adam zivo: surprise, b.c.'s lenient drug policies haven't helped opioid crisis
new study showing safer supply associated with increased hospitalizations vindicates critics
4 minute read
hydromorphone pills sit on a table thursday, jan. 26, 2017 in belleville, ont.
luke hendry/belleville intelligencer/postmedia network
a new peer-reviewed study has found that british columbia’s “safer supply” policy was associated with a statistically significant increase in opioid hospitalizations with no reduction in deaths. to make matters worse, it found that the addition of drug possession decriminalization policies was associated with a further increase in hospitalizations. this research vindicates critics of the harm reduction movement, and raises serious concerns about whether the federal liberals and b.c. ndp acted recklessly by forwarding these untested policies.
the study, which was published in jama health forum last month, says that safer supply alone was associated with a 33 per cent increase in opioid hospitalizations, while the introduction of drug decriminalization was associated with a further spike, leading to a combined 58 per cent increase compared to provincial rates seen in the late 2010s.
although some harm reduction activists insist that safer supply and drug decriminalization save lives, the study found that neither policy was associated with decreased opioid deaths — but there was no associated increase, either.
the study used publicly available health data to compare hospitalization and mortality rates between b.c. and six other canadian provinces, with the latter acting as a control group. this data spanned from the beginning of 2016 until the end of 2023, and, for the purposes of the study, was divided into three periods: pre-safer supply (2016-2019), only safer supply (2020-2022) and safer supply plus decriminalization (2023).
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the researchers determined that “neither the safer opioid supply policy nor the decriminalization of drug possession seemed to alleviate the opioid crisis,” and hypothesized that widespread diversion of safer supply opioids onto the black market, which has been “increasingly documented,” could explain increased hospitalization rates.
the researchers cautioned that “diverted opioids could attract new users, including youth,” and that such users “face a higher risk of overdose, even from pharmaceutical-grade opioids,” because they are opioid-naive. however, they added that “the absence of a significant increase in overdose deaths suggest that the availability of pharmaceutical-grade opioids may have mitigated some of the risks associated with (the) unregulated opioid supply, potentially reducing the severity of outcomes.”
in other words: they suspected that diverted safer supply opioids may have saved some lives, but that this benefit was partly cancelled out by new deaths caused by diversion-related drug use — hence stable mortality and more hospitalizations.
however, according to dr. lori regenstreif, a hamilton-based addiction physician, there could be a significant delay before safer supply diversion causes a measurable increase in deaths, as individuals who develop addictions to pharmaceutical opioids generally die many years later, often after escalating to stronger substances. she noted that such a delay was observed with the oxycontin crisis, which safer supply bears a striking resemblance to. this muddles the study’s claims about the potential lifesaving benefits of safer supply opioids, which are already meagre to begin with.
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the researchers were far more uncertain about the effects of b.c.’s drug decriminalization experiment, predominantly because it was implemented in tandem with safer supply, making it impossible to study in isolation. they further noted that, in this context, increased hospitalizations could be explained in two opposing ways: either decriminalization increased drug use and caused new overdoses, or, alternatively, it “reduced stigma associated with drug use, encouraging persons merely gave addicts the confidence to seek medical assistance they would’ve otherwise avoided.”
the study data cannot, by itself, clarify which explanation is more plausible. as such, either side of canada’s harm reduction debate could conceivably present these increased hospitalizations as a victory, depending on what other data they use to contextualize this phenomenon.
as the evidence base behind safer supply and b.c.-style drug decriminalization is very thin, and marred with low-quality research, this study is an invaluable addition to the national discourse — but it is also undermined by some serious methodological limitations.
the statistical analysis it employed (known as “difference-in-differences”) relied on drawing comparisons between b.c. and several other canadian provinces — but many of these comparator provinces also had safer supply during the study period, to varying extents, which undermined their efficacy as a control group. in ontario, for example, seizures of hydromorphone, the opioid predominantly distributed via safer supply, increased by over 1,000 per cent in several mid-sized cities between 2019 and 2023.
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to make a comparison: if you want to study how cigarettes affect cancer rates, it’s better to compare a daily smoker to a non-smoker, rather than to a weekly one.
real life is messy, and, according to the study, there were many other confounding factors which could have contributed to the divergent health outcomes between the provinces, such as employment rates or changes in the availability of naloxone or evidence-based addiction medications (i.e. methadone).
many of the authors behind this study released a similar paper last year, which also found that safer supply was associated with increased hospitalizations, but received some criticism for failing to address these confounding factors. while this new paper improves upon its predecessor by taking a “synthetic” approach that filters out some potential confounders, it’s just not feasible to perfectly eliminate these potential sources of bias.
in an email to national post, dr. meldon kahan, medical director of the meta:phi provincial network, wrote that it is “very difficult to control for confounding variables in large observational studies,” and cited evolving fentanyl distribution patterns as an example: “if b.c. gets fentanyl from china before it’s distributed to other provinces, then b.c. might have a larger share of the fentanyl supply than other provinces, and this could explain the discrepancy in overdoses.”
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despite methodological limitations, kahan nonetheless believed that the study supports the hypothesis that safer supply drugs are being widely diverted, expanding the consumption of opioids and exacerbating the national overdose crisis.
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