The Daily - Vancouver’s Unconventional Approach to Its Fentanyl Crisis

Episode Date: September 2, 2022

 An influx of Fentanyl, a highly lethal synthetic narcotic, has aggravated the opioid crisis in the United States and prompted communities to scramble for ways to lower the skyrocketing rates of overdose deaths.In Vancouver, a Canadian city that has been at the forefront of innovative approaches to drug use, a novel and surprising tactic is being tried: It’s called “safer supply.”Guest: Stephanie Nolen, a global health reporter for The New York Times.Background reading: The mounting toll of overdose deaths has spurred a search for new solutions, and Vancouver has tried more of them, faster, than anywhere else.Why is fentanyl so deadly? How can you ensure that your loved ones, including your children, stay safe? Experts offer tips to talk about opioids with your family.For more information on today’s episode, visit nytimes.com/thedaily. Transcripts of each episode will be made available by the next workday. 

So it's a rainy and windy morning in Vancouver, and I'm just walking down the street in the area of the city called the Downtown Eastside, which is really the heart of the opioid crisis. There are a lot of people lying on the sidewalks, kind of crashed out asleep on the sidewalk in the rain. I just passed a couple of people who were cooking fentanyl on the sidewalk. I just walked past a middle-aged woman in pink track pants with a ponytail who was slumped over a suitcase. From the New York Times, I'm Natalie Kittroweth. This is The Daily. All right, we've been reporting this week on America's worsening fentanyl crisis.

The number of people dying from fentanyl has recently tripled. The opioid crisis has gotten much deadlier because of an influx of the highly lethal synthetic opioid fentanyl, fentanyl, fentanyl, fentanyl, which is increasingly contaminating all kinds of drugs. Fentanyl is like rocket fuel in the sharp rise of this crisis. They're lacing other drugs with fentanyl, so no drugs are safe. Nearly 108,000 Americans died from overdoses last year. That's the most ever. To try to save lives, officials are searching for solutions.

Communities and leaders across the United States are desperate to stop the skyrocketing rates of overdose deaths. Today, the White House released its plan to address the crisis. What we're really talking about here is steps that we're taking as a federal government to address the opioid epidemic. Today, my colleague Stephanie Nolan reports from Vancouver, Canada, where the city is trying a novel and surprising approach to combat the fentanyl crisis. It's Friday, September 2nd. Stephanie, you're a global health reporter, and you've covered drug use and health policy in a lot of places around the world.

Tell us about what's happening in Vancouver. So, you know, the opioid crisis has people all over North America trying to figure out what to do. And I've been paying attention for a while to what's been happening in Vancouver. The city has this sort of fascinating history, both as a place with a long struggle with drug use and overdoses, but also it's a place that's really been at the forefront of innovation and trying to respond. So Vancouver, you know, it's a port city. It's always been a transit point for drugs. And for a long time, that meant cocaine and heroin. And there were overdose deaths in those years. But like most

other places in North America, in the past few years, this has really become a crisis with the introduction of fentanyl. And the thing about fentanyl, right, is that it's just so much more potent than other opioids that people have been using in the past. It's 50 times stronger than heroin. It's 100 times stronger than morphine. So for people who don't have a lot of exposure or tolerance, it's really pretty easy to fatally overdose. And that's how we got to the point of this really rapidly rising rate of death. And so that's spurred this conversation kind of everywhere that's grappling with the opioid crisis about what we call harm reduction, which is this basket of practices that aim to help mitigate the dangerous effects of drug use. And the reason that I went

to Vancouver is that they are really decades further along in that conversation and in their experiments with trying to figure out ways that they can reduce the harms that come with drug use. How so? ways that they can reduce the harms that come with drug use. How so? So Vancouver has had needle exchanges and supervised injection sites, right, like places where people can use where there's other people around to intervene if they overdose. They've had those for almost 30 years. Right, those are the strategies we've started to hear more about in the states in the last few years or so. Right, exactly. And so in Vancouver, in addition to those, there's another harm reduction program they're trying, which is called Safer Supply.

What is that? What's Safer Supply? So the thinking behind Safer Supply is that one of the reasons that drugs kill people is that they end up taking things that aren't what they thought they were taking. They don't know how much is in them. They don't know how strong they are. And the idea is that if you can replace the illicit or black market drugs, the stuff that people buy from drug dealers, you replace those with pharmaceutical grade drugs where people know exactly what they're getting, how much they're using, then that's the first step to keep people from dying in overdoses. using, then that's the first step to keep people from dying in overdoses. So we're talking about giving people pharmaceutical-grade illicit drugs that aren't laced with anything to keep them alive, basically. Yeah, that's the thinking. So Vancouver has been trying this with different drugs over the

past 15 years. But recently, one doctor in the city said, look, the drug that's in everything, the drug that's killing people is fentanyl. That's the most common drug on the streets now. It's supplanted the supply of heroin. It's in the Adderall that high school students might buy at a party. People have been exposed by tainted drug supplies. In some cases, they're now hooked on fentanyl. And that's where we get this crisis. So she said, if we're going to do safer supply, then what we need to figure out is a way to give people safer fentanyl. Wow. Okay. So tell me about this doctor. Good morning. Stephanie Nolan. I'm looking for Christy Sutherland. She'll be here shortly. So this doctor's name is Christy Sutherland. And she practices in the downtown east side of Vancouver, which is the center of the city's challenges with drug use.

And I went to see this new site that she set up recently, which is part clinic, part dispensary. site that she set up recently, which is part clinic, part dispensary. Staff, and then some people check in, and then they come and they see a nurse. Come down here. And she gave me a tour. And this is, this looks like a sort of like an industrial bank safe or something. It really looks like any kind of family doctor's office, except for the fact that... Oh, exactly. We just ordered seven kilos of fentanyl.

She tells me that they just ordered seven kilos of fentanyl. She tells me that they just ordered seven kilos of fentanyl. Seven kilos. Wow. Right? There were these little reminders that there are aspects of what they're doing there that is really quite radical. And I really needed to understand better how this works. And so we sat down and we started to talk about how it is that a family doctor ends up in the business of prescribing people fentanyl. So tell me about that. What was the story of Dr. Sutherland's personal progression? I started out thinking that drugs were illegal because drugs were bad,

that drugs were illegal and that decreased drug use. So when she started, after she graduated from medical school, she was working with homeless people and patients who were in jails and really vulnerable populations. And many of them had been arrested for reasons to do with their drug use. I think it really was my patients that changed me, because I worked in the jail for a little while. And so I'd go in the morning and do rounds on everyone who had been arrested in the past 24 hours with the jail nurse.

And so she really saw up close what criminalization means as a response to drug use. And Dr. Sutherland actually went and did a specialization in addictions medicine. But a lot of what she learned there about drug use as an illness, the result of something that's wrong with your brain, right? After a while, that didn't really seem accurate to her either. She says, you know, it just didn't take into account that drug use seems like a pretty logical response when you look at the pain and struggles in the lives of her patients. and struggles in the lives of her patients. And a lot of what she had to recommend to those patients, like residential treatment programs that would get them to be 100% abstinent from drugs,

get them to totally stop using, they didn't make sense and they didn't work for the majority of people. And it took me a long time to realize how wrong all of those things were. And that we have medicalized recovery and pathologized drug use. And then actually drug use is a very normal part of being a human. Humans have always used

drugs throughout time, throughout society. And so she's come to think that even though she's an addictions medicine specialist, responding to drug use like a disease is not the answer. Stephanie, this feels so different from how we often talk about drug users. I mean, it seems like the conversation is often about quitting. And so this whole approach of keep them using but safely, what does it actually look like in practice? So she's set up this site that's sort of part clinic, part dispensary. And she has patients who are longtime and pretty serious users of fentanyl. And so she has them come in and have a regular primary health checkup.

And she does blood work. And she works with the nurses and other folks on her team to sort of establish what people are using now. Because what they want to do is replace that with the pharmaceutical-grade fentanyl, but not give people any more than they're already using. And initially, folks in the program crush the fentanyl tablets and cook them and inject them in the site under the supervision of nurses. And one of the things that was really the most surprising for me in the time that I spent there is the amount of fentanyl that people are using. So these are longtime users. Dr. Sutherland has about 20 people enrolled in the

program now, and they're using 100,000 micrograms of fentanyl every day. I don't have any sense of what that means. It sounds like a lot, but can you put it in context for me? Yeah. So if you fell down the stairs tomorrow, God forbid, Natalie, and broke your leg and went to the emergency room, they might give you 50 micrograms, maybe 100 micrograms to control the pain from your broken leg. And these are people who are using 100,000 micrograms a day. Wow. I mean, hence the seven kilo order. Yeah. And the whole point of trying to match that street dose is that you want to stop people from feeling what they call dope sick, the withdrawal from an opioid, which is intense and

terrible. And if you hear anyone who's ever talked about it, it's just like a huge amount of physical suffering that people will go to huge lengths to try to avoid. And so the thinking behind programs like this is if you can take away that kind of panicky need to make sure where the next hit is coming from, then you create all this new space in a person's life to start to think about how could they connect with their family, what could be done about their housing situation, and potentially getting them into some kind of housing, into addressing other healthcare needs that they might have. It just takes away the whole focus of your existence being, how can I keep from being dope sick? So avoiding that feeling of withdrawal is the priority here. Well, I think Dr. Sutherland would say the priority is to keep heavy fentanyl users,

longtime fentanyl users safe. She would say that in order to do that, yes, you need, first of all, to keep them from getting dope sick, but you also need to think about the euphoria that people get from using an opioid. And I had to ask Dr. Sutherland about this a lot to sort of get my head around it. Because it's a lot, right, to think that the public health care system, a family doctor's office, is supplying a drug to get people high. People have this idea of a myth of a dose of an opioid that gets someone out of withdrawal and takes away their cravings, but is not euphoric. And then I have learned as a clinician over the years that dose doesn't exist. That cravings, withdrawal, euphoria, and pain are also intermingled in our brains. So she said to me, look, there isn't some magical dose of fentanyl that will keep you

from being dope sick, but not give you euphoria. Brains don't work that way. And right, these folks that are using fentanyl, they're buying it, they're buying it in the street because they're seeking that euphoria. If she doesn't replace that, then she's not giving them what they need. And so her program isn't going to work. So I am not against euphoria and that I let the patients tell me what their dose should be within the safety parameters of the system. So she's saying, I'm not against having a role in helping people get high.

That in contrast to a lot of sobriety-focused programs, Dr. Sutherland's asking, why do we say we have to start with taking away the euphoria? Why do we say we have to deny that to people, people who might be having a really hard time? Why do we have to deny them that little hit of euphoria they're seeking? I have to admit to feeling a little uneasy just hearing a doctor talking about wanting to facilitate the kind of high that someone gets from fentanyl, which is obviously this incredibly deadly drug. Yeah, I get that. I think Dr. Sutherland would say that her vision is for a regulated public supply of this drug, the kind that Canada already has for other drugs, right?

You buy wine at the liquor store. You buy your CBD gummies at the cannabis store. Those are legal and regulated by the Canadian government. And she's saying that fentanyl would be handled in a sort of similar way with obviously very tight controls. But she has an idea that in the future, clients might pick up drugs to use off-site and not have to come into the clinic four times a day. But I mean, we've just been talking about how lethal fentanyl is, how little of it it takes to kill you. It just strikes me that these substances, wine, marijuana, they're just, they're not as deadly as fentanyl. Yeah. I think the thing to remember is that her vision is a tightly regulated dispensary where people are not just nipping in to pick up a little fentanyl the way they might go to get a pinot grigio for dinner, right? Her hope is that through this

program, long-term, she stabilizes people, they start to diminish the amount that they're using, and that's when you start to talk about people potentially using off-site. Got it. Is that something you were able to talk to Dr. Sutherland's clients about? Yeah. So after I heard about all this from Dr. Sutherland, we went back over to the fentanyl site. And while we were there, I had the chance to talk to a few different people who are part of the program. And I met one guy, Dean Wilson, who was coming up on his 50th anniversary as an opioid user. Wow. He's also a longtime advocate for harm reduction, and he was there to pick up his prescription fentanyl.

To me, I've been doing this a long time. I felt like a human being walking in, getting what I wanted, like a bottle of red wine, paying, going home. And he said, look, this is what the drug response should be. You know, there's no toxic drugs here. That's what's killing us out there. It is dignifiedified and it is compassionate and I feel cared for and I feel respected. So these are great interventions. It's the greatest thing that's ever happened.

And he picked up his prescription and used there under the supervision of the nurse and... So we're going to get 3,000 today. It's just going to be in one tablet. And it's going really sort of startling thing to see. And it really left me with a lot of questions about whether this is the way that you respond to the opiate crisis. Thank you. Okay. Ciao. Thank you. Okay.

Ciao. Thank you, Nicole. Bye. See you later. We'll be right back. Stephanie, you just walked us through this pretty radical program. And you told us that visiting the clinic left you with all of these questions about whether this is really the best way to respond to the opioid crisis. And I'm wondering, is there any evidence that this program, that prescribing fentanyl to users could actually work? I mean, that it could actually improve

the lives of drug users? So we don't know because this program is very new right it's the only one in north america it is being studied but it'll be a while before there's any real evidence any real conclusions about how much change this makes in the lives of the people who are part of it but like i said earlier the safe supply program idea that's not new in in Vancouver. So I went a couple blocks down the street from the fentanyl dispensary to a program that's been doing safer supply with a different drug, heroin, for around 15 years. And that's a program that really does have a lot of evidence. It's been very closely studied, and it gives you, I think, a pretty good picture of what Dr. Sutherland's anticipating could come out of her fentanyl program. So while I was at that site, I got talking with a woman named Lisa James,

who lives a little ways outside the city and who actually let me come home with her and hear about her story about how she got enrolled in that program. Yeah, so if you can tell us about how you got involved with them and then what that has looked like and what has changed in your life, that would be great. I was using street drugs. So Lisa told me that before she started going to this clinic, her life was really chaotic and unstable. She was completely broke.

She couldn't care for her unstable. She was completely broke. She couldn't care for her daughter. She was totally dependent on street heroin. I was stealing from different places that sold meat. Then I would go downtown with my boyfriend and he would sell it. And that would be how our whole day went every day just every morning she would go out and steal meat actually from supermarkets and then resell it there was one guy who would actually phone us with orders there was there were a couple restaurant people though

yeah which if you think about it that's where it's coming from. And make enough money just to buy a hit. And she had to do that pretty much every single day for five years. And if it took her a little bit longer to score the drug, then she would already be getting the kind of sweaty, sick feeling that comes with being dope sick. I would get up and I'd already be sick. You've got the runs, you're throwing up, your head is pounding, your eyes, your pupils are suddenly huge and you can't see properly even. It's really debilitating, but you still have to get up and go out because it's going to get worse. It's just going to keep getting worse until you do something about it. And off and on through that time, she tried a lot of different interventions.

She tried 12-step programs and she tried going cold turkey. And over and over and over again, she would just end up using heroin. I mean before if I go see a doctor and say look I'm going through withdrawals he'd say go to a meeting and come and see me in a week. You know I went to meetings for 18 years. I tried everything to stop my addictions. She couldn't maintain stable housing. She couldn't take care of her daughter. She couldn't hold down a job. And that's how she was living until she got connected with this heroin saver supply program. I used to dream of something like this. If they could just somehow give us what we need, most people would not go out and screw up their lives if they don't need to, you know.

And since she's been enrolled in that program, she gets her heroin supplied free through that program. She uses once every day on their site and she takes the needle home with her. And that just allowed for so much stability in her life, right? She got connected with an affordable housing program. She lives with her daughter. She's been employed. And the thing that really struck me talking to her in her living room is that she's got the space in her life now to have dreams, which clearly was just not something she had at all back when it was a daily grind to figure out how to get heroin. What's on your goals list at this point? What

are the things when you look into the future, what are the things you think you'd like to do? Honestly, just take a couple trips with my daughter. Where do you want to go? We want to go to Hawaii again. Lisa also told me that she'd really like to be working more, but it's hard, right? Because she still needs to go down to the clinic every single day, 365 days a year, and pick up her heroin. And it's hard to build a professional life around that. It was nice to meet you.

It was super nice to meet you. I may well end up needing to call you back because there's probably things I forgot to ask you, but I know how to reach you. Absolutely. I I love that. On the one hand, it seems pretty clear that Lisa could have died over the last 10 years or ended up in jail. over the last 10 years or ended up in jail. And so the mere fact that she's alive, no longer stealing in a stable apartment, that is a huge improvement for her. But it also strikes me that to a lot of outsiders, those things alone might not look like a picture of success.

Her life still revolves around doing this drug. success, her life still revolves around doing this drug. Yeah, so I met a lot of people who work in substance use or addictions in Vancouver who raised that issue with me, that they feel like anytime you're talking about somebody who still has a serious dependence on an opioid, you can't call that success. They see the value in safer supply. They agree that first and foremost, keeping people from dying is important. But they have a lot of questions about safer supply and in particular about this fentanyl program. What are those questions? So the first one is around diversion, which is what they call it when a drug that's being prescribed in a safer supply program ends up not in the hands of the people to whom it was prescribed, but in the larger market.

And definitely in Vancouver, they've seen that happen with some of the other drugs that have been used in safer supply. And obviously, as we've been talking about, fentanyl, so lethal, what if it ends up in the hands of people other than those to whom it was prescribed? So that's one big fear. And the other one, I would say, also has to do with normalization. That just even talking about the public health system supplying fentanyl starts to take it out of the realm of the really, really frightening. So if this is seen to be a safer supply, will you have people who are more willing to experiment with it, more willing to use it because it feels less frightening? And we know historically, right, that that's what happened

with Oxycontin and opioids in the U.S., where they went from being something that were sort of rare and unusual to something that people didn't really feel very frightened of at all. And then you had this sort of real explosion in use. And so the fear is that you might also be starting to normalize the idea of fentanyl. And, you know, the last thing that I heard from the doctors that I spoke to who are critical of this program was that, you know, this is against their Hippocratic Oath. This is not why they went to medical school. This is not the role of a doctor. It's a role for a drug dealer. There is no context in which a doctor should be giving out an opioid except for pain relief. should be giving out an opioid except for pain relief.

How does someone like Dr. Sutherland respond to those concerns, the concerns you just laid out? Well, she'd say I think that her role as a doctor, first and foremost, is to keep people from dying, and this is a way to do that. You know, she's working with people who are long-term pretty serious users of fentanyl she's not normalizing anything for them that hasn't been a part of their life for a long time and she also feels like they have a large number of controls in place to make sure that there isn't diversion from the dispensary that the drug that she's prescribing isn't ending up in anybody else's hands again she's making sure that people get exactly what they need to replace their street supply. So if they're selling it or

giving it to somebody else, they're not getting their own drugs. They're going to end up dope sick. She feels quite confident that is not something that her clients are doing. Okay, so given everything we've talked about, are there any quantifiable measures that show that this approach is actually saving lives, that it's reducing overdoses, broadly speaking? So while Vancouver has been pouring money and energy into these interventions, overdose deaths have risen, not fallen. Okay, so how should we interpret that? That this city that has been a pioneer for the harm reduction strategy has actually not seen a reduction in the specific kind of harm we care most about, which is death. So I think it's important to remember a couple of things. One is that harm reduction is still a tiny, tiny fraction of the overall spending. The bulk of the money that goes

into responding to substance use in Vancouver goes into residential treatment programs and interventions that are focused on total sobriety. So things like the heroin and fentanyl programs, safer supply, it's a very small part of the intervention. And right now, they're only aiming to reach a small number of long-term users. The bigger issue, though, I think is what's happened in the overall drug landscape, right? What we were talking about before, fentanyl is in everything. It's in all of the drugs. And so you have these quite small interventions that are coming up against a problem that's growing incredibly quickly. Stephanie, when I think

about where this conversation started with you, with your journey to see how Vancouver is trying to stop the flood of overdose deaths, I just have a hard time seeing a program like this existing in the United States, even given the dire phase of the crisis that we're in. Am I wrong in thinking that? I don't think you're wrong, Natalie. The whole idea of the state giving people drugs, the public health care system giving people drugs. And the idea of moving past thinking about addiction as a disease, that's a big leap for people, right? The Biden administration has said they're really interested in pursuing harm reduction as an approach, and yet it's been months and months and they haven't announced anything

in terms of policy. You mean harm reduction policy generally, right? Not safer supply specifically. Right, exactly. A few days ago in California, Governor Newsom vetoed a bill that would have potentially brought supervised injection sites to the state. And I just think like, if you can't embrace that idea in California, I really have trouble seeing it happening anywhere else in the U.S. That said, it's also true that when my story on this published, there was this tide of response from readers in the U.S. And I was actually really startled because almost all of it was responses from people who were really positive about Dr. Sutherland and her ideas and what she's trying to do. And I heard from a lot of people who said, you know,

my sister overdosed, my son died of an overdose. And they said, like, we tried everything for my kid, for my sister. We tried all the programs, all the things, and it didn't work. They said, if we'd had access to safer drugs, my son, my sister, they might not be dead. So those people can really understand the idea of safer supply. So I think if change is going to come on this in the U.S., it's going to be because so many people have got to the point that they don't see an alternative. Thank you, Stephanie. Thank you. We'll be right back.

Here's what else you need to know today. Here's what else you need to know today. In a primetime address, President Biden delivered a sharp warning about threats to American democracy. Too much of what's happening in our country today is not normal. Donald Trump and the MAGA Republicans represent an extremism that threatens the very foundations of our republic. Saying that the nation's democratic values were under assault by forces of extremism loyal to Donald Trump. They promote authoritarian leaders and they fan the flames of political violence that are a threat to our personal rights,

to the pursuit of justice, to the rule of law, to the very soul of this country. In the speech, the president painted a grim picture of a country beset by politically violent rhetoric and efforts to undermine elections, while also trying to offer a sense of optimism about the future. No matter what the white supremacists and the extremists say, I made a bet on you, the American people, and that bet is paying off. Proving that from darkness, the darkness of Charlottesville, of COVID, of gun violence, of insurrection, we can see the light.

Urging Americans to vote, the president used the address to define the midterm elections as a battle for the soul of the nation. And if we do our duty, if we do our duty in 2022 and beyond, then ages still to come will say, we, all of us here, we kept the faith. We preserved democracy. Today's episode was produced by Sydney Harper and Jessica Chung with help from Aastha Chaturvedi.

It was edited by M.J. Davis-Lynn and Liz O. Balin with help from Ben Calhoun. Contains original music by Marion Lozano, Dan Powell, Alisha Ba'itup, and Chelsea Daniel. And was engineered by Chris Wood.

Our theme music is by Jim Brunberg and Ben Landsberg of Wonderly. That's it for today. I'm Natalie Kitchoff. See you on Tuesday. you