Adam Zivo: "Safe supply" drugs are flooding communities: the evidence piles up
Programs are inundating communities with hydromorphone, crashing its street price while spurring new addictions, especially among youth.
By: Adam Zivo
New research from Ontario has yielded further evidence that Canada's "safer supply" drug programs are being widely defrauded and putting addicts' lives at risk.
These programs claim to reduce overdoses and deaths by providing drug users with pharmaceutical alternatives to potentially tainted illicit substances. In Canada, that typically means distributing large volumes of hydromorphone, an opioid as potent as heroin, in the hope of reducing consumption of illicit fentanyl.
Addiction experts have widely reported that, based on their clinical experiences, drug users regularly trade or sell (“divert”) some (perhaps much) of their safer supply on the black market to fund the purchase of stronger substances. This has flooded some communities with hydromorphone, crashing its street price by up to 95 per cent over the past three years while spurring new addictions, especially among youth.
The federal government denies that these problems exist and has said that any evidence of harm is “anecdotal” — but two addiction experts working in a hospital in London, Ontario recently used patient data to show that the problem is indeed very real.
Dr. Sharon Koivu and Allison Mackinley (a nurse practitioner) examined the charts of 200 patients who had been referred to Victoria Hospital’s addiction medicine consultation service between January and June 2023.
The review showed that 32 per cent of patients who were not in a safer supply program had self-reported using diverted hydromorphone — the vast majority of these patients indicated that their hydromorphone came from purchasing drugs provided to someone else as part of a safer supply program.
“It was more common for them to actually specify safer supply than to say they didn’t know the source,” said Dr. Koivu in an interview. “They said things like, ‘The person in the apartment beside me goes and picks up her safer supply and when she comes back I get 20 of her pills.’ It was quite specific.”
Diversion was not the only problem that was validated.
The chart data suggested that safer supply clients were roughly five-to-10 times more likely to be hospitalized than drug users receiving traditional, evidence-based addiction medications, such as methadone or buprenorphine (these medications are known as “opioid agonist therapy,” or “OAT”). Compared to OAT patients, drug users on safer supply were more than 15 times more likely to be hospitalized for serious infections.
These findings were so concerning that when a group of 35 addiction physicians recently wrote an open letter calling upon the federal government to reform safer supply, they included this data in their accompanying evidence brief.
(This chart, included in a recent evidence brief, compares the number of hospitalized patients with the number of drug users in London, Ontario who receive safer supply (250), methadone (2,000), and buprenorphine (300).)
Safer supply patients also had a slightly higher hospitalization rate, and only slightly lower infection rate, than patients who were receiving no addiction treatment at all, which suggests that the health benefits of safer supply may actually be negligible.
Dr. Koivu said that the hospitalization rate seen among safer supply patients was “alarmingly high” considering that safer supply programs provide significant wraparound supports (i.e. access to doctors, housing and social assistance) in conjunction with free hydromorphone. Any patient who receives such supports should see substantially improved health outcomes.
The London chart review did not provide enough data to make meaningful conclusions about mortality rates. While safer supply advocates argue that their programs reduce overdose deaths, the evidence backing this claim is inconclusive. In some cases, activist groups have misrepresented studies to argue that "safer supply saves lives" – for example, by claiming that the positive results seen in some heroin-based OAT programs, which require supervised consumption, apply to unsupervised safer supply.
However, Dr. Koivu and Mackinley saw a clear correlation between hydromorphone injection and severe infections. Every single patient who had a spine infection had used hydromorphone – half of those patients were in a safer supply program, and half of them used diverted hydromorphone.
“People's drug use can be complicated and complex, but the thing that everyone had in common was the use of Dilaudid (brand name hydromorphone). It would, to me, be highly indicative that that is most likely the drug that was causing their infection. And in certain cases, the patients were extremely emphatic that they had not used other drugs at all, not just at the time of their infection, but period. That Dilaudid was the only drug that they had used prior to getting an epidural abscess (spinal infection),” said Dr. Koivu.
It is common practice for drug users who acquire hydromorphone pills to crush and inject them, as this produces a stronger effect. While many safer supply programs condone this practice, these pills are designed for oral consumption and contain materials that are not safe for intravenous use, which can cause excruciating infections that can leave patients paralyzed. Dr. Koivu hypothesized that tablet particles, which fail to dissolve in blood, were passing through patients' hearts before damagingly lodging themselves inside tiny vessels located in the spine and causing infections there.
The prevalence of these disabling spinal infections has raised questions about whether safer supply patients are adequately informed about the program’s risks, and whether they can provide informed consent to receive safer supply without this information.
“All of the patients that I saw in the program and who were injecting Dilaudid said they believed it was safe. They did not understand the infection risks and felt that even the information they were told about risks of infection were just about a local infection. They really did not have a perception that it could cause any infection that would be significant or harmful,” said Dr. Koivu.
She noted that, while researchers and policymakers tend to focus on overdoses when measuring addiction-related harms, they generally overlook infections and hospitalization — even though infections cause as much death as overdoses among drug users.
In addition to widespread diversion and infections, the Victoria hospital chart data also suggested that safer supply dissuades patients from seeking addiction treatment.
Of the patients included in the chart review, between 50-60 per cent who were not in an addiction treatment program initiated OAT by the time they were discharged from Victoria hospital. However, only five per cent of patients who were enrolled in safer supply initiated OAT at discharge.
Safer supply is not considered an addiction treatment and is meant to keep patients alive until they decide to seek recovery, but it seems that being on safer supply is actually associated with a 90 per cent reduction in the uptake of evidence-based addiction treatment.
Dr. Koivu was open about the limitations of her work. As she and Mackinley had no funding, they each had to volunteer an estimated 50 hours of their time, primarily over evenings and weekends, toward conducting the review. This prevented them from gathering as much data as they’d have liked.
“I think that we need more data and more research. But I think that there is enough evidence that we should be looking at a precautionary principle of not recommending this pill be injected, nor should we be accepting injection of these pills,” she said.
While Dr. Koivu and Mackinley's research is compelling, it remains to be seen whether the federal government will pay any attention to it. Over the autumn, dozens of addiction experts asked Ya'ara Saks, the Minister of Mental Health Addictions, to reform or abolish safer supply – but physicians have told me that the Minister seems to be ignoring them. How many more people have to suffer before the government admits that its signature addiction strategy was a mistake?
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Every time opioids have become more accessible, it's been accompanied by an addiction crisis. Opium in China, morphine in the 19th century, Bayer heroin in the early 20th century, oxycontin in the late 20th/early 21st century. Diversion of "safe supply" drugs exacerbating existing addiction problems and expanding the number of addicts is depressingly predictable.
It often seems like activists concerned with drug addiction miss the fact that the drug use *is* the problem. The homelessness, disease transmission, overdoses, social dysfunction, and crime all follow from the drug use. The fact that we talk about drug use instead drug *abuse* suggests another way we've lost the plot here: these are pharmacological substances with positive and negative effects. When used for pain management, particularly temporarily, the benefits outweigh the negatives. Using them for recreation or getting high is abusing them. When these drugs don't kill their users quickly with overdoses, any experienced medical professional can tell you stories about all the other nasty consequences that manifest with chronic use. Preventing overdoses with things like safe supply is at best a means of buying time to get people into recovery. If you can't get them into recovery, you're just prolonging the time it takes for drug abuse to kill them.
Thanks for all your work on this file, Adam. The gaslighting around safer supply is similar to the gaslighting around puberty blockers. Ideological capture makes evidence based decision making next to impossible. Aside from confirmation bias, too many people have invested too much personal credibility to walk back unfounded beliefs. (See also the general unwillingness of politicians and media to correct false claims of mass graves, and of prosecutors to own up to wrongful convictions.)