Reflections on 20 years of harm reduction in British Columbia
Harm reduction has many definitions but in essence is an evidence-based and person-centred approach that seeks to reduce the harms associated with substance use. It provides people who use drugs with resources to make healthier and safer choices without insisting on abstinence. I have worked in harm reduction and substance use for 20 years, including 18 years as medical lead for harm reduction at the BC Centre for Disease Control. During that time, I was privileged to collaborate with many compassionate colleagues across different sectors and alongside the experts, people with lived and living experience of substance use.
In the last 10 years, the harm reduction response has faced dramatic changes in the substance use landscape. These changes include the emergence of fentanyl in the unregulated drug supply, increasing polysubstance use, adulteration of the unregulated supply with sedatives, the COVID-19 pandemic and ongoing issues related to colonialism and a worsening housing crisis. At the same time, harm reduction programs have been opposed based on ideological disagreements that are not supported by data. In this current climate, it’s important to look back on the lessons we’ve learned over the years and how harm reduction has previously responded to needs and been shaped by evidence and collaboration.
Responding to evidence and need
Engaging people with lived and living experience is an important aspect of all harm reduction responses. Authentic engagement involves asking people who use drugs what issues should be prioritized and what they need to ensure policy, services and research are relevant and accessible. I have witnessed the impact that listening to people who use drugs can have when developing harm reduction programs. For example, people with lived and living experience in B.C. advocated to make naloxone widely available so they can save the lives of their friends and loved ones. When BCCDC started the provincial naloxone distribution program in 2012, we estimated the demand would be about 40,000 kits per year, however 35,000 kits are now shipped every month to more than 2,200 sites across B.C. Listening to the practical and experiential evidence shared by community members who respond to overdoses informed the Canadian take-home naloxone program guidance, and we know that thousands of lives have been saved thanks to naloxone.
Provision of harm reduction services in B.C. has continually evolved in response to the latest data from research and evaluations. Recent evidence from surveys and coroners data found despite many believing that smoking drugs is safer than injecting, smoking was the predominant mode of substance use prior to overdose deaths in B.C. Subsequently, the B.C. ministry provided funding in 2020 for additional safer smoking supplies and to develop inhalation overdose prevention sites (OPS). This is an example of using data to inform a response that increases engagement with people who smoke drugs and increases access to harm reduction services, supplies and information.
Pragmatic responses to the overdose crisis, now called the unregulated drug poisoning emergency
In 2016, fentanyl emerged as the primary driver behind an increase in overdoses and deaths across Canada, especially in B.C. Federal and provincial governments and agencies responded pragmatically in order to save lives. For example, that same year Health Canada removed naloxone from the prescription drug list, which simplified distribution and expanded naloxone access and B.C. declared a public health emergency and directed all emergency departments to provide take-home naloxone.
Despite these measures the alarming rate of overdoses continued. However, obtaining exemptions from criminal laws to allow supervised consumption sites (SCS) to open was a lengthy process. Advocates and people who use drugs set up unsanctioned overdose prevention sites (OPS) to respond to overdoses in their communities. In December 2016 the B.C. Minister of Health, enacted a ministerial order to sanction OPSs and support their development in all health authorities. In B.C. there are currently 51 OPS/SCSs with 70,000 visits and over 200 overdoses reversed each month; to date only one death has been reported in more than four million visits.
Safer supply, also known as prescribed alternatives, is another response to the overdose crisis. It entails providing people who use substances, with regulated drugs of known type, quality, and concentration so that they are not seeking drugs from the highly toxic unregulated market. Safer supply was initially implemented in B.C. as Risk Mitigation Guidance to address issues related to COVID-19. Evidence is emerging that safer supply reduces deaths. Clients report decreasing their substance use and having fewer overdoses. Many believe that without safer supply, their use of toxic drugs would have led to a fatal overdose.
There remain many gaps and challenges in our responses. Intersecting crises have had disproportionate impacts in many communities. For example, despite ongoing efforts to improve services and supports, vast disparities and inequities of access to resources occur in B.C., especially in rural and remote areas. First Nations people in B.C. are six times more likely than other BC residents to die of an overdose. These complex challenges highlight the need to listen to people with lived and living experience, to implement community-driven harm reduction responses and to support Indigenous-led solutions.
Ignoring the evidence
Stigmatizing discourses about harm reduction and people who use drugs have increased. Negative anecdotes about harm reduction responses, including OPS and safer supply are increasingly seen in media and popular narratives, ignoring the evidence that underpins these approaches. This situation has been exploited for ideological and political gain, with media and some politicians promoting a stigmatizing false dichotomy between treatment and harm reduction. There is no one-size fits all solution. It is essential to have a range of programs and services that meet people where they are and provide supports in their substance use journey.
Disregarding evidence when it does not fit with political ideology is not new. In 2007, despite extensive data from research published in peer reviewed journals, including showing increased engagement in treatment, the federal Minister of Health opposed extending the exemption from criminal drug laws that allowed Vancouver’s Insite, the first legally sanctioned safer consumption site in North America, to operate. Ultimately, the Supreme Court of Canada ordered the exemption to continue, finding that drug possession laws would violate the constitutional rights of Insite’s clients and staff. Insite has since reversed thousands of overdoses, helped dramatically reduce the incidence of HIV among people who inject drugs, and has supported thousands of clients to access the co-located withdrawal management facility.
Where do we go from here?
The devastating loss of life and urgency to act are indisputable. As recommended by the Harm Reduction Nurses Association, we need to scale up SCS and OPSs, regulate, evidence-based voluntary non-profit treatment services, invest in affordable housing and poverty reduction initiatives and also include people who use drugs further in proposed responses and solutions.
We need to re-prioritize evidence in all our responses. This includes evidence from research and from lived and living experience. It is also imperative that all responses to this crisis are held to the same standard. We need services and programs implemented by the treatment industry to be accountable by collecting and publishing outcomes, to ensure that all our responses are informed by evidence.
Politically motivated ideology and hearsay only set us back. We need collaboration and respectful discussion grounded in compassion. Through evidence-based and person-centred responses to the drug toxicity crisis, we, a society that includes people who use drugs, can be more empathic and understanding to ensure the well-being of everyone.
Jane Buxton was medical lead for harm reduction at the BC Centre for Disease Control, where in 2011 she developed the Drug Overdose and Alert Partnership, an inter-sectoral committee including representation from health, coroners, ambulance, enforcement, drug checking and people who use drugs. In 2012 she introduced the B.C. take-home naloxone program and province-wide harm reduction client survey. Jane acknowledges all achievements are the result of the tireless dedication of many colleagues including people with lived and living experience of substance use. She advocates for peer engagement in all aspects of harm reduction policy, planning, implementation, evaluation and research. Jane was appointed to the Order of British Columbia in 2023.