By the B.C. Centre on Substance Use 

In British Columbia, the fabric of society is fraying. The morgues are full of community members who have died of opioid overdoses as a result of fentanyl poisoning of the illicit drug supply. For the first time in recent history, the life expectancy in British Columbia is decreasing due to extreme rates of overdose deaths. Behind this public health crisis are powerful organized crime groups reaping billions from the illegal fentanyl trade and targeting the local real estate market to launder drug profits, contributing to the housing affordability crisis. The causal relationship between drug prohibition and transnational organized crime’s growth is well known and has been clearly articulated, while all available evidence indicates that efforts to curtail the fentanyl supply through drug law enforcement have failed. Instead, prohibition has enriched organized crime groups to the point where recent reports suggest as much as $5 billion annually in drug and organized crime profits is laundered through Vancouver-area real estate in recent years.

In the face of this reality, this report describes a model that has the immediate potential to address the underlying structural basis that has led to unprecedented levels of organized crime profits, unaffordable housing and opioid poisonings. This model is inspired by cannabis compassion clubs and buyers clubs, both of which emerged in the 1980s and 1990s in response to the AIDS epidemic—the last public health emergency our province faced. Then as now, compassion clubs functioned to provide a safe place for people to access medical cannabis and connect with a range of health services, while buyers clubs procured lifesaving treatment for patients living with HIV and AIDS when government inaction limited access to these medicines. Similar small user-driven underground initiatives to ensure access to heroin exist today, but they are risky, illegal and without a secure supply of fentanylunadulterated heroin. This severely limits access and sustainability.

This report proposes evaluating an updated model to these patient-led responses: a cooperative approach through which heroin could be restricted to members and legally obtained from a pharmaceutical manufacturer and securely stored in much the same way as it is already obtained and stored for heroin prescription programs, while also undertaking scientific evaluation to assess impacts. A cooperative could undermine the illegal market wherever it is set up. It could be initiated at little to no operating cost to the public, with the potential to reduce fentanyl-related opioid poisonings and decrease the spread of opioid addiction in the province.

In a public health emergency, urgency is required. It is proposed that this model be rapidly implemented and rigorously evaluated to understand how this model for regulation and control of the heroin market might reduce fentanyl overdose deaths while undermining organized crime profits and improving public health and safety in British Columbia.

British Columbia is in the midst of a drugrelated public health crisis. In recent years, thousands of British Columbians have lost their lives to overdose and other drug-related harms. While the recent spike in overdose deaths has been primarily driven by organized crime through the introduction of illicitly manufactured fentanyl analogues in street opioids (e.g., “heroin”), other harms stem from the contaminated illicit drug supply, including brain injuries from non-fatal overdoses, also contribute to major morbidity, mortality and health care cost.

From an evidence-based public policy perspective, fentanyl adulteration in the illicit drug supply is a predictable unintended consequence of drug prohibition. Specifically, the same forces that pushed the market away from relatively bulky opium towards heroin, a more concentrated opioid that was easier to transport clandestinely, have continued to push the opioid market to increasingly potent synthetic opioids, including a range of fentanyl analogues. At the same time, the prohibition of drugs continues to contribute to a range of health and social consequences and, via the criminalization of people struggling with illicit drug addiction, perpetuates stigma towards people who use drugs (see page 8).

British Columbia’s longstanding drug-related organized crime concerns have also recently reached a crisis level stemming from the province’s growing unregulated illegal drug market. The profits enriching organized crime groups have recently generated increasing public interest, given high profile investigations of how the province’s casinos have been used to launder the proceeds of organized crime. However, less attention among the public has been paid to acknowledging the links between money laundering schemes and the source of organized crime profits: the illegal drug trade. Similarly, while many in the public view drug market violence as resulting from the effects of drugs (e.g., drug-induced psychosis), and high-level violence in drug markets has been used to stigmatize people who use drugs, criminology and law enforcement research demonstrates the clear links between the profits afforded to organized crime groups as a result of prohibition and drug market violence.9,10 Drug prohibition and the criminalization of people who use drugs contributes to a host of other harms to drug users and society at large (see page 8).

While addiction treatment and harm reduction interventions are a critical component of the public health response to substance use, addiction and related harms, these interventions do not address the structural factors that have given rise to the poisoning of the drug supply (e.g., organized crime profit motives) and related public health and safety concerns. Similarly, harm reduction, addiction treatment and recovery services, even when sufficiently brought to scale, will have a limited impact in addressing direct unintended effects of drug prohibition that are driven by organized crime profits in the illegal market.

In this context, this report describes a membership-based cooperative model that has the immediate potential to reduce the public health consequences stemming from the poisoning of the illicit drug supply while also disrupting organized crime concerns, including the financial driver of the fentanyl– money laundering–real estate cycle. This model is inspired by cannabis compassion clubs and buyers clubs, both of which emerged in the 1980s and 1990s in response to the AIDS epidemic, providing safe access to medicines. Given that the number of British Columbians with opioid addiction is currently estimated to exceed 120,000 in part as a result of unsafe physician prescribing and the proliferation of the fentanyl market under heroin prohibition, this model does not undermine efforts to promote cultural changes in the demand for drugs and, in fact, may actually reduce interest in opioids among high-risk populations.

It is proposed that an evaluation of this model be urgently undertaken with an initial trial site or sites to be established in neighbourhoods with high overdose morbidity and mortality, such as Vancouver’s Downtown Eastside.