Adam Zivo: Yes, “safer supply” is really harming youth
We have real evidence of a growing problem. Why aren't we trying to learn more?
By: Adam Zivo
Addiction physicians across Canada have spent months warning that the federal government’s “safer supply” programs are getting youth hooked on opioids. Their voices can no longer be ignored. While advocates of these programs have long dismissed clear warning signals as “anecdotal,” more evidence is rolling in that supports the claims and fears of the programs’ critics.
A new report published last month by the B.C. Coroner’s Service provides, for the first time, hard data which appears to substantiate allegations of harm. The data shows that as “safer supply” programs have expanded, the drug distributed by these programs, hydromorphone, has been increasingly implicated in youth drug deaths — accounting for nearly a quarter of drug-related fatalities in that age group last year alone. Before 2020, the year safer supply was expanded, hydromorphone was implicated in zero youth deaths. While that change is concerning in and of itself, it may also be indicative of larger trends in general youth drug use. That is, it may suggest that more young people are availing themselves of the legally prescribed opioids now flooding the drug market. With safer supply participants frequently receiving more than 10 hydromorphone pills a day, and with each pill being strong enough to cause an overdose among opioid-naïve users, parents have good reason to be concerned.
Despite dismissals from naysayers who have rejected warnings about this very problem, the data now suggests that handing drug users legal “safer” opioids is contributing to more young people getting addicted to these very drugs.
As safer supply is highly controversial and politically fraught, the release of this data is a very big deal. It ought to give the programs’ advocates pause, and to encourage the provinces to slow their adoption of this ideologically driven addiction policy. It doesn’t seem that it will.
For those who are new to this issue, “safer supply” programs claim to reduce overdoses and deaths by distributing free drugs as alternatives to potentially tainted illicit substances. Canadian safer supply typically distributes 8 mg tablets of hydromorphone, an opioid as potent as heroin, as an alternative to illegally sourced fentanyl.
These programs are admirable in theory. Since January, however, I have interviewed more than 25 addiction medicine experts who say that, due to widespread fraud, actual impacts have been disastrous. Hydromorphone is not powerful enough to get fentanyl users high, so users often consume just enough tablets to pass the urine tests needed to stay on the program, and then sell (“divert”) the rest to purchase harder substances (typically more illicit fentanyl).
As users are typically not supervised while they consume their safer supply prescriptions, there are few, if any, barriers to prevent hydromorphone from flooding the black market. In several cities where safer supply programs are active, addiction physicians say that the street price of the drug has collapsed by 70-95 per cent: An 8 mg tablet can now be bought for as little as $1-2.
Safer supply harms youth
The addiction physicians I interviewed were consistent in their concerns: they said that abundant, cheap hydromorphone has recently led to a rise in opioid use, particularly among youth (defined as individuals younger than 18). These physicians have either directly worked with hydromorphone-addicted youth, or have met with colleagues who handle such patients in their clinics.
Youth are often unaware of hydromorphone’s risks and underestimate how perilous the drug is, partially because it originates from a pharmacy and is widely marketed as “safe.” This makes them more open to experimenting with it, in contrast to stigmatized substances, like heroin, which are widely understood to be dangerous.
Yet 8 mg tablets of hydromorphone are not safe for opioid-naïve users. Just one tablet is four times the dose typically used in a hospital setting to manage surgery-related pain. Consuming only a few tablets can cause an overdose, especially if they are mixed with alcohol.
Individuals who abuse opioids quickly develop a tolerance to them, but youth who get addicted to hydromorphone often require ever-higher doses, and stronger substances, to achieve the same high — which causes some to graduate to using fentanyl. This outcome is, ironically, the very opposite of the idealized "harm reduction" that animates these programs.
In an interview earlier this year, Dr. Caroline Ferris, a Victoria-based addiction physician who prescribes safer supply, said that her colleagues have been concerned by the “unprecedentedly young” ages of some new patients, with children as young as 12 to 14 getting hooked on hydromorphone and then graduating to fentanyl.
In late May, I connected with the father of Kamilah Sword, a 14-year old-girl who died of an apparent hydromorphone overdose last August. I subsequently interviewed three of Kamilah’s close friends — all of whom were teenage girls who struggled with hydromorphone addiction in Port Coquitlam, B.C. Their statements corroborated the observations made by the addiction physicians I’d interviewed earlier in the year.
The girls said, for example, that abuse of “dillies” (hydromorphone) was ubiquitous in their communities and that the drug’s low price made it an attractive option for them. They recalled being told that dillies were not dangerous, but that, upon trying them, they quickly became addicted and were then pressured by dealers to purchase more expensive substances, such as heroin.
The girls also described several hydromorphone-related overdoses which they had personally witnessed; for example, friends and acquaintances overdosing after consuming only a few tablets at once, or being hospitalized after taking dillies while drinking.
Critically, the girls said that the dillies sold in their community originated from downtown Vancouver; it was well-known among their peers that “homeless people” tell pharmacies that they need free hydromorphone to manage their drug use, and then sell their safer supply to youth.
Criticism of anecdotal evidence
In early May, the National Post published a 10,000 word investigative story of mine which detailed the harms of safer supply. The response was electric. The report was cited in parliamentary debate, and, shortly after, the Conservatives put forward a motion (which failed) to defund safer supply and reallocate funding towards recovery-oriented treatment. I have since written several follow-up stories on the issue.
Safer supply advocates have often responded to my journalism by arguing that any evidence of harm is anecdotal, and that, as such, there is no real proof that safer supply is harming communities. There is some truth to that — anecdotes, including my own, have limits.
But the broader context matters: although safer supply is a high-stakes policy backed by tens of millions of federal dollars, it, too, relies on a fallible evidence base. Most of the studies supporting these programs use self-reported data — typically interviews with safer supply recipients, who have strong incentives to romanticize the program. These kinds of low-quality studies would be unacceptable in most health-care environments.
Worse yet, the researchers behind these studies rarely, if ever, interview other community stakeholders who may experience harm; some interview guides even appear to be biased towards producing positive assessments of the program.
In some instances, government officials have dismissed concerns of safer supply by relying on misleading data interpretation.
For example, in early June the B.C. Coroner’s Service asserted that hydromorphone is playing no “significant” role in overdose deaths. That statement was misleading. Addiction physicians who have raised concerns about safer supply have claimed that, while safer supply diversion is creating new addictions, the risk of death largely arises from subsequent fentanyl use. If true, hydromorphone would not be expected to be a significant cause of death, in and of itself. The phenomena is not much different from the abuse of other prescription opioids, which, like hydromorphone, kill relatively few people but still indirectly cause deaths through escalating addiction.
Meanwhile, the B.C. Coroner’s Service also tried to rebut my reporting by asserting that there has been no measurable increase in the rate of opioid use disorder among youth. However, this statistic cannot be used to conclusively dismiss physician observations, as it is possible that rising youth opioid addiction simply isn’t being diagnosed, or has not yet been noted with adequate data collection. Canadian health-care systems evidently struggle with measuring addiction. For example, a report published in Ontario last month showed that, while opioid-related harms significantly increased among youth between 2014 and 2021, rates of treatment significantly declined. During this period, less than half of youth who died from opioids were diagnosed with opioid addiction. It is reasonable to ask whether these same measurement issues are happening in B.C., considering the stark mismatch between the province’s data and physicians’ front-line observations.
This just scratches the surface of the problems with safer supply’s evidence base. However, what is important to know is that, in general, there have been no serious attempts to study the program’s downsides. In some cases, such research seems to have been actively suppressed. For example, I interviewed a B.C.-based physician, who worked at a major institute associated with safer supply, who told me that their job security was threatened after they volunteered to use their spare time to crunch their workplace’s data to measure negative outcomes. This allegedly happened with other colleagues, too.
Safer supply advocates insist that their program is science based, but if research into downsides and unintended consequences is being suppressed or interfered with, we cannot draw conclusions from the lack of evidence of harms. That means that my journalism has had to fill a big gap. I have tried to be meticulous, but a single investigative journalist is no replacement for multi-million dollar, multi-year scientific studies.
One physician, Dr. Ferris, put things into perspective: “Anecdotal evidence precedes the data collection. Somebody sounds an alarm and then we collect data. With the OxyContin crisis and fentanyl, we in the field knew what was happening before there was data to support it.” She’s right. The correct government response to frontline stories of safer supply harms should be to commission high quality studies by scientists who do not have an ideological agenda to fulfil.
This has not yet happened, and it’s hard to think of a charitable explanation.
New data substantiates concerns
This is not sustainable. Hard data is starting to roll in about these programs, despite advocates’ best efforts. As mentioned earlier, the B.C. Coroner’s Service recently released a new report that included, for the first time, detailed data about youth drug deaths between January 2017 and December 2022. Shortly after, I called a contact who was dissecting the data with some physicians. “We found the smoking gun,” they said.
The report showed that, since 2020, youth drug deaths have been increasing at an unsettling pace, jumping from 13 in 2019 to 36 in 2022, making drug toxicity the leading unnatural cause of death among youth last year. To put things into perspective, the 2022 numbers represent a 500 per cent increase in mortality compared to what was seen in the early 2010s (this comparison can be made because, while most of the data in the report begins from 2017, the data about overall deaths begins from 2012).
The report also stated that hydromorphone was present in only eight per cent of youth drug deaths from 2017 to 2022 — but, somewhat oddly, the authors failed to flag a disturbing trend.
Between 2017 and 2019, before safer supply was widely available in the province, zero per cent of youth-related drug deaths involved hydromorphone. When safer supply expanded in 2020, things changed. That year, hydromorphone was involved in 5.5 per cent of youth drug deaths — then 9.6 per cent in 2021 and 22.2 per cent in 2022.
We can now definitively say that since safer supply was expanded in B.C., the use of hydromorphone has spiked among youth drug users, and at the same time, deaths in that age group from overdoses have been increasing. Is there a direct link? We don’t know, and don’t seem to want to know.
When the report was released, safer supply advocates responded by pointing out that, of these hydromorphone-involved youth deaths, one third also involved fentanyl (or fentanyl analogues) and two thirds involved only low amounts of hydromorphone (aka: hydromorphone was unlikely to have contributed to those particular deaths). They thus concluded that hydromorphone was not an issue.
Yet this data is consistent with exactly the phenomenon that addiction physicians have been describing. If the hypothesis is that safer supply primarily kills youth by creating hydromorphone addictions which later mature into fentanyl abuse (or abuse of other dangerous substances), it would make sense that hydromorphone is not the sole cause of many of these deaths. In other words, the rising presence of hydromorphone among youth deaths is enough to raise eyebrows, regardless if the drug directly kills its victims.
Multiple addiction physicians have alleged to me that the B.C. government appears to be doing very little, if anything, to investigate whether fentanyl deaths have any connection to diverted safer supply — so this pool of victims, whatever its size, is currently invisible.
While the B.C. report’s new data about youth drug deaths supports frontline observations made by Canadian addiction experts, it’s important to note that this data does not conclusively validate my reporting. It simply makes it more likely that my interviewees are describing a real and widespread problem (we need more data for absolute certainty). But while the report may not exactly be the “smoking gun” some believe it is, it should nonetheless increase people’s concerns that something is, indeed, amiss with safer supply — something we seem to be going out of our way to learn nothing about.
The Line is entirely reader funded. If you value our work and worry about what will happen when the conventional media finishes collapsing, please make a donation today.
The Line is Canada’s last, best hope for irreverent commentary. We reject bullshit. We love lively writing. Please consider supporting us by subscribing. Follow us on Twitter @the_lineca. Fight with us on Facebook. Pitch us something: firstname.lastname@example.org.