B.C.’s ‘safer supply’ program ethically justified despite potential harm to public, analysis finds

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British Columbia’s health ethics advisory team has concluded that it is ethically defensible to provide drug users with pharmaceutical alternatives to toxic, illicit substances to reduce their considerable risk of death, even if it results in some potential harm to the broader population.

The ethical analysis, led by co-chairs Alice Virani of the Provincial Health Services Authority and Bethan Everett of Vancouver Coastal Health, is contained within a broader review of the province’s “safer supply” programs, led by Provincial Health Officer Bonnie Henry and released publicly on Thursday.

It puts a spotlight on the most hotly debated aspect of the intervention: While a growing body of evidence shows that pharmaceutical alternatives reduce harms for those at high risk of overdose or death, potential unintended consequences – such as medications from the program falling into the hands of young people – remain a significant concern. The analysis urged better, regular monitoring.

“When harms to individuals are certain, severe or irreversible, there is ethical justification to implement effective interventions that reduce or eliminate those harms even when it means there may be some uncertain harms to individuals,” the ethical analysis said.

“Drawing on the value of utility, the certain, serious or irreversible harms related to the unregulated drug supply that [prescribed safer supply] can reasonably be expected to address (for some individuals) can ethically be prioritized over harms that are uncertain (e.g. harms from diversion).”

The team, which includes ethicists and health care providers from all B.C. health authorities, said its position is predicated on pharmaceutical alternatives being “reasonably effective.” It would become less justifiable to accept uncertain harms to the broader population if the intervention wasn’t working. As such, safer-supply programs must be continually assessed, and simultaneous actions must be taken to identify and reduce unintended harms as much as possible, the team said.

At least 2,511 people died from illicit drug toxicity in B.C. last year, a grim record eight years after the province declared a public-health emergency in response to soaring drug deaths from an increasingly toxic illicit supply.

Alexis Crabtree, a senior scientist with the BC Centre for Disease Control who spoke alongside Dr. Henry and Dr. Virani at a news conference announcing the review on Thursday, said it will be important to build a “diverse research base” into the new intervention, which still has limited evidence.

“I think there’s a very strong need right now on outcomes with strong control groups that allow us to see what would have happened for people accessing prescribed safer supply compared to people who are very like them, who didn’t access prescribed safer supply,” she said. “Looking at the population level is very important.”

The first population-level evaluation of safer supply in B.C., published last month in the British Medical Journal, found that people who were prescribed a one-day supply of a pharmaceutical alternative to illicit opioids were 61 per cent less likely to die from any cause the following week. Those who were prescribed four days’ worth were 91 per cent less likely to die from any cause the following week.

Dr. Henry announced her broader review of B.C.’s safer-supply programs last June, primarily in response to concerns raised about the prescribing of hydromorphone. Typically used to treat moderate to severe pain, the opioid is the most commonly prescribed medication in the program, with nearly 90 per cent of participants receiving it at least once in July, according to government figures.

As part of the review, the Provincial Health Officer commissioned the health ethics advisory team; consulted with clinicians, researchers and people who use drugs; and reviewed policy documents and evidence on prescribed safer supply.

In her report, Dr. Henry wrote that diversion of hydromorphone is reported by program staff and clients as a “common occurrence,” often because it does not meet the needs of people who have developed a much higher tolerance to opioids because of fentanyl. Some recipients reported diverting it to obtain other substances that more effectively staved off their withdrawal, or to support someone else who could not access prescribed safer supply.

Both Dr. Henry and the ethics team said that while current data do not show an increase in youth opioid use disorder, anecdotal reports of young people accessing diverted hydromorphone are concerning and that better monitoring for unintended consequences is needed. This could include regular surveys of youth substance use, Dr. Henry said.

The Provincial Health Officer recommended the B.C. government develop different models and protocols aimed at making safer-supply programs more effective. Access could be expanded through medical models that don’t require individual prescribing clinicians, such as access through multidisciplinary clinics or health authority overdose prevention sites. The report briefly referenced non-medical models such as compassion clubs – an idea the government has repeatedly rejected, and which Dr. Henry’s office is preparing a separate report on.

Adding additional medications that better meet the needs of recipients, such as powdered fentanyl and heroin, would remove the incentive to divert, she said, adding that these medications should, at least initially, require witnessed dosing.

Dr. Henry also recommended the creation of a formal review committee with representatives from the ethics team, regulatory colleges, researchers and people who use drugs through which people can report concerns about the program. The committee could then provide advice to the Ministry of Mental Health and Addictions.

Jennifer Whiteside, Minister of Mental Health and Addictions, said Thursday her office is reviewing the report but reiterated that non-medical models are not being considered. Ms. Whiteside said work is under way to update B.C.’s safer-supply program, including the requirement that witnessed dosing be the default for new medications.

The report noted that about 115,000 people in B.C. have a diagnosed opioid-use disorder, while only 4,331 – less than 4 per cent – accessed a prescribed alternative at the time the report was written. A separate coroner’s report estimated that about 225,000 people use illicit substances. Since 2016, more than 14,000 people have died.