SBS Seminar: “Addressing the Overdose Crisis Through Safe Supply”

April 14, 2021

Information

Ryan McNeil, Ph.D
Associate Professor, Yale School of Medicine
Director of Harm Reduction Research, Program in Addiction Medicine
April 13, 2021

ID6437

To CiteDCA Citation Guide

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>