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S01E08

Dr Mark Tyndall—Harm reduction for opioid use and vaping

Duration: 58:23

Uploaded: August 8, 2020

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About Dr Mark Tyndall

Dr Mark Tyndall is a physician, epidemiologist and public health expert. He has worked as the Director of the British Columbia Centre for Disease Control and as a Professor of Medicine at the School of Population and Public Health at UBC. Dr Tyndall has dedicated most of his career to studying HIV, poverty and drug use in multiple places around the world, starting with Nairobi, and now in Vancouver. He was one of North America’s earliest advocates for harm reduction programs and was at the forefront of North America’s first legally sanctioned supervised injection facility—INSITE—which was established in Vancouver in 2003. 

Dr Tyndall has also recently launched The MySafe projectan opioid dispensing machine rolled out in Vancouver that resembles an ATM and gives people addicted to opioids access to a prescribed amount of medical-quality hydromorphone. He developed the project in an attempt to reduce the number of deaths via overdose in Vancouver. The vending machine still requires a prescription but gives people access to a safer source than buying off the streets, where all too often people accidentally buy fentanyl instead of heroin. Fentanyl is 50-100 times more potent than heroin and, over the past year, was found in the bodies of 82% of Vancouver’s overdose victims.

Dr Tyndall also spends a good amount of his time on the media circuit debunking myths about vaping. Viewing vaping as another harm reduction tool, he is committed to correcting the point that while vaping isn’t necessarily good for you, it is certainly better than smoking tobacco and that deaths that have been tied to vaping are being incorrectly reported.

Show notes

Check our Dr. Mark Tyndall’s research profile here and his most recent publications here.

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Transcription

Michael McKay:

So just to start, can you maybe just provide a bit of background on yourself? Maybe starting back with you know, medical school and kind of the work that you’ve done up until now.

Dr. Tyndall:

Okay, seems like a long time ago but I yeah, I was a, when I finished medical school at McMaster University I really wanted to get into global health and, and the best way to do that I figured was through infectious disease training. And I picked a program that took me to Kenya for several years and working in the early days of HIV, in the early ’90’s when there was no treatment. And then I decided I wanted to do more research in this area. I went to Harvard, to the school of public health and did a doctoral degree in epidemiology and, and biostatistics. And, and then I, in part of my PhD work I, I went back to Kenya and did more work in, in HIV and prevention. And then I did other, some other global health work and then ended up deciding that I had a young family and didn’t want to travel as much. I ended up taking a job in Vancouver. And that was 1999 and I was still quite interested in HIV prevention and transmission, but the, the major issue at that time was transmission among people using injection drugs. And yeah, that was you know, over 20 years ago. And I worked clinically, I tried to, I worked a lot with people who are using drugs and when I started with the treatment part they were not really eligible for treatment because it was thought, people using drugs were incapable of taking the medication. And I was involved in early studies showing that indeed they could successfully take the medication. And then I got involved in harm reduction in general and I was one of the evaluators, or the main evaluator of Insight. Which was our first supervised injection site and that opened in 2003 and sort of been doing that kind of stuff ever, ever since. More harm reduction, but I’ve always maintained a clinical practice, treating people with HIV and Hepatitis C. 

Michael McKay:

And it’s, you’ve been working mainly in Vancouver for, since the ’90’s. Is that correct?

Dr. Tyndall:

Yeah, I mean I, I’ve done some international stuff in there but not, not for long term. And I also did four, for four years I was the head of infectious diseases at the University of Ottawa, in Canada. And that was about six years ago I moved back to B.C., to take a job as head of the B.C. Centre for Disease Control. Which is kind of the provincial place where we look for, look at public health. And I left that job about one year ago. 

Michael McKay:

And for people who have been to Vancouver and, and they know downtown East Side. They’ve kind of got this image in their, in their mind of what that looks like. But for those who haven’t been to Vancouver’s downtown East Side, can you maybe just describe its condition and yeah, what’s going on there?

Dr. Tyndall:

Yeah, you know what’s going on there now is quite horrible. My focus has been on the overdose crisis and in, in that community, that little community that’s not more than six square blocks, there’s probably been 400 people die of an overdose in the, in the past three years. So it’s highly concentrated part of the city where there’s just a lot of poverty and a lot of homelessness and drug use. And it’s quite shocking for people who you know, come to Vancouver which is otherwise a, a very you know, modern, active, very wealthy city. And somehow we’ve decided to create a ghetto right in the middle of the city that we’ve called the downtown East Side. And historically its existed there for decades. And right now, I mean I spend my days down there now with the, the work I’m doing with the overdose crisis. And it’s really a, it’s really quite a dramatic, dramatic scene. We estimate there’s maybe somewhere between 12 and 15,000 people living in a very small area and a large proportion of those people are you know, treating their trauma with drugs. 

Michael McKay:

Yeah and it’s quite a stark visual, not just with the people living on the streets. But the roads are all very decrepit and then on, you know, just outside of the block you’ve got high priced condos and businesses, with people in suits. And it’s just very, it’s just a different scene. 

Dr. Tyndall:

A different scene, I mean I, you know when I went there in ’99 it was, it was even more a stark contrast. There has definitely been a lot of gentrification happening over the last couple of decades. So interspersed now with you know, these dilapidated hotels where people are living there’s, there is nice restaurants and coffee shops and so it is, it is, it is changing but not with the, not with the interest of the people living there in mind. It’s really a way to squeeze people out and as a result of the gentrification, many of the surrounding communities are now facing issues around homelessness and drug use that even ten years ago they weren’t having to deal with. 

Michael McKay:

And just in brief, how did it get this way? In terms of this particular location?

Dr. Tyndall:

Well you know, I’ve read about it historically. You know in the, it’s a port city. There’s a lot of people in, in shipping and in the lumber industry working you know, long, for long periods of time. And then coming into the city and needing a quick place to sleep and live. And a lot of hotels were spawned during that time. And I mean, through government policies a lot of these hotels have been turned into housing units. And so historically it was a place where there was a lot of bars and you know, a lot of sex work and a lot of very short term occupancy hotels. And they’ve just over the years turned into semi-permanent housing for people. 

Michael McKay:

And in terms of the opioid crisis and the area in general, it, there obviously, there was more white powder heroin back in the day. And then the fentanyl’s kind of come in and that’s become the big killer. Can you kind of explain when that transition occurred and what kind of motivated that transition?

Dr. Tyndall:

Sure so I mean drugs have always been a big part of that community and people with, who couldn’t afford housing or often a lot of people are traumatised. People suffering from mental illness ended up in this very small area. And drugs were very common. And you know, I’ve been seeing the devastation of drug use for over 20 years as I’ve said. But everything really changed about four years ago when heroin quite suddenly disappeared. I mean it was a, a whatever organisation was supplying heroin to, to the west coast, Vancouver in particular decided to switch the product or maybe they left entirely and somebody came in with new product. But the white powder heroin that we were getting from Afghanistan for decades was all of a sudden replaced. And it started creeping in fairly slowly, when the heroin was mixed with fentanyl. But within six months basically heroin disappeared and all people could buy was powdered fentanyl. And the quality of the product and the way it was processed was totally inconsistent. And people initially were totally surprised when they got a big wack of fentanyl and went down. But you know, over the last three years people know exactly that they are getting fentanyl but still have no control and no way of knowing how potent the product that they’re buying on that particular day is.

Michael McKay:

And what kind of percentage of overdose victims have fentanyl in their systems?

Dr. Tyndall:

Like 85%. Maybe higher. Because some of the 15% that appear to have died of a you know, opioid overdose could quite likely had analogues of fentanyl. So we go through waves when we have carfentanil and, and other types of analogues that aren’t routinely measured by toxicology. So the theory is that you know, pretty much all of it, all of the deaths are due to contaminated drugs that contain some sort of fentanyl.

Michael McKay:

And I know that some of it’s coming, or it seems that some of it’s coming from Mexico. Is it coming from China as well or do we, I guess we don’t fully know where it’s coming from considering it is illegal. But do we, do we have an idea of the sources?

Dr. Tyndall:

Yeah I mean, the police are still very active tracking things down and busts occur all the time. And China’s been the main country that’s been identified as the main, the main supplier. But there’s also you know, it’s all very convoluted and complicated. And there’s somehow, you know, the Canadian government still believes that investing in trying to inter, intercept fentanyl from China is somehow a workable solution and it’s kind of a waste of time. So yeah, so you know the supplier, probably the main supply has come from China.  But it comes from all different kinds of routes and all different kinds of criminal groups are bringing it in. 

Michael McKay:

And in your Ted talk you talk about how, you know, if thousands of people were being poisoned by food or, or water we would, we would make changes to legislation. We’d try and support those victims. But when it comes to drugs it’s, it’s a completely different thing. Like how many people have, for instance in North America, have died in the last year from these kinds of drugs and, and what’s their kind of stance on it?

Dr. Tyndall:

Yeah I mean, North America we’re in like 100,000 range. So it’s incredible how, how the governments inaction of this is been played out. I mean I think, you know when I speak to people and they hear I’m from Vancouver and the work that I’m doing. I think we’re still considered sort of on the cutting edge of trying to reduce, you know, reduce the harms of drug use with harm reduction programs. But at the end of the day, it’s still an illegal activity, we still punish people, our criminal justice system is basically filled with cases of non-violent drug offences. And people are, you know, the blame for the situation people find themselves in are routinely put back on the person that’s been, been tortured and victimised. So it’s very yeah, we, we really haven’t come a long way in our empathy and as you said, if you know, if we were seeing people being poisoned by anything, the first thing we’d do is give them an alternative, non-poisonous source. And, and up until now at least we, we haven’t gone that route. 

Michael McKay:

And I really do want to get into the dispensing machines that you’re piloting. But just, just to get gauge on you know, the, like you said there’s, it’s a criminal activity and that’s what it’s treated like. And I know that your view is that decriminalisation of drugs, which is to others maybe considered a radical idea. But can you kind of explain, just in brief yeah, why you  have this view?

Dr. Tyndall:

Well I mean we take the, you know, the most vulnerable people and the most traumatised people in our communities, who are basically all using drugs as some sort of self-medication. And we just continue to punish them for it. It’s a, it’s a crazy thing. When you, when you’re talking about a radical approach to something, you know, it’s what we’re currently doing is terribly radical. How, you know, we take traumatised people who are using drugs. We call the drugs illegal and then punish them some more. It’s a, it’s a pretty crazy thing we’re doing right now. So you know, it’s just so obvious to me at this point that the last thing people need, who are dependent on these products is that we, we put them in the criminal justice system. So we could spend our money far better and have far better results, both for society and obviously for the people that are being victimised by this. 

Michael McKay:

Yeah and, and what is the drug treatment courts, yeah where are they at at the moment in terms of how they’re treating people who are being convicted?

Dr. Tyndall:

Well I mean, in a way the drug courts that we have and the way that some people are processed outside of the traditional justice system is really just another extension on the war on drugs. It’s a, it’s a more, maybe more economical way to do it. But invariably if you follow people who have gone the drug courts system, they’re given a, a set of rules to stay out of jail that they rarely can follow. Like abstinence. And they’re reconvicted and they end up in jail. So for a lot of people that I know of that have been through that system, drug courts you know, maybe delay their incarceration. But for most it doesn’t eliminate it and they end up even with worse jail sentences because they’ve, they’ve crossed the line with their probation and things like that. So you know, as long as we put unrealistic expectations on people, which in some ways would sound simple. You know, just stop using drugs and we’ll leave you alone. People just do not stop using drugs, so we, we basically put a set of, a set of demands on people that are unrealistic. And then when they fail, we blame them again. So it’s a, it’s a revolving door for most people.

Michael McKay:

When you mentioned that there are about 100,000 deaths in North America, is that in a single year? Or is it, is that over the course of?

Dr. Tyndall:

I think we’re like, I mean the last two years have been particularly brutal. In, in Canada it was, it was, in the last four years it’s around 12-14,000 people in Canada have died. This year will probably, certainly in British Columbia the number of deaths have gone down. But the number of overdose calls has stayed about the same. So it really shows that we’ve done a pretty good job in reversing overdoses, there’s so much Naloxone that’s out there on the streets now. We have about 30 overdose prevention sites that are reversing overdoses all the time. So we’re still, we’re doing a better job at reversing overdoses. But we’re, we really haven’t cut into the fact that people are, are still overdosing. And you know, a reversal of overdoses. I’ve been at, I’ve attended I don’t know by now, maybe 100 overdoses I’ve seen over the last few years. And I mean, there’s some celebration when somebody’s brought back to life. But it means they, their brains been without oxygen for a minute or so. It’s just not a, it’s really not great for people to overdose. And we haven’t really done anything that will, you know, diminish the chance that people will actually overdose in the first place. 

Michael McKay:

And you know, and I think you mentioned on your Twitter that, that during the Canadian Federal election there wasn’t a question asked about the overdose crisis, and you’ve still got 13,000 people dead. So it’s, yeah.

Dr. Tyndall:

Yeah no, it’s crazy. You know, I mean how can that happen? You know, this is clearly by the numbers the worst public health crisis that Canada’s faced in a generation as far as the death of young people. And it was really hard to get any traction from the politicians. And most just said the same old thing, you know. We, we really care about this problem and we’re going to get more treatment. And to say we’re going to get more treatment for people is basically saying they’re not going to do anything. Because it’s a, this is not a problem that’s going to be fixed by building hospital beds. So they, as long as we keep it criminalised and as long as the stigma and oppression is put on this, these people that use drugs I think we’re not going to make much headway.

Michael McKay:

And like I said, I really want to dive into the dispensing machines. But just kind of just to give a bit of a timeline of things that have moved up to that point. Because I know that, for the time that you’ve spent in Vancouver, you’ve spent a lot of time being one of the spearheads of the harm reduction kind of things going on. And there are obviously a lot of other figures who are helping as well. But just to kind of go back a little bit to 327 Carroll Street. And maybe describe what, what that supervised injection site looks like and how it kind of operated?

Dr. Tyndall:

Yeah I, ironically I was being by there, well it happened about a month ago. But that actual building no longer exists. So [19.50 unclear] took a demolition ball to that whole building. So they’ll build something else there now. But it was a, you know, it’s kind of an old building and a community group called Dandoo started allowing people to inject in that room. Kind of a, you know, an underground supervised injection site. There were, you know, the police knew about it but they pretty much left it alone. You know, it’d come and go that they’d clear everybody out and lock it up and things. But it was a place, as a physician I could just go out, drop by there after work and just, just help people with wounds and give them suggestions. Mostly, you know, I had a little bit of medical material there. But mostly just to tell people that you know, what I’m looking at right now like, looks really bad and you better get to the hospital. So but it, yeah it was just  way, it was just a very low threshold place where people could gather and give each other support and, and people were injecting drugs there. 

Michael McKay:

And, and that led to Insight, which is?

Dr. Tyndall:

Pretty much directly. You know, there is other, there is probably three sort of underground kind of places that were operating. And there was a real you know, push that people should be able to inject under supervision. And that led to, finally led to Insight and it was really spearheaded by the Portland Hotel Society. Sort of a powerful NGO group who worked in housing. And so they got funding and that was allowed to go. My initial involvement in Insight was as the evaluator. So the Canadian government approved it as a, as a research study, a three year research study. And so we were the ones sort of trying to collect data and, on Insight. And it, you know, looking back it was kind of fascinating because it was, the idea was it was supposed to be very low threshold. So people did not have to give their identity and we weren’t really able to ask any questions initially. And we did a lot of our tracking of the uptake of Insight just as outside, just counted people walking in and out and that kind of thing. And as we gained some confidence and people gained some confidence in, in us being around we started asking more survey questions and started getting more indepth data. And as a result there’s, there’s probably been you know, 50 or 60 peer reviewed papers just around Insight. Showing how, how effective it was for the people using it. 

Michael McKay:

So, so considering its success, was it, did it continue on? Or is that something that continues today?

Dr. Tyndall:

Yeah, so Insight continues today. Its kind of a, become a landmark of Vancouver. So there’s like three or four things people want to visit when they come to Vancouver and probably one of them is Insight. Or at least people I know because we’re, but so yeah. It still, it’s still there. So the history of Insight though, the, the conservative government came in. Decided that although the research was successful, they still ideologically were opposed to this and the case went all the way up to Canada’s Supreme Court to, to keep it open. And a judgment at that time was it would be unethical to stop it, because it would actually, it caused people to die. And they were using this to, we were using this to save people’s lives. So that court case I think was like 2011 or something, by the time the Federal government, so Insight’s pretty protected by that. But although the government or the Supreme Court was very positive and protective of supervised injection sites, there wasn’t any new ones for almost a decade and it wasn’t until the, the overdose crisis hit that the, the provincial government decided that they would ignore the Federal regulations due to the emergency. And starting in 2016 a bunch of other ones opened and its kind of stalled out again, but there’s about 30 active supervised injection sites. Or now we call them overdose prevention sites in the province of British Columbia. 

Michael McKay:

Awesome. So maybe just yeah, lets get into the dispensing machine. Because it sounds, it sounds like these are very new. It’s something that you’ve piloted or you and, and a team. But maybe just describe what it is and what’s kind of going on?

Dr. Tyndall:

Yeah so it’s been a, the timing of this conversation is, is good because basically we just got, we just allowed some media attention to this last week. So you know, back to the reason why you’d offer people a safe supply is if you put it in the language of a poisoning epidemic, then just watching people purchase deadly drugs on the street without offering them any alternative is just not working very well. You know, maybe we just suspect that if we put the message out there, that look the next drug could use could kill you. Then maybe that would be a disincentive. But for people that are you know, regular opioid users that’s not a disincentive. People will take their chances and the chances often end up very terrible. So, so the discussion around a safe supply has been there a while. Now the, the other important part of that is two trials that happened in Vancouver about a decade ago. One Naomi trial, which offered people injectable heroin. And a Salomi trial, which was an extension of that but also offered people injectable hydromorphone. And so that clinic has been going on again for probably ten years. There’s about 140 people that go there about three times a day and are observed taking their injectable solutions and the, the data from that is also very positive. People who got in that program are able to adjust their lives somewhat and, and stabilise and continue to use that program. But it’s, it’s pretty intensive and very medicalised and a lot, in an illegal situation and a very stigmatised situation, people are not, everybody certainly is not willing to go and use drugs in front of people three times a day on a certain schedule. So, and I would estimate that 80% of people who are at risk of overdoses would never commit to that kind of intense medicalisation. So we’ve been trying to work on ways that people could access a safer supply of drugs. And in a much lower threshold way. And be able to use these drugs as they wanted and not in a, not under observation. And that’s been a, you know, the conversation about a safe supply has gone quite a ways in, in British Columbia in the last two or three years. So there’s you know, a bunch of us have been really calling for safe supply. And there’s been a very strong and consistent voice from community groups that that’s really, you know, they are terrified of the drugs on the street and want, want an alternative. So probably about two years ago I talked, I got a grant actually from the Federal government to dispense dilotted pills. But getting that off the ground proved to be quite difficult because there was still a lot of apprehension about allowing people to take anything with them and that was the program I was working on. And then I started thing about ways that we could distribute them in a regulated fashion and I was contacted, I, I talked about putting them in vending machines at a conference and I was contacted by somebody, a manufacturer who actually had a machine that could do that. And so I’ve been working with this company called Dispension for two years, to come up with a prototype of what a regulated machine would look like. And we just got it delivered in December and, and we’ve just been pilot testing it for about the last six weeks. I didn’t want it, I wanted to keep it very low key, because I really didn’t have everybody’s support and permission to do this. But as of Friday, we sort of got some media attention about it and I have now ten people using this machine. And the technologies brilliant, so I can explain. I mean it’s basically an 800 pound steel box and it has a, a biometric sensor that reads the palm, the persons vein pattern in their palm. It’s really you know, full proof. So only the people that are registered for the program can get access to the machine. You simply put your hand up to this scanner, there’s a message on the video screen that says that you know, what you’re getting and that your medication is being dispensed. It’s dropped into a box at the bottom of the machine. People pick it up and they leave. So it takes, the whole process once you’re enrolled in the program takes about ten seconds. And, and you have your medication. Now that we’re using a dilotted or hydromorphone pills on people. And I can, the machine allows me to time when people can get it. So most people can come back to the machine every three hours and get another dose. And it, I can decide how much they get per, per dispension.

Michael McKay:

Yeah, so which is interesting. So, because obviously you’re a physician who can, who can actually give out these prescriptions. But how do you, do you control how much you can give out in advance, based on the times? Or is it something that you have to do case by case, as it comes through?

Dr. Tyndall:

Yeah it’s case by case. I mean I, I you know, my attitude is it’s your body, it’s your drugs, you can help me decide how much you need. I want, the idea would be that this would be a substitute so that you don’t have to buy drugs on the street. Although it is a harm reduction model. So if people use the machine 75% of the time and 75% less likely that they’re going to overdose. So we’re just looking at that now and the, I have really only long term data on five people. Because five were enrolled in the last three to five days, but of the five already I’ve seen quite a difference. And they can, they’re on different dosing. So anywhere from eight pills a day to 16 pills a day. And I’m in communication with them and if they say that you know, I’m still buying Fentanyl. I need a bit more. Then we can adjust, we can adjust their dose as necessary. 

Michael McKay:

And you talk about it, that, that solutions like this help in two main reasons. Which is to first, you know, stop overdoses. Which is a massive one. But you also talk about how it gives people back their lives. Can you kind of explain what you mean by this?

Dr. Tyndall:

Well, we’ve created situations for a lot of people where their lives consist of searching out drugs. And that often leads them into you know, dangerous situations or criminal activities. Women often turn to sex work and it’s all to keep feeding their, their drug habit and drug use. And instead of getting up in the morning and feeling drug sick and having to go do something, you can just come to a machine and get your dose. I mean for most people, that’s pretty life changing. So it’s a really way to help stabilise people, get them into some kind of routine and allow them to interact with other services. So I, you know, as a physician working there. It was always a bit frustrating that people would never show up for the appointments and you know, like you don’t appear to have a regular job and you know, while, you know you’re sick. You really should see a doctor. But the people are really busy and pre-occupied with where they’re going to get their next, their next hit. And it’s now, you know, now I’ve come to realise that that’s, that’s people’s priority. And they can’t have, they don’t really have time to take care of their health or their nutrition, or their housing, or whatever. It’s really a, a 24-7 grind to get as much money as you possibly can to get your drugs. And so it’s a really horrible situation that we’ve, we put people in and if you can break that cycle that, you know, for most people it’s a downward spiral. You can make a huge difference in people’s lives. 

Michael McKay:

And I really like the way that you framed it as, I actually heard this in a different interview. But the breaking the hustle. Because it, like you said it, it seems like every day people are getting up and putting themselves in danger to kind of hustle their way to get what, what they’re looking for. 

Dr. Tyndall:

Yeah and we just chase them around, you know, we spend most of our, most of our time and, and resources chasing them around with, you know. Whether it’s social workers chasing people around or police chasing people around. It’s, it’s really people are very, in a very unstable situation. Because it costs a lot of money to buy illegal drugs and you are, you know, people have; the other thing that you know, that should be so obvious. How extortionary the illegal system is. So one dilloted pill that people get from the pharmacy is 35 cents. And to get a, a similar, a similar product on the street you know, would cost them $10-$15. So you know, people are spending a huge amount of money, everything they have certainly on the, on the illegal drug market. And it, the drugs themselves are, should be very inexpensive. 

Michael McKay:

Yip and I think there’s also another point that you raise and again it was come from a different interview that I was listening to, but that there’s also the benefit of people coming, interacting. You know, instead of going down an alleyway, that they might be you know, coming into a, into the clinic and actually interacting with others, interacting with, with doctors. Is that seen as a benefit? 

Dr. Tyndall:

Yeah, I mean I, I do. I think it’s important to explain as, one of the, one of the concerns people have is that it’s a machine. And people, you know, you talk about you know, connecting with people. That they, what can a machine do? But being in the program, we have peers and people around. So I, I know from my experience that people who want to reach out and will do it on their own terms and you know, and when they’re ready. And the idea that we, we serve people by tying them to methadone pharmacies and to supervised situations, where that day they’re just probably are not ready to talk to you. And there’s so much shame and stigma, and pain. And over time people have an opportunity to come around. But a lot of people just enjoy going to the machine, don’t have to bother talking to anybody that day if they don’t want. In ten seconds they can walk out with their meds. And maybe tomorrow they’ll feel like talking to somebody. So the opportunity is always there for them, but there’s no expectation that they have to interact. 

Michael McKay:

And it seems that the, you can set questions on the machine as well that asks you know, kind of people to rate their, how they feel. And those questions could be changed. Is, is that helpful as well? In just terms of you know, seeing how people are trending?

Dr. Tyndall:

Yeah, we’re testing it out. I mean you know, we just, we put some questions. It’s a you know, basically the machine has a computer in it. So we can basically ask people whatever we, we feel would be appropriate. I think yeah, people may enjoy checking in. I mean, you know, even the fact that we know if people you know, go missing. There’s so many of the tragic overdose stories I hear is, you know, it doesn’t come to people’s attention that they haven’t seen so and so for three days. And somebody goes and breaks into their room and there they are, they’ve been there for three days dead. So you know, you do have, once you’re in the program. We do have the ability to make sure people are you know, around and coming in. The part of the program though is low barrier, so if people miss a dose we don’t go out chase them, or try and contact them. But certainly if they didn’t come round for a day or two we’d, we’d know that something was up. 

Michael McKay:

And what is the next step for the dispensing machines? It sounds like you know, like you said you’re in a, the pilot phase. What’s the next steps?

Dr. Tyndall:

Yeah well that’s, I don’t know. I think it’s not funded right now, so I have an agreement with the company that donated the machine. I have a lot of community support and volunteers, I’m writing scripts. So it’s, right now it’s you know, not an expensive thing to do. But if we did want to expand it. The machines themselves are about $30,000. And probably you’d come up with a lease plan or something, because you’d need technical support in that. So people, probably in Canada it would be about $2,500 a month to have one of these machines in place. And one machine using a prescription model can handle about 50 people. Ultimately you’d like a whole network of these machines, so people aren’t necessarily physically tied to a machine. Because I know from all my experience with harm reduction and dealing with people using drugs, convenience is really important. People stick to their block or stick, you know, they kind of hang out in certain places and will not travel long ways to get services or probably get drugs. So a whole network of these machines would be great. People could access different ones. Again, we know from the methadone program one of the huge barriers for people is they are stuck to one pharmacy and they, you know, they can’t go to visit their friend down you know, in another city or you know, close by even. And so technically the technology would allow you to network these machines and program them to allow people to use them in different, in different communities. 

Michael McKay:

And this is obviously one big part of the work that you do. And another part is vaping and the kind of, where we’re at in terms of vaping. Can you talk a little bit about your stance on this and maybe the stance of where Vancouver, sorry not Vancouver but where Canada is on vaping as well? 

Dr. Tyndall:

Okay, change gears. But my interest in vaping is the same, is the exact same principles of harm reduction. So to me vaping is a, the, you know, the definition of harm reduction. You take a product that kills people and you offer them a way to get nicotine that doesn’t kill them. It’s just so obvious to me that people should all be switching to get rid of their cigarettes. And I came to this through kind of serendipity. I mean, I have a lot of experience working with community groups. And a lot of my research projects involved advisory groups from the community. So if I was doing an HIV project, I’d have a bunch of people with HIV who you know, would help design the study and, and work with me with the study. And in Ottawa, this was probably eight or nine years ago now, I created one of these committees. And everybody had HIV, but everybody was doing fine on their medications. And, but people were dropping out because they were dying of tobacco. And so they had, one person had lung cancer and one person had severe COPD. Both died within the first couple of months. And everybody on my committee were like, heavy smokers. And it appeared to me this is, you know, I’m spending all this time trying to treat people’s HIV and keep them on HIV treatment. And HIV treatment now is pretty easy and nobody’s probably going to die of their HIV. But everybody’s going to die of their cigarettes. So when I first you know, heard about vaping and alternatives I’ve been quite interested in. Especially you know, very marginalised populations. People with mental illness, their rates of smoking are extremely high and most people will die of their, of a smoking related problem. So if we can deliver nicotine in a safer fashion then, then I think we should offer it to people. And so I’ve been, yeah, trying to, trying to promote vaping. And interestingly the, you know, one of my, one of my mentors about, around harm reduction – Alex Wodak from Australia, also has jumped on the vaping band wagon. And Gerry Stimson, another kind of leader in harm reduction. You know, all of us have come to the same conclusion. That all the stuff we went through with harm reduction for, for other drugs really applies to vaping. And now there’s kind of a whole war against vaping. Which to me is irrational. 

Michael McKay:

Yeah, why do you think, I mean it’s, I guess it’s falling under the guise of cigarettes. But why do you think there is this kind of moral panic about vaping?

Dr. Tyndall:

Yeah go figure, I don’t know. I mean, a lot of my colleagues in public health are, are supportive of general harm reduction and are dead set against vaping. It’s, it’s somewhat though I think we’ve, we don’t really care about people who are smoking cigarettes. Like they, they’re going, again blaming the victim. It’s your problem, if you don’t want to die of heart attack or lung cancer then you should stop smoking. And we have a few things that might be helping you but we know they’re not going to work and you know, we don’t want, we don’t really care. What we care about in public health is making sure we don’t have a new generation of nicotine addiction. And that’s, it’s crazy. Like it’s, that’s not to happen with cigarettes. That’s not going to happen with vaping or cigarettes. The youth numbers are going down quite dramatically with tobacco use. And it’s not, it’s highly unlike that you’re going to ever get a whole generation of youth starting vaping and all of sudden starting buying cigarettes. It’s just not going to happen. But that’s where public health seems to have landed, that this is our main goal is to save our youth from nicotine exposure. And basically whatever happens to smokers doesn’t really matter. And people use, you know, they, you look at graphs of smoking prevalence and in most countries it’s actually going down. But that’s very slowly and it’s driven by deaths. So we’re just you know, allowing a whole generation of people who smoked just to die of their cigarettes. Youth, we’ve been relatively successful in getting education out to youth that cigarettes are a bad thing and so youth, youth smoking is down. But that, that is not you know, we’ll be decades and decades before we see prevalence go down to reasonable rates. And since we have a tool now that could really reduce the harms of cigarette smoking, I just think it’s a massive missed opportunity if we don’t promote them to smokers. 

Michael McKay:

Is, and has there been much studies done on, on the effects of, of vaping? I guess obviously there’s no long term studies, because it’s a new?

Dr. Tyndall:

Yeah well I mean, I think because they’ve kind of come from the grassroots. They didn’t go through like any big, rigorous clinical evaluations because they, they were, the promoters of these were people who felt way better when they switched to vaping and became mini evangelists for this technology. So and weren’t organised to do any long term studies. But we’ve had, you know, ten years of experience with this now. And it’s just common sense that if you eliminate you know, 95% of the dangerous chemicals involved with combustible cigarettes, that things will be safer. So people argue whether it’s 95% safe or not. But the, what, when that came out from the, from public health in the UK. That they were 95% safer. I’ve seen nothing in the past four years since that statement came out that’s dissuaded me that yeah, it’s probably, it’s very true. It’s so much safer that, that we should be embracing this in public health as a way to, to reduce tobacco exposure. 

Michael McKay:

And what is the, the American Heart Association stance on vaping? I mean, I’m sure it changes all the time. But at the moment?

Dr. Tyndall:

Well we think we really, so for those of us who you know, have been at this for a few years. I mean, we’ve really lost a lot of ground. So I think the public opinion and the statements from organisations have really become much more, much more anti-vape. So there’s, you know this, a lot of organisations vaping was of interest as a tool to help people off cigarettes four or five years ago. But now the statements are quite, you know, quite harsh against vaping. That you know, there’s no proof that this is any safer than cigarette smoking. And there’s all kind of unknown things. And really the message from you know, major organisations is that people should not vape and that they should not, they should not smoke. But there’s, there’s really no message out there saying if you smoke you should, you should vape. Now the Canadian government does still have that on their website, saying that vaping is a safer alternative to smoking and should be considered. But then there’s all kinds of now, all kinds of other caveats around you know, the unknowns and youth. And a large focus on youth vape and so the public opinion, the you know, people in Canada I think it’s like 60% feel or are convinced that vaping is just as bad as smoking. And that’s just so against reality, that it’s, it’s mind boggling how that’s happened. 

Michael McKay:

Yeah, it’s insane. And I think you touched on it, which is just the idea that teens is always the word that’s attached to it. We, we must prevent teens doing this thing. But I think you make a very good point that it’s not about you know, getting rid of all harm. It’s about reducing harm and it’s the same way that you know, that we use vaccines or needle exchanges, or even seatbelts. That kind of thing. It’s like it’s not, it’s not to remove all danger but it’s to reduce that, reduce the danger. And have there, have there been any, like because I know for instance that CNN has reported 33 deaths. I also know that news outlets can you know, jump with numbers or correlate things that shouldn’t correlated but have there been any deaths related to vaping?

Dr. Tyndall:

Well what’s, what’s really set it back in September was all these, what were, were publicised to be vaping related deaths in the United States. So I, I know it’s in the, it’s in the 400 person range of people who have died. And I don’t know, 2,000 or – I should have these numbers better in my head. But you know, it’s in the thousands of reported cases of severe lung disease due to vaping. But now it’s all come out and it’s just been in the last few weeks that finally the CDC and Atlantis come clean that there’s no evidence this is related to nicotine vaping. It’s all boot leg, contaminated pods. Much like we’ve seen with any prohibition. And the interesting, it’s really drive by THC and somebody had the bring idea to put Vitamin A, Vitamin E acetate into the mixture and it’s very toxic to the lungs and creates a huge immunological response when inhaled. So it pretty much everybody now admits that this was nothing to do with vaping nicotine, all these deaths. But to do with bootleg THC pods.

Michael McKay:

Okay, interesting. And when you’re talking about THC, that’s THC that hasn’t been played with? Because I know you said bootlegging pods but is it THC itself bad or is the way it’s being …?

Dr. Tyndall:

No it’s the way it’s formulated to be vaporised with this Vitamin E. So vaping you know, vaping cannabis is probably again a much safer way than burning it. And it can be done quite safely. But when it gets into the black market and people are trying to make more money and there’s no quality assurance or control, bad things happen. And in this case, a very bad thing happened. And you know, it’s tragic. All these young people who you know, lost their lives or have permanent lung damage because of these bootleg products. And again you know, all of these restrictions we’re trying to build in around youth is basically a recipe for bootleg products. It’s just so obvious that if you, if you get hard on prohibition you just continue to, you just promote dangerous, unregulated products that people will still use. 

Michael McKay:

And in general are you seeing vaping usage at the same levels as it was? These things, they seem they come in phases as well, you know, or fads I should say. Is usage going up, is it going down, is it staying the same?

Dr. Tyndall:

It’s going down. Because I think, I do some work now with the Vaping Association. And yeah, full disclosure as of last October I’m kind of a harm reduction consultant to them. And I, I get a stipend for that work. So I, I do take some money from an organisation that’s related to industry now. Because I just feel so strongly about the thing, about the whole issue. But they, they say that sales have gone down 60% in the last three or four months. So yeah, the message out there is that vaping is bad for you and that if you, there’s been a lot of people in Canada who successfully transitioned to a safer product like vaping, and have gone back to cigarettes. And I think that’s just tragic. 

Michael McKay:

So yeah, and that’s what I was going to ask. And you might not have the numbers but cigarettes in general, obviously they’ve been trending down for a long time. But is, with that correlation with you know, with vaping going down. Like you said, some people have been returning. Have you actually seen physical statistics going up?

Dr. Tyndall:

Yeah, I don’t have the numbers. A lot of it’s still anecdotal because nobody’s really collecting that kind of information Canada wide. It’s, you know, estimated in Canada that you know, there might be a million vapers. But you know, it’s really hard to get your handle on the, on all that data. The, the stuff that’s really been promoted in the media though is youth vaping. And there are statistics out there that you know, 35% of teenagers have tried vaping. But the, the comparison is how many, what proportion have tried alcohol? What proportion have tried cannabis? You know, what proportion have you know, drive without seatbelts? I mean, you know there’s going to be, there’s going to be risk taking for sure. But the numbers of actual youth who have never smoked and now are regular vapers is very small. Like people, this idea that people instantly become addicted to nicotine is just false. And there’s a, been a lot of experimentation and most of the vaping has been very sporadic. But if you ask the question, have you tried a vape in the last six months? Yeah, 35% of youth will say yes. 

Michael McKay:

And just to, to kind of yeah, just to wrap things up. I’m just interested you know, are there future projects that you’ve kind of got? You know, like we’ve discussed the pilot program with a dispensing machine is very early days and where that goes is really dependent on usage and response. But yeah, are there other projects that you’re working on at the moment that people might find interesting?

Dr. Tyndall:

I’m very, I’m very keen on this technology and health, so technology and public health. And this kind of system, you know, in some ways I picked the hardest thing to dispense in a regulated fashion in, in like opioids. But clearly these machines could be used for a wide range of things that are currently stigmatising or embarrassing or whatever. So you know, HIV medications could come out of these machines, Hepatitis C medications, pre-exposure prophylactics for HIV could come from these machines. We could do a whole, cannabis even. You know, as cannabis kind of explodes. We still have issues with whose getting access and, and try to prevent youth access. Vaping obviously. So I’m, I’m quite interested in how this, how we can use technology to help people with access and stigma that currently, through our regular pharmacy system per se, it doesn’t allow. I think it’s very exciting what we could, what we could use with technology to help people. And so much things are turning into, you know, we’re using technology for all kinds of things. This machine could be linked to different apps that you can have on your phone and you can know things. So it’s very, it’s very exciting what could happen with, if we could expand this technology to other areas. 

Michael McKay:

Yeah, fantastic. And, and just as a final message. Is there just any, any parting words for those who perhaps work with people suffering from opioid addictions or other addictions?

Dr. Tyndall:

Well I’ve learned a lot of my lessons from like, from colleagues in Australia who are also you know, some really good spokespeople and smart people who are working in this area for years. And, but I think they’re up against kind of the same push back as we have. And all our harm reduction thinking is always at risk. So you know, different governments come in with different ideas based on ideology. And you know, harm reduction is a, is a hard road. And it’s always at risk, we’re always getting pushback. You know, supervised injection sites which at this point of my life, are just so obvious. Why would you want people to you know, inject in alleys in the rain when they can come in? You know, it’s just common sensical things to me now, are still under great risk. And in Canada there’s, the other provinces who did respond to their overdose crisis with some supervised injection sites now are threatening to shut them down. New governments have come in with different ideas and again, it’s back to the same old thing. That this is a criminal activity and the harder we are on people, the less likely they are to use drugs. And, and that has just been proven to be false.

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