Vincent Lam is an addictions medicine physician and an author. He is the Medical Director of the Coderix Medical Clinic, an addictions clinic in Toronto.
Last month, Vancouver City Council voted to support a federal application by the Drug User Liberation Front for an exemption to the Controlled Drugs and Substances Act. DULF – a non-profit – is seeking legal permission to purchase heroin, cocaine and methamphetamine from the Dark Web, which it plans to test, label and distribute. They have framed this practice as “safe supply,” an increasingly catch-all term for the practice of supplying known formulations of addictive drugs to people in an attempt to reduce harms. “Safe” represents the hope that the practice will reduce people’s chances of overdosing (and possibly dying) from using illicit fentanyl, an extremely powerful opioid that has found its way into nearly every uncontrolled substance intended to provide a recreational “high.”
Meanwhile, in my addictions medicine clinic, patients who feel trapped by fentanyl ask me to prescribe them hydromorphone, a commonly used strong opioid painkiller that is employed in a different sort of “safe supply” currently offered in Ontario and British Columbia. In this, doctors prescribe high doses of hydromorphone for patients to use anywhere, and to swallow, crush, or inject as they prefer. With no clear evidence yet on whether this kind of “safe supply” saves lives overall, I urge these patients to instead take treatments for opioid use disorder that are supported by medical science, such as methadone and buprenorphine – opioid agonist therapy (OAT). When they learn that I will not fulfill their request for hydromorphone, some are disappointed, or angry. “It’s what I need,” I’ve been told. “Why won’t you give it to me?”
I decline to write these prescriptions because I am not convinced they are “safe.” Much of my discomfort with “safe supply” comes from what I am told by other patients who are also struggling with substances in their lives. They say that “safe supply” is harming them, as street availability has risen and prices have fallen.
Patients of mine who were free of illicit opioids for years now struggle with hydromorphone, which they are buying from those to whom it is prescribed. One told me they prefer to sleep outside rather than in shelters, because they cannot avoid hydromorphone in the shelters. One who has never tried fentanyl – which hydromorphone is meant to protect them from – is injecting high doses of hydromorphone daily, struggling to get off, while their tolerance rapidly increases.
What is difficult about “safe supply,” and what causes me and others moral distress, is that the same pills that one patient insists are needed to save their life may bring harm to another patient of mine, or one I have not yet met. In medicine we are taught primum non nocere, first do no harm.
At this moment, both people who use drugs and the professionals who are trying to offer care feel that a tidal wave of harm is engulfing us. Nat Kaminski, president of the Ontario Network of People Who Use Drugs, says, “What’s currently on the street, you can’t figure it out.” A former drug user, they cannot recognize the “high” of people on the current illicit supply. An amount that a person could tolerate on one day causes them to overdose the next. I routinely learn of the deaths of my patients who have been among the 22,828 apparent-opioid toxicity deaths in Canada between January, 2016, and March, 2021. This number approaches the 29,384 lives we have lost in Canada because of COVID. A national tragedy with complex origins demands a coherent response. Instead, Health Canada seems to be at cross-purposes, both calling for restrictions on the marketing and advertising of opioids, and for the increased availability of opioids under the guise of “safe supply.”
“Safe supply” has now been offered in Canada for the past five years, first in a handful of Ontario Community Health Centres, and more broadly in British Columbia since March, 2020, where its mandate was expanded to help support COVID distancing. Some patients feel it has helped them. One of the first patients of a Toronto pilot program, Ari, tells me that with “safe supply” he has turned his life around, has found success at work, has bought a home. “It takes out the chance. I would like to see another day instead of buying something that’s cross contaminated with fentanyl.”
Unfortunately, despite anecdotal evidence, thus far there has been little objective evidence that “safe supply” reduces fentanyl usage or deaths. Dr. Launette Rieb, an addictions doctor in British Columbia, says “ ‘Safe supply’ is a misnomer. It is not treatment and it is an unproven intervention.” Injecting substances that are not meant to be injected – which includes both illicit fentanyl and the hydromorphone tablets of “safe supply” – come with the major medical risk of debilitating and life-threatening infections of the heart and spinal column.
A French study showed that giving people morphine tablets to take home, rather than providing less easily injected methadone and buprenorphine, resulted in higher rates of unintentional overdose, bacterial infection, dangerous blood clots and overall rates of death. Dr. Mel Kahan, an addictions doctor in Toronto, says, “Ontario physicians have reported an increase in the number of hospitalizations for injection-related infections, in patients on ‘safe supply’ and in patients who purchased hydromorphone tablets from ‘safe supply’ patients.”
The argument for “safe supply” often equates it with a very different approach – injectable opioid agonist therapy (iOAT) – in which people are provided with injectable heroin or hydromorphone in a controlled setting that provides medical support and does not permit off-premises use. The submission by DULF cites a study of supervised injectable heroin, as well as other references that any undergraduate science student would realize do not support DULF’s conclusion that “when drug users are provided non-toxic drugs, the death rate is vastly lower.” City councils and policy makers entertaining such submissions should examine the references with care.
A commitment to iOAT – which differs from supervised injection sites where users bring their own drugs, and also differs from standard OAT, where take-home options of prescribed medications exist – requires immense staffing and resources, and availability of iOAT remains limited. The cost to patients is that multiple daily visits to receive iOAT make it prohibitive to work or attend school. It is convenient for the federal government to pretend that iOAT and “safe supply” both enjoy the support of scientific evidence – because it costs nothing for Health Canada to endorse the writing of prescriptions. Dr. Lisa Bromley, an Ottawa addictions medicine physician, says “the evidence for iOAT was stretched beyond recognition to apply to ‘safe supply.’ If doctors provide prescriptions, it lets governments completely off the hook to craft rational drug policy. It was a brilliant move by the federal government to dodge responsibility for drug policy.”
Much depends on the frame of observation. It is probably true that one person is less likely to die injecting hydromorphone in their next “smash,” a single use of intravenous opioids, than street fentanyl. But with a medical problem that is characterized by repeated injections, we don’t know if it actually keeps anyone from also injecting fentanyl or dying. Studies are under way to assess whether the “safe supply” of hydromorphone actually helps those to whom it is prescribed. Supporters of “safe supply” often frame diversion as being a public-health benefit – because someone found hydromorphone instead of finding fentanyl, but we will only know after the fact if “safe supply” seeds the next decades of suffering for new patients who become addicted to hydromorphone bought off someone with a prescription.
One of the reasons both users and prescribers of “safe supply” tell me it is not currently working for some fentanyl users who receive it is because it does not match the strength of the drugs they are using. In the “British Columbia COVID-19 Risk Mitigation Interim Clinical Guidance,” up to 112 milligrams of daily hydromorphone can be prescribed, a medication whose starting dose for pain control in an opioid-naïve patient would be 1-4 mg.
Ash Heaslip, a family doctor and addiction medicine specialist in Victoria, tells me, “The idea of this being proposed as an alternative to street fentanyl is quite unrealistic in terms of the tolerance levels we are seeing in many patients these days. If it’s being positioned as something that should be replacing their need to access the illicit market, it’s not achieving that goal for many patients.” Dr. Heaslip would prefer broader access to hydromorphone through public-health mechanisms, without prescribers like her acting as gatekeepers.
As with any opioid, hydromorphone tablets can be a commodity, so that some “safe supply” hydromorphone is sold by fentanyl users to people with lower opioid tolerance – the profits of which they will use to buy fentanyl. “Patients have said to me, ‘I’m not using these tablets,’” Dr. Heaslip says. “Sometimes they are being sold or traded in circumstances where patients are not finding them beneficial. In some communities, the street value of hydromorphone tablets has dropped significantly since the beginning of COVID because they are more widely available.” I have heard from both doctors and patients that some dealers are buying hydromorphone in cities like Toronto and Vancouver, and shipping them to other cities in Canada and the U.S. where they are more valuable.
If you are a proponent of “safe supply,” the ineffectiveness of prescribed hydromorphone in replacing street fentanyl supports the argument of making pharmaceutical grade heroin available instead, with more open access to this higher potency molecule. If you are a skeptic, it points to the futility of the effort. When the argument that we should offer less risky substances to satisfy people who will always seek euphoria, “the high,” meets the concept that achieving euphoria requires stimulus above a physiological baseline – and continuing use of substances raises that baseline – the notion of “safe supply” looks more like an infinite escalator than a destination. As dose and potency escalate, risk and harm escalates, and yet “safe supply” is sold as harm reduction. On the ground, the irony is that current “safe supply” does not meet the opioid requirements of those who are at highest risk – but it is these high-risk users whose lives it is meant to save.
This conundrum results in varying conclusions. Some advocates, like DULF, conclude that what is needed is free access to tested, labelled drugs that people can use as they wish. Ms. Kaminski asks me, “You can drink wine, why can’t I do a line of coke? If I want to use a substance, I want the ability to go buy it from someone whom I trust.” Some advocates and prescribers argue that for “safe supply” to have useful impact, prescribers need to be taken out of the picture – and drugs should be available through public health without the bottleneck of a prescriber. Many prescribers feel there is little clinical judgment involved in any case – they simply fulfill the request for hydromorphone.
Dr. Paxton Bach, an internist and addictions specialist who works in Vancouver’s Downtown East Side, is conflicted, “Safe supply is the most immediate tool that I have available to try and stop somebody from dying tomorrow,” he says, “but I worry that a discussion on safe supply in isolation, without talking about the systematic drivers of substance use, is incomplete. I’m less worried about de novo opioid-use disorder tomorrow with some diverted hydromorphone tablets, but I do wonder where this ends up taking us over the next 10 years without addressing these bigger questions.” The forces behind substance misuse and addiction are the roots of suffering in Canadian society - trauma, mental illness, racism, poverty, homelessness, physical injury and pain. These are at once so diffusely powerful and inadequately addressed, that those of us who wield prescription pads are easily seduced by the promise of a solution by prescription, just as opioids promise solace in the smooth form of a nice, safe pill.
Oxycodone once promised easy solutions, and instead was a key force in fuelling today’s opioid crisis. I worry that “safe supply” has the potential to seed the next one. In the late 1990s and 2000s the pharmaceutical company Purdue made an earlier unfounded claim of safety – telling doctors that if oxycodone was prescribed for pain, patients would not become addicted. Within a Medicare system that funds physicians and often pills – but less often provides multidisciplinary management of chronic pain – oxycodone was the go-to for pain for almost a decade. Stingy sick leave policies make it difficult for injured workers to recover from painful injuries. Many who suffered in non-physical ways – from trauma to untreated mental illness – also discovered that opioids helped to ease their suffering temporarily. In addition to being swallowed, oxycodone tablets like Percocet were sometimes sold, chewed and snorted.
Now, as I struggle to stabilize my opioid-addicted patients, I am sometimes haunted by the patients who prevailed upon me almost 20 years ago, often after midnight in the emergency department when I could not corroborate much information, to write prescriptions for “just a few more” oxycodone tablets. At the time, these prescriptions were received with gratitude and thanks. I wonder how many would thank me today?
We now know that 80 per cent of heroin users initially misused prescribed opioids. While the provinces are trying to wrest Canada’s share of settlement funds from Purdue for flooding North America with opioids, doctors who have been chastised for a decade for causing the opioid crisis through their prescriptions, are hearing from advocates of “safe supply,” and from Health Canada that the best way to save lives is now to liberally prescribe opioids. Many are unconvinced. “In BC, we are flooding the streets with prescription opioids due to diversion,” says Dr. Nick Mathew, an addictions psychiatrist in Vancouver. “The benefits of the B.C. safe supply model are entirely unproven and theoretical. The downsides of increasing the amount of opioids in the population have a known harm.”
The call for “safe supply” comes from a place of desperation, and justified anger, whose causes need to be understood and addressed. “When I say my friends are dead – all my friends are dead,” Ms. Kaminski tells me. There is desperation when treatment is inaccessible, or doesn’t seem to work. Patients of mine are rightly angry when – as often occurs – they seek general medical care and are belittled, condescended to, or refused pain management because they are a person who uses drugs. Many Canadian hospitals do not provide addictions services. The result is that people who suffer from substance-use disorders who are admitted for other urgent medical reasons often leave because they are suffering the agony of withdrawal, and therefore do not receive other essential medical services. In this way, they are denied what is promised by the Canada Health Act – universal access to health care.
What everyone seems to agree on is that the issue and the required solutions are broader than just the molecules on-hand. Stephanie Callaghan, a nurse with the Hydromorphone Intensive Engagement Program in Vancouver, tells me, “If I were to look at what really worked for this program, it wouldn’t be so much about prescribing, it would be around connection and engagement.” Ms. Kaminski says of physician allies, “It is empowering for people who use drugs to feel like there are doctors on their side. They’re our doctors and also our allies.” Clinics that offer comprehensive primary care, housing and food programs, alongside “safe supply” offer a glimpse of what we owe to our vulnerable citizens – but it may be that the greatest benefits are not the hydromorphone.
“Safe supply” embodies a push against entrenched powers – both legal and illegal. The most lethal power rests with the producers and distributors of the current toxic drug supply, and “safe supply” is sometimes framed as an attempt to take power from this unregulated force by shifting the marketplace. Since power can only be exercised upon, or taken from, those who can be reached, individual users of drugs are criminalized, and the health care system is asked to both provide solutions and relinquish its oversight. A distinction between the exercise of punitive powers, and limits based upon science and safety, is important. I have not yet met an addictions professional who does not support decriminalization of the possession of small amounts of drugs for personal use – as the revolving door of the criminal justice system destabilizes people who use drugs and makes their lives more dangerous. We must find a way as a society to give people agency and choice – without the widespread, uncontrolled distribution of the same molecules that got us here.
Simon Fraser University has issued a “Call to Action” to the British Columbia Government, drawing on 15 years of research to show that for the same cost as existing programs, recovery-oriented housing to support people affected by homelessness, addiction and mental illness would result in a 70-per-cent reduction in crime and a 50-per-cent reduction in medical emergencies. This is the kind of leadership and commitment that provincial and federal governments need to show, rather than a contradictory and patchwork throw-away, telling doctors not to prescribe opioids – except when they are supposed to be prescribing far more than ever before.
Those of us who practise addictions medicine need to ask ourselves hard questions about how we can be more patient-centred and responsive to the dangers our patients now face. Addictions medicine has too often been structured to suit the needs of regulators and care providers before the needs of patients. Inpatient rehabilitation facilities that do not offer OAT ignore three decades of science. Outpatient clinics that profit from insisting upon frequent mandatory urine testing, along with regulations which require patients to attend a pharmacy daily to obtain prescribed treatment, make it difficult for many patients to be in treatment programs and attend school or work. In some smaller communities often no addictions treatment is available. Methadone and buprenorphine are on the WHO list of essential medicines, and yet pharmacies can opt out of dispensing them: dispensing other opioids and not dispensing the treatments for opioid use disorder is akin to allowing people to build bonfires without having buckets of water.
Addictions care is starting to change, with more rapid dosing protocols and combinations of medications to address the higher tolerance era of fentanyl.
Dr. Rieb says, “we can work to adjust medications and behavioural treatments for opioid use disorder that are proven to be effective.” There are now monthly injectable treatment options of buprenorphine. Virtual options are expanding access to care. Guidelines for prescribing medications are becoming more flexible. Some hospitals are beginning to expand addictions consult services. All of these changes are happening too slowly and inconsistently, and need to move forward with urgency.
Ultimately, this divisive issue is one that hinges on questions of power, inclusion, agency, as well as science. People who use drugs have felt powerless, and excluded. More than ever, their lives are at stake. A meaningful response needs to take place in addictions medicine, the broad health care system, and government, and in our communities – with people who use drugs at the centre in such a way that they are served by institutions and by science. Prescribed opioids were an integral part of the creation of this crisis. We are not going to be able to prescribe our way out of it.
The opioid crisis in Canada: More from The Globe and Mail
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