Prescribed safer supply policymaking in BC: A qualitative analysis of problematizations, intervention, and evidence making during dual public health emergencies
Date
2025
Authors
Gudiño Pérez, Daniel
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Abstract
In British Columbia (BC), the unregulated toxic drug supply has become the leading cause of premature death among people in their most active and productive years. Although the province declared a public health emergency nearly a decade ago, toxic drug deaths have continued to escalate, signaling the limitation of public health responses to date. The COVID-19 pandemic further intensified these harms: public health directives reduced direct care for people who use drugs and access to harm reduction services, while international border closures destabilized an already volatile unregulated drug supply.
In the context of dual public health emergencies, BC introduced Risk Mitigation Guidance (RMG) in March 2020 to empower eligible prescribers to facilitate access to pharmaceutical-grade alternatives to opioids, stimulants, and benzodiazepines for individuals at risk of withdrawal, overdose, and/or COVID-19 infection. Some defined RMG as an initial model of prescribed safer supply.
The dual public health emergencies created an opening for novel drug policymaking in BC. However, significant gaps remain in our understanding of how policymakers defined the problems and envisioned policy solutions to an increasingly toxic drug supply. In this research, I analyze the decision-making and policymaking processes during the implementation of RMG to understand how the province of BC a) interprets the current unregulated toxic drug emergency; b) intervenes with policy instruments to address identified issues; and c) uses policy instruments to respond to the public health emergency, from the perspective of people who use drugs in BC. The dissertation is organized into three papers and is guided by a qualitative interpretive research approach, informed by policy studies, and poststructural and critical theories.
In paper one, I examine how health policymakers problematized the dual health emergencies and then critically interrogate how RMG came to be a policy response. I use Carol Bacchi’s (1999) “What is the problem represented to be?” framework to show that RMG was a contingency measure to COVID-19 that rendered the unregulated toxic drug supply a secondary issue to a communicable disease infection. Competing interpretations of RMG among policymakers reflected tensions about RMG’s aims and about the implementation process.
In paper two I examine the diverse ways RMG was understood and implemented across different geographic areas in BC. I use the Evidence Making Intervention (EMI) conceptual framework developed by Rhodes and Lancaster (2019) to understand the local factors that shaped RMG’s implementation throughout the province. I identify that RMG resulted in dynamic and context-dependent interventions that were enacted either as a COVID-19 response or as a harm reduction tool to disconnect people who use drugs from the unregulated toxic drug supply. I argue for localized evaluations of prescribed safer supply, where evidence of the intervention is being generated as it is implemented in local contexts, producing different forms of evidence and contextual effects.
In paper three I analyze the dynamic nature of unregulated drug markets and how people who use drugs navigate real-time shifts and changes in BC’s drug supply after being deprescribed. Through thematic analysis (Braun & Clarke, 2022), I identify user-defined experiences of safety and danger in local unregulated drug markets and highlight policy interventions such as scale up of safer supply, drug checking and drug regulation to support communities’ efforts in enhancing safety. Together, the three papers offer an integrated policy analysis of prescribed safer supply, foregrounding the perspectives of people who use drugs in assessing the effectiveness and relevance of policy interventions that impact their lives.
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Keywords
Prescribed Safer Supply, Harm Reduction, COVID-19, Overdose, Public Health Emergency, Unregulated Toxic Drug Supply, Risk Mitigation Guidance, Canadian Drug Policy