TORONTO — The Finks, married just a month earlier, sat down for their appointment, Kim dressed in head-to-toe pink and Chris in all black. He was taciturn, while she joked she couldn’t stop talking long enough to have her blood pressure taken.
Jouvence Tshiyoyo Bukumba, a nurse, asked Kim, 46, about her cardiology appointment and Chris, 54, about his nerve pain. Then came “the SOS questions” — safer opioid supply. How were their doses? Did they feel any cravings or withdrawal?
The Finks are participants in a program at the frontiers of the desperate attempts to reduce never-before-seen levels of overdose deaths. Here at the light-filled Parkdale Queen West Community Health Centre, clients like the Finks receive prescriptions for government-funded, pharmaceutical-grade opioids they can use to feel the euphoric hit provided by drugs or at least ward off withdrawal, instead of having to rely on street drugs. The program, called safer supply, is part of an expanding movement in Canada to counter the increasingly treacherous drug supply.
“This program’s really saved us,” Kim said.
As the term “safer supply” connotes, such programs are not without risks. They are not without critics, either, including some addiction medicine doctors who argue people should be directed toward treatment and that providers should be focused on reducing drug use, not furnishing the drugs. Fears of diversion — that clients could sell these powerful opioids to others — also weigh against the programs. A major report this year from a Stanford-Lancet commission cautioned against take-home safer supply programs, invoking the overprescribing of painkillers that helped ignite the overdose crisis and saying supporters’ arguments “echo the opioid manufacturers in presuming that unrestricted opioid provision can only improve public health.”
Such concerns ignore the emergency of implacable and preventable overdose deaths happening every day as a result of complacency and inaction, supporters argue. The drug supply has grown so dangerous with the takeover of synthetic opioids like fentanyl that experts describe it as “poisoned.” Whatever risks come with safer supply, advocates say, they don’t stack up to the very real risk of people dying when they have to use what’s available on the street. For people who are not yet ready for treatment, or for whom treatment hasn’t worked, safer supply is an alternative that can help avert death.
All the clients who spoke with STAT said they knew many people who had died from overdoses, particularly in recent years.
“Folks sometimes see SOS as, ‘Well, you’re just giving Angela free drugs, you’re encouraging Angela’s habit,’” said Angela Robertson, the centre’s executive director. “But the goal of a safer supply program is really to keep people alive, so that those other things people might be interested in having folks explore or consider as options, like treatment, folks can then do that.”
As such programs grow in Canada, nothing of the sort exists in the United States, where 108,000 people died from overdoses in 2021, largely driven by fentanyl.
Such programs would be illegal under U.S. policies, which strictly govern how opioids can be prescribed. It’s also unlikely that the Biden administration, despite touting its support for select harm reduction strategies like syringe service programs and fentanyl test strips, would embrace such a concept. But listen to advocates, and they say if you really are on board with harm reduction principles — that is, helping people use drugs in safer ways, avoid infections, and ultimately stay alive — safer supply is exactly what that looks like.
“The U.S. is facing the worst opioid overdose death crisis we’ve ever seen,” said Kimberly Sue, an addiction medicine physician at Yale and the former medical director at the National Harm Reduction Coalition. “We need to be doing everything possible to try, at a minimum, to make a dent in the unrelenting deaths that in large part have been due to changes in the unregulated drug supply.”
Here at Parkdale Queen West, clients in the SOS program don’t have to stop their illicit use, but providers have seen clients cut back. Some have transitioned entirely to the opioids they pick up daily at pharmacies.
As Tshiyoyo Bukumba wrapped up her SOS questions with the Finks, she asked one more.
“Any fent use?” she said, referring to street fentanyl.
Both had easy answers: No.
Safe supply, as safer supply is often called, is more of a principle than a specific program. It’s also not a new concept. Some countries have offered prescription heroin for years. More recently, some clinics have started providing pharmaceutical-grade fentanyl, in an attempt to match the sky-high tolerances people are developing from the street supply. Clinics sometimes provide other classes of drugs as well, including stimulants.
At Parkdale Queen West’s opioid program, clients are prescribed something like long-acting morphine to provide a baseline level, as well as hydromorphone, or Dilaudid. As the clinic’s pamphlet says, clients use the Dilaudid tablets to get high, manage withdrawal, cut cravings, and treat pain. Doses are calibrated to clients’ needs.
Providers here started offering opioids to clients in 2019. The clinic built out the program the following year when the Canadian government, recognizing the toll of the pandemic on overdoses, issued funding to a handful of sites for safer supply pilots. Around the country, the pandemic and its impact on overdoses led to a “rapid increase in safer supply services” as more prescribers started offering it, said Stephanie Glegg of the British Columbia Centre on Substance Use.
Researchers are still evaluating the impact of the programs, but early research indicates they lower overdose risks, according to the Canadian government. A study published Monday found that participants in a safer supply program in London, Ontario had fewer ER visits and hospital admissions after joining the program. Past studies from different countries have shown that providing heroin to people when other treatment strategies haven’t worked can reduce their illicit use and connect them to care. A 2016 study found that injectable hydromorphone offered comparable benefits.
One client here, who goes by Kenzie Q., said the opioids provided through the program helped her reduce her fentanyl use gradually to the point where she no longer touched the street supply.
She described the nervous look her pharmacist would give her when she picked up the opioids, but thanks to that option, “fentanyl is not your only opiate choice out there,” said Kenzie, 40. If the program “didn’t come around, I don’t think I could have made it.”
Safe supply has some overlaps but key differences compared to using medications like methadone or buprenorphine to treat opioid addiction. Those medications, which are opioids themselves, stave off withdrawal and minimize cravings, but don’t provide a high. The drugs offered by safe supply programs can. Moreover, clients of safe supply programs can use their Dilaudid how they want — it’s given as a tablet, but they can inject the drug. While the focus of treatment programs is to get people to stop using drugs, at safe supply programs, it's more about reducing the risks of drug use and lowering people's reliance on illicit drugs.
While the primary goal of safe supply is reducing overdoses, providers say they are finding other benefits as well.
The clients described how, before the program, their days were dictated by finding and using drugs, starting from the moment they woke, in order to keep from getting “sick” — suffering terrible withdrawal symptoms. Having a reliable supply, however, meant they could reconnect with work or family. The clinic also linked them with other services, from housing to health care. Multiple clients described themselves now as “functional.” Several said they were addressing health issues they had long put off — including cancer and mental health screenings — and that for the first time, they felt like they could be honest with their doctors.
“You now have the space in your life to even think about that,” said Mish Waraksa, a nurse practitioner and the clinical lead for the centre’s safer supply program.
Nicholas Gouvis, 58, another client, said his whole routine used to revolve around using, describing it as “like a job.” But Gouvis, who started misusing painkillers decades ago and then turned to heroin, only to watch as fentanyl took over the drug supply, was at the clinic one day last month for a physical therapy appointment. He was taking care of himself, he said. “You want solutions?” he asked. “They’re there.”
The drug supply has not only grown more lethal; it’s also a mess. Potency varies dramatically from one batch to another, and other drugs are contaminating the opioid supply. In the U.S., a tranquilizer called xylazine that seems to result in horrific skin wounds is becoming widespread. In Canada, benzodiazepines have become more prevalent. For people who use the street supply, that much benzo use seems to cause memory issues that clear up once people are provided regulated opioids, Waraksa said.
Over time, more providers have come around to the programs, their hesitancy fading in the face of the pandemic-driven surge in overdoses, Glegg said. But providers have also reported criticisms from colleagues. Certain provincial governments remain opposed, and some professional bodies that oversee licensing have not endorsed the programs.
The debate in Canada has played out both in medical journals and the press. In a November piece in the Globe and Mail, Vincent Lam, an addiction medicine physician in Toronto, argued that safe supply programs violated providers’ commitment to do no harm. He said he instead tried to steer patients to methadone or buprenorphine, and that he has heard that hydromorphone is appearing for sale on the street.
“What is difficult about ‘safe supply,’ and what causes me and others moral distress, is that the same pills that one patient insists are needed to save their life may bring harm to another patient of mine, or one I have not yet met,” Lam wrote in the piece, which was rebutted by providers supportive of safe supply as well as members of the Canadian Association of People Who Use Drugs.
Keith Humphreys, a drug policy expert at Stanford, chaired the Lancet commission that, in its sweeping report on the North American opioid crisis, warned against take-home safe supply programs. He said he is not opposed to providing people who use drugs with pharmaceutical-grade supplies, but only under supervision. People who use the street supply have incredibly high tolerances, so programs have to prescribe extremely high doses to meet their needs. Dispensing that many Dilaudid tablets would inevitably lead to some being sold — and new people becoming addicted and possibly dying, Humphreys argued.
“The basic policy of saying, our population would be better off if we had a large, easily available supply in the community of opioids that were legally made, clearly labeled, and in consistent doses — we had that policy,” Humphreys said, pointing to the early days of the prescription opioid crisis. “And that didn’t work out very well.”
Supporters counter that argument, noting that opioid manufacturers pushed doctors to offer high-dose, long-lasting prescriptions broadly to people with pain, most of whom had no experience with opioids. Safe supply is for a very select group of patients well accustomed to high-dose opioids.
In early findings of the programs it funded, the Canadian government has reported that clients showed health as well as quality-of-life improvements, though it did identify diversion as a challenge. The top challenge, the government said, was that people now have such high tolerances that even high doses of Dilaudid sometimes have limited benefits.
At Parkdale Queen West, to guard against diversion, clients have to do urine screens to show that they’re using what’s prescribed. If there are concerns that someone is selling their Dilaudid, clients can be moved into an arm of the program in which people use the drugs under supervision, instead of being allowed to take home the tablets.
As for the argument that people should be directed to treatment, providers point out that buprenorphine and methadone — as effective as they are — don’t work for everyone, certainly not on the first try. Clients whom STAT spoke with said they had previously tried such medications, as well as a range of other treatment options.
Waraksa said people’s positions on safe supply came down to where they saw the greatest net harms. Whatever risks came with these programs, she said, “on the flip side, we have mass death.”
Calls for safer supply programs in the United States have been growing among advocates and certain public health officials and experts. A March study that looked at overdose deaths by race and ethnicity, for example, suggested that “providing individuals with a safer supply of drugs” was one step that could reduce the widening disparities.
But doing so would require action from regulators or Congress that doesn’t seem likely. Federal policies restrict how opioids can be prescribed, with one requiring clinicians to dispense controlled medications only “for a legitimate medical purpose” and “in the usual course of ... professional practice.” While there is some ambiguity in the language, “I don’t think there’s any way to legally do” safe supply, said Corey Davis, the director of the Harm Reduction Legal Project, who supports such programs.
The push for safe supply programs in the United States comes as the broader harm reduction field encounters both victories and setbacks. The Biden administration has embraced some harm reduction strategies, and New York City has opened the country’s first supervised consumption sites. But some communities have moved to shutter syringe service programs, and just last month, California Gov. Gavin Newsom, a Democrat, vetoed a bill to open supervised consumption sites.
With political will lacking, the most likely way a safe supply program could start in the U.S. would be for researchers to get approval for a trial, as drug laws allow exceptions for studies, Davis said.
Jeanette Bowles, who grew up in the United States and is now a community health researcher at the B.C. Centre on Substance Use, said she sometimes hears that interventions like supervised consumption sites or safe supply aren’t transferable to the United States. While there might be variation in the drug supply and local challenges, she said, the needs of people who use drugs aren’t all that different.
“When there’s pushback that says the U.S. is too different to adopt Canadian interventions, I just haven’t seen that that’s true,” she said. “This is what drug use looks like.”
Even in Canada, there are a limited number of safe supply programs, and they only have so many client slots. At Parkdale Queen West, providers prioritize people who face the highest overdose risks or barriers to treatment, including those who have overdosed in the past, lack housing, or have been hospitalized for infections including endocarditis and HIV.
Ian McPherson, 46, didn’t have stable housing when he joined the program. He used to shoplift so he could buy drugs. Now he has housing, and has been connected with dental and vision care.
“Every day, instead of shoplifting, I had another option,” he said about the provided opioids. “That was a big deal, a big deal.”
For a time, McPherson continued to use street fentanyl. But he’s transitioned fully to the drugs he gets at the pharmacy every morning. He said he had overdosed “many times,” but not since he started in the program.
“Fentanyl, you never know what’s going to happen,” he said. “Any time you get a person to not use it, even for one day, I think that’s a benefit.”
This story is part of a series on addiction in 2022, supported by a grant from the National Institute of Health Care Management. Previous articles covered risks from a veterinary tranquilizer spreading in the drug supply, the spike in overdose deaths among Black Americans, and the Americans with Disabilities Act’s protection of people with addiction histories.
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