For almost a decade, British Columbia has been in the grip of a devastating overdose epidemic, exacerbated by an increasingly toxic unregulated drug supply. In 2016, the province declared a public health emergency as overdose deaths surged, driven primarily by the rise of fentanyl in the drug market. As of 2023, the situation shows no signs of improvement, with over 38,500 overdose deaths reported across Canada since 2016. In response, BC introduced various harm reduction policies, including safer supply programs, aimed at mitigating the overdose crisis. But as these measures unfold, questions arise about their implementation, effectiveness, and the broader implications for public health.
The Role of Safer Supply in Harm Reduction
One of BC’s more innovative responses to the overdose crisis has been the introduction of Risk Mitigation Guidance (RMG), which allows healthcare providers to prescribe pharmaceutical alternatives to toxic street drugs. RMG, introduced in March 2020, was developed as a means of reducing the risks associated with the dual public health emergencies of COVID-19 and overdose deaths. The aim was to provide safer, regulated alternatives to the highly toxic unregulated drug supply that had caused so many deaths in the province.
Safer supply programs are not new but were rapidly expanded during the pandemic. These programs provide prescription opioids, stimulants, and benzodiazepines to individuals at high risk of overdose, offering a regulated alternative to dangerous street drugs. The goal is to reduce illicit drug use, prevent overdoses, and engage people in healthcare services. Unlike traditional opioid agonist therapy (OAT), safer supply programs focus on harm reduction rather than solely on abstinence or recovery.
But the question remains: are these programs working? And if so, are they being implemented widely enough to make a significant impact on the crisis?
Concerns About Overprescribing and Professional Scrutiny
One of the main barriers to broader adoption of RMG has been concerns over the potential for overprescribing. Healthcare providers remain wary of increased scrutiny and the possibility of audits, particularly in the context of a public discourse that often links prescription opioids with the overdose crisis.
This fear is not unfounded. The first wave of the opioid overdose epidemic in North America (1999-2015) was linked to the overprescribing of pharmaceutical opioids. In response, BC and other jurisdictions introduced stricter prescribing guidelines, which have since led to a significant reduction in opioid prescriptions. However, this reduction also led to unintended consequences—many individuals who were dependent on prescribed opioids turned to the unregulated drug market when their prescriptions were tapered or discontinued. The shift from prescription opioids to street fentanyl has been identified as a major driver of the current overdose crisis.
The College of Physicians and Surgeons of BC (CPSBC) introduced guidelines aimed at reducing opioid prescriptions in 2016, contributing to a culture of cautious prescribing among healthcare providers. Despite RMG’s aim of addressing the overdose crisis by providing safer alternatives to street drugs, many physicians remain hesitant to fully embrace the program due to fears of being seen as overprescribing. In 2020, CPSBC reinforced this by advising prescribers to be cautious, even as they encouraged adherence to RMG during the pandemic.
Rural and Remote Challenges
Although RMG was introduced as a province-wide policy, the uptake has been largely concentrated in urban centres like Vancouver and Victoria. According to a study evaluating RMG implementation, prescribing safer supply has been limited, with just a fraction of BC’s healthcare providers actively engaging in the program. This is especially true in rural and remote areas, where access to prescribers and harm reduction services remains scarce.
Of the 13,672 healthcare providers eligible to prescribe opioid use disorder (OUD) or substance use disorder (SUD) medications in the two years prior to March 2020, only 612 prescribed RMG medications within the first six months of the program. Most of these prescribers were located in urban centres, leaving large portions of the province underserved. This urban-rural divide highlights a critical gap in the accessibility of safer supply programs—a gap that leaves many individuals in more remote areas at continued risk of overdose.
Nurse Practitioners (NPs), particularly those with experience in opioid agonist therapy (OAT), were three times more likely to prescribe RMG than general practitioners (GPs). This disparity suggests that specialized training and experience in treating substance use disorders are key to increasing the program’s reach. However, given BC’s healthcare shortages, especially in general practice, the province faces challenges in scaling up safer supply beyond its urban centres.
Balancing Harm Reduction and Public Concerns
While RMG and safer supply programs have shown promise in reducing overdose risk, their implementation has raised concerns about potential drug diversion. Critics argue that by prescribing opioids and other substances to individuals with substance use disorders, healthcare providers risk enabling a secondary market for these drugs.
However, studies from both BC and internationally show that the benefits of providing safer supply far outweigh the risks of diversion. In Switzerland, for instance, the distribution of heroin through regulated programs during the pandemic improved quality of life for participants without increasing overdose rates or evidence of diversion. In BC, early data indicates that hydromorphone, the most common opioid prescribed under RMG, has been linked to less than 4% of overdose deaths, while fentanyl remains the primary driver of fatalities.
For many prescribers, diversion is a form of harm reduction in itself. Individuals who share or sell their prescribed medications often do so to help others avoid the toxic street supply. Moreover, diversion helps generate income for basic necessities like food and shelter, further underscoring the socioeconomic factors at play in substance use.
Nonetheless, diversion remains a contentious issue, and public concerns about increasing exposure to addictive substances, especially among youth, have hindered the wider adoption of safer supply programs.
Downtown Eastside Shows the Limits of BC’s Drug Policies
Vancouver’s Downtown Eastside (DTES) has been at the epicentre of BC’s overdose epidemic for years. This neighbourhood, known for its high rates of homelessness, poverty, and drug use, has long been a testing ground for harm reduction strategies, including the introduction of supervised injection sites and safer supply programs.
In the DTES, safer supply has been seen as a lifeline for many individuals who would otherwise be relying on fentanyl-laced drugs from the unregulated market. Programs like RMG have allowed healthcare providers to prescribe safer alternatives, keeping many people alive and engaged in care. Yet, despite these interventions, overdose deaths in the DTES continue to rise, raising questions about the limits of harm reduction in addressing the root causes of addiction and poverty.
While harm reduction services like safer supply are essential, they do not address the broader societal issues that contribute to the overdose crisis. The ongoing housing crisis, lack of mental health services, and deep-rooted poverty in areas like the DTES mean that many individuals remain trapped in cycles of addiction, with no clear path to recovery.
Does British Columbia Need a Shift in Drug Policy?
British Columbia is at a crossroads in its fight against the overdose crisis. While the safer supply program has provided some immediate relief, it’s time to question whether it’s the right path forward. The province must strike a balance between harm reduction and addressing the root causes of addiction.
The solution to the overdose crisis isn’t just about replacing toxic street drugs with pharmaceuticals. It’s about creating a society where people have access to the support they need—whether that’s mental health care, affordable housing, or job opportunities. Only by addressing these underlying issues can BC hope to make a lasting impact and bring an end to this devastating crisis.
It’s clear that the conversation around safer supply and harm reduction needs to continue. The stakes are too high, and the costs—both human and societal—are too great to ignore. BC’s government must take a hard look at its policies and ensure that it is not just reacting to the crisis but proactively creating a healthier and more supportive future for its most vulnerable citizens.
DOWNTOWNEASTSIDE.ORG is a collective author account used by several DTES contributors to discuss key issues and events in the neighbourhood. Articles under this authorship reflect diverse perspectives from those directly connected to the community. If you’d like to reach a specific contributor, please contact us via email.
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