experience and um i hope the discussion keeps going thank you very much for having

00:48:04.560 me full comment is a post media podcast my name is brian lily your host this episode was produced

00:48:10.960 by andre prue with theme music by bryce hall kevin liban is the executive producer you can subscribe

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Full Comment - June 12, 2023

Canada’s great addictive hard-drug giveaway experiment somehow goes awry

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