00:00:00.000Welcome to Canada's Most Irreverent Talk Show. This is the Andrew Lawton Show, brought to you by True North.
00:00:10.700Hello and welcome to another edition of the Andrew Lawton Show here on True North.
00:00:15.920It is Friday, August 18th, and as you know by now on the Friday show, we like to rip up the usual format and do a deep dive into a big picture issue.
00:00:25.580Now, this is a big picture issue, but it's also one that on the ground has very significant implications for community safety, for public health, and as a result, it's been very heavily politicized.
00:00:38.180We've seen in the course of the drug crisis in Canada, massive increases in just one metric alone, the number of opioid deaths per year.
00:00:47.780Now, I live in Ontario, and I can say that for years, we all used to look at the drug problem as being a British Columbia thing.
00:00:54.860You'd look out and say, oh, well, yeah, all those things they're doing in Vancouver are not affecting our city.
00:00:59.880And very quickly, my own city of London, Ontario, became one of the hotbeds of this drug and addiction crisis.
00:01:07.000And now we're seeing there really isn't a community in Canada that is immune to this.
00:01:12.780And there have been all sorts of proposals that have been pushed forward under the auspices of harm reduction,
00:01:18.280the most contentious of which I'd say is so-called safe supply, which is predicated on this belief that the dangers in the drug supply are among the most pressing threats to drug users.
00:01:31.280So if we can eliminate that variable, we can make drug use somewhat safer.
00:01:37.740Well, there have been a lot of very conflicting perspectives on this and perspectives that have shifted.
00:01:42.540Just this week, for example, there was – now, this is not a safe supply issue –
00:01:47.840but there was a story about a clinic in Toronto, in Leslieville, that had to apologize after they were giving out free chocolate in exchange for needles,
00:01:56.780which obviously the parents of children in that area weren't exactly too keen on.
00:02:01.280So there are a lot of different threads to pull on this issue.
00:02:05.020So we may go in some different directions here, but I have a tremendous panel of guests that have all done a great deal of work on this,
00:02:12.620either in the clinical setting, the research setting, or in the media setting, and in some cases in all three forums.
00:02:20.020So we'll bring into this show Adam Zivo, who is a columnist with the National Post and wrote a tremendous piece back in May
00:02:27.260that really delved into this issue from a lot of different angles.
00:02:30.300Dr. Julian Summers, who is a clinical psychologist and addiction specialist and a health sciences professor at Simon Fraser University.
00:02:39.320And Dr. Sharon Koivu, who is an addiction medicine consultant, actually in my neck of the woods, in London, Ontario, with London Health Sciences Centre.
00:02:47.820All three of you, it's wonderful to talk to you. Thank you for joining me today.
00:02:52.040Let me start with you, Dr. Koivu, because I know you've actually evolved yourself on this issue quite a bit,
00:02:58.160and you've not come at this because of any political reason.
00:03:01.200You've just done what I think researchers are supposed to do, which is followed the science
00:03:05.280and have found that safe supply isn't really what you once thought it was.
00:04:34.140This was specifically to get people off of hydromorph content.
00:04:37.460And I was one of the people that thought it sounded like a good idea.
00:04:41.820It sounded like a good idea on paper because of the problems we were having in London at the time.
00:04:48.600But once it was in place, I started seeing other problems.
00:04:53.500So yes, HIV, we no longer have the outbreak of HIV.
00:04:58.600We were able to get on top of that for many reasons with a community effort.
00:05:02.740And our endocarditis rates have improved.
00:05:05.120But what I started seeing clinically was an increase in other infections.
00:05:12.720So since this started in London, we have had an increase in essentially all other infections that are related to injection drug use.
00:05:22.400The ones that particularly alarmed me was I started seeing an increase in spine infections.
00:05:30.320So an increase in what we call epidural abscesses, which for some people can cause horrific pain, horrific suffering, and often leads to paraplegia or quadriplegia.
00:05:43.700And currently, I have a patient, I've been working with a patient who's quadriplegic and a patient who's paraplegic and one that we're hoping will be able to walk, but related to injecting.
00:05:54.220And just like when I was seeing people with the heart valve infections, I spent a lot of time asking patients what they were taking.
00:06:04.180And really, the common thread for almost all patients that I was seeing with this increase in infection was using Dilaudid, often either from the Safe Supply Program or diverted from it.
00:06:19.780And I think it's, you know, now people often will say, well, it's from the fentanyl.
00:06:24.200At the time when I started seeing these infections, we still did not have a problem with fentanyl in London.
00:06:30.860We do now, and we can talk about how I think it's related to the increase in opioids in London.
00:06:38.680The two main drugs were crystal methamphetamine and Dilaudid.
00:06:42.780And really, the common thread I found was the Dilaudid.
00:06:48.540And it led to other problems, too, that we can, you know, with diversion, making it cheaper, making it more accessible.
00:06:56.800But I think we can, those were the first things that really got me to start being aware and critical.
00:07:03.640And I took that information back to the community and was kind of surprised that it wasn't kind of welcomed as a place we needed to start doing research.
00:07:15.440Well, and this was obviously a story that is somewhat familiar to you, Dr. Summers.
00:07:20.380I know you did something very similar.
00:08:05.440Sex workers at very high risk in a variety of ways and then seeing the unintended consequences of the implementation of that service in other patient groups or other segments of society.
00:08:18.300And these risks are not only the acute risks that Dr. Koivu and other clinicians see in their practices, but also longer-term risks that they might also see, but that become more apparent when we group people together and look at the entire population.
00:08:34.300So it's well known that long-term administration, self-administration of opioids results in chronic risks as well as acute level risks.
00:08:44.840And so there are a variety of ways in which this approach poses risks.
00:08:51.300It also, I think more fundamentally, mischaracterizes how we would best address harms associated with substance use, including addiction in the population.
00:09:03.380It has nothing to do with a focus on supply.
00:09:06.140That's the approach of the war on drugs, is to focus on supply.
00:09:10.200And we've learned in these last 60 years that that doesn't result in much measurable improvement in our local populations.
00:09:17.360It's important, but it doesn't result in much measurable improvement, where all of the research has backed opportunities for progress is on demand reduction.
00:09:26.620Focus on the conditions that put people at high risk where resorting to addictions, addictions that put them and others at great risk, is a preferred approach to coping.
00:09:37.360There are ways of helping people, but it involves focusing on those very demand drivers.
00:09:43.240And we've been lied to, I think, by leaders, some deliberately, some innocently.
00:09:49.960And we've opened floodgates for profit interests to enter into the field.
00:09:55.160And that takes it well away from a focus on particular patient groups, high-risk sex workers and others, and seeks where's the biggest bottom line return.
00:10:04.580And we see companies now formally seeking investors in order to back an expected expansion of so-called safer supply in Canada initially and then internationally.
00:10:17.600I'm simply summarizing from their promotional materials to investors.
00:10:21.120And Adam knows more about this than me.
00:10:23.060Some of what I've learned has been through his reporting.
00:10:25.820But the backlash was severe, unlike anything I've encountered previously in my career.
00:10:34.580That, you know, bringing to light that the backlash is really a big part of the story here.
00:10:41.080Under what circumstances do scientists who have no evidence to support what they're advocating for jump aggressively on someone who's raising, in our case, myself and my co-authors, reasonable grounds for concern?
00:10:56.760How much is this program going to cost per year?
00:10:58.980And importantly, there are several concerns, but what's the exit strategy?
00:11:03.640If we succeed in engaging disaffected, disenfranchised people, remember, safe supply is not a treatment program.
00:11:10.720It's framed as a way of engaging people who are alienated from care.
00:11:18.840And there's a flat refusal to talk about it.
00:11:21.140And it sounds perhaps cynical to say this, but I believe there's a deliberate refusal because the entire profit motive hinges on perpetuating people's suffering so they remain good customers.
00:11:31.940You've touched on, I think, an important aspect of this, which is the motivation.
00:11:37.400And I wanted to bring you in on this, Adam, because I do feel there's been a fair bit of mission creep on harm reduction itself.
00:11:45.060I remember originally when we were talking about insight in BC many years ago, and there were obviously some concerns about that.
00:11:52.860A lot of the argument for just supervised injection sites, not providing supply, which at the time I think would have been seen as insane.
00:12:00.940But the arguments in favor of it were that, OK, we bring people into a space where we can then give them the resources to get clean and get off drugs.
00:12:09.620There was always that, whether it was honest or not, there always seemed to be this idea that if we bring people into the system, so to speak, we can work with them and help them get off drugs.
00:12:18.940With safe supply, I don't hear those arguments anymore.
00:12:21.940And maybe I've missed something, but it actually, to me, strikes me as though they're giving up on that idea of trying to fight addiction.
00:12:30.120And I don't know if that's an accurate read on my part, Adam.
00:12:32.700Like, what is the stated purpose of this program?
00:12:35.940Well, I mean, we have to keep in mind that there are different stakeholders who have different motivations.
00:12:40.980So there's one part of this camp which is ideologically motivated by this idea that drug use is a right, that you can use drugs safely, that harms associated with drug use come from the criminalization of these drugs, not from the drugs themselves.
00:12:56.340And for these people, they don't think it's a problem if someone is chronically using opioids.
00:13:08.560And they espouse this kind of strange strain of libertarianism that prioritizes the individual liberty of the drug user above all else, including community good, right?
00:13:20.060And so we see that now where we aren't allowed to criticize people for being addicted to, you know, various drugs and harming others because that's imposing on their right to use drugs euphorically.
00:13:34.100Now, there's another group of stakeholders who seem to be more profit-oriented.
00:13:37.860And as Julian mentioned, there are definitely companies that are looking to make quite a bit of money off of this.
00:13:45.080So one thing that I became aware of earlier in the year was the existence of a new company known as the Safer Supply Streaming Corporation, which is currently seeking investors so that it can capture the entire value chain of Safer Supply.
00:14:00.100Basically, the people who are leading this program are people who have had a history of monetizing on psychedelics and cannabis.
00:14:09.840So they're looking at this in a sort of recreational lens, not like an addiction treatment lens.
00:14:17.460I think it's concerning that for-profit actors are coming into this space with no real background in addiction medicine and seem to be conceptualizing opioids and cocaine as like one big party.
00:14:31.720Now, you have these two poles, and you also have people who are a little bit in the middle.
00:14:36.420And one example here would be, let's say, Perry Kendall, who was the former public health officer in BC.
00:14:41.840So in his capacity as a public health officer, he declared the opioid epidemic to be a public health crisis, which then allowed for changes in the policy environment in BC to allow for the approval of therapeutic use of heroin and the importation of heroin without getting, you know, seeking approval from the federal government.
00:15:02.300After he advocated for all of these changes, he then went on to create a for-profit company known as Fair Price Pharma, which, you know, coincidentally specialized in importing and producing heroin.
00:15:16.440And then he received a contract with the federal government to do just that, which is very questionable.
00:15:21.600I mean, there seems to be a very strong conflict of interest here.
00:15:23.740Now, from my conversations with other people who are involved in this space, it seems like he is genuinely concerned about the well-being of people who are in addiction.
00:15:34.100But at the same time, one has to wonder how pure can his motives be if he's starting a full-profit company?
00:15:40.360As another example, you have Dr. Evan Wood, who founded the BCCSU, the British Columbia Central on Substance Use, which is very influential in the addiction policy space.
00:15:49.120And when he was running that organization, they accepted dollars, they accepted funding from cannabis companies, and then produced low-quality research, which suggested that cannabis would be an adequate response.
00:16:01.660Cannabis consumption would be an adequate response to opioid addiction, research that completely contradicted higher-quality studies being produced elsewhere in Canada.
00:16:10.180And then afterwards, he left the BCCSU and then accepted a high-paid position at a cannabis company, which I think should raise a lot of eyebrows here.
00:16:20.580So you see this habit of harm-reduction leaders having very few scruples about accepting for-profit positions where they monetize off the consumption of drugs.
00:16:32.660And I think that any Canadian should be concerned about that.
00:16:35.100Well, I know money is a very powerful force, and even in academia, money is tied to research grants, and sometimes there's no money in researching one thing, but there is in researching something else.
00:16:46.920But just to go back to the story you told about your own shift on this, Dr. Koivu, you were not one of these evil, maniacal profit-seekers when you thought this was in the best interest of patients.
00:16:57.480And looking around at your colleagues in medicine now that still very much believe in safe supply, which of those camps, to use the categories that Adam set out, do you think most of them fall in?
00:17:12.440Or are they people that, you know, maybe they're not ideologues, but they genuinely believe that's where the science is leading?
00:17:17.300I think that it's a tough question, Andrew, because just to really know someone's motive can be a bit tricky.
00:17:26.220I think that what I'm seeing, my perspective would be that a lot of the people in this area, for example, are ideologues, and that they really, it's become something they believe in.
00:17:39.700And at the, without sort of like believing in it so much that they're not seeing the downsides, sort of like seeing your child and not seeing the harm that they could do, that they don't want to see the harm.
00:17:55.300But having said that, the programs are receiving millions of dollars in funding.
00:18:03.460So even if that's not something that people take home with them, there can be lots of reasons to want to keep that kind of funding for your organization that isn't directly profit-seeking.
00:18:15.160But with that million dollars, I think it's really important, you know, there, I think it was $6 million for the program in London.
00:18:21.980None of that covers the cost of the drugs.
00:18:25.300So I'm not exactly sure what cost it covers, but it doesn't cover the cost of the drugs.
00:18:37.780So profit, so any amount of funding from the federal government doesn't really cover the cost of the program.
00:18:45.980But that funding for an organization like a community health center is really important funding.
00:18:52.420So I don't know how much is motivated by a sort of desire to keep that kind of funding, even if that's in the context of a belief that that funding will help people and help the organization.
00:19:06.080So I think it's very complicated, but I also think it's really interesting how hard it's been to express any concerns about the program.
00:19:20.680I've never felt, I was a very quick adapter of being critical of Purdue.
00:19:26.680I gave talks before it was the thing to do.
00:19:31.420And every time I gave a talk, I would start by criticizing Purdue.
00:19:35.960And I remember being asked if I was worried about Purdue.
00:20:27.300I think the other thing that I want to make sure gets out there is that increasing more opioids has done nothing to decrease fentanyl, which is illicit fentanyl, toxic fentanyl.
00:20:45.320So and the goal that is now claimed is that it's to be a safer alternative to toxic fentanyl.
00:20:54.480It's increased fentanyl in London and increased overdose deaths in London.
00:20:58.460It's increased hospitalizations and ED visits in London.
00:21:02.560And looking at diversion hasn't been part of what the programs have done.
00:21:08.880But looking at specifically just looking at the kind of goal of decreasing toxic fentanyl, once people become addicted to an opioid, to get the same effect, they either have to take more of it or something stronger.
00:21:23.660And what I'm seeing over and over again are people that have started with safe supply or started with diverted opioids that then progress to using fentanyl.
00:21:35.760So if anything, I'm finding that it is absolutely worsened the fentanyl crisis in our area.
00:21:41.860Well, that's the yeah, let's go ahead, Adam.
00:21:45.560Yeah, I just want to make a point of clarification for listeners who aren't aware of why safe supply doesn't dissuade people from using fentanyl.
00:21:53.620So safe supply programs in Canada predominantly distribute hydromorphone, which is an opioid which is roughly as potent as heroin, if not more potent.
00:22:01.060And that's dangerous for someone who's opioid naive.
00:22:04.620However, fentanyl is at least 10 times stronger than that, which means that for a fentanyl user that because of their high tolerance, hydrolofen doesn't actually do anything for them.
00:22:14.260At most, it manages their withdrawals, but it doesn't give them the euphoric high that they crave.
00:22:18.740So the actual premise of safer supply, that these drugs are an actual substitute for fentanyl, doesn't check out at all.
00:24:10.380Um, and we have, you know, like it's, it's a bit of an embarrassment that we're producing clinicians who reflexively draw a comparison between, um, untreated addiction and diabetes.
00:24:21.260There's, there's no one in the clinical literature who has decided through a force of frustration and will to quit diabetes, right?
00:25:14.500And nothing, because nothing has changed in neighborhoods like the downtown east side of where I live and in others,
00:25:20.140clinicians have gone there and seen, well, this is like nothing changes here.
00:25:24.560That's not because the people are incapable of change.
00:25:27.240And that's one of my biggest frustrations is we've had the opportunity in Canada.
00:25:31.500At Home Chaisois was a multi-site randomized control, several randomized control trials that, that aimed to investigate if people deemed the hardest to house in, in different regions of the country could in fact experience wellness.
00:25:47.660The answer is a resounding yes, with crime reduction, with reductions in medical emergencies, improvements in quality of life, and social reintegration.
00:25:58.860Portugal had already shown the possibility at the population level because their whole plan revolves around social reintegration.
00:26:06.660That's a core construct in their national strategy, the 2000 national strategy, social reintegration.
00:26:13.420Now, having committed to that goal and realizing all of the improvements that they did over the next decade, it's important to note they did it without a single drug consumption site.
00:26:24.460The harm that's addressed by consumption sites includes not having safe places to live, being on the street and exposed to predation and violence.
00:26:34.380If one is committed to addressing those harms by providing people with safe places to live, you don't need consumption sites.
00:26:42.040So it's not a matter of, are you for harm reduction or against harm reduction?
00:26:45.800It's about how should we best reduce the harms that are associated with drug use in our population?
00:26:51.800Portugal remains, I think, a real important test or learning opportunity for us, a natural experiment.
00:26:59.660They built on the experiences in Switzerland and England before in previous decades.
00:27:04.040So there's there is a volume of evidence that hangs together, both from other countries and experimentally in Canada that we're turning our backs on.
00:27:13.920And the result is people who have who are not aware of that literature making decisions.
00:27:22.280And as Adam said, you know, often with the with good intentions, we also have this weird dynamic where, look, addictions are are diagnosed as mental disorders.
00:27:34.040At their core, they involve an agonizing frustration around loss of control.
00:27:41.260It's the loss of one's own control to influence behavior that is resulting in harms to oneself and often to others as well.
00:27:49.820And that's that's a core dynamic in what we refer to as harmful addictions and why and why they are so why they create such strong mental suffering.
00:28:02.320And so we have this weird dynamic where we're asking people who are likely experiencing addictions, a loss of control over behavior that causes harm to them if they would like publicly funded drugs to be provided.
00:28:20.780Well, they have not had much reason to think that effective treatment is available or that there are ways in which they can gain greater control.
00:28:33.320And so, of course, they say, yes, of course, that would be beneficial.
00:28:37.460That would be an improvement over what they're currently doing.
00:28:41.080We should be asking them, would you like access to the same resources that restore control that have been available to physicians who experience addictions for decades or airline pilots or in B.C., public servants?
00:28:57.360Yes, because all of those groups and wealthy people, because all of those groups have access to forms of addiction treatment that focus on the psychological and the social and that preclude use of drugs, at least in the short term, and they are highly effective.
00:29:12.820If, on the other hand, you are poor in Canada, there is no way for you to get access to psychological and social supports addressing addiction and all we provide are drugs.
00:29:27.980Any leader who says safe supply is about stigma reduction doesn't know the meaning of the word stigma because it is the definition of responding differently to two groups in the population based on how they look.
00:29:43.620If you look like a doctor, if you look like a public servant, an airline pilot, a safety sensitive employee, we want to take care of you.
00:29:51.260We want you to have control of your life back.
00:30:06.260Now, that's a fascinating and quite upsetting analysis there.
00:30:10.860And when you talk about housing, one tweet that I wanted to bring up at some point in the show is that it illustrates that when you have one problem, it starts to skew your way of dealing with other problems.
00:30:24.240And this is a tweet from a Toronto community worker that I think is involved with some of these organizations that are in the harm reduction space.
00:30:31.580And she writes, meth is a smart way to stay awake and avoid assault or theft on the street or in a shelter.
00:30:38.000This is someone who is looking at meth, which has destroyed people's lives and done so much damage and saying, well, this is actually a thing that will help you avoid being raped or assaulted or killed if you live in a shelter because you don't have a home.
00:30:54.900So it strikes me that the problem here is actually the maybe we should make sure that either shelters are safer or that people have a safe place to be and not use meth as a harm reduction tool.
00:31:07.820And again, I'm extrapolating a fair bit from one tweet here, but it's that these problems are, as you say, Dr. Summers, very interconnected here.
00:31:15.380And I just want to make a point that we've been talking about this and nowhere in this discussion has there been anything unsympathetic to people with addiction.
00:31:23.840It's not looking at them. No one's saying we need to lock them up.
00:31:26.700And I think often in a political context, that's what people try to reduce this thing to, which is, you know, you're either anti-addicts or you're pro-harm reduction, which is not at all the case here.
00:31:37.880We are out of time, but I just want to give the last word to you on this, Dr. Koivu, because when we are talking about, you know, the stigma issue here and the idea of treatment,
00:31:48.920is there a viable model that you've seen to get us where we need to go?
00:33:24.600That can't be where you get those services.
00:33:27.660We need to have an integrated approach.
00:33:29.840We need to have an accessible, rapid access, good integration.
00:33:33.980We need to look at what really happened in Portugal, not how people are translating the decriminalization to justify things that weren't Portugal's experience.
00:33:45.860We need to look at what Alberta is doing.
00:33:48.160We need to look at what really has been done in Switzerland and recognize the harm that we're doing
00:33:58.500and not be afraid to recognize the harm, both to the individual involved, that we're keeping, we're locking into an addiction.
00:34:06.820And the community, and really look at why are there so many more encampments in London?
00:34:13.920And why are just, you know, adding hubs, I mean, might be a short solution.
00:34:19.560But as long as we're creating an environment in which people want to be in the core, want to be near the diverted drugs,
00:34:25.380whether they were housed from another community and are coming into London to get the diverted drugs,
00:34:31.400we have to be looking at the source of the problems we're creating and stop the flood of that problem as we're creating an integrated approach.