Bonnie Larson, Ginetta Salvalaggio, based in Alberta, and Claire Bodkin in Ontario are family physicians who care for people who use drugs. Their practice spans a continuum of care that includes evidence-based prevention, harm reduction and treatment interventions.
Some physicians will sympathize with Vincent Lam’s recent opinion (Nov. 27) column, in which he argues that safe supply is harmful. Although taking this position might release a doctor from the discomfort of prescribing opioids at a time when physicians are encouraged to “deprescribe,” or take patients off their medicines, others understand that safe supply is a critical component of any strategy to end drug poisonings. Regardless of where a physician stands on this issue, the importance of getting it right has never been higher. It is truly a matter of life or death.
Dr. Lam’s critique of safe supply concentrates on prescribing hydromorphone – one of several opioid medications for severe pain that can be used this way – to patients with opioid-use disorder. “Safe supply” has many facets, however, only one of which is prescribing pharmaceuticals to replace tainted drugs. Compassion clubs, or co-ops where resources are pooled to purchase and check substances for contaminants, offer another model of safe supply that does not necessitate any doctors’ involvement.
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Dr. Lam also assumes that provision of safe supply is meant to be a treatment for addictions. This is a mistake, because the primary outcome of ensuring access to drugs that are not poisoned is survival, not recovery. The first must precede the latter in any case.
The prescribing of opioids is misattributed by many, including Dr. Lam, as the cause of the current crisis. At best, this is only partly true historically and is now practically irrelevant. Nearly all opioid-related poisonings in Canada are currently caused by an adulterated supply, coupled with prohibitionist drug policy. Present-day mortality is not caused by prescriptions, nor a rise in substance-use disorders. In fact, many deaths have nothing at all to do with “addiction.”
People who use drugs do not want to be sickened or harmed, and – just like everyone else – they have the right to interventions that keep them alive. People consume substances for many reasons, even in the face of risk – particularly if abstaining causes intolerable effects such as suicidal thoughts, the surfacing of awful memories, being assaulted if you fall asleep on the streets, or the severe symptoms of opioid withdrawal.
Recent modelling by Health Canada shows that between 1,600 and 1,700 Canadians will die every three months until June, 2022, if health interventions and the level of fentanyl in the drug supply stay the same. This confirms our worst fears, but still it is doubtful efforts to reduce opioid-related deaths will result. In contrast, when governments see a COVID-19 curve with cases soaring exponentially, they act swiftly and boldly to prevent deaths. Without rapid scale-up of life-saving interventions, projections indicate that drug-poisoning deaths will at best plateau or even continue to rise.
This public-health emergency is taking the lives of nearly 20 Canadians each day. Evidence-informed interventions such as safe supply, supervised consumption services, and reallocating law-enforcement investment to health and social supports have not been adopted nearly widely enough to bend the curve of drug-poisoning deaths.
When poisoning deaths started rising after 2014, it was thought that decreasing the general availability of pharmaceutical opioids would help. Doctors received firm messaging from professional governing bodies to avoid writing new prescriptions and deprescribe. This was a disaster for patients. It caused deaths because tapers were done far too quickly. Worse, many people were simply cut off cold turkey. Some died by suicide; others were desperate and driven to use unregulated toxic street supply.
Even with a strong therapeutic relationship and a willing and motivated patient, it can take years to complete an opioid taper. Just as Dr. Lam claims that prescribing got us into “this deadly mess,” we could also say that deprescribing made it even more deadly.
All medical interventions have benefits and risks. Part of a physician’s job is to work with patients to determine whether those benefits are worth the risks. Just as a bleeding trauma patient is rushed directly to the operating room despite the risks of surgery, safe-supply prescribing is potentially immediately life-preserving, and therefore worth the risk in many cases. The circumstances may not be ideal, but the patient may die if urgent action is not taken. There is no time for ambiguity, moralizing or further research in such a critical moment; the hemorrhage must first be staunched. Only then can we stand back and plan how to repair the bones.
Once we embrace the benefits of safe supply, there is guidance available to help. As clinicians who care daily for people with substance-use disorders, we have many evidence-based tools to mitigate possible harms, including Dr. Lam’s fear that pills may end up in the hands of someone other than whom they were prescribed for.
Examples include short dispensing intervals; collaborating with pharmacies, case managers and peer outreach workers; communicating with housing and shelter staff; and promoting intensive wraparound programs such as injectable treatment for the few who need it. Perhaps most importantly, the building of trusting relationships with patients is a powerful risk-mitigation manoeuvre.
Although physicians should never presume to solve complex problems such as poverty, racism, drug poisonings and homelessness with prescription pads, a comprehensive safe-supply strategy can certainly be enhanced by individual prescribers.
This cannot be done adequately, however, without robust policy support. All levels of government, law enforcement, medical licensing bodies, and even our peers – as Dr. Lam’s article as well as a controversial panel on safe supply at the recent national addictions medicine conference confirm – contribute to physicians’ fears, confusion and reluctance to prescribe. Transformational policies in these arenas would strengthen physicians’ confidence in caring properly for all patients, including those who use drugs.
Dr. Lam is correct that physician prescribing – alone – will not resolve this horrific situation. Nevertheless, prescription of pharmaceuticals is a far more powerful – and safer – strategy for helping to end the current devastation than avoidance of action.
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We have chosen to ignore or even disparage many evidence-based interventions that should be a part of a genuine response to this emergency. An honest attempt to end the deaths must include: a model for decriminalization of possession of drugs for personal use that centres people who use drugs in its development and implementation; community-led safe-supply initiatives such as drug checking and compassion clubs; free access to take-home naloxone kits; and low-barrier, relationship-centred care that values and incorporates the deep knowledge of individuals with lived experience.
Just as we do for the COVID-19 public-health emergency, we should all be doing everything in our power, for as long as it takes, to reduce drug-poisoning deaths until they are no longer a daily threat to the lives of people who use drugs.
Doctors are compelled by a pledge to do no harm. We must therefore have a crystal-clear understanding that harm can be caused not only by the things we say and do, but also – and perhaps far more insidiously – by what we fail to say and do.
When we are confronted by difficult and complex decisions, do no harm can also mean do whatever causes less harm.
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