Vancouver stimulant users worry authorities' focus on fentanyl is leaving them behind

People who use drugs like cocaine and methamphetamine say they understand why opioids receive so much attention, but argue they still deserve a say in drug-policy reform

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      B.C.’s overdose crisis has accelerated public debates around an end to the war on drugs. With the province suffering more than 1,400 fatal overdoses each year, policymakers are increasingly open to initiatives that were once dismissed as radical.

      Last week (February 21), for example, the B.C. Centre on Substance Use (BCCSU)—a research organization with close ties to government—published a report suggesting that Vancouver establish “heroin compassion clubs,” where people addicted to opioids could access pharmaceutical heroin that’s regulated and guaranteed free of dangerous contaminates like fentanyl.

      Drug users applauded the idea, but a number have also said that a focus on opioids is leaving stimulant users behind.

      Eris Nyx is a member of the Coalition of Peers Dismantling the Drug War (CPDDW), a group formed in the Downtown Eastside last November that’s focused on the question of how to provide clean drugs that are free of fentanyl and other unknown adulterants. She told the Straight there’s a growing feeling among people who use cocaine, crack, and methamphetamine that too-often they are left out of discussions about B.C.’s opioid epidemic and drug-policy reform.

      “We need to expand the conversation beyond what it’s looking at right now and figure out how we are going to include different types of drug users who use their drugs by different routes of administration,” Nyx said in a telephone interview. “We need to make sure no one is left out.”

      She didn’t criticize the BCCSU report directly but described it as part of a broader problem wherein the fentanyl crisis has led authorities to forget about people whose drug of choice is cocaine or crystal meth. Nyx said she understands why stakeholders are focusing on opioids, given that much of the data B.C. has on overdose deaths suggests it is primarily illegal opioids that are contaminated with fentanyl. But Nyx argued some of that data is flawed and subject to misinterpretation.

      “The lived experience of peers on the ground tells a totally different story,” she said. “The kinds of overdoses we’re seeing and responding to also involve stimulants.”

      The BCCSU’s report suggests a sort-of drug-user co-op, where prescription heroin (diacetylmorphine) is purchased from a legal producer in Europe and sold to club members under an exemption from Canada’s Controlled Drugs and Substances is Act.

      “This model is inspired by cannabis compassion clubs and buyers clubs, both of which emerged in the 1980s and 1990s in response to the AIDS epidemic,” it reads. The document made no mention of cocaine or methamphetamine.

      The same day it was released, the Canadian Association of People Who Use Drugs (CAPUD) published a similar document that received much less attention. Titled “Safe Supply,” CAPUD’s report does include a discussion of stimulants.

      “There is an ongoing search in the research community to find a replacement for cocaine that will retain participants in cocaine replacement trials, but the level of success has been limited,” the report reads.

      In a telephone interview, CAPUD national program director David Mendes said providing regulated substitutes for stimulants likely would be more complicated than for opioids, but he maintained there are options worthy of further study.

      “We want to see if Dexedrine would be a good alternative to crystal meth, for the time being,” he said. “Or things like Adderall….With these two drugs, the chemistry is very similar to methamphetamine.”

      In a separate interview, CAPUD executive director Jordan Westfall described these potential substitutes for illicit drugs as a “big part of the conversation that’s missing”.

      “With the way [fentanyl] contamination is continuing, I think we need to reassess everything, including stimulant use,” he said. ““There is stuff available, even if we need to get creative….We need safe supply for everybody.”

      A matter of priorities

      Dr. Patricia Daly is chief medical health officer for Vancouver Coastal Health (VCH) and a former executive director of B.C.’s Overdose Emergency Response Centre. She told the Straight that while the data isn’t perfect, it does clearly show that efforts to provide clean alternatives to contaminated street drugs for now should focus on opioids.

      “In the current crisis is, stimulants are not, by and large, contaminated with fentanyl,” Daly said in a telephone interview.

      According to VCH, drug-checking services at supervised-injection and overdose-prevention sites in B.C. suggest approximately three percent of stimulants contain fentanyl. That compares to 56 percent of all drugs tested in December 2018.

      Other statistics concerning stimulants are more troubling. “Crystal meth use in Vancouver has risen 600% over the last decade,” reads a headline CBC News published in November 2017. That article presents VCH statistics that show the number of visits to Vancouver’s first supervised-injection facility, Insite, that involved methamphetamine increased from 4,981 in 2005 to 35,238 in 2016.

      B.C. Coroners Service

      While meth use is up, Daly said there’s a second reason authorities have started with opioids: because we know more about opioid substitutes and how effective they are.

      “It is easier to begin with opioids, because we have pharmaceutically produced, safe options available," she explained. "And people can actually be relatively stable on long-term opioids.”

      Daly pointed to Vancouver’s Crosstown Clinic and a prescription-heroin trial conducted there that showed that after participants were provided with a regulated and regular supply of pharmaceutical opioids, a majority gained enough stability in their lives to find long-term housing and many took jobs, rejoining the legitimate economy.

      “Stimulant use is different and while I’m not an expert, it is not clear to me that people can live that kind of a stable life while they have a stimulant-use disorder,” Daly said.

      She emphasized this does not mean people who use cocaine or methamphetamine are being ignored.

      Daly pointed to a 2014 discussion paper published by the Health Officers Council of British Columbia in which she and her colleagues recommended B.C. regulate the supply of all drugs, removing them from the black market and bringing distribution under government control.

      “Everything that is currently illegal, which includes stimulants,” Daly said.

      “At public health, we monitor the safety of the food supply, and if we have an outbreak of a food-borne illness or a contaminated food item, we pull it off the shelf and we replace it with an uncontaminated supply of that food item,” Daly added. “But with an illegal substance, we haven’t been able to do that. So I think this would be an innovative approach.”

      Daly expressed support for the BCCSU’s proposed model for “heroin compassion clubs” and said that conversations around regulated supply should now also include stimulants.

      Research suggests challenges ahead

      Research proving the effectiveness of opioid substitutes such as methadone goes back decades. On prescription heroin, there also exists a growing body of scientific research, primarily from Europe and Canada, which shows there are many health benefits associated with providing people addicted to heroin with a pharmaceutical supply.

      There is significantly less academic literature concerning pharmaceutical substitutes for stimulants like cocaine, crack, and methamphetamine. Two reviews of existing clinical research summarize what’s out there.

      In 2013, the U.S. National Institute of Health published a paper that concludes, “Agonist replacement therapy may be effective for managing stimulant use disorders.” However, it adds, “A widely effective pharmacotherapeutic adjunct has yet to be identified and approved for managing stimulant use disorders.”

      That means that a cocaine user, for example, likely could benefit from a regulated supply of a substituted drug, but that there’s a challenge identifying an appropriate substitute. In addition, researchers cautioned that a substitute for cocaine would likely not work well as a substitute for methamphetamine, and vice versa. (The paper goes into much greater detail.)

      Travis Lupick / B.C. Coroners Service

      In September 2016, the UK-based Cochrane Collaboration published a second review that focused on cocaine dependence.

      “This review found mixed results,” it concludes. “Existing evidence does not clearly demonstrate the efficacy of any pharmacological treatment for cocaine dependence, but substitution treatment with psychostimulants appears promising and deserves further investigation.”

      Existing services leave gaps

      Many stimulant users prefer to inhale their drugs. That’s why Insite originally intended to open in 2003 with an industrial ventilation system designed to facilitate indoor smoking. Health concerns and city bylaws prevented Insite from ever using the system. Its failure to accommodate smoking is another example stimulant users raise when claiming government neglect. Finally, in 2016, a group of Downtown Eastside activists overcame these barriers when they established an overdose-prevention site as an outdoor facility sheltered with a tent.

      Sarah Blyth is executive director of the site’s operator, the Overdose Prevention Society (OPS). In a telephone interview, she told the Straight her team has had stimulant users in mind from day one. The OPS includes B.C.'s only supervised-inhalation site, at 62 East Hastings Street. Still, she said in Vancouver’s Downtown Eastside, there remains a need for harm-reduction services designed for drugs other than opioids.

      “People use stimulants and some stimulants have fentanyl in them,” she said. “They also have all sorts of other things in them, so any step toward safe supply is the right direction.”

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