O/N H-1075020 IN THE MATTER OF THE SPECIAL COMMISSION OF INQUIRY - - PDF document

.KERR WITNESS STATEMENT 11.9.19 P-1

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TRANSCRIPT OF VIDEO PRESENTATION

O/N H-1075020

IN THE MATTER OF THE SPECIAL COMMISSION OF INQUIRY INTO THE DRUG “ICE” THOMAS KERR (VANCOUVER, CANADA) HARM REDUCTION - VIDEO PRESENTATION WEDNESDAY, 11 SEPTEMBER 2019 TRANSCRIBED BUT NOT RECORDED BY AUSCRIPT AUSTRALASIA PTY LIMITED

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DR KERR: Hello. My name is Dr Thomas Kerr, and I am a Professor in the Department of Medicine at the University of British Columbia in Vancouver,

• Canada. I am also a Senior Scientific Advisor and Senior Scientist with the British

Columbia Centre on Substance Use. I’m very honoured to provide testimony today 5 to the Special Commission of Inquiry into the Drug ‘Ice’. And I’ve been asked to speak about our experience with Harm Reduction Interventions in Vancouver, Canada. Vancouver, like Sydney, is a beautiful city. It’s surrounded by the ocean and the 10 mountains and like Sydney is consistently rated as one of the most liveable cities in the world. However, like many large urban centres it has an inner-city core which is marked by a high density of low-income housing, high levels of poverty, substance use and mental illness. In the mid-90s, Vancouver experienced what has been described as the most explosive epidemic of HIV infection ever observed outside of 15 sub-Saharan Africa. And this, really, was a result of the high prevalence of stimulant injection, in particular, cocaine injecting. This slide shows you the number of new diagnosed HIV infections among people who inject drugs in Vancouver, as recorded by the BC Centre on Disease Control. 20 And, as you can see, the number of new infections began to rise steadily in the early 90s, all the way through to 1996. At the same time, our province was experiencing an epidemic of overdose deaths due to heroin use, with about one person dying per day in the province. We now have a new problem, which is the emergence of synthetic

• pioids in our drug supply, such as fentanyl, carfentanyl and related analogues. And

25 sadly, synthetic fentanyl is approximately 50 to 100 times more potent than heroin, and has thus resulted in a massive escalation in drug related deaths in our setting. This slide shows you the number of overdose deaths involving fentanyl from 2007 to

• 2017. And as you can see, there has been a steady increase in the number of deaths

30 since 2013. This data from the Provincial Coroners Office shows you the proportion of overdose deaths involving fentanyl. And this has increased, also, significantly in recent years, with over 60 per cent of deaths involving fentanyl. And these are not just deaths 35 involving heroin use. In fact, we are finding that an increasing proportion of deaths where methamphetamine is involved also involve fentanyl. In response to drug related harm in Canada, a number of Harm Reduction Programs have been implemented, including: syringe and crack and meth pipe distribution programs, a range of educational initiatives, Naloxone kit distribution, overdose prevention sites, 40 drug checking programs, substitution treatments and what has become known as ‘safe supply’ interventions and supervised drug consumption facilities. I’d like to spend a bit of time talking about each one of these interventions, including their implementation context, their limitations and what we’ve learned about them through scientific evaluation where possible. 45 So I’d like to start with syringe and pipe distribution programming. The goal of these programs is really to prevent the transmission of infectious diseases and injuries, such as oral sores that can occur from pipe smoking. But also, these programs seek to make contact with people who use drugs and engage them in the 50 SCII.013.025.0019

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broader system of health care. These programs are delivered, typically, through community-based health services and related outreach services, as well as hospitals. They’re typically funded through our provincial health system. And, although they have been found to be effective, some of their limitations include challenges with coverage, in particular, ensuring that all the people who need access to safer injecting 5 and smoking equipment are getting it. And changes in funding over time. In Vancouver, we thought we were doing a good job with needle exchange because we had one of the largest needle exchanges in North America, exchanging over 2,000,000 needles per year. However, in the presence of this needle exchange, we 10 experienced an epidemic of HIV infection among people who inject drugs. Subsequent follow-up studies revealed that, in fact, many people who injected drugs were having considerable difficulty accessing syringes. And difficulty accessing syringes was associated with syringe borrowing and lending, the behaviours that 15 account for the majority of HIV and hepatitis C infections in our setting. And the reasons why people were having difficult accessing syringes in some cases were quite simple. The needle exchange program closed at 8.00 pm and we had a stimulant epidemic with people often staying awake for days on end and needing access to equipment throughout the night. As well, people would often not have a 20 syringe to exchange or they missed the van because they didn’t know where it was. And some were also being refused syringes at pharmacies. This led to a revision of the Needle Exchange Policy in Vancouver. During 2000 to 2002, there were a number of changes implemented including: the program was 25 decentralised, there was a move away from exchange to a focus just on distribution, the number of sites distributing syringes were expanded, and the limits on the number of syringes that could be obtained were removed. Also, the functions of distribution and recovery were separated. 30 We evaluated these changes in a paper published in the American Journal of Public Health in 2010. This slide shows you the rate of syringe borrowing in the period before, during and after the policy change, and as you can see, there were substantial declines in syringe borrowing following the policy change in 2002. But also, we detected very large declines in HIV incidents associated with this policy change - 35 suggesting that, really, critical to the success of the Needle Exchange Program was enhancing access and ensuring a high volume of needles were making it into the hands of people who inject drugs. In response to rising crack use and related harms in our city, a crack pipe distribution 40 was implemented in around 2009, and as you can see, the number of crack pipes that were distributed increased substantially, and in 2012, over 100,000 crack pipes were

• distributed. This led many people to question whether distributing pipes in this

fashion would facilitate drug use, make crack use more fashionable and lead to increases in crack use. However, we evaluated these effects through our Cohort 45 Study of people who use drugs in Vancouver, which is funded by the US National Institute on Drug Abuse and is known as the Vancouver Drug Users Study. And here, we found that in the period where there is a huge increase in the number of crack pipes being distributed, there was actually a substantial decline in the number

• f people reporting daily crack smoking. Suggesting quite clearly that providing

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crack pipes was not in any way facilitating crack use or increasing it among people who were already smoking crack. A number of education programs have also been implemented. These seek to reduce harms through increased in knowledge and associated behaviour change. They’re 5 delivered through various community-based health services, peer organisations and through the use and distribution of pamphlets, posters, online posts and commercials. They’re funded through the provincial health system and grant funding, and our Federal Government has recently launched a national social marketing campaign focused on the dangers of fentanyl use. 10 Some of the limitations include unintended consequences, which I’ll speak about in a

• moment. Issues of penetration, in particular, reaching the population at risk. At

times, a lack of cultural appropriateness. And, overall, a lack of potency in terms of impact. 15 This is an example of some of the safer crack smoking and safer crystal smoking materials that are implemented locally. And these are some of the advertisements issued by the Federal Government and the Province in response to the fentanyl

• verdose epidemic.

20 As I mentioned, there are sometimes unintended consequences of such educational

• campaigns. In this paper published in Addiction, we demonstrated that a warning

that was issued by health officials warning people about the presence of strong heroin on the streets of Vancouver and a recent spike in overdose actually prompted 25 drug users to go and seek and use that heroin. Also important in our environment has been the implementation of a Naloxone Distribution Program. The goal of the program is to reduce overdose by equipping community members with the opioid overdose reversing drug, naloxone. This is 30 delivered through various BC Centre on Disease Control outlets, community-based health services and peer organisations. It’s funded through the provincial health system and is now –naloxone is now unscheduled and can be sold and distributed anywhere. 35 Some of the – the only limitations of this program is that many people who receive the kits and related training don’t carry their kit. Also, an increasing number of people in our province are dying of overdoses at home alone, which suggests that this type of intervention could be limited insofar as when people are using alone there is no one there to administer naloxone in the event that they do overdose. This is a 40 picture of a naloxone kit, which includes gloves and alcohol swabs, a couple of syringes and vials of naloxone and instructions for administration. The take home naloxone program has been dramatically scaled up, as you can see. In 2016, over 4000 kits were actually administered in overdose events, and over 45 22,000 kits in total had been distributed. So this program seems to be effective; people are receiving kits, and they are using them to reverse overdose events - but more on some of the evidence later. We have also recently implemented intra-nasal naloxone among first responders to ensure the rapid and easy administration of naloxone without the use of syringes. 50 SCII.013.025.0021

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Another recent innovation has been the use of drug checking programs. This is one very simple intervention, which is the use of test strips to test drug solution for the presence of fentanyl. The goals of these programs are to reduce the risk of overdose by increasing awareness of contaminated drugs, and also by promoting changes in behaviour as a result of this increased awareness. These programs are delivered 5 through community-based health services, supervised consumption sites and housing environments, and funded through the provincial health system and grant funding. Some of the limitations include low uptake by the target population, many people simply don’t avail themselves of these programs and some of the technologies, in 10 particular, the more technical ones are burdensome and expensive. And, also, there has really been limited evaluation to date. And again, with existing evaluations, although suggesting that drug checking can produce some behaviour change, with potential to reduce drug related harm, very few people avail themselves of these programs. 15 Critical to the response to drug related harm in British Columbia has been the implementation of a range of substitution treatments and safe supply interventions. The goal of such programs are to reduce the use of illicit and contaminated drugs by substituting safer alternatives. These are delivered through community-based health 20 services, pharmacies, hospital and physicians’ offices and funded through the provincial health system and regulated both federally and provincially. Some of the limitations include low uptake of these programs and long-term retention in them, as well as programmed demands, such as daily witnessed injection and cost. 25 We have long offered methadone in our province and, more recently, methadose, the newer formulation of methadone. And we have also recently made Suboxone a first line therapy. Which has a better safety profile than methadone and can allow for take-home dosing so that daily witnessed injection is not required. We also have a prescription heroin program. This was initially implemented through a randomised 30 control trial. The results of which were published in the New England Journal of

• Medicine. And the investigators found that those who had repeatedly failed

methadone and were prescribed injectable heroin had substantial reductions in illicit drug use and other illegal activities, and also had far superior rates of retention in addiction treatment. And, as a consequence, this program is now being scaled up. 35 But given that we know that very few people access suboxone and methadone or are retained after one year, and very few people are eligible for prescription heroin, other substitution treatments are now being made available, including slow-release oral morphine and hydromorphone tablets, which can be taken orally or injected. 40 In order to really promote the broader use of opioid substitution treatment, the BC Centre on Substance Use has implemented a range of clinical guidelines for the clinical management of opioid use disorder which have now been adopted at the national level. And, this has been supported by a range of educational interventions 45 targeting health care providers. We have a range of seminar series which have so far reached over 2,500 hundred clinicians through almost 70 seminars and over 45 locations. 50 SCII.013.025.0022

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We also have an addiction, care and treatment online certificate course., which is linked with best available evidence and clinical guidelines and has interactive

• features. And to date, over 15,000 people have registered in this program. We also

have a Provincial Opioid Addiction Treatment Support Program with over 24,000 residents and 83 preceptors. And to date, over 200 physicians have been fully 5 trained and 64 new nurse practitioners have also been trained. And there have been some notable impacts as a result of these efforts. This is a slide showing you the number of people receiving any type of opioid agonist treatment, as shown by the black line. You can see the number of people receiving OAT has 10 increased from 15,000 in 2015 to over 22,000 in 2019. And while the use of methadone has remained fairly stable, we have seen an increase in the use of other treatments, including suboxone and slow-release oral morphine and hydromorphone. Also critical to the response to drug related harm, throughout Canada, has been the establishment of supervised drug consumption services. 15 The goals of these programs are to reduce public disorder by bringing people out of public spaces for the purpose of consuming drugs, reducing risk behaviour such as syringe sharing, preventing overdose fatalities and connecting people who use drugs to a range of services including addiction treatment. These services are typically 20 delivered through community-based health services and NGOs, housing environments and peer organisations. They’re funded through the provincial health system and regulated through Health Canada. Although these programs have found to be effective in addressing a variety of harms, 25 they do have some limitations including low coverage. In particular, many people are unwilling to travel great distances to use these services. And, although models vary considerably, some can be expensive to develop, implement and operate. This is ‘Insite’, North America’s first supervised injecting site that opened in 2003. 30 It has a number of booths for the injections of pre-obtained illicit drugs. Nurses are present onsite to provide supervision, education around safer injecting, emergency response in the event of overdose, referrals to external health services and to also provide basic primary health care. 35 There are now over 40 peer reviewed studies focused on the evaluation of Insite, including potential benefits and negative effects. These appear in some of the world’s best journals including the New England Journal of Medicine, The Lancet, The British Medical Journal and Addiction. There isn’t time to discuss all these

• studies. But I will summarise some of the main findings. Very early on, we found

40 that the site was succeeding in reducing public disorder by reducing the rate of injecting in public. Several studies also showed large declines in syringe sharing associated with frequent use of Insite. And we saw increases in other safer injecting behaviours, including those that reduce the likelihood for cutaneous infections and related hospitalisations. 45 In a paper published first in the New England Journal of Medicine, we demonstrated that more frequent use of Insite was associated with more rapid time to entry into detoxification programs, as indicated by a linkage to the Detoxification Program

• Database. We followed that up with a study in addiction which showed that

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comparing the period before Insite to after; there was a greater than 30 per cent increase in the number of individuals entering addiction treatment. And in a paper published in Drug and Alcohol Dependence in 2010, we also demonstrated that many people who were being referred to addiction treatment from Insite were also ceasing injecting drugs altogether. 5 We have also demonstrated that by providing a safe space where women can control their use of drugs, violence is being reduced against women. And, importantly, and in a paper published in The Lancet in 2011, we demonstrated that the establishment

• f Insite was associated with significant declines in overdose deaths in the area

10 around the facility. As I mentioned, we also determined, sought to determine whether the facility was having any negative impacts. And we showed that there were no negative impacts in community drug use patterns. And there were also no increases in rates of initiation 15 into injection drug use. So the facility wasn’t really sending the wrong message and encouraging people to take up injecting or initiate it for the first time. We also, using police statistics, obtained from the Vancouver Police Department; we showed that the establishment of the facility was not associated with increases in 20 drug-related crime. And we also exported data to a number of health care economists., who consistently found that Insite was highly cost effective. However, the establishment of this facility was not without its challenges. After it

• pened, Canada elected a Conservative Government which opposed harm reduction

25 in general and sought the right to close the facility. But after a number of provincial court hearings, the case made it all the way to the Supreme Court of Canada where the Justices ruled unanimously in favour of the continued operation of Insite. And in their ruling – the Justices said, “The Minister of Health’s failure to grant [an exemption] to Insite… contravened the principles of fundamental justice.” They 30 went onto say that, “Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada.” There are now over 33 supervised drug consumption sites operating in Canada. Among them is a new innovation called ‘overdose prevention sites’. When 35 Vancouver started to experience a massive escalation in fentanyl-related overdoses, the Provincial Minister of Health declared a Public Health Emergency and called on health officials to establish these low threshold overdose prevention sites. While these are like supervised injecting environments, they’re much more simple in their

• peration. They can be mobile like the one on the right, or established in housing

40

• environments. And their primary goal is to provide an emergency response in the

event of an overdose. Another recent intervention has been the opening of an inhalation site in Lethbridge, Alberta. This is being subjected to evaluation, and we hope to learn more about it soon. 45 So what have we learned about the impacts of these harm reduction interventions? Well, among the positive impacts has been a massive decline in HIV incidents among people who inject drugs in Vancouver. Specifically, the annual incidents of HIV infection fell from a high of 18.6 per 100 person years in 1996/97 to less than 0.3 per 100 person years since 2008, and this trend has remained stable. We have 50 SCII.013.025.0024

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also observed large declines in HIV incidents among people who use drugs in our setting. And also, importantly, this data from the BC Coroners Office shows that we have recently begun to see a large decline in overdose deaths in Vancouver as a result of 5 the implementation of the various interventions we’ve been discussing today. As you can see, while deaths reached a peak of 4.84 per 100,000 population in 2017, it’s now declined to 1.74 per 100,000 population. Recently, scientists at the BC Centre on Disease Control and the BC Centre on 10 Substance Use modelled the combined impact of interventions in averting overdose deaths during our synthetic opioid overdose epidemics. They found that between 2016 and 2017, 2177 overdose deaths were observed with 77 per cent of these involving fentanyl. They estimated that approximated 330 death events had been averted by all interventions combined. They estimated that approximately 1,580 15 were averted by take home naloxone, 230 by overdose prevention services and 590 were averted by the provision of opioid agonist therapy. However, we have some emerging challenges. Like New South Wales, we are

• bserving an increase in crystal methamphetamine use, as illustrated by the purple

20 line in this graph. Interestingly, this has coincided with a decline in cocaine use, suggesting that methamphetamine may be replacing cocaine use, in our setting - which is also concerning because we have seen a stark increase in the number of

• verdoses involving methamphetamine contaminated with fentanyl.

25 So in summary, a range of harm reduction programs have been implemented throughout Canada. These include the provision of safer injecting and smoking equipment, educational initiatives, drug checking programs, naloxone distribution,

• pioid substitution therapies and supervised drug consumption facilities. Many of

these interventions are supported by high quality evaluation and scientific evidence. 30 And what we have learned is that most of these interventions do succeed in preventing harm and increasing engagement in the broader health system. And this is an important point. Because, there is a large body of scientific evidence that demonstrates, quite clearly, 35 that many of the highest risk drug users, the people at the highest risk of experiencing drug related harm such as infectious disease acquisition or overdose are

• ften disconnected from the health care system. Therefore, harm reduction services

provide a primary point of contact and also reduce immediate harms while also promoting broader engagement in the health system, including addiction treatment. 40 A whole host of indicators suggests that the implementation of harm reduction programs have had positive impacts at the population level, including preventing the acquisition of infectious diseases and overdose fatalities. And importantly, although efforts have been made to determine whether negative impacts are occurring as a 45 result of the implementation of these services, to date, these have not been observed. It’s also important to emphasise that efforts to scale up opioid substitution and educate health care providers about its use have also been key to our success. And while crystal meth use is rising again in our setting, it’s very concerning to us that 50 SCII.013.025.0025

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there, at this time, exists no evidence-based substitution therapy for crystal meth

• dependence. So therefore, we greatly hope that there will be more investment in

innovation, research and development, and that, hopefully, we will have a substitution therapy available for people who use crystal meth, sometime soon. 5 I’d like to thank you for the opportunity to present this evidence and experience

• today. And I look forward to speaking with you again in the future.

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