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Safer supply prescribing not enough to end devastating opioid epidemic, experts say

Ending the opioid epidemic that is devastating Canadian communities will require a multi-faceted approach that is beyond the reach of the health system alone, say addiction treatment providers.

Despite expanded funding for safer supply programs, overdoses, hospitalizations and emergency medical service calls have skyrocketed over the past two years of COVID-19 restrictions. In 2020, there were 6,306 opioid-related deaths in Canada, the highest number recorded in a single year. Though full data are not yet available, all signs point to an even higher number of lives lost in 2021. In the face of this crisis, addictions care providers, public health agencies and drug users are calling for new approaches to reduce the number of overdose-related deaths.

Although Safer Opioid Supply (SOS) prescribing, a harm reduction strategy, has existed in Canada since 2019, it is now rapidly gaining traction.

“Since the beginning of the pandemic, there’s been an expansion in the (Canadian federal) government’s willingness to fund safer opioid supply programs and have them be robustly evaluated in order to understand how safer opioid supply programs function in somebody’s life and how we improve them so that we can ideally reduce catastrophic overdose rates, which is really difficult to do amid a global pandemic,” explains Jeanette Bowles, a researcher with the Centre on Drug Policy Evaluation in Toronto.

However, despite the significant media attention they have received, and the controversy they have generated among addictions treatment providers, these programs are only accessible to a small number of people, and larger structural changes will be required to fully address the opioid epidemic.

What is safer opioid supply?

SOS is “a harm reduction driven, public health approach that involves the provision of a pharmaceutical drug supply of known quantity and quality to adults who use illegal drugs and who are at high risk of overdose and other harms,” according to the National Safer Supply Community of Practice. In SOS programs, people who use drugs are prescribed pharmaceutical opioids, typically hydromorphone tablets, that can be crushed and injected or taken orally.

These programs are for patients who are continuing to use drugs, and generally reserved for patients who have not found other treatments, such as opioid agonist therapy (OAT), to be helpful in preventing or reducing their drug use.

“The difference with SOS is the paradigm that it’s founded on is less about a treatment paradigm and more about avoiding the overmedicalization of addiction and honouring the fact that some people may use drugs for the rest of their lives,” says Bowles. “It’s not our place to judge or place value on what we think a meaningful life is. If somebody isn’t interested in treatment at this point in their life, or might never be interested in treatment, it’s really important that there’s still an option that can increase their likelihood of survival while using drugs.” Bowles adds that SOS programs also offer traditional treatment options, like OAT, to those interested.

Intended benefits

SOS programs have in part been established to provide an alternative to the increasingly toxic street drug supply in Canada. The supply of unregulated fentanyl in Canada is now widely laced with benzodiazepines, a powerful class of sedating medications. The potency of unregulated fentanyl can vary widely from week to week and increases the risk of accidental overdose, which can be fatal. The hope is that SOS programs can reduce the risk of unintentional overdose by providing pharmaceutical opioids of a known quantity and free of other dangerous contaminants.

“Programs are really responding to calls from the communities of people who use drugs, saying that they need safer access to opioids that are not street supply, which is becoming more heavily tainted and toxic and deadly for people,” says Sarah Griffiths, a Toronto-based physician with expertise in addictions medicine who spends part of her practice working in a safer supply program. “These programs are designed for people who, for whatever reason, cannot or do not want to stop using opioids, but obviously also don’t want to overdose.”

SOS programs also frequently provide an array of low-barrier services to clients, as well as other forms of treatment for substance use. The teams, consisting of primary care providers, psychiatric care providers, social workers and peer support workers, help patients improve their overall health and deal with aspects of their lives that may be contributing to their drug use, such as homelessness or mental illness.

“Many patients have found their substance use is a large barrier to engaging with care,” Griffiths explains. “So sometimes when people come to an SOS program, they come for the prescribing, but we’re able to build a relationship with them and then we can start picking away at the primary care, the mental health concerns, the case management and housing. Ideally, it’s a gateway back into the full spectrum care for people who otherwise often have too many barriers to access these sorts of things.”

Proponents argue that the programs provide an opportunity for clients to remain connected to the health-care system and access other elements of care even as they continue to use drugs. Furthermore, after establishing relationships with providers in an SOS program, some patients may be more willing to engage in other forms of treatment for opioid use, such as OAT.

Potential harms

However, some providers worry about the concrete, unintended consequences that SOS programs may have, such as deterring patients from first-line, proven treatments, like OAT. Another frequently raised concern is the diversion of opioids prescribed through SOS programs. Opioids like methadone or suboxone, which are used for OAT, are long-acting medications taken once daily; patients on these medications usually visit their pharmacy to take their medication in the presence of the pharmacist until they achieve a period of stability and are prescribed “carries,” or take-home doses. However, opioids prescribed by SOS programs are short-acting and intended to be taken several times per day, so patients are dispensed a limited number of tablets each day by the pharmacy, which they take home immediately. Thus, there is the potential that the tablets will be given or sold to others. Some providers, like Jennifer Wyman, an addictions physician who practices in Toronto, worry that this may lead to an increased availability of unregulated pharmaceutical-grade opioids.

“I think that there is a risk that prescribing pharmaceutical tablets (through safer supply programs) might not only put more tablets on the street in terms of availability,” she says, “but may also make opioid use a little bit less risky-seeming for people who, when starting to use substances, might otherwise be more leery to use opioids because of the known risks. This may make it seem as though using hydromorphone is less risky than it actually is.”

Beyond these pragmatic issues, certain providers have also expressed philosophical concerns with safer supply prescribing. New treatments are generally studied thoroughly through real-world experiments before they are incorporated into routine medical practice. While there have been some studies demonstrating that specific models of safer supply prescribing are effective, there is less evidence for the way these programs are currently operating. This lack of evidence has led to hesitancy in supporting safer supply until more data is gathered, but some, like Griffiths, believe that the situation is too dire to wait.

“We’re in this beginning stage of this new intervention, although there are injectable opioid agonist therapy models that have very good evidence in both B.C. and in Europe. We can look to that for a bit of guidance, but there is no specific evidence around the models that we’re using here in Ontario. There’s the argument that we need to wait for evidence, and then the argument that things are in such a critical state right now that we can’t afford to wait any longer.”

Other solutions

SOS prescribing has sparked an important, and sometimes heated debate, says Wyman.

“I think that safe supply is shaking up addiction medicine in a way that probably needed to happen long ago, in terms of looking at why the barriers to care have been historically so high and why the retention rates in treatment are so low,” she says. “I think that we can learn a lot from the safer supply models around patient-centered care and engaging patients as partners and in dialogue. That doesn’t always mean that we’re going to agree on everything, but I think that we all need to do a better job of providing comprehensive care.”

The debate is necessary as SOS represents a paradigm shift in the medical system’s response to the opioid crisis. However, the energy devoted to the debate is disproportionate to the actual impact safer supply is having. Access to SOS programs is still limited, and demand for these programs among people who use drugs far outstrips their availability.

“I am concerned that this conversation around safer supply distracts from all the other things, like decriminalization, that need to be part of a holistic overdose crisis response,” says Griffiths. “When you look at how small these programs are, versus the amount of discussion around them, I think it’s disproportionate. And I worry that we’re not talking about the other things.”

Regardless of their stance on SOS, addictions treatment providers agree that tackling the epidemic will require numerous interventions, many of which go beyond the scope of the medical system. Access to treatment services will need to continue to expand, and the current model of specialized addictions medicine clinics may not be enough.

“I think that we need to do a better job of providing comprehensive care,” explains Wyman. “Part of that comprehensive care should be embedding treatment for addictions in family health teams and community health centres. I think that care for people with substance use issues really needs a home in the primary care model so that we don’t have these silos where someone feels like they’re seeing different doctors all the time.”

Decriminalization is another measure many have been advocating for. This would eliminate or decrease legal consequences for possession of small amounts of drugs, such as arrest and incarceration, and allow for greater focus on treatment and decreasing the stigma surrounding drug use.

The federal government so far is not considering decriminalizing drug possession. In late 2020, Prime Minister Justin Trudeau stated that the government is “prioritizing the things that are going to make the biggest difference immediately (including safer supply),” and that “the opioid crisis is much more a health issue than a justice issue,” pointing to safer supply prescribing as an alternative to decriminalization, rather than a complementary measure.

Providers say government action will be required to target the social conditions that contribute to drug use. These range from personal experiences of adverse childhood events, trauma and mental illness to social circumstances such as poverty and unstable housing. These are complex issues; solutions to them will require concerted public policy efforts to enact structural changes.

“I don’t think safe supply alone is going to end the overdose crisis,” Griffiths says, “and I don’t think the medical system alone is going to end the overdose crisis.”

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Jeremy Cygler

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Jeremy Cygler is a general internal medicine fellow at the University of Toronto. His areas of interest include health equity, addictions medicine and the intersection of medicine and social justice.

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