Should safer-drug-supply programs expand to N.L.?
Canadian physicians specializing in addictions and substance-abuse disorders are divided when it comes to one treatment methodology: safer drug supply.
Safer-supply programs are not implemented in most provinces, and whether or not they should remains in question.
Drug toxicity deaths are on the rise in Newfoundland and Labrador. According to the province’s chief medical examiner, drug toxicity took the lives of at least 63 people in 2023.
Since 2019, drug toxicity deaths in the province have increased, with 41 in 2019, 35 in 2020, 50 in 2021, and 57 in 2022.
DATA ON TREND
These increases are a trend in the rest of Canada, which has seen elevated numbers of opioid-related deaths and other harms since 2016.
Between January and June 2023, Canada averaged 22 opioid toxicity deaths per day, totalling 3,970. This was an increase of five per cent compared to the same period in 2022.
Health Canada blames drugsupply toxicity and multi-drug toxicity for the country’s overdose crisis.
To help address the crisis, the federal government has funded 10 safer-supply pilot projects, which will provide prescribed medications as a safer alternative to the toxic illegal drug supply to people who are at high risk of overdose, according to the Government of Canada.
The goal of the safer-supply services is to help prevent overdoses, save lives, and connect people who use drugs to other health and social services.
Newfoundland and Labrador doesn’t have a safer-supply program — but should it?
Here’s what some of Canada’s addiction physicians have to say.
DR. ROB COOPER TORONTO
Dr. Rob Cooper is a family physician who specializes in addiction medicine and coowns two methadone clinics, one in Toronto and the other in Orillia, Ont.
Cooper says he values harm reduction. He has administered and prescribed methadone and suboxone for those with addictions and substance-abuse disorders for years.
“Methadone and suboxone are long-acting opiates that people take every day. They don’t feel high from it. It allows them to function properly, and stops the withdrawal symptoms and cravings,” he said.
Cooper has treated some patients for years who have gone on to live fulfilling lives, but he pointed out methadone and suboxone clinics do not function the same as the safesupply programs being administered across Canada.
He sees safe supply as unsafe and threatening for those he treats daily.
“They are taking people who have opiate addictions that are doing particularly well and weren’t doing any testing to see if they have a problem, and they are giving them large amounts of takehome opiates to do whatever they want,” Cooper said.
RISK OF RESALE
Some people sell the opiates they obtain through safersupply programs, he said.
“The reality is, people are taking these drugs from pharmacies on a daily basis, large amounts of opiates, and they’re selling them and funding their drug habits with them,” Cooper said.
“We have patients coming in saying they went down there and they got these pills, people who’ve been stable for years, not taking any extra opiates, stable on methadone, and they were getting safer supply.”
‘THEY’RE NOT SAFE’
Cooper says those in his clinic who have been stable on methadone or suboxone for years and haven’t used illicit substances shouldn’t be candidates for safer-supply programs.
He says the opiates aren’t safe, prescribed or not.
“When you call it safer supply, it makes people think that these pills and drugs are safe. They’re not safe. If they were safe, they would be showing up at supermarkets. They are highly potent opioids that are linked to addiction,” he said.
NOT A MAGICAL SOLUTION
Coopers says there isn’t enough research to back safer-supply programs, but methadone and suboxone programs can be supported because it’s been proven they are successful.
“People love to pick up on something and think they have this magical solution,” he said.
“To pretend that we have this new form of treatment where we figured out that if we give people all the drugs they need, they’re going to be better. It’s incorrect.”
DR. SHARON KOIVU LONDON, ONT.
Dr. Sharon Koivu is an addiction medicine physician in London, Ont., who is pro harm reduction and against safer supply.
Koivu has been vocal in her opposition to the programs because of what she sees on the frontlines.
“I think it’s really important to define what safe supply is, which is prescribing of large doses of unwitnessed opioids,” Koivu said.
“It’s anything but safe, and calling it safe supply, I think, is so reckless. To me, it’s unconscionable because it actually makes people think that it’s safe to both be in the program and buy diverted drugs from the program.”
EARLY DAYS OF SAFE SUPPLY
London, Ont., was one of the first regions to pursue a safer-drug-supply program. Koivu said it started in 2016, when fentanyl wasn’t a problem. Instead, prescribing oxycontin was an issue.
“When that came off the market, the drug that doctors switched to primarily was a drug called hydromorph contin,” she said.
This drug became problematic because users injected the capsule, which led to heart valve damage.
“People were suffering from endocarditis. We actually had to declare a public-health emergency for endocarditis related to hydromorphone,” Koivu said.
SPINAL INFECTIONS, HIV
Soon after, Koivu started to notice the same population getting HIV despite a needle exchange program.
Later, she started seeing spinal infections due to injection drug use.
“I was seeing more people with quadriplegia and paraplegia related to spine abscesses and all sorts of other infections,” she said.
As the safer-drug-supply programs have progressed, she said, things have gotten worse – even outside the health-care facilities.
“I had patients who would tell me that they were housed, but they left their apartments or their homes to live in encampments behind the pharmacy, where most of the diversion was taking place, because the drugs were cheaper there,” she said.
“It’s not harm reduction. At best, safe-supply is harmsideswiping.”
She would like to see the money the government is putting into these programs reallocated to wrap-around supports such as physician accessibility, housing, and mental-health care.
DR. DAVID MARTELL NOVA SCOTIA
Dr. David Martell, a physician in rural Nova Scotia, has a different perspective on safer-drug-supply programs — he first outlined a change in terminology. He calls safer supply prescribed alternatives to the toxic drug supply.
Martell sees the program as a method of intervention.
“It’s not just one thing. There are many ways to get prescribed alternatives to people to keep them safe,” he said.
DIFFERS BY REGION
In rural Nova Scotia, for example, a safer-drug-supply program isn’t necessary because drug toxicity hasn’t changed dramatically in the last 10 years.
Martell said perspectives will change based on region.
“You see news stories in Belleville, Ont., and different parts of British Columbia for years, and where I practice is not like that at all, but we do need to have some elements of this available everywhere,” Martell said.
As a result, safer-supply programs won’t have the same demand in all areas, but addiction programs are still needed, he said.
WHY THE INCREASE IN DRUG USE?
Martell attributes the overall increase in drug use and overdoses to income inequality.
His ultimate goal is to eliminate the stigma around substance-abuse disorders.
“Nobody who has an addiction wants to have an addiction. I think I try to instill hope, but I’d like people to know that if they’re living with a substance-use disorder, people care about them,” he said.
DR. LESLEY MANNING AND JENNIFER PATRICK, NURSE PRACTITIONER ST. JOHN’S
Dr. Lesley Manning and nurse practitioner Jennifer Patrick practise within the Opioid Dependence Treatment Hub in St. John’s.
While Newfoundland and Labrador doesn’t have a safer-drug-supply program, Manning and Patrick can see it as being beneficial.
“We’re seeing that the substances that the clients are using is changing considerably and there’s an increased amount of different substances available in the community that are becoming more dangerous for the clients to ingest,” Patrick said.
HARM-REDUCTION APPROACH
Manning says Newfoundlanders and Labradorians have traditionally used prescription opioids, which are safer than the transition they are witnessing now toward synthetic substances like fentanyl.
“Those medications are significantly more potent and significantly at risk of drug toxicity or overdose, especially when combined with other substances,” Manning said.
Using drugs is pervasive among all demographics, and Patrick and Manning treat everyone from teenagers to seniors in their 80s. They take a harm-reduction approach to treating patients.
As a result, Manning considers safer drug supply in the realm of harm reduction.
“While we don’t have one here, it’s certainly a very evidence-based procedure that’s shown to help people who do substances,” she said.
WHY THE DIVISION?
While some doctors are for safer-drug-supply programs and others are against them, Dr. Shawn Bugden, dean of Memorial University of Newfoundland’s (MUN) school of pharmacy, said the division between doctors shows there is an opioid problem.
Bugden said safer drug supply makes logical sense – but the counterargument against safer drug supply also holds validity.
“The safer drug supply is part of a harm-reduction strategy which makes logical sense that the way we would treat people with opioid use disorder is with replacement opioids,” he said.
“The counterargument moves more opioids into the system, (when) we really haven’t done a thorough evaluation of whether safer drug supply actually works to improve outcomes, reduce deaths and hospitalizations.”
NOT ENOUGH RESEARCH
Ultimately, there is not enough research to back up either argument.
“I think that the jury is still out on whether this is helpful,” Bugden said.
“For the people that say that it’s helpful, I would say that’s nice, but I think we would be naive to not try to evaluate to ensure that this intervention is actually producing benefits and reducing deaths.
“People on the other side of the perspective say this (safer supply) is marketing, or this is not something we should do. I think we have to do something.”