People march to remember those who died during the overdose crisis and to call for a safe supply of illicit drugs on International Overdose Awareness Day, in Vancouver, on Aug. 31.DARRYL DYCK/The Canadian Press
Carlyn Zwarenstein’s latest book, On Opium: Pain, Pleasure, and Matters of Substance, was published earlier this month.
Overdose deaths caused by drugs, often opioids in combination with other substances, have killed more than 21,000 Canadians since 2016. Canada-wide statistics for the first half of 2021 aren’t available yet, but data from various provinces suggest this year’s rates will be substantially worse. And yet at the start of the election campaign, the overdose crisis garnered no attention at all.
The cause of the dramatic increase in drug-related deaths since the COVID-19 pandemic began, and the steady rise in accidental overdose deaths that was already under way, is not addiction. Overdoses of opioids such as fentanyl, which is used safely at known doses in hospital settings even for very young children, occur in the illicit market because what is sold as fentanyl or heroin may in fact contain unknown amounts of potent benzodiazepines, other drugs (including the illicitly produced fentanyl that has largely replaced heroin in most local drug markets) and an unholy mix of other unexpected and unknown dose substances, making safe dosing impossible. Accidental overdose of this kind also occurs among people who think they are taking non-opioid drugs such as methamphetamine or cocaine (not cannabis, since fentanyl adulteration of weed has never been proven and does not make sense, as the opioid would be destroyed during combustion).
The extreme peril of the illicit drug market results from a potent combination of prohibition-driven market forces incentivizing ever stronger and more compact illicit drugs; an affordable housing crisis; and increasingly economically precarious lives. The fact that only the Conservatives – the party with absolutely the worst drug policy offerings – even bothered to address the issue at first tells us all we need to know about politicians’ perceptions of how much Canadians care about the lives and deaths of those most affected. They assume that the death and suffering of people who use drugs is inevitable, and that effective drug policy will not bring in the votes. This is the result of moralistic, emotion-driven and poorly evidenced ideas about substance use, people who use and sell drugs, opioids and addiction. It is wrong, both morally and factually.
Research suggests that up to 90 per cent of people who use any drug do so in the context of well-managed lives, where people have jobs or hobbies, families and other relationships, health comparable to that of non drug users, and a community. More desperate and compulsive-seeming use is typically diagnosed as either a substance-use disorder or, more hatefully, a “zombie apocalypse,” prompting calls for forced treatment or “cleaning up the streets.” But what we see and assume to be addiction or harmful drug use is in fact largely the effect of one or more of the following: poverty; homelessness; criminalization and incarceration; social norms that stigmatize use of certain drugs; and interruptions to supply for physically dependent people (who will become sick if they must interrupt regular use, whether or not they are actually addicted).
It’s important to understand that the Conservative promise to provide 1,000 “treatment beds” and establish 50 “recovery communities” to move people from drug use to abstinence is not merely weak: It is actually – as the results of this model’s recent implementation in Alberta demonstrate – extremely dangerous. Many critics have pointed out that the unregulated, privatized Wild West of rehab centres may not always make things better, but that severely understates the problem.
Treatment beds should not be uncritically seen as good, or even as better than nothing, because research does not support that conclusion at all. A 2020 study of 37,090 people with opioid use disorder, for example, found all forms of in-patient treatment (short or long, abstinence-based or followed by out-patient medication) to be associated with higher rates of overdose and hospitalization than out-patient treatment with medication. Other research has shown that abstinence – what Erin O’Toole means by both “treatment” and “recovery” – in fact increases the risk of death among people with opioid-use disorder.
Whether the goal is staying alive or living full lives, we should not allow political leaders to simply blather on about “treatment” – exactly what intervention they have in mind is absolutely critical. An important 2020 study of 40,885 adults with opioid-use disorder that compared six treatment pathways available in the United States found that the medications methadone and buprenorphine, both opioids themselves, were the only effective treatments for prevention of overdose deaths. Other forms of treatment, from intensive behavioural therapy to drugs such as Vivitrol that block the effects of opioids, did not prevent overdose death.
American studies cannot include treatment using pharmaceutical diacetylmorphine (heroin), fentanyl, hydromorphone or morphine, all of which have proven extraordinarily effective both in preventing death and in giving people back their lives. Each of these treatments has been used successfully in Canada but only by those few who qualify for “safe supply” programs the Liberal government funds as an emergency alternative to legal regulation. These programs are kept far too restrictive for this otherwise effective measure to be able to really turn things around.
The NDP supports decriminalization, but their policy shows confusion about the causes of the crisis. They promise to “get tough” on drug dealers, ignoring significant research showing that low-level drug sellers and drug users are overlapping groups; dealers may practice harm reduction in important ways; and “decriminalization” that still criminalizes people who sell drugs (such as with restrictive personal use amounts) further marginalizes those at greatest risk. These were notable flaws in Portugal’s renowned decriminalization model, which has had dramatically positive results including drug death rates among the lowest in Europe, overall drug use below average European rates, and a major drop in both petty crime and blood-borne disease prevalence – but which, 20 years in, is due for an update. Pharmaceutical opioids, too, have been conclusively shown to not be a driving force in overdose as the NDP suggests; rather, as prescribing rates drop, overdose rates are skyrocketing.
The Green Party supports decriminalization and safe supply. The Bloc Québécois’ platform does not mention opioids or drug policy at all, but they are also on record as supporting decriminalization. Both the Greens and the Bloc have further expressed support for legal regulation of substances in their responses to questions from advocates.
Beyond that, no parties have committed to legal regulation, which makes uncontaminated opioids or other drugs accessible to anyone at risk. None seem to have meaningfully consulted experts: drug user organizers who understand the intricacies of dependence, the multidrug nature of the issue, and how the impact of prohibition policies plays out according to race and class. (As with COVID-19, greatest losses are suffered by historically oppressed groups including Indigenous peoples and Black communities.) These are the people best positioned to design effective policy. Unfortunately, the Liberal Party consulted non-meaningfully for years, soliciting input then persistently refusing to implement policies such as decriminalization and legal regulation called for by virtually every respondent.
To intervene directly in the process by which people who use drugs – chaotically or moderately, diagnosably or recreationally – are put at dramatic risk of accidental death, we must start with three fundamental measures, done right: decriminalization of realistic personal-use amounts of all drugs; scaled up and targeted harm-reduction measures; and legal and regulated drugs under one of a number of possible safe supply scenarios (avoiding incentivization of obscene profit as occurred with cannabis, alcohol and pharmaceutical opioids).
This is the approach endorsed by virtually all experts, both those who use drugs and researchers. The Globe and Mail endorses it, as do the feds – not in Liberal Party election promises, sadly, but in the report of an expert task force, released quietly by Health Canada in June. Thus Canadians, though warming increasingly to decriminalization and even legal regulation, continue to believe these policy proposals are radical, rather than evidence-based and proven effective in multiple contexts.
Proper legalization and regulation would further remove market incentives for ever-more potent, easy-to-produce-and-smuggle substances, and dismantle illicit drug cartels (and the violence they bring) far more effectively and permanently than any sting operation. A party serious about ending the overdose crisis now would dramatically expand low-barrier access to the most effective addiction treatments, heavily regulate the rest (cracking down on those that are exploitive and death-dealing); end the financialization of housing markets that has increased desperation across the country (producing both homelessness and money-laundering of drug profits); and remove criminalization of both drug use and sales.
A party serious about ending the overdose crisis would further make pharmaceutical-grade opioids of different potencies and routes of administration available so people could gradually work their way off extremely high doses – moving, for example, from injecting fentanyl to drinking poppy tea – and they would do the same with other currently illicit drugs. They would maximize community-led harm reduction and make long-term trauma counselling easily accessible and universally funded, giving people the opportunity to stabilize their lives. And they would avoid shifting people from one drug to the next with successive crackdowns on opioids, then amphetamines, then benzodiazepines and so on. Enough with whack-a-mole drug policy.
Last month, a group of drug users and allies in Vancouver handed out free, tested, ingredient-labelled drugs to drug users who had pre-registered for the event. In a striking act of solidarity and pragmatism, a group of mothers whose adult children have died of overdose joined other volunteers, distributing neatly labelled, known-dose, uncontaminated heroin, cocaine and methamphetamine. This direct action response led by the people most affected by toxic illicit drug supply has not resulted in any reported overdoses, and represents a genuinely effective way of preventing death. If only politicians showed a fraction of their boldness by enacting policy measures advocates and researchers have been calling for, for so long. The event was titled “Death is not our Destiny,” and it’s true. Deaths owing to opioids and other drugs are preventable.
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