WEBVTT

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<v ->All right, welcome everyone.</v>

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Let's go ahead and get started.

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So it is my pleasure to introduce our speaker for today,

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Dr. Ryan McNeil.

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Dr. McNeil is an Assistant Professor,

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was joining appointments at the Yale School of Medicine

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and also here at the Department of Social

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and Behavioral Sciences at Y.S.P.H.

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He is teaching a course on Harm Reduction this semester

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which many of you might be taking.

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Dr. McNeil received his PhD

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from university of British Columbia.

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And he joined the Yale Faculty in December, 2019.

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Dr. McNeil's research exams to Social Structural

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and Environmental Influences

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on the Implementation and Effectiveness

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of Harm Reduction and Addiction Treatment Interventions.

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He also studies the Influence of Housing

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and Housing Based Interventions

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and overdose related risk.

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He is the principal investigator on multiple grants,

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both from N.I.H

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and from the Canadian Institute of House Research.

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And he's also the co-creator

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and scientific lead of Crackdown.

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So this was a Podcast launching January, 2019

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and it is designed to mobilize research

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and amplify The voices of people who use drugs.

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This media collaboration has been called a podcast

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most likely to save lives,

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and he has received a number of awards

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including the Third Coast International Audio Festivals

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on the Radio Impact Award,

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the Canadian Hillman Prize and a Silver Medal

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from New York FestivalS Radio Awards.

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So without further ado, let's a welcome Dr. McNeil.

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<v ->Hi everyone, Katie, thanks for very kind introduction.</v>

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It always reminds me that I feel like I need

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to update my Faculty page.

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So it has like a tighter description of the things

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that I do 'cause it always feels a little bit much

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which is to say I'm just really happy to have you all here

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and present on both the broader concept and idea

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of safe supply in the context of the overdose crisis.

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And talk about some of the work

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that we've been doing.

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Looking at this, this might be new to some of you,

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so please don't hesitate to ask questions.

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I'll try to leave ample time at the end,

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and please bear with me in the clunkiest

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of presenting formats.

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I can't be the only one who's looking forward

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to doing talks in person again.

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Great, so a few notes as I get started,

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a lot of the discussion will focus on work

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I've been engaged with in Vancouver, Canada

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which is both where I moved here from

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and where I continue to run a range of different projects

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that are examining the Implementation

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of safe supply and its role in responding

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to the overdose crisis.

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I'll spend a bit of time conceptualizing the overdose crisis

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as well as getting into some of the specific dynamics

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worth considering as we move into

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frankly a period of severe overdose related morbidity

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and mortality.

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A lot of the work and thinking about safe supply

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for me really comes out of this particular space

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which is the Washington Needle Depot which became the Molson

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or the Maple Overdose Prevention Site

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in Vancouver, Canada's Downtown Eastside.

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And really it was the beginning of 2017

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as the city was grappling with a severe overdose crisis.

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When you know, longstanding ideas of drug legalization

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and alternatives to an illegal drug supply,

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increasingly characterized by fentanyl and other adulterants

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began to really percolate in the community

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and become a topic of discussion

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as people sought out alternatives

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to increasingly toxic drug supply that was killing people.

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So during field work in work that I do primarily

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as an ethnographer at this site,

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both people involved in operating it

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as well as others visiting the site

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began to talk a lot about the need for alternatives

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and the need for a safe supply.

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And this was very much aligned

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with other discussions that were happening

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in Circles of Drug-User Activists in the community

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which has a longstanding history of drug user organizing.

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That's been critical to advancing Drug Policy Reform

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both in Canada and globally,

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including the implementation of supervised consumption sites

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and other interventions.

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Now I'll get into this a little bit later,

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but that the city has also been home

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to several clinical trials

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for advanced treatment options for opioid use disorder

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including a heroin prescription heroin trial

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and an injectable hydromorphone trial

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that further prime the community

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for discussions of alternatives

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to a toxic drug supply and available treatment programs

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that weren't were meeting people's needs.

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And so this began to become more pronounced

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with an Activist Circles and really

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became a bit of a rallying cry as the community was impacted

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by just an incredible level of loss

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in the wake of a sustained overdose crisis.

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It really raises I think three interlocking questions,

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really the heart of what I wanna touch on today

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which is effectively, why were so many people dying?

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What is safe supply,

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and how does it address the overdose crisis?

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And so certainly there's broader narratives

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in terms of how we think about the overdose crisis

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that become dominant,

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that in kind of relatively straightforward waves

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of prescription opioids, onto heroin, onto fentanyl

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onto now psychostimulants and other drugs.

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But it's always been a little bit messier than that.

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And the period I'm really gonna concentrate on

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is kind of this period of fentanyl and other adulterants

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within the supply.

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And certainly as folks are likely aware,

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fentanyl has been associated with a rapid escalation

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of the overdose crisis across North America

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as a more potent opioid that is becoming a primary driver,

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well is long the primary driver

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of overdose deaths in North America.

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And really, what are my early orientations

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to the scope and severity of fentanyl

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happening alongside field work that we were doing?

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So running studies out of an area

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with really one of the most severe

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fentanyl driven overdose crises

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was certainly an experience of, you know,

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doing the work against the backdrop

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of profound loss and this grappling

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with what was happening in the community.

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Early on, as we were doing and running studies

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and doing other work engaged with folks

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who use drugs in the community,

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there was certainly this tectonic shift

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as we all started to really grapple with what was happening

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as fentanyl became more prominent within the drug supply,

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and it became the dominant illicit opioid within the supply.

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First being sold kind of as heroin

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then outright displacing heroin within the local supply.

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And so it really struck us early on,

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at first we were just losing people.

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I remember a study we were operating at that time

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that involve follow-up interviews with folks

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who had lost their housing to eviction.

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And, you know, effectively

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we quickly realized that this was happening

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as the shift was happening and we couldn't find people.

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And then it quickly dawned on us that, you know,

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they were people who we were losing to this rapid spike

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that was happening in overdoses in the community.

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And it was fundamentally different.

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And so we commonly encountered people who would put it

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really as such.

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You know, with heroin you feel it coming on,

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you feel the intensity, you feel like you're gonna puke.

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You know, keeps coming, and you know,

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I'm going to go down.

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Fentanyl, you're sitting there waiting for something,

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and the next thing you know,

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there's an ambulance attendant there

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it hits you like a Mac truck.

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You don't feel it, nothing just boom, down.

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You get up and swear that you didn't even do your shot,

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you're looking for it.

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And so this certainly for me,

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always perfectly summed up that this transition

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from, you know, a community that long been impacted

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by a high level of overdoses within the context

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of a very kind of contained drug scene

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to suddenly something completely different,

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and, you know, the comparison of

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it hits you like a Mac truck

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really felt like what happened to the whole community.

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And then this certainly was consistent

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with what was happening across North America at this time.

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So in the United States, you know,

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you'll notice this graph from the C.D.C

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that gets circulated,

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and I think I see in every presentation

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on the overdose crisis at this point.

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When you see this orange line,

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the begins to take off in, in 2015

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and really becomes the dominant

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and still more recently further dominant

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cause of overdose deaths.

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But they're just primarily synthetic opioids

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and specifically fentanyl and fentanyl adulterated drugs.

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So just in case folks aren't aware

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fentanyl is effectively a much more potent opioid

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that's associated with a much higher risk of overdose.

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And certainly that's been born out by the data.

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The onset tends to be quicker,

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they tend to be more severe

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and it certainly becomes challenging to navigate

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especially transitional drug supplies

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wherein fentanyl is replacing heroin or other opioids,

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or, you know, across a lot of different contexts

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where, you know, one doesn't necessarily know the potency

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of fentanyl from one package to the next when using.

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And so fentanyl, you know, certainly has become

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this key driver of the overdose crisis.

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And so if we think about Canada,

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where I'm gonna really kind of concentrate on a bit,

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you know, we similarly see, so, you know,

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this is a graph depicting total opioid related deaths

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by opioid type.

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And you'll certainly notice that, you know,

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more and more over time,

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these are dominated by fentanyl

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and other fentanyl related analogs

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that can be even more potent.

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And then certainly

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because I think it bears specific attention,

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especially within a policy context

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wherein discussions of the overdose crisis

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still remain dominated by an emphasis on pharmaceutical

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or prescribed opioids

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which we're gonna flip a little bit here.

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Did the majority of deaths in Canada has elsewhere

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certainly are driven by, you know,

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non-pharmaceutical opioids,

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even if used in combination.

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So as this has happened,

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and I mentioned these framing pieces,

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you know, early attention to the overdose crisis

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in North America is really emphasized

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and it happened alongside this period

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of declining life expectancy among white folks.

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And certainly it became a dominant narrative.

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This was very much driven by, you know,

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the overdose crisis and deaths of

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what became term deaths of despair, you know.

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And this really configured a set of policy responses

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that were distinct from more traditional

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war on drugs approaches even as those continued to dominate.

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But also frankly, is obscured the severe impact

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of the overdose crisis on communities of color.

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Certainly, you know, it's really no longer the case

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that deaths among white folks and in the U.S

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far exceed those of other folks.

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And in fact, among people of color,

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overdose rates are rising quite dramatically

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and among indigenous folks remain incredibly high

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and in fact the highest of any population.

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And so I think, you know, this is just a point

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to emphasize because we'll cycle back to this

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in that when emphasizing, you know, deaths of despair,

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it's to foreground that the broader range

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of structural inequities that certainly drove to some extent

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heightened overdose mortality

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among specifically poor white folks.

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These have had longstanding

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and severe disproportionate impacts on communities of color.

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So things from policing to impacts of hosing

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and equities and vulnerabilities, poverty, et cetera.

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So I mentioned the specific research context

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I'm gonna be focusing on is in Vancouver, Canada.

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00:14:29.110 --> 00:14:31.870
So Vancouver is located in British Columbia, Canada.

269
00:14:31.870 --> 00:14:35.170
And it's commonly, you know, when you hear about Vancouver,

270
00:14:35.170 --> 00:14:37.950
you frankly commonly hear about, you know,

271
00:14:37.950 --> 00:14:39.200
two things at this point.

272
00:14:39.200 --> 00:14:43.230
One is frankly, a severe overdose crisis,

273
00:14:43.230 --> 00:14:45.140
but it's long been characterized

274
00:14:45.140 --> 00:14:47.180
as one of the world's most livable cities.

275
00:14:47.180 --> 00:14:51.520
Kind of nested between the Pacific ocean and the mountains

276
00:14:53.260 --> 00:14:57.063
and in the Pacific Northwest it's, you know, beautiful.

277
00:14:58.830 --> 00:15:01.160
And that framing it's really overlooked the extent

278
00:15:01.160 --> 00:15:04.400
to which it's also a site of extreme social

279
00:15:04.400 --> 00:15:06.670
and structural inequalities.

280
00:15:06.670 --> 00:15:11.510
So the profits itself underwent a relatively rapid shift

281
00:15:11.510 --> 00:15:12.880
in the illicit drug supply.

282
00:15:12.880 --> 00:15:17.680
And it's long had a sustained heroin scene

283
00:15:18.970 --> 00:15:21.210
really stretching back decades.

284
00:15:21.210 --> 00:15:26.210
And, you know, effectively what we saw in really, you know,

285
00:15:27.000 --> 00:15:29.380
catalyzing in 2015,

286
00:15:29.380 --> 00:15:33.223
was the gradual replacement of heroin by fentanyl.

287
00:15:34.980 --> 00:15:37.163
First being sold alongside fentanyl,

288
00:15:38.090 --> 00:15:41.130
adulterated within fentanyl and then, you know,

289
00:15:41.130 --> 00:15:44.560
later becoming what one would just expect to find

290
00:15:44.560 --> 00:15:48.563
when purchasing illicit opioids in that context.

291
00:15:51.170 --> 00:15:53.990
And so this rapid escalation in overdose deaths

292
00:15:53.990 --> 00:15:57.700
led to the declaration of a public health emergency,

293
00:15:57.700 --> 00:16:00.450
which later created basically a pathway

294
00:16:00.450 --> 00:16:03.920
for the further scale-up of overdose prevention

295
00:16:03.920 --> 00:16:05.750
and response interventions.

296
00:16:05.750 --> 00:16:09.630
So Vancouver had long been side of, you know,

297
00:16:09.630 --> 00:16:13.740
I mentioned these trials looking at injectable opioids

298
00:16:13.740 --> 00:16:16.640
as an option for folks with opioid use disorder

299
00:16:16.640 --> 00:16:18.870
on through to supervise consumption

300
00:16:18.870 --> 00:16:20.743
or overdose prevention sites.

301
00:16:23.000 --> 00:16:25.510
And this emergency situation allowed these

302
00:16:25.510 --> 00:16:26.670
to be further scaled up.

303
00:16:26.670 --> 00:16:29.650
So we saw the rapid implementation, so sorry.

304
00:16:29.650 --> 00:16:33.020
So these are largely clustered in the Downtown Eastside

305
00:16:33.020 --> 00:16:37.060
which is see this bar of people always covers

306
00:16:37.060 --> 00:16:38.260
what I'm trying to find.

307
00:16:40.060 --> 00:16:44.823
This darken neighborhood toward the top of the map,

308
00:16:46.960 --> 00:16:49.680
which is about a 10 by 10 block neighborhood

309
00:16:49.680 --> 00:16:51.820
and the side of a lot of these interventions

310
00:16:51.820 --> 00:16:53.070
that I'll be speaking of.

311
00:16:58.200 --> 00:17:00.390
So this emergency order, you know,

312
00:17:00.390 --> 00:17:03.530
first activists began pushing for the opening

313
00:17:03.530 --> 00:17:04.990
or outright opening interventions

314
00:17:04.990 --> 00:17:07.610
including supervised consumption sites

315
00:17:07.610 --> 00:17:08.850
as part of the response,

316
00:17:08.850 --> 00:17:11.750
which are sites where people could use pre obtained drugs,

317
00:17:14.630 --> 00:17:17.030
which were later scaled up

318
00:17:17.030 --> 00:17:19.083
under the authority of the Province.

319
00:17:22.460 --> 00:17:24.050
Further involved the scale up

320
00:17:24.050 --> 00:17:26.540
of injectable treatment options

321
00:17:28.470 --> 00:17:32.003
and fentanyl testing strips and drug checking technologies.

322
00:17:34.720 --> 00:17:37.040
We saw the extension of these interventions

323
00:17:37.040 --> 00:17:39.130
into a variety of settings.

324
00:17:39.130 --> 00:17:41.610
So this is a shot of an emergency shelter

325
00:17:41.610 --> 00:17:44.060
that had adapted supervised consumption approaches

326
00:17:44.060 --> 00:17:47.653
into its setting to increase safety for folks staying there.

327
00:17:50.170 --> 00:17:53.070
And yet, even as these interventions were scaled up

328
00:17:53.070 --> 00:17:55.680
and, you know, public health modeling

329
00:17:55.680 --> 00:17:59.150
and other data showed a significant positive impact

330
00:17:59.150 --> 00:18:01.063
on overdose mortality.

331
00:18:02.740 --> 00:18:05.733
High rates of overdose is still persistent.

332
00:18:08.150 --> 00:18:12.350
Now certainly a large part of this

333
00:18:12.350 --> 00:18:17.350
was just the extreme shift within the drug supply

334
00:18:18.090 --> 00:18:21.350
and, you know, the fact that fentanyl

335
00:18:21.350 --> 00:18:25.580
had become the dominant opioid, later other adulterants

336
00:18:25.580 --> 00:18:27.820
entered the supply for sporadically

337
00:18:27.820 --> 00:18:30.940
and then more regularly from a tassel land

338
00:18:30.940 --> 00:18:34.700
periodically synthetic cannabinoids to occasionally Xylazine

339
00:18:34.700 --> 00:18:36.833
which is a tranquilizer.

340
00:18:38.700 --> 00:18:43.260
So there was this complex kinda mix within the local supply.

341
00:18:43.260 --> 00:18:47.280
Now, certainly a range of structural factors

342
00:18:47.280 --> 00:18:49.030
continued to drive overdoses

343
00:18:49.030 --> 00:18:52.810
in the setting, which we've looked at extensively.

344
00:18:52.810 --> 00:18:55.170
Things like policing strategies,

345
00:18:55.170 --> 00:18:57.610
which rocked in place-based and displaced people

346
00:18:57.610 --> 00:19:00.363
from overdose prevention and response interventions,

347
00:19:01.370 --> 00:19:05.010
high levels of poverty, which, you know,

348
00:19:05.010 --> 00:19:08.310
impact people's ability to manage drug use

349
00:19:08.310 --> 00:19:10.670
within the context of prohibition

350
00:19:10.670 --> 00:19:13.350
and can be a particularly dangerous mix

351
00:19:13.350 --> 00:19:16.673
in the context of a very toxic drug supply.

352
00:19:18.440 --> 00:19:21.110
On through to a range of other inequities

353
00:19:21.110 --> 00:19:25.163
that drive overdose related mortality.

354
00:19:26.040 --> 00:19:28.660
And so within this backdrop, I really cycle back

355
00:19:28.660 --> 00:19:30.050
to some of those early conversations

356
00:19:30.050 --> 00:19:31.980
that were happening within Activist Circles

357
00:19:31.980 --> 00:19:33.310
and in the sites where people

358
00:19:33.310 --> 00:19:36.470
were accessing safer places to use

359
00:19:36.470 --> 00:19:39.060
as the drug supply went sideways,

360
00:19:39.060 --> 00:19:41.670
and that was a push for safe supply.

361
00:19:41.670 --> 00:19:45.120
And so at its most basic level, you know,

362
00:19:45.120 --> 00:19:48.870
safe supplies laid out wonderfully in this concept document

363
00:19:48.870 --> 00:19:51.610
by the Canadian Association of People who Use Drugs

364
00:19:52.490 --> 00:19:54.230
which is effectively the safe supply

365
00:19:54.230 --> 00:19:56.900
refers to illegal unregulated supply of drugs

366
00:19:56.900 --> 00:19:58.600
with mind or body altering properties

367
00:19:58.600 --> 00:19:59.930
that traditionally have been accessible

368
00:19:59.930 --> 00:20:02.230
only through the illicit drug market.

369
00:20:02.230 --> 00:20:04.900
Drugs included are opioids such as heroin,

370
00:20:04.900 --> 00:20:08.063
stimulants such as cocaine and crystal methamphetamine,

371
00:20:09.360 --> 00:20:12.583
hallucinogens such as M.D.M.A and L.S.D and marijuana.

372
00:20:13.820 --> 00:20:16.530
So effectively, you know,

373
00:20:16.530 --> 00:20:21.530
what the concept of safe supply seeks to do

374
00:20:21.650 --> 00:20:24.580
is intervene mean to address overdoses

375
00:20:24.580 --> 00:20:28.570
driven by supply characterized by, you know,

376
00:20:28.570 --> 00:20:33.570
being toxic by fentanyl, high concentrations of fentanyl

377
00:20:34.660 --> 00:20:36.300
or other adulterants.

378
00:20:36.300 --> 00:20:38.360
By providing people with an alternative

379
00:20:38.360 --> 00:20:40.210
in a way that respects their agency

380
00:20:40.210 --> 00:20:42.660
and choice in relation to their drug use

381
00:20:42.660 --> 00:20:45.543
as well as the variety of ways in which people may use.

382
00:20:47.030 --> 00:20:52.030
And so this concept, you know, really came out of

383
00:20:52.800 --> 00:20:54.630
and I can't emphasize this enough,

384
00:20:54.630 --> 00:20:58.850
the work of Drug User Activists and Organizers.

385
00:20:58.850 --> 00:21:01.620
It later got pick up so here's a document

386
00:21:01.620 --> 00:21:03.870
that we've worked on at a center

387
00:21:03.870 --> 00:21:07.240
that I was asked slash still am affiliated with

388
00:21:07.240 --> 00:21:09.060
when we pick up this idea and think about it

389
00:21:09.060 --> 00:21:11.270
in the context of Compassion Club Models

390
00:21:11.270 --> 00:21:16.270
that could provide people with safer access, you know,

391
00:21:16.450 --> 00:21:20.510
and quickly this became part of a larger discussion

392
00:21:20.510 --> 00:21:23.510
happening within the academic literature.

393
00:21:23.510 --> 00:21:26.650
First as something that has a critical role

394
00:21:26.650 --> 00:21:29.440
in addressing the overdose crisis,

395
00:21:29.440 --> 00:21:32.500
on through to something that also could address harms

396
00:21:32.500 --> 00:21:35.930
driven by escalating stimulant overdoses

397
00:21:35.930 --> 00:21:37.470
that include in some cases,

398
00:21:37.470 --> 00:21:40.513
those driven by fentanyl adulterated stimulants,

399
00:21:42.530 --> 00:21:44.520
on through to, and I think one of the coauthors

400
00:21:44.520 --> 00:21:45.943
of this is on this call.

401
00:21:47.680 --> 00:21:51.020
On through to something that could play a critical role

402
00:21:51.020 --> 00:21:53.470
in responding to an escalation and overdoses

403
00:21:53.470 --> 00:21:56.810
that have happened under conditions imposed by COVID-19

404
00:21:56.810 --> 00:21:59.323
especially wherein people are injecting alone.

405
00:22:02.960 --> 00:22:05.140
And more recently on through to some,

406
00:22:05.140 --> 00:22:07.920
an approach that could, you know,

407
00:22:07.920 --> 00:22:12.530
rethink the ways in which Drug Policy operates globally

408
00:22:12.530 --> 00:22:16.740
and could effectively trace a pathway for redressing

409
00:22:16.740 --> 00:22:20.530
some of the harms caused by the war on drugs

410
00:22:20.530 --> 00:22:22.500
specifically by involving folks

411
00:22:22.500 --> 00:22:25.880
who have been disproportionately impacted

412
00:22:25.880 --> 00:22:30.670
by this in production and export to markets

413
00:22:30.670 --> 00:22:34.060
with a need for safer pharmaceutical,

414
00:22:34.060 --> 00:22:36.663
alternatives and legalize options.

415
00:22:38.750 --> 00:22:40.610
And so, you know, by and large,

416
00:22:40.610 --> 00:22:43.490
this was really just a concept circulating within circles

417
00:22:43.490 --> 00:22:45.230
as people were working behind the scenes

418
00:22:45.230 --> 00:22:46.893
as an effort to scale these up.

419
00:22:47.730 --> 00:22:51.180
But what they effectively did is extend a longstanding logic

420
00:22:51.180 --> 00:22:55.360
that, you know, opioids especially

421
00:22:55.360 --> 00:23:00.360
are part of the response to the harms of overdose.

422
00:23:01.470 --> 00:23:06.253
So certainly there's a Cochrane review.

423
00:23:07.210 --> 00:23:09.590
They really helps to establish the efficacy

424
00:23:09.590 --> 00:23:14.030
of heroin maintenance or heroin based treatment

425
00:23:14.030 --> 00:23:16.570
for folks who are heroin dependent,

426
00:23:16.570 --> 00:23:19.810
as something in this particular review

427
00:23:19.810 --> 00:23:23.690
as a kind of add on therapy to methadone,

428
00:23:23.690 --> 00:23:26.070
but that cannot reduce engagement

429
00:23:26.070 --> 00:23:29.290
with an illicit drug supply.

430
00:23:29.290 --> 00:23:32.360
On through to work that is further established

431
00:23:32.360 --> 00:23:37.360
its effectiveness in minimizing engagement

432
00:23:37.720 --> 00:23:40.360
in what often get characterized

433
00:23:40.360 --> 00:23:42.680
as social harms associated with drug use

434
00:23:45.860 --> 00:23:48.663
such as engagement in criminal activity, et cetera,

435
00:23:50.110 --> 00:23:53.520
and certainly further trial work that is even established it

436
00:23:53.520 --> 00:23:55.690
as potentially superior to methadone

437
00:23:55.690 --> 00:23:57.830
for the treatment of opioid use.

438
00:23:57.830 --> 00:24:00.030
This trial in the New England Journal

439
00:24:00.900 --> 00:24:05.500
finding it effectively to be superior for folks

440
00:24:06.620 --> 00:24:09.130
who had not previously benefited from methadone,

441
00:24:09.130 --> 00:24:12.210
on through to more recent work,

442
00:24:12.210 --> 00:24:14.250
through a trial where they compared heroin

443
00:24:14.250 --> 00:24:18.113
to hydromorphone further establishing that as an Option.

444
00:24:19.340 --> 00:24:22.810
And so effectively, you know, people are bringing up this

445
00:24:22.810 --> 00:24:25.780
and pushing for this, this need for a shift

446
00:24:25.780 --> 00:24:30.610
toward access to better regulated safer opioids.

447
00:24:30.610 --> 00:24:34.870
And so, you know, eventually we saw programs implemented

448
00:24:34.870 --> 00:24:36.603
on a pilot level,

449
00:24:38.320 --> 00:24:40.630
which is partly what I'll be focusing on

450
00:24:42.280 --> 00:24:43.790
based on work that we've been doing.

451
00:24:43.790 --> 00:24:47.520
So here you see a shot of an overdose prevention site,

452
00:24:47.520 --> 00:24:49.130
the Molson overdose prevention site

453
00:24:49.130 --> 00:24:51.383
in Vancouver's Downtown Eastside.

454
00:24:53.360 --> 00:24:55.470
And it implemented a program wherein

455
00:24:55.470 --> 00:24:57.180
people could be referred in through

456
00:24:57.180 --> 00:25:00.830
and were effectively followed through primary care,

457
00:25:00.830 --> 00:25:05.830
but could be effectively dispensed two mil, eight milligram

458
00:25:06.210 --> 00:25:10.220
tablets of hydromorphone to five times a day

459
00:25:10.220 --> 00:25:11.350
during the operating hours

460
00:25:11.350 --> 00:25:13.450
of the overdose prevention site,

461
00:25:13.450 --> 00:25:16.080
so as to limit their engagement

462
00:25:16.080 --> 00:25:18.060
with the illicit drug supply.

463
00:25:18.060 --> 00:25:19.940
And so you'll notice this,

464
00:25:19.940 --> 00:25:21.890
I don't know if you can see my pointer,

465
00:25:23.110 --> 00:25:27.550
but so folks would effectively come into the space

466
00:25:27.550 --> 00:25:31.090
through this door above the text box.

467
00:25:31.090 --> 00:25:33.680
And you know, this is an open overdose prevention site

468
00:25:33.680 --> 00:25:38.350
wherein folks are able to effectively ingest

469
00:25:38.350 --> 00:25:41.240
with the exception of by inhalation

470
00:25:42.360 --> 00:25:43.560
drugs that they bring in

471
00:25:43.560 --> 00:25:46.010
or if registered in this program

472
00:25:46.010 --> 00:25:48.480
associate with the Primary Care Clinic

473
00:25:48.480 --> 00:25:52.120
could effectively pick up hydromorphone dispense

474
00:25:52.120 --> 00:25:55.253
through this nursing window and use onsite.

475
00:25:59.720 --> 00:26:04.720
Now, still later further program was implemented

476
00:26:08.240 --> 00:26:10.130
really just prior to COVID hitting

477
00:26:12.620 --> 00:26:16.310
wherein people could similarly access effectively

478
00:26:16.310 --> 00:26:18.340
an equivalent amount of hydromorphone

479
00:26:19.290 --> 00:26:22.030
through a still lower threshold method

480
00:26:22.030 --> 00:26:24.590
which was effectively, I mean,

481
00:26:24.590 --> 00:26:26.670
it's basically a vending machine

482
00:26:26.670 --> 00:26:28.640
that takes a biometric reading

483
00:26:28.640 --> 00:26:31.690
wherein someone would effectively place their hand

484
00:26:31.690 --> 00:26:36.100
on the screen, and then they would be dispensed

485
00:26:37.080 --> 00:26:40.710
hydromorphone in accordance with their prescription

486
00:26:40.710 --> 00:26:42.103
and dosage schedule.

487
00:26:43.530 --> 00:26:46.520
And so this later within the context of COVID

488
00:26:46.520 --> 00:26:50.260
and the serious concerns of what, I mean,

489
00:26:50.260 --> 00:26:53.240
frankly ended up happening with an escalation of overdose

490
00:26:54.480 --> 00:26:57.940
into prescribing guidance documents

491
00:26:57.940 --> 00:27:00.410
for the Province of British Columbia

492
00:27:00.410 --> 00:27:03.190
to further allow providers

493
00:27:03.190 --> 00:27:06.940
to outright prescribe hydromorphone

494
00:27:06.940 --> 00:27:09.547
and then also Dexedrine and mesocolon

495
00:27:09.547 --> 00:27:13.340
to folks for the purposes of

496
00:27:13.340 --> 00:27:15.790
still further limiting potential engagement

497
00:27:15.790 --> 00:27:17.860
with a drug supply that, you know,

498
00:27:17.860 --> 00:27:21.113
certainly in the lead up to COVID had become even more,

499
00:27:23.720 --> 00:27:25.070
I mean, I wanna say erratic,

500
00:27:25.070 --> 00:27:26.890
but there's certainly much more direct language

501
00:27:26.890 --> 00:27:29.453
I could use to to characterize what was happening.

502
00:27:31.270 --> 00:27:33.500
And the deep concern about, you know,

503
00:27:33.500 --> 00:27:35.210
an escalation of overdose deaths

504
00:27:35.210 --> 00:27:37.843
that you know, frankly has subsequently born out.

505
00:27:39.290 --> 00:27:41.010
And so I'm gonna really talk about

506
00:27:41.010 --> 00:27:43.940
some of the work we've done, looking at the implementation

507
00:27:43.940 --> 00:27:47.770
and effectiveness of these programs for folks

508
00:27:47.770 --> 00:27:49.840
drawing on Ethnographic Fieldwork

509
00:27:49.840 --> 00:27:51.920
and qualitative interviews.

510
00:27:51.920 --> 00:27:54.710
And so that site, the most, an overdose prevention site,

511
00:27:54.710 --> 00:27:56.910
implementing the hydromorphone distribution program.

512
00:27:56.910 --> 00:28:00.620
So we've done extensive ethnographic fieldwork at that site,

513
00:28:00.620 --> 00:28:02.330
including with a specific focus

514
00:28:02.330 --> 00:28:04.503
on the hydromorphone distribution program.

515
00:28:05.650 --> 00:28:08.550
Observing its operation, spending time around it,

516
00:28:08.550 --> 00:28:11.590
interacting with folks, accessing or trying to access it

517
00:28:11.590 --> 00:28:13.430
to get a sense of how it both fits

518
00:28:13.430 --> 00:28:16.800
into people's daily routines and lives

519
00:28:16.800 --> 00:28:18.930
and its impacts on them.

520
00:28:18.930 --> 00:28:19.990
And then alongside that,

521
00:28:19.990 --> 00:28:22.540
we were effectively interviewing as many folks as we could

522
00:28:22.540 --> 00:28:24.350
enroll through that program

523
00:28:26.710 --> 00:28:28.780
to get a further sense of its impacts.

524
00:28:28.780 --> 00:28:32.390
Now we started these interviews and then COVID hit

525
00:28:32.390 --> 00:28:36.400
so our followup rate certainly dropped down.

526
00:28:36.400 --> 00:28:39.390
We interviewed 42 of the then 69 folks

527
00:28:39.390 --> 00:28:42.100
who had been enrolled in the program

528
00:28:42.100 --> 00:28:46.830
and I wanna say we got 16 for followup

529
00:28:48.720 --> 00:28:52.320
before suspending activities due to due to COVID.

530
00:28:52.320 --> 00:28:53.270
And then alongside that,

531
00:28:53.270 --> 00:28:56.420
we've more recently been doing interviews with folks

532
00:28:56.420 --> 00:29:01.420
we're at 22 right now, accessing safe supply

533
00:29:01.540 --> 00:29:03.870
through the risk mitigation guidelines,

534
00:29:03.870 --> 00:29:05.853
implemented post-COVID.

535
00:29:08.910 --> 00:29:11.410
And so what really concerned with

536
00:29:11.410 --> 00:29:15.010
in this work is how broader factors

537
00:29:15.010 --> 00:29:17.900
are impacting the implementation of the program.

538
00:29:17.900 --> 00:29:20.620
So how dynamics within the risk environments

539
00:29:20.620 --> 00:29:22.630
of folks who use drugs.

540
00:29:22.630 --> 00:29:27.400
So this complex assemblage of social, physical, economic

541
00:29:29.130 --> 00:29:32.210
and policy factors that shape the situations

542
00:29:32.210 --> 00:29:34.390
or settings in which people use drugs

543
00:29:34.390 --> 00:29:39.100
including their ability to access safe supply.

544
00:29:39.100 --> 00:29:42.720
And then further considering differential impacts

545
00:29:45.880 --> 00:29:47.200
on folks who use drugs

546
00:29:47.200 --> 00:29:49.620
on the basis of their social position.

547
00:29:49.620 --> 00:29:53.720
So how relational aspects of their identities,

548
00:29:53.720 --> 00:29:56.220
experiences and positions on the basis of things,

549
00:29:56.220 --> 00:30:00.680
like age, class, sexuality, gender, race, ability,

550
00:30:00.680 --> 00:30:04.280
citizenship status, kind of act in relation

551
00:30:04.280 --> 00:30:05.750
to these broader sets of factors

552
00:30:05.750 --> 00:30:06.760
within the risk environment

553
00:30:06.760 --> 00:30:09.343
to shape their specific sets of experiences.

554
00:30:19.130 --> 00:30:22.640
And so I'll be sharing some findings from the first round

555
00:30:22.640 --> 00:30:24.063
on the Molson risk prevention site,

556
00:30:24.063 --> 00:30:25.670
as well as emerging findings

557
00:30:25.670 --> 00:30:26.700
based on the work we've been doing

558
00:30:26.700 --> 00:30:28.453
on the Risk Mitigation Guidelines.

559
00:30:29.860 --> 00:30:30.693
And so the first thing

560
00:30:30.693 --> 00:30:33.100
and I can't emphasize emphasize this enough

561
00:30:33.100 --> 00:30:36.850
because it became certainly a thing

562
00:30:36.850 --> 00:30:39.740
that impacted how we thought about these programs early on.

563
00:30:39.740 --> 00:30:41.390
And that quite simply was the question

564
00:30:41.390 --> 00:30:42.630
of whether or not these programs

565
00:30:42.630 --> 00:30:46.083
can attract folks who use drugs.

566
00:30:47.040 --> 00:30:48.780
And what we effectively found

567
00:30:48.780 --> 00:30:51.170
is that people are highly motivated

568
00:30:51.170 --> 00:30:54.770
to access alternatives to the illicit drug supply.

569
00:30:54.770 --> 00:30:57.540
And low threshold access to pharmaceutical alternatives

570
00:30:57.540 --> 00:31:01.130
in particular, can reduce their potential exposure

571
00:31:01.130 --> 00:31:04.990
to fentanyl and other adulterants.

572
00:31:04.990 --> 00:31:08.730
So effectively, what we found is that people

573
00:31:08.730 --> 00:31:11.000
would often describe their motivation

574
00:31:11.000 --> 00:31:13.990
for accessing the program as being specifically driven

575
00:31:13.990 --> 00:31:17.770
by concerns with the illicit drug supply.

576
00:31:17.770 --> 00:31:20.120
So there have at times been narratives

577
00:31:20.120 --> 00:31:21.610
around fentanyl seeking

578
00:31:21.610 --> 00:31:24.693
within the context of the overdose crisis.

579
00:31:25.690 --> 00:31:27.300
And while people's use of fentanyl

580
00:31:27.300 --> 00:31:32.010
was exceedingly complex shaped by opioid tolerance,

581
00:31:32.010 --> 00:31:34.553
environmental conditions and exposure,

582
00:31:35.560 --> 00:31:38.070
we found that people had deep concerns

583
00:31:38.070 --> 00:31:42.090
about potentially being exposed to drugs

584
00:31:42.090 --> 00:31:44.040
that contained more fentanyl

585
00:31:44.040 --> 00:31:46.760
than they might expect an air ago,

586
00:31:46.760 --> 00:31:49.490
heightening their potential risk of overdose

587
00:31:51.450 --> 00:31:52.995
as well as other adulterants

588
00:31:52.995 --> 00:31:54.823
that were showing up in the supply.

589
00:31:57.520 --> 00:31:59.860
And People in turn reported that they

590
00:31:59.860 --> 00:32:01.540
in accessing this program,

591
00:32:01.540 --> 00:32:04.860
weren't as reliant on accessing the drug supply.

592
00:32:04.860 --> 00:32:08.810
Now one of our participants put it as such.

593
00:32:08.810 --> 00:32:12.200
Now I'm on this hydromorphone program.

594
00:32:12.200 --> 00:32:14.230
It's changing my drug use a lot actually.

595
00:32:14.230 --> 00:32:17.010
Like I went from using fentanyl five to 10 times a day

596
00:32:17.010 --> 00:32:18.550
to using once a day.

597
00:32:18.550 --> 00:32:21.490
So in the last month I've gone down to just once a day,

598
00:32:21.490 --> 00:32:23.990
twice a day, and that's good.

599
00:32:23.990 --> 00:32:27.700
So certainly, and I'll touch on this in a bit

600
00:32:27.700 --> 00:32:29.590
within the context of, you know,

601
00:32:29.590 --> 00:32:32.140
programs operating within a limited timeframe

602
00:32:32.140 --> 00:32:33.360
around the operating hours

603
00:32:33.360 --> 00:32:35.650
of the overdose prevention site,

604
00:32:35.650 --> 00:32:37.630
and certainly people's lives were complex

605
00:32:37.630 --> 00:32:39.810
and would sometimes place them

606
00:32:39.810 --> 00:32:41.440
in places where they couldn't access it

607
00:32:41.440 --> 00:32:42.410
when needing to use.

608
00:32:42.410 --> 00:32:45.390
People nonetheless reported that they were using

609
00:32:48.100 --> 00:32:52.160
illicit drugs less often because they had an alternative

610
00:32:52.160 --> 00:32:56.040
and that they saw this as a chief benefit of the program.

611
00:32:56.040 --> 00:32:59.660
Now, alongside this motivation that people had

612
00:32:59.660 --> 00:33:03.970
to access the program, certainly we observed demand

613
00:33:03.970 --> 00:33:07.630
far exceeding the ability of the site

614
00:33:07.630 --> 00:33:09.410
and the attached Primary Care Group

615
00:33:09.410 --> 00:33:13.040
to effectively enroll people quickly enough to,

616
00:33:13.040 --> 00:33:15.070
and, you know, with sufficient capacity

617
00:33:15.070 --> 00:33:20.070
to provide support in this program.

618
00:33:20.950 --> 00:33:24.240
It wasn't unusual to be doing field work at the site

619
00:33:24.240 --> 00:33:25.650
and have someone show up

620
00:33:26.740 --> 00:33:28.590
wanting to get on the program immediately

621
00:33:28.590 --> 00:33:31.730
because they needed, you know,

622
00:33:31.730 --> 00:33:35.240
something to mitigate withdrawal experiences

623
00:33:35.240 --> 00:33:38.533
which can cause severe pain and discomfort.

624
00:33:41.069 --> 00:33:44.520
And you know, who yet weren't able to enroll at that time.

625
00:33:44.520 --> 00:33:48.260
So certainly, you know, people want it on this.

626
00:33:48.260 --> 00:33:50.840
They wanted to reduce their exposure to fentanyl

627
00:33:50.840 --> 00:33:53.303
and the program couldn't keep up with demand.

628
00:33:56.410 --> 00:34:01.410
Now certainly we found that access to a reliable supply

629
00:34:02.080 --> 00:34:05.370
of pharmaceutical alternatives to the illicit drug supply,

630
00:34:05.370 --> 00:34:07.300
enabled people to minimize their engagement

631
00:34:07.300 --> 00:34:08.793
in drug scene activities.

632
00:34:10.440 --> 00:34:12.960
It also helped them establish drug use routines

633
00:34:12.960 --> 00:34:16.590
that help them to maintain their health and well-being.

634
00:34:16.590 --> 00:34:19.743
And so specifically, you know,

635
00:34:21.410 --> 00:34:24.580
people didn't have to generate the income or funds

636
00:34:24.580 --> 00:34:26.150
that they often would have to

637
00:34:26.150 --> 00:34:29.490
through informal or illegal income generation

638
00:34:29.490 --> 00:34:32.600
so as to purchase illicit opioids

639
00:34:32.600 --> 00:34:34.700
within the local drugs scene.

640
00:34:34.700 --> 00:34:36.660
And so people really emphasize

641
00:34:36.660 --> 00:34:39.950
the positive impact on their lives, both in terms of

642
00:34:39.950 --> 00:34:44.093
and especially for folks who are racialized or minoritized,

643
00:34:46.250 --> 00:34:48.660
how this limited their potential exposure

644
00:34:48.660 --> 00:34:50.910
or engagement with police

645
00:34:50.910 --> 00:34:55.910
and further engagement in carceral systems.

646
00:34:57.870 --> 00:35:01.210
Especially for women who are accessing the program

647
00:35:01.210 --> 00:35:03.570
they really emphasized in many cases

648
00:35:03.570 --> 00:35:07.760
that they were able to reduce or, you know,

649
00:35:07.760 --> 00:35:11.320
effectively stop engagement with sex work

650
00:35:14.020 --> 00:35:16.010
which for many was driven by their need

651
00:35:16.010 --> 00:35:21.010
to generate money to maintain their opioid use

652
00:35:22.770 --> 00:35:25.303
within the context of drug prohibition.

653
00:35:28.400 --> 00:35:31.130
One of our participants put it quite directly, you know,

654
00:35:31.130 --> 00:35:34.030
when I used to run out of money, I would do crime, right?

655
00:35:34.030 --> 00:35:34.863
So that stopped.

656
00:35:34.863 --> 00:35:36.150
I'm not running out of money

657
00:35:36.150 --> 00:35:38.300
because this hydromorphone is free, right?

658
00:35:38.300 --> 00:35:39.780
That's a big bonus for me.

659
00:35:39.780 --> 00:35:43.200
I don't have to decide between eating and doing dope, right?

660
00:35:43.200 --> 00:35:46.263
I can do my dope here and then go eat, it's working fine.

661
00:35:47.390 --> 00:35:50.670
And you know, this further really hits on the point

662
00:35:50.670 --> 00:35:52.550
that, you know, people talked about, you know,

663
00:35:52.550 --> 00:35:55.440
the extreme time and energy

664
00:35:55.440 --> 00:35:58.590
and work that goes into managing opioid use

665
00:35:58.590 --> 00:36:00.980
within the context of severe poverty

666
00:36:00.980 --> 00:36:03.630
and the war on drugs, you know,

667
00:36:03.630 --> 00:36:06.310
effectively meant that people had to make these trade offs.

668
00:36:06.310 --> 00:36:08.610
And so people were better able to attend to things

669
00:36:08.610 --> 00:36:10.160
that were critical to their health and well-being

670
00:36:10.160 --> 00:36:11.783
like quite simply eating.

671
00:36:13.980 --> 00:36:16.180
You know, and benefit for many people,

672
00:36:16.180 --> 00:36:18.710
so a number of people were what we might consider

673
00:36:18.710 --> 00:36:20.650
orphan pain patients who had previously

674
00:36:20.650 --> 00:36:24.240
been on long-term opioid therapies before being cut off.

675
00:36:24.240 --> 00:36:26.310
And a lot of these folks would specifically

676
00:36:26.310 --> 00:36:29.270
emphasize the positive impacts on pain management

677
00:36:29.270 --> 00:36:32.683
to have routine access to opioids.

678
00:36:34.723 --> 00:36:37.340
So this one person started accessing the program

679
00:36:37.340 --> 00:36:42.340
and injecting before moving to oral ingestion.

680
00:36:42.780 --> 00:36:43.890
So I was doing the injections,

681
00:36:43.890 --> 00:36:44.950
but now I'm doing the oral

682
00:36:44.950 --> 00:36:47.400
which is two pills I get of Dilaudid

683
00:36:47.400 --> 00:36:48.620
and it helps me with pain.

684
00:36:48.620 --> 00:36:51.794
The last time I was in hospital, I got some oral Dilaudid

685
00:36:51.794 --> 00:36:53.000
and I liked it, it helped me a lot.

686
00:36:53.000 --> 00:36:54.680
So I was looking forward to it.

687
00:36:54.680 --> 00:36:55.940
I thought I'd like the injections,

688
00:36:55.940 --> 00:36:58.120
but it turns out I liked the oral better.

689
00:36:58.120 --> 00:37:01.580
And so this was a common sentiment in that, you know,

690
00:37:01.580 --> 00:37:03.970
people reported severe chronic,

691
00:37:03.970 --> 00:37:06.990
and in some cases acute pain that they further felt

692
00:37:06.990 --> 00:37:10.273
that this program was critical in helping them manage.

693
00:37:12.360 --> 00:37:15.100
Now certainly the one thing that we found,

694
00:37:15.100 --> 00:37:20.100
so, you know, if we think back to that Canadian Association

695
00:37:20.330 --> 00:37:23.030
of People who Use Drugs, framing, you know,

696
00:37:23.030 --> 00:37:25.970
what we're effectively talking about as a regulated

697
00:37:25.970 --> 00:37:29.480
or legal market for drugs as an alternative,

698
00:37:29.480 --> 00:37:31.320
and yet both in terms of this

699
00:37:31.320 --> 00:37:33.290
hydromorphone distribution program

700
00:37:33.290 --> 00:37:36.653
and still later the risk mitigation guidelines,

701
00:37:38.170 --> 00:37:41.800
you know, these are being delivered through Primary Care.

702
00:37:41.800 --> 00:37:45.660
And what we've effectively found is that the medicalization

703
00:37:45.660 --> 00:37:47.200
of approaches to safe supply

704
00:37:47.200 --> 00:37:50.690
has actually constrained the effectiveness of this approach.

705
00:37:50.690 --> 00:37:52.580
And it's done this in a number of ways

706
00:37:52.580 --> 00:37:56.460
both through misaligning the intervention design

707
00:37:56.460 --> 00:37:58.393
and the underpinning philosophy.

708
00:38:00.130 --> 00:38:02.410
And, you know, subsequent to that,

709
00:38:02.410 --> 00:38:04.363
not fully meeting people's needs.

710
00:38:06.030 --> 00:38:08.030
And so there's really kind of three points here

711
00:38:08.030 --> 00:38:09.510
that I like to emphasize.

712
00:38:09.510 --> 00:38:13.250
So first is that, you know, primarily

713
00:38:13.250 --> 00:38:15.070
and especially opioid prescribing

714
00:38:15.070 --> 00:38:16.720
within the context of these programs

715
00:38:16.720 --> 00:38:19.390
has had an emphasis on withdrawal management.

716
00:38:19.390 --> 00:38:21.580
That is effectively prescribing people

717
00:38:21.580 --> 00:38:25.090
on amount that isn't necessarily aligned

718
00:38:25.090 --> 00:38:30.090
or kind of a match for the level of illicit opioids

719
00:38:30.180 --> 00:38:33.760
that they're using especially within the context of fentanyl

720
00:38:33.760 --> 00:38:35.960
and fentanyl injecting.

721
00:38:35.960 --> 00:38:39.730
And people often, you know, reported that

722
00:38:39.730 --> 00:38:42.120
what they'd received was effectively enough to

723
00:38:42.120 --> 00:38:44.240
you know, in some cases, you know,

724
00:38:44.240 --> 00:38:46.860
mostly if not totally allow them

725
00:38:46.860 --> 00:38:50.163
to not experience dope sickness.

726
00:38:51.130 --> 00:38:53.160
But not necessarily get the high

727
00:38:53.160 --> 00:38:54.960
that they may be looking for.

728
00:38:54.960 --> 00:38:57.240
And certainly there's deep questions

729
00:38:57.240 --> 00:39:00.840
of agency and choice in the context of substance use

730
00:39:00.840 --> 00:39:05.600
that this raises in so far as, and especially

731
00:39:05.600 --> 00:39:09.300
within the context of severe social suffering, you know,

732
00:39:09.300 --> 00:39:11.970
the pleasure associated with drugs is something

733
00:39:11.970 --> 00:39:15.170
that warrants attention and, you know,

734
00:39:15.170 --> 00:39:18.040
maybe should prompt us to rethink our approach

735
00:39:18.040 --> 00:39:20.070
to prescribing, so as to allow people

736
00:39:20.070 --> 00:39:22.273
to have experiences that they may wish for.

737
00:39:24.330 --> 00:39:27.763
Second enrollment is not meeting demands.

738
00:39:29.160 --> 00:39:30.750
We saw this both in the context

739
00:39:30.750 --> 00:39:33.430
of the hydromorphone distribution program

740
00:39:33.430 --> 00:39:36.070
wherein people were routinely showing up

741
00:39:36.070 --> 00:39:39.830
hoping to get on the program, you know,

742
00:39:39.830 --> 00:39:42.430
being in withdraw and subsequent to that

743
00:39:42.430 --> 00:39:45.610
at an extreme risk of purchasing illicit opioids

744
00:39:45.610 --> 00:39:49.460
and using within context that may heighten

745
00:39:49.460 --> 00:39:53.150
their potential risk of overdose,

746
00:39:53.150 --> 00:39:56.283
having to rush injecting or not do a test for a shot.

747
00:39:59.660 --> 00:40:03.650
And effectively the program needed scale up

748
00:40:05.140 --> 00:40:08.440
to meet the severe demand for the program.

749
00:40:08.440 --> 00:40:10.910
And then second, you know, within the context

750
00:40:10.910 --> 00:40:13.770
of the implementation of risk mitigation guidelines,

751
00:40:13.770 --> 00:40:16.410
you know, what we've effectively see is

752
00:40:17.370 --> 00:40:20.630
you know, the number of people on the program

753
00:40:20.630 --> 00:40:22.710
is only a small fraction of the number of folks

754
00:40:22.710 --> 00:40:24.550
who may be eligible.

755
00:40:24.550 --> 00:40:27.380
And so within the context of a drug supply

756
00:40:27.380 --> 00:40:30.480
that's gone further sideways, especially with the estazolam,

757
00:40:30.480 --> 00:40:34.180
which is a benzo showing up in addition to fentanyl

758
00:40:34.180 --> 00:40:36.240
within the illicit opioids supply,

759
00:40:36.240 --> 00:40:38.853
a rapid escalation of overdose deaths.

760
00:40:39.830 --> 00:40:42.850
And so enrollment, I believe is hovering around

761
00:40:42.850 --> 00:40:46.210
three and a half to 4,000 right now,

762
00:40:46.210 --> 00:40:49.190
where there's a potentially up to 70,000 people

763
00:40:49.190 --> 00:40:52.460
in the Province who may be eligible for the program.

764
00:40:52.460 --> 00:40:55.110
And so certainly in the interviews

765
00:40:55.110 --> 00:40:56.330
that we've been doing with people

766
00:40:56.330 --> 00:40:57.900
about their experiences of getting on

767
00:40:57.900 --> 00:41:00.780
or trying to get on this program, we're finding that people

768
00:41:00.780 --> 00:41:03.490
are encountering Primary Care Providers

769
00:41:05.640 --> 00:41:08.790
unwilling to pick up these guidance documents

770
00:41:08.790 --> 00:41:13.540
and provide them with alternatives to a toxic drug supply.

771
00:41:13.540 --> 00:41:18.540
And while certainly it is important that, you know,

772
00:41:18.800 --> 00:41:21.490
treatment options be made available, you know,

773
00:41:21.490 --> 00:41:25.560
for those not wanting to go on those, you know,

774
00:41:25.560 --> 00:41:29.713
they're really being put in a horrible risk.

775
00:41:30.840 --> 00:41:32.750
Finally, you know, the majority of folks

776
00:41:32.750 --> 00:41:37.510
who've been accessing through the Risk Mitigation Guidelines

777
00:41:37.510 --> 00:41:40.100
have, you know, effectively been required

778
00:41:40.100 --> 00:41:43.703
to pick up their drugs in the pharmacy every day.

779
00:41:44.790 --> 00:41:47.640
And so this has raised concerns for people

780
00:41:47.640 --> 00:41:48.770
both within the context

781
00:41:48.770 --> 00:41:51.660
of managing potential exposure to COVID.

782
00:41:51.660 --> 00:41:55.670
As you know, I think we collectively know, you know,

783
00:41:55.670 --> 00:41:59.470
COVID has disproportionately impacted vulnerable communities

784
00:41:59.470 --> 00:42:01.120
and especially folks who use drugs,

785
00:42:01.120 --> 00:42:03.430
grappling with multiple other structural vulnerabilities,

786
00:42:03.430 --> 00:42:08.330
including, you know, housing vulnerability and poverty

787
00:42:08.330 --> 00:42:11.140
as well as, you know, racial discrimination

788
00:42:11.140 --> 00:42:13.700
within a variety of systems.

789
00:42:13.700 --> 00:42:17.470
And so these placed a burden on people that, you know,

790
00:42:17.470 --> 00:42:19.560
what's concerning within the context of COVID

791
00:42:19.560 --> 00:42:22.943
but was also difficult to meet at times, given, you know,

792
00:42:23.970 --> 00:42:26.943
just all of the other things happening in people's lives.

793
00:42:28.190 --> 00:42:31.370
And so certainly, you know, we've gone

794
00:42:31.370 --> 00:42:35.920
from a model originally envisioned it is quite flexible

795
00:42:35.920 --> 00:42:38.170
and low threshold to one that, you know,

796
00:42:38.170 --> 00:42:40.350
still while representing an advance

797
00:42:40.350 --> 00:42:44.090
in available interventions for

798
00:42:44.090 --> 00:42:46.210
in the context of the overdose crisis

799
00:42:46.210 --> 00:42:49.010
this still might have thresholds that exceed that

800
00:42:49.010 --> 00:42:50.560
which people were able to meet.

801
00:42:51.820 --> 00:42:53.830
And so if folks are interested in learning more,

802
00:42:53.830 --> 00:42:55.710
we published a couple of papers already

803
00:42:55.710 --> 00:42:57.210
based on the work

804
00:42:58.340 --> 00:43:00.760
around the hydromorphone distribution program

805
00:43:00.760 --> 00:43:05.760
at the Molson overdose prevention site, you know.

806
00:43:06.100 --> 00:43:08.020
And just to cycle back.

807
00:43:08.020 --> 00:43:12.980
So, you know, we're effectively in an era

808
00:43:12.980 --> 00:43:17.980
characterized by severe overdose related mortality,

809
00:43:18.130 --> 00:43:22.190
driven by a toxic drug supply associated with fentanyl

810
00:43:22.190 --> 00:43:23.510
and other adulterants.

811
00:43:23.510 --> 00:43:26.050
You know Connecticut is an example, you know,

812
00:43:26.050 --> 00:43:31.050
13% of overdose deaths involved Xylazine in 2020.

813
00:43:31.660 --> 00:43:33.860
And certainly this raises concerns

814
00:43:33.860 --> 00:43:36.870
about how can we effectively intervene.

815
00:43:36.870 --> 00:43:39.320
Now, certainly the further scale up

816
00:43:39.320 --> 00:43:41.240
of evidence-based treatment options

817
00:43:41.240 --> 00:43:43.370
and medications for opioid use disorder

818
00:43:43.370 --> 00:43:46.180
like buprenorphine and methadone,

819
00:43:46.180 --> 00:43:48.710
represent aN important priority.

820
00:43:48.710 --> 00:43:51.970
I think we also need to start asking ourselves, you know,

821
00:43:51.970 --> 00:43:55.770
what are we doing for folks who aren't able to access these

822
00:43:55.770 --> 00:43:59.260
or don't have interest in accessing these treatment options?

823
00:43:59.260 --> 00:44:04.260
And effectively safe supply, you know, could be that thing.

824
00:44:04.690 --> 00:44:06.010
And very much 'cause I think

825
00:44:06.010 --> 00:44:08.320
the Vancouver experience points to

826
00:44:08.320 --> 00:44:12.460
is something that can work for people and is feasible.

827
00:44:12.460 --> 00:44:17.110
And certainly, you know, rather than asking ourselves

828
00:44:17.110 --> 00:44:19.570
whether we should prioritize one thing over the other,

829
00:44:19.570 --> 00:44:23.300
you know, we're losing tens of thousands of people a year.

830
00:44:23.300 --> 00:44:26.450
And I think what we effectively need to reflect back on

831
00:44:26.450 --> 00:44:29.880
is within the context of such severe suffering

832
00:44:32.200 --> 00:44:34.900
and loss, you know.

833
00:44:34.900 --> 00:44:38.200
We need to be doing everything that we can, and, you know,

834
00:44:38.200 --> 00:44:42.350
this represents one potential pathway forward

835
00:44:42.350 --> 00:44:47.350
specifically important for folks whom if not on methadone

836
00:44:47.810 --> 00:44:50.410
or not on buprenorphine, you know,

837
00:44:50.410 --> 00:44:53.830
right now in the U.S have no other options

838
00:44:53.830 --> 00:44:57.760
than to to roll the dice each time they purchase and use

839
00:44:57.760 --> 00:44:59.123
and hope that, you know,

840
00:45:00.320 --> 00:45:02.220
this isn't the time that they go down.

841
00:45:03.320 --> 00:45:06.480
So with that, I'm happy to answer any questions

842
00:45:06.480 --> 00:45:10.340
and thank you for joining and especially sitting

843
00:45:11.278 --> 00:45:14.830
through this with me on a zoom presentation

844
00:45:14.830 --> 00:45:16.923
which I know can be brutal.

845
00:45:20.660 --> 00:45:21.853
<v ->Any questions.</v>

846
00:45:42.730 --> 00:45:45.463
<v Lauretta>I'll ask a couple of questions then.</v>

847
00:45:46.610 --> 00:45:48.930
So thank you very much,

848
00:45:48.930 --> 00:45:53.093
it was a very interesting presentation

849
00:45:54.040 --> 00:45:56.433
and an exciting place to be.

850
00:45:57.460 --> 00:45:59.480
I was wondering a couple of things

851
00:45:59.480 --> 00:46:04.480
with the kind of routinizing of the user's day

852
00:46:04.680 --> 00:46:09.040
in having to go and get their hydromorphone, you know,

853
00:46:09.040 --> 00:46:14.040
on a regular basis, the increased womanizing of their day

854
00:46:16.050 --> 00:46:21.050
might empower them to perhaps aspire

855
00:46:21.240 --> 00:46:25.560
to entering some kind of methadone

856
00:46:25.560 --> 00:46:28.270
or buprenorphine treatment.

857
00:46:28.270 --> 00:46:31.230
So I was wondering, are you tracking entry

858
00:46:31.230 --> 00:46:34.410
into some sort of M.A.T program

859
00:46:34.410 --> 00:46:38.680
and kind of a sub-question to that is

860
00:46:38.680 --> 00:46:42.110
do they have expedited access

861
00:46:42.110 --> 00:46:46.870
for being, you know, in this hydromorphone program?

862
00:46:46.870 --> 00:46:49.440
Do they have an expedited access

863
00:46:49.440 --> 00:46:54.133
into M.H.E if they choose to enter?

864
00:46:56.240 --> 00:46:58.600
<v ->Yeah, so I'll answer the second part first,</v>

865
00:46:58.600 --> 00:47:00.530
and then jump to the first.

866
00:47:00.530 --> 00:47:04.540
So, you know, one of the great things about Vancouver

867
00:47:04.540 --> 00:47:08.090
is the settings effectively, you know,

868
00:47:08.090 --> 00:47:11.620
if you wanna be on methadone or Suboxone

869
00:47:11.620 --> 00:47:13.530
like it's gonna happen on the spot.

870
00:47:13.530 --> 00:47:16.050
There's a number of low threshold clinics

871
00:47:16.050 --> 00:47:18.640
that effectively someone shows up

872
00:47:18.640 --> 00:47:20.583
they'll work to get them inducted.

873
00:47:22.930 --> 00:47:27.390
So, you know, while folks could wanna do that

874
00:47:27.390 --> 00:47:31.490
that wasn't necessarily a pathway that we see

875
00:47:31.490 --> 00:47:33.323
now with that.

876
00:47:33.323 --> 00:47:36.090
You know, one of the exciting things about Canada

877
00:47:36.090 --> 00:47:39.310
is there's just a greater range of treatments available

878
00:47:39.310 --> 00:47:41.080
for opioid use disorder.

879
00:47:41.080 --> 00:47:42.820
So there's national guidelines

880
00:47:42.820 --> 00:47:44.920
for the treatment of opioid use disorder

881
00:47:44.920 --> 00:47:49.820
that include, you know, Suboxone as a first-line treatment,

882
00:47:49.820 --> 00:47:53.980
then, you know, methadone, then slow-release oral morphine,

883
00:47:53.980 --> 00:47:56.630
then, you know, injectable hydromorphone

884
00:47:56.630 --> 00:47:59.240
as part of a structured treatment program.

885
00:47:59.240 --> 00:48:03.870
And what we would often see is less someone transitioning

886
00:48:03.870 --> 00:48:08.180
from a safe supply program onto Suboxone or methadone

887
00:48:08.180 --> 00:48:12.700
and more see them transitioning onto a slow release

888
00:48:12.700 --> 00:48:17.080
or morphine or moving into or quite often just between,

889
00:48:17.080 --> 00:48:19.410
depending on what worked for them at the time,

890
00:48:19.410 --> 00:48:21.490
the more structured injectable

891
00:48:21.490 --> 00:48:23.620
hydromorphone treatment program.

892
00:48:23.620 --> 00:48:26.870
And so, you know, frankly, I think it really also flips

893
00:48:26.870 --> 00:48:29.010
how we might think about the continuum

894
00:48:29.010 --> 00:48:31.840
of treatment options available to people.

895
00:48:31.840 --> 00:48:35.000
And so we've run a series of kind of interlocking

896
00:48:35.000 --> 00:48:37.340
a longitudinal ethnographic projects,

897
00:48:37.340 --> 00:48:41.870
looking at these broader treatments available

898
00:48:41.870 --> 00:48:45.200
within the local context in Vancouver.

899
00:48:45.200 --> 00:48:47.200
And, you know, we effectively find

900
00:48:47.200 --> 00:48:49.360
that people move between them

901
00:48:49.360 --> 00:48:51.390
and not with the directionality

902
00:48:51.390 --> 00:48:53.580
assumed by the treatment guidelines

903
00:48:53.580 --> 00:48:57.330
wherein someone, you know, try Suboxone moves to methadone

904
00:48:57.330 --> 00:48:59.880
maybe tries kadian or an injectable,

905
00:48:59.880 --> 00:49:03.510
but more so they'll maybe start on a safe supply,

906
00:49:03.510 --> 00:49:08.090
move to injectable hydromorphone, then onto Kadian,

907
00:49:08.090 --> 00:49:11.280
and then, you know, maybe onto methadone at that point.

908
00:49:11.280 --> 00:49:13.590
But all of this is to say the people's trajectories

909
00:49:13.590 --> 00:49:17.810
are just really, really diverse and shaped often

910
00:49:17.810 --> 00:49:21.970
by what they both hope to get out of treatment

911
00:49:21.970 --> 00:49:25.453
and what their preferences are around drug use itself.

912
00:49:28.390 --> 00:49:30.830
The key thing that tended to more drive it for people

913
00:49:30.830 --> 00:49:34.840
is if folks just didn't want to be injecting anymore.

914
00:49:34.840 --> 00:49:38.930
And certainly the oral therapies that weren't just Suboxone

915
00:49:38.930 --> 00:49:40.870
or methadone were incredibly helpful

916
00:49:40.870 --> 00:49:42.587
to people in that context.

917
00:49:53.207 --> 00:49:55.060
<v Ashley>Hi, Ryan, it's Ashley.</v>

918
00:49:55.060 --> 00:49:58.723
I have two questions and they're very different.

919
00:50:00.080 --> 00:50:01.660
So the first is you said a lot

920
00:50:01.660 --> 00:50:06.660
of really evocative statements about social suffering

921
00:50:06.710 --> 00:50:10.310
and pointing to some solutions that might allow

922
00:50:10.310 --> 00:50:13.563
for individuals to access euphoric experiences.

923
00:50:15.318 --> 00:50:17.920
I'm very curious to learn more about that.

924
00:50:17.920 --> 00:50:19.550
Can you talk a little more about

925
00:50:19.550 --> 00:50:21.053
some of those recommendations?

926
00:50:21.980 --> 00:50:26.980
And then the second question is I'm curious to learn more

927
00:50:27.380 --> 00:50:31.410
about how this really powerful ethnographic

928
00:50:31.410 --> 00:50:34.310
and qualitative work is informing

929
00:50:34.310 --> 00:50:36.990
some of the more epidemiologic

930
00:50:36.990 --> 00:50:39.700
or more quantitative work that you've been doing.

931
00:50:39.700 --> 00:50:40.940
So if you could talk a little bit

932
00:50:40.940 --> 00:50:43.430
about some of the mixed methods that you're using as well,

933
00:50:43.430 --> 00:50:45.063
I'd love to hear that.

934
00:50:47.610 --> 00:50:50.170
<v ->So I think first, I mean</v>

935
00:50:50.170 --> 00:50:52.590
we probably collectively just need to reckon

936
00:50:52.590 --> 00:50:56.960
with the fact that, you know, people have been getting high

937
00:50:56.960 --> 00:51:01.680
or intoxicated in some form or another for,

938
00:51:01.680 --> 00:51:06.140
I mean perhaps like almost the whole of human existence

939
00:51:06.140 --> 00:51:08.110
or at least thousands of years.

940
00:51:08.110 --> 00:51:13.110
And, you know, this has been a longstanding current

941
00:51:14.410 --> 00:51:18.540
across so much of the work that I've done wherein, you know

942
00:51:18.540 --> 00:51:20.900
we think about people's drug use primary lead

943
00:51:20.900 --> 00:51:25.900
through a lens of harm without looking at, you know,

944
00:51:25.910 --> 00:51:29.940
the ways in which it can even be a positive thing for people

945
00:51:29.940 --> 00:51:32.020
or allow them certain experiences

946
00:51:32.020 --> 00:51:33.710
that are especially attractive

947
00:51:33.710 --> 00:51:36.240
within the context of social suffering.

948
00:51:36.240 --> 00:51:41.240
And so, you know, people often spoke of in this work,

949
00:51:42.560 --> 00:51:45.390
you know, I want to be safer

950
00:51:45.390 --> 00:51:47.543
but I still want to be able to get high.

951
00:51:49.953 --> 00:51:53.060
And they were motivated to be engaged with programs

952
00:51:53.060 --> 00:51:54.670
that allowed them to be safer.

953
00:51:54.670 --> 00:51:56.040
And certainly this is consistent

954
00:51:56.040 --> 00:51:59.293
with work we've done on supervised consumption sites.

955
00:52:00.860 --> 00:52:03.700
But they still effectively wanted to have choice

956
00:52:03.700 --> 00:52:07.080
in terms of what they choose to do with their body,

957
00:52:07.080 --> 00:52:10.940
how they choose to live and so forth.

958
00:52:10.940 --> 00:52:14.470
And, you know, I don't think we can separate this

959
00:52:14.470 --> 00:52:17.823
from the backdrop for so many folks.

960
00:52:19.160 --> 00:52:21.650
It was one of the few pleasurable experiences

961
00:52:21.650 --> 00:52:24.860
that they often had open to them within the context to,

962
00:52:24.860 --> 00:52:27.693
you know, perhaps managing severe chronic pain,

963
00:52:29.230 --> 00:52:33.920
living in conditions that Canada should be embarrassed of

964
00:52:35.545 --> 00:52:39.690
and you know, effectively urban slums.

965
00:52:39.690 --> 00:52:43.900
Of, you know dealing with severe hardship

966
00:52:43.900 --> 00:52:46.810
and the people characterized

967
00:52:46.810 --> 00:52:49.100
as a positive part of their lives

968
00:52:49.100 --> 00:52:51.330
and that many sought to continue

969
00:52:51.330 --> 00:52:52.930
even when engaged with treatment

970
00:52:54.430 --> 00:52:56.517
if that was something that they were interested in.

971
00:52:56.517 --> 00:53:00.060
And so, you know, there's probably just a much broader need

972
00:53:00.060 --> 00:53:01.523
to interrogate that,

973
00:53:03.400 --> 00:53:06.400
as we think through how we intervene in people's lives

974
00:53:06.400 --> 00:53:08.360
and do so in a way that's, you know,

975
00:53:08.360 --> 00:53:11.010
aligned with and sensitive to what they need or want.

976
00:53:13.090 --> 00:53:15.320
You know, more directly, so all of this work

977
00:53:15.320 --> 00:53:19.660
is operated alongside a series of other kind

978
00:53:19.660 --> 00:53:24.180
of more clinically or epidemiologically oriented evaluations

979
00:53:25.230 --> 00:53:28.380
of these interventions, which, you know,

980
00:53:28.380 --> 00:53:31.903
honestly things have been just really messed up by COVID,

981
00:53:33.290 --> 00:53:38.290
and COVID related restrictions on research activities

982
00:53:38.900 --> 00:53:41.233
which is really frankly unfortunate.

983
00:53:42.850 --> 00:53:45.380
But effectively what it's really allowed us to do

984
00:53:45.380 --> 00:53:49.090
is interrogate findings out of that have emerged

985
00:53:49.090 --> 00:53:53.250
at a preliminary epidemiological analysis, as well as,

986
00:53:53.250 --> 00:53:56.560
you know, effectively flag things that have been emergent

987
00:53:56.560 --> 00:53:59.790
within the qualitative work to help better understand

988
00:53:59.790 --> 00:54:01.080
what's happening.

989
00:54:01.080 --> 00:54:02.440
And so, you know, to go back

990
00:54:02.440 --> 00:54:07.440
to Lauretta's question about movement between programs

991
00:54:07.660 --> 00:54:10.360
certainly one of the things observed early on

992
00:54:10.360 --> 00:54:14.170
in our ethnographic qualitative work is that, you know,

993
00:54:14.170 --> 00:54:17.170
people had different trajectories within these programs

994
00:54:17.170 --> 00:54:19.397
than you might've anticipated, you know.

995
00:54:21.220 --> 00:54:25.890
And that's something that's been further built

996
00:54:25.890 --> 00:54:30.890
into the evaluation activities associated with the work.

997
00:54:31.150 --> 00:54:34.120
You know, another example would be

998
00:54:34.120 --> 00:54:35.760
just understanding the points

999
00:54:35.760 --> 00:54:37.650
at which people might have interruptions

1000
00:54:37.650 --> 00:54:40.730
in their access to these programs, which were, you know,

1001
00:54:40.730 --> 00:54:45.550
frankly found that were often much better able to track

1002
00:54:45.550 --> 00:54:47.900
through our ethnographic and qualitative work,

1003
00:54:47.900 --> 00:54:51.123
because we're just a little bit more engaged with folks.

1004
00:54:53.150 --> 00:54:55.390
So all of this is to say that running these things

1005
00:54:55.390 --> 00:54:57.300
in tandem has really helped us understand

1006
00:54:57.300 --> 00:55:00.160
the richness of these programs in people's lives

1007
00:55:00.160 --> 00:55:02.710
and interrogate emergent findings coming out

1008
00:55:02.710 --> 00:55:06.663
of the kind of more numbers based quantitative analysis.

1009
00:55:11.400 --> 00:55:12.253
Ali.

1010
00:55:14.320 --> 00:55:16.160
<v ->Hi, thank you so much.</v>

1011
00:55:16.160 --> 00:55:18.710
This has been a wonderful experience to listen

1012
00:55:18.710 --> 00:55:22.260
to your work and your expertise.

1013
00:55:22.260 --> 00:55:24.880
I was wondering, it kind of sounds like

1014
00:55:24.880 --> 00:55:28.830
where you're coming from in the experiences that you've had

1015
00:55:28.830 --> 00:55:30.690
and from Canada specifically,

1016
00:55:30.690 --> 00:55:32.620
there's a completely different mindset

1017
00:55:32.620 --> 00:55:37.250
behind the idea of harm reduction and treatment

1018
00:55:37.250 --> 00:55:40.020
or non-treatment and like what someone's trajectory

1019
00:55:40.020 --> 00:55:42.180
actually looks like from the onset

1020
00:55:42.180 --> 00:55:44.000
of interaction with harm reduction.

1021
00:55:44.000 --> 00:55:45.200
And I was just wondering,

1022
00:55:45.200 --> 00:55:47.180
did Canada always start out that way

1023
00:55:47.180 --> 00:55:50.390
or was there a big shift and how did that shift happen

1024
00:55:50.390 --> 00:55:52.650
and how can you see that shift happening here in the U.S

1025
00:55:52.650 --> 00:55:55.230
because, I mean, I've just been sitting here thinking,

1026
00:55:55.230 --> 00:55:56.461
wow, we are trash.

1027
00:55:56.461 --> 00:55:58.544
(laughs)

1028
00:56:05.590 --> 00:56:07.030
<v ->I mean, so I don't want you to come away</v>

1029
00:56:07.030 --> 00:56:09.230
from this feeling like that.

1030
00:56:09.230 --> 00:56:11.280
That's like my worst outcome for the day.

1031
00:56:12.490 --> 00:56:15.110
<v ->In a good way, like inspired we're trash,</v>

1032
00:56:15.110 --> 00:56:16.023
we need to fix it.

1033
00:56:17.300 --> 00:56:19.913
<v ->So, you know, there's been a couple of things</v>

1034
00:56:19.913 --> 00:56:22.360
that have really helped in the Canadian context.

1035
00:56:22.360 --> 00:56:25.470
One and I can't understate this enough,

1036
00:56:25.470 --> 00:56:27.863
Drug User Organizing and Activists.

1037
00:56:29.426 --> 00:56:31.600
And certainly the war on drugs in the U.S

1038
00:56:31.600 --> 00:56:34.230
and mass incarceration, I would argue

1039
00:56:34.230 --> 00:56:37.210
have really impeded Drug User Organizing

1040
00:56:37.210 --> 00:56:39.080
by frankly destroying communities

1041
00:56:39.080 --> 00:56:41.080
and especially communities of color

1042
00:56:41.080 --> 00:56:45.450
that should be central to organizing in this context.

1043
00:56:45.450 --> 00:56:48.200
Alongside that, you know, frankly,

1044
00:56:48.200 --> 00:56:50.680
a lot of other people have really stuck their neck out

1045
00:56:50.680 --> 00:56:54.700
around this and committed to working in allyship

1046
00:56:54.700 --> 00:56:58.730
with people who use drugs to advance intervention

1047
00:56:58.730 --> 00:57:01.860
in a way that meets their needs

1048
00:57:03.600 --> 00:57:06.150
to the extent that it is,

1049
00:57:06.150 --> 00:57:10.740
you know, I've been in kind of Drug Policy forums

1050
00:57:10.740 --> 00:57:12.310
and events in the U.S

1051
00:57:12.310 --> 00:57:15.230
that haven't included folks who use drugs.

1052
00:57:15.230 --> 00:57:17.370
I don't think you could do that in Canada

1053
00:57:17.370 --> 00:57:20.270
without probably having someone throw a shoe at you

1054
00:57:20.270 --> 00:57:21.293
at this point.

1055
00:57:22.210 --> 00:57:23.930
And all of this is to say as a challenge

1056
00:57:23.930 --> 00:57:27.200
to every single person here and as collectively.

1057
00:57:27.200 --> 00:57:32.200
If we're not working to center folks who use drugs

1058
00:57:32.530 --> 00:57:36.763
in policymaking processes and interventions in this area,

1059
00:57:37.957 --> 00:57:40.020
what the fuck are we doing?

1060
00:57:40.020 --> 00:57:42.123
And we have to commit to doing that.

1061
00:57:45.181 --> 00:57:47.790
It's not easy, it can be hard.

1062
00:57:49.720 --> 00:57:51.410
We're more accountable in it

1063
00:57:51.410 --> 00:57:53.870
in ways that can be really difficult to grapple with

1064
00:57:53.870 --> 00:57:55.630
but you have to commit to doing it

1065
00:57:55.630 --> 00:58:00.630
if you wanna meaningfully intervene to address the crisis

1066
00:58:02.000 --> 00:58:03.890
and have policy that actually matches up

1067
00:58:03.890 --> 00:58:05.140
with people's experiences

1068
00:58:05.140 --> 00:58:07.230
and avoid some of the unintended consequences

1069
00:58:07.230 --> 00:58:09.130
that we've seen a policy for too long.

1070
00:58:11.900 --> 00:58:15.250
So I think those things really need to happen together

1071
00:58:15.250 --> 00:58:18.660
and, you know, people working as allies

1072
00:58:18.660 --> 00:58:20.350
need to just as much work

1073
00:58:20.350 --> 00:58:23.063
to hold other people accountable, you know,

1074
00:58:26.613 --> 00:58:29.370
who were the people you're meeting with,

1075
00:58:29.370 --> 00:58:31.090
who isn't getting in those doors

1076
00:58:31.090 --> 00:58:33.030
and what can you do to get them there?

1077
00:58:33.030 --> 00:58:38.030
And especially, you know, doing so has to center folks

1078
00:58:39.990 --> 00:58:42.790
who are disproportionately impacted by the war on drugs.

1079
00:58:43.710 --> 00:58:46.273
Otherwise again, am like what are we doing?

1080
00:58:49.385 --> 00:58:51.960
<v ->All right, so it is actually one o'clock.</v>

1081
00:58:51.960 --> 00:58:53.740
So we are out of time.

1082
00:58:53.740 --> 00:58:55.730
I see Mariah, you have your hand raised.

1083
00:58:55.730 --> 00:58:58.030
Do you want to ask your question very quickly?

1084
00:58:59.080 --> 00:59:00.330
<v ->Yeah, I can ask you to complete</v>

1085
00:59:00.330 --> 00:59:03.790
I suppose I could also ask Ryan in class tomorrow.

1086
00:59:03.790 --> 00:59:08.280
But so I just sort of say shamelessly follow

1087
00:59:08.280 --> 00:59:10.480
a lot of like Canadian harm reduction groups

1088
00:59:10.480 --> 00:59:14.260
on social media and I've been seeing a lot of posting

1089
00:59:14.260 --> 00:59:17.040
about the Drug Users Liberation Front

1090
00:59:17.040 --> 00:59:22.040
giving out a safe supply of meth and heroin and cocaine

1091
00:59:22.170 --> 00:59:26.430
that's been tested by spectometry and immunoassay.

1092
00:59:26.430 --> 00:59:28.255
And I just didn't know if

1093
00:59:28.255 --> 00:59:29.460
(inaudible)

1094
00:59:29.460 --> 00:59:32.220
into what response around that has looked like in Canada

1095
00:59:32.220 --> 00:59:36.290
and potential also like scale up of those tech knowledges

1096
00:59:36.290 --> 00:59:37.853
for drug testing.

1097
00:59:39.090 --> 00:59:40.360
<v ->Sorry, you kinda cut out on me</v>

1098
00:59:40.360 --> 00:59:42.243
on the last part of your question.

1099
00:59:43.090 --> 00:59:45.710
<v ->Sure, so I was just talking about like</v>

1100
00:59:48.282 --> 00:59:49.370
spectrometry and immunoassay.

1101
00:59:49.370 --> 00:59:52.560
I was just wondering what response in Canada has been like

1102
00:59:52.560 --> 00:59:56.780
for like guard to groups, giving out safe supply

1103
00:59:56.780 --> 01:00:00.173
and also what scale up of that tech might look like.

1104
01:00:01.470 --> 01:00:03.750
<v ->Yeah, I mean, so, you know</v>

1105
01:00:03.750 --> 01:00:07.130
it's primarily been something that's just happened

1106
01:00:07.130 --> 01:00:09.190
across a series of kind of events

1107
01:00:09.190 --> 01:00:10.910
done for the purposes of drawing attention

1108
01:00:10.910 --> 01:00:14.020
to the need for more options for people

1109
01:00:14.020 --> 01:00:15.833
and more generally illegal market.

1110
01:00:18.080 --> 01:00:20.450
And I would say part of it is

1111
01:00:20.450 --> 01:00:24.440
it occupies a bit of a policy curiosity for folks

1112
01:00:24.440 --> 01:00:29.440
more than anything at this point.

1113
01:00:29.460 --> 01:00:32.720
And yet kind of symbolically is

1114
01:00:32.720 --> 01:00:36.120
I think really interesting in, you know,

1115
01:00:36.120 --> 01:00:38.993
demonstrating the further alternatives are available.

1116
01:00:40.640 --> 01:00:42.350
You know, it certainly dovetails

1117
01:00:42.350 --> 01:00:44.030
with the advocacy and activism

1118
01:00:44.030 --> 01:00:47.820
being led by so many people around this.

1119
01:00:47.820 --> 01:00:51.890
Now with that said, you know, I think part of your question

1120
01:00:51.890 --> 01:00:54.100
was about drug checking and you and I need to,

1121
01:00:54.100 --> 01:00:56.703
I think separately connect about this.

1122
01:00:57.840 --> 01:00:59.960
I mean, we're not gonna end the overdose crisis

1123
01:00:59.960 --> 01:01:02.740
with fentanyl test strips as an example.

1124
01:01:02.740 --> 01:01:05.950
I just wanna say that I feel like I say this all the time.

1125
01:01:05.950 --> 01:01:08.380
But if fentanyl is the dominant opioid in a setting

1126
01:01:08.380 --> 01:01:09.620
and you have something that just tells you

1127
01:01:09.620 --> 01:01:10.950
whether or not it has fentanyl in it,

1128
01:01:10.950 --> 01:01:13.260
like, honestly it's not really helpful

1129
01:01:13.260 --> 01:01:15.350
except for people who use stimulants

1130
01:01:15.350 --> 01:01:17.750
who are maybe worried about cross-contamination.

1131
01:01:18.980 --> 01:01:21.720
And stimulants, like not weed.

1132
01:01:21.720 --> 01:01:23.560
I don't think anyone has ever found weed

1133
01:01:23.560 --> 01:01:25.470
contaminated with fentanyl,

1134
01:01:25.470 --> 01:01:28.383
so disclaimer, like that's not a thing.

1135
01:01:30.260 --> 01:01:33.660
Now with like the more advanced drug checking technologies

1136
01:01:33.660 --> 01:01:36.800
like they can prove helpful for folks

1137
01:01:36.800 --> 01:01:39.600
but I think we need to better locate

1138
01:01:39.600 --> 01:01:41.470
how we understand these interventions

1139
01:01:41.470 --> 01:01:43.020
alongside an interrogation

1140
01:01:43.020 --> 01:01:44.740
of how people's structural vulnerabilities

1141
01:01:44.740 --> 01:01:48.360
and especially poverty fit into this complex calculation

1142
01:01:48.360 --> 01:01:50.910
of how people engage with drugs in the drug supply.

1143
01:01:52.620 --> 01:01:56.330
So sort like I'm coauthored a bunch

1144
01:01:56.330 --> 01:01:57.700
of the drug checking studies.

1145
01:01:57.700 --> 01:01:59.760
And like one of the early ones that gets picked up

1146
01:01:59.760 --> 01:02:00.890
is when we did it inside

1147
01:02:00.890 --> 01:02:03.150
that looked at people's use of strips.

1148
01:02:03.150 --> 01:02:04.450
You know, that found that, you know,

1149
01:02:04.450 --> 01:02:06.770
some folks were finding positive with fentanyl

1150
01:02:06.770 --> 01:02:09.330
and maybe a few of them were pitching their drugs,

1151
01:02:09.330 --> 01:02:10.820
but like let's take a step back.

1152
01:02:10.820 --> 01:02:13.830
That was like 1% of folks who are going into insight

1153
01:02:13.830 --> 01:02:16.340
were using these strips to begin with.

1154
01:02:16.340 --> 01:02:19.230
A smaller percentage still of those folks

1155
01:02:19.230 --> 01:02:20.610
were disposing of their drugs

1156
01:02:20.610 --> 01:02:23.493
if they had something they didn't expect to find in them.

1157
01:02:25.470 --> 01:02:27.050
And we were doing field work and interviews

1158
01:02:27.050 --> 01:02:28.580
with people at that time, and a lot of those folks

1159
01:02:28.580 --> 01:02:29.910
were people who were selling drugs,

1160
01:02:29.910 --> 01:02:32.210
who just wanted to figure out what was in their supply

1161
01:02:32.210 --> 01:02:33.900
and didn't necessarily have an intention

1162
01:02:33.900 --> 01:02:35.343
to be using that anyways.

1163
01:02:38.460 --> 01:02:41.423
So drug checking is not gonna save us.

1164
01:02:43.050 --> 01:02:47.510
Even if available, like it's never gonna meet the demand

1165
01:02:47.510 --> 01:02:50.000
for how often people are using,

1166
01:02:50.000 --> 01:02:52.520
the supplies really erratic.

1167
01:02:52.520 --> 01:02:54.150
We have all of these new adulterants

1168
01:02:54.150 --> 01:02:57.411
and centering the supply from Xylazine, to estazolam,

1169
01:02:57.411 --> 01:02:58.970
to synthetic cannabinoids to,

1170
01:02:58.970 --> 01:03:00.840
and we could just keep on going through them

1171
01:03:00.840 --> 01:03:02.713
and there will still be further ones.

1172
01:03:04.590 --> 01:03:06.700
So the nimbleness of this as an approach

1173
01:03:06.700 --> 01:03:10.660
is probably never gonna match on to what people need.

1174
01:03:10.660 --> 01:03:15.660
Now incredibly useful for drug surveillance, right?

1175
01:03:16.260 --> 01:03:19.590
Like the one place we found it helpful is like, you know

1176
01:03:19.590 --> 01:03:23.470
a bad package of benzo dope starts going around

1177
01:03:23.470 --> 01:03:25.173
and you can let people know.

1178
01:03:26.010 --> 01:03:30.230
But beyond that, like I think drugs,

1179
01:03:30.230 --> 01:03:32.070
every bit of energy spent on drug checking

1180
01:03:32.070 --> 01:03:34.933
should just be redirected toward thinking about safe supply.

1181
01:03:40.030 --> 01:03:41.520
And if that doesn't answer your question,

1182
01:03:41.520 --> 01:03:42.770
I'll try better tomorrow.

1183
01:03:47.350 --> 01:03:50.370
<v ->All right, thank you so much, Ryan, for joining us today.</v>

1184
01:03:50.370 --> 01:03:52.910
I think this was a very self provoking

1185
01:03:52.910 --> 01:03:54.080
and interesting presentation.

1186
01:03:54.080 --> 01:03:56.180
And I hope there will be many opportunities

1187
01:03:56.180 --> 01:03:59.700
for us to continue this conversations in the future.

1188
01:03:59.700 --> 01:04:03.150
And thanks very much to everyone who joined us today

1189
01:04:03.150 --> 01:04:06.070
and for asking all this very interesting questions.

1190
01:04:06.070 --> 01:04:08.003
So thanks everyone, thanks Ryan.

1191
01:04:10.770 --> 01:04:11.970
<v ->Cool, thanks everyone.</v>