The scope and breadth of the opioid crisis and the unfathomable numbers of opioid deaths seen across the continent, has forced a shift in how scientists, medical professionals and politicians have viewed substitution therapy and specifically “safe supply.”
The recent successes and broader acceptance of heroin, hydromorphone, and fentanyl safe supply programs have experts now looking at how stimulants such as cocaine may soon be included in these life saving approaches. Nowhere is this more evident than in Vancouver, Canada which, because of its high profile open drug use, has long been at the vanguard of novel and leading edge drug policy approaches.
Below are some examples of how this shift in approach to stimulant safe supply is being viewed in both the scientific and political realms.
1) “Safe Supply a concept document” presented to Vancouver City council Feb. 2019
“While options of dexedrine, ritalin, adderall, etc. as replacements for illicit stimulants are helpful, policy makers need to consider ways to provide regulated access to cocaine for people who seek cocaine. This drug is already used in Canada as a topical anaesthetic for some surgical procedures in a liquid hydrochloride preparation.”
2) Stimulant safe supply: a potential opportunity to respond to the overdose epidemic. Harm Reduction J 17, 6 (2020). Given that many stimulant users desire the “high,” any proposals for stimulant safe supply would need to acknowledge and emphasize user agency in diverse consumption practices.
Access to a consistent supply of stimulants of known quality can possibly lead to the same improved health outcomes observed among participants in injectable hydromorphone and diacetylmorphine interventions, such as reductions in abscesses transmission of infectious disease (e.g., hepatitis C, HIV), early mortality, and reduced engagement with law enforcement. Additionally, stimulant safe supply approaches may provide opportunities to engage hard-to-reach populations in care in situations that are not informed by crisis (e.g.hospitalization, overdose). Ongoing engagement in safe supply programming could also allow for medical staff to monitor and care for participants whose use could be associated with risk for coronary disease, low body weight, anxiety, psychosis, and other health concerns. Through therapeutic and nonjudgmental service provision, providers may also be able to facilitate access to other forms of treatment, although the harm reduction goals (e.g., overdose prevention) should be prioritized.
Drug user activist groups have recently argued the necessity of a safe stimulant supply in Canada, acknowledging that any form of medication-based approach is likely to fail if it does not mirror what people who use drugs seek (i.e., the “high”) in the illicit market. Current candidate medications have thus far only been studied in the context of treatment of stimulant use disorder, with the eventual goal of reductions in, or abstinence from, stimulant use. To date, trials have not included doses that would enable participants to achieve the “high” associated with a medication’s illicit proxy or to freely use these medications (e.g., user agency in dose amount, frequency, method of consumption). Thus, to study current candidate medications in a safe supply context will require that medications be administered in potentially larger doses than have previously been investigated, and potentially more frequently than once per day. Efforts are urgently needed to investigate the feasibility of pharmacological stimulant-based interventions that address safe supply needs and the underlying risk that a fentanyl-contaminated supply poses to people who use stimulants or are polysubstance users, as well as the lack of non-abstinence-based treatment options.
3) “Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021” Published Online: March 29, 2022 American Journal of Public Health.
The findings demonstrate the potential of safe supply approaches to reduce overdose vulnerability by providing people with alternatives to potentially toxic drugs. Researchers say the experiences they observed suggest that safe supply be extended to all people who use drugs and low-barrier, non-prescriber models must also be implemented to maximize access, efficacy, and equity.
4) “Access to Prescribed Safer Supply in British Columbia: Policy Direction” July 15, 2021 Ministry of Mental Health and Addictions Ministry of Health
With respect to stimulants, drug checking services across B.C. continue to detect the unexpected presence of fentanyl in stimulant samples such as methamphetamine and cocaine, suggesting that individuals who use stimulants could benefit from separation from the toxic drug supply. In the published literature, available evidence is concentrated on the use of psychostimulants and other pharmacotherapies for the treatment of stimulant use disorder. As this research is focused on treatment, with the primary goal of increased abstinence and reduction in use, outcomes may not align with patient goals when stimulants are prescribed in a harm reduction setting. While further research is warranted to determine the use of psychostimulants for the treatment of stimulant use disorders, initial research may help inform the direction of future research and initiatives for pharmaceutical-grade stimulants.