Front Burner - The drug harm reduction backlash

Episode Date: July 24, 2024

Vincent Lam is a Canadian addictions doctor and award-winning author who's written a couple of op-eds in the Globe and Mail on the opioid crisis in recent months, and his most recent novel, On The Ravine, is about the subject. Over 44 thousand people in Canada have died since 2016. Some see safer supply, or the prescription of pharmaceutical-grade opioids to drug users, and supervised consumption sites as crucial parts of curbing this crisis. Lam talks to host Jayme Poisson about the backlash to those measures, and what he thinks is missing from the conversation about it.For transcripts of this series, please visit: https://www.cbc.ca/radio/frontburner/transcripts

In the Dragon's Den, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem, brought to you in part by National Angel Capital Organization, empowering Canada's entrepreneurs through angel investment and industry connections. This is a CBC Podcast. Hi, it's Jamie Poisson. If you like listening to FrontBurner and you want to stay on top of all of the news, analysis, and deep dives that you love, make sure to follow our feed so you never miss another episode. Now on to today's show. For more than a decade, Canadian doctor and award-winning writer Vincent Lam has been treating patients with opioid addictions.

When he first started, he mostly saw people who used heroin. These days, they're much more likely to use some cocktail of fentanyl and other drugs, really deadly stuff. The toxic drug crisis has killed over 44,000 people in Canada since 2016. And many see harm reduction measures as a big part of the answer to curbing this crisis. So what am I talking about? Supervised consumption sites where people can use drugs close to medical help if they overdose, safe or safer supply where pharmaceutical-grade opioids are prescribed by a doctor, and the decriminalization of drugs. These measures have dominated headlines and generated significant backlash. Just have a listen to conservative leader Pierre Paglia from over a week ago. We will close safe injection sites next to schools, playgrounds,

anywhere else that they endanger the public and take lives. We will defund. By the way, they're not safe injection sites. I'm sorry. I used your dishonest language. They're drug dens. They're drug dens. Vincent Lam is someone that I've been wanting to get on the show

for a while to talk about this bitter debate. He's written a few op-eds in the Globe and Mail on the subject in recent months, and his most recent novel, On the Ravine, is actually about the opioid crisis. Vincent, hi. It's such a pleasure to have you on FrontBurner. Hi, thanks for having me. So you are not only an addictions doctor, you also write nonfiction and fiction about that work. Can you tell me a little bit about your book and why you wanted to write a novel about the opioid crisis? Sure. On the Ravine is a novel about a talented violinist, and she finds that opioids help her to overcome physical pain and also her belief that she's not good enough. But pretty soon

opioids are controlling her life, and they're a big problem for her. It's also a novel about a doctor who deeply wants to help her, but he has to figure out how to care for her, even when she makes choices that seem as if they're causing her harm. And the story of addiction is a very human story. That's why I wanted to write about it as a novelist, because I think often in fiction, we can enter truths and understand truths in a very human and real way. in a very human and real way. What do you want people to take away from your novel after reading it about life as an opioid user? I think I would like people to understand that a lot of addictions are a human story in which someone has found something that solves an emotional problem in the short term, but it

doesn't really work in the long term. And in the long term, it causes them harm. But these are all really normal forces. These are all normal choices that we all could make. I'd also like people to understand something about the nuances and the balance that's required to help someone who has an addiction. I want to talk with you more today about what that balance looks like for you. What help and treatment you think is the best path here, right? Because we're in this crisis in this country.

And maybe one place for us to start would be to go through one by one some of the big issues when we're talking about how to address the crisis. The first one you hear a lot about is the supervised consumption sites, right, where people can go to do drugs that they bring in a safer environment. We just heard in the intro there a conservative leader, Polyev, called them drug dens. And what do you think of the criticism that they are these like lawless places that actually encourage people to stay on drugs? That seems to me to be a really pejorative type of description to use language like drug dens. I think that supervised consumption sites are a really important part of the response to the opioid crisis. I don't really think it's

that constructive to talk about defunding them. I think that what we should really be talking about is how to do a better job making sure that they reach people who need them, and also how to do a better job making sure that they can potentially connect people who want treatment and recovery-oriented care to that treatment and recovery-oriented care. And we also have to think about how supervised consumption sites can be good members of their communities if they're going to be in those communities. Let me pull this apart with you a little bit more here. So one of the criticisms that I often hear from people who are pro-supervised consumption sites, as you've just alluded to, they're often so underfunded and understaffed that they make

it challenging to effectively help people get the treatment and help them get the support to get off drugs. We have in the last few months seen an increase in demand by over 200 new individuals accessing services, which requires us to have a lot more staff on site. This has been an incredibly difficult decision because we know as of May 1st, when the doors lock at 4 p.m., there is nowhere for people to go. And I just wonder if you could elaborate on that for me. Yeah, well, I think a reasonable way to think about it is that if we're really commonly seeing open public drug use, and if we're really commonly seeing as a system that people are overdosing and dying in places where they don't have access to help, then that seems to me to be a pretty good metric that we need better access to supervised consumption sites.

And you also mentioned the criticisms that we hear about what's happening outside the sites, largely from the communities that they're in. So we're seeing a lot of that in St. Henry, in Montreal right now, where the site is a block away from an elementary school and residents have complained about needles and public sex acts. It will have problems. Kids will have some risk to see and be exposed every day to this type of clientele.

We've seen it in Toronto's East End as well, where a woman was fatally shot near a supervised consumption facility. We're talking about a location that is right around the corner from two primary schools. You know, we're within 150 metres of six daycares. And the density of children living in the area is very, very high. And ultimately, it's just not the optimal location. I think you have a community that is very supportive of harm reduction services. We're just asking for it not to be around the corner from the school. I know each site is unique, but more broadly, do you think there should be changes in how these sites are run or maybe where they are run?

or maybe where they are run? Yeah, I want to be careful because I don't know the day-to-day specifics of those sites, although I actually live quite close to the supervised consumption site in the East End of Toronto, which you mentioned. And there's just no doubt it's a horrible tragedy when anyone loses their life to gun violence. And there's just no two ways about that. I think that if we're speaking broadly about supervised consumption sites, I think

it means having a plan to address and monitor some of the things that people commonly talk about, such as litter. I think it's absolutely reasonable that there needs to be a plan to discourage street-level crime. And I would say also there that that actually potentially works fairly well hand-in-hand with the decriminalization of possession for simple use of a small personal amount. And by that, what I'm thinking through is that we might say, you know, it's reasonable to have a bit more of a police presence in neighborhoods where there are supervised consumption sites. And we wouldn't want that to discourage people from using supervised consumption sites. So if it was clear that possessing a small amount

of illicit drugs for personal use would not result in a criminal charge, then those two things could coexist. And I do think that we should be talking more, we should be talking more about having supervised consumption sites in hospitals. And there are a lot of natural synergies here. There's access to life-saving care, right? So if supervised consumption sites

are intended to reverse overdoses, a really appropriate place to reverse an overdose, to make sure to connect someone with the right care is in a hospital. But I should also say here that for this to take place in a lot of hospitals, that really kind of necessitates a cultural change because many hospitals are places which are currently not welcoming of people who use drugs. Why do you think that is? If you could just expand on why we haven't seen more of this in hospitals. We're kind of in this track where we've been for decades, where we simultaneously believe that it's a health problem and then take the position that it's a healthcare problem or it's a health problem,

which is not to be dealt with in the healthcare system, not in hospitals, but in rehabs. And so we've created this weird kind of situation where the care that we offer sometimes begrudgingly to people with addictions is kind of this red-headed stepchild and it's not connected to the rest of the system which it really needs to be in the dragon's, a simple pitch can lead to a life-changing connection. Watch new episodes of Dragon's Den free on CBC Gem. Brought to you in part by National Angel Capital Organization,

empowering Canada's entrepreneurs through angel investment and industry connections. Hi, it's Ramit Sethi here. You may have seen my money show on Netflix. I've been talking about money for 20 years. I've talked to millions of people, and I have some startling numbers to share with you. Did you know that of the people I speak to, 50% of them do not know their own household income?

That's not a typo, 50%. That's because money is confusing. In my new book and podcast, Money for Couples, I help you and your partner create a financial vision together. To listen to this podcast, just search for Money for Couples. On the issue of safe supply, safer supply, specifically, so the prescription of pharmaceutical grade drugs by a doctor. We know we've also seen a lot of backlash to this, including in BC recently reject its top doctor's recommendation

to expand safer supply programs. Are you a proponent of safe supply generally? Just tell me what your thoughts on it are. Yeah, so I'm more comfortable with the terminology prescribed alternatives, and I think that's a bit more neutral. It doesn't presume the safety aspect. I think that the initiatives towards prescribed alternatives came with a lot of hopes for benefits. And were really undertaken by really well-meaning, compassionate people.

We've been doing prescribed alternatives now for a number of years, and I haven't yet seen any really compelling evidence around those benefits. So there haven't been a lot of quantitative studies. There was one quantitative study that looked at what we call health administration data, so kind of a surrogate for prescribed alternatives out of British Columbia. It had a very short follow-up period. They were looking at potential benefits a week after prescriptions, and we know that opioid use disorders are a really long-term problem over years. So it's hard to draw conclusions from that short follow-up period. They didn't set out to look at a comparison between prescribed alternatives and the standard

accepted treatments, which we call OAT. And so those are methadone and buprenorphine generally. And that would have been important. Then the really biggest thing is that we have not seen any really clear academic work around some of the harms that we know result from the prescription of large quantities of short-acting opioids. So we know in this continent that the widespread prescription of oxycodone in the 90s and the 2000s was really the seed for our current opioid crisis, and we're still grappling with it decades later. the seed for our current opioid crisis, and we're still grappling with it decades later. There hasn't really been a clear look at this whole risk side of the prescribed alternatives programs. There certainly have been a lot of concerning news stories, and there's concerning coverage about the phenomenon of medications from those programs being diverted,

meaning sold to someone for whom it was not intended. And it's important to point out that once a medication is sold to someone for whom it's not intended, it is now part of the illicit supply. It's no longer... Unintended consequences, yeah. That's right. And the concern there is that new people will be introduced to opioids and will develop an opioid use disorder. Yeah, yeah. number of years of prescribed alternatives being in practice, that there's clear benefit in the long term that's superior to existing accepted treatments, or that we've really looked carefully

or addressed the concerns around risks. So I can't really endorse prescribed alternatives. So, I mean, like the prescribed alternatives, the safer supply, the safe injection sites, the decriminalization, which you mentioned. Is it fair for me to say that these take up most of the oxygen when we're talking about how to deal with the opioid crisis. Would you agree with that? Yeah, I think that's absolutely true. All of these measures are in this group that we call harm reduction. And absolutely, they've taken up most of the public discussion space. I think that's for a few reasons. I think that they function really well as wedge issues. So from a political point of view, and unfortunately, it seems that these days politics is the art of dividing people. It is true that a lot of harm reduction measures fall well into that mold of being a wedge issue because they're controversial, they're new, they challenge

societal norms. There's different people within my world, within addictions, who have different views. So they function really well to divide people. I don't think they're the most important issue. I think what we should really be talking about is how to better implement treatments and interventions where we have a robust body of science, where we have a lot of experience and we know that they can work. And that's not sexy. It's not really divisive. You end up having to talk about healthcare systems. You end up having to talk about what kind of commitments we can make to institutions in the long term and to people who use drugs in the long term. So it's not sexy, not divisive, not a great wedge issue. But I think those are actually the important issues that we should be talking about. And I

think that the other important thing to say is that we really need both. We really need harm reduction, and we really need a commitment to treatment and recovery. And then within that basket of interventions that we call harm reduction, we should look at these measures individually, in the same way that if we were looking at antibiotics, we wouldn't just say, oh, well, all antibiotics are good or bad. We would try to figure out, okay, for what situations are which antibiotics the right antibiotics? What is it specifically that you would like to see from politicians, from lawmakers that you aren't seeing right now? What would you like them to propose? What would it look like exactly? I think at the federal level, it would be really, really helpful if OAT medications, so methadone and buprenorphine, were included in the first round of medications

that are going to be part of Bill C-64, so that they're universally covered and we remove that barrier to access. I think in many cases, really, addiction medicine in the community needs to be in a wraparound context. So it needs to be delivered in a context where patients have access to primary care and behavioral therapy, if that's what they are interested in, and case management. And I think it's incredibly important that we strengthen our systems for care around anxiety, trauma, and pain. These are ubiquitous in addictions. And this care, broadly speaking, is also really important for prevention because often anxiety, trauma, and pain precede much of addiction. anxiety, trauma, and pain precede much of addiction. And then I think if we kind of zoom out,

part of it is about access to these specific services, but also it's really important that people understand that they are accessing care that's part of the healthcare system, that they feel that if they have a crisis related to their problem, you know, just like if you were having a heart attack and you were having terrible chest pain, you would go to the hospital. Someone would feel like, wow, if I'm having a crisis related to my addiction, I can go to the hospital and I'm going to receive good care. People have to feel and understand that they have a legitimate healthcare problem that deserves high-quality healthcare. I wonder what you might say to somebody who's listening to what you're saying right now and thinking, that sounds great, but it takes resources, a lot of resources, and time and political buy-in.

And we're at this really critical juncture where deaths have not gone down. And we just actually, to save as many lives as possible, that we need to accelerate harm reduction and that we need more safe injection sites just anywhere, for example. more safe injection sites, just anywhere, for example? I really think that we should be capable, and we are capable, of addressing both short-term crisis management and serving the long-term goals of our patients. And that's what our patients want. They don't just want help on one day. Yes, they want to get through that day, but they want help in the long term that helps them get their lives back. And often there's a really clear synergy. So for instance, if we reverse an opioid overdose, that person typically goes into a terrible withdrawal.

Their life has been saved, but then they feel like they're going to die. It's a horrible experience. One really effective second step after their overdose has been reversed is actually to immediately give them a dose of buprenorphine. And that just happens to be a long-term treatment, but starting it in the midst of a short-term crisis can help a person to feel better right away. can help a person to feel better right away. So some ambulance services in Canada, as well as ambulance services in California, have started to do that. But it's a really clear synergy between wanting to move people towards long-term treatment and wanting to help people right now, right here. The other thing I would say is that if we imagine someone who's in crisis, someone who's using drugs in a high-risk way, who will they reach out to for help?

If there's a social worker or a nurse or a doctor they trust, that's going to be the person they'll reach out to. They work as part of long-term public investments and commitments to care. part of long-term public investments and commitments to care. That relationship of trust has to be built over the long term so that it's there for a person in their moment of crisis when they have a short-term immediate need. I don't really think that it needs to be one or the other that we can think short-term or think long-term. I think our best thinking should be how to address the short-term crisis that we're facing in a way that moves us into a long-term strategy. And we have to commit to the idea that people can move towards meaningful and fulfilling lives. And many of my patients do. I have patients whom I've had the

privilege of caring for for years at this point, who have gone from a really, really hard place to a much better place where they're doing things that matter to them. They're engaged with people around them. They're engaged in work or school. But we have to be willing to walk alongside people on that journey while believing they can get to a better place. people on that journey while believing they can get to a better place. Vincent Lam, I think that's an excellent place to end. Vincent Lam, thank you so much. It was such a pleasure to have you on. Thanks for having me. It's really great to be here. All right, that is all for today. I'm Jamie Poisson. Thanks so much for listening. Talk to you tomorrow.

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