Safe Supply Is A Controversial Policy, But It's Ultimately A Good One

Opinion by Eugene Jeoung.

The following article contains a discussion of drug use, addiction, needles, and overdoses. This may be considered disturbing or difficult by some readers.

The onset of the COVID-19 pandemic has undoubtedly impacted every aspect of the way we live, but some of its most devastating impacts have been experienced by people who use drugs (PWUD). Not only have physical distancing and lockdown measures limited the ability of PWUD to access critical drug services like safe injection sites, but the illicit drug market continues to create uncertainty in the quality of drugs sold on the street, which can increase opioid-related overdose mortality rates [1][2]. In fact, the Public Health Agency of Canada estimates that the crude rate of overdose deaths have increased two-fold since the beginning of the pandemic, and it also projects that these could further increase over the next six months [3][4]. To respond to some these challenges, some cities and provinces have implemented ‘safe supply’ programmes, which seek to provide a regulated and untainted supply of traditionally ‘illegal’ drugs to PWUD in an effort to reduce violence and harms associated with drug acquisition [5].

Of course, like any policy, safe supply isn’t without its critics; some doubt whether the strategy is truly ‘safe.’ Just in the last two months, two opinion pieces were published in reputable news websites that claimed safe supply is creating nothing but a “right to get high” and that the policy goes against the central principle of medicine to ‘do no harm’ [6][7]. Some researchers echo similar sentiments in medical journals, hypothesizing that safe supply could instead create opioid diversions and increase harms for PWUD [8]. In short, they ask: can we and should we really prescribe ourselves out of a problem we’ve prescribed ourselves into?

My answer to that question? Yes.

While most of the literature can only hypothesize on the impacts of safe supply given how recent the policy is, even these hypothetical benefits seem promising. The most common positive health outcome mentioned is the possible reduction of overdose deaths resulting from a decrease in the use and misuse of illicit fentanyl-based opioids [9]. Other studies mention the ability for safe supply to mitigate the transmission of viruses normally associated with needle-sharing activities (e.g., HIV, hepatitis C),

reduce the rates of opioid-related withdrawals, and help PWUD for whom other treatments are difficult to initiate or retain [10][11][12]. It is also purported to help with mental health outcomes by allowing PWUD to improve their moods while helping them avoid the stigmatization traditionally associated with drug use and seek critical services such as counselling [13].

And it’s not like we haven’t already seen some of these positive impacts in real life. Preliminary findings of some safe supply initiatives suggest that safe supply was associated with lower rates of stigmatization, illegal drug use, and overdose and withdrawal rates, as well as improved physical and mental health and well-being [14][15][16][17]. These findings also suggest that safe supply allowed for PWUD to focus their resources toward meeting other needs, such as relieving their debt or devoting more time to their families [18].

Not only that, but we’ve also seen the ability of safe supply to adapt to the conditions of the pandemic. The MySafe initiative based in British Columbia shows that flexible pick-ups are possible with minimal staffing requirements, which allows for PWUD to maintain compliance with public health restrictions while continuing to access necessary substances [19]. Additionally, with stay-at-home and self-isolation orders, a cleaner supply of opioids has been found to reduce the risk of overdose deaths in unsupervised areas [20].

This isn’t to deny the genuine concerns that people have about safe supply. There needs to be more choices available to PWUD who require more potent substances to ease withdrawal symptoms, as the currently used hydromorphone is much less potent than fentanyl and can hence increase rates of diversion to the illicit market [21]. Further, there is a critical lack of research on safe supply initiatives outside of a select few cities, meaning that the results of the studies above may not necessarily be generalized across different contexts. But irrespective of these concerns, the message is clear: we need better regulations in drug policy that reduces harms experienced by

PWUD. After all, you can’t treat harm on someone who’s dead, and no one is heartless enough to suggest that PWUD should die when most of them are only trying to cope with their pain.

I’m not saying that the work is done with safe supply. Even with a legally regulated supply of drugs, the context of drug use will remain the same and simply implementing the policy won’t help everyone quit misusing various substances. But safe supply was never meant to be a catch-all solution; to reduce rates of substance use disorder, we also need other strategies that support the health and well-being of PWUDs. Continued monitoring of the policy is also required to ensure that there are no unintended consequences of safe supply that exacerbate drug-related harms. Yet, while we continue to inhabit a peri-pandemic world, safe supply might be all we have to prevent overdose deaths and reduce drug-related harms, so why not give it a shot?

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Bibliography

[1] Wiley D. Jenkins et al., “COVID‐19 During the Opioid Epidemic – Exacerbation of Stigma and Vulnerabilities,” The Journal of Rural Health, June 2020, jrh.12442, https://doi.org/10.1111/jrh.12442.

2]Alanna Smith, “Illicit Drug Supply Potentially More Dangerous amid COVID-19 Pandemic,” Calgary Herald, May 19, 2020, https://calgaryherald.com/news/illicit-drug-supply-potentially-more-dangerous-amid-covid-19-pandemic.

3] Special Advisory Committee on the Epidemic of Opioid Overdoses, Opioid- and Stimulant-elated Harms in Canada (Ottawa: Public Health Agency of Canada, 2021), https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants.

4] Public Health Agency of Canada, “Joint Statement from the Co-Chairs of the Special Advisory Committee on the Epidemic of Opioid Overdoses – Latest Modelling Projections on Opioid Related Deaths and National Data on the Overdose Crisis,” statements, Government of Canada, December 15, 2021, https://www.canada.ca/en/public-health/news/2021/12/joint-statement-from-the-co-chairs-of-the-special-advisory-committee-on-the-epidemic-of-opioid-overdoses--latest-modelling-projections-on-opioid-re.html.

5] Mark Tyndall, “Safer Opioid Distribution in Response to the COVID-19 Pandemic.,” The International Journal on Drug Policy, July 27, 2020, 1–5, https://doi.org/10.1016/j.drugpo.2020.102880.

6] Daphne Bramham, “Will a ‘safe’ Drug Supply Ease Vancouver’s Overdose Epidemic?,” Vancouver Sun, October 29, 2021, https://vancouversun.com/news/daphne-bramham-will-a-safe-drug-supply-ease-vancouvers-overdose-epidemic.

7] Vincent Lam, “Opinion: As a Doctor, I Was Taught ‘First Do No Harm.’ That’s Why I Have Concerns with the so-Called ‘Safe Supply’ of Drugs,” The Globe and Mail, November 20, 2021, https://www.theglobeandmail.com/opinion/article-as-a-doctor-i-was-taught-first-do-no-harm-thats-why-i-have-a-problem/.

8] Melanie Willows et al., “Is All ‘Safe Supply’ Safe?,” Canadian Journal of Addiction 11, no. 1 (March 2020): 30–31, https://doi.org/10.1097/CXA.0000000000000079.

9] Geoff Bardwell et al., “‘People Need Them or Else They’re Going to Take Fentanyl and Die’: A Qualitative Study Examining the ‘Problem’ of Prescription Opioid Diversion during an Overdose Epidemic,” Social Science & Medicine 279 (June 1, 2021): 113986, https://doi.org/10.1016/j.socscimed.2021.113986; Judy Chang, Jake Agliata, and Mauro Guarinieri, “COVID-19 - Enacting a ‘New Normal’ for People Who Use Drugs,” International Journal of Drug Policy 83 (September 1, 2020): 102832, https://doi.org/10.1016/j.drugpo.2020.102832; Taylor Fleming et al., “Stimulant Safe Supply: A Potential Opportunity to Respond to the Overdose Epidemic,” Harm Reduction Journal 17, no. 1 (January 10, 2020): 6, https://doi.org/10.1186/s12954-019-0351-1; Nickie Mathew, James S. H. Wong, and Reinhard M. Krausz, “An inside Look at BC’s Illicit Drug Market during the COVID-19 Pandemic,” British Columbia Medical Journal 63, no. 1 (January 2021): 9–19.

10] Matthew Bonn et al., “Addressing the Syndemic of HIV, Hepatitis C, Overdose, and COVID-19 Among People Who Use Drugs: The Potential Roles for Decriminalization and Safe Supply,” Journal of Studies on Alcohol and Drugs 81, no. 5 (September 1, 2020): 556–60, https://doi.org/10.15288/jsad.2020.81.556.

11] Noa Krawczyk et al., “Early Innovations in Opioid Use Disorder Treatment and Harm Reduction during the COVID-19 Pandemic: A Scoping Review,” Addiction Science & Clinical Practice 16, no. 1 (November 13, 2021): 68, https://doi.org/10.1186/s13722-021-00275-1.

12] Bardwell et al., “‘People Need Them or Else They’re Going to Take Fentanyl and Die.’”

13] Canadian Mental Health Association, “Expand Access to Harm Reduction Interventions during COVID-19: CMHA Ontario Branches Support Safer Supply Approaches” (Toronto, February 8, 2021), https://ontario.cmha.ca/news/cmha-ontario-branches-support-safer-supply-approaches/; Reinhard M. Krausz et al., “Canada’s Response to the Dual Public Health Crises: A Cautionary Tale,” The Canadian Journal of Psychiatry 66, no. 4 (April 1, 2021): 349–53, https://doi.org/10.1177/0706743721993634.

14] Tyndall, “Safer Opioid Distribution in Response to the COVID-19 Pandemic.”

15] Eugenia Oviedo-Joekes et al., “Diacetylmorphine versus Methadone for the Treatment of Opioid Addiction,” New England Journal of Medicine 361, no. 8 (August 20, 2009): 777–86, https://doi.org/10.1056/NEJMoa0810635.

16] Miriam T.H. Harris et al., “A Descriptive Comparison of Substance Use Services in Recovery and Isolation Sites for People Experiencing Homelessness During the COVID-19 Pandemic, Boston and Toronto,” Public Health Reports 136, no. 5 (September 1, 2021): 532–37, https://doi.org/10.1177/00333549211032974.

17] Andrew Ivsins et al., “Barriers and Facilitators to a Novel Low-Barrier Hydromorphone Distribution Program in Vancouver, Canada: A Qualitative Study,” Drug and Alcohol Dependence 216 (November 1, 2020): 108202, https://doi.org/10.1016/j.drugalcdep.2020.108202; Andrew Ivsins et al., “‘It’s Helped Me a Lot, Just Like to Stay Alive’: A Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada,” Journal of Urban Health 98, no. 1 (February 1, 2021): 59–69, https://doi.org/10.1007/s11524-020-00489-9.

18] Ivsins et al., “‘It’s Helped Me a Lot, Just Like to Stay Alive.’”

19] Tyndall, “Safer Opioid Distribution in Response to the COVID-19 Pandemic.”

20] Mariya Cherkasova, “Addiction in the Times of Pandemic,” The Canadian Journal of Addiction 11, no. 2 (June 3, 2020): 9–12, https://doi.org/10.1097/CXA.0000000000000082.

21] Jeremy Allingham, “B.C.’s Safer Supply Program Needs More Choice, Say Drug Users and Advocates,” CBC, June 29, 2021, https://www.cbc.ca/news/canada/british-columbia/bc-safer-supply-needs-more-choice-1.6078921.