Urgent call on clinicians: Prescribe alternatives to poisoned drug supply
New data from Statistics Canada has shown that life expectancy in Canada did not increase from 2016 to 2017—the first plateau in the trend to increases in over 40 years. This is largely due to increased mortality from the overdose crisis, which is even more pronounced in B.C., where life expectancy has actually declined for two years in a row. The numbers behind this trend are staggering: In just three years, over 11,500 people have died from preventable opioid overdoses across Canada.
The criminalization of drugs and people who use drugs has created the largest public health crisis of our time. It has led to the drug supply in North America being systematically contaminated with illicitly produced fentanyl and analogues of fentanyl (such as carfentanil), which are typically many orders of magnitude more potent than heroin. These are found in imprecise amounts in the street supply of opioids, leading to people inadvertently consuming lethal doses and dying of overdose. Communities of people who use drugs have been sounding the alarm on the poisoned illicit drug supply for years, but politicians and health care providers have been slow to respond.
We believe that prescribers have an urgent role to play in stopping these overdoses and overdose deaths. We need to address this crisis at its root and establish access to emergency safer supply programs now.
Current strategies to address the crisis have been insufficient and even harmful. Medications such as methadone and buprenorphine, meant to curb withdrawal symptoms and reduce cravings for people who want to stop using opioids, don’t work for everyone. Many people in methadone or buprenorphine programs continue to use drugs from the poisoned supply; many wind up dropping out and losing contact with medical and social supports. Meanwhile, prescription monitoring programs have contributed to the abrupt discontinuation of prescribed opioids. This leaves people with intolerable withdrawal symptoms and pain, forcing them to seek drugs from the poisoned illicit market. The reasons for drug use are complex, and range from pleasure-seeking to coping with stress, trauma and pain. Refusing to offer prescriptions other than methadone and buprenorphine creates barriers to equitable health care for people who use drugs.
Safer supply programs recognize the right of all people who use drugs to stay alive during this crisis. They extend harm reduction beyond sterile equipment for drug use and supervised consumption sites to include access to a safer supply of drugs by prescribing an opioid of known dose to people who are dependent on illicitly obtained opioids. Safer supply programs are based on heroin-assisted treatment programs which have been functioning since the 1990s in Europe, where people who have not responded to other treatment options are provided with a daily dose of pharmaceutical heroin. Research found that these programs contributed to decreased use of street drugs, reduced involvement in illegal activities and increased treatment retention. Programs like this already exist in Vancouver and Ottawa.
Safer supply programs utilize this evidence base and push for an emergent response to the crisis by prescribing hydromorphone, a commonly used opioid that is similar to heroin. Hydromorphone in its tablet form can be taken orally, or crushed for use via nasal inhalation or by injection. This off-label use is done to ensure that people who are dependent on an illicit supply of opioids can get access to a regulated pharmaceutical drug.
By prescribing opioids to opioid-dependent patients, we protect them from seeking a deadly street supply, and therefore reduce the risk of overdose deaths. Safer supply programs can help address broader social determinants, such as criminalization and poverty, that impact the health of people who use drugs. They can also become an entry point for people who have been systematically excluded from the health care system, due to the stigma surrounding illicit drug use.
Safer supply programs can provide widespread access to safer drugs via low barrier, community-based programs in primary care settings. Combating this crisis will require a continuum of options, ranging from models that dispense medications like hydromorphone daily for at-home use, to higher-barrier models that rely on supervised dosing. Dr. Sereda, a co-author of this opinion piece, has followed more than 100 high-risk people who inject drugs in her low-barrier safer supply program over the past three years in London, Ont. There have been no fatal overdoses in this group, and there have been profound gains in health and social functioning for these patients.
To ensure the success of safer supply programs, people who use drugs must be key voices in their development and implementation. This means ensuring that people who are poor, homeless and/or underhoused, Indigenous, Black, or of colour—who are disproportionately affected by this crisis—are involved in all aspects of program development and evaluation.
In past epidemics, front-line health care providers and public health workers mobilized to save lives. During the SARS outbreak, the death rate in Canada was low (44 people) because an emergency response was mounted that was fully resourced. A similarly coordinated response with rapid availability of resources is needed today. This is why we call on all clinicians to exercise their privilege, pick up their prescription pads, and work with people who use drugs to develop responsive programs. Politicians, public health officials, and our respective colleges and regulatory bodies must also act with courage and accountability, to ensure that access to safer supply programs is supported as an integral part of responding to this public health emergency. Someone in Canada is dying every two hours from an overdose. We cannot wait; communities need us to act courageously now.
Nanky Rai is formally trained in public health and practises as a primary care physician at Parkdale Queen West Community Health Centre in Toronto.
Andrea Sereda is a family physician at London InterCommunity Health Centre in London, Ont., providing primary care to injection drug users.
Jessica Hales is a nurse practitioner who delivers primary care to people who are homeless and/or use drugs in downtown Toronto.
Gillian Kolla is a Ph.D. candidate at the Dalla Lana School of Public Health, University of Toronto.