COVID-19 has made a severe overdose crisis much worse. Border closures have caused major disruptions to drug supplies, increasing the need to “cut” the existing supply with substances such as fentanyl or benzodiazepines. Social distancing requirements have reduced the capacity and reach of lifesaving harm reduction programs. And more people are having to use their drugs alone, with no one to respond if they overdose.
In the United States, local and state-level estimates are suggesting fatal overdoses have increased dramatically over the course of the pandemic, in line with preliminary national data for early 2020. In Canada, provinces such as British Columbia and Alberta have seen record-breaking numbers of overdose deaths since March.
Calls for more access to treatment and supervised consumption services have been joined by growing support for drug decriminalization. In Canada, mayors of major cities, public health officials and the Canadian Association of Chiefs of Police all support it. In the US, Measure 110, moving to decriminalize personal-quantity possession of illicit drugs, is on Oregon’s November ballot.
While needed, none of these measures address the tainted drug supply that is directly behind the overdose surge.
Seeking to do so, British Columbia released “safe supply” guidelines in April—allowing people who use drugs and are at high risk from COVID-19 to access prescribed opioids, benzodiazepines and stimulants to avoid withdrawal and stay “comfortable.”
The inclusion of stimulants in BC’s safe supply program was significant. It signaled that health officials were finally acknowledging that overdose risk and a tainted drug supply extend beyond opioids.
Kali Sedgemore, executive director of the Coalition of Peers Dismantling the Drug War and peer supervisor at a Vancouver overdose prevention site, says that stimulant users’ voices are wrongly excluded from overdose crisis discussions. “The overdose crisis has such a focus in opioids, and it’s understandable why,” they told Filter, “but those of us who use stimulants are often left unheard, and not believed about meth or cocaine being contaminated with fentanyl or benzos.”
BC has provided a proof of concept for provision of prescription stimulants for those who want them.
Drawing inspiration from existing opioid safe supply programs, such as oral hydromorphone distribution, stimulant users in BC can now be prescribed Dexedrine or methylphenidate (Ritalin), and have a minimum of 23 days of medications delivered to where they are living. Research suggests that Dexedrine can be suited for people who use cocaine, and methylphenidate for people who use methamphetamine, although they may not work for everyone.
Despite some oversights in implementation—for example, in terms of scaling and speed of rollout—BC has provided a proof of concept for safe supply to be piloted in other parts of Canada, and for provision of prescription stimulants for those who want them, all within the country’s current legal drug policy framework.
Sedegmore believes that the past omission of stimulants from safe supply conversations has been “due to the stigma and [the] myth you can’t OD on stimulants.” While stimulants’ different properties compared with opioids lead some harm reductionists to prefer the term “overamping” for the former, deaths still occur—and stimulant-supply adulteration greatly increases their likelihood. It has long been clear that the term “opioid crisis” is not appropriate.
Stimulant-involved deaths have been steadily increasing over the past several years. According to the CDC, they are now comparable to, and in some states have even surpassed, opioid-involved deaths. For example, from 2015 to 2020 US overdose deaths involving methamphetamine have increased five-fold, while those involving cocaine have tripled.
Meanwhile, US DEA seizures of cocaine and methamphetamine are increasingly testing positive for fentanyl, and Canadian drug checking programs are showing that street-level supplies are contaminated not only with fentanyl, but with other, harmful substances such as ground pumice stone and plaster.
Despite these trends, Sedgemore said, “people are still shocked when someone who strictly uses stimulants dies of an overdose.”
The majority of illicit-drug deaths have long involved combinations of different substances. More and more deaths involving stimulants and opioids are being recorded, with estimates suggesting one in three US overdose fatalities in 2019 involved both of these drug classes.
The extent to which such cases involve either conscious polydrug use or adulteration isn’t entirely clear, however. “Although there are drug markets where fentanyl-adulterated stimulants are driving deaths, little is understood on how much adulteration or polydrug/co-use is contributing to these opioid-stimulant overdose deaths,” Sheila Vakharia, deputy director of the Department of Research and Academic Engagement at the Drug Policy Alliance*, told Filter.
Drug checking data throughout the pandemic have shown that the street-level stimulant supply is also increasingly, and concerningly, being contaminated with benzodiazepines. Naloxone doesn’t work to reverse the effects of benzodiazepines like it does with opioids, further emphasizing the need for a safe supply of stimulants.
While support in Canada comes from various government officials, public health officers, and healthcare providers, the US Drug Enforcement Agency is a major barrier to any advancements in drug policy south of the border, let alone safe supply, said Dr. Vakharia.
“We have seen their [DEA] involvement be a barrier to access to current approved treatments for opioid use disorder, namely methadone and buprenorphine, through overregulating the supply and dispensing, prescribers, and instilling fear in systems to avoid ‘diversion,’” she said. Such restrictions have made it “especially difficult to make progress on access to safe supply for opioids or stimulants, which may even be perceived as more controversial than the current medication options.”
A false perception persists that problematic stimulant use can only be addressed with behavioral or psychosocial treatments.
According to Dr. Vakharia, a stimulant safe supply may be especially hard to achieve because “there are no FDA-approved medications for stimulant use disorders” as there are for opioids. A false perception persists that problematic stimulant use can only be addressed with behavioral or psychosocial treatments, such as 12-step programs or contingency management, rather than through healthcare.
Sedgemore echoed these frustrations with how inadequate current options for stimulant users are, criticizing “stigmatized guides or reports on what needs to be done to stimulant users, that often are focused on abstinence-based options or some intensive therapy.”
Building the evidence base is a crucial next step towards a stimulant safe supply. While promising, currently available research on stimulant substitution is sparse. Small-scale pilots that include a range of prescription stimulants—and even opioids for polydrug users—need to be developed in partnership with people who use drugs, particularly in areas with a higher prevalence of stimulant-involved deaths.
Although it may seem attractive to model a stimulant safe supply pilot off of existing opioid agonist therapy programs, Dr. Vakharia stresses that to do so runs the risk of recreating the problems within those systems. “They don’t allow effective access to opioid treatments and pose significant barriers,” she said, such as restrictions on dosing amounts, procedures and timing, as well as limitations placed on prescribing physicians.
Instead, she argues, potential future stimulant safe supply programs will need to “acknowledge the different lifestyle factors driving/contributing to stimulant use—Including the intermittent and binge patterns.”
Colloquially, BC’s new guidelines are being called “safe supply,” but they’re not true to the spirit of how drug-user led organizations define safe supply. To Sedgemore, safe supply should be “low-barrier,” and include “both prescription medication and illicit drug supply that has been drug tested.”
BC’s stimulant safe supply program has not only reduced their risk of overdose, but also allows them to go about their day more easily.
This reiterates what drug-user-led organizations have been saying—that safe supply of any kind won’t work unless it can offer people who use drugs what they seek in the illicit market. For some, this is getting high; for others, it could revolve around how they consume their drugs, by smoking, for example, or injecting.
Still, Sedgemore said that BC’s stimulant safe supply program has not only reduced their risk of overdose, but also allows them to go about their day more easily. “It’s changed the frequency of needing to pick up; while at work I don’t need to worry about needing to do a fix a couple times in my shift.”
Thanks to the program, they added, if an illicit supply became unavailable or accessible for any reason, “I wouldn’t need to miss work because of withdrawal.”
Contrary to widespread prejudices, people who use stimulants are perfectly able to live positive, productive lives. The biggest benefit of safe supply programs is their potential to save lives. Yet they could also change public attitudes toward highly stigmatized drugs and the people who use them.
* The Drug Policy Alliance has previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship. Dr. Vakharia is also a member of the board of directors of The Influence Foundation.