Measuring the harms of safer supply
The BC Coroners Service (BCCS) has often claimed there is no evidence that Canada’s experimental “safer supply” programs are harming communities. Critics counter however that because the province’s death investigations are less rigorous than those in many other jurisdictions, the possibility exists that these harms are simply not being measured.
“Safer supply” refers to the practice of distributing free addictive drugs, typically through prescription, as an alternative to potentially-tainted illicit substances. That typically means giving out hydromorphone, an opioid as potent as heroin, to dissuade clients from using street fentanyl.
Advocates claim that safer supply saves lives, but there is widespread evidence that these taxpayer-funded drugs are resold (“diverted”) on the black market, where they spur new addictions and relapses, including among youth.
Before retiring last month, former B.C. chief coroner Lisa Lapointe was one of Canada’s leading advocates for safer supply. She regularly played down the prevalence of safer supply diversion, which she deemed a myth, and emphasized that hydromorphone deaths had not significantly increased since safer supply was scaled up in 2020.
Her comments raised eyebrows among addiction experts, who noted that individuals who become addicted to hydromorphone often graduate to using fentanyl, which then kills them instead. As such, stagnant hydromorphone deaths cannot be used to rule out the dangers of safer supply diversion.
Concerns about Lapointe’s stance only intensified last summer when the BCCS released a report analyzing provincial youth drug deaths between 2017 and 2022. The report played down safer supply diversion and emphasized that, during this period: 1) fentanyl was the cause of most deaths; and 2) hydromorphone was present in only eight per cent of all cases, usually as an auxiliary drug.
When a group of physicians examined the report’s data however, they noticed an alarming trend. While hydromorphone was not found in any youth drug deaths between 2017 and 2019, before safer supply was made widely available, its presence skyrocketed afterwards — to 5.5 per cent of cases in 2020, 9.6 per cent in 2021 and 22.2 per cent in 2022.
The physicians were perplexed as to why the BCCS failed to acknowledge this spike and why the numbers had instead been presented in a manner that minimized growing hydromorphone use.
Additionally, while critics have spent the past year questioning the BCCS’S interpretation of key data, some experts have started to question the reliability of the data itself.
Most Canadian provinces, such as Alberta and Ontario, require all unnatural and unexpected deaths to be investigated by specialists who have medical backgrounds — oftentimes, that means physicians trained in pathology. But B.C. relies on lay coroners who aren’t required to have medical degrees.
At the same time, while autopsies are the gold standard for determining cause of death, B.C. has minimized their use for suspected overdoses in recent years, relying instead on far less reliable toxicology testing. According to an investigative report by The Tyee this month, most provinces conduct autopsies on 80 to 100 per cent of suspected overdoses, but B.C. does so for only 15 per cent.
The lay coroner system, combined with the low autopsy rate, means that when someone dies of a suspected overdose in B.C., their body is generally examined on-site, often in poor lighting, by a coroner with only cursory medical training. The coroner then uses their limited knowledge to interpret a toxicology report — and that’s it.
This system falls far below the standards used in most jurisdictions, and produces questionable results. In fact, The Tyee suggested in its report that some homicide cases in the province may have been improperly recorded as overdoses.
As for instances where diverted safer supply drugs may have played a role in an overdose death, the case of 14-year-old Kamilah Sword, who died in 2022 after becoming addicted to hydromorphone, is an illustrative example.
Upon her death, Kamilah was found with low levels of hydromorphone, flualprazolam, cocaine metabolite and methylenedioxymethamphetamine (MDMA) in her blood. The coroner concluded that the girl died of a cardiac arrhythmia caused by cocaine and MDMA; the other drugs detected were considered “unlikely to have played a role in her death.”
However, two experienced forensic pathologists confirmed that the current best practice for complex, poly-drug cases is to list every major substance as a cause of death. This means that hydromorphone should have been included, especially given the presence of flualprazolam in Kamilah’s system (the drug increases opioid overdose risk).
It is also concerning that the coroner did not interview Kamilah’s friends and family, who say she had been accessing diverted safer supply.
One wonders if hydromorphone deaths are being missed and connections to safer supply aren’t being found because of a failure to follow best practices.
With Kamilah’s case, the truth will never be certain. No autopsy was done on her body, and the BC Coroners Service declined to meaningfully answer a detailed list of questions about her death investigation.
“In my opinion, the fundamental problem in this case is that we are lacking autopsy data to provide a backdrop upon which the toxicology findings can be properly interpreted,” says Matthew Orde, an Alberta-based forensic pathologist. “On the basis of the information we currently have, I think the cause of her death is best regarded as undetermined.”