“Injustice is fatal.” This was the message Karen Ward began sharing in 2017, around the time her friend Tracey Morrison, a warm and dedicated housing and drug-policy activist, passed away. Today, the COVID-19 pandemic has amplified the injustices faced by those suffering from poverty, systemic oppression, and what Ward calls “excess mortality.”

On paper, Morrison died from an overdose, the result of an increasingly poisoned drug supply seeping across North America. But according to Ward, Morrison’s death is part of this “excess mortality,” by which she means a lack of access to necessary resources, such as a stable income, a self-determined and culturally appropriate medical and legal framework, protection from systemic violence, and a safe, pharmaceutical-grade opioid supply.

“People aren’t going to live through this [crisis] and it’s not necessarily because of COVID, it’s because everyone’s going to struggle so much,” she says.

Isolation and overdose

In mid-March, when cities across Canada began to promote and enforce social distancing, many single-room-occupancy (SRO) residential units were hit with a guest ban. The following month, Ward said in a phone interview, she expressed her concerns that the policy would increase the risk of overdose to a city councillor. They then spoke on the issue at a council meeting with Vancouver Coastal Health’s chief medical health officer, Dr. Patricia Daly. Since then, there has in fact been an uptick in accidental overdose deaths.

While B.C. was successful throughout 2019 in decreasing overdose deaths — largely due to drug user activists operating research-backed overdose prevention sites and health officials advocating for increased use of the overdose reversal drug naloxone — effective prevention strategies have suffered in 2020 due to lack of resources. Illicit-drug toxicity deaths have skyrocketed, reaching 909 for the year as of July 2020, in contrast to 948 for all of 2019.

Before the lockdown in March, the number of toxicity deaths per month ranged from 59 to 79 from September 2019 to February 2020. Then, from March to May, deaths jumped to 113, 119, and 174. June’s total of 177 toxicity deaths represents the highest number recorded in a single month in B.C. In July, there were another 175 toxicity deaths, a 136 per cent increase from the same month last year.

With SRO residents left in isolation and staff asked to stay at home to prevent the spread of COVID-19, individuals who use drugs were put in harm’s way.

Research shows that isolation is a factor in addiction, and without the company of a peer who carries naloxone, drug use can be fatal. Ward, who lives in supportive housing, says she has seen so many drug-related deaths in her building since the beginning of the pandemic that she doesn’t know how much more she can take. With no COVID-19 outbreaks in any SROs or supportive housing units, she wonders why guests were not permitted again as early as April. If housing providers are concerned about their staff, Ward suggests allowing residents to run the SROs in a co-op fashion. Many supportive housing providers have since relaxed their visitor bans, allowing up to two guests per room at maximum. But the lift came too late.

“The phrase that drives us crazy — they use it in policy all the time — they say, ‘Oh, these are unintended consequences.’ People use this phrase. It’s like the policy version of a shrug,” Ward says. In contrast to the swift response to COVID-19 and heeding of advice from healthcare professionals, the response to the overdose crisis has been slow, despite health officials calling for a safe drug supply for years, says Ward. In 2020 so far, B.C. has recorded 204 deaths from COVID-19 and over 900 from illicit drugs, which leaves her questioning whose lives are deemed more valuable.

“The only thing we can do after all this time to stay alive, they say, is, ‘don’t be alone.’ And then they take that away from us because they’re concerned about themselves, as staff,” she says.

For Ward, who has worked with the Vancouver Area Network of Drug Users and the City of Vancouver on harm reduction strategies, the current crisis is political. While living in the Downtown Eastside, she’s seen narratives about drug use shift, from viewing it as a criminal issue to a disease. Now, she says, the issue is policy failure.

“You go to a medical facility that’s informed by evidence to address an individual problem. That is a health issue and I agree. Some of [addiction] stems from trauma but it’s also about addressing physical dependency. But five and a half thousand people dying in Canada since 2016 of overdose — of poisoning, in this context — that’s not a health issue. It’s clearly a political issue,” Ward explains.

Safe alternatives to illegal drug supply

In 2018, Ward worked with Dr. Mark Tyndall and the B.C. Centre for Disease Control to produce a report that was in many ways a blueprint for today’s harm reduction strategies. Their recommendations, including expanded access to injectable opioid agonist therapy, have been echoed by other community members and health officials across Canada.

In March 2020, Vancouver Coastal Health released new prescriber guidelines amid the dual public health emergencies of drug overdose and COVID-19. Intended to prevent drug withdrawal and the spread of COVID-19, the guidelines allow doctors and nurse practitioners to prescribe medications to meet people’s substance needs. With safe prescription alternatives to the illegal drug supply, the hope is that overdoses will decline. “People in the Downtown Eastside (DTES) are doing their part to reduce the transmission of COVID-19 by self-isolating; we need to do our part in supporting them,” states the document.

While commending these efforts to move toward drug decriminalization and a safe supply, Jordan Westfall, CEO and co-founder of the Canadian Association for Safe Supply, says this is not enough.

Opioid substitution therapies (OST) include methadone as well as the more recent Suboxone, a combination of naloxone and buprenorphine. Methadone activates the opioid receptors in the brain, producing a euphoric sensation, whereas naloxone attaches to the brain’s opioid receptors without activating them, blocking other opioids in the process. Buprenorphine is in a category of its own — it can block other opioids while having some opioid effect of its own to suppress withdrawal symptoms and cravings. What alarms Westfall is that Suboxone, produced by Indivior, has become the go-to treatment — by building drug policy around a pharmaceutical company, we fail to learn from past mistakes, he says.

“We went through an era where pharmaceutical companies were very aggressive in promoting pain pills and now I feel they’ve just moved over to OST. Now instead of doctors pushing pain meds, it’s doctors pushing OST meds,” he explains. “The part about it that concerns me is that they’re getting paid to choose this as a first-line treatment.”

Westfall is excited by an initiative announced by Fair Price Pharma, a non-profit launched in July that aims to produce injectable heroin, or diacetylmorphine (DAM). Addiction researcher and epidemiologist Dr. Martin Schechter and B.C.’s first provincial health officer, Dr. Perry Kendall, came together on the initiative after Schechter’s research%20in%20the%20Canadian%20context.) showed that DAM helped users who had not benefited from other available OST therapies such as methadone and who experienced unstable housing and social marginalization. Initial trials could only incorporate around 250 Vancouver users, and DAM faced regulatory barriers (researchers had to import the opiate from Europe). When the carfentanil and fentanyl drug poisoning epidemic skyrocketed in 2016, Kendall and Schechter decided it was time to make a move.

Westfall, who has conducted research with Schechter, explains that while the current crises present an unprecedented challenge, a safe — and fair — supply rests on whether the province will work with the new non-profit. “Fair Price Pharma requires about $3 million from the government. That’s something the province should take leadership on,” he says. “Combining that with an expansion of pharma coverage for injectables is crucially important. Right now in B.C., only about 220 people get coverage — but we have tens of thousands of people at risk of overdose — and that is strictly through B.C.’s injectable opioids program, so you have to go through that [process] for it to be covered. We need to expand pharma coverage to cover everybody.”

I asked Westfall, who has done safe supply consulting in Alberta — a province less friendly to harm reduction approaches — to help explain why abstinence-based treatment programs are outdated. Research shows that for opiate addiction, abstinence doesn’t work as an effective long-term treatment option. Public policy is often a reflection of what the general public believes, and Narcotics Anonymous and Alcoholics Anonymous, two abstinence-based models, remain a popular recommendation for both family and employers. “I think people should know the facts: that an abstinence treatment course could increase overdose or risk of overdose. You look at the people who abstain, their tolerance falls and then something stressful happens [such as a pandemic] and they go to use and they overdose,” he tells me. “That’s really important for government decision-makers to know. This isn’t an easy fix, and it could actually increase the risk of overdose.”

To save lives, a safe supply is necessary. But Ward says policy needs to address more for her and her peers — and that includes freedom from poverty and an end to institutionalized harassment. On Aug. 17, the Public Prosecution Service of Canada revised its approach to simple possession offences under the Controlled Drugs and Substances Act, instructing prosecutors to focus on cases with public safety concerns. It is a step in the right direction, and Ward can give credit where it’s due. But prosecution matters only if the first interaction with our justice system is addressed, she says.

The Vancouver Police Department claims it doesn’t bother people for small drug possession, but community members contest that. Ward provided a [records access request] she had asked another reporter to file, detailing drug seizures by the police department from 2019 to June 2020. The list of tiny amounts taken from people was tens and tens of pages long. “This IS criminalization,” Ward texted me.

Her sentiment echoed a parallel she had drawn earlier over the phone. When a user faces an unpredictable supply and then has to dodge enforcement in order to achieve respite from what can be a violent and traumatic world, more stress and fear is created.

“I noticed this at the beginning of [COVID-19], in March,” she told me. “All of you people are running around, freaking out, buying toilet paper — you’re doing this because this is your fear response to not knowing the future. Well, welcome to being a penniless drug user. … You have no idea what the future is so you’re freaking out. You’re trying to buy a stash. So welcome to being us, and it’s not pleasant. Not knowing your future, not being sure you have one. This is why we act like this. [So] just say you are scared and maybe we can form some empathy,” she suggested.

“There’s an opening, right? For the first time, I can actually conceive of [us] levelling, of changing the way that we relate to each other, and making a conscious decision to say, ‘You know what? Instead of this, let’s have not just equity, but let’s have justice. Let’s do it, let’s go,” Ward says. “There’s a real possibility for the first time ever in our lifetime, in our generation, to do that: to make that choice, and to make it real.”