A safer drug supply: a pragmatic and ethical response to the overdose crisis

CMAJ recently published a commentary regarding safer supply, pharmaceutical alternatives to the poisoned drug supply fueling the overdose crisis(1). Tyndall’s article describes the roots of the overdose crisis; calling for a clear strategy to scale up safer supply prescribing(1). Addressing barriers to prescribing, coupled with decriminalization of drugs, is essential to realizing success of this approach.

Tyndall indicates physician provision of safer supply has been met with reluctance and prescribing rates are falling short to impact the overdose crisis(1). This is in part due to prescription review programs by regulatory colleges, with perceived inappropriate prescribing being grounds for reprimand. Federal Minister of Health Patty Hajdu released a letter calling on colleges to support clinicians and increase access to safer supply(2). As the Minister points out, important measures to prevent opioid over-prescribing must be weighed against the need to prescribe pharmaceutical alternatives. Supporting clinicians to prescribe without fear of reprisal may impact access to safer supply.

Prescribing rates, however, for even evidence-based therapies for opioid use disorder are low among physicians indicating the widespread adoption of safer supply prescribing will remain challenging(3). A practitioner-led model requires engagement from more clinicians, with access to a wider array of opioid formulations. Recently British Columbia implemented a Public Health Order expanding access to safer supply by authorizing prescribing by registered nurses. This is a major step for increasing access to safer supply.

In Ontario, safer supply programs have been in place for up to 5 years showing initial results of decreased overdose, decreased infections, improvements in chronic disease management and decreased illegal activities to fund illicit drug purchase(4). These programs are creating compelling evidence that many of the harms of illicit drug use are in fact related to prohibition of these substances and our societal response to their use(4). PM Justin Trudeau specifically indicated that decriminalization of drugs is not being considered and that safer supply is the government’s key priority for addressing the overdose crisis(5). However, criminalizing drugs and the people who use them disproportionately impacts poor and racialized groups, undermining efforts made to improve access to health care services, such as safer supply. Government officials should look to decriminalization as part of next steps to support expanded access to safer supply. This would require legislative change and coordination amongst government agencies, as has been done in response COVID-19.

Swift and decisive action has been crucial to Canada’s success limiting COVID-19. The same emphatic response is needed now combat the overdose crisis. Clinicians must be supported by regulatory colleges to prescribe in tandem with decriminalization of drugs and people who use them.

Tyndall’s article (1) provides timely insight regarding the overdose epidemic. The COVID-19 pandemic poses unprecedented risk to Canadians with opioid use disorder, who- already marginalized -are quite dependent on in-person health care delivery. In regard to COVID-19 prevention, the Canadian Government defines clinically vulnerable people as those with “mild to moderate respiratory disease” or with a “weakened immune system as the result of certain conditions or medicines they are taking” and are advised to take extra care. Thus, patients with chronic opioid dependence should be included in the clinically vulnerable high-risk group, this means we need to create healthcare policies supporting them.

Due to COVID-19, there is a severe shortage of clean opioids for these patients. Hence, rapid action on the part of the healthcare community is needed to mitigate the risks of disrupted care for these patients. The COVID-19 pandemic has reversed system-level gains in expanding access to medication for opioid use disorder and halted critical opioid research on prevention and care. Resultantly, rises in opioid overdose-related problems have been seen due to multiple factors (1).

A key point in this article is that physicians in BC have been cautious prescribing opioid medications despite clinical guidance provided during the COVID-19 pandemic (1). The cautious approach to prescribing opioid medications may be the result of messages physicians have seen (2). These messages stigmatize opioids and create fear amongst physicians, as they worry their patients may become addicted and succumb to their addiction (2). It is important to address the discomforts physicians have in regard to prescribing opioids. Moreover, additional factors exist around opioid medications have to be considered including socioeconomic status, mental health and substance use problems (3). These factors create a situation where it is less likely physicians prescribe opioid medications.

We suggest further resources be created to support physicians become more comfortable prescribing opioid medications, as most physicians lack training to optimally prescribe opioids (4). The current guidelines in BC- addressing both the overdose and COVID-19 crises -provide a great deal of clinical support for prescribing healthcare professionals including valuable case studies (5). However, these guidelines would benefit from additional resources to support healthcare professionals reflect on their positionality in regard to prescribing opioids and to develop additional confidence in their ability to manage patients with opioid use disorder. Specifically, programs similar to the BC project ECHO on substance use disorder- it supports care providers assist patients with opioid use -are valuable resources that should be included in clinical guidelines. Resources that support health care professionals better understand how to use opioids empowers us to make evidence-based decisions confidently.