Oct. 4, 2021

Psychosocial treatment should also be for everyone, not just the rich

Meredith Dan was sitting in her East Vancouver home with her sister and her niece when she received the most devastating news of her life. Her son, Glenn Rebic, who had been missing for four excruciating days, had been found deceased.

Rebic had gone out with friends on June 21 for Go Skateboarding Day, but no one had heard from him since that evening. According to Dan, friends remember seeing him leave a bar in the Downtown Eastside because it was closing. But no one knew where he went after that.

Diagnosed with ADHD as a child, Rebic faced adversities in school. He had tried medications, but went off them because they made him overthink everything and he needed a break. A doctor had recommended that Dan encourage her son’s involvement in sports, and he quickly fell in love with skateboarding, which his friends note he had a particular talent for.

“He was better at focusing on individual sports than team sports,” Dan told me over the phone in late July. “He was always able to compete against himself to get better at it.”

As he grew older, Rebic got into drinking, like many teenagers do. While she never wanted to lecture her son into victimhood, Dan says she did warn him about partying. “Sadly, he comes from alcoholism on both sides of his gene pool,” she explained. Dan’s mother, who came from the Líl̓wat Nation, ran away from a residential school in Kamloops when she was young. At 36, she died of alcohol poisoning, when Dan was just 10 years old.

“I always made sure to tell Glenn that we’re not victims. ‘Don’t let people’s opinions of what they think you’ll be influence you. You don’t have to be a victim of your circumstance, but know that the alcoholism is there,’” she remembers saying often.

Because of the precise developmental stage that their brains are at, teenagers are impulsive. The prefrontal cortex — which is responsible for long-term planning and weighing consequences — isn’t robust enough to overcome the commands from the more rash, reward centre of the brain (the part that makes us want to drink and party).

Rebic listened to his mother, but his lust for life overpowered these warnings. “As he got older, he was never into pot or ecstasy but he did get into cocaine,” she said.

Because she wasn’t there when her son died, Dan wanted to read every document about her son’s last moments. “I got all four of the police reports and emergency service reports and ambulance reports,” she said. “I needed to know exactly what killed him and that he got the amount of care he deserved.”

According to those reports, Rebic had gone to purchase cocaine near Pigeon Park in the Downtown Eastside. He died from a lethal amount of fentanyl, which stopped his heart right then and there. “Within a minute of when Glenn went down, someone called the ambulance,” Dan learned. “People had already given him Narcan and done CPR on him” when paramedics arrived. But he couldn’t be revived.

Safe drugs save lives

Dan, who has worked in government for 17 years — first at Service Canada, then Vancouver Coastal Health, and later in mental health at the Hey-way’-noqu’ Healing Circle for Addictions Society and the First Nations Health Authority — is a proponent of the “safe supply” drug model.

“I would rather have safe stuff out there that would be legally distributed than have the drug dealers lacing it and killing people,” she told me. Fentanyl and carfentanil have been mixed into the street drug supply, leaving people unaware that their drugs are contaminated and may kill them.

The current approach to safe supply is highly regulated with many barriers to access. Typically, a user must prove to a prescribing doctor that they have a substance use disorder and then commit to prescriptions, taking only routine amounts, and check-ins.

“It’s a lot for them to go through,” said Dan. “All the hoops and everything they have to jump through; it’s such a controlled environment and people who have an addiction sometimes can’t deal with that structure.”

Could Rebic’s death have been prevented if he was part of the current safe supply model?

“That would have been a hard no,” Dan emphasized. Committing to specific medications and being told when and where to show up every week was not how her son wanted to live his life. Reiterating that she’s “100 per cent for safe injection sites and supply,” she said she wants to see solutions for people who don’t have a substance use disorder and may only occasionally use drugs.

If there were a place “where I can go to get my CBD to help me sleep, and people could go get clean drugs to use at a party, that would be safer for everyone,” she said.

Conflating two crises

Dan isn’t the only one who is taking a more nuanced look at the safe supply model. Dr. Julian M. Somers, distinguished professor of health sciences at Simon Fraser University, made parallel points when I spoke with him last spring. He works to improve clinical practices and public policies related to addiction and mental health.

“When we administer those prescriptions,” Somers begins, “and let’s say it’s methadone, you have to go every day. If it’s diacetylmorphine, or heroin, you have to go three times a day—and physically go. That’s not the case for any other medication that I’m aware of. And it’s done that way because we say, ‘Well, we can’t trust you.’ So the very intervention itself reinforces the message from society that the person, in a very unique way, cannot be trusted.”

The distinction that isn’t made enough in public discourse is that two separate crises — substance use disorder and the rising number of opioid overdose deaths — fall under the same one-dimensional solution.

The safe supply model is about keeping people alive who are at risk of unintentional overdose, which is the clinical way of saying drug poisoning. While critical to saving lives, safe supply is not touted as a long-term treatment for those with a substance use disorder. By and large, the model should be easier and more widely available to those who use, whether they have an addiction or not. But for those with sustained addiction, Dr. Somers says, we’re not doing nearly enough.

“Giving people syringes and naloxone and other things that they want and may benefit from, that expresses caring,” he says. “A lot of people say at the outset in the research side of things, when we ask ‘what would you most like help with?’ — they’d like help getting off drugs and they’d like help reestablishing jobs.”

Psychological and social factors

Dr. Somers knows a lot about environmental contributors to addiction, such as unemployment. In the mid-1980s, he worked with Dr. Bruce Alexander, who ran the famous Rat Park study. The young scholar was drawn to Dr. Alexander’s theorizing that when people’s basic needs aren’t being met — housing, employment, belonging, a sense of agency — they are prone to developing a substance use disorder or getting pulled into criminal activity. The environmental causes of the severe distress that lead people to substance use must be addressed, according to Dr. Somers.

The clinical psychologist pointed to the work of Vincent Dole and Marie Nyswander, who developed methadone therapy as a way to treat heroin addiction. “One of their JAMA articles focused on people who were already involved with criminal justice, had been incarcerated, had all sorts of problems including narcotic addiction, and they reported astounding success rates. But it wasn’t due to methadone. These were two- to four-year-long intensive programs focusing on family life, employment, community membership,” he says. Yet “that’s how methadone really got its reputation as a success.”

Dr. Somers notes the research showed the benefit of inducement. “It was like harm reduction before harm reduction. It was a way of meeting people where they were,” he says. Importantly, methadone was not intended to be an ongoing therapy, which the researchers noted. Instead, it was a way of reaching people to offer services and address the psychosocial aspects of substance use disorders. “And this got completely, completely ignored.”

But there’s one rung of society where the research on social factors isn’t being ignored, Dr. Somers says.

“If you’re wealthy or a so-called ‘valued’ member of society, a lawyer or physician, then you get the focus on psychosocial aspects of your life,” he adds. “If I was to talk about the Rat Park comparison, most of the needs we’ve identified that are relevant to us ending addiction can be summarized as psychosocial: between a person’s experience of the world and people around them. It takes place in plain sight.”

“If you’re valued, we capitalize on that. Betty Ford, for anyone with money, can have a remarkable impact. And all of these professional programs — programs for public servants in British Columbia, programs for professionals, programs for wealthy people — they all substantially de-emphasize any ongoing medication or drug use,” he points out. Instead, they emphasize what’s happening in the person’s life, including any trauma, isolation, grief, or other torment that people are seeking escape from through drug use.

To Dr. Somers, it’s critical this type of treatment is offered to anyone who needs it, not just certain echelons of society. And, like many others, he wants to see the safe supply discourse focus more on that, so we can implement additional services and effective policies.

‘He continues to make a difference’

While still living through devastating grief, Meredith Dan has experienced a sort of Florence Nightingale happenstance, as the skateboard community her son was a part of flocked to her side.

“It’s been 667 days since Glenn died,” she told me at the time. “And for 667 days, not one has passed where I haven’t been contacted by a friend from his friend group,” she tells me. “I’ve held orphans’ Christmases and he left me a plethora of kids, so I’ll never be alone. It’s awful that it’s not him but it’s beautiful that I have the embrace of them — and it’s because of him.”

Since his death, every June 21, on national Go Skateboarding Day — and National Indigenous Peoples Day — Rebic’s friends wear a t-shirt in his memory. Dan has learned of the immense impact her son had on so many others who struggled with hardship, trauma, and substance use disorders.

“One of the kids said ‘Glenn was so good to me, he would see me and show me how to do a skate trick properly. He wouldn’t sit there and make fun of me,’” Dan recounted. “And so many of his friends have stopped drinking and stopped doing cocaine. He had an impact.

“I call him my baby, my brat, my little legend. I am so damn proud to be that kid’s mom. It kills me to know that he’s not here, but he continues to make a difference from the other side and I couldn’t be prouder.”