Safe Supply Roundtable - Beyond Medical Models
When MSTH co-founders Leslie McBain and Petra Schulz first met with Carolyn Bennett, the Federal Minister of Mental Health and Addictions and Associate Minister of Health, we discussed the importance of developing scalable models for safe supply. When the Minister offered that she would attend a round table on the topic if we were to organize one, we immediately jumped at the opportunity and reached out to the Canadian Drug Policy Coalition to help us organize and host.
The round table took place on March 10, 2022 with Minister Bennett, Deputy Minister Stephen Lukas and an expert panel led by people who use drugs (see list of panelists below), as well as observers from Health Canada, MSTH and other national organizations in attendance. The focus of our meeting was to explore models for non-medicalized safe supply.
We posed six key questions
What is Safe Supply?
What should non-medicalized Safe Supply look like in Canada? How can it be implemented?
What does the Government of Canada need to make these things happen?
Where are there gaps for substances other than opioids? Where are the gaps for different methods of consumption?
What do you need from us to make this happen?
How do we move forward, what are the next steps?
The round table discussion resulted in four key recommendations:
Start legislative change to bring the Controlled Drugs and Substances Act (CDSA), the Tobacco and Vaping Products Act (TVPA), the Cannabis Act, and any other relevant federal legislation under a single public health legal framework with regulatory structures that are specific to different types of substances
Have cocaine, heroin and methamphetamine available to buyers’ clubs or compassion clubs
Fund and resource Design Charrettes to develop safe supply models
For Minister Bennett to implement a nationwide s. 56(1) exemption to facilitate community-based safe supply, including via compassion club and other community-based distribution models
Next Steps: Minister Bennett agreed to meet with the panel again to explore a design process to develop non-medical safe supply models
Summary of Meeting Highlights
Leslie McBain and Minister Bennett gave opening Remarks by Minister Carolyn Bennett and Leslie McBain, highlighting the importance of working together with people with lived and living experience in finding solutions to the drug poisoning crisis.
Setting the stage
The Iron Law of Prohibition Global Commission on Drug Policy. Regulation: The Responsible Control of Drugs. 2018.
To set the stage Dr. Elaine Hyska focused on a public health approach to safe supply. The data she presented showed an exponential growth curve in drug poisoning mortality that has corresponded directly with expanding supply control efforts and larger and larger drug law enforcement budgets and facilitated by other socio-structural factors.
Dr. Hyshka concluded her presentation with the following recommendations:
Develop a roadmap for tightly controlled regulation for currently illegal drugs
Expand the range of substances available in standard doses with known purity
Educate the public and depoliticize drugs
Issuing standing orders [allow access to a medication without a prescription to a specific patient] combined with a section 56 exemption were presented as a short-term solution that could provide access to safe supply [recommendation made during the discussion].
Frank Crichlow from the Canadian Association of People Who Use Drugs (CAPUD) spoke of the importance of safe supply for the African Caribbean Black (ACB) community. He explained that the ACB community is excluded from current safe supply models. To meet their needs cocaine and methamphetamine must be included in the formulary. Frank reminded round table participants that his community is disproportionately harmed by drug policies rooted in racism and colonialism. The community wants to work collaboratively on safe supply strategies.
Facilitated discussion
The facilitated discussion of the meeting was guided by the six key questions noted above and began with an exploration of what we define as safe supply.
What is [not] safe supply?
Safe Supply
is not treatment (OAT is not safe to supply)
is a replacement for the illegal drug market
has to be more appealing than the illicit market
has to include a clean supply of heroin, cocaine and methamphetamine
is a consensual process that is based on the leadership of people who use drugs
responds to the range of reasons why people use drugs
means people know what the drug is, how strong it is and that they can get it when they need it
Safer Supply Checklist - Aids Vancouver Island, 2022
Guiding Principles of Safe Supply, Imagine Safe Supply project
In the facilitated discussion on the first four questions, several key issues emerged. The summary below captures contributions and questions from all participants, including Minister Bennett.
Safe supply and treatment
To say that safe supply and harm reduction are against treatment is a false narrative. People who are pro-safe supply are pro-treatment, but most importantly they are pro about keeping [themselves and] our families and friends alive. We fully support treatment, especially when it is evidence-based, ethical and non-coercive.
The need for safe supply
People who die are not only those with addiction but include people who use only occasionally or for the first time. People die in greater numbers because the drug supply is becoming increasingly contaminated, especially during COVID19. The longer we wait for regulated supply, the harder, more complex the street drug supply becomes. People use drugs for more reasons than just avoiding withdrawal. People want a safe supply that helps them function. A Safe Supply that the PWUD decides for themselves what success is.
Models of safe supply
We need to expand safe supply to include community models, as people do not deserve to die because the only available responses are medicalized programs. Overwhelming medicalized programs are not what people want to see. Currently, compassion clubs would have to buy on the street or the web and test, as there is no regulated pharmaceutical supply available. Compassion clubs provide a cost-saving to the public health system as people would fund their own supply using the collective purchasing advantage. “We don't want others to pay for our drugs, we want to pay for them. We just don't want to die.”
Smoking options for safe supply
There is not an accessible safe supply for those who prefer smoking and that is who is dying right now. Options for powdered cocaine and morphine are being explored, but there are regulatory implications.
Benzodiazepine contamination
Participants highlighted the greater toxicity of substances that include benzodiazepines and explained that there is increased contamination during COVID19 due to disrupted supply routes. People who use opioids or stimulants do not necessarily seek out benzodiazepines, but have no choice as the substances they buy are contaminated. In a cross-Canada scan conducted by CAPUD, one of the findings is that people have ‘no consent’ to what they are taking - they didn’t consent to the benzos, they consented to opioids. People quickly become use dependent on benzodiazepines and the drug-poisoning response (Naloxone does not reverse Benzo poisoning), as well as withdrawal management, becomes increasingly more difficult. Safe supply alternatives have to be available to people who are using and want to use Benzodiazepine.
Drug Checking/Testing
Drug testing was discussed as a possible solution to a contaminated supply, but it was pointed out that people are going to use the drug anyway, as they can't make a full consented choice when there are no other options. A concern was raised that conservative governments may try to use drug checking as a solution, but it is not an alternative to safe supply. Drug testing needs to go hand in hand with real safe supply. Drug testing is more effective for party substances where people have a choice not to use when there is contamination. Buyers' clubs are so important because of the quality of drug checking and then people will know what they are getting.
Safe supply outside of the BC Lower Mainland and Ontario
In much of the country, especially in the north, safe supply is not available and opioid agonist treatment (OAT) is often equated with safe supply. Governments refuse to provide funding, even vilify safe supply (prairie region).
Safe supply is a reconciliation issue and Indigenous people, much like the ACB community, are disproportionately affected by toxic drugs. The north, rural and remote can’t be left behind, because right now they are in crisis.
What is needed and how do we move forward?
There is a lack of consultation with PWUD by provincial and regional actors and this needs to change to move forward. It is essential that the federal government hold the provinces/territories accountable for being authentic with any program funding they provide. We see provinces announce programs that are not implemented or if implemented not in the way in which they were intended. We need a commitment from the federal government to have clear benchmarks attached to payments to provinces.
The BC Coroners Report released on March 9, 2022, highlights that people are dying from a toxic drug supply and that safe supply is urgently needed to stop the dying.
The important question we need to ask is not if we should do this [safe supply] but how!
Safe supply models need to be developed from the bottom up with people who use drugs leading the way. We need to hold a rigorous design process across the country to find the best way to create safe supply and we need much stronger leadership at the federal level to make this happen. People who use drugs, represented by CAPUD and other organizations need to be at the design table in all regions of the country. This needs to include a strong voice from the ACB and the Indigenous community.
The panel discussed if the term regulated supply would be a better term than safe supply. There was agreement that regulation with a public health focus should be the aim, and preferred terminology should be explored with people who use drugs.
The discussion concluded with the presentation of the key recommendations noted above. All participants, including Minister Bennett, agreed that there was an urgent need to meet again and to continue this important conversation.
Closing remarks were provided by Petra Schulz who asked all participants to remember the In the thousands we mourn and read statements families used to describe their loved ones. One thousand such statements were collected in the See-Beyond project, in collaboration with Dr. Rebecca Haines Saah.
Resources shared during the discussion:
A pharmaceutical version of Methamphetamine is approved in the USA, but not in Canada.
Round table participants and observers:
Participants: Carolyn Bennett Minister of Mental Health and Addictions and Associate Minister of Health and Deputy Minister Stephen, Frank Crichlow and Natasha Touesnard (CAPUD), Leslie McBain and Petra Schulz (MSTH), Donald MacPherson (CDPC), Brontë Renwick-Shields (Blood Ties Four Directions), Celine Cote (Imagine Safe Supply), Corey Ranger (HRNC + AVI), Dr. Elaine Hyshka (University of Alberta), Erin Howley (Imagine Safe Supply), Jason Mercredi (Prairie Harm Reduction), Jeremy Kalicum (DULF), Sandra Ka Hon Chu (HIV Legal Network),
Moderator: Catharine Vandelinde, Tech Admin: Shay Vanderschaeghe (CDPC)
Round table observers from the following organizations and government bodies: Canadian Association of People Who Use Drugs (CAPUD), Moms Stop The Harm (MSTH), Canadian Drug Policy Coalition (CDPC), Drug User Liberation Front (DULF), EACH&EVERY Businesses for Harm Reduction, National Safe Supply Community of Practice (NSS). Number of observers: 40