72 doctors sign letter blasting "safer supply" in British Columbia

"I think it’s important for politicians to know what a really sizeable proportion of physicians in British Columbia really think about safer supply."

A group of 72 doctors in B.C., including several of the province’s leading physicians, have signed a letter criticizing Canada’s experimental “safer supply” programs. The letter argues that, not only are these programs unscientific, they are being widely defrauded and seriously harming youth.

“Safer supply” refers to the distribution of free recreational drugs, typically through prescription, as an alternative to potentially-tainted street substances. While advocates claim that these programs save lives, there is widespread evidence that clients regularly resell (“divert”) their safer supply on the black market to purchase stronger illicit drugs, which then floods communities with cheap opioids and fuels new addictions, particularly among youth.

Dozens of addiction experts have also argued that there is no evidence that safer supply works. Most studies which support the strategy use low-quality research methodologies that are considered unacceptable in most healthcare studies – for example: simply asking drug users if they benefit from safer supply, or if they resell their drugs, and then treating their answers as objective fact.

The new 72-doctor letter, which was originally published in February as an op-ed in the Times Colonist, reiterated many of these concerns and expressed frustration with the B.C. NDP’s inconsistent claims about safer supply.

Lead author Dr. Mark Mallet, a hospitalist at Victoria General Hospital, wrote that, although the provincial government spent nearly a year dismissing safer supply diversion as an “urban myth,” it was gratifying to see top officials recently admit that it is actually a common occurrence. However, he said that it is “unsettling” that such officials, including Provincial Health Officer Bonnie Henry, repeatedly assured the public that diversion was being closely monitored when, evidently, it was not.

Dr. Mallet also expressed frustration with the government’s tendency to vilify doctors who criticize safer supply. Until very recently, such experts often stood accused of “politicizing” the issue and inciting a “moral panic” through “anecdotes” – but their concerns, by the provincial government’s own admission, turned out to be entirely justified.

The doctor said that it is shocking that, almost four years after safer supply was expanded across Canada, there are still almost no credible studies into these programs or their unintended consequences.

“We should be drowning in evidence by now,” he wrote, noting that, in light of this gap, it is “not surprising” that harm reduction advocates have been able to dismiss signs of diversion as merely anecdotal. “It is impossible for anecdotes to rise to the level of evidence if no one is systematically collecting data.”

Dr. Mallet criticized the provincial government’s plans to further expand safer supply, and argued that more research, with credible methodologies, is urgently needed instead. Until such research is produced, he believes that safer supply must be reformed so that it is “tightly controlled, rigorously monitored and meticulously documented.”

“It is virtually unheard of for a potentially dangerous medical intervention to be expanded beyond a pilot project without significant evidence showing efficacy, and similarly significant evidence showing an absence of harm,” he wrote.

71 doctors jump into the fray

After Dr. Mallet’s op-ed was published, the document was re-formatted into a letter and signed by 71 additional medical experts. The new signatories included high-profile leaders within Victoria, B.C.’s medical community, such as the Medical Chiefs of Staff of both the Royal Jubilee Hospital and the Victoria General Hospital, as well as the Medical Lead for Pediatrics at the Victoria General Hospital.

Two weeks ago, the letter was sent to B.C.’s minister of mental health and addictions, Jennifer Whiteside, as well as her federal counterpart, Ya’ara Saks.

Neither Whiteside nor Saks are strangers to such outreach. Since last autumn, dozens of addiction experts have published multiple public letters criticizing safer supply – although the organizers of these initiatives say that their efforts were almost entirely ignored.

In contrast to these initiatives, which relied almost exclusively on signatures from addiction experts, Dr. Mallet’s letter was mostly signed by doctors working outside of addiction medicine. Signatories included, for example, professionals working in family medicine, pediatric psychiatry and adolescent medicine.

In a phone interview, Dr. Mallet explained that, after he outed himself as a critic of safer supply, almost every doctor he personally came into contact with, and who had read his pieces, agreed with his views. It thus only made sense to turn his latest op-ed into a co-signed letter and call attention to this broad base of support.

“I think it’s important for politicians to know what a really sizeable proportion of physicians in British Columbia really think about safer supply. Our concerns are shared by the vast majority of physicians, in my opinion,” said Mallet.

He said that the actual opinions of the province’s physicians are often not accurately conveyed to the public. Many journalists do not understand addiction medicine, cannot critically analyze scientific studies and are enamoured with the ideals of harm reduction. As such, they have a tendency to assiduously ignore doctors who are critical of safer supply.

Dr. Mallet was particularly concerned about teenagers accessing, abusing and being grievously harmed by diverted hydromorphone, a safer supply opioid that is as potent as heroin. Many of his colleagues, including a sizeable chunk of his letter’s signatories, have treated such cases – even if the federal and B.C. governments have routinely downplayed or denied their existence.

“Doctors who don’t work in addiction, but who have patients who are harmed by safer supply, have been reluctant to speak up because they feel that they lack the expertise to do so. Each doctor has one or two of those kinds of patients in their practice, so none of them feel like they can be a spokesperson for raising concerns about this program,” said Dr. Mallet.

Having just one or two hydromorphone-addicted teenagers per doctor, in settings where addiction is not the norm, is concerning and suggests that a significant problem is brewing.

Dr. Mallet even described how “dillies” (the slang term for hydromorphone) had shown up in his own personal life. One of his friends had a teenage child who experimented with dillies, as they did not know what the drug was or what its risks were, and quickly became addicted. The addiction was eventually discovered and treated after the family went on vacation and the teenager, having run out of their supply, began experiencing debilitating withdrawal symptoms.

“They really didn’t even know that that’s what was happening. Most teenagers don’t even know that dillies are an opioid. The teenagers I talk to are shocked to find out that this is a pill version of heroin,” said Dr. Mallet. He added that his own teenage children, who do not use dillies, have confirmed to him that they have peers who have developed opioid addictions due to the drug.

Despite these issues, Dr. Mallet and many of his colleagues still believe that safer supply can be useful – but only if the system is radically reformed and significant safety guardrails are put into place. For example, safer supply patients are currently permitted to take almost all of their drugs “home” for unwitnessed use. Many physicians say that this urgently needs to stop and that supervised consumption must be mandatory.

While such reforms are commonsensical, neither the B.C. NDP nor the federal Liberals seem interested in implementing them.

For example, the aforementioned addiction physicians, who previously sent Minister Saks public letters about safer supply, said that they were ignored for months. Although they were eventually permitted to give Saks a detailed and thoroughly-researched presentation about their concerns, the minister simply resumed ignoring them afterwards. She then disregarded all of their research and publicly claimed that criticism of safer supply is illegitimate and rooted in “fear and stigma.”

Dr. Mallet was not involved in that incident, but he said that it is “hard not to feel frustrated” by Saks’ comments, as they fundamentally misunderstand the relationship that most doctors have with their patients. “It’s so insulting and so ignorant. I don’t know what else to say.”

He observed that government officials who support safer supply “tend to very carefully use language that obscures what is actually happening.” For example, some officials claim that there is “no evidence of diversion,” but then fail to disclose to the public that the government is not actually measuring the problem.

“Just because no one’s collecting the data, it doesn’t mean that it’s not happening. These comments give the impression to the public that diversion is not happening, and that this is being well-studied and under control – even though we all know that diversion is happening. Almost any physician on the ground will tell you that this is not being well studied. And it’s certainly not under control,” he said.