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Ontario Premier Doug Ford recently called on Canada's Prime Minister Justin Trudeau to stop approving and launch a review of the country's current safe supply programs, which are intended to provide a safer alternative to toxic illegal drugs for people who are at high risk for overdose. He also requested that provincial support be a requirement for sites that offer safe supply.

At safe supply sites, at the discretion of healthcare practitioners, opioids, stimulants, or benzodiazepines may be prescribed as alternatives to toxic street drugs to patients at high risk for overdose, according to Health Canada, which currently approves the sites. Other services may include more accessible locations, flexible dosing, substance use disorder treatment, and mental health counseling and support.

"Due to Health Canada's siloed approval process, the province is completely in the dark about where these federally approved sites are operating and the quantity of controlled and illegal substances they dispense," said Ford, as reported by Global News.

Ford also expressed concern about diversion of the medications obtained at safer supply sites. He raised the prospect of recipients trading the controlled drugs on the street for more harmful drugs such as fentanyl.

"It is quite scary to see how fast politicians are dismantling life-saving initiatives," Eugenia Oviedo-Joekes, PhD, Canada Research Chair in Person-Centered Care in Addiction and Public Health at the University of British Columbia in Vancouver, British Columbia, Canada, told Medscape Medical News.

"We had decade after decade of the war on drugs, stringent treatment regulations, [and] widely expanded treatments without much improvement," she said. However, "after a few years of these [safe supply] pilot programs, with a lot of insecurity regarding funding and the future of the programs, there is a call to backtrack on these initiatives, without evidence."

"A few specific, deeply sad deaths that have occurred, potentially related to the availability of prescribed alternatives, cannot obfuscate the number of lives saved, [compared with] thousands who have died due to the toxic drug supply."

For any other illness, said Oviedo-Joekes, "it would be unthinkable to stop a service that saves lives due to [stigma] or situations that require improvement in the services."

Ford's position is "misguided," Elaine Hyshka, PhD, Canada Research Chair in Health Systems Innovation at the University of Alberta's School of Public Health in Edmonton, Alberta, Canada, told Medscape Medical News. "The programs were funded to address the worsening drug poisoning epidemic and are undergoing scientific evaluation. Ending funding for these programs would have direct negative consequences for participants by increasing their reliance on the illegal drug supply and their risk of drug poisoning death."

What's the Evidence?

Since national surveillance began in 2016, Canada has seen "substantially elevated" numbers of opioid-related deaths and other harms, according to Public Health Agency of Canada statistics. For example, 42,494 apparent opioid toxicity deaths were reported between January 2016 and September 2023.

From January to September 2023 alone, there were 5975 apparent opioid toxicity deaths, which is 8% higher than the same period in 2022. In addition, there were 4646 opioid-related poisoning hospitalizations (13% higher than the same period in 2022), 21,708 opioid-related poisoning emergency department visits (14% higher than the same period in 2022), and 33,015 emergency medical services responses to suspected opioid-related overdoses (18% higher than the same period in 2022).

Although limited and ongoing, studies on safer supply so far have generally had favorable results. For example, the London InterCommunity Health Centre in Ontario launched a safer opioid supply program in 2016. An interrupted time series analysis compared London residents who received a diagnosis of opioid use disorder and entered the program between 2016 and 2019 with individuals matched on demographic and clinical characteristics who did not participate in the program.

Researchers found reductions in hospital admissions, emergency department visits, and overall healthcare costs not related to primary care or outpatient medications. In addition, no opioid-related deaths occurred among safer supply participants in the year after they entered the study.

In 2020, the Substance Use and Addictions Program at Health Canada funded 10 time-limited safer supply pilot projects in three provinces and contracted a 4-month qualitative assessment of the projects from December 2020 to March 2021. The assessment found that, among other benefits, participants reported improved health, well-being, and quality of life; decreased overdose risk and decreased use of street drugs; reduced stress; more energy; eating and sleeping better; increased stability in their lives; and feeling hopeful about the future.

Staff reported that "key successes related to staffing have included the benefits of a multidisciplinary team where team members have diverse perspectives and common goals. The team is well-rooted in community harm reduction practice, has a keen social justice analysis, and has established open modes of communication and support."

Public perception (ie, stigma against opioid users) can be a barrier to safer supply program implementation. Yet a recent study led by Hyshka looked at public support for safer supply programs in Alberta and Saskatchewan, two provinces that had not endorsed the initiatives at the time of the study (March 2021), and found that most Canadians living in those provinces supported provincial government efforts to expand safer supply.

This finding suggested that a lack of public support is not the main barrier to implementation and that "efforts at mobilizing this public opinion are needed to scale up and facilitate evaluation of this drug poisoning response," according to the authors.

However, a more recent assessment of British Columbia's safer supply policy found that 2 years after its 2020 launch, while the policy was associated with higher rates of safe supply opioid prescribing, it was also associated with a significant increase in opioid-related poisoning hospitalizations.

The authors hypothesized that the higher hospitalization rates could result from diversion of the safer opioid supply, which Ford alluded to. An increase in prescription opioid misuse, given the increase in opioid prescriptions, is another potential explanation. Finally, the availability or toxicity of the unregulated drug supply may have increased more in British Columbia than in other provinces, thus leading to more hospitalizations in British Columbia. The authors concluded that the findings could inform "ongoing debates" about safe supply policy in Canada.

'Toxic Drug Crisis' Continues

"The consequences of closing programs will be devastating, not just for the people that the program serves but for the staff and harm reduction in general," said Oviedo-Joekes. "We were a country moving in the direction of destigmatizing services for people who use drugs and innovating in person-centered addiction care. These setbacks can really put substance use care years behind."

Rather than closing safer supply sites, she added, "It is time to improve upon what we are learning and solidify these services."

Hyshka urged clinicians to "learn more about the toxic drug crisis, trends in the illegal drug supply in your community, and stay on top of emerging evidence in this area. Advocate for an evidence-informed public health response to drug poisoning that includes continued efforts to expand access to opioid agonist treatment and evaluate various models of safer supply."

As of May 17, Trudeau had not said whether the government would pause safe supply approvals or conduct a review of current sites, according to The Canadian Press.

Marilynn Larkin, MA, is an award-winning medical writer and editor whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.