Andrea Sereda and Sharon Koivu have a lot in common. Both are addiction doctors in London, Ont. Both are devoted to their patients. Both have seen many of those patients die despite their best efforts, cut down by an overdose epidemic that is killing about 20 people a day across the country.
They know each other well. When Dr. Sereda was starting out, she looked up to the older Dr. Koivu.
Now they find themselves on opposite sides of a bitter debate that has split the addiction-medicine community in the midst of Canada’s worst-ever drug crisis. At issue is something with an innocuous-sounding name: safe supply.
Advocates like Dr. Sereda, who pioneered the safe-supply approach at the downtown London clinic where she works, says that the cause of Canada’s opioid crisis is a toxic drug supply. The spread of potent opioids such as fentanyl has made taking street drugs like playing Russian roulette. So she and others have been giving their patients prescription opioids instead, usually in the form of pain pills.
Federal and provincial governments are spending tens of millions of dollars on safe-supply programs, from Victoria to Ottawa to Fredericton. In British Columbia alone, 4,331 people were being prescribed safe-supply (sometimes called safer-supply) drugs in September. Dr. Sereda’s London program has been getting funding from Ottawa since 2020.
But Dr. Koivu and a growing number of fellow clinicians say the idea has backfired in a spectacular fashion.
Because some patients sell part of their prescription instead of taking it, communities like London have been inundated by the pills, which now go for about the price of a can of beer in the Southwestern Ontario city of 420,000. Some of those pills, the doctors say, are ending up at teenage parties, leading to a rise in youth overdoses.
The two sides have been battling it out for months on opinion pages, social media and medical forums. The debate has even broken into national politics. Conservative Leader Pierre Poilievre has accused Prime Minister Justin Trudeau of flooding Canadian communities with “taxpayer-funded hard drugs.”
Safe-supply advocates say the critics are distorting the evidence and putting lives at risk by casting doubt on a proven strategy. The critics reply that the advocates are so wrapped up in their own dogma that they are closing their eyes to what is going on in the real world.
Dr. Sereda and Dr. Koivu, each passionate and highly articulate, are in the vanguard of their respective camps.
Dr. Sereda, 43, grew up in a small town near London, the daughter of a teacher and a stay-at-home mom. A hardcore Star Trek fan, she idolized Roberta Bondar and wanted to be an astronaut until an unkind teacher said she wasn’t physically fit enough.
She settled on being a doctor. After graduating “dead broke” from medical school, she got a job doing the overnight shift at a detox centre, where people with drug addictions go to get sober. She had found her calling. In 2012, she started working at the London InterCommunity Health Centre, which specializes in helping those who live on the city’s streets.
The job means working long hours and witnessing a lot of pain. She gets up at 4:30 a.m. to check whether any of her patients ended up in the emergency department overnight. In winter, she often sees people with frostbite so bad it leads to amputation. She has stopped putting the names of patients who have died on her office wall. There just isn’t room for them all.
The drug crisis has affected Dr. Sereda at the most personal level, too. Her husband, who suffered from mental illness, began using drugs and became violent. After that, it was like “a snowball down a mountain.” She was forced to leave the marriage. The two had been together since they were 17.
Now she is raising an eight-year-old kid with the help of a supportive partner. Her profile on X, the social-media platform formerly known as Twitter, reads: “Physician. Safer Supply prescriber. Eccentric. Mom to a badass daughter. More fun than I sound.”
Not long after Dr. Sereda started her work, fentanyl arrived in London. Easy and cheap to make, the synthetic opioid soon took over from heroin, cocaine and medicine-cabinet opioids to become the king of street drugs.
With overdose rates soaring, the doctor says, “We knew we had to do something different.”
She landed on giving her patients prescriptions for hydromorphone, a common painkiller. Taking it would allow them to fend off the agony of withdrawal and lessen their dependence on fentanyl.
It was not an entirely novel notion. In the early 20th century, a new miracle drug, heroin, was considered a promising treatment for morphine addiction. When heroin addiction became a bigger problem after the First World War, a New York clinic gave out prescribed heroin to thousands of users dependent on the drug.
Today, addiction doctors often treat their patients with methadone or Suboxone, substitute opioids that keep drug cravings at bay but don’t give the same high or carry the same risks as street drugs. But some patients complain those drugs make them feel unwell and don’t quiet their drug cravings. To Dr. Sereda, giving them prescription hydromorphone tablets instead seemed like a possible solution.
She started small. At first, she prescribed hydromorphone to just three women: one who had untreated HIV, one who was constantly having overdoses and one who was doing dangerous sex work to pay for drugs. Hydromorphone is not officially approved for addiction treatment, so Dr. Sereda prescribed them “off-label,” something doctors often do if a drug shows promise for an illness they are treating.
“It worked,” she says. The three women started getting better. She thought, “Maybe we have something here!” Quietly, over 2016 and 2017, Dr. Sereda started putting more and more patients on hydromorphone.
One of her collaborators at the time, she says, was Sharon Koivu.
A doctor at London Health Sciences Centre, a local hospital complex, Dr. Koivu had herself been giving hydromorphone to patients who came in with painful drug-related problems like endocarditis, a heart infection that can come from injecting drugs with a syringe.
The drug eased their pain and prevented them from plunging into withdrawal. Instead of leaving in search of street drugs, they would stay in hospital long enough to get better.
At first, Dr. Koivu even prescribed hydromorphone to some patients when they left hospital. Those patients would often end up in the hands of Dr. Sereda, who noticed they seemed to be doing a lot better on the pain drug than they would have otherwise. She wondered: Why not just keep them on hydromorphone? In other words, says Dr. Sereda, the woman who would become one of the most vocal critics of safe supply, helped give her the idea in the first place.
The two doctors often talked about addiction treatment. If Dr. Sereda was on the street doing outreach work with drug users at night, she would sometimes ring Dr. Koivu to ask for advice.
Dr. Sereda said it was “a natural partnership.” She considered Dr. Koivu a mentor and a friend.
But as time went on and the safe-supply program grew, Dr. Koivu began to have doubts. Born in 1960, she grew up in London in a family involved in social causes. Her father, a teacher like Dr. Sereda’s, had run for the federal NDP and led the union at London’s Fanshawe College. Tommy Douglas, founder of the party, visited the family home.
After volunteering in high school for Amnesty International and an Indigenous-rights group, she decided that she wasn’t satisfied with just talking and advocating. If she were really going to help others, she needed a skill. She had a eureka moment – of course, medicine! – “and never looked back.”
When Dr. Sereda started the safe-supply program, Dr. Koivu says, “I thought it sounded really good on paper. And I supported it for a while. And then I started seeing things that really concerned me.”
For one thing, she came across more patients with serious infections of the bone and the spine caused by injecting drugs. The pain they were experiencing, she said, was “the worst suffering I have ever seen.” Many were taking hydromorphone pills, crushing and “cooking” them and injecting the resulting liquid, a common method among drug users.
Some of the pills were the very ones that Dr. Sereda was prescribing. Dr. Sereda’s patients were selling or trading them to get by – a practice known as diversion. They were ending up in the street-drug market. On the streets of London today, they are known as “dillies,” short for Dilaudids, the commercial name for hydromorphone.
Cheap drugs mean more drug addiction, Dr. Koivu says, just as cheap cigarettes mean more smokers. She says she is seeing patients who started their serious drug use with Dilaudid. She knows of at least one patient who moved into a homeless encampment behind the drugstore where safe-supply pills are dispensed so that he could easily buy diverted pills.
The encampment is gone now, but people still buy and sell drugs out back of the drugstore on London’s Dundas Street. On one recent afternoon, a well-dressed young couple walking a dog approached a group of men gathered there and asked, “Got any D8s?” – the name for eight-milligram Dilaudid pills. People living on the streets of London say the price of the pills has plummeted, going from $20 to $10 to $3 and now $2.
The pills are available online, too. Adam Zivo, a journalist who has been writing a series of critical columns on safe supply for the National Post, often posts images of the stacks of pills he finds for sale on the internet.
Despite the name of Dr. Sereda’s program, Dr. Koivu says, it’s wrong to call hydromorphone truly safe. “If you take too much of it, you die.” She herself has a son who has struggled with substance use and she says “I honestly believe that if safe supply had been available when my kids were in high school, I might be less one child.”
She says that even those who don’t suffer overdoses from hydromorphone sometimes find they are not getting high on it anymore and step up the ladder to fentanyl. So the program designed to calm the opioid crisis might be deepening it instead. Oxycontin was a “safe” prescription drug, too, Dr. Koivu adds, but once the pain pills got into circulation they kicked off the North American opioid crisis that is still with us now.
Dr. Koivu took her concerns to Dr. Sereda and the doctor’s colleagues as early as 2019, but she says they rebuffed her. So she has been speaking out with more and more urgency about her concerns. She went to Victoria this fall to issue a warning about safe supply at a medical conference. She went to Alberta last spring to testify in the case of a woman who is challenging new restrictions placed on safe supply by the provincial government.
If that puts her in the crosshairs of some advocates, so be it. “I don’t want to be loved,” she says. ”I want good care, evidence-based care.”
Dr. Sereda disagrees with just about everything her former mentor says. Though she doesn’t want to make their disagreement personal, she says most of the objections to safe supply are not just wrong but often plain “silly.”
With 274 patients on safe supply in London out of an estimated 6,000 or more drug users, she says it makes no sense to say that the program is having such a catastrophic effect. The overdose crisis is bad everywhere, even in remote Northern Ontario communities with no such program.
Nor does it make sense to blame safe supply for a spike in infections. The clinic coaches its patients on sanitary injection of their drugs. If they are getting infections, she says, it is more likely through using fentanyl cooked up in someone’s dirty kitchen.
As for diversion, she says that, yes, some people sell their pills, partly because they are often homeless and desperate and need the money. Maybe “they didn’t have anything to eat, or their kid needed a pair of boots, or they’re getting jumped outside of the pharmacy.”
But she usually knows about it. She checks her patients’ urine regularly. If there is no hydromorphone in it, she will pull them aside for a talk. Though nobody is kicked out of the program, some are told they must take their pills while they are at the pharmacy, a system known as witnessed or supervised use. At the clinic, she says, “We do our absolute best to make sure that people we prescribe medication to are taking their medication.”
Far from rebuffing the critics of safe supply, she says “we have systematically addressed every single concern they have brought to us.” She finds it devastating that prominent voices in addiction medicine – people “who have so much influence over whether people live or die” – are “choosing conflict over collaboration in this crisis.”
Both women have fierce defenders. Meldon Kahan, a respected authority on addiction treatment who recently retired from his post at Toronto’s Women’s College Hospital, calls Dr. Koivu a “true pioneer” for speaking out about safe supply and for enduring the abuse that followed from safe-supply advocates. “These people can be really, really mean and nasty if they feel their empire is being attacked,” he said.
Dr. Kahan argues the diversion problem is real. He himself had a patient who had given up cocaine and heroin and was reducing his dose of methadone, only to get hooked on diverted safe-supply hydromorphone. The pills were so cheap he couldn’t resist.
On Dr. Sereda’s side are those like Gillian Kolla, a well-known University of Victoria researcher who helped evaluate the London program. She says Dr. Sereda’s commitment to stick with her safe-supply program is “very brave.” Right now, she says, “the level of vitriol that’s being directed at her is completely unfair.”
Dr. Sereda has admirers among her patients, too. Melvin Albert, 54, says he got addicted to painkillers after a work injury that left him with steel plates in his back. Before he started on safe supply five years ago, he says, he was injecting fentanyl and in and out of jail. Now he just goes to the pharmacy for his pills.
He says he owes Dr. Sereda his life. “I love her. She’s great.”
Both doctors insist they have the facts on their side. “Our research, our scientific evidence, our data refutes everything they say,” Dr. Sereda says of the safe-supply critics.
The B.C. Coroners Service states flatly that “there is no indication that prescribed safer supply is contributing to unregulated drug deaths.” In fact, an expert panel of the service recently called for expanding the program, making the drugs available to users even without a prescription.
Dr. Sereda points to a study this year that surveyed safe-supply patients in London. About half said that they had decreased their fentanyl use since starting the program (though many still used the drug) and more than half said their physical and mental health had improved. More than half also said they stopped committing crimes or doing sex work.
In short, Dr. Sereda says, safe-supply patients are faring “wildly better” than those who aren’t in the program and are simply smoking or injecting fentanyl, which can kill in minutes. Thanks to a four-year grant from Health Canada, she has been able to offer them not just pills but “wraparound support” for problems such as diabetes, schizophrenia or lack of housing.
Dr. Koivu is not at all convinced. She says that surveying patients is a poor way to evaluate safe supply. As she puts it: “Asking people if they want to get a drug for free is hardly evidence to support a program.”
Dr. Kahan adds that the survey had a second defect: It did not compare the London results with existing, established treatments, like giving patients methadone or Suboxone. In November, he and 34 other doctors sent a letter to Ottawa’s Minister of Addiction and Mental Health saying that “the evidence in support of safe supply is weak.” In fact, they said, evidence is growing that safe-supply pills are being sold to youth and others who do not use opioids, subjecting them to “grave risk” of addiction, overdose and infections.
On one thing at least, the two doctors agree: The divide over safe supply is unfortunate.
“I have zero interest in being in a conflict with Dr. Koivu. Or anyone else,” Dr. Sereda says. In fact, she says, “my arm is tired from holding on to the olive branch.”
She would far prefer to get to a “kumbaya place” where addiction doctors come up with mutual solutions to the real problem at hand: the thousands of lives still being lost to toxic drugs. The crisis has only worsened since the onset of the pandemic in 2020. In British Columbia, overdoses are now the leading cause of death for those aged 10 to 59, causing more deaths than suicides, murders, accidents and diseases put together. In the London region alone, about nine people a month died from overdoses in the first nine months of last year.
Dr. Koivu, too, regrets all the polarization and division. She says she agrees with Dr. Sereda about a lot of things, including the need for supervised drug consumption sites and other forms of “harm reduction,” such as supplying drug users with sanitary needles and other equipment.
A few years ago, she recalls, the two doctors spoke at a conference about the importance of collaboration in the health community. That seems a long time ago now.