Cautious, compassionate safe supply is good public policy

As Canadian political parties engage in name-calling and partisan bickering over safe supply, the opioid crisis and apparent opioid toxicity (AOT) deaths continue to escalate as threats to public health.

More than 42,000 Canadians have died from AOT since 2016, with an average of 22 deaths daily in 2023. British Columbia, Alberta, and Ontario account for 88 per cent of deaths.

Around one in five Canadians experience a substance use disorder (SUD) at some point in their lifetime. While the majority of SUDs involve alcohol and cannabis, opioid use is especially dangerous given the substance’s extreme potential for misuse, withdrawal, overdose and adulteration with fentanyl, carfentanil and xylazine.

In regulated clinical environments, safe supply refers to the prescription of pharmaceutical-grade medications for patients suffering from severe and treatment-refractory SUDs. Whereas opioid agonist therapy uses long-acting medications (e.g., buprenorphine and methadone) to prevent opioid cravings and withdrawal, safe supply provides short-acting medications (e.g., hydromorphone and morphine derivatives) to elicit desired effects/intoxication and prevent overdoses in high-risk SUD patients. The former helps treat illness while the latter preserves life.

Safe supply is not a magic bullet to cure our overdose emergency. However, under cautious guidelines, harmonizing prescriber-based safe supply initiatives with existing evidence-based practices such as opioid agonist treatment has a role to play in saving lives.

More than 40,000 AOT hospitalizations have occurred Canada-wide since 2016, with fentanyl detected in 82 per cent of Canadian AOT deaths. Political and historical injustices contribute to disproportionate impacts and inequitable treatment access among rural, remote and Indigenous communities. While in Ontario more than 90 per cent of deaths are among White Ontarians, an increasing proportion from 2017-2021 are Asian, Black, and Latin American.

Accidental AOT emergency department visits quadrupled between 2014 and 2021 in Ontario; fentanyl was reported in 94 per cent of all provincial deaths during the COVID-19 pandemic. In B.C., substance overdose is the leading cause of death for people aged 10-59 years-old; fentanyl was found in more than 79 per cent of B.C.’s deaths in 2024.

Behind each statistic is a human life, family tragedy and community disaster.

While substance use is inevitable in society and cannot be completely eliminated, morbidity and mortality can be reduced with comprehensive, evidence-based public health and risk reduction strategies. Any approach must maximize benefit and minimize potential harms, protect the dignity and autonomy of those affected, and promote justice and equity. Approaches are often organized into three broad categories: primary, secondary and tertiary interventions.

Primary interventions use upstream and community-level programs to reduce health inequities and predisposing factors to prevent SUD development (e.g., housing/financial supports, education, public green spaces). Primary prevention is optimal; however, our current state of emergency has shifted focus toward life-saving tertiary interventions such as safe supply.

Secondary interventions involve early detection and treatment (e.g., psychotherapy, medication, peer support) and tertiary interventions manage existing illness and reduce harm (e.g., naloxone kits, clean needles, opioid agonist therapy, controlled substance decriminalization, free or subsidized rehabilitation/detox, overdose prevention sites). No one approach should operate in isolation. Comprehensive public health strategies leverage appropriate interventions across all three levels.

The Ontario Drug Policy Research Network conducted a rapid review synthesizing evidence from 20 peer-reviewed studies on Canadian safe opioid supply programs. It found safe supply reduced health-care costs, emergency department admissions and hospitalization, social stigma, criminal activities, police interactions, use frequency, street supply reliance, anxiety surrounding dangerous use and AOT (fatal and non-fatal). Safe supply increased personal autonomy, housing and financial stability, healthy weight gain, self-care, chronic illness treatment and physical and mental well-being.

The review further identified possible issues and barriers associated with safe supply. Among these are drug diversion and sharing, limited distribution hours, poor accessibility in rural/remote communities, non-adherence, high costs and small sample sizes. It also found pervasive confounding factors in several program evaluation studies. Mitigation of such challenges could include witnessed doses, expanded operation hours and more rigorous study design.

Despite the remediable shortcomings of safe supply, its implementation shows markedly reduced AOT deaths and reduced health-care costs. Yet, it remains a controversial and polarizing public policy matter for many Canadians and elected officials. Indeed, Canada is not alone in questioning its progressive public health drug-related policies, considering the uncertainties and walk-backs on decriminalization in Oregon and Portugal.

All Canadian lawmakers seem to agree on the urgency and severity of Canada’s opioid crisis. They disagree, however, on the best approach moving forward. A recent Business of Supply debate in the House of Commons illustrates the ideological divides across our political spectrum and the discordance surrounding safe supply’s future.

Bottom line: We must balance Liberal progressivism with Conservative pragmatism.

On one side of this debate, safe supply opponents (overwhelmingly Conservative Members of Parliament) raised issues relating to its implementation. They highlighted concerns of safe supply drugs being diverted back into street circulation, misuse and illegal sale, increased addiction and overdoses, over-prescription and excessive leniency, inflated health-care costs and speculations of social chaos and violent crime. Rather than invest in safe supply, the Leader of the Opposition advocated for continued criminalization and using allocated funds for expanded rehabilitation and psychotherapy.

Conversely, many Liberal and NDP proponents of safe supply emphasized its potential to reduce AOT deaths when used in conjunction with other tertiary interventions. They point to preserving life, observing risk-reduction alongside use-prevention, deriving evidence from similar projects, addressing health disparities due to racism and remnants of colonialism, expanding social support services (including rehabilitation, housing support and family therapy), promoting patient-centred care and reducing stigmatizing and inflammatory political discourse.

Under tightened diversion protection measures, safe supply should occur in supervised consumption environments after standard-of-care interventions (e.g., opioid agonist therapy, psychotherapy, peer support) have been exhausted. Casting aside political positions and instead focusing on the well-being of patients and families, safe supply would be a last resort for people with severe and treatment-resistant SUDs. Diverse provisions and safeguards are essential to ensure adherence to its intended use and prevent diversion.

Bottom line: We must balance Liberal progressivism with Conservative pragmatism.

Funding for safe supply comes from private donors and Health Canada’s Substance Use and Addictions Program (SUAP). Since 2020, about $100 million in SUAP funding has supported 29 different safe supply projects across Canada. Despite House of Commons testimony from physicians, policy-makers and public health experts, SUAP funding expired for 19 projects this past March. Canada’s three remaining safe supply projects will lose funding in March 2025.

Regardless of political affiliation, as Canada transitions from risk prevention strategies (e.g., criminal penalties) and toward risk reduction, safe supply is an important tertiary intervention that must be refined.

The RCMP Commanding Officer in B.C. and its Solicitor General state that widespread diversion of drugs from safe supply has not occurred. However, to strengthen public confidence, cautious operation protocols could include standardized provincial- or federal-level theft/diversion prevention approaches and penalties. Simultaneously, these policies should allow the flexibility and jurisdiction for communities to individualize safe supply protocols to address unique access and health needs at the municipal level.

For instance, proposed measures to prevent could include witnessed doses to ensure intended use and ATM-style safes secured by biometric scanning to prevent theft. Examples of local initiatives that serve high-risk groups such as the homeless/unsheltered (Inner City Family Health Team), recently incarcerated (the University of British Columbia), Indigenous (Kilala Lelum Health Centre), rural/remote (AVI Health and Community Services Society) and 2SLGBTQIA+ (Sherbourne Health Centre Corporation) should be shared.

Safe supply does not cure SUDs nor solve the systemic barriers creating them. Rather, it allows for the preservation of life as more sustainable primary and secondary interventions emerge. In a future in which our public health agencies gravitate toward proactive and upstream approaches, certain “last-resort” tertiary interventions such as safe supply may fade into history. We have not yet reached this point and a robust three-tiered approach must be maintained to serve those in immediate need and prevent future SUDs.

Inclusion and compassion are our best guides for next steps as we refine safe supply. This requires prioritizing evidence and research over opinions and assumptions. It is our duty as a society to critically reflect on current health issues and past approaches, think beyond ourselves and advocate for impactful and meaningful change to advance human welfare.