Despite the “challenge” of reselling Dilaudid tablets on the street, the safer supply program providing access to opioids prescribed in pharmacies “helps save lives and improve people’s quality of life” demonstrate recent data.
“I no longer do fentanyl, I no longer do crack, I no longer commit crimes to pay for my drugs, I am able to be functional and presentable,” proudly affirms Éric, who requested anonymity given his precarious situation.
For almost three years, the man met outside a Montreal pharmacy has received methadone and eight Dilaudid tablets every morning to overcome his opioid addiction. Although he knows others do it, he has no desire to sell his tablets. “I’m good about it, I have peace of mind, I don’t want to do stupid things or shoplift,” he assures.
Yvan agrees. The man, who began taking opioids to relieve his back pain several years ago, feels safer since he picks up his supplies at the pharmacy every morning. “I like it better than the black market,” he said. If you buy morphine on the street, you don’t know where you’re going with it. There, you know what you are taking and you can calibrate your dose. » And he sees a noticeable improvement. “Before, I took the whole dose intravenously. Now I only take half intravenously and the rest by mouth. »
The testimonies of Eric and Yvan echo those of Canadian patients who have been recorded in recent studies on the subject. “Among people prescribed safer substances, drug-related deaths and deaths from all causes were rare, and overdoses were fewer,” reads the summary of new evidence published in July 2023 by the National Community of Practice on Safer Procurement.
We are talking about a “significant reduction in emergency room visits and hospitalizations”, “improved physical and mental health”, a “reduction in drug use from the unregulated market and, in some cases , [de la] reduction of drug use in general or [d’un] stopping drug use by injection.
“Hijacking” of Dilaudid
The National Community of Practice on Safer Supply nevertheless notes that there are “challenges”, including that associated with the “diversion” of Dilaudid tablets. “Diversion (the sharing, trading and selling of prescribed medications as part of a safer supply) reflects the fact that individual and community needs are not being met. »
The phenomenon is so well known in the field that the organization published a twenty-page discussion paper last year for health professionals who are wondering about the diversion of substances. “Possible cases of drug diversion from a safer supply program must be addressed with empathy and an understanding of the complex reasons why people use them to meet their needs,” the document reads.
The authors believe that “punitive approaches are counterproductive, restrictive and stigmatizing”. They conclude that “the benefits of providing pharmaceutical alternatives, even if they are susceptible to diversion, far outweigh the risks and harms associated with the diversion and use of drugs from a toxic market and volatile.”
Survival economy
Some professionals find that the doses are too high, which encourages resale, as revealed The duty Friday. But for the DD Marie-Ève Goyer, deputy head of specific dependency and homelessness programs at the CIUSSS du Centre-Sud-de-l’Île-de-Montréal, it’s probably the opposite. “If the person resells what I prescribed, it’s because I didn’t prescribe the right thing,” she says. Because the objective of safer supply is to compensate for consumption. »
However, people hardly use heroin anymore, but fentanyl, explains the specialist, who gives numerous conferences to health professionals to explain the safer supply program. “It’s hard to keep up, I’m constantly running behind. And so, we have to ask ourselves the question: if people are reselling, does that mean that I’m not prescribing enough? Does that mean we are not prescribing the right doses? That we are not prescribing the right molecule? Or does it mean something else? »
She also notes that those who sell their doses often say they do so to buy food or clothing. “It is still disturbing for me, as a doctor, to realize that with my prescriptions, I am fighting against poverty. We still have to name it,” she asserts with confidence.
“The people I treat are poor, they are in a survival economy. Sometimes that can mean selling your body or selling your medicine. I find it very simplistic to approach the risk of reselling safer supplies as a simple thing in itself. All this takes place in a context of poverty, vulnerability and social inequalities. We’re going to have to talk about this at some point instead of always hitting on people who are in situations of unspeakable precariousness. »
Compassion Club
In Quebec, the safer supply program is offered by doctors in addiction treatment clinics. There are advantages to this, since it allows doctors to see patients they would never have seen otherwise, explains the DD Goyer. “It’s often a springboard,” she says. A first way to have you with me in treatment so that, quietly, together, we obtain therapeutic objectives. »
However, the fact that the safer supply program is in the hands of a “handful of doctors” does not make it possible, according to her, to cover the real needs of users, who continue to die of overdoses on the streets. “What people would like is a solution available without complex assessments, without the barrier of accessing a doctor. »
She gives the example of the DULF (Drug User Liberation Front) model, a compassion center which opened in 2021 in Vancouver. The organization purchases illicit drugs from dark web, analyzes them to ensure the quality of the product and resells them to consumers who have a membership card. “That’s the real model [d’approvisionnement plus sécuritaire] which is claimed”, affirms the DD Goyer.
She believes that to counter the epidemic of overdoses, “we will have to be courageous and creative” because the current safe supply model does not give the expected results. “As long as it’s in the hands of prescribers to do a kind of disguised legalization for certain patients, it’s not going to work from a public health point of view. »
Russian roulette
Because the real problem, she says, what she calls “the elephant in the room”, is the toxicity of the substances on the market. The illicit market is creating “increasingly complex and dangerous substances” at a phenomenal rate, she explains.
“I had never seen this in my career: the illicit market is producing substances that do not exist in medicine. Before, we were in the mode: I do fentanyl in patch, you make fentanyl powder. I make Ativan, you make Ativan and you add a little sugar and caffeine so that it costs less. But that’s not it anymore. The illicit market began to produce things itself and mix substances. We are in a really very intense Russian roulette that we have never seen before, with the complexity of managing overdoses, withdrawals and treatments because we no longer really know what we are ultimately treating. »
She believes that there is a need for “societal reflection” on public policies on drugs, as was done for cannabis, which gave rise to the creation of the Société québécoise du cannabis (SQDC). “I don’t have a model to offer you for how we could sell heroin or fentanyl on the streets tomorrow, but we’re going to have to talk about it. Because talking about safer supplies is not talking about real business. The real deal is that our control of the illicit market is not working at the moment. »
To read Monday: the story of an opium addict