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Matthew Bonn is program coordinator, Canadian Association of People Who Use Drugs; Vanessa Gruben is associate professor, Faculty of Law, University of Ottawa; Elaine Hyshka is assistant professor, School of Public Health, University of Alberta; Carol Strike is professor, Dalla Lana School of Public Health, University of Toronto.

The overdose epidemic has had a devastating impact on those who use drugs, made worse by the COVID-19 pandemic. The Public Health Agency of Canada reported 1,705 apparent opioid toxicity deaths between July and September, 2020, a 120-per-cent increase from the same period in 2019. This is the highest quarterly count since national surveillance began in 2016, the year when the British Columbia government declared overdose a public health emergency. Almost all of these deaths were accidental overdose deaths. COVID-19 border closures and travel restrictions have disrupted the illegal drug supply, making it less steady and more dangerous..

Many governments have expressed concern regarding this deepening crisis, yet public health measures have led to more people being forced to use alone, contrary to the universal harm reduction message to ‘not use alone, start low and go slow, and carry naloxone’. Furthermore, reduced access to harm reduction services, such as needle and syringe programs, and overdose prevention and supervised consumption sites, have further increasing overdose risks. Thus, to address the crisis words must be accompanied by a strong commitment to provide secure, scalable and sustainable funding for robust evidence-based prevention, treatment, and harm reduction programs. Like all other healthcare programs, the Canada Health Act requires that these programs be designed to protect and promote physical and mental well-being and be reasonably accessible to those who need them.

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Although the pandemic has exacerbated the overdose epidemic, the primary cause of these deaths and drug related harms is the increasing presence of fentanyl, and other novel synthetic drugs, in the illegal drug supply. In 2020, 75 per cent of the opioid toxicity deaths in Canada involved fentanyl. Since drug checking services remain very limited in scope, it is nearly impossible for people to determine the quality or quantity of the drugs they are taking. This is why people die.

To mitigate these risks, people who use drugs need person-centred care that fits with their individual needs, goals, and life circumstances. The most effective treatment options for opioid use disorder are opioid agonist medications, which prevent cravings and withdrawal. These would cut the risk of overdose death in half, and help many stop using illegal opioids over the long term. While, some of these medications, such as methadone, buprenorphine, and slow-release oral morphine are taken orally, injectable opioid agonist treatment programs (iOAT) are also highly effective. In the case of iOAT, patients attend a clinic to inject medication and receive access to psychosocial support, primary health care, housing, income assistance, and other services delivered by a team of peer support workers, nurses, social workers, physicians and pharmacists. Studies show that iOAT reduces improves health and prevents overdose death as well as illegal drug use and criminal activity. Despite this, iOAT is not consistently offered across Canada or within provinces, and is difficult to access because of long wait lists, poor availability of injectable medications, and onerous program requirements.

Safe supply programs are emerging interventions to address some of the challenges of conventional substance use treatment systems. Currently, their focus is on prescribing medications (e.g, hydromorphone tablets) to reduce a number of risks associated with illegal drug use, including the risk of overdose, and to encourage access to ongoing health and social care. Some have argued for more comprehensive programs that include drugs such as cocaine, fentanyl and diazepam. Safe supply programs target people who are either not eligible, interested, or able to access substance use treatment and early evidence indicates that these programs may offer them important benefits.

Core to the success of each of these programs are patient autonomy, non-judgment and trust. Given the historical oppression, marginalization and discrimination that people who use drugs have experienced when engaging with the healthcare system, building back trust is essential. The programs, informed by people with lived or living expertise of drug use, must be stable, secure, and continuous so that those who use drugs can count on the services these teams offer. If they are unable to do so, people are at high risk of returning to illegal drug use where they face the prospect of overdose death and a range of other health and social harms.

Regrettably, government support for treatment and safe supply programs has been inconsistent and unpredictabl, in part because they have sometimes opposed on ideological grounds. This often leaves patients no choice but to turn to the courts for relief. Most notable is Canada v PHS, where the Supreme Court of Canada concluded that the Minister of Health’s failure to renew the exemption that allowed Insite’s supervised consumption service to operate violated the clients’ rights to life and security of the person which are protected by the Canadian Charter of Rights and Freedoms.

More recently, several patients filed a lawsuit in 2020 arguing that the government of Alberta’s decision to terminate two iOAT programs violated their Charter rights . The applicants produced over twenty affidavits including people with lived experience and medical experts. Their extensive work and evidence gathering was to support an injunction to keep the clinics open during the litigation, which likely would have taken several months, if not years. The matter was settled when the government committing to continue iOAT for existing patients. Although the courts can be a powerful tool, litigation is far from ideal: it is costly, time-consuming and takes an enormous toll on those who have the courage to bring a case against the government.

The harm suffered by people who use drugs over the past decade is staggering and cannot continue to be ignored. The pandemic has shone a light on this ongoing crisis and post-pandemic it is essential that renewed attention is given to the unacceptable incidence of overdoses, as well as a robust commitment to reduce health harms to people who use drugs. The onus rests on governments to ensure equitable and sufficient access to a range of safe and securely funded health programs that are protected from political interference rather than leaving these crucial decisions up to the courts. Anything less breaks Canada’s promise of providing universal access to healthcare services to those who urgently need them.

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