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Benedikt Fischer is a senior scientist at the Institute for Mental Health Policy Research, Centre for Addiction and Mental Health and a professor of psychiatry at the University of Toronto. Mark Tyndall, is Executive Medical Director at the BC Centre for Disease Control, and professor at the School of Population and Public Health, University of British Columbia.

Canada is in the grip of an unprecedented opioid crisis. An estimated 2,458 Canadians died of opioid-related overdose deaths in 2016 – more than the national count of motor-vehicle accident and homicide deaths combined. British Columbia reported 967 (mainly opioid) drug-overdose fatalities in 2016, and is on track for 1,500 in 2017. Alberta and Ontario have also seen substantial increases. Numerous interventions have been discussed and initiated recently – yet, the number of deaths continue to rise.

Part of this deadly stalemate relates to the fact that, underlying the opioid crisis are two paradoxically linked challenges – neither of which are adequately understood or addressed by current responses. On the one hand, a substantial portion of the present crisis is due to years of systemic and non-evidence based overprescribing, which put too many people, for too long, on too high doses, of opioid drugs. To counter this, excessive opioid prescribing levels have to be substantially reduced in order to prevent even more Canadians being exposed to opioid misuse, dependence and undue death. These sensible reductions in harmful opioid prescribing at the individual and population level are the central objective of newly tabled Canadian prescription guidelines.

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However, reductions in opioid prescribing are not occurring in a vacuum and are generating substantial collateral damage. While concrete numbers are lacking, it is estimated several hundred thousand Canadians are problematic opioid users (including those with dependence). While trauma, pain and mental illness often facilitate substance use, most people using opioids non-medically began or sustained their drug use with access to medically prescribed opioids. In addition to systemic overprescribing, the supply of pharmaceutical opioids is generated through double-doctoring, symptom feigning and diversion through or with the help of others. However, while engaging in "non-medical use," the supply of opioids mostly originated from within the medical system, hence providing relatively predictable drug potency and purity.

Yet, here is the critical dilemma: An unintended consequence of recent, well-intentioned efforts to curtail opioid overprescribing has resulted in marked reductions in medical opioid supply. These supply gaps have resulted in an emerging illegal, potent and toxic drug supply, including illegally produced fentanyl and carfentanyl and other illegal drugs laced with toxic opioid analogs. This dynamic, at least in British Columbia and Alberta, has fuelled the majority of recent opioid overdose deaths. Thus, the present challenge is to devise strategies that simultaneously address both these core fronts of the opioid emergency in ways that minimize further unintended consequences. While excessive opioid prescribing must be reduced, it is equally important that those Canadians with existing problematic opioid use – i.e. those at greatest risk for overdose deaths – are not suddenly deprived of their (relatively) safe opioid supply.

Standard 'harm reduction' interventions – for example, naloxone programs or supervised consumption facilities – even if greatly expanded, are unlikely to substantially reduce the overdose toll in an environment of a toxic drug supply. Nor can this be achieved through sole reliance on evidence-based addiction treatment programs (e.g., opioid, even if these include heroin-based, pharmacotherapy treatment), as these approaches are neither feasible to the required scale, nor do they provide desirable options for many at-risk users. In other words: These measures reach too few at-risk people with too little protective impact in the current crisis scenario.

What is urgently required is creative thinking outside of the box. Thus, we concretely propose, at least for the regional hotspots of the present emergency, a comprehensive program to provide the at-risk opioid user population a safer opioid drug supply for survival. For ideal reach and impact, such a protective program would identify and register current high-risk opioid users to – at least temporarily – receive access to safe opioid medications through the public health system (e.g., hospitals, community clinics, mobile distribution). This targeted distribution program would – as an emergency measure – seek to protect vulnerable, treatment-resistant opioid-dependent users from acute risk of overdose, while providing links to addiction treatment and other services where desired. The details of such an emergency distribution program should be tailored to regional contexts, and developed with input from key stakeholders (e.g., public health and medical authorities, law enforcement, first responders).

This opioid distribution program for high-risk users would be an emergency measure to respond to an exceptional public health crisis. Its underlying idea resembles the "British System" of medical narcotics prescribing in Britain (1920s to 60s). Combined with initiated reductions in inappropriate opioid prescribing, these measures have the potential to significantly reduce the number of opioid overdose deaths in the short-term, while addressing the long-term hazards of excessive opioid availability in the population. This would be in the interest of the health and safety of all Canadians.

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