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Matthew Bonn is program co-ordinator at the Canadian Association of People Who Use Drugs.

Adrian Guta is an associate professor at the University of Windsor’s School of Social Work.

Vanessa Gruben is an associate professor at the University of Ottawa’s faculty of law.

Elaine Hyshka is an assistant professor at the University of Alberta’s School of Public Health.

Carol Strike is a professor at the Dalla Lana School of Public Health in the University of Toronto.

In 2020, Canada reported 6,214 fatalities, the highest-ever annual death toll from drug poisoning (overdose), with the majority between the ages of 19-39. What has changed dramatically is the composition of opioids being sold on the illegal market.

Highly toxic and unpredictable, novel synthetic drugs, such as illegally produced fentanyl, have come to replace heroin and legal pharmaceuticals like oxycontin and hydromorphone that have been diverted. There are increasing reports of other types of illicit drugs – cocaine, MDMA, acid, stimulants – found with amounts of fentanyl and other synthetic opioids. That means anyone purchasing illegal drugs is at an increased risk of a deadly overdose.

As the re-elected Trudeau government establishes its priorities in the coming weeks, it is more important than ever that the primary focus be on keeping people alive. This means being clear about what factors have led to the situation we are in, and what new policy options are best to address them.

Canada needs a comprehensive approach to this drug-toxicity crisis, where a range of evidence-based interventions are supported. Indeed, the COVID-19 pandemic has shone a spotlight on Canada’s health inequities. During the recent federal election, more addiction treatment and recovery services were posited as the main answer to drug-poisoning deaths. This narrative has also emerged at the provincial level. For example, the Alberta government reoriented its provincial strategy in 2019, shifting support away from harm reduction services to residential-treatment beds and recovery centers.

The overdose crisis is not driven by a dramatic increase in drug addiction as non-medical opioid use has been relatively stable throughout the past decade in Canada. Maintaining a policy focus on addiction will not fix the current crisis: it requires harm reduction and supply-side intervention through drug checking, safer supply programs, and novel forms of medication treatment like injectable hydromorphone or heroin to immediately stem the number of deaths. The focus right now must be on reducing the risk of exposure to toxic street drugs.

For opioids and treatment of opioid-use disorder, dedicated treatments are by far the most effective option, not residential programs or in-patient beds. These include daily doses of prescribed oral and injectable medications such as methadone, buprenorphine, hydromorphone that treat withdrawal and cravings, as well as help patients with their long-term recovery. However, access to these treatments remains inconsistent across Canada, and many people have difficulty adhering to program requirements like daily observed dosing, or short prescription intervals.

Although these treatments work for some patients, they were not developed and tested in the context of the current illegal drug supply, which is contaminated with synthetic opioids and, increasingly, with clandestinely produced benzodiazepines (a class of sedative drugs that are difficult to stop using abruptly after dependence forms). Drugs circulating today have a higher potency and can increase tolerance and risk of fatality. Unregulated fentanyl was found in 82 per cent of drug-related overdose fatalities. That means conventional medication treatments like buprenorphine and methadone will not work for everyone.

Residential-treatment beds have been proposed as an alternative to medication treatments. While they may be helpful for some patients, current evidence suggests that they are unlikely to be effective. In some instances, these abstinence-based treatment programs can increase risk of harm, especially those with short-term periods of abstinence, as it lowers tolerance to opioids and increases the risk of drug poisoning in the event of a return to use after discharge. While residential-treatment beds can be helpful for people struggling with stimulants or alcohol, investments in these programs should not be construed as a primary way to stop opioid-poisoning deaths. Interventions that focus on supply are absolutely necessary.

We must move swiftly to decriminalize drugs. Multiple governments, political parties and other stakeholders have endorsed the need to address drug use as a health rather than a criminal law issue. To do so, the federal government must decriminalize personal possession to avoid the conflict with the law. Only then, when people who use drugs are destigmatized, can we begin to address drug use as a health issue.

Decriminalization is a necessary step in empowering the correct stakeholders and systems, and to communicate unequivocally that drug use is a health issue, and not one of morality or wrongdoing. People who use drugs should not be judged or risk penalization under the law for seeking support and options to lower their risk of harm.

To save lives now, robust access to a range of harm-reduction services is required, including innovative and novel models of care, such as safe supply. Now, and in the future, we need to listen, and be led by the evidence and realities of those affected.

To continue to save lives, we need to listen to and support those at the front lines of this crisis, as we have those on the front lines of the COVID-19 pandemic.