Transcript: Julian Somers

My conversation with the director of Simon Fraser University's Centre for Applied Research in Mental Health and Addiction

One of the themes of the Lean Out podcast is open inquiry. And my guest on the program today has some thoughts on this. He’s concerned about the suppression of discussion and debate and viewpoint diversity in the field of addiction — and he points to specific actions from the B.C. government and the B.C. Centre on Substance Use. But, as we learn at the end of today’s episode, both view the issue quite differently. (Scroll down for statements.)

Julian Somers is a clinical psychologist, a distinguished professor at Simon Fraser University, and the director of its Centre for Applied Research in Mental Health and Addiction.

This is an edited transcript is for paid subscribers. You can listen to the interview for free here.

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TH: Julian, welcome to Lean Out.

JS: Great to be with you, Tara.

TH: It’s nice to have you on. I’m from Vancouver. I did both my degrees at SFU, and the issue we’re going to be talking about today is one that I care deeply about. There are listeners in other countries for this podcast. Let’s start by describing the current overdose crisis in British Columbia. In 2020, according to the Stanford Lancet Commission, drug overdose deaths in Canada rose by 67 percent in that single year. And according to the [Vancouver Sun], the BC government has spent 1 billion dollars on this issue since declaring a health emergency in 2016. Walk us through where B.C. is currently at when it comes to the toll this epidemic is taking.

JS: Wow. I’ll say upfront, it’s likely impossible to do the issue justice, given the many ways in which not only the deaths that are so arresting, and impact people’s lives, but the problem of having an ever-increasing death toll is that it’s not possible to have that unless there is an ever-increasing replacement of people who are at similar risk to those who’ve succumbed already, and experienced those risks before. So we have to look elsewhere in our society to see, what’s the evidence of a larger iceberg that it makes it possible for this kind of a crisis to continue?

And some of the ways that that’s evident are over recent years — it’s a slightly longer trajectory, really, over a decade — the numbers of people who have been involuntarily hospitalized in B.C. for substance use disorders … So, we have involuntary hospitalization for other types of mental illnesses where people are a risk to themselves or to other people. But when those risks are specifically related to substance use, it suggests a different dynamic. So we’ve seen, as I said, a more than doubling of involuntary hospitalizations for substance use. We’ve also seen an increasing use of our correctional facilities. So, in B.C., in provincial corrections, we detain about 11,000 people a year. That’s what we have room for. About half of them are detained without a sentence, so-called remanded into custody. Others are sentenced. But regardless of the reason why people are detained, a similar picture emerges there. In the most recent year we had available, which is only 2018, more than three quarters of the people who had been detained, for any reason, had been diagnosed beforehand. So, this is a conservative estimate, because these are people who have records in our medical system of diagnoses involving substance use, mental disorders, or very often both. What I mean by that is people who’ve been diagnosed with a substance use disorder and also with a disorder like schizophrenia or bipolar disorder, and who are being detained.

Then we have other evidence of people increasingly living rough on the streets. It used to be certain neighbourhoods, and even certain cities, where this was talked about. Now it’s really throughout the entire province — small towns, communities are affected. So there is a huge backdrop of despair and suffering that goes along with the more blunt and shocking evidence of fatalities involving drugs.

TH: That’s really important context to have. For listeners outside of Canada, as well, I think it’s important to know that B.C. has recently embarked on a three-year pilot project to decriminalize possession of small amounts of certain drugs. Walk us through the province’s current ethos when it comes to addiction, and how this approach came about.

JS: To be honest with you, for people like myself, it’s a little hard for people working in the field of addiction to make a lot of sense of the approach we’re taking. You referred a moment ago to the work of the Stanford Lancet Commission. A colleague, Dr. Keith Humphreys, chaired that process. Their recommendations are considerable. They have addressed the crisis in both Canada and the U.S. They are trying to propose things that are meant to be helpful in our context. They mentioned many things, but they also highlight two things that they say, “People should be skeptical of these things while you’re contemplating what to do.” One of those things was installing vending machines to dispense drugs to people. The second was to establish a pharmaceutical supply of drugs with the hope of displacing the illicit supply. B.C. is doing both of those things conspicuously.

TH: Sorry, just to cut in. Does that mean safe supply, what you’re referring to?

JS: Yeah. Well, I should have said, “No, it doesn’t.” Because the term you’ve used is not a scientific term, or one that the Stanford Lancet Commission, or my colleagues and I use. We use the descriptor of “public supply of addictive drugs,” which is meant to be descriptive. The term “safe supply” seemed to come out of nowhere. There was and remains no evidence that the practice that is referred to is beneficial for people. There’s lots of evidence that it’s harmful — or poses risks, I should say. But the branding of a practice in the absence of any evidence as “safe supply” is just a bit of a head-turner from within the field. Because it’s really a blatantly uncautious way of representing a practice that’s fraught with risk.

But back to your question on our provincial approach. The document that summarizes this, I think, most clearly is one written by our Provincial Health Officer, and that was the basis for the federal government’s deliberations on whether to grant this three-year exemption.

The document refers, I think correctly, to the goal of decriminalizing drug users. And what I mean by that is there’s ample evidence — my team and I have done about 20 years of research looking at how people with addictions are involved with courts, corrections, medical facilities, hospitals, and also with the plight of living homeless. And, through that work, it’s clear that people with severe addictions are preventively and recurrently exposed to police, courts, and corrections. So decriminalizing those individuals is a laudable goal. One we should be pursuing.

The problem is that the landing place of the Provincial Health Officer was on decriminalizing possession. And to illustrate why this is I think is relatively useless: In some of our research, looking at 15,000 British Colombians diagnosed with opiate use disorder, they had on average five sentences a piece. So, 70,000 for this large group. Of that total number, possession accounted for 3.8 percent of their sentences, the reasons they were sentenced. Usually it’s bundled, by the way. When it appears, it’s usually bundled with a more serious offence. Arresting officers are adding it to lend some further emphasis to the safety risks that an individual posed, in the course of committing an offence. So the majority of these offences — more than 50 percent — involve theft. Because people are relying on theft to survive. They’re overwhelmingly unemployed.

About another 10 percent are associated with violent offences. These are due, in part, to the chaos that they are surrounded by, and forced to live with. And also the fact that many of this particular group of 15,000 — over one third had been diagnosed also with either schizophrenia or bipolar disorder. So, they’re dealing with a considerable amount of chaos associated with their own thoughts and experiences. So, decriminalizing possession while leaving the other determinants of these people’s wellbeing unaddressed, it’s very difficult to see how that is going to result in any improvement.

TH: You mentioned in our correspondence you were recently in Alberta. You were speaking at a national conference on addiction and recovery, and serving with an international expert advisory group. First, let’s talk a bit about the international perspective on addiction versus the B.C. perspective. How do those two diverge?

JS: Well, they’re quite varied. If we bring to mind places with incredibly punitive policies — Singapore comes to mind — and others with a relatively testing-the-boundaries, more laissez-faire approach, which, unfortunately, B.C. would be in that group now. [And] there are a number in between. We have to think of what would be sensible comparators. Who do we want to be like? Do we want to be more Oregon? Or more like Norway? It’s been, in my experience growing up — this is a personal observation — that we’ve tended to look more to Western European countries countries with well-established social safety nets as comparators. I’m not sure if that’s any longer true. This would be a good point, in my view, for Canadians to reconsider our social contract. What really do we want for one another in this regard?

It’s clear we can do a lot better, that’s for sure. A number of places have encountered very serious crises involving substance use and addiction, and have made major changes. Portugal is probably the most well-known example. But it’s important to emphasize, I think, that before putting their national strategy to paper, there was a considerable effort made at national consensus-building. The document itself refers to the fact that every Portuguese citizen must see themselves in this strategy. So, we are not there yet. We certainly didn’t have that type of consensus-building prior to developing the case for decriminalization in B.C.

TH: My understanding is that Portugal poured a lot more resources into treatment, as well. Is that correct?

JS: The document is “A National Strategy for the Fight Against Drugs.” It sounds almost war-on-drugs like, but that could simply be a translation. But it is true that the document, and the ethos, and the follow-through are not pro-drug — not even pro-drug as a lifestyle choice. Recall that one of the main catalysts was the prevalence of open-air drug use and related fatalities in just about every Portuguese town, the highest level in Europe. They said in the document, and this is part of what they did follow through on, that when it comes to treatment, and this is a direct quote, “Strictly speaking, there is no such thing as addiction treatment without social reintegration.” So, we have to think about that. That means a home, and a job, and people that you network with, who are your people.

So, how do you do that? Well, they did it with 60-something therapeutic communities. And, by the way, because they had made such a forceful commitment to social reintegration for those that needed it, in their vision, they made all of these changes without a single drug consumption site. This is not an argument against consumption sites. But it makes the point that if we are committed as a society, or if one is committed as a member of a society, to ensuring that everyone who needs a home has a home, everyone who needs an opportunity for work and wants to work has an opportunity to pursue that, then we don’t need consumption sites because everyone has a consumption site. It’s their place. Just like everyone else in Canadian society today who uses drugs.

So, their goal was not drug-free, or anything of that sort. It was everybody having a place. And their vision was incredibly resonant, which is key to its success. It has to be something that’s supported by the population in a very substantial way.

TH: In terms of within this country, Alberta is taking a different approach than B.C. Walk me through how that approach is different.

JS: If you’ve ever thought about this metaphor of building the airplane while you’re flying, that’s what they are doing there. It’s an incredibly ambitious sea change in Canadian responses to addiction. I’ll exempt Quebec from my comments, because I know Quebec always has a distinct thing going on. But in other provinces, at least.

They are shifting resources much in the same way that Portugal did. So, my prior comments. They are shifting resources in order to create opportunities that previously were not available in Alberta, and are not available in B.C. This includes things like therapeutic communities, or therapeutic living units, where people can go for extended periods of time, and experience enough practice living without taking drugs. This will be for people who have relatively severe addictions. But also, developing skills and abilities, developing networks, that will enable them to relocate following the completion of their stays. And not only have places to live, but have the opportunity to work, and work in skilled occupations.

They have eliminated things like user fees for people to gain access. They have implemented programs through police, for instance, that would enable people who’ve been detained to help ensure that once they’re released, first of all, that they’re not going to be at higher risk for a poisoning, due to reduced tolerance. There are medications that are available that can last from 24 hours to 30 days. These are medications that are not cheap — they are about 1,000 dollars per administration — but they’ve made them available universally, so that police, with very minimal friction, can make these services available to people.

Then they’re building out the full continuum. Our work together advising the government is to look at the flow through, from street, from police contact, from somebody referring themselves for assistance — and ensuring that at every turn, the things that typically would reduce follow-through, like a delay making an appointment, or a fee, or a service that doesn’t really fit what the person is looking for, that all of those things are addressed for the entire population.

Not only that, there is a distinct pathway, and Canadians would expect this, that is responsive to the needs of Indigenous communities. And that is contributing in some way to this large outstanding project of reconciliation. So they’re thinking it through in this respect, with Indigenous leaders doing that work. As I said, it’s an incredibly ambitious process of change, and one that, in the last six or eight months, is beginning to show some fairly compelling evidence of impact, even based on what they’ve done.

TH: It’s interesting. Coming to this conversation, I have to say, I have read a fair bit on this topic. I have, as recently as 2019, been on Vancouver’s Downtown Eastside doing a radio series. I’ve been really influenced by the work of Johann Hari, who I know and admire. I had come to the conclusion that harm reduction was the way to go, that this the best of terrible options. Here’s why: The failures of the drug war. The ongoing cost of criminalizing drugs, in healthcare, and policing, and social costs. I had Overdose author and law professor Ben Perrin on the podcast. He made the case that it’s impossible to stem the flow of drugs at the border, that the fentanyl is being shipped into Canada in greeting cards some of the time. Then there’s a policing issue with the drug supply being so toxic like this — that the normal policing tactic would be to allow drugs into circulation long enough that they can identify the traffickers and build a case. [Which you can’t do with a lethally toxic drug supply.] So there’s all these issues. Then, on top of that, the issue that I think Gabor Maté has done such a good job of highlighting: That there is trauma at work here. That if you’re taking a population who’s been traumatized, and adding a layer of criminalization, you’re taking a vulnerable population and making their lives harder. What am I missing in that line of logic?