How Diverting Opioids Can Be Harm Reduction

Ensuring that people who use opioids receives their medication from a trusted source can be a matter of life and death. Source: Andrei Rahalski

What cops and regulators consider to be the boogeyman of the Canadian overdose crisis is in fact a tactic that criminalized drug consumers and their advocates believe is a means of survival in the face of an ever-more potent, volatile illicit drug supply.

 

They’re talking about ‘diversion’, the use of medicines for purposes or by consumers unauthorized by prescribers or regulators. For years, it has been accepted by the medical establishment as a driver of overdose and addiction. In a transformative shift in discourse, drug-user activists and researchers are speaking out about how the pharmaceutical-quality of diverted prescription opioids (PO) can actually reduce overdose risks, and how the income from their sale empowers diverters to get what they need to survive—all evidenced by a growing body of literature.

“What they call diversion, we call helping each other out and keeping ourselves safe,” says Guy Felicia, a harm reduction advocate who uses his experience as a formerly-unhoused drug consumer to advance policy reform. “If I saw someone who was in withdrawal and I [had] a couple of Dilaudid, I would give that to them.”

In agreement with Felicia is a researcher at the forefront of researching the potential benefits of diversion. “People have access to drugs,” says Dr. Geoff Bardwell, a research scientist at the British Columbia Centre on Substance Use and co-author of three scientific studies on diversion published in 2021. “They know they’re safe. So sharing them or doing trades fits within the history of drug users protecting and caring for their communities.”

As overdose deaths continue to reach unprecedented highs in Canada, people who use criminalized drugs describe diversion as an overdose prevention strategy. When asked by Bardwell and colleagues about the benefits of diversion, a participant for their June study reports, “[W]ell it’s fucking necessary, because people need them, or else they’re going to take fentanyl and die.”  Another speaks to the safety of diverted POs, in contrast to the illicit supply’s volatility: “I don’t know if I’m selling you carfentanil and you’re going to go home and you’re going to be by yourself and you’re going to pass away. I couldn’t live with that with myself. And that’s what I told my friends. That’s why when I do sell anything, it’s pills.”

While Bardwell has yet to directly link diverted PO consumption with reduced overdoses, he and his team have shown that it can slash the risk of factors driving the mass loss of life, totaling 22,828 apparent deaths attributable to opioids between January 2016 and March 2021 as estimated by the Canadian government. Among 1,150 individuals from Vancouver, the significant proportion consuming diverted POs (one-fifth, or 21%) were 30% less likely than their non-diversion peers to be exposed to fentanyl, according to researchers' article in the November 2021 issue of Drug and Alcohol Dependence. This shielding effect, they suggest, may result from characteristics of the pill in question (slow-release oral morphine)––the effects and street cost of which are longer and cheaper, respectively, than other POs and fentanyl.

Bardwell’s findings build upon the existing scientific literature that shows diverted opioid agonist therapy (OAT) medication can protect vulnerable consumers. According to American researchers in an April 2020 study identifying “a potential harm reduction consequence of diversion,” overdose risk was shown to be increasingly reduced with more frequent use of diverted buprenorphine, a partial agonist used to treat opioid use disorder that has been preliminarily shown to rival naloxone in reversing suppressed breathing induced by methadone. Generally, buprenorphine diversion seems to be regarded as a means to prevent and treat withdrawal symptoms, and like the PO-diverters interviewed by Bardwell and colleagues, some people who divert buprenorphine to support others experiencing withdrawal have explained to researchers that the sharing of their prescription is perceived as an act of “helping.” Another diverted OAT medication, methadone, reportedly functions for consumers as a way to manage drug consumption, prevent withdrawal, strengthen community, and shield themselves from hepatitis C transmission. Researchers behind this finding describe it as a harm reduction practice.

What’s unique about the work of Bardwell and colleagues is their particular attention to the diversion of POs prescribed to treat chronic pain, a phenomenon that has been the subject of law enforcement and regulatory crackdowns which, as a result, is devastatingly consequential for chronic pain patients who have been caught in the crossfire. In 2016 and 2017, Canada launched initiatives to crackdown on what they identified as contributing factors to ‘drug misuse’: over-prescribing and diversion. Following the United States’ lead, provincial and federal regulatory bodies published prescribing guidelines that were purported to not replace “clinical judgment”. Yet as legal investigations were launched into the conduct of practitioners prescribing large amounts of opioids, others feared becoming a target. The guideline’s numbers, like arbitrary dosage limits similar to those promulgated in the US, were interpreted by some anxious prescribers as sure-fire criteria for avoiding scrutiny or reducing the risk of opioid use disorder, resulting in some cases in abrupt, forced tapers or other forms of patient abandonment. Caution was favored over their patients’ needs, resulting in some patients abruptly losing access to care, as VICE reported. The consequences? Untreated pain that led some to find relief on the adulterated unregulated market, and face potentially fatal overdoses. For others, the unbearable pain may lead to suicide.

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Overdose prevention has come to be a cornerstone of harm reduction practice in a continent facing an ever escalating death toll, and so diversion's protective features are unsurprisingly framed as its primary outcome. But Bardwell and colleagues found it has other benefits that are less recognized as core features of the harm reduction movement, but nonetheless vital to the health of people who use drugs. In question is diversion’s ability to empower consumers to self-determine what they are putting into their body, all in the face of the medical profession’s monopoly on allocating opioids.

Diversion can help circumvent the limitations on agency imposed by medical practitioners on patients. In fact, ironically, prescribers’ fear of diversion––usually driven by a fear of being labeled and investigated as a ‘dope doctor’ or ‘pill mill’––may prompt diversion in the first place, according to Bardwell and colleagues. In an interview with TalkingDrugs on the results of his June 2021 study, he says “most people who bought [diverted] prescription opioids were prescribed them”––21 study participants of the 24 total fit the bill. “It’s either [that] people are not getting enough, or people are not getting the right drugs,” likely as a result of prescriber’s austerity mindset. “It’s not just that they’re prescribed opioids and buying others; it's that they want other ones.”

Sourcing supplemental medication to treat chronic pain from the illicit diverted market is a well established practice. What’s lesser known is the way diversion is used to cope with British Columbia and federal regulators’ inadequate adoption of a harm reduction policy demanded for years by activists. 

The country’s ‘Safer Supply’ program has been deployed, and is meant to reduce the use of substances sourced from the unregulated supply and unpredictably contaminated with potent opioids and sedatives by prescribing select pharmaceutical-grade POs to consumers. But in reality, the policy’s implemented options may not be meeting many consumers’ needs. As a result, such shortcomings create the conditions in which consumers living in poverty are only able to access the substance they need to get by through diverted prescriptions provided by a Safer Supply prescriber. 

Such is the case for Jon, a 44-year-old drug-user activist involved with the legendary Vancouver Area Network of Drug Users (VANDU), who has transitioned from heroin to exclusively preferring fentanyl, one of the potent opioids generally regarded by governments and nonprofits as an undesirable adulterant. “I don’t think people realize that heroin has been totally replaced by fentanyl. Heroin is non-existent here,” he says, a claim that seems to be increasingly true since at least about four years ago to today, as researchers have found. About one-third of the relatively small cohort (21 people) interviewed by Bardwell and colleagues for the July 2021 study reported they preferred fentanyl.

Jon’s Safer Supply prescriber will only provide him Dilaudid––not fentanyl. Technically, patches and tablets of fentanyl should be available since their inclusion in the province’s July 2021 expanded policy. Fentanyl is not inherently dangerous, but rather the unregulated supply can be difficult to accurately dose, and toxic chemicals from illicit manufacturing are a variable risk. Jon reports that none of his community members, whom he says total roughly one hundred individuals, are receiving it from prescribers who are allowed by the new policy to choose which medications they will make available. To satisfy their high tolerance, program participants are instead cashing out their Dilaudid to acquire the far-more potent opioid.

Interestingly, the Safer-Supply Dilaudid is diverted by Jon to other victims of the medical monopoly: the chronic pain patients rendered as casualties of the pain pill prescription freeze. “People buying my Dilaudid are older and need a minor pain treatment,” he says, noting “doctors won’t prescribe it.”

A participant from one of the studies authored by Bardwell and colleagues provides insight into the dynamic. “I’m prescribed Dilaudid and then I purchase Dilaudid off the street because my doctor’s been taking me down, pushes me back up, takes me down,” the participant says. “Then every time he takes me down, then I tell him it forces me onto the street...Like he’s got me like almost down to half my pills, which wasn’t fair because I suffer from chronic pain, fibromyalgia.”

Jon’s access to Safer Supply has provided an unadulterated source to others with untreated pain, while he remains as a consumer at risk of overdose from illicit fentanyl. While it seems the inadequacy of Vancouver’s rollout of fentanyl prescriptions is jeopardizing the policy’s intended outcomes, Safer Supply does indirectly provide an asset to people like Jon that’s not usually associated with harm reduction: economic power, in this case thanks to diversion. 

It “put[s] money in the pocket of the addict to get what he wants,” says Jon. “It’s the money they [the Canadian government] should be giving us anyways.” Other people who divert prescription opioids––Safer Supply or not––find it is a useful side income; one participant in the July 2021 authored by Bardwell and colleagues attributed his diversion to what it first gave him–– “Money, because I didn’t have money––and what it yielded––”Food. Debts that I had. I needed extra money.”

Of course, the income to be earned is not much; the street price of 8 milligram tablets of Dilaudid was once approximately CAN$10 a pop, and since Safer Supply, it’s reportedly dropped to just one Canadian dollar. But that’s nothing to turn down when the alternative for some may be panhandling or criminalized activities. One professionalized harm reduction organizer employed by VANDU, who deals with pain and has purchased Jon’s supply, explains diversion’s broader political implications. “VANDU understands drug war as class war. Any way we can get money back down to people on the street is another form of harm reduction.”

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Purposeful pill diversion may be a community practice of care and empowerment in the face of insufficient government policy. But activists like Guy Felicia and Jon know it is not a tenable solution to the harm prohibition and criminalization produce for people who use drugs.

Felicia’s political priority is the provision of on-demand safer supply of heroin and other drugs––all without needing to see doctors, the very people who have long refused to provide access to what will keep consumers safe. Models for a truly community-led safe supply are already being outlined and demanded. Presented in an August 31, 2021 letter, the Drug User Liberation Front (DULF), an off-shoot and affiliate of VANDU, is calling on the federal government to exempt them from the Controlled Drugs and Substances Act so they can procure, store, and distribute the substances needed for what they’re calling a Cocaine, Heroin, and Methamphetamine (CHM) Compassion Club. Unlike the current Safer Supply policy as well as diverted POs, the exact preferred drug and formulation would be provided, all without needing to face the medical profession’s gate-keeping. 

DULF’s effort is gaining political momentum: on October 7, the Vancouver City Council voted to endorse the demand. In the meantime, DULF is running an unsanctioned Safer Supply Fulfillment Centre, in which activists source illicit CHM, check its purity, package and label its contents, and distribute at no cost to those in need.

The long term success of DULF’s proposed CHM Compassion Club necessitates another policy transformation advocated by activists who support and people who themselves use diversion for survival in the meantime. Federal decriminalization of all drugs could make the need for prior exemption obsolete. Beyond practicality, Jon believes decrim will help realize the full potential of safe supply by disentangling the threat of arrest and incarceration from consumers’ agency. Currently the City of Vancouver is seeking a federal exemption similar to DULF’s, except it’s just for small-quantity possession. Other cities, including Toronto, Ottawa, and potentially Montreal, are following suit. Although similar to grassroots proposals, advocates fear that the low-thresholds proposed will exacerbate disparate effects, leading to the continued criminalization of people who buy wholesale to access higher-purity products for better prices, or simply purchase large quantities to satisfy their frequent, high-dose consumption. 

Additionally, decriminalization does nothing for people who sell drugs, including those diverting prescriptions. Bardwell believes they should also be included in the reform. “There’s all this push around decriminalization, but we call for the decriminalization of trafficking,” he says. “I’m absolutely for the decriminalization of all trafficking. But there’s something different about diversion: people [are] giving away their drugs as a protective measure.”

Bardwell thinks the prospect of DULF’s exemption is a long-shot. But it’s worth noting that their demand inherently circumvents an effective talking point used by safe-supply opponents.

“The biggest [reason for] push back [to safer supply] from physicians is diversion,” said Bardwell, which is not applicable to substances of which the pharmaceutical availability is either banned, like heroin, methamphetamine, and cocaine. 

Nonetheless, anti-diversion rhetoric threatens the continuation of a win, the Safer Supply policy. It also reflects what DULF and others are up against: the medical professions’ apathy to the lives, and deaths, of people who use drugs.  “Why is diversion your biggest concern? We’re five years into an overdose epidemic, and you’re concerned about diversion, and not people dying?” Bardwell poses. “Does one trump the other? I think so.”

Whatever proposal is adopted, none is a silver bullet. “I support all community-led models, but at the end of the day people need options,” says Bardwell. Likewise, Felicia suggests: “We need a medical model for some people, but we need to look at a model that meets the needs of all substance users.” Beyond institutionalized programs, care by and for community members must be practiced to realize the agency and health of people who use drugs. The lesson of British Columbia’s struggle to prevent overdose makes that evident, as Bardwell has learned from his research.  “Diversion is providing a safe supply when they can’t access it elsewhere.”

*Sessi Kuwabara Blanchard is an independent drug journalist and transgender critic. Previously, she was the original staff writer at Filter, an online publication dedicated to covering harm reduction and drug policy. Follow her on Twitter, @SessiBlanchard.