An open letter to CSAM-SMCA about the Government of Alberta SCS Review
Reply from CSAM, received by email March 11, 2020.
Dear Ms. Schulz,
Thank you for your letter. Our deepest condolences regarding the tragic loss of your son. We respect the important work that Moms Stop The Harm (MSTH) does to advocate for harm reduction and compassionate care for people with substance use disorders.
It is clear from your letter and the Government of Alberta Report “Impact: A socio-economic review of supervised consumption sites in Alberta” that there is a need for standardized definitions and methods of data collection and reporting in all areas of addiction care so that the system will be better able to determine appropriate steps for quality improvement. The report needs to be used as a starting point for further dialogue, the allocation of additional resources and to advocate for improved services for people with substance use disorders.
The Canadian Society of Addiction Medicine (CSAM) supports harm reduction strategies and safe consumption sites. CSAM supports evidence-based interventions for all persons with substance use disorders including harm reduction, recovery-based approaches and addiction treatment. Clients and families deserve easy and timely access to harm reduction, addiction, mental health and physical health services. We share concerns that it would be harmful to close existing SCS without evidence supporting their closure.
The CSAM Board of Directors is comprised of independent practitioners who volunteer their time to serve on the board. Board members work in various settings, often with associations with universities, hospitals and other organizations. CSAM was not involved in the creation of the above-noted report and Dr. Tanguay was not acting as a representative of CSAM in his work on the report.
We admire MSTH’s advocacy for saving lives through harm reduction, supporting recovery and ending the harm caused by bad drug policies. Thank you for your efforts to improve the care of people with substance use disorder.
Kind regards,
Dr. Melanie Willows, CSAM President
Dr. Jennifer Brasch CSAM President Elect
Dr. Paul Sobey, CSAM Past President
And my reply March 14, 2020.
Dear Dr. Willows, Dr. Brasch and Dr. Paul Sobey,
Thank you for your kind words of condolence. Anyone who is fortunate and has not experienced the loss of a child will have a hard time understanding the devastation such a loss brings, especially when the death is preventable, especially when we continue to lose others for the same reason, and especially when evidence based life saving measures are under threat.
I will not repeat what I wrote in my first letter and not respond to you point by point, but will say that I am very disappointed in your lack of understanding of the meaning of the report and your lack of willingness to take a public stand. While you say that your organization "supports evidence-based interventions for all persons with substance use disorders", this is actually not what you are doing in this case.
This report can never be a starting point of discussion, as it is too deeply flawed. How much so is explained by Dr. Cam Wild in this news article https://calgaryherald.com/news/local-news/academics-question-methodology-of-ucp-approved-supervised-consumption-sites-report
In regards to your comment about CSAM not being involved in the report, Dr. Tanguay notes his role with CSAM in his credentials on the Government of AB website.
My husband is a research scientist in the Department of Pediatrics at the University of Alberta, where physicians take a strong position in support of vaccinations. I wonder how the Canadian Pediatric Society would feel about a pediatrician who speaks against vaccinations? Speaking against SCS is akin to speaking against vaccinations. I know Dr. Tanguary now claims in the media this is not what he has done or meant, but the report states otherwise and to date he has not distanced himself from the report. It is a deeply flawed document against a proven public health intervention that saves lives. By adding his name to it, Dr. Tanguay speaks against this intervention. By not speaking out, your organization endorses this position and I am most certain this will be noted by addictions experts in this country who practice evidence based medicine.
There is no need to reply to my reply. At this point we can agree to disagree, unless there is a change of heart in your leadership and you feel the need to take a stand for science, for evidence and for life.
Regards,
Petra Schulz, Danny's mom.
My letter to CSAM, sent March 8, 2020.
Attention Dr. Melanie Willows, President, Canadian Society of Addiction Medicine Board of Directors; Cc: Dr. Jennifer Brasch, President Elect, Dr. Paul Sobey, Past President
Re: CSAM Board of Directors official position in regard to the Government of Alberta Supervised Consumption Site report
Dear Dr. Willows,
I will start with an introduction, as I do not believe we have met before. I am one of the co-founders and a director of Moms Stop The Harm (MSTH), an organization of Canadian families who have been affected by substance use. Most of us mourn a loved one.
My youngest son Danny died from accidental fentanyl poisoning in 2014 at the young age of 25. He was in recovery at the time, but relapsed and did not know the potency of the substance he believed to be a “fake oxy” or heroin. After our son died I started with my advocacy work and realized that I had not understood the nature of substance use disorder, the risk of relapse, what effective treatment should look like and how I could have saved him with harm reduction. This knowledge came too late for Danny, and it drives my work.
As a group, MSTH supports evidence-based solutions to the overdose crisis. We especially understand the importance of harm reduction, including supervised consumption services (SCS), as these public health interventions keep our loved ones alive and healthy so we can hope for the future. I am sure you are familiar with the medical evidence that supports the efficacy of SCS, so I do not need to add citations here.
I am writing to you because I am deeply concerned about a review of our local SCS that the Government of Alberta recently released, a report that was co-authored by one of your board members, Dr. Robert Tanguay, the Alberta and North West Territories Regional Director. The report uses questionable methodology, unsubstantiated data, contains factual errors and came to unscientific conclusions that risk the life and well-being of the people we care about, people who use drugs (PWUD), who access these services.
I would like to highlight some of the errors contained in this document.
In the executive summary, the administration of oxygen in an overdose is questioned and portrayed as an attempt to inflate the number of overdose reversals at the sites. Several medical experts (physicians and nurses working in SCS) that I consulted on this issue confirmed that serious consequences such as hypoxic brain injury from opioid overdose (not to mention death, the worst outcome of all) are directly attributable to lack of adequate oxygenation. The administration of oxygen should always be the first response in an overdose event. Here is a quote from Dr. Mark Tyndall on this question: “It should be stated that first line of treatment for someone who is overdosing is oxygen and it does reverse overdoses,” (Retrieved from Calgary Herald, March 7, 2020 .
Further information on the importance of oxygen was provided by the harm reduction nurse Corey Ranger (personal correspondence, March 7, 2020), formerly from Alberta, now working in Victoria, BC.
There are three main indications for using oxygen without following up with the administration of naloxone. First and foremost as a precautionary intervention; oftentimes with good stimulation, close monitoring and some oxygenation, we can divert a potential opioid overdose that would even require naloxone. Oxygen saturation in the 80-ish percentile and respiration’s under 8-10/min could mean that overdose is imminent. Secondly, to prevent hypoxia and anoxic brain injury. Prolonged time with a diminished oxygen saturation could cause undue stress and subsequent damage to the brain. We administer oxygen to prevent this, without ever having to resort to naloxone. There is a substantial body of people living with undiagnosed brain injury due to poor oxygen supply. Finally, when we rush to administer naloxone we push someone into physical withdrawal and often that is unnecessary and causes severe discomfort in people. Often it’ll be the thing that makes them want to use again right away and ultimately leads to another overdose.
When someone overdoses the mechanisms are simple. First breathing slows, then it stops. Then the heart stops and blood flow to the brain and other vital organs ceases. If one maintains respirations and oxygenation, the heart will never stop. Many have reversed full overdoses through respirations and oxygenation without any naloxone. It’s not recommended, but airways and oxygen are the number one resolution.
The Alberta SCS report also claims that death rates in the vicinity of the SCS have increased “substantially” (p. 18) but cites statistics that group “drug and alcohol death” without a breakdown. As you must be well be aware, SCS do not address alcohol use. Notwithstanding that issue, the document also does not address that fact that a correlation does not mean that there is a causative effect and that overall death rates in Alberta have remained unchanged since June of 2019 (see Government of Alberta).
The SCS report claims to use a “convenience sample”, which in itself is a sampling method that has great limitations, however, what was employed was a sampling method that only considered those opinions that aligned with the findings the Government of Alberta was looking for. To me it is a biased “sample“. In the literature this sampling method is also defined as “haphazard sampling”. Neuman and Robson (2012) caution: “haphazard sampling can produce ineffective, highly unrepresentative samples and is not recommended (p. 135)”. The many positive voices at the SCS hearings in various cities (I attended 2 full days of hearings in Edmonton) are not reflected in the report.
Further critique of the report was provided by Dr. Cam Wild, an expert in substance use and public health from the University of Alberta, who stated: “I would say that the only conclusion that a reasonable and fair-minded reader should draw is that the report is a political document and not an objective or scientifically credible evaluation of supervised consumption sites.” Dr. Wild came to the conclusion that “Albertans should demand a more balanced evaluation of the province’s harm reduction services” (As cited in the Calgary Herald, March 7, 2020).
This guest blog by Dr. Jamie Livingston provides further insight into the flawed methodology of this report, as does a tweet by Dr. Tommy Brothers, who explores what the medical evidence is in regards to the conclusions they report came to.
In his tweet Dr. Brothers also discusses the erroneous assertion in the report that SCS are not intended to serve individuals who use stimulants, in particular methamphetamine. This is also addressed in a news article in the National Post quoting Calgary physician Dr. Bonnie Henry, who said: ““What we’re looking at is a contaminated drug supply, a poisoned drug supply...Nobody’s meaning to overdose on fentanyl regardless of what drugs they’re taking, but they are at a high risk of overdosing and dying even if their whole intention was to use methamphetamines.” (National Post March 8, 2020 )
The report also attributes changes in neighborhood ratings to the SCS that are unrelated, an assertion refuted by the authors of these ratings (Avenue Magazine, as cited by CBC News on March 7, 2020)
Now I come to the reason for writing to you. The question is what role does CSAM have regarding this report and the situation in Alberta. As noted above and stated in the report (see p. 1), one of your directors, Dr. Rob Tanguay was a member of the SCS review panel and allows his name stand on this flawed, erroneous, unscientific document that has the potential to inflict serious harm for PWUD in Alberta.
I question if this report and Dr. Tanguay’s endorsement is in keeping with your organization’s vision and mandate. On your website it is written that “Our Society offers a resource of scientific and medical information about addiction, for professionals and the general public.” You state that your primary goals are “To advance the education of health professionals in the field of addiction medicine by developing and providing courses and conferences, conducting research and establishing clinical standards” and To educate the public about the assessment, treatment and prevention of addiction by collecting, and disseminating information on that topic” (cited in your website).
In keeping with this vision and these goals, does your organization, in particular members of your board, not have the duty to uphold these goals by standing up for science, evidence and most importantly the welfare of your patients, the people who use drugs?
On behalf of families who have lost loved ones and who have loved ones living with substance use, I hereby request that you publicly state your position regarding the Government of Alberta’s review of SCS and recently released report. I furthermore request review the role Dr. Tanguay has as a director of your organization. I also request that you as an organization state your position in regards to SCS as a public health intervention in the midst of a public health crisis that is killing twelve Canadian’s every day.
As an organization and as physicians you have a duty to stand up for the welfare of the patients you serve and for the integrity of your organization, which is being undermined by Dr. Tanguay’s support of this report.
I look forward to your response and hope that your reply will be made publicly. This letter has been posted on our website [insert URL] and shared in our social media channels.
Regards,
Petra Schulz, Forever Danny’s mom. Co-Founder of Moms Stop The Harm
LETTER: REJECT THE SOCIO-ECONOMIC “REVIEW” OF SUPERVISED CONSUMPTION SITES IN ALBERTA
A group letter by the Canadian HIV Legal Network and over 30 organizations including Moms Stop The Harm that was sent to the Premier of Alberta, Jason Kenny, and several of his ministers is linked on the AidsLaw website.