Doctors Call For Safer Cocaine Supply

As drug toxicity deaths and overdoses in Canada continue to soar to unprecedented levels due to the increasingly volatile illicit market, advocates and doctors are calling for more stimulants including cocaine to be part of safe supply efforts.

“I would welcome the inclusion of cocaine, as well as methamphetamine, frankly, in safe supply programs. This is something that is urgently needed due to the severe risks associated with the illicit stimulant supply,” said Ryan McNeil, who researches drug use and policy in Canada as director of Harm Reduction Research at the Yale University School of Medicine.

“However, we need to ensure that there are concrete plans as to how cocaine, and other criminalized drugs, will be sourced and made available. Otherwise, its inclusion is aspirational.”

Last year was the worst on record for opioid toxicity deaths, with some estimates showing at least 5,200 people in Canada died during that time. At the same time, there has been a significant spike in deaths and hospitalizations linked to stimulants. Data from six provinces for the first half of 2020 shows that about half of opioid toxicity deaths involved a stimulant, which was cocaine in around 70 percent of those cases.

“Stimulants too often are an afterthought for decision-makers despite a rapid increase in stimulant-involved overdoses,” McNeil continued. “We need to ensure that people who use stimulants have a say in decision-making. Their lives are at stake.”

Safe supply is when people who use drugs are prescribed pharmaceutical-grade versions of street drugs as a way to help prevent them from dying from the street supply and link them with health and social services. For instance, patients may be prescribed hydromorphone as an alternative to illicit heroin. There are several federally funded safe supply programs across the country, most of which focus on opioids, as well as physicians who practice it independently. Health Canada lists three prescription stimulants for safe supply as part of its guidelines on medications covered by public drug plans, including Ritalin and Dexedrine.

While drug policy experts and physicians have long said that discussions about safe supply (and the overdose crisis generally) need to be more inclusive of people who use stimulants, there was renewed attention over what that could look like after the Globe and Mail reported last month that B.C. was considering expanding its safe supply guidance to include various pharmaceutical opioids—and also cocaine powder.

The B.C. Ministry of Mental Health and Addiction wouldn’t comment directly on whether cocaine was being considered, but a spokesperson said the list of specific drugs to be added to the guidance is not yet finalized.

“Work is underway to update the guidance for prescribers in an effort to safely expand the types of medications available as alternatives to toxic, illicit street drugs,” the ministry spokesperson told VICE World News in an email. “We know that some people with addictions use a number of substances—the goal is to separate people from the poisoned street drug supply and provide access to supports.”

Health Canada did not give VICE World News a response by deadline. This story will be updated when it does.

If cocaine does make it onto B.C.’s safe supply guidance, it would be one of the only efforts of its kind in the world. One of  the best known examples of doctors administering cocaine in a safe supply setting was from 1988 to 1998 when a doctor in England ran a clinic that prescribed pure cocaine and pharmaceutical-grade heroin to hundreds of patients with chronic addictions. A drop in crime and addictions was reported as a result, but the clinic was forced to close due to backlash from the government.

However, safe supply prescribers say that while they would support including cocaine in safe supply programs in B.C. and the rest of the country, they foresee a number of logistical and regulatory hurdles that would need to be overcome.

Pharmaceutical-grade cocaine is infrequently used as a topical anaesthesia, as a treatment for nosebleeds, and for diagnostic purposes by ophthalmologists.

“But that volume is so infinitesimal compared to what somebody (who uses cocaine) would need,” Dr. Andrea Sereda, who leads the Safer Supply program at the London InterCommunity Health Centre in Ontario and works mostly with patients who use opioids, said in an interview.

Sereda added there is limited scientific data about the efficacy of prescription stimulants generally in safe supply settings compared to opioids. There would have to be a lot of adapting and learning in real-time about how effective cocaine would be in a safe supply setting.

“I’m completely for cocaine being added to the formulary,” Sereda said in an interview.

“(But) most people, at least who I take care of, don’t use pure street-level cocaine. They use crack cocaine; they use crystal meth. So there would need to be a lot of consideration around what is an appropriate and safe substitute.”

Guy Felicella, a peer clinical adviser at the B.C. Centre on Substance Use who spent decades living in Vancouver’s Downtown Eastside, said that for many people he knows who use street stimulants, being prescribed a pharmaceutical alternative such as Adderall does not necessarily replace their illicit use altogether to the same extent as it does with prescription opioids.

“And that’s just because the illicit stimulants are so powerful,” Felicella said in an interview. “If we do ever have approved pharmaceutical-grade cocaine, I still don’t believe that will stop stimulant crystal meth use, for example. A lot of the challenges that happen with the pharmaceutical clean version is that there’s no substitution for the street version of whatever you’re using.”

Dr. Paxton Bach, a Vancouver-based physician who practices safe supply prescribing including for patients who use stimulants, said that given the current limited state of access to pharmaceutical cocaine, there would be a lot of work to do on the supply chain before it could be considered appropriate for safe supply.

“I find it challenging to see how that will be provided through a medical model,” Bach said in an interview. “And plugging (cocaine) into a medical model where the physicians are now the gatekeeper for something that’s not even a medication, as we traditionally think of it, is a real challenge for doctors.”

It’s for that reason Bach said he’d be more inclined to support removing doctors out of the equation completely when it comes to bringing drugs such as cocaine into safe supply discussions. What this could look like is something more akin to the “heroin buyers club” or compassion club proposal previously put forward by the B.C. Centre on Substance Use where groups of people who use drugs purchase quality-controlled, tested substances for one other.

“If you’re starting to provide access to safe supplies of drugs like that one (cocaine) for recreational purposes, I think that continuing to then try and hammer that into the medical model and make doctors the gatekeepers is going to probably cause frustration both from physicians as well as clients,” Bach said. “Because it’s not really appropriate for me to tell somebody whether or not they should use recreational cocaine and how much and how often.”

To that end, Sereda said that while she thinks that cocaine should be pursued as a possibility for safe supply, “a better approach would be legalization and regulation.”

“Instead of (doctors) being required to generate evidence to do this in a medicalized context and become gatekeepers now to cocaine as well, the government should just step up and have the moral authority to legalize and regulate it,” she said.

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