SBS Seminar: “Addressing the Overdose Crisis Through Safe Supply”
April 14, 2021Ryan McNeil, Ph.D
Associate Professor, Yale School of Medicine
Director of Harm Reduction Research, Program in Addiction Medicine
April 13, 2021
Information
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- 6437
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- DCA Citation Guide
Transcript
- 00:02<v ->All right, welcome everyone.</v>
- 00:04Let's go ahead and get started.
- 00:06So it is my pleasure to introduce our speaker for today,
- 00:10Dr. Ryan McNeil.
- 00:12Dr. McNeil is an Assistant Professor,
- 00:15was joining appointments at the Yale School of Medicine
- 00:18and also here at the Department of Social
- 00:20and Behavioral Sciences at Y.S.P.H.
- 00:23He is teaching a course on Harm Reduction this semester
- 00:27which many of you might be taking.
- 00:30Dr. McNeil received his PhD
- 00:32from university of British Columbia.
- 00:34And he joined the Yale Faculty in December, 2019.
- 00:40Dr. McNeil's research exams to Social Structural
- 00:43and Environmental Influences
- 00:45on the Implementation and Effectiveness
- 00:48of Harm Reduction and Addiction Treatment Interventions.
- 00:52He also studies the Influence of Housing
- 00:55and Housing Based Interventions
- 00:57and overdose related risk.
- 01:01He is the principal investigator on multiple grants,
- 01:04both from N.I.H
- 01:05and from the Canadian Institute of House Research.
- 01:09And he's also the co-creator
- 01:11and scientific lead of Crackdown.
- 01:14So this was a Podcast launching January, 2019
- 01:18and it is designed to mobilize research
- 01:20and amplify The voices of people who use drugs.
- 01:25This media collaboration has been called a podcast
- 01:28most likely to save lives,
- 01:30and he has received a number of awards
- 01:33including the Third Coast International Audio Festivals
- 01:38on the Radio Impact Award,
- 01:41the Canadian Hillman Prize and a Silver Medal
- 01:43from New York FestivalS Radio Awards.
- 01:46So without further ado, let's a welcome Dr. McNeil.
- 01:52<v ->Hi everyone, Katie, thanks for very kind introduction.</v>
- 01:56It always reminds me that I feel like I need
- 01:58to update my Faculty page.
- 01:59So it has like a tighter description of the things
- 02:03that I do 'cause it always feels a little bit much
- 02:07which is to say I'm just really happy to have you all here
- 02:10and present on both the broader concept and idea
- 02:14of safe supply in the context of the overdose crisis.
- 02:17And talk about some of the work
- 02:18that we've been doing.
- 02:20Looking at this, this might be new to some of you,
- 02:22so please don't hesitate to ask questions.
- 02:25I'll try to leave ample time at the end,
- 02:27and please bear with me in the clunkiest
- 02:32of presenting formats.
- 02:35I can't be the only one who's looking forward
- 02:37to doing talks in person again.
- 02:51Great, so a few notes as I get started,
- 02:56a lot of the discussion will focus on work
- 02:58I've been engaged with in Vancouver, Canada
- 03:01which is both where I moved here from
- 03:03and where I continue to run a range of different projects
- 03:06that are examining the Implementation
- 03:08of safe supply and its role in responding
- 03:11to the overdose crisis.
- 03:13I'll spend a bit of time conceptualizing the overdose crisis
- 03:18as well as getting into some of the specific dynamics
- 03:21worth considering as we move into
- 03:24frankly a period of severe overdose related morbidity
- 03:29and mortality.
- 03:35A lot of the work and thinking about safe supply
- 03:38for me really comes out of this particular space
- 03:41which is the Washington Needle Depot which became the Molson
- 03:46or the Maple Overdose Prevention Site
- 03:48in Vancouver, Canada's Downtown Eastside.
- 03:51And really it was the beginning of 2017
- 03:55as the city was grappling with a severe overdose crisis.
- 03:59When you know, longstanding ideas of drug legalization
- 04:04and alternatives to an illegal drug supply,
- 04:08increasingly characterized by fentanyl and other adulterants
- 04:11began to really percolate in the community
- 04:14and become a topic of discussion
- 04:16as people sought out alternatives
- 04:18to increasingly toxic drug supply that was killing people.
- 04:23So during field work in work that I do primarily
- 04:26as an ethnographer at this site,
- 04:30both people involved in operating it
- 04:32as well as others visiting the site
- 04:34began to talk a lot about the need for alternatives
- 04:37and the need for a safe supply.
- 04:39And this was very much aligned
- 04:41with other discussions that were happening
- 04:43in Circles of Drug-User Activists in the community
- 04:49which has a longstanding history of drug user organizing.
- 04:52That's been critical to advancing Drug Policy Reform
- 04:56both in Canada and globally,
- 04:58including the implementation of supervised consumption sites
- 05:01and other interventions.
- 05:03Now I'll get into this a little bit later,
- 05:06but that the city has also been home
- 05:08to several clinical trials
- 05:11for advanced treatment options for opioid use disorder
- 05:14including a heroin prescription heroin trial
- 05:19and an injectable hydromorphone trial
- 05:22that further prime the community
- 05:24for discussions of alternatives
- 05:26to a toxic drug supply and available treatment programs
- 05:32that weren't were meeting people's needs.
- 05:35And so this began to become more pronounced
- 05:38with an Activist Circles and really
- 05:40became a bit of a rallying cry as the community was impacted
- 05:45by just an incredible level of loss
- 05:48in the wake of a sustained overdose crisis.
- 05:56It really raises I think three interlocking questions,
- 05:59really the heart of what I wanna touch on today
- 06:02which is effectively, why were so many people dying?
- 06:05What is safe supply,
- 06:07and how does it address the overdose crisis?
- 06:15And so certainly there's broader narratives
- 06:19in terms of how we think about the overdose crisis
- 06:21that become dominant,
- 06:23that in kind of relatively straightforward waves
- 06:31of prescription opioids, onto heroin, onto fentanyl
- 06:34onto now psychostimulants and other drugs.
- 06:40But it's always been a little bit messier than that.
- 06:44And the period I'm really gonna concentrate on
- 06:46is kind of this period of fentanyl and other adulterants
- 06:51within the supply.
- 06:52And certainly as folks are likely aware,
- 06:56fentanyl has been associated with a rapid escalation
- 06:59of the overdose crisis across North America
- 07:01as a more potent opioid that is becoming a primary driver,
- 07:07well is long the primary driver
- 07:10of overdose deaths in North America.
- 07:16And really, what are my early orientations
- 07:20to the scope and severity of fentanyl
- 07:23happening alongside field work that we were doing?
- 07:26So running studies out of an area
- 07:28with really one of the most severe
- 07:32fentanyl driven overdose crises
- 07:34was certainly an experience of, you know,
- 07:38doing the work against the backdrop
- 07:39of profound loss and this grappling
- 07:42with what was happening in the community.
- 07:44Early on, as we were doing and running studies
- 07:47and doing other work engaged with folks
- 07:49who use drugs in the community,
- 07:51there was certainly this tectonic shift
- 07:52as we all started to really grapple with what was happening
- 07:55as fentanyl became more prominent within the drug supply,
- 08:01and it became the dominant illicit opioid within the supply.
- 08:06First being sold kind of as heroin
- 08:08then outright displacing heroin within the local supply.
- 08:14And so it really struck us early on,
- 08:16at first we were just losing people.
- 08:20I remember a study we were operating at that time
- 08:23that involve follow-up interviews with folks
- 08:26who had lost their housing to eviction.
- 08:29And, you know, effectively
- 08:33we quickly realized that this was happening
- 08:35as the shift was happening and we couldn't find people.
- 08:38And then it quickly dawned on us that, you know,
- 08:40they were people who we were losing to this rapid spike
- 08:43that was happening in overdoses in the community.
- 08:48And it was fundamentally different.
- 08:50And so we commonly encountered people who would put it
- 08:55really as such.
- 08:57You know, with heroin you feel it coming on,
- 08:59you feel the intensity, you feel like you're gonna puke.
- 09:02You know, keeps coming, and you know,
- 09:05I'm going to go down.
- 09:06Fentanyl, you're sitting there waiting for something,
- 09:09and the next thing you know,
- 09:10there's an ambulance attendant there
- 09:12it hits you like a Mac truck.
- 09:13You don't feel it, nothing just boom, down.
- 09:17You get up and swear that you didn't even do your shot,
- 09:19you're looking for it.
- 09:21And so this certainly for me,
- 09:24always perfectly summed up that this transition
- 09:27from, you know, a community that long been impacted
- 09:30by a high level of overdoses within the context
- 09:35of a very kind of contained drug scene
- 09:38to suddenly something completely different,
- 09:41and, you know, the comparison of
- 09:43it hits you like a Mac truck
- 09:45really felt like what happened to the whole community.
- 09:48And then this certainly was consistent
- 09:51with what was happening across North America at this time.
- 09:54So in the United States, you know,
- 09:57you'll notice this graph from the C.D.C
- 09:59that gets circulated,
- 10:00and I think I see in every presentation
- 10:02on the overdose crisis at this point.
- 10:05When you see this orange line,
- 10:09the begins to take off in, in 2015
- 10:12and really becomes the dominant
- 10:14and still more recently further dominant
- 10:18cause of overdose deaths.
- 10:20But they're just primarily synthetic opioids
- 10:23and specifically fentanyl and fentanyl adulterated drugs.
- 10:28So just in case folks aren't aware
- 10:29fentanyl is effectively a much more potent opioid
- 10:33that's associated with a much higher risk of overdose.
- 10:41And certainly that's been born out by the data.
- 10:44The onset tends to be quicker,
- 10:48they tend to be more severe
- 10:50and it certainly becomes challenging to navigate
- 10:54especially transitional drug supplies
- 10:57wherein fentanyl is replacing heroin or other opioids,
- 11:00or, you know, across a lot of different contexts
- 11:04where, you know, one doesn't necessarily know the potency
- 11:08of fentanyl from one package to the next when using.
- 11:15And so fentanyl, you know, certainly has become
- 11:18this key driver of the overdose crisis.
- 11:21And so if we think about Canada,
- 11:23where I'm gonna really kind of concentrate on a bit,
- 11:28you know, we similarly see, so, you know,
- 11:31this is a graph depicting total opioid related deaths
- 11:37by opioid type.
- 11:41And you'll certainly notice that, you know,
- 11:43more and more over time,
- 11:45these are dominated by fentanyl
- 11:48and other fentanyl related analogs
- 11:51that can be even more potent.
- 11:55And then certainly
- 11:56because I think it bears specific attention,
- 11:59especially within a policy context
- 12:00wherein discussions of the overdose crisis
- 12:03still remain dominated by an emphasis on pharmaceutical
- 12:07or prescribed opioids
- 12:08which we're gonna flip a little bit here.
- 12:12Did the majority of deaths in Canada has elsewhere
- 12:15certainly are driven by, you know,
- 12:18non-pharmaceutical opioids,
- 12:20even if used in combination.
- 12:26So as this has happened,
- 12:28and I mentioned these framing pieces,
- 12:32you know, early attention to the overdose crisis
- 12:35in North America is really emphasized
- 12:39and it happened alongside this period
- 12:40of declining life expectancy among white folks.
- 12:45And certainly it became a dominant narrative.
- 12:50This was very much driven by, you know,
- 12:53the overdose crisis and deaths of
- 12:55what became term deaths of despair, you know.
- 13:00And this really configured a set of policy responses
- 13:03that were distinct from more traditional
- 13:05war on drugs approaches even as those continued to dominate.
- 13:10But also frankly, is obscured the severe impact
- 13:13of the overdose crisis on communities of color.
- 13:17Certainly, you know, it's really no longer the case
- 13:21that deaths among white folks and in the U.S
- 13:26far exceed those of other folks.
- 13:29And in fact, among people of color,
- 13:32overdose rates are rising quite dramatically
- 13:36and among indigenous folks remain incredibly high
- 13:39and in fact the highest of any population.
- 13:42And so I think, you know, this is just a point
- 13:45to emphasize because we'll cycle back to this
- 13:47in that when emphasizing, you know, deaths of despair,
- 13:51it's to foreground that the broader range
- 13:53of structural inequities that certainly drove to some extent
- 14:00heightened overdose mortality
- 14:01among specifically poor white folks.
- 14:04These have had longstanding
- 14:06and severe disproportionate impacts on communities of color.
- 14:11So things from policing to impacts of hosing
- 14:14and equities and vulnerabilities, poverty, et cetera.
- 14:22So I mentioned the specific research context
- 14:24I'm gonna be focusing on is in Vancouver, Canada.
- 14:29So Vancouver is located in British Columbia, Canada.
- 14:32And it's commonly, you know, when you hear about Vancouver,
- 14:35you frankly commonly hear about, you know,
- 14:38two things at this point.
- 14:39One is frankly, a severe overdose crisis,
- 14:43but it's long been characterized
- 14:45as one of the world's most livable cities.
- 14:47Kind of nested between the Pacific ocean and the mountains
- 14:53and in the Pacific Northwest it's, you know, beautiful.
- 14:59And that framing it's really overlooked the extent
- 15:01to which it's also a site of extreme social
- 15:04and structural inequalities.
- 15:07So the profits itself underwent a relatively rapid shift
- 15:12in the illicit drug supply.
- 15:13And it's long had a sustained heroin scene
- 15:19really stretching back decades.
- 15:21And, you know, effectively what we saw in really, you know,
- 15:27catalyzing in 2015,
- 15:29was the gradual replacement of heroin by fentanyl.
- 15:35First being sold alongside fentanyl,
- 15:38adulterated within fentanyl and then, you know,
- 15:41later becoming what one would just expect to find
- 15:45when purchasing illicit opioids in that context.
- 15:51And so this rapid escalation in overdose deaths
- 15:54led to the declaration of a public health emergency,
- 15:58which later created basically a pathway
- 16:00for the further scale-up of overdose prevention
- 16:04and response interventions.
- 16:06So Vancouver had long been side of, you know,
- 16:10I mentioned these trials looking at injectable opioids
- 16:14as an option for folks with opioid use disorder
- 16:17on through to supervise consumption
- 16:19or overdose prevention sites.
- 16:23And this emergency situation allowed these
- 16:26to be further scaled up.
- 16:27So we saw the rapid implementation, so sorry.
- 16:30So these are largely clustered in the Downtown Eastside
- 16:33which is see this bar of people always covers
- 16:37what I'm trying to find.
- 16:40This darken neighborhood toward the top of the map,
- 16:47which is about a 10 by 10 block neighborhood
- 16:50and the side of a lot of these interventions
- 16:52that I'll be speaking of.
- 16:58So this emergency order, you know,
- 17:00first activists began pushing for the opening
- 17:04or outright opening interventions
- 17:05including supervised consumption sites
- 17:08as part of the response,
- 17:09which are sites where people could use pre obtained drugs,
- 17:15which were later scaled up
- 17:17under the authority of the Province.
- 17:22Further involved the scale up
- 17:24of injectable treatment options
- 17:28and fentanyl testing strips and drug checking technologies.
- 17:35We saw the extension of these interventions
- 17:37into a variety of settings.
- 17:39So this is a shot of an emergency shelter
- 17:42that had adapted supervised consumption approaches
- 17:44into its setting to increase safety for folks staying there.
- 17:50And yet, even as these interventions were scaled up
- 17:53and, you know, public health modeling
- 17:56and other data showed a significant positive impact
- 17:59on overdose mortality.
- 18:03High rates of overdose is still persistent.
- 18:08Now certainly a large part of this
- 18:12was just the extreme shift within the drug supply
- 18:18and, you know, the fact that fentanyl
- 18:21had become the dominant opioid, later other adulterants
- 18:26entered the supply for sporadically
- 18:28and then more regularly from a tassel land
- 18:31periodically synthetic cannabinoids to occasionally Xylazine
- 18:35which is a tranquilizer.
- 18:39So there was this complex kinda mix within the local supply.
- 18:43Now, certainly a range of structural factors
- 18:47continued to drive overdoses
- 18:49in the setting, which we've looked at extensively.
- 18:53Things like policing strategies,
- 18:55which rocked in place-based and displaced people
- 18:58from overdose prevention and response interventions,
- 19:01high levels of poverty, which, you know,
- 19:05impact people's ability to manage drug use
- 19:08within the context of prohibition
- 19:11and can be a particularly dangerous mix
- 19:13in the context of a very toxic drug supply.
- 19:18On through to a range of other inequities
- 19:21that drive overdose related mortality.
- 19:26And so within this backdrop, I really cycle back
- 19:29to some of those early conversations
- 19:30that were happening within Activist Circles
- 19:32and in the sites where people
- 19:33were accessing safer places to use
- 19:36as the drug supply went sideways,
- 19:39and that was a push for safe supply.
- 19:42And so at its most basic level, you know,
- 19:45safe supplies laid out wonderfully in this concept document
- 19:49by the Canadian Association of People who Use Drugs
- 19:52which is effectively the safe supply
- 19:54refers to illegal unregulated supply of drugs
- 19:57with mind or body altering properties
- 19:59that traditionally have been accessible
- 20:00only through the illicit drug market.
- 20:02Drugs included are opioids such as heroin,
- 20:05stimulants such as cocaine and crystal methamphetamine,
- 20:09hallucinogens such as M.D.M.A and L.S.D and marijuana.
- 20:14So effectively, you know,
- 20:17what the concept of safe supply seeks to do
- 20:22is intervene mean to address overdoses
- 20:25driven by supply characterized by, you know,
- 20:29being toxic by fentanyl, high concentrations of fentanyl
- 20:35or other adulterants.
- 20:36By providing people with an alternative
- 20:38in a way that respects their agency
- 20:40and choice in relation to their drug use
- 20:43as well as the variety of ways in which people may use.
- 20:47And so this concept, you know, really came out of
- 20:53and I can't emphasize this enough,
- 20:55the work of Drug User Activists and Organizers.
- 20:59It later got pick up so here's a document
- 21:02that we've worked on at a center
- 21:04that I was asked slash still am affiliated with
- 21:07when we pick up this idea and think about it
- 21:09in the context of Compassion Club Models
- 21:11that could provide people with safer access, you know,
- 21:16and quickly this became part of a larger discussion
- 21:21happening within the academic literature.
- 21:24First as something that has a critical role
- 21:27in addressing the overdose crisis,
- 21:29on through to something that also could address harms
- 21:33driven by escalating stimulant overdoses
- 21:36that include in some cases,
- 21:37those driven by fentanyl adulterated stimulants,
- 21:43on through to, and I think one of the coauthors
- 21:45of this is on this call.
- 21:48On through to something that could play a critical role
- 21:51in responding to an escalation and overdoses
- 21:53that have happened under conditions imposed by COVID-19
- 21:57especially wherein people are injecting alone.
- 22:03And more recently on through to some,
- 22:05an approach that could, you know,
- 22:08rethink the ways in which Drug Policy operates globally
- 22:13and could effectively trace a pathway for redressing
- 22:17some of the harms caused by the war on drugs
- 22:21specifically by involving folks
- 22:23who have been disproportionately impacted
- 22:26by this in production and export to markets
- 22:31with a need for safer pharmaceutical,
- 22:34alternatives and legalize options.
- 22:39And so, you know, by and large,
- 22:41this was really just a concept circulating within circles
- 22:43as people were working behind the scenes
- 22:45as an effort to scale these up.
- 22:48But what they effectively did is extend a longstanding logic
- 22:51that, you know, opioids especially
- 22:55are part of the response to the harms of overdose.
- 23:01So certainly there's a Cochrane review.
- 23:07They really helps to establish the efficacy
- 23:10of heroin maintenance or heroin based treatment
- 23:14for folks who are heroin dependent,
- 23:17as something in this particular review
- 23:20as a kind of add on therapy to methadone,
- 23:24but that cannot reduce engagement
- 23:26with an illicit drug supply.
- 23:29On through to work that is further established
- 23:32its effectiveness in minimizing engagement
- 23:38in what often get characterized
- 23:40as social harms associated with drug use
- 23:46such as engagement in criminal activity, et cetera,
- 23:50and certainly further trial work that is even established it
- 23:54as potentially superior to methadone
- 23:56for the treatment of opioid use.
- 23:58This trial in the New England Journal
- 24:01finding it effectively to be superior for folks
- 24:07who had not previously benefited from methadone,
- 24:09on through to more recent work,
- 24:12through a trial where they compared heroin
- 24:14to hydromorphone further establishing that as an Option.
- 24:19And so effectively, you know, people are bringing up this
- 24:23and pushing for this, this need for a shift
- 24:26toward access to better regulated safer opioids.
- 24:31And so, you know, eventually we saw programs implemented
- 24:35on a pilot level,
- 24:38which is partly what I'll be focusing on
- 24:42based on work that we've been doing.
- 24:44So here you see a shot of an overdose prevention site,
- 24:48the Molson overdose prevention site
- 24:49in Vancouver's Downtown Eastside.
- 24:53And it implemented a program wherein
- 24:55people could be referred in through
- 24:57and were effectively followed through primary care,
- 25:01but could be effectively dispensed two mil, eight milligram
- 25:06tablets of hydromorphone to five times a day
- 25:10during the operating hours
- 25:11of the overdose prevention site,
- 25:13so as to limit their engagement
- 25:16with the illicit drug supply.
- 25:18And so you'll notice this,
- 25:20I don't know if you can see my pointer,
- 25:23but so folks would effectively come into the space
- 25:28through this door above the text box.
- 25:31And you know, this is an open overdose prevention site
- 25:34wherein folks are able to effectively ingest
- 25:38with the exception of by inhalation
- 25:42drugs that they bring in
- 25:44or if registered in this program
- 25:46associate with the Primary Care Clinic
- 25:48could effectively pick up hydromorphone dispense
- 25:52through this nursing window and use onsite.
- 26:00Now, still later further program was implemented
- 26:08really just prior to COVID hitting
- 26:13wherein people could similarly access effectively
- 26:16an equivalent amount of hydromorphone
- 26:19through a still lower threshold method
- 26:22which was effectively, I mean,
- 26:25it's basically a vending machine
- 26:27that takes a biometric reading
- 26:29wherein someone would effectively place their hand
- 26:32on the screen, and then they would be dispensed
- 26:37hydromorphone in accordance with their prescription
- 26:41and dosage schedule.
- 26:44And so this later within the context of COVID
- 26:47and the serious concerns of what, I mean,
- 26:50frankly ended up happening with an escalation of overdose
- 26:54into prescribing guidance documents
- 26:58for the Province of British Columbia
- 27:00to further allow providers
- 27:03to outright prescribe hydromorphone
- 27:07and then also Dexedrine and mesocolon
- 27:10to folks for the purposes of
- 27:13still further limiting potential engagement
- 27:16with a drug supply that, you know,
- 27:18certainly in the lead up to COVID had become even more,
- 27:24I mean, I wanna say erratic,
- 27:25but there's certainly much more direct language
- 27:27I could use to to characterize what was happening.
- 27:31And the deep concern about, you know,
- 27:34an escalation of overdose deaths
- 27:35that you know, frankly has subsequently born out.
- 27:39And so I'm gonna really talk about
- 27:41some of the work we've done, looking at the implementation
- 27:44and effectiveness of these programs for folks
- 27:48drawing on Ethnographic Fieldwork
- 27:50and qualitative interviews.
- 27:52And so that site, the most, an overdose prevention site,
- 27:55implementing the hydromorphone distribution program.
- 27:57So we've done extensive ethnographic fieldwork at that site,
- 28:01including with a specific focus
- 28:02on the hydromorphone distribution program.
- 28:06Observing its operation, spending time around it,
- 28:09interacting with folks, accessing or trying to access it
- 28:12to get a sense of how it both fits
- 28:13into people's daily routines and lives
- 28:17and its impacts on them.
- 28:19And then alongside that,
- 28:20we were effectively interviewing as many folks as we could
- 28:23enroll through that program
- 28:27to get a further sense of its impacts.
- 28:29Now we started these interviews and then COVID hit
- 28:32so our followup rate certainly dropped down.
- 28:36We interviewed 42 of the then 69 folks
- 28:39who had been enrolled in the program
- 28:42and I wanna say we got 16 for followup
- 28:49before suspending activities due to due to COVID.
- 28:52And then alongside that,
- 28:53we've more recently been doing interviews with folks
- 28:56we're at 22 right now, accessing safe supply
- 29:02through the risk mitigation guidelines,
- 29:04implemented post-COVID.
- 29:09And so what really concerned with
- 29:11in this work is how broader factors
- 29:15are impacting the implementation of the program.
- 29:18So how dynamics within the risk environments
- 29:21of folks who use drugs.
- 29:23So this complex assemblage of social, physical, economic
- 29:29and policy factors that shape the situations
- 29:32or settings in which people use drugs
- 29:34including their ability to access safe supply.
- 29:39And then further considering differential impacts
- 29:46on folks who use drugs
- 29:47on the basis of their social position.
- 29:50So how relational aspects of their identities,
- 29:54experiences and positions on the basis of things,
- 29:56like age, class, sexuality, gender, race, ability,
- 30:01citizenship status, kind of act in relation
- 30:04to these broader sets of factors
- 30:06within the risk environment
- 30:07to shape their specific sets of experiences.
- 30:19And so I'll be sharing some findings from the first round
- 30:23on the Molson risk prevention site,
- 30:24as well as emerging findings
- 30:26based on the work we've been doing
- 30:27on the Risk Mitigation Guidelines.
- 30:30And so the first thing
- 30:31and I can't emphasize emphasize this enough
- 30:33because it became certainly a thing
- 30:37that impacted how we thought about these programs early on.
- 30:40And that quite simply was the question
- 30:41of whether or not these programs
- 30:43can attract folks who use drugs.
- 30:47And what we effectively found
- 30:49is that people are highly motivated
- 30:51to access alternatives to the illicit drug supply.
- 30:55And low threshold access to pharmaceutical alternatives
- 30:58in particular, can reduce their potential exposure
- 31:01to fentanyl and other adulterants.
- 31:05So effectively, what we found is that people
- 31:09would often describe their motivation
- 31:11for accessing the program as being specifically driven
- 31:14by concerns with the illicit drug supply.
- 31:18So there have at times been narratives
- 31:20around fentanyl seeking
- 31:22within the context of the overdose crisis.
- 31:26And while people's use of fentanyl
- 31:27was exceedingly complex shaped by opioid tolerance,
- 31:32environmental conditions and exposure,
- 31:36we found that people had deep concerns
- 31:38about potentially being exposed to drugs
- 31:42that contained more fentanyl
- 31:44than they might expect an air ago,
- 31:47heightening their potential risk of overdose
- 31:51as well as other adulterants
- 31:53that were showing up in the supply.
- 31:58And People in turn reported that they
- 32:00in accessing this program,
- 32:02weren't as reliant on accessing the drug supply.
- 32:05Now one of our participants put it as such.
- 32:09Now I'm on this hydromorphone program.
- 32:12It's changing my drug use a lot actually.
- 32:14Like I went from using fentanyl five to 10 times a day
- 32:17to using once a day.
- 32:19So in the last month I've gone down to just once a day,
- 32:21twice a day, and that's good.
- 32:24So certainly, and I'll touch on this in a bit
- 32:28within the context of, you know,
- 32:30programs operating within a limited timeframe
- 32:32around the operating hours
- 32:33of the overdose prevention site,
- 32:36and certainly people's lives were complex
- 32:38and would sometimes place them
- 32:40in places where they couldn't access it
- 32:41when needing to use.
- 32:42People nonetheless reported that they were using
- 32:48illicit drugs less often because they had an alternative
- 32:52and that they saw this as a chief benefit of the program.
- 32:56Now, alongside this motivation that people had
- 33:00to access the program, certainly we observed demand
- 33:04far exceeding the ability of the site
- 33:08and the attached Primary Care Group
- 33:09to effectively enroll people quickly enough to,
- 33:13and, you know, with sufficient capacity
- 33:15to provide support in this program.
- 33:21It wasn't unusual to be doing field work at the site
- 33:24and have someone show up
- 33:27wanting to get on the program immediately
- 33:29because they needed, you know,
- 33:32something to mitigate withdrawal experiences
- 33:35which can cause severe pain and discomfort.
- 33:41And you know, who yet weren't able to enroll at that time.
- 33:45So certainly, you know, people want it on this.
- 33:48They wanted to reduce their exposure to fentanyl
- 33:51and the program couldn't keep up with demand.
- 33:56Now certainly we found that access to a reliable supply
- 34:02of pharmaceutical alternatives to the illicit drug supply,
- 34:05enabled people to minimize their engagement
- 34:07in drug scene activities.
- 34:10It also helped them establish drug use routines
- 34:13that help them to maintain their health and well-being.
- 34:17And so specifically, you know,
- 34:21people didn't have to generate the income or funds
- 34:25that they often would have to
- 34:26through informal or illegal income generation
- 34:29so as to purchase illicit opioids
- 34:33within the local drugs scene.
- 34:35And so people really emphasize
- 34:37the positive impact on their lives, both in terms of
- 34:40and especially for folks who are racialized or minoritized,
- 34:46how this limited their potential exposure
- 34:49or engagement with police
- 34:51and further engagement in carceral systems.
- 34:58Especially for women who are accessing the program
- 35:01they really emphasized in many cases
- 35:04that they were able to reduce or, you know,
- 35:08effectively stop engagement with sex work
- 35:14which for many was driven by their need
- 35:16to generate money to maintain their opioid use
- 35:23within the context of drug prohibition.
- 35:28One of our participants put it quite directly, you know,
- 35:31when I used to run out of money, I would do crime, right?
- 35:34So that stopped.
- 35:35I'm not running out of money
- 35:36because this hydromorphone is free, right?
- 35:38That's a big bonus for me.
- 35:40I don't have to decide between eating and doing dope, right?
- 35:43I can do my dope here and then go eat, it's working fine.
- 35:47And you know, this further really hits on the point
- 35:51that, you know, people talked about, you know,
- 35:53the extreme time and energy
- 35:55and work that goes into managing opioid use
- 35:59within the context of severe poverty
- 36:01and the war on drugs, you know,
- 36:04effectively meant that people had to make these trade offs.
- 36:06And so people were better able to attend to things
- 36:09that were critical to their health and well-being
- 36:10like quite simply eating.
- 36:14You know, and benefit for many people,
- 36:16so a number of people were what we might consider
- 36:19orphan pain patients who had previously
- 36:21been on long-term opioid therapies before being cut off.
- 36:24And a lot of these folks would specifically
- 36:26emphasize the positive impacts on pain management
- 36:29to have routine access to opioids.
- 36:35So this one person started accessing the program
- 36:37and injecting before moving to oral ingestion.
- 36:43So I was doing the injections,
- 36:44but now I'm doing the oral
- 36:45which is two pills I get of Dilaudid
- 36:47and it helps me with pain.
- 36:49The last time I was in hospital, I got some oral Dilaudid
- 36:52and I liked it, it helped me a lot.
- 36:53So I was looking forward to it.
- 36:55I thought I'd like the injections,
- 36:56but it turns out I liked the oral better.
- 36:58And so this was a common sentiment in that, you know,
- 37:02people reported severe chronic,
- 37:04and in some cases acute pain that they further felt
- 37:07that this program was critical in helping them manage.
- 37:12Now certainly the one thing that we found,
- 37:15so, you know, if we think back to that Canadian Association
- 37:20of People who Use Drugs, framing, you know,
- 37:23what we're effectively talking about as a regulated
- 37:26or legal market for drugs as an alternative,
- 37:29and yet both in terms of this
- 37:31hydromorphone distribution program
- 37:33and still later the risk mitigation guidelines,
- 37:38you know, these are being delivered through Primary Care.
- 37:42And what we've effectively found is that the medicalization
- 37:46of approaches to safe supply
- 37:47has actually constrained the effectiveness of this approach.
- 37:51And it's done this in a number of ways
- 37:53both through misaligning the intervention design
- 37:56and the underpinning philosophy.
- 38:00And, you know, subsequent to that,
- 38:02not fully meeting people's needs.
- 38:06And so there's really kind of three points here
- 38:08that I like to emphasize.
- 38:10So first is that, you know, primarily
- 38:13and especially opioid prescribing
- 38:15within the context of these programs
- 38:17has had an emphasis on withdrawal management.
- 38:19That is effectively prescribing people
- 38:22on amount that isn't necessarily aligned
- 38:25or kind of a match for the level of illicit opioids
- 38:30that they're using especially within the context of fentanyl
- 38:34and fentanyl injecting.
- 38:36And people often, you know, reported that
- 38:40what they'd received was effectively enough to
- 38:42you know, in some cases, you know,
- 38:44mostly if not totally allow them
- 38:47to not experience dope sickness.
- 38:51But not necessarily get the high
- 38:53that they may be looking for.
- 38:55And certainly there's deep questions
- 38:57of agency and choice in the context of substance use
- 39:01that this raises in so far as, and especially
- 39:06within the context of severe social suffering, you know,
- 39:09the pleasure associated with drugs is something
- 39:12that warrants attention and, you know,
- 39:15maybe should prompt us to rethink our approach
- 39:18to prescribing, so as to allow people
- 39:20to have experiences that they may wish for.
- 39:24Second enrollment is not meeting demands.
- 39:29We saw this both in the context
- 39:31of the hydromorphone distribution program
- 39:33wherein people were routinely showing up
- 39:36hoping to get on the program, you know,
- 39:40being in withdraw and subsequent to that
- 39:42at an extreme risk of purchasing illicit opioids
- 39:46and using within context that may heighten
- 39:49their potential risk of overdose,
- 39:53having to rush injecting or not do a test for a shot.
- 40:00And effectively the program needed scale up
- 40:05to meet the severe demand for the program.
- 40:08And then second, you know, within the context
- 40:11of the implementation of risk mitigation guidelines,
- 40:14you know, what we've effectively see is
- 40:17you know, the number of people on the program
- 40:21is only a small fraction of the number of folks
- 40:23who may be eligible.
- 40:25And so within the context of a drug supply
- 40:27that's gone further sideways, especially with the estazolam,
- 40:30which is a benzo showing up in addition to fentanyl
- 40:34within the illicit opioids supply,
- 40:36a rapid escalation of overdose deaths.
- 40:40And so enrollment, I believe is hovering around
- 40:43three and a half to 4,000 right now,
- 40:46where there's a potentially up to 70,000 people
- 40:49in the Province who may be eligible for the program.
- 40:52And so certainly in the interviews
- 40:55that we've been doing with people
- 40:56about their experiences of getting on
- 40:58or trying to get on this program, we're finding that people
- 41:01are encountering Primary Care Providers
- 41:06unwilling to pick up these guidance documents
- 41:09and provide them with alternatives to a toxic drug supply.
- 41:14And while certainly it is important that, you know,
- 41:19treatment options be made available, you know,
- 41:21for those not wanting to go on those, you know,
- 41:26they're really being put in a horrible risk.
- 41:31Finally, you know, the majority of folks
- 41:33who've been accessing through the Risk Mitigation Guidelines
- 41:38have, you know, effectively been required
- 41:40to pick up their drugs in the pharmacy every day.
- 41:45And so this has raised concerns for people
- 41:48both within the context
- 41:49of managing potential exposure to COVID.
- 41:52As you know, I think we collectively know, you know,
- 41:56COVID has disproportionately impacted vulnerable communities
- 41:59and especially folks who use drugs,
- 42:01grappling with multiple other structural vulnerabilities,
- 42:03including, you know, housing vulnerability and poverty
- 42:08as well as, you know, racial discrimination
- 42:11within a variety of systems.
- 42:14And so these placed a burden on people that, you know,
- 42:17what's concerning within the context of COVID
- 42:20but was also difficult to meet at times, given, you know,
- 42:24just all of the other things happening in people's lives.
- 42:28And so certainly, you know, we've gone
- 42:31from a model originally envisioned it is quite flexible
- 42:36and low threshold to one that, you know,
- 42:38still while representing an advance
- 42:40in available interventions for
- 42:44in the context of the overdose crisis
- 42:46this still might have thresholds that exceed that
- 42:49which people were able to meet.
- 42:52And so if folks are interested in learning more,
- 42:54we published a couple of papers already
- 42:56based on the work
- 42:58around the hydromorphone distribution program
- 43:01at the Molson overdose prevention site, you know.
- 43:06And just to cycle back.
- 43:08So, you know, we're effectively in an era
- 43:13characterized by severe overdose related mortality,
- 43:18driven by a toxic drug supply associated with fentanyl
- 43:22and other adulterants.
- 43:24You know Connecticut is an example, you know,
- 43:2613% of overdose deaths involved Xylazine in 2020.
- 43:32And certainly this raises concerns
- 43:34about how can we effectively intervene.
- 43:37Now, certainly the further scale up
- 43:39of evidence-based treatment options
- 43:41and medications for opioid use disorder
- 43:43like buprenorphine and methadone,
- 43:46represent aN important priority.
- 43:49I think we also need to start asking ourselves, you know,
- 43:52what are we doing for folks who aren't able to access these
- 43:56or don't have interest in accessing these treatment options?
- 43:59And effectively safe supply, you know, could be that thing.
- 44:05And very much 'cause I think
- 44:06the Vancouver experience points to
- 44:08is something that can work for people and is feasible.
- 44:12And certainly, you know, rather than asking ourselves
- 44:17whether we should prioritize one thing over the other,
- 44:20you know, we're losing tens of thousands of people a year.
- 44:23And I think what we effectively need to reflect back on
- 44:26is within the context of such severe suffering
- 44:32and loss, you know.
- 44:35We need to be doing everything that we can, and, you know,
- 44:38this represents one potential pathway forward
- 44:42specifically important for folks whom if not on methadone
- 44:48or not on buprenorphine, you know,
- 44:50right now in the U.S have no other options
- 44:54than to to roll the dice each time they purchase and use
- 44:58and hope that, you know,
- 45:00this isn't the time that they go down.
- 45:03So with that, I'm happy to answer any questions
- 45:06and thank you for joining and especially sitting
- 45:11through this with me on a zoom presentation
- 45:15which I know can be brutal.
- 45:21<v ->Any questions.</v>
- 45:43<v Lauretta>I'll ask a couple of questions then.</v>
- 45:47So thank you very much,
- 45:49it was a very interesting presentation
- 45:54and an exciting place to be.
- 45:57I was wondering a couple of things
- 45:59with the kind of routinizing of the user's day
- 46:05in having to go and get their hydromorphone, you know,
- 46:09on a regular basis, the increased womanizing of their day
- 46:16might empower them to perhaps aspire
- 46:21to entering some kind of methadone
- 46:26or buprenorphine treatment.
- 46:28So I was wondering, are you tracking entry
- 46:31into some sort of M.A.T program
- 46:34and kind of a sub-question to that is
- 46:39do they have expedited access
- 46:42for being, you know, in this hydromorphone program?
- 46:47Do they have an expedited access
- 46:49into M.H.E if they choose to enter?
- 46:56<v ->Yeah, so I'll answer the second part first,</v>
- 46:59and then jump to the first.
- 47:01So, you know, one of the great things about Vancouver
- 47:05is the settings effectively, you know,
- 47:08if you wanna be on methadone or Suboxone
- 47:12like it's gonna happen on the spot.
- 47:14There's a number of low threshold clinics
- 47:16that effectively someone shows up
- 47:19they'll work to get them inducted.
- 47:23So, you know, while folks could wanna do that
- 47:27that wasn't necessarily a pathway that we see
- 47:31now with that.
- 47:33You know, one of the exciting things about Canada
- 47:36is there's just a greater range of treatments available
- 47:39for opioid use disorder.
- 47:41So there's national guidelines
- 47:43for the treatment of opioid use disorder
- 47:45that include, you know, Suboxone as a first-line treatment,
- 47:50then, you know, methadone, then slow-release oral morphine,
- 47:54then, you know, injectable hydromorphone
- 47:57as part of a structured treatment program.
- 47:59And what we would often see is less someone transitioning
- 48:04from a safe supply program onto Suboxone or methadone
- 48:08and more see them transitioning onto a slow release
- 48:13or morphine or moving into or quite often just between,
- 48:17depending on what worked for them at the time,
- 48:19the more structured injectable
- 48:21hydromorphone treatment program.
- 48:24And so, you know, frankly, I think it really also flips
- 48:27how we might think about the continuum
- 48:29of treatment options available to people.
- 48:32And so we've run a series of kind of interlocking
- 48:35a longitudinal ethnographic projects,
- 48:37looking at these broader treatments available
- 48:42within the local context in Vancouver.
- 48:45And, you know, we effectively find
- 48:47that people move between them
- 48:49and not with the directionality
- 48:51assumed by the treatment guidelines
- 48:54wherein someone, you know, try Suboxone moves to methadone
- 48:57maybe tries kadian or an injectable,
- 49:00but more so they'll maybe start on a safe supply,
- 49:04move to injectable hydromorphone, then onto Kadian,
- 49:08and then, you know, maybe onto methadone at that point.
- 49:11But all of this is to say the people's trajectories
- 49:14are just really, really diverse and shaped often
- 49:18by what they both hope to get out of treatment
- 49:22and what their preferences are around drug use itself.
- 49:28The key thing that tended to more drive it for people
- 49:31is if folks just didn't want to be injecting anymore.
- 49:35And certainly the oral therapies that weren't just Suboxone
- 49:39or methadone were incredibly helpful
- 49:41to people in that context.
- 49:53<v Ashley>Hi, Ryan, it's Ashley.</v>
- 49:55I have two questions and they're very different.
- 50:00So the first is you said a lot
- 50:02of really evocative statements about social suffering
- 50:07and pointing to some solutions that might allow
- 50:10for individuals to access euphoric experiences.
- 50:15I'm very curious to learn more about that.
- 50:18Can you talk a little more about
- 50:20some of those recommendations?
- 50:22And then the second question is I'm curious to learn more
- 50:27about how this really powerful ethnographic
- 50:31and qualitative work is informing
- 50:34some of the more epidemiologic
- 50:37or more quantitative work that you've been doing.
- 50:40So if you could talk a little bit
- 50:41about some of the mixed methods that you're using as well,
- 50:43I'd love to hear that.
- 50:48<v ->So I think first, I mean</v>
- 50:50we probably collectively just need to reckon
- 50:53with the fact that, you know, people have been getting high
- 50:57or intoxicated in some form or another for,
- 51:02I mean perhaps like almost the whole of human existence
- 51:06or at least thousands of years.
- 51:08And, you know, this has been a longstanding current
- 51:14across so much of the work that I've done wherein, you know
- 51:19we think about people's drug use primary lead
- 51:21through a lens of harm without looking at, you know,
- 51:26the ways in which it can even be a positive thing for people
- 51:30or allow them certain experiences
- 51:32that are especially attractive
- 51:34within the context of social suffering.
- 51:36And so, you know, people often spoke of in this work,
- 51:43you know, I want to be safer
- 51:45but I still want to be able to get high.
- 51:50And they were motivated to be engaged with programs
- 51:53that allowed them to be safer.
- 51:55And certainly this is consistent
- 51:56with work we've done on supervised consumption sites.
- 52:01But they still effectively wanted to have choice
- 52:04in terms of what they choose to do with their body,
- 52:07how they choose to live and so forth.
- 52:11And, you know, I don't think we can separate this
- 52:14from the backdrop for so many folks.
- 52:19It was one of the few pleasurable experiences
- 52:22that they often had open to them within the context to,
- 52:25you know, perhaps managing severe chronic pain,
- 52:29living in conditions that Canada should be embarrassed of
- 52:36and you know, effectively urban slums.
- 52:40Of, you know dealing with severe hardship
- 52:44and the people characterized
- 52:47as a positive part of their lives
- 52:49and that many sought to continue
- 52:51even when engaged with treatment
- 52:54if that was something that they were interested in.
- 52:57And so, you know, there's probably just a much broader need
- 53:00to interrogate that,
- 53:03as we think through how we intervene in people's lives
- 53:06and do so in a way that's, you know,
- 53:08aligned with and sensitive to what they need or want.
- 53:13You know, more directly, so all of this work
- 53:15is operated alongside a series of other kind
- 53:20of more clinically or epidemiologically oriented evaluations
- 53:25of these interventions, which, you know,
- 53:28honestly things have been just really messed up by COVID,
- 53:33and COVID related restrictions on research activities
- 53:39which is really frankly unfortunate.
- 53:43But effectively what it's really allowed us to do
- 53:45is interrogate findings out of that have emerged
- 53:49at a preliminary epidemiological analysis, as well as,
- 53:53you know, effectively flag things that have been emergent
- 53:57within the qualitative work to help better understand
- 54:00what's happening.
- 54:01And so, you know, to go back
- 54:02to Lauretta's question about movement between programs
- 54:08certainly one of the things observed early on
- 54:10in our ethnographic qualitative work is that, you know,
- 54:14people had different trajectories within these programs
- 54:17than you might've anticipated, you know.
- 54:21And that's something that's been further built
- 54:26into the evaluation activities associated with the work.
- 54:31You know, another example would be
- 54:34just understanding the points
- 54:36at which people might have interruptions
- 54:38in their access to these programs, which were, you know,
- 54:41frankly found that were often much better able to track
- 54:46through our ethnographic and qualitative work,
- 54:48because we're just a little bit more engaged with folks.
- 54:53So all of this is to say that running these things
- 54:55in tandem has really helped us understand
- 54:57the richness of these programs in people's lives
- 55:00and interrogate emergent findings coming out
- 55:03of the kind of more numbers based quantitative analysis.
- 55:11Ali.
- 55:14<v ->Hi, thank you so much.</v>
- 55:16This has been a wonderful experience to listen
- 55:19to your work and your expertise.
- 55:22I was wondering, it kind of sounds like
- 55:25where you're coming from in the experiences that you've had
- 55:29and from Canada specifically,
- 55:31there's a completely different mindset
- 55:33behind the idea of harm reduction and treatment
- 55:37or non-treatment and like what someone's trajectory
- 55:40actually looks like from the onset
- 55:42of interaction with harm reduction.
- 55:44And I was just wondering,
- 55:45did Canada always start out that way
- 55:47or was there a big shift and how did that shift happen
- 55:50and how can you see that shift happening here in the U.S
- 55:53because, I mean, I've just been sitting here thinking,
- 55:55wow, we are trash.
- 55:56(laughs)
- 56:06<v ->I mean, so I don't want you to come away</v>
- 56:07from this feeling like that.
- 56:09That's like my worst outcome for the day.
- 56:12<v ->In a good way, like inspired we're trash,</v>
- 56:15we need to fix it.
- 56:17<v ->So, you know, there's been a couple of things</v>
- 56:20that have really helped in the Canadian context.
- 56:22One and I can't understate this enough,
- 56:25Drug User Organizing and Activists.
- 56:29And certainly the war on drugs in the U.S
- 56:32and mass incarceration, I would argue
- 56:34have really impeded Drug User Organizing
- 56:37by frankly destroying communities
- 56:39and especially communities of color
- 56:41that should be central to organizing in this context.
- 56:45Alongside that, you know, frankly,
- 56:48a lot of other people have really stuck their neck out
- 56:51around this and committed to working in allyship
- 56:55with people who use drugs to advance intervention
- 56:59in a way that meets their needs
- 57:04to the extent that it is,
- 57:06you know, I've been in kind of Drug Policy forums
- 57:11and events in the U.S
- 57:12that haven't included folks who use drugs.
- 57:15I don't think you could do that in Canada
- 57:17without probably having someone throw a shoe at you
- 57:20at this point.
- 57:22And all of this is to say as a challenge
- 57:24to every single person here and as collectively.
- 57:27If we're not working to center folks who use drugs
- 57:33in policymaking processes and interventions in this area,
- 57:38what the fuck are we doing?
- 57:40And we have to commit to doing that.
- 57:45It's not easy, it can be hard.
- 57:50We're more accountable in it
- 57:51in ways that can be really difficult to grapple with
- 57:54but you have to commit to doing it
- 57:56if you wanna meaningfully intervene to address the crisis
- 58:02and have policy that actually matches up
- 58:04with people's experiences
- 58:05and avoid some of the unintended consequences
- 58:07that we've seen a policy for too long.
- 58:12So I think those things really need to happen together
- 58:15and, you know, people working as allies
- 58:19need to just as much work
- 58:20to hold other people accountable, you know,
- 58:27who were the people you're meeting with,
- 58:29who isn't getting in those doors
- 58:31and what can you do to get them there?
- 58:33And especially, you know, doing so has to center folks
- 58:40who are disproportionately impacted by the war on drugs.
- 58:44Otherwise again, am like what are we doing?
- 58:49<v ->All right, so it is actually one o'clock.</v>
- 58:52So we are out of time.
- 58:54I see Mariah, you have your hand raised.
- 58:56Do you want to ask your question very quickly?
- 58:59<v ->Yeah, I can ask you to complete</v>
- 59:00I suppose I could also ask Ryan in class tomorrow.
- 59:04But so I just sort of say shamelessly follow
- 59:08a lot of like Canadian harm reduction groups
- 59:10on social media and I've been seeing a lot of posting
- 59:14about the Drug Users Liberation Front
- 59:17giving out a safe supply of meth and heroin and cocaine
- 59:22that's been tested by spectometry and immunoassay.
- 59:26And I just didn't know if
- 59:28(inaudible)
- 59:29into what response around that has looked like in Canada
- 59:32and potential also like scale up of those tech knowledges
- 59:36for drug testing.
- 59:39<v ->Sorry, you kinda cut out on me</v>
- 59:40on the last part of your question.
- 59:43<v ->Sure, so I was just talking about like</v>
- 59:48spectrometry and immunoassay.
- 59:49I was just wondering what response in Canada has been like
- 59:53for like guard to groups, giving out safe supply
- 59:57and also what scale up of that tech might look like.
- 01:00:01<v ->Yeah, I mean, so, you know</v>
- 01:00:04it's primarily been something that's just happened
- 01:00:07across a series of kind of events
- 01:00:09done for the purposes of drawing attention
- 01:00:11to the need for more options for people
- 01:00:14and more generally illegal market.
- 01:00:18And I would say part of it is
- 01:00:20it occupies a bit of a policy curiosity for folks
- 01:00:24more than anything at this point.
- 01:00:29And yet kind of symbolically is
- 01:00:33I think really interesting in, you know,
- 01:00:36demonstrating the further alternatives are available.
- 01:00:41You know, it certainly dovetails
- 01:00:42with the advocacy and activism
- 01:00:44being led by so many people around this.
- 01:00:48Now with that said, you know, I think part of your question
- 01:00:52was about drug checking and you and I need to,
- 01:00:54I think separately connect about this.
- 01:00:58I mean, we're not gonna end the overdose crisis
- 01:01:00with fentanyl test strips as an example.
- 01:01:03I just wanna say that I feel like I say this all the time.
- 01:01:06But if fentanyl is the dominant opioid in a setting
- 01:01:08and you have something that just tells you
- 01:01:10whether or not it has fentanyl in it,
- 01:01:11like, honestly it's not really helpful
- 01:01:13except for people who use stimulants
- 01:01:15who are maybe worried about cross-contamination.
- 01:01:19And stimulants, like not weed.
- 01:01:22I don't think anyone has ever found weed
- 01:01:24contaminated with fentanyl,
- 01:01:25so disclaimer, like that's not a thing.
- 01:01:30Now with like the more advanced drug checking technologies
- 01:01:34like they can prove helpful for folks
- 01:01:37but I think we need to better locate
- 01:01:40how we understand these interventions
- 01:01:41alongside an interrogation
- 01:01:43of how people's structural vulnerabilities
- 01:01:45and especially poverty fit into this complex calculation
- 01:01:48of how people engage with drugs in the drug supply.
- 01:01:53So sort like I'm coauthored a bunch
- 01:01:56of the drug checking studies.
- 01:01:58And like one of the early ones that gets picked up
- 01:02:00is when we did it inside
- 01:02:01that looked at people's use of strips.
- 01:02:03You know, that found that, you know,
- 01:02:04some folks were finding positive with fentanyl
- 01:02:07and maybe a few of them were pitching their drugs,
- 01:02:09but like let's take a step back.
- 01:02:11That was like 1% of folks who are going into insight
- 01:02:14were using these strips to begin with.
- 01:02:16A smaller percentage still of those folks
- 01:02:19were disposing of their drugs
- 01:02:21if they had something they didn't expect to find in them.
- 01:02:25And we were doing field work and interviews
- 01:02:27with people at that time, and a lot of those folks
- 01:02:29were people who were selling drugs,
- 01:02:30who just wanted to figure out what was in their supply
- 01:02:32and didn't necessarily have an intention
- 01:02:34to be using that anyways.
- 01:02:38So drug checking is not gonna save us.
- 01:02:43Even if available, like it's never gonna meet the demand
- 01:02:48for how often people are using,
- 01:02:50the supplies really erratic.
- 01:02:53We have all of these new adulterants
- 01:02:54and centering the supply from Xylazine, to estazolam,
- 01:02:57to synthetic cannabinoids to,
- 01:02:59and we could just keep on going through them
- 01:03:01and there will still be further ones.
- 01:03:05So the nimbleness of this as an approach
- 01:03:07is probably never gonna match on to what people need.
- 01:03:11Now incredibly useful for drug surveillance, right?
- 01:03:16Like the one place we found it helpful is like, you know
- 01:03:20a bad package of benzo dope starts going around
- 01:03:23and you can let people know.
- 01:03:26But beyond that, like I think drugs,
- 01:03:30every bit of energy spent on drug checking
- 01:03:32should just be redirected toward thinking about safe supply.
- 01:03:40And if that doesn't answer your question,
- 01:03:42I'll try better tomorrow.
- 01:03:47<v ->All right, thank you so much, Ryan, for joining us today.</v>
- 01:03:50I think this was a very self provoking
- 01:03:53and interesting presentation.
- 01:03:54And I hope there will be many opportunities
- 01:03:56for us to continue this conversations in the future.
- 01:04:00And thanks very much to everyone who joined us today
- 01:04:03and for asking all this very interesting questions.
- 01:04:06So thanks everyone, thanks Ryan.
- 01:04:11<v ->Cool, thanks everyone.</v>