Landmark studies: hydromorphone and morphine are the new buprenorphine and methadone, just as lethal

by Clark Miller

Published February 10, 2024

There is nothing new about “safer supply” or “risk mitigation” medical prescriber practices implemented in British Columbia and elsewhere in Canada in desperate attempts to reduce lethal opioid overdoses, apart from the opioids supplied – hydromorphone and morphine – being more potent and less controlled than their predecessors, buprenorphine and methadone. 

Nor anything new, as we will see here, in the ways that the medical/media collusion uses deception and cultivated incompetence to distort and hide the ineffectiveness and lethality of the approach. 

The study, published in the British Medical Journal, is described as “the first known instance of a North American province or state providing clinical guidance to physicians and nurse practitioners for prescribing pharmaceutical alternatives to patients at risk of death from the toxic drug supply.”

Researchers looked at anonymized health-care data of 5,882 people between March 2020 and August 2021, all of whom had opioid or stimulant use disorder.

Those individuals filled a prescription under the B.C. Risk Mitigation Guide — clinical guidance developed in March 2020 to allow for physical distancing during the COVID-19 pandemic, and to reduce deaths through harm reduction.

That cohort was compared to a second, similar group that did not receive medication under the Risk Mitigation Guidance program.

That clinical treatment rationale – “physicians and nurse practitioners for prescribing pharmaceutical alternatives to patients at risk of death from the toxic drug supply.” – is no different than that for the decades-long, failed, lethal approach of dispensing the pharmaceutical alternatives methadone and buprenorphine to high-risk opioid users on the never-supported fiction that those opioids would satisfy the desperate psychic need for more potent effects. 

In rationale, branding, and intent, Canada’s safer supply program is no different than the medical provision of “safer” substitute opioids in the U.S., Canada, and elsewhere begun decades ago, before fentanyl, and with predictable effects of worsening a lethal opioid crisis

The conclusion seems inescapable – that the New Safer Supply, of medically dispensed more potent, more powerfully mood-altering opioids morphine and hydromorphone constitutes desperate acknowledgment of the failure and harms of safer supply, of opioid substitute treatment, OST (aka MAT, MOUD). 

One might be led to wonder – if the neurobiological and clinical rationales and evidence for “safer supply” were ever valid, why must safer, failed buprenorphine and methadone now be replaced by more potent opioids?

Here’s the “landmark study” in the British Medical Journal – 

British Medical Journal article title

Some salient points from the study included that 

 – While there were fewer lethal opioid overdoses for RMG subjects, there were no differences in acute care visits for opioid overdose = high-risk use

 – There was no reduction in lethal overdose for subjects receiving RMG for stimulant drugs

 – While protocols varied and were unspecified, dosing and dispensing, as in other RMG programs in Canada, involved multi-weekly or daily contact with health care settings

From the CDC piece describing the research and outcomes – 

The study did not confirm whether the drug users took the drugs as intended. Bach said a significant criticism of safe supply programs is the fear that prescription opioids will be diverted or shared with those for whom the drugs are prescribed.

“That remains a complicated question,” said Bach. “This study design cannot speak to that specific question. 

Other investigations can, including the reporting discussed in this recent postwith findings including that – 

A four-month investigation by columnist Adam Zivo with our sister paper, the National Post, suggests the federal government’s “safer supply” program meant to wean addicts off the deadly opioid fentanyl, is having the opposite effect.

In interviews with 20 health-care experts, including 14 specializing in addiction medicine, Zivo was told many addicts are selling on the black market the free drugs they are given to reduce their dependency on fentanyl, to buy more fentanyl.

Compounding the problem is that this has caused the street price of the opioid they are given as a substitute— mainly hydromorphone — another powerful opioid, although nowhere near as potent as fentanyl — to plummet down to a few dollars per tablet.

The lower street price for hydromorphone because of the increased supply, Zivo reports in, “Drug fail: The Liberal government’s ‘safer supply’ is fuelling a new opioid crisis” has led to a wave of hydromorphone addiction across the country, particularly among the young.

The problem is that while hydromorphone is five to 10 times more powerful than morphine, it doesn’t eliminate the craving for many addicted to fentanyl, which is 50 to 100 times more potent than morphine.

But hydromorphone can be deadly for novice drug users, particularly when hydromorphone tablets, intended for oral consumption, are crushed for intravenous injection, potentially leading to excruciating and disfiguring infections and in some cases, paralysis.

But an expert cited in the CDC piece claims that the reduced lethal opioid overdoses in B.C. must have been due to subjects using the dispensed opioids,  to their benefit. 

Dr. Thomas Brothers, a resident physician in general internal medicine at Dalhousie University who is not affiliated with the study, said the extent to which mortality was reduced suggests users were themselves using what was prescribed.

“Some of the community of researchers and addiction medicine physicians who are more skeptical of safer supply have particular concerns about the amount of medication that might be diverted to others beyond the person that it was prescribed to,” he said.

“I think this may reassure them because the evidence of a mortality benefit means that the patient who is prescribed the medication must be taking some of it.”

Benefitting from “taking some of it”? 

Or from the obvious confounding factor that would have and has consistently accounted for reduced incidence of lethal opioid overdose in studies claiming benefit from the treatment effects – differential availability, monitored provision of, and use of lethal OD-reversing naloxone in a population with more frequent and intensive contact with care providers and settings, and identified higher risk?   

Would naloxone have likely been differentially provisioned and dispensed to, with more regular interactions to assure possession and potential life-saving use in the RMG treatment population than in the comparison population not receiving safer supply services? 

Let’s consider. 

Generally, the development of safer supply programs in Canada has included integrated efforts to “provide access to harm reduction and overdose prevention supplies and education” [emphasis added]. In the current study, dispensing of the opioids – requiring contact with care providers and settings including pharmacy, safe use sites, other clinical or support settings – appears to have occurred multiple times weekly of not daily. Typical protocols and supports in safer supply may include community outreach and contact with diverse members of a care team including nurses, case managers, care facilitators, social workers, outreach workers and housing workers“. In B.C. daily contact for safer supply recipients may be the norm, where “Clients pick up their medications daily at community pharmacies; selected pharmacies offer a delivery service to the sheltering sites and other locations to support physical distancing and self-isolation.

There is a picture emerging here, part of it a factor not recorded, nor available for analysis in the “landmark study”, not part of the reported results, conclusions or interpretations. The care team members, community supports, and settings for daily contact by clients receiving RMG would predictably involve persons carrying naloxone and trained on its use. As part of naloxone campaigns in B.C. as elsewhere, community saves would have become more frequent, and not part of any clinical record. As of 2021, one group estimated that naloxone saves in B.C. had reached 1,000 to 2,000 per month. The picture has high-risk opioid users buying fentanyl and other “real dope” with the free hydromorphone and morphine they are provided, continuing to engage in high-risk opioid use (hence the absence of any decrease in visits for opioid overdoses), and regularly revived by unrecorded instances of community or professional reversals, with significantly higher probability due to daily contact than the RMG non-exposed group. 

There is  no evidence – none – in the “landmark study” or elsewhere to disconfirm that all of the apparent decrease in lethal opioid overdoses are attributable to naloxone saves, differentially more probable for clients in the RMG group than in the non RMG group. 

There is, however, additional relevant evidence – the lack of any protective effect, in our current study, against lethal overdose for illicit stimulant users provided RMG with pharmaceutical stimulants. 

That’s a bit of a discrepancy. 

And a no-brainer, isn’t it?

There is no naloxone and no naloxone campaigns for potentially lethal stimulants. 

And there’s this JAMA report, published January 16, 2024. 

JAMA article key points

Comparing trends in B.C. to those in two other Canadian provinces without implementation of RMG, high-risk opioid use increased in B.C., predictably, as measured by hospitalizations for “opioid-related poisonings”. 

That is to say, predictably, the provision of street currency for fentanyl  and other illicit high-risk opioids led to worsening rather than protective effects against high-risk use, that presumed protection the only way that safer supply or opioid substitute treatment (OST) can have beneficial effect. That is, the new safer supply with use of more potent opioids is no less counter-therapeutic and no less predictive of a continuously worsening lethal crisis than the decades-long lethal failure of buprenorphine and methadone

As investigative reporter Adam Zivo put it – 

The problem is that while hydromorphone is five to 10 times more powerful than morphine, it doesn’t eliminate the craving for many addicted to fentanyl, which is 50 to 100 times more potent than morphine.

Yes, that’s the problem. The problem underlying the decades-long “safer supply” of buprenorphine and methadone driving an increasingly lethal crisis, now with the more potent opioids morphine and hydromorphone. 

The opioids supplied, without there ever having been  a body of research supporting safety and benefit from the begining, do not meet the untreated needs of users desperately compelled to experience the relief from psychic pain and anguish that their more potent street opioids provide them, opioids easily obtained with the currency of their free, medically dispensed opioids. Their publicly financed vouchers.  

That desperately needed relief from the psychic pain that drove their dependene on opioids has never been treated, the effective psychological, mental health and psychosocial treatments and supports never offered to them. They don’t exist, displaced by cronyism employment systems and lethal medical interventions the entirely non-medical condition of compulsive substance use. 

Opioid high-risk use and deaths in the U.S. and Canada continue to mount, year by year, as expert cures are increasingly dispensed. 

Safer supply is the new safer supply, as lethal as ever.

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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