News Medical Regulations Research
The state of safe supply

By Michelle Gamage, Local Journalism Initiative Reporter and Jen St. Denis

Before Brian O’Donnell was prescribed the opioids hydromorphone and methadone by his doctor, he used cocaine, heroin and fentanyl to manage  chronic pain from injuries he sustained earlier in life.

“If I didn’t have access to tested, safe drugs I’d probably be dead, just like a lot of my friends,” O’Donnell says.

O’Donnell, who lives in Vancouver, accesses British Columbia’s prescribed safer supply program, where clinicians  prescribe pharmaceutical alternatives to illicit drugs in order to  separate people from the dangerous illicit market.

It’s a program that users, doctors,  advocates and researchers say saves lives, but it has also come under  fire: Conservative Leader Pierre Poillievre recently introduced a motion in the House of Commons in May to end the program, saying it was fuelling addictions to opioids.

Poillievre’s motion, which  did not pass, proposed redirecting money spent on safe supply programs  to addiction treatment programs.

Dr. Caroline Ferris, a  doctor who prescribes safe supply as part of addiction treatment, says  safe supply programs should not be stopped. But Ferris said there are  problems with the reliance on hydromorphone — also known by its brand  name Dilaudid — in safer supply programs. She said hydromorphone doesn’t  match the strength of fentanyl, the drug most opioid users are now  addicted to, leading some to sell their prescriptions.

That in turn could be fuelling new opioid  addictions, Ferris said. She said the studies that have been done of the  program so far have focused on qualitative data — stories from people  prescribed safe supply. “But we don’t really have data to crunch and  there’s been a few problems with collecting that data for various  reasons,” Ferris said.

Safer supply is designed to reduce harm,  but experts are divided when it comes to weighing its pros and cons.  Some experts worry access to pharmaceutical-grade drugs could encourage  people to try drugs, or continue using drugs. Others say expanding safer  supply reduces overdoses from illicit street drugs.

Bernie Pauly, a scientist with the Canadian Institute on Substance Use Research who has participated in evaluations  of safer supply programs in Canada, says it’s clear that illicit  fentanyl, not diverted safe supply, is killing people. She pointed to research by the BC Centre for Disease Control  that found less than two per cent of illicit drug deaths in 2020 and  2021 involved hydromorphone with no fentanyl. Of those 45 deaths where no fentanyl was detected, there was an average of seven other substances  in the person’s body. There were no deaths where only hydromorphone was  detected.

Should we be concerned about diversion of safer supply?

Ferris says data collection on safe supply  is in the early stages and individual anecdotes about young people using  hydromorphone shouldn’t be discounted.

“We knew [Oxycontin] was out there before  it hit the headlines, we knew fentanyl was out there long before it was  declared a public health crisis — because we see people and we talk to  them and we test the urine and we know what they’re using,” she said.

While prescribed drugs are safer than drugs  bought from the illicit supply because pharmaceutical drugs have a  known potency and purity, they still carry a risk, Ferris says. If  someone is buying diverted hydromorphone, for example, they may not know  what dose of pill they are getting and for those who aren’t used to  taking opioids, two tablets of eight milligrams of hydromorphone could  be fatal.

“I’m not sure that it’s doing a favour for  youth,” said Ferris, who says she knows of several teens under the age  of 15 who recently died from suspected overdoses that included  hydromorphone.

“If the person for whom it’s prescribed is  taking it, yes, it probably benefits them. But if they’re diverting it, I  think it’s doing a lot of harm. And I think we have to acknowledge that  diversion does occur.”

Data on youth drug toxicity deaths  from the BC Coroners Service shows that between 2017 and 2022, there  were 12 deaths in youth under 18 where hydromorphone was detected. One  of the deaths happened in 2020, three occurred in 2021, and eight deaths  were from 2022. In all of the deaths, at least one other substance that  contributed to the death was found.

The data also shows that the vast majority  of young people who died of drug toxicity used fentanyl: of the total  142 youth deaths between 2017 and 2022, fentanyl or its analogues were  found in 112.

Not everyone agrees that  diversion of hydromorphone is a problem. Garth Mullins, a drug user  advocate who has been on methadone for 20 years, said he sometimes  relies on diverted hydromorphone given to him by friends who have a  prescription. Mullins said he takes hydromorphone when he’s having an  off day and might be tempted to get drugs from the illicit market  instead. He said many of the people he knows who have a hydromorphone  prescription take a mix of hydromorphone and fentanyl because  hydromorphone doesn’t completely replace fentanyl — but having the  prescription allows them to use less illicit fentanyl.

Mullins said hydromorphone pills have  always been sold on the street, but the cost has dropped dramatically  over the years: from $10 a pill in the late 1990s to $1 a pill today.

It can also be hard to judge how much  hydromorphone sold on the street has been diverted from prescribed safer  supply programs. A B.C. government report  said hydromorphone was dispensed 585,000 times to over 80,000 patients  in 2018-19. That’s prior to introduction of the prescribed safer supply  program in 2020, which Dr. Alexis Crabtree, a public health physician  with the BC Centre for Disease Control, says around 5,000 patients  — about 5 per cent of people who have been diagnosed with opioid use  disorder in B.C. — have accessed so far.

Opioid use disorder is defined by  the BC Centre on Substance Use as a chronic relapsing illness  associated with high risk of death. It doesn’t matter if someone gets  their opioids from their family doctor or an illicit dealer. People can  get better if they can access treatment, the BCCSU adds.

Public health officer Dr. Bonnie Henry and  B.C. chief coroner Lisa Lapointe have stressed all people with opioid  use disorder are at risk of overdose if they use drugs from the illicit  market.

What exactly is safe supply and how did we get here?

There’s a long history of successful prescribed safer supply pilot projects in B.C.

The 2008 North American Opiate Medication Initiative and 2011 Study to Assess Longer-term Opioid Maintenance Effectiveness found patients could benefit from access to doctors and opioids to treat severe opioid use disorder.

B.C. has been in a public health emergency  since April 2016, when drug dealers in the illicit market started adding  the powerful synthetic opioid fentanyl to their supply.

This led to a spike in deaths from drug  poisoning. Harm reduction initiatives like safe consumption sites, where  people could take drugs while being supervised by health-care workers  who would intervene if they overdosed, and naloxone distribution  programs, which can temporarily reverse opioid overdoses, were  successful in starting to lower the rate of death by 2019.

But in early 2020, the COVID-19 pandemic  erased any progress that had been made: closed borders and supply chain  disruptions led to an unpredictable, and often deadly, supply of illicit  drugs.

Around 200 people a month — more than six people a day — are currently losing their lives to toxic drugs in this province, the highest death rate ever recorded. Since 2013,  13,497 British Columbians have lost their lives due to unregulated drugs according to the BC Coroners Service.

In an effort to help people who use drugs  isolate without going into withdrawal at the start of the COVID-19  pandemic, the BC Centre on Substance Use published “Interim Clinical Guidelines: Risk Mitigation in the Context of Dual Health Emergencies,” which  gave clinicians guidance on what they could prescribe as an alternative  to toxic street drugs, including recommended doses.

Doctors have always been able to prescribe  medication for pain, says Crabtree. These medications can include a  family of drugs known as opioids, such as morphine, fentanyl,  hydromorphone and heroin. If you’ve ever had a surgery you may have been  prescribed an opioid for pain management — hydromorphone is very  commonly prescribed for short-term pain, like knee surgery, or  longer-term pain like pain associated with cancer, Crabtree says.

A year after the BCCDC published its guidelines, the provincial government introduced a policy that supported the guidelines and recommended prescribed safer supply as a way to reduce toxic drug deaths.

Under the provincial policy clinicians can  prescribe fentanyl patches, fentanyl tablets, injectable hydromorphone,  tablet hydromorphone and other opioids “as determined by programmes,”  Crabtree says. These drugs are sourced from regulated pharmaceutical  producers so clinicians and patients can know for certainty the dosage,  potency and purity of the product.

The BCCSU guidelines also cover morphine,  stimulants, benzodiazepines and alcohol withdrawal medication, she says.  Clinicians are given guidance on dosages but ultimately choose what  they should prescribe for their patient.

This policy allocated funding to the health  authorities for prescribed safer supply, which they offered as part of a  comprehensive addiction medicine program that also offered opioid  agonist therapy and other treatments, Crabtree says.

Opioid agonist therapy is designed to treat  opioid use disorder by giving people longer-lasting drugs that don’t  provide a euphoric rush but do prevent people from experiencing  withdrawal. It is different than prescribed safer supply which is  designed to replace a person’s illicit drug supply.

Under the current policy, patients don’t  have to pay for prescribed safer supply or opioid agonist therapy — they  get it for free, similar to other drugs covered by the provincial  Medical Services Plan. The policy also allowed clinicians not associated  with health authorities, such as family doctors, to offer their  patients prescribed safer supply.

Why hasn’t safer supply reduced drug deaths?

Safer supply was supposed to reduce  overdose deaths, but the number of overdose deaths continue to rise  — fuelling criticism that the program is  misguided.

While safer supply programs have rolled out across the province the illicit drug supply continues to increase in potency  and with added substances that can increase the risk of overdose, like  benzodiazepines, which depress the central nervous system and can  increase the risk that someone stops breathing during an overdose.

Supporters say the program does save lives,  and works for those who can access it. They also point out that judging  the program before it’s been scaled up — only 5,000 of B.C.’s 100,000  people with diagnosed opioid use disorder have accessed prescribed safer  supply — is premature.

When a person wants to access safer supply,  they start by talking with a doctor or nurse who will do a full  assessment, including the person’s full history of substance use,  current substance use, past diagnoses or treatment they’ve gone through  and personal goals for their substance use, Crabtree says. This program  is targeted at people with opioid use disorder.

What people are prescribed will be based on  the assessment, but patients should also come in with an idea of what  substances they take and at what potency they take them so they can ask  for their prescription to replace that, Crabtree adds.

It’s important for prescribed safer supply  to meet people where they’re at, says Guy Felicella, a peer clinical  advisor with the BC Centre on Substance Use.

He says safer supply is about reducing how  much people access the illicit market. For him, it’s still a win if  someone accesses prescribed safer supply and the illicit market five  times in a day rather than the 10 times they would have before their  prescription. This is similar to a nicotine patch helping people reduce  the number of cigarettes they smoke in a day, said Felicella.

To keep people away from the toxic street  supply you need to provide the right substances and right potency to  fully replace what they were taking before, Felicella says. Otherwise  they’ll likely turn to the illicit market if they’re not getting their  needs met by the prescription.

But that can be tricky for a number of  reasons. First, someone might not know what they’re buying from the  illicit market. Most street drugs look the same, taste the same and seem  the same but can contain several different substances with wildly  different potencies, Felicella says.

Second, prescribed safer supply needs to  source drugs from regulated pharmaceutical manufacturers, and there just  aren’t that many people making diacetylmorphine, also known as  medical-grade heroin, Crabtree says.

The drugs that people can access through  prescribed safer supply were chosen largely because they were what was  available, she adds.

Where to go from here

None of the experts The Tyee spoke to are  calling for the end of safe supply, but they all had ideas to improve  and expand the program.

Ferris said addictions doctors are  frustrated by the role of gatekeeping, and called for more  non-prescribed models for safe supply. Crabtree echoed this.

“I think that [drug] prohibition should end  and that people should be able to go buy whatever they want to get high  on,” Ferris said, comparing the end of this prohibition to the end of  prohibitions on alcohol and cannabis.

“If they’re in a rural or remote area, it’s  really difficult to access safe supply,” Ferris adds. “So there’s a  terrible inequity about the availability of safe supply and there’s a  real fatigue on the part of prescribers.”

Crabtree advocates for a non-prescribed  safer supply where people can access substances of known purity and potency, similar to how people currently access other psychoactive  substances. She says she doesn’t know exactly what that would look like  and couldn’t point to another jurisdiction with regulations like she’d  want to see here, but added regulations would need to be much stronger  than how alcohol or cannabis are controlled.

There’s no clear solution for how to avoid  diversion. Doctors can require witnessed consumption or ask users of  safer supply to take urine tests, but that creates barriers to access  and can make drug users feel as though they’re being constantly policed.

When it comes to the concern about young  people using hydromorphone, Mullins said young people have always  experimented with drugs — in the 1980s, Mullins said, he went to a  middle-class high school in Vancouver and had no problem getting heroin.

“I just think that kids need to know what’s  the difference between down that you buy on the street and dilly,” Mullins said. Dilly is the street name for hydromorphone and “down” refers to opioids.

“What’s in the pill? What does it mean? What’s an opiate? People need that good drug education. They need good support.”