Safer Opioid Supply reduces death risk
Recently, critics have called for the defunding of Safer Opioid Supply (SOS) initiatives that prescribe unsupervised doses of Dilaudid due to fears that programs increase the availability of the opioid in street markets.
In Canada, approximately 20 people a day died of opioid overdose in 2022. Of these deaths, 81 per cent involved unregulated fentanyl. Addressing this alarming number of fatalities requires rethinking our long-held beliefs about prohibition. It’s time to recognize that the benefits of offering safer drugs far outweigh the risks.
Prohibition has led to an unregulated opioid supply containing unpredictable amounts of nonpharmaceutical fentanyl and adulterants like carfentanil, nitazenes, xylazine and benzodiazepines, which cause many adverse effects, including prolonged sedation and overdose. Prohibition removes our ability to control the unregulated drug supply fuelling this lethal crisis.
This is the context that makes SOS programs so vital. Currently 28 small SOS projects are funded across four provinces. SOS teams aim to reduce harm by prescribing Dilaudid and other regulated opioids to people at high risk of overdose.
The majority of people served have tried abstinence-based treatment and continue to use street opioids daily.
Programs also deliver primary care and refer to resources and drug treatment when desired.
Evidence suggests that SOS programs reduce the risk of death from any cause, including overdose while decreasing emergency department visits and health-care costs. Participants see their relationships and mental and physical health improve. They report less street drug use and decreased involvement in and exposure to violence, criminal activities and legal issues. By meeting people where they are, SOS programs provide another pathway to stability.
Some SOS programs utilize supervised dosing to prevent diversion (the selling of prescribed medication), which necessitates frequent clinic visits — up to three times per day. Frequent visits reduce retention and make maintaining work, education and relationships challenging.
Supervising doses is resource intensive, limiting scalability. This translates to less access. Programs often see people on their wait-list die of overdose. Meeting the need for safer drugs is not feasible with supervised programs alone.
The rationale against providing unsupervised doses revolves around preventing diversion. While this concern is not unwarranted, it is vital to contextualize it. It’s not new that prescription medications are sold on the street — the availability of virtually any medication predates SOS initiatives.
Compared to the poisoned street supply, diverted medications carry far less overdose risk.
In Ontario, during the early pandemic both the percentage and overall number of Dilaudid-related deaths decreased despite increased prescribing.
Another concern is that diversion will contribute to more substance use. Reasons for substance dependence are often multi-faceted and more complex than simply having access to drugs. There will always be people who use drugs. Unregulated opioids are causing extremely high mortality rates. Given this, withholding access to a regulated supply in an attempt to reduce opioid use and harm is unjustifiable and unrealistic.
Programs have room for improvement. Some people’s opioid tolerance is not met with Dilaudid, leading to reduced but continued street opioid use. Access to opioids not currently covered by provincial drug plans, including pharmaceutical fentanyl, heroin, and injectable hydromorphone is needed.
Non-medicalized models like buyers clubs and regulation would bring greatest benefit. A wider range of options would meet diverse needs leading to less diversion and more success. Rather than terminating life saving programs, governments should remove the barriers that impede enhancements to SOS initiatives.
We are at a critical juncture. Failing to meet the need for safer drugs promotes a deadly unregulated supply and devalues the lives of people who use drugs. Providing safer drugs will save lives.