Health Committee on Feb. 26th, 2024

[Dr. Andrea Sereda]

I think there's always this question of whether it is the safe supply that is making people well. What we need to know is that the outcomes we were seeing.... We compared them to match controls and people who were not receiving a safer supply, and we simply could not see the positive health and social outcomes that we are seeing if people are on mass diversion, as is being alluded to here in this committee.

The 6% of folks we lost were lost to long-term incarceration, long-term hospitalization, and yes, we have tragically lost some people to infections and overdoses. What we do know is that, of the people who are confirmed by urine toxicology to be only using safe supply hydromorphone, zero of those people have died. It is people who continue to engage with the toxic illicit fentanyl street supply who have gone on to overdose. We know that proportionally we've lost so many fewer.

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

It's interesting that you say that, because you're familiar with Dr. Sharon Koivu. She is a site chief at the London Health Sciences Centre, and former acting medical officer of health. There was a study by her and Allison Mackinley, a nurse practitioner—and I'm sure you're aware of this—that examined the charts of over 200 patients who had been referred to Victoria Hospital’s addiction medicine consultation service between January and June 2023. It shows that safe supply hydromorphone from your program is causing harm, such as serious infections and new addictions.

What do you have to say about that?

[Dr. Andrea Sereda]

I have a lot to say about that.

I've actually been in communication with Dr. Koivu about this data that you just discussed, for about three months—maybe a bit more—trying to find out what her methodology, her inclusion and exclusion criteria—

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

You're questioning her methodology.

[Dr. Andrea Sereda]

Yes, because she hasn't released it. This is not a published study. There's no—

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Then that would be anecdotal information as well.

[Dr. Andrea Sereda]

When I have approached her, she's told me she actually cannot discuss any of this with me. Although she can't discuss the findings of her research or give her methodology, which all good researchers do, she can release it to Adam Zivo of the National Post, and she can release it on social media.

These things don't line up, and when you look at the denominator—

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Dr. Koivu also stated that some of her patients who get safe supply hydromorphone from your program have housing but choose to sleep outside Chapman's Pharmacy in tents to be first in line to get the prescription in the morning, which they often sell so that they can buy illicit fentanyl.

Some of these patients are vulnerable women who are being pressured to secure as much hydromorphone as possible so that their spouses or pimps can confiscate the drugs for resale. These patients also claim that the criminals wait outside the pharmacy and intimidate vulnerable people to hand over the hydromorphone.

What do you have to say about that?

[Dr. Andrea Sereda]

I would say that Dr. Koivu tells a lot of stories. Another story she is—

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Again, you're discrediting another doctor. Is that what you're doing?

[Dr. Andrea Sereda]

I am saying that what she has shared with you is not accurate in my experience. Dr. Koivu has also testified that safe supply has a 100% mortality at five years, yet she works in this community that has had safe supply for eight years and has 300 living patients.

I think we need to take those reports with a big grain of salt.

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Dr. Koivu is also stating that safe supply hydromorphone from your program was present in London before there was much, if any, illicit fentanyl, and that hydromorphone from your program has fuelled the fentanyl gangs and new addictions.

[Dr. Andrea Sereda]

I really think that—

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Do you discredit that as well?

[Dr. Andrea Sereda]

I really think that speaks to Dr. Koivu's lack of experience with this population, because that's not true. Fentanyl has been present in London, Ontario since 2012. It really started to pick up in 2013 through 2015, which is why we actually started the program in 2016, because at that point fentanyl was dominating the opioid sales on the streets of London. That's why we needed to make a change at that point.

[Todd Doherty, Conservative, Cariboo—Prince George, BC]

Dr. Samuel Weiss from the Canadian Institutes of Health Research testified to this committee on December 4 that based on a study they were conducting on 11 safe supply programs, wraparound supports are critical to any purported benefits from the program.

Given that your program offers wraparound supports, how can you credibly claim that a safe supply of hydromorphone is providing any benefits?

[Dr. Andrea Sereda]

First, I think it's pretty funny that a criticism of safe supply programs is that they give excellent care and excellent wraparound supports, but also, the data that I presented to you from the CMAJ study was before we had SUAP funding for those wraparound supports. The data I reported to you about a 50% reduction in emergency department admissions and the number of infections and a 50% reduction in costs was only from safe supply prescribing. At that time, we had no wraparound supports. That speaks clearly—

[The Vice-Chair, Conservative, Stephen Ellis]

Dr. Sereda, I'm going to have to stop you there, please, because your time is up.

Dr. Powlowski, you have the floor for five minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Sereda, convince me.

I like Gord Johns over there. He's a very passionate guy. He has a lot of good ideas.

My daughter actually works in the homeless community in Vancouver and she's a big advocate for safe supply. She's having trouble with dad. I'm not just a politician. I've worked in acute care medicine for almost 40 years, including 20 years in a Thunder Bay emergency room, which sees its fair share of overdoses.

We've heard anecdotes on both sides here, but I'd like you to comment on the recently released JAMA internal medicine study from January 2024, “British Columbia's Safer Opioid Supply Policy and Opioid Outcomes”, where they found that after B.C. instituted safe supply, “the opioid-related poisoning hospitalization rate increased by 3.2 per 100 000”, which was statistically significant, with a P value of .01. Deaths from opioid toxicity didn't increase significantly. They did increase, and the P value was .26.

The authors of the paper, as they're commenting on why these numbers went up, ask:

What could explain the higher hospitalization rate after the policy's implementation? One potential reason is that participants in British Columbia's Safer Opioid Supply policy program diverted safer opioid supply for various reasons, including to purchase unregulated fentanyl. It is also possible that a higher supply of prescription opioids led to an increase in prescription opioid misuse, which in turn, could increase hospitalization risks.

It doesn't look real positive for safe supply. Can I have your comments with respect to that article?

[Dr. Andrea Sereda]

The authors of that JAMA article seem to confuse correlation with causation. We know that there are about 4,500 people on safe supply in British Columbia, but we also know that there are over 225,000 people who were diagnosed with opioid use disorder and use street-level fentanyl. The idea that we can have a population effect from 5,000 people in the context of a denominator of 225,000 people is not reasonable. Safe supply prescriptions are not prevalent enough to be able to do that. We also need to remember that over 90% of hydromorphone prescribing in British Columbia is actually to chronic pain patients and not to safe supply patients. They're less than 10%.

The reason fatal overdoses have climbed in B.C. is actually because of an increase in the volatility in the supply. During that time period, we have seen the introduction of benzodiazopenes and xylazine to the toxic supply. People are dying because the fentanyl they're using is more deadly.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Let me just point out, though, that in that study they also compared mortality rates in British Columbia versus Manitoba and other provinces—Nova Scotia, I think, and Saskatchewan—and a number of other places that did not institute safe supply. They looked at their rates over the same period and asked if this is because there's a more unsafe supply of fentanyl. However, B.C.'s increased more. Yes, you can't prove causality, but certainly it's suggestive of a problem there, and certainly the authors pointed that out.

Could you please send me the evidence? You say there's a lot of evidence for the use of safe supply and how it helps.

This is all my evidence, and I have it all before me. I'm looking at it.

The one fairly good paper, I think, was the BMJ paper of 2023, Slaunwhite's, which I could talk about further. I would suggest that there are possible problems with that paper.

There's the CMAJ paper of 2022, on London. As has already been pointed out, it wasn't just safe supply. There were also comprehensive health and social supports involved.

I looked through the other studies that were “evidence”. A lot of them were basically a bunch of anecdotes. They talked to people on safe supply who said, “Yes, I feel better on safe supply”, but it's not exactly good evidence. A lot of the other trials—the Andalusian trial and all the heroin-assisted treatment studies—were all with directly observed treatments—not letting people go home with a lot of narcotics.

If you could, please send me the evidence.

Lastly, if I still have time, I would like you to comment. We had the chair of the Stanford-Lancet commission here, who was against safe supply. His reasoning for being against safe supply was this. He said, why did we get into this trouble to begin with? It was because of the over-prescription of narcotics by us doctors. There's evidence that it's often not the person who's prescribed it who is using it, but someone else who is using their drugs, someone else in the family, or it's being sold to other people. That was the source. How can you argue against his saying that if we provide safe supply we're just doing the same thing again?

[The Vice-Chair, Conservative, Stephen Ellis]

Dr. Powlowski, I'm enjoying your scientific debate with yourself. However, unfortunately, there's no more time. Perhaps your colleague Ms. Sidhu may have that question answered for you. I do apologize for that.

Mrs. Goodridge, you have the floor for five minutes, please.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you.

Actually, I'll just say, in the spirit of friendliness, could you answer Dr. Powlowski's question?

[Dr. Andrea Sereda]

I absolutely can. There's a lot there. I'm going to do my best to remember everything that came up.

I think you were first speaking to the JAMA study. You were talking about how they compared B.C. to Manitoba and Saskatchewan. Those illicit drug supplies are vastly different. In Ontario, the average amount of fentanyl in a piece of fentanyl is 5%. In B.C., it is 16% to 20%, so B.C. is unique. These are not directly comparable patient groups because the fentanyl in B.C. is at least four times as strong as what people in Manitoba and Saskatchewan would be using. I think it's very reasonable to understand that when you have a more toxic supply in one province, you're going to see a greater proportion of deaths than in a province where you have less toxic supply.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Dr. Sereda, thank you. I really appreciate that.

Could you table with us any of that information so that we can have that as evidence?