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Addictions

Alberta and opioids III: You can’t always just stop

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29 minute read

Monty Ghosh at Highlevel Diner, May 30.                                                                            Photo: Paul Wells

This is the concluding installment in a series on drugs in Alberta. Previously:

i. “Worse Than I’ve Ever Seen,” June 4

ii. “Alberta’s System Builder,” June 7


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A matter of expectations

Street family

My tour guide for much of my visit to Edmonton was Dr. Monty Ghosh, a clinician who’s on faculty at the University of Calgary and the University of Edmonton. He seems to talk to everybody who works with substance users in Alberta, from his own patients to front-line clinicians to the Alberta government. His relations with the latter go up and down, but he urged me to talk to Marshall Smith, the chief of staff to premier Danielle Smith.

On my first night in Edmonton Ghosh walked me around a neighbourhood that included the George Spady Society  supervised-consumption site, the Hope Mission’s Herb Jamieson Centre, and the Royal Alexandra Hospital, which has a supervised-consumption service on its premises.

A lot of people use the services these places provide. Other people don’t. Shelters in particular are tricky: they’re usually for single people who arrive alone. “The Hope, the Herb, the Navigation Centre, offering the world,” one Edmonton Police Service officer told me. “But all these places have one thing in common: rules.” If you have a spouse or a pet, you want to keep your drug supply or you want to stay close to your “street family” — the community spirit in neighbourhoods like this is striking, and might be surprising to people who prefer to stay away — a shelter’s probably not for you.

Several of the places we visited weren’t ready to welcome us when we showed up unannounced. To say the least, they’re busy. That was the case at Radius Community Health and Healing, an institutional building in a more residential part of the neighbourhood. Radius is a drop-in clinic and, as we’ll see, quite a bit more.

On a sunny weekday afternoon, more than a dozen people stood, sat or lay on the building’s front steps and truncated lawn. One lay on his back, shirtless, not moving visibly. Ghosh asked the man whether he was all right, asked again, finally nudged him. The man stirred, looked around. Ghosh apologized mildly for bothering him, then checked in on two other people who also weren’t moving. They turned out to be all right too.

Francesco Mosaico, Radius’s medical director, was on his way home for the day when we arrived, but we made plans to talk the next day. When I returned, I met Mosaico and Radius’s executive director, Tricia Smith, in her office.

I think it’s important to hear them out, because when drug use becomes the object of political debate, it’s natural to talk as though policy decisions are the main thing keeping people from getting well. This can lead to a lot of blame on one hand, and to excessive optimism on the other. In fact the biggest thing that keeps people from getting well is often the entire sum of their lives until now, compounded by the influence of drugs that are more potent than anything earlier generations had to deal with.


The most complex patients

Radius offers primary care to people “experiencing multiple barriers,” Smith said. That can include homelessness, addiction, severe mental health problems, criminal records. The centre’s team includes 12 family physicians and three psychiatrists. They currently see about 3,000 patients.

Radius has Western Canada’s only non-profit dental clinic. The centre runs a respite program for people who are not sick enough to be in acute care but are too sick to be managing independently on their own. It has a program for pregnant women experiencing homelessness. It runs on a harm-reduction model, so they don’t need to be drug-free to go into the program. It has an interdisciplinary Assertive Community Treatment team to help people with mental-health and substance problems find and stay in market apartments, with frequent assistance. There’s a supervised consumption site in the basement.

“In fact,” Smith said, “we actually have an exemption from the College of Physicians and Surgeons of Alberta to filter out and keep the most complex patients. The least complex, we refer elsewhere.” I couldn’t get care in Radius if I tried; they’d politely refer me elsewhere. They’re for the people who need the most help.

After my visit, Smith wrote to me to add another program to the list: Kindred House, which for more than 25 yearss has supported women and Trans women sex workers. “The women we see are from age 18 to 50, predominantly Indigenous, have intergenerational trauma, past/current trauma, substance use issues, often houseless or couch surfing,” Smith wrote.

Smith has been at Radius for three and a half years. While I was there, I asked her how work at Radius is going. “It’s going fabulously, honestly,” she said. She arrived early in the COVID pandemic, after eight years in Alberta government departments — which in turn followed 20 years as a Canadian Forces army nurse, including in combat zones. “I’m in the right place,” she said of Radius. “It felt like coming home.”

How come? “The staff, the team, the work, the dedication. It just feels like family. I missed that. Being in the military was a big thing. This work that this group does is just really amazing. The team is amazing and it’s hard, but it’s good work.”

And how’s the workload evolving? “Unfortunately, for this population, the struggles are only increasing, and the number of individuals that are experiencing those challenges is not getting less,” she said. “The workload isn’t going anywhere. It’s getting more difficult.”

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“Especially in the last couple years, I don’t think things have ever been worse for the vulnerable population,” Mosaico, Radius’s medical director, added. The same housing crunch that has made homes less affordable for everyone has put thousands of the most vulnerable on the street. Results: more frequent frostbite or burns from lamps lit to keep from freezing. Body lice. Trauma from watching friends die. And to Mosaico’s astonishment, frequent shigella outbreaks.

“Shigella’s a bacteria that causes torrential bloody diarrhea. It can be treated with a single dose of antibiotics. But if you’re homeless and you don’t have a place to take care of yourself… 70 percent of the cases have had to be hospitalized in the last two years…. I mean, they’re talking about potentially calling it an endemic disease, and it’s a disease of destitution. You see it in refugee camps in developing countries, not in the capital of Alberta, you know?”

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Ten thousand times deadlier

Radius also works closely with the Alberta government to integrate its services with the “recovery-oriented system of care” that I told you about last week. There are two Radius staffers working at the Integrated Care Centre the police set up to replace the old, passive holding cells for overnight detention. There are two more at the Navigation Centre, which steers people toward social and government services. If there’s an Alberta model, they’re part of it. So I was fascinated by the response when I asked my hosts the basic question that sent me to Alberta: Why are so many people dying?

“I think it’s the nature of the drugs,” Mosaico said. “You know, people used to overdose and die. But I’ve been here 17 years. I think in the first 10 or 11 years it wasn’t very common to hear about overdoses by opioids. Every once in a while you’d hear about it, but it wasn’t a daily thing. Whereas now with fentanyl and carfentanil, it’s really dangerous.”

Carfentanil is 10,000 times more potent than morphine, 100 times more than fentanyl. The Edmonton Police won’t return stolen cars they recover until they’ve scrubbed them thoroughly, because even trace amounts of these drugs are too dangerous. “We’re finding clients who use methamphetamines and swear up and down they’re not taking opioids,” Mosaico said. “And then we do urine tests and it’s there. We think their dealers are lacing methamphetamine with fentanyl because it increases the addiction.”

The other big thing on his mind, Mosaico said, is that any program to guide users into recovery will bump up against the fact that different people have often lived starkly different lives.


93% 4+

“I don’t know if you’re familiar with Adverse Childhood Experiences — the ACEs study,” Mosaico said. I was, barely, but I needed a refresher.

The original study began in 1985 in San Diego, under Vincent Felitti, who ran an obesity clinic, and Rob Anda from the Centres for Disease Control. (If you want to learn more about the study, this article and this speech on Youtube are good places to start.)

“They surveyed 17,000 people,” Mosaico said. “They found, you know, if people had developmental trauma — so, trauma between the ages of 0 and 18 — and there are 10 different forms of trauma that the study bore out as being detrimental. Things like physical, emotional, sexual abuse; physical, emotional neglect; substance use in the family; untreated mental illness in the family; separation from biological parents; maternal figure being treated violently; and a household member going to jail.

“If those things occurred, you would just tally up the number of types of trauma and you’d get a score out of 10. What they found was, if you scored four or greater, that there seem to be adverse health effects in adulthood. And it wasn’t just the presence of addictions or mental illness. It was lung disease, heart disease, liver disease, certain forms of cancer, diabetes, obesity.” This is almost folk wisdom today, but at the time, Felitti and Anda were amazed at the strength of the correlations between childhood trauma and adult physical and mental health.

The original test has been widely replicated, and it usually finds that the proportion of people in a sample who’ve had four or more adverse childhood experiences is about 12%. So something like every eighth person you meet had a really difficult childhood, and while you can’t predict for individuals from statistical trends, there’s a good chance they’re still living with the fallout.

The team at Radius surveyed a large sample of the population under their care. The prevalence of high-risk ACE scores was about 93 percent, compared to 12 in the general population,” Mosaico said.

“Harvard has a center on the developing child, which has pulled together a lot of the science that explains the neurobiological link between the adverse trauma and the adverse health effects. They talk about limitations in the development of executive function, of decision-making, emotional regulation. Impulse control is underdeveloped, neuroanatomically in the brain. And instead what over-develops is the fight-or-flight response.

“So you’re dealing with a population that, because of their experiences, isn’t the same as the general population . And then that’s compounded by the fact that a high percentage of those clients who have high ACE scores also have traumatic brain injuries from living rough on the street. They also have adult trauma that compounds the childhood trauma. They have [fetal alcohol spectrum disorder], which impairs executive function even further.

“I hear these success stories and I think they’re wonderful, when you hear about people who have a difficult life and then they straighten up. And then, you know, they go back to their jobs and their families and they become leaders in their communities. But this is a population which is over-represented in every aspect of society, negatively as it were. In the prisons and child family welfare services. In the health system, you know, prevalence of HIV, tuberculosis, Hepatitis C, STIs, all that.

“And you look at them and you think, even if they managed to wait, you know, six months to get into an addiction recovery bed, after waiting for weeks to get into detox and they go through the program, what do they go back to? Most of them had to drop out of school. They have criminal records, which makes it hard to get a job. They’re disconnected and estranged from their families. They haven’t learned social skills.

“I had a client who lived in dumpsters for two and a half years. The fact that he just stayed housed — on income support — for the rest of his life was a huge win, right? It was important for his dignity, his quality of life. It’s just a matter of adjusting your expectations of what might actually be realistic.”

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Dr. Larson writes

The idea for these stories goes back to February, when it first became clear to me that 2023 would be Alberta’s worst year for overdose fatalities. I asked the communications team at the University of Calgary for names of people to talk to. Many weeks went by, because sometimes it’s ridiculous how hard it is to extract myself from Ottawa routine. After I published the second article in this series, the one where Marshall Smith showed me all the stuff Alberta is building, I received an email from Dr. Bonnie R. Larson, who’s on faculty at the University of Calgary. She thought I should have talked to her, and she thought I was too credulous in reporting the Alberta government’s side. I asked if I could publish part of her email. Here it is.

What cannot be taken for granted is Mr. Smith’s view that his goals are different, somehow nobler, than those of us on the front line.  Smith paints a picture that front line providers’ priorities are at odds with his own.  His perspective is at once undemocratic, insulting, and arrogant, belittling those who are doing the hard work of keeping people alive every day.  

I will not have Smith speak for me in his suggestion that front liners lack system knowledge and that is why we support harm reduction. This ignores the excellent evidence supporting harm reduction interventions at the population level.  Smith seems to think he knows from whence I “enter this conversation”.  If so, why does he not engage me and my expert colleagues?  Where I “enter this conversation” is at 20 years of working with the affected community and 13 years of post-secondary education.  The only reason I am what Smith likes to dismiss as a “radical harm reduction activist”, is because the UCP, immediately upon taking office, set out to destroy harm reduction in Alberta.  Nobody would have ever needed to fight this soul-destroying battle in the first place if Smith hadn’t put Alberta squarely on its current path of destruction. Yes, we should hope for a better tomorrow but that doesn’t excuse ignoring the past and present.  

I would ask you to think about several additional factors that your analysis appears to ignore, including who actually benefits, in power and wealth, from Smiths’ system of so-called care?  DId you consider the other ways that the UCP policy direction is moving the entire publicly-funded system steadily towards profit?  Gunn (McCullough Centre) was a wonderful non-profit facility that helped many of my patients find their way to recovery from substance use disorders. While I agree that people should not have to pay for treatment, the question remains:  in whose pockets do those tax dollars ultimately land?

You report that Smith indicates that they are “monitoring” the entire system.  Where is the data from that monitoring?  They have had five years now to show some outcomes, but who am I, just a lowly street doctor, to ask for population data?  What I do know is that if deaths begin to decline, it is because so many are already gone.  You should ask to see the data about which Smith so proudly boasts.    

Smith’s entire premise that he is fixing the ‘addiction crisis’ is a fallacy.  Addictions are not increasing.  Deaths by drug poisonings are, however, and Smith’s circus is only making that worse.  Allow me to spell it out for you:  harm reduction addresses the drug poisoning crisis that is, no question, taking a horrific toll in Alberta and nationally.  Smith’s ROSC, in contrast, addresses a figmentary addictions crisis.    

One last tip. Medications used for opioid agonist treatment are not harm reduction, they are treatment.  Nobody here is against treatment or recovery.  But Marshall Smith is against harm reduction.  Why can’t we just have the full spectrum of care???  Polarization is created by politicians to benefit politicians.   

I don’t endorse everything Dr. Larson writes here. The data, or a lot of it, seems to me to be publicly available on the province’s impressive dashboard website. Use the tabs at the top of the page to navigate. And indeed, the story the dashboard tells is alarming, which, as I explained in this series’ first instalment, is why I flew west. But Larson’s years of front-line work has earned her, at the very least, a right of rebuttal.


Synthesis

On my last day in Edmonton, I met Monty Ghosh at Highlevel Diner, at the outer edge of the hip Strathcona neighbourhood on the south of the North Saskatchewan River. Highlevel is famous for its cinnamon buns, which, if I’m going to be honest, are noteworthy mostly for being large.

If the Alberta government and its most vociferous critics are thesis and antithesis, Ghosh tries to provide synthesis. He helped design the National Overdose Response Service, or NORS, which provides some of the emergency-response capability supervised consumption sites offer to people who aren’t near such a site or can’t use it for other reasons. He’s been critical of the Alberta government, but both sides keep lines of communication open.

I asked him about diverted safe supply — the idea that pharmaceutical opioids used in safe-supply programs in BC, principally hydromorphone tablets, are being sold or distributed away from their intended use. “I know it happens,” Ghosh said. “We sometimes get clients from British Columbia who come to Alberta to try to escape BC, because they’re looking for a fresh start. They’re looking for support and they’ll tell me themselves that they’ve diverted their safe supply.”

But what are the quantities? Trivial so far, Ghosh maintains. “Have I seen hydromorphone come into our province? Not at all, not yet.” This is the same thing I heard from Warren Driechel, the Edmonton deputy police chief.

Why do people divert their prescribed safe supply anyway? The answer Ghosh gave me was the answer I heard from everyone I asked. “They never used it. It just was not effective. The potency of the hydromorphone that they’re getting was nowhere near touching the fentanyl that they were using. It wasn’t dealing with the cravings, it wasn’t dealing with withdrawals, they felt it was useless. So what did they do? They sold it. They’re incredibly poor, they cannot afford their substance-use concerns and so therefore they supplement with revenue from hydromorphone.”

Before I flew to Edmonton, when Ghosh and I were trying to gauge on the phone what each of us thought of this infernal crisis, he figured out that I was interested in the differences between government policy in British Columbia and Alberta. “I’m not sure you want to hear this,” he said, “but I think it’s going to be bad everywhere.” I said that’s what I think too. Perhaps I surprised him.

I don’t know what happens next. Maybe things just stop getting worse everywhere on their own, for big complex reasons that resist easy analysis. Overdose deaths were lower last year in the United States, the capital of this hellscape, than the year before.

If not… well, we shall see. I wonder what happens in year six or seven of the effort the Alberta government is building. Is there resentment among people in ordinary hospitals and correctional facilities, who don’t have access to bespoke programs and personal attention? Does the ROSC system become bureaucratized after the first generation of administrators moves on?

Or does it start to win converts? David Eby, the NDP premier of British Columbia, has started putting distance between himself and his public-health advisors on legalization and safe supply. A new appointment in BC is being closely watched in Edmonton.

Or, conversely, does the Alberta recovery effort bump up against the limits imposed by the substances involved and by human nature? Reported recovery rates from addiction vary widely, depending in part on how you measure them. This paper puts the rate at less than 30%. If you even manage to double it, that still leaves a large cohort who aren’t getting better. Would their neighbours see them as people who “failed recovery” or “blew their chance?”

I won’t claim to know. I do hope that in the year ahead, more Canadians check their assumptions and stow their cheap certainties. Especially those who aspire to positions of leadership.

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Addictions

Ontario to restrict Canadian government’s supervised drug sites, shift focus to helping addicts

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From LifeSiteNews

By Anthony Murdoch

Doug Ford’s Progressive Conservative government tabled the Safer Streets, Stronger Communities Act that will place into law specific bans on where such drug consumption sites are located.

Ontario Premier Doug Ford is making good on a promise to close so-called drug “supervision” sites in his province and says his government will focus on helping addicts get better instead of giving them free drugs.

Ford’s Progressive Conservative government on Monday tabled the Safer Streets, Stronger Communities Act that will place into law specific bans on where such drug consumption sites are located.

Specifically, the new bill will ban “supervised” drug consumption sites from being close to schools or childcare centers. Ten sites will close for now, including five in Toronto.

The new law would prohibit the “establishment and operation of a supervised consumption site at a location that is less than 200 meters from certain types of schools, private schools, childcare centers, Early child and family centers and such other premises as may be prescribed by the regulations.”

It would also in effect ban municipalities and local boards from applying for an “exemption from the Controlled Drugs and Substances Act (Canada) for the purpose of decriminalizing the personal possession of a controlled substance or precursor.”

Lastly, the new law would put strict “limits” on the power municipalities and local boards have concerning “applications respecting supervised consumption sites and safer supply services.”

“Municipalities and local boards may only make such applications or support such applications if they have obtained the approval of the provincial Minister of Health,” the bill reads.

The new bill is part of a larger omnibus bill that makes changes relating to sex offenders as well as auto theft, which has exploded in the province in recent months.

In September, Ford had called the federal government’s lax drug policies tantamount to being the “biggest drug dealer in the entire country” and had vowed to act.

In speaking about the new bill, Ontario Minister of Health Sylvia Jones said the Ford government does not plan to allow municipal requests to the government regarding supervised consumption sites.

“Municipalities and organizations like public health units have to first come to the province because we don’t want them bypassing and getting any federal approval for something that we vehemently disagree with,” Jones told the media on Monday.

She also clarified that “there will be no further safe injection sites in the province of Ontario under our government.”

Ontario will instead create 19 new intensive addiction recovery to help those addicted to deadly drugs.

Alberta and other provinces have had success helping addicts instead of giving them free drugs.

As reported by LifeSiteNews, deaths related to opioid and other drug overdoses in Alberta fell to their lowest levels in years after the Conservative government began to focus on helping addicts via a recovery-based approach instead of the Liberal-minded, so-called “safe-supply” method.

Despite public backlash with respect to supervised drug consumption sites, Health Canada recently approved 16 more drug consumption sites in Ontario. Ford mentioned in the press conference that each day he gets “endless phone calls about needles being in the parks, needles being by the schools and the daycares,” calling the situation “unacceptable.”

The Liberals claim their “safer supply” program is good because it is “providing prescribed medications as a safer alternative to the toxic illegal drug supply to people who are at high risk of overdose.”

However, studies have shown that these programs often lead an excess of deaths from overdose in areas where they are allowed.

While many of the government’s lax drug policies continue, they have been forced to backpedal on some of their most extreme actions.

After the federal government allowed British Columbia to decriminalize the possession of hard drugs including heroin, cocaine, fentanyl, meth and MDMA beginning January 1, 2023, reports of overdoses and chaos began skyrocketing, leading the province to request that Trudeau re-criminalize drugs in public spaces.

A week later, the federal government relented and accepted British Columbia’s request.

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Addictions

BC Addictions Expert Questions Ties Between Safer Supply Advocates and For-Profit Companies

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By Liam Hunt

Canada’s safer supply programs are “selling people down the river,” says a leading medical expert in British Columbia. Dr. Julian Somers, director of the Centre for Applied Research in Mental Health and Addiction at Simon Fraser University, says that despite the thin evidence in support of these experimental programs, the BC government has aggressively expanded them—and retaliated against dissenting researchers.

Somers also, controversially, raises questions about doctors and former health officials who appear to have gravitated toward businesses involved in these programs. He notes that these connections warrant closer scrutiny to ensure public policies remain free from undue industry influence.

Safer supply programs claim to reduce overdoses and deaths by distributing free addictive drugs—typically 8-milligram tablets of hydromorphone, an opioid as potent as heroin—to dissuade addicts from accessing riskier street substances. Yet, a growing number of doctors say these programs are deeply misguided—and widely defrauded.

Ultimately, Somers argues, safer supply is exacerbating the country’s addiction crisis.

Somers opposed safer supply at its inception and openly criticized its nationwide expansion in 2020. He believes these programs perpetuate drug use and societal disconnection and fail to encourage users to make the mental and social changes needed to beat addiction. Worse yet, the safer supply movement seems rife with double standards that devalue the lives of poorer drug users. While working professionals are provided generous supports that prioritize recovery, disadvantaged Canadians are given “ineffective yet profitable” interventions, such as safer supply, that “convey no expectation that stopping substance use or overcoming addiction is a desirable or important goal.”

To better understand addiction, Somers created the Inter-Ministry Evaluation Database (IMED) in 2004, which, for the first time in BC’s history, connected disparate information—i.e. hospitalizations, incarceration rates—about vulnerable populations.

Throughout its existence, health experts used IMED’s data to create dozens of research projects and papers. It allowed Somers to conduct a multi-million-dollar randomized control trial (the “Vancouver at Home” study) that showed that scattering vulnerable people into regular apartments throughout the city, rather than warehousing them in a few buildings, leads to better outcomes at no additional cost.

In early 2021, Somers presented recommendations drawn from his analysis of the IMED to several leading officials in the B.C. government. He says that these officials gave a frosty reception to his ideas, which prioritized employment, rehabilitation, and social integration over easy access to drugs. Shortly afterwards, the government ordered him to immediately and permanently delete the IMED’s ministerial data.

Somers describes the order as a “devastating act of retaliation” and says that losing access to the IMED effectively ended his career as a researcher. “My lab can no longer do the research we were doing,” he noted, adding that public funding now goes exclusively toward projects sympathetic to safer supply. The B.C. government has since denied that its order was politically motivated.

In early 2022, the government of Alberta commissioned a team of researchers, led by Somers, to investigate the evidence base behind safer supply. They found that there was no empirical proof that the experiment works, and that harm reduction researchers often advocated for safer supply within their studies even if their data did not support such recommendations.

Somers says that, after these findings were published, his team was subjected to a smear campaign that was partially organized by the British Columbia Centre on Substance Use (BCCSU), a powerful pro-safer supply research organization with close ties to the B.C. government. The BCCSU has been instrumental in the expansion of safer supply and has produced studies and protocols in support of it, sometimes at the behest of the provincial government.

Somers is also concerned about the connections between some of safer supply’s key proponents and for-profit drug companies.

He notes that the BCCSU’s founding executive director, Dr. Evan Wood, became Chief Medical Officer at Numinus Wellness, a publicly traded psychedelic company, in 2020. Similarly, Dr. Perry Kendall, who also served as a BCCSU executive director, went on to found Fair Price Pharma, a now-defunct for-profit company that specializes in providing pharmaceutical heroin to high-risk drug users, the following year.

While these connections are not necessarily unethical, they do raise important questions about whether there is enough industry regulation to minimize potential conflicts of interest, whether they be real or perceived.

The BCCSU was also recently criticized in an editorial by Canadian Affairs, which noted that the organization had received funding from companies such as Shoppers Drug Mart and Tilray (a cannabis company). The editorial argued that influential addiction research organizations should not receive drug industry funding and reported that Alberta founded its own counterpart to the BCCSU in August, known as the Canadian Centre of Recovery Excellence, which is legally prohibited from accepting such sponsorships.

Already, private interests are betting on the likely expansion of safer supply programs. For instance, Safe Supply Streaming Co., a publicly traded venture capital firm, has advertised to potential investors that B.C.’s safer supply system could create a multi-billion-dollar annual market.

Somers believes that Canada needs more transparency regarding how for-profit companies may be directly or indirectly influencing policy makers: “We need to know exactly, to the dollar, how much of [harm reduction researchers’] operating budget is flowing from industry sources.”

Editor’s note: This story is published in syndication with Break The Needle and Western Standard.

The Bureau is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

Dr. Julian M. Somers is director of the Centre for Applied Research in Mental Health and Addiction at Simon Fraser University. He was Director of the UBC Psychology Clinic, and past president of the BC Psychological Association. Liam Hunt is a contributing author to the Centre For Responsible Drug Policy in partnership with the Macdonald-Laurier Institute.

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