Evidence bags containing fentanyl are displayed during a news conference at Surrey RCMP Headquarters, in Surrey, B.C, on Sept. 3, 2020. Fentanyl, detected in less than 5 per cent of drug deaths in 2012, is now found in about 85 per cent of them.DARRYL DYCK/The Canadian Press
An economic analysis of British Columbia’s prescribed safer supply program cautions that widely expanding access to free or low-cost opioids could depress illicit drug prices, increase total opioid consumption and facilitate the export of such drugs to other markets.
However, strategies to mitigate these issues, such as charging for regulated substances or requiring a health care professional to witness ingestion, present their own challenges and could drive away the very people the program aims to protect.
The independent white paper by Jonathan Caulkins, a professor and expert in drug-policy research at Carnegie Mellon University in Pittsburgh, examines the economic and market implications of various scenarios that B.C. could pursue with its program to provide people at high risk of overdose from toxic illicit drugs with prescribed alternatives. Its goal is not to evaluate the program.
It is one of several resources informing a new report by Provincial Health Officer Bonnie Henry, released Thursday, in which she recommends expanding access to regulated substances without a prescription. Former chief coroner Lisa Lapointe and an expert panel struck by the coroner service issued the same call last November.
Like that time, the B.C. government swiftly rejected the idea, with Minister of Mental Health and Addictions Jennifer Whiteside citing the importance of the patient-prescriber relationship, and her government’s focus on treatment and recovery services.
“Dr. Henry is an important independent voice on public-health issues in this province, and we respect her advice,” she said in a statement issued Thursday. “However, this is a topic we do not agree on. The province will not go in the direction of compassion clubs and other non-medical models of distributing medications.”
Now in its fourth year, the prescribed alternatives program has become a lightning rod amid increasing polarization over drug use and related policies. Advocates say it needs to be drastically scaled up, by size and medications, to make any meaningful impact in B.C.’s runaway drug crisis. Critics, citing unintended consequences, counter that it should be scrapped altogether.
Health officials have estimated that between 165,000 and 225,000 people in B.C. use illicit drugs. Most do not have substance use disorders, necessitating non-medicalized approaches to combat drug deaths, Dr. Henry said.
Nearly 15,000 people have died since 2016, the year a public-health emergency was declared. Fentanyl, detected in less than 5 per cent of drug deaths in 2012, is now found in about 85 per cent of them. In April, the most recent month for which data are available, 4,387 people in B.C. were dispensed a prescribed alternative, of whom 4,129 received an opioid.
In an interview Wednesday with The Globe and Mail, Prof. Caulkins, an expert in drug interventions and illegal markets, said the deepening schism in B.C. over prescribed alternatives may be attributed to opposing groups disagreeing on who is most at risk.
“I think an important part of the talking past each other that may be happening in British Columbia is there’s a set of people who essentially define the stakeholders only as the people who currently have substance use disorder,” he said. “They aren’t including the folks who do not now have any substance use disorder but may develop it in the future.
“And there are probably people who are the opposite, too, who are entirely focused on kids who haven’t yet started using and are perhaps in some judgmental way kind of writing off people who already have substance use disorder.”
In his report, Prof. Caulkins writes that the program in its current form – with take-home medications, mostly the opioid hydromorphone, at low or no cost – should benefit participants and is too small to affect the equilibrium of the illicit opioid market.
However, the flow of hydromorphone from the program is not negligible when compared with the amounts prescribed for pain management, he wrote. And an expansion of prescribed alternatives to every high-volume illicit opioid user in B.C. could drive down the price of illegally manufactured opioids, potentially increasing total opioid consumption.
On diversion, Prof. Caulkins sketched a hypothetical scenario in which people receiving prescribed alternatives trade some of them for illegal opioids, with the regulated substances all going to a wholesale dealer who could then ship in volume to other jurisdictions where they would command a higher price – arbitrage that could negatively affect people outside of B.C.
On charging market prices for prescribed alternatives – a model intended to deter people from selling or giving away their medications and which is already happening on a very small scale – Prof. Caulkins noted the geographical variations in illegal drug prices. As well, the premium that some are willing to pay for regulated substances, the accessibility of legal versus illegal substances and the variation in value that people place on drug potency versus drug safety all complicate implementation.
Requiring on-site, witnessed ingestion would almost certainly eliminate diversion, Prof. Caulkins said. However, it could also present a significant barrier for participants.
In an interview, Dr. Henry said she commissioned the white paper to better understand possible paths forward on prescribed alternatives, which she underscored is just one component of a spectrum of services that also includes early intervention, social supports, and treatment and recovery services. She said was particularly interested in Prof. Caulkins’s findings on drug market fluctuations and the need to better monitor both the local market and other jurisdictions.
She dismissed the scenarios of rapidly expanding prescribed alternatives to every high-volume illicit opioid user and networks that would aggregate wholesale amounts of hydromorphone for export. The program is currently too small, she said, and strategies to scale up must come with protections. The province has already moved to require witnessed dosing for new medications, as an example.
“Yes, if you do too much too fast, these things can happen,” she said. “But if you do nothing, we are in the situation we are still in.”
Dr. Henry said the province has been building up its prescribed alternatives programs, updating guidelines and educating physicians. In her report, she lists a number of possible models to further expand access, including integrated care teams and compassion clubs that don’t require prescriptions.
She concluded the report by saying that expanding evidence-based treatment services, preventing substance use harms among youth, and addressing poverty and homelessness are critically important.
“Yet, to not think beyond the limits of the services and supports we have offered over the past eight years, as the death toll has continued to climb, is to accept a paradigm that has produced unacceptable, record-high rates of preventable deaths from unregulated drugs,” she wrote.