If you met BeeLee Lee in the lobby of her apartment building in Vancouver, British Columbia, you probably wouldn’t suspect that just a few years ago, she nearly died several times from fentanyl overdoses.
Lee, who’s nearly always accompanied by Sadie, her loyal labrador/husky companion, now has her life in order. She has a full-time job, is reconnecting with her children and grandchildren and leads a stable, middle-class life.What made that possible, Lee says, is safe supply – a system of prescribed, regulated drugs that serve as an alternative to fentanyl.
In Washington, a work group funded by the Legislature in 2023 is examining what it would take to set up a safe-supply system similar to the one launched in British Columbia in 2020. The work group is the first government-sanctioned panel in the United States tasked with making policy recommendations about safe supply. It will submit its recommendations by the end of the year.Though British Columbia’s safe-supply project – which provides prescription drugs mimicking heroin and fentanyl to between 4,000 and 5,000 people a year – is controversial, there’s evidence it significantly reduces the risk of fatal overdose, and can have other positive effects for people like Lee.“If I was not on safe supply, I would probably be dead,” Lee said. “That’s where I was heading.”British Columbia looks to evidence-based solutionsThe number of fatal overdoses in Washington continues to skyrocket. According to data from the Centers for Disease Control, there were 3,421 fatal overdoses statewide in 2023, up 20 percent from the previous year. This means that on average, in Washington, nine people die every day because of the toxic drug supply.In British Columbia, the figures are similarly grim: More than 2,500 people died from overdoses in the province last year. Illegal drug overdoses are now the leading cause of death for those between ages 10 and 59 in British Columbia.The combination of fentanyl’s potency and the unpredictable contents of street drugs have made it the leading cause of overdose deaths in Washington. Malika Lamont, program director of VOCAL-WA, which advocates for people who use drugs or are homeless, explained, “Fentanyl is actually quite easy to get hold of, and cheap. And deadly – because there’s no regulation to it.”Although it’s 50 to 100 times stronger than heroin, fentanyl is not inherently dangerous – in the correct dose. Fentanyl is frequently prescribed after surgery to reduce pain, and is administered by either patches, lozenges, lollipops (for children) or injection. Palayew, a member of the safe-supply work group, is an epidemiology Ph.D. candidate who researches harm-reduction efforts. While safe supply can be implemented in different ways, they explain the core strategy as “providing people with a regulated supply of drugs, so that when they decide to use, they know what is in it – from both a potency point of view and so they know how much active ingredient there is.”For comparison, Palayew noted that when a person purchases a bottle of gin, they know it will be 40 percent alcohol and can decide on how they’ll consume based on that information. “Alcohol is not legal because it’s safe,” Palayew said. “But it’s safer because it’s legal. And that idea, I think, is true for every drug.”British Columbia, which for several decades has faced an overdose crisis that began with heroin and has now intensified because of fentanyl, has taken relatively bold steps to address what it officially declared a public health emergency in 2016. North America’s first sanctioned supervised injection site opened in Vancouver in 2003. Now called overdose prevention sites – where drug users can consume with access to medical attention if needed – 46 are currently operating throughout British Columbia. The province also pioneered take-home naloxone (an overdose-reversal medication) in 2012, and in 2023 decriminalized possession of most illegal drugs.In March 2020, just as the pandemic began, British Columbia launched what it calls “risk mitigation guidance,” a safe-supply system that allows medical professionals to prescribe pharmaceutical alternatives to illicit drugs. “Risk mitigation guidance was a form of prescribed safer supply that really laid out the use of hydromorphone or Dilaudid [its brand name] as opioid replacement,” said Bernie Pauly, a scientist with the Canadian Institute for Substance Use Research at the University of Victoria.Hydromorphone is the closest pharmaceutical equivalent to morphine and heroin. At the outset of British Columbia’s program, patients were required to be observed by pharmacists while consuming pills, or to receive an injection on-site at a pharmacy. As the program evolved during the pandemic, some patients are now allowed to take home prescriptions (known as “carrys,” these are what Lee is currently prescribed). Some pharmacies now also prescribe fentanyl transdermal patches, which meter out doses gradually over several days. Pauly says that currently, a little over 4,000 people with substance-use disorder are being prescribed these medications in British Columbia. But unlike traditional treatments for addiction such as methadone or buprenorphine, the goal isn’t necessarily abstinence. “It’s been really clear when safer supply got introduced that it was meant to replace the illicit drug market, so that people don’t die.” Paxton Bach, an assistant professor of medicine at the University of British Columbia and an addiction medicine physician at St. Paul’s Hospital in Vancouver, has been studying the effects of medical safe supply on drug users. “The less they are playing this game of Russian roulette, the better,” Bach said. “If it helps them engage with a prescriber, engage with a clinic, consider other options or move toward other evidence-based treatments, that is excellent, that is something to celebrate.”“But that should not be the primary metric,” he emphasized. “Because the primary goal of this is to keep somebody from accessing fentanyl and dying today.”A study published in 2024 by the British Medical Journal, which both Pauly and Bach were involved in, found that those who received safe-supply prescriptions were 55 percent less likely to die of an overdose after one day in the program and 89 percent less likely to die of overdose after a week in the program.Pauly notes that while these results are impressive, the number of people on safe supply represents only a small percentage of the estimated 225,000 illicit drug users in British Columbia. “That 4,000 is reaching a very small portion of those who have substance-use disorder, which is more than 70,000,” Pauly said. “So it’s a really big implementation challenge.”Safe supply has become a hot-button issue in both British Columbia’s upcoming provincial election and in Canada’s national election campaign. Pierre Poilievre, leader of Canada’s Conservative Party, has called for the end of safe-supply programs across Canada and wants to redirect the funds to treatment programs. Elenore Sturko, a member of the B.C. Legislature from the Vancouver suburb of Surrey, has made skepticism of safe supply a central theme of her reelection campaign. Sturko said she instead favors a recovery-based system, noting “British Columbia feels like it’s a one-legged stool with all of the emphasis being put on harm reduction and not on finding ways for people to improve their situation.”Sturko and others in the Conservative Party of B.C. are critical of what is known as “diversion” within the safe-supply system – when those who have prescriptions share or sell their medications to others. “Can we help people and also make sure that we don’t cause harm to other British Columbians at the same time?” she said.Sturko believes the province should modify the current safe-supply program with an emphasis on treatment, and by monitoring patients when they take the medications to ensure that medications don’t leave those they’re prescribed to. “We need to make sure that we don’t create new opioid users by trying to help other people,” she said.Bach, however, said that while published studies of diversion of safe supply are limited, there’s no evidence in coroner reports or public health data that diversion is contributing to overdose deaths. “We are not seeing any change in rates of hydromorphone detected in overdose deaths,” he said, “And we’re not seeing any change in the trajectory of new diagnoses of opioid-use disorder, particularly among youth,” he said.Pauly noted that safer-supply medications account for only about 14 percent of all prescribed opioids in the province, and when diversion happens, it accounts for only a small fraction of illicit prescription drugs in circulation. A report issued by provincial health officer Bonnie Henry in late 2023 found that while diversion is relatively common among drug users on prescribed safe supply, it often occurs when the medications aren’t strong enough to meet the needs of heavy drug users. The report notes “Some clinicians expressed the view that diverted [prescribed safer supply] is itself harm reduction, as diverted pharmaceutical alternatives are still safer than the toxic illicit supply.”What would safe supply look like in Washington?Washington’s safe-supply work group has its origins in the state Supreme Court’s 2021 Blake ruling, which found the state’s felony drug possession law unconstitutional. Legislation that created a temporary fix was passed in 2021, which reduced drug possession to a misdemeanor and also created the Substance Use Recovery Services Advisory Committee. In 2022 the committee issued a report that offered an array of policy recommendations, including the creation of health hubs focused on treatment and other services, as well as expansion of harm-reduction services. It also recommended creating a safe-supply work group and decriminalizing drug possession. In 2023 the Legislature passed a permanent law to replace the one voided by the Blake ruling. But instead of following the committee’s recommendation on decriminalization, it made drug possession and public drug use a gross misdemeanor.That bill also included funding for health hubs and treatment services, as well as for supporting the safe-supply study. Rep. Roger Goodman, D-Kirkland, one of the authors of the final compromise bill, is a longtime supporter of more liberal drug policies.“Given the synthetic opiate crisis, we need to focus on reducing deaths first, before reducing abuse or misuse of drugs,” Goodman said. “Reducing deaths should be the priority. And that’s what harm reduction is all about. And that’s what the safe-supply initiative is about as well.”If Washington decided tomorrow that it wanted to set up a medicalized safe-supply system, there would be numerous legal hurdles to overcome. According to a presentation at a recent safe-supply work-group meeting by Dari Pogach, an attorney and consultant for Health Management Services, current Food and Drug Administration (FDA) and Drug Enforcement Agency (DEA) rules prevent prescriptions like those made in British Columbia.The DEA classifies all drugs on a scale from Schedule 1 to Schedule 5, with 1 designating drugs deemed the highest addiction risk and 5 the least risky. Injectable hydromorphone is classified as a Schedule 1 drug by the DEA, which means it’s not approved for any medical use at all. Hydromorphone tablets (also known as Dilaudid) and fentanyl patches are classified as Schedule 2, which means they can be prescribed – but the FDA currently allows them to be prescribed only for alleviating pain, not for treatment of opioid-use disorder.The DEA is currently moving toward redesignating marijuana from Schedule 1 – a drug it says has no medical use – to Schedule 3. So changes in both DEA and FDA policy are possible, and could eventually allow Washington to move forward on safe supply. Palayew said a small pilot program that’s part of a medical study would be a logical first step. “I think there are a lot of factors at the state level that need to change,” they said, “as well as federally, things would also need to be aligned. I think a good start could be a pilot project where you could get a research exemption for some of these substances.”If Washington were to follow British Columbia’s lead on safe supply, it would be doing so in a much different context: In Washington, drugs are still criminalized and overdose prevention sites – or safe-injection sites – are both illegal and politically unpopular. Meanwhile, some activists in Vancouver believe in taking safe supply even further: making tested drugs available to all users, not just as medical treatment for substance-use disorder. In 2020, in order to curtail fatal overdoses, a group known as the Drug User Liberation Front established what it calls a “compassion club” in Vancouver’s Downtown Eastside. This club made rigorously tested versions of heroin, cocaine and methamphetamine available to users. In October founders Eris Nyx and Jeremy Kalicum were arrested for breaking B.C.’s drug laws, and the club was forced to shut down. A 2024 study of the compassion club published in the International Journal of Drug Policy found that among 47 clients of the club, the rate of non-fatal overdose declined by 51 percent. Such clubs, if they existed in Washington, would also be illegal. Palayew said they once asked an attorney involved with a harm-reduction legal project what laws would be broken if someone were to set up a similar club in Washington. “They took a pause, and then responded with: I think the question is, what laws would you not be breaking?”“Everything just started coming into place”Dean Wilson is a longtime drug user and activist who was instrumental in getting InSite, Vancouver’s first overdose prevention site, started in 2003. In the first days of British Columbia’s safe-supply system, he was also an early adopter.“I was the very first person to ever buy fentanyl in the world legally,” said Wilson, who has a dark sense of humor and no qualms about saying what he thinks. He was part of an early trial of the safe-supply program that gave him injectable fentanyl. “I still have it because it’s not enough,” Wilson said, noting that medical doses are often insufficient for heavy users like himself. But he still believes it’s a crucial tool for saving the lives of certain drug users.He points to a mother he knows who picks up safe-supply medications for her adult child, who has opioid-use disorder. “She actually rations it, so they’re not going to be dope sick but also not doing it at dinnertime,” he said. “They’re keeping their kids alive while they wait for them to get into recovery.”BeeLee Lee’s opioid use began after she was diagnosed at age 20 with fibromyalgia, a painful chronic nerve disorder, and prescribed oxycodone. After several years of becoming dependent on prescription meds, Lee was cut off by her doctor, and turned to heroin in the Downtown Eastside around 2010. She eventually lost her job, her children went to live with her mother, and she occasionally slipped into homelessness.She went into recovery and treatment several times, but said, “nothing ever worked right. My obsession was so intense and so real.”“Relapse is so much a part of my story. And it’s part of a lot of people’s.”Her beloved dog Sadie entered her life in 2019, just about the time fentanyl arrived and decimated her community. Around this time, Lee was living in a low-barrier housing unit that allowed her to keep using.“I was surprised I didn’t die,” she said. “The staff found me many times, face down, feet blocking the door. They thought I was already deceased.”After getting into treatment and relapsing once again, in 2020 she convinced a nurse to prescribe her safe supply. Lee’s first treatments were muscle injections of hydromorphone at a pharmacy. “Sadie and I would go twice a day,” she said. “I’d get my dose and then have to sit there for 15 minutes.”The pandemic, however, quickly made in-person injections impossible. But since Lee had recently got a new job as a peer observer at an overdose prevention site, she was deemed stable enough to qualify for “carrys” – hydromorphone tablets she could take at home. “Everything just started coming into place,” Lee said. “I transitioned from a cash job into a union job and then a year went by and then two years went by and then three years went by. I go into a management job, and now I only go to the clinic twice a week.”She’s started to reconnect with her daughters and grandchildren, though she says “It’s still a work in progress” to process the trauma of the long separation.Lee is grateful that a nurse agreed to put her on safe supply.“If not, I would not have my kids. I would not be working and giving back to the community. I wouldn’t be alive. And I believe that I will probably be on these medications for the rest of my life,” she said.Treatment and 12-step programs work for some people, Lee said, but the critical issue is that so many people around her are dying. “I can’t even tell you how many times I think I see somebody I know, and then I remember: Oh no, they’re dead.”To critics of safe supply, who say it condones drug use and should be replaced with programs that insist on abstinence, Lee said, “Here’s the thing. Not everyone’s ready. But that doesn’t mean they should be dead.”
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