December 14th, 2023
The Honourable Mark Holland
Minister of Health
House of Commons
Ottawa, ON K1A 0A6
The Honourable Ya’ara Saks
Minister of Addiction and Mental Health
House of Commons
Ottawa, ON K1A 0A6
Dear Minister Holland and Minister Saks,
As researchers and clinicians across Canada, we are writing out of concern regarding the increased politicization surrounding the response to the drug toxicity overdose crisis that is taking the lives of 21 Canadians every day. We are particularly concerned about the spread of misinformation and the denial of the evidence-base on harm reduction interventions, such as prescribed safer supply programs.
The ongoing drug toxicity overdose crisis needs to be recognized as a public health emergency driven by an unregulated and volatile drug supply composed of fentanyl, fentanyl analogues and other contaminants of uncertain dose and composition. Prescribed safer supply programs aim to reduce overdose by providing regulated, pharmaceutical drugs of known potency and consistency to people who use unregulated drugs. These programs have been piloted on a small-scale since 2020 to provide a new option for people at high risk of overdose and for whom traditional treatment options like opioid agonist treatments (OAT) have not worked or provided sufficient benefit.
Research demonstrates positive impacts of safer supply programs
Currently, there are 24 prescribed safer supply programs across Canada receiving federal funding for operations. Research and evaluation conducted over the last three years has demonstrated important and significant health and social benefits for clients in prescribed safe supply programs. This includes 15 peer-reviewed research studies and five program evaluations, as documented by a recent rapid review by the Ontario Drug Policy Research Network (ODPRN) (1). Published research in well-respected medical and public health journals and program evaluations on prescribed safer supply programs have shown positive outcomes for clients including: decreased use of unregulated fentanyl and related overdose risk; reduced frequency of injection; increased uptake of health services and subsequently improved physical and mental health outcomes; improvements to financial and housing stability; and increased stability and agency over drug use patterns (2-16). Additionally, an analysis of provincial health administrative data in Ontario found significant reductions in emergency department visits, hospital admissions, admissions for infectious complications, and health care costs among people in a safer supply program in the year after beginning safer supply (8) .
However, despite the positive findings from this expanding evidence base, funding contracts for 21 currently operating safer supply programs are set to end in March 2024. This means that thousands of people nationwide will suddenly lose access to life-saving prescribed safer supply medications. Additionally, many individuals will also lose access to their primary care clinician, as well as vital social support from case managers, health navigators, and harm reduction workers currently working in these programs.
Given the ongoing overdose crisis driven by the unregulated drug supply, discontinuing safer supply programs is a dangerous decision. It will foreseeably result in the deaths of people currently receiving regulated prescription of pharmaceuticals, forcing them to return to an unregulated fentanyl market that is volatile and deadly. Furthermore, ending these programs will simultaneously affect existing research projects that are documenting the strengths and challenges of this model of care. This will hinder efforts to generate evidence on the health and social services needed to address drug toxicity deaths across the country.
Diversion of prescribed safer supply medications continues to be monitored
Current criticisms of prescribed safer supply programs largely center around fears that diversion will lead to opioid related deaths or contribute to new opioid use. Recent calls from healthcare providers and politicians to end life-saving safer supply programs have been based on personal anecdotes or opinion, and often reinforce stigmatizing and fear-mongering narratives about people who use drugs. In contrast to these narratives, evidence from both BC and Ontario suggests no measurable impacts from diversion of safer supply medications. BC Coroners Service has been monitoring the drugs involved in overdose deaths, including in youth (17), and has stated that there is no indication that prescribed safer supply is contributing to unregulated drug deaths in the province (17). In Ontario, rates of fatal overdoses involving hydromorphone have decreased since safer supply programs were initiated (18). Additionally, the BC Centre for Disease Control recently reported that there has been no increase in new cases of opioid use disorder in youth since safer supply began (19). And according to a recent report by ODPRN, in Ontario there were 5,401 opioid-related emergency department visits and 752 deaths for youth aged 15 to 24 from 2014 to 2021, with fentanyl as the primary driver of these fatalities (20). This research also notes that there has been a sustained decrease in OAT prescribing to youth, a critical issue that must be addressed.
Questions around diversion and initiation of drug use among youth are important to address, and comprehensive research on diversion and monitoring of trends in substance use initiation and use patterns is ongoing. This research will provide crucial evidence on both the extent and impact of these issues; comprehensive research is necessary to inform policy solutions that are based in evidence. Ignoring the coroner’s data on actual causes of drug toxicity deaths while using anecdotes as rationale to end programs showing positive results in numerous research studies conducted in multiple provinces would be reckless and harmful.
Ending funding for safer supply programs has dangerous consequences
Prescribed safer supply programs are providing accessible, low-barrier care to people for whom other treatment modalities like OAT have not been effective (21-24). Existing research has documented how rapid tapers and opioid deprescribing puts people at high risk of using opioids from unregulated sources and subsequent overdose (25-29). Research and program evaluations have also documented how many people receiving care through prescribed safer supply programs have struggled to access primary care through mainstream delivery models, were disconnected from care prior to receiving safer supply, and their needs have not been met by traditional addiction treatment programs (11). Due to the complexity of their needs, there is a strong danger that people who lose access to safer supply programs will not only lose access to a source of regulated, prescribed opioids, but will also lose access to the comprehensive primary care they have been receiving through SUAP-funded programs. This will result in poor health outcomes and even death for many people currently receiving safer supply.
The number of preventable fatal poisoning deaths caused by the unregulated fentanyl supply in Canada is staggering and constitutes a major public health emergency. There is a history of contentious and highly politicized debates delaying the implementation and scale-up of life-saving harm reduction programs, despite research evidence showing strongly positive benefits. Examples include syringe distribution programs, supervised consumption sites, heroin-assisted treatment and now, prescribed safer supply programs. The resistance to providing long term funding for prescribed safer supply programs is not justifiable based on the current evidence-base, with over 20 peer-reviewed publications and program evaluations showing the effectiveness of these programs. Research and evaluations should continue to explore potential challenges and issues, such as the scale, magnitude and impacts of any diversion that might be occurring. However there is a danger that the implementation of safer supply programs will be delayed by contentious and highly politicized debates, and that currently operating safer supply programs providing crucial and life-saving care will be forced to close due to lack of funding. This will predictably result in unnecessary deaths as people are forced to return to the unregulated drug supply, and must be avoided based on the current evidence available.
Due to this, we call on the federal and provincial governments to immediately:
- Work together to ensure stable and ongoing funding for currently operating prescribed safer supply programs and scale-up programs in areas of high need.
- Support research and evaluation of prescribed safer supply to ensure that this intervention is being provided in a way that is safe and effective for individuals and their communities, and decisions regarding safer supply are evidence-based.
- Engage in collaboration with people who use drugs to develop new programming to deliver a regulated drug supply, in line with recent recommendations from the Chief Coroner of BC Lisa Lapointe (30).
Signatories (in alphabetical order):
Dr. Javed Alloo, MD
Family Physician
CAMH
Dr. Tony Antoniou, PhD
Scientist
Dr. Jaime Arredondo Sanchez Lira, PhD
Canada Research Chair on Substance Use and Health Systems
Assistant Professor, School of Public Health and Social Policy, University of Victoria
Jacqueline Atkinson, NP, MN
Nurse Practitioner Mobile Outreach Street Health (MOSH), North End Community Health Centre
Dr. Brittany Barker, PhD
Senior Scientist
First Nations Health Authority, Canadian Institute for Substance Use Research
Dr. Sofia Bartlett, PhD
Scientific Director (Interim), Clinical Prevention Services, BC Centre for Disease Control
Adjunct Professor, School of Population and Public Health, University of British Columbia
Rebekah Barrett, NP
Nurse Practitioner
Regent Park Community Health Centre
Dr. Ahmed Bayoumi, MD
Professor and Clinician-Scientist
University of Toronto, Unity Health Toronto
Dr. Daniel Bear, PhD
Director, Humber Centre for Social Innovation
Humber College
Dr. Mergim Binakaj, MD
Resident Physician
Dr. Claire Bodkin, MD
Assistant Clinical Professor (Adjunct)
McMaster University
Dr. Jeanette Bowles, DrPH
Research Scientist
BC Centre on Substance Use, University of British Columbia
Dr. Jade Boyd, PhD
Assistant Professor
BC Centre on Substance Use, University of British Columbia
Dr. Susan Boyd, PhD
Distinguished Professor, Emerita
University of Victoria
Dr. Charles-Antoine Breau, MD, CCFP (AM, EM)
Recovery Care
Dr. Ami Brosseau, MD
Family practitioner
Dr. Thomas Brothers, MD PhD FRCPC
Resident physician
Dalhousie University & Nova Scotia Health
Lauren Bryson, NP
Nurse Practitioner
Grand River Community Health Centre
Dr. Jane Buxton, MBBS, MHSc, FRCPC
Professor Emerita
University of British Columbia
Dr. Ashley Carver, PhD
Associate Professor
Saint Mary’s University
Dr Kate Colizza, MD, FRCPC, DRCPSC AM, ISAM
Addiction Medicine and General Internal Medicine
Dr. Diane Crocker, PhD
Professor
Saint Mary’s University
Dalena Dang, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Dr. Sara Davidson, MD
Medical Director
River Stone Recovery Centre
Dr. Kora DeBeck, PhD
Associate Professor
Simon Fraser University
Zoe Dodd, MES
Community Scholar
MAP Centre for Urban Health Solutions, Unity Health Toronto
Dr. Alexa Dodge, PhD
Assistant Professor
Saint Mary’s University
Dr. Ariel Ducey, PhD
Professor
University of Calgary
Dr. Griffin Epstein, PhD
Professor of Social Service Work
George Brown College
Dr. Deinera Exner-Cortens
Associate Professor
University of Calgary
Dr. Danya Fast, PhD
Assistant Professor
University of British Columbia
Dr. Jessie Flear, MD
Addiction Medicine and General Practitioner
Dr. Lewis Forward, MD
Resident Physician
Dalhousie University – Department of Emergency Medicine
Maeve Freeman-McIntyre, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Emilie Frenette, NP
Nurse Practitioner
Tanja Futter, RN
Pastoral Director
Sanctuary
Dr. Marilou Gagnon, RN, ACRN, LLM, PhD
Professor
School of Nursing, University of Victoria
Dr. Sarah Gander, MD, FRCPC
NB Social Pediatrics
Dr. Leah Genge, MD CCFP AM, MSc
Mobile Outreach Street Health (MOSH), North End Community Health Centre
Assistant Professor – Department of Family Medicine – Dalhousie University
Dr. Michael Gniewek, MD, CCFP
Mobile Outreach Street Health (MOSH), North End Community Health Centre
Assistant Professor – Department of Family Medicine – Dalhousie University
Dr. Tara Gomes, PhD
Assistant Professor and Scientist
University of Toronto, Unity Health Toronto
Trevor Goodyear, RN, PhD(c)
PhD Candidate
University of British Columbia
Alicia Grant-Singh, NP
Mobile Outreach Street Health, North End Clinic
Dr. Sarah Griffiths, MD CCFP(AM)
Lecturer, University of Toronto
Dr. Adrian Guta, PhD, MSW, RSW
Associate Professor
School of Social Work, University of Windsor
Marlene Haines, RN, PhD(c)
PhD Candidate
University of Ottawa
Jessica Hales, NP, MN
Nurse Practitioner
Regent Park Community Health Centre
Laura Hanson, NP
Nurse practitioner
Andalib Haque, MD, CCFP
Parkdale Queen West Community Health Centre
Kathy Hardill, NP, MScN
Nurse Practitioner
Peterborough 360 Degree Nurse Practitioner-Led Clinic
Dr. Kanna Hayashi, PhD
Associate Professor
Faculty of Health Sciences, Simon Fraser University
Prof. Matthew Herder
Professor, Dalhousie University
Dr. Ryan Herriot, MD, CCFP, c.ISAM
Cool Aid Community Health Centre
Kate Hodsgon, NP
Nurse Practitioner
North Island Medical Clinic
Dr. Elaine Hyshka, PhD
Associate Professor and Canada Research Chair in Health Systems Innovation
University of Alberta
Sarah Innis, NP
Nurse Practitioner
Parkdale Community Health Centre
Dr. Andrew Ivsins
Postdoctoral Research Fellow
BC Centre on Substance Use, University of British Columbia
Dr. Lois A. Jackson, PhD
Professor
School of Health and Human Performance, Dalhousie University
Maya Jayarajan, NP
Nurse Practitioner
Dr. Leah Jones, MD, CCFP
Family Physician
Dalhousie University
Danielle Howson, NP
Nurse Practitioner
Peterborough 360 Degree Nurse Practitioner-Led Clinic
Dr Sonika Kainth, MD
Family Physician
Parkdale Queen West Community Health Centre
Emily Kedwell, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Dr Erika Kellerhals, MD, CCFP
Clinical Instructor UBC
Past Geo 1 lead addiction medicine
Past medical director North Island Medical Clinic
Nikki Kelly, NP
Nurse Practitioner
Mobile Outreach Street Health (MOSH), North End Community Health Centre
Dr. Mary Clare Kennedy, PhD
Assistant Professor and Canada Research Chair in Substance Use Policy and Practice Research
University of British Columbia – Okanagan
Dr. Kathleen Kenny PhD
Postdoctoral Fellow,
Department of Community Health Sciences
University of Manitoba
Dr. Thomas Kerr, PhD
Professor/Head
Division of Social Medicine, University of British Columbia
Dr. Rod Knight, PhD
Assistant Professor
School of Public Health, University of Montreal
Bryce Koch, NP
Nurse Practitioner
Dr. Peter Centre
Dr. Gillian Kolla, PhD
Postdoctoral Researcher
Canadian Institute for Substance Use Research
University of Victoria
David Kryszajtys, PhD(c)
PhD Candidate, Post Doctoral Fellow
University of Toronto, Unity Health Toronto
Katie Langille, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Dr. Bonnie Larson, MD, CCFP (AM)
Family Physician
Joady Lengacher, NP
Nurse Practitioner
Somerset West Community Health Center
Erika Liban, NP
Nurse Practitioner
Sanguen Health Centre
Dr. Marc Likharovich-Fournier MD, c.ISAM
Addiction Medicine Physician
AVI Community Health Center
Dr. Katie Lines, MD, FRCPC, BSc. Pharmacy
Assistant Professor
Department of Psychiatry and Department of Anesthesia
Dalhousie University
Dr. Jamie Livingston, PhD
Associate Professor
Department of Criminology
Saint Mary’s University
Dr. Scott MacDonald, MD
Providence Health Care, Crosstown Clinic
Dr. Andrew MacLean, MD
Direction 180, Halifax, Nova Scotia
Dr. Zack Marshall, MSW, PhD, RSW
Associate Professor
University of Calgary
Dr. Randal Mason, MD, CCFP, CCSAM
Addiction Medicine/Family Physician
Westshore Community Health Centre
Dr. Leah Mayo, PhD
Professor
University of Calgary
Dr. Samara Mayer, MPH, PhD
Postdoctoral Researcher
Canadian Institute for Substance Use Research and Institute on Aging and Lifelong Health, University of Victoria
Dr. Ryan McNeil, PhD
Associate Professor
Yale School of Medicine
Dr. Isabelle Moore, MD, CCFP
REACH Niagara
Dr. Heather Morris, RN PhD
Assistant Professor
Faculty of Nursing, University of Alberta
Jessica Nanni, NP, MN
Nurse Practitioner
South Riverdale Community Health Centre
Kathy Nash, NP, MN
Nurse Practitioner
Regent Park Community Health Centre
Dr. Tiffany O’Donnell, MD, CCFP, c.ISAM
Mobile Outreach Street Health (MOSH), North End Community Health Centre
Wije’winen Health Centre
Assistant Professor, Dept. Family Medicine, Dalhousie University
Dr. Michelle Olding, MPH, PhD
Postdoctoral Researcher
Dalla Lana School of Public Health, University of Toronto
Emmet O’Reilly, NP
Nurse Practitioner
South Riverdale Community Health Centre
Dr. Tim O’Shea MD, MPH
Associate Professor
McMaster University
Charlotte Osler, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Dr. Eugenia Oviedo-Joekes, PhD
Professor
Canada Research Chair in Person-Centered Care in Addiction and Public Health
University of British Columbia
Dr. Heather Palis, PhD
Postdoctoral Fellow
University of British Columbia
Dr. Rakesh Patel MD, PharmD, M.Sc.
Associate Professor, University of Ottawa,
Medical Director, Ottawa Inner City Health,
Staff Intensivist & Internist, The Ottawa Hospital
Dr. Andrew Patterson, MD
Addiction Medicine Physician
Dr. Bernie Pauly RN, PhD
Scientist, Canadian Institute for Substance Use Research
University of Victoria
Kelly Pensom, NP
Nurse Practitioner Lead / Clinic Director
Peterborough 360 Degree Nurse Practitioner Led Clinic
Melissa Perri, PhD(c)
Researcher and PhD Candidate
Dalla Lana School of Public Health, University of Toronto
Prof. Ben Perrin
Professor
Peter A. Allard School of Law, University of British Columbia
Michelle Pittman, NP
River Stone Recovery Centre
Dr. Nanky Rai, MD, MPH, CCFP
Family Physician, Lecturer
Parkdale Queen West Community Health Centre, University of Toronto
Kim Reilly, NP
Nurse practitioner
Parkdale Queen West Community Health Centre
Dr. Katherine Rudzinski, PhD
Postdoctoral Researcher, Adjunct Assistant Professor
School of Social Work, University of Windsor
Dr. Rebecca Saah, PhD
Associate Professor
Cumming School of Medicine, University of Calgary
Dr. Ginetta Salvalaggio, MD, MSc, CCFP(AM)
Professor and Research Director
Department of Family Medicine, University of Alberta
Dr. Simarjot Sandhu, MD, MSc, CCFP
Family Physician
Parkdale Queen West Community Health Centre
Dr. Peter Saranchuk, MD
REACH Niagara Mobile Health
Rose Schmidt, PhD(c)
Researcher and PhD Candidate
Dalla Lana School of Public Health, University of Toronto
Dr. Stephen Schneider, PhD
Professor
Department of Criminology, Saint Mary’s University
Dr. Richard Scott, MD, FCFP
Reach Niagara
Dr. Stefan Sereacki, MD
Physician
Cool Aid Community Health Centre
Dr. Andrea Sereda, MD CCFP(EM)
London InterCommunity Health Centre
Carolyn Shafer, NP
Nurse Practitioner
Sanguen Health Centre
Gillian Shepherd, NP
Nurse Practitioner
Hamilton Urban Core CHC
Dr. Maria Eugenia Socias, MD, MSc
Assistant Professor
British Columbia Centre on Substance Use, University of British Columbia
Dr. Christopher Steingart, MD
Founder and Executive Director
Sanguen Health Centre
Dr. Karl Stobbe, MD CCFP(EM)
REACH Niagara
McMaster University
Dr. Carol Strike, PhD
Professor, Dalla Lana School of Public Health
University of Toronto
Dr. Ginger Sullivan RN, PhD
Assistant Professor, MacEwan University
CISUR Affiliate Researcher, University of Victoria,
Brandi Tapp, NP
Nurse Practitioner
London InterCommunity Health Centre
Dr. Euan Thomson, PhD
Executive Director
EACH+EVERY: Businesses for Harm Reduction
Dr. Lianping Ti, PhD
Assistant Professor
University of British Columbia
Rachel Toyonaga, NP
Nurse Practitioner
Peterborough 360 Degree Nurse Practitioner-Led Clinic
Dr. Mark Tyndall, MD, ScD
Professor
University of British Columbia
Dr. Karen Urbanoski, PhD
Associate Professor
University of Victoria
Dr. Bruce Wallace, PhD
Professor
School of Social Work, University of Victoria
Mark Wakefield, NP
Nurse Practitioner
Bridges Community Health Center
Marysia (Mish) Waraksa, NP
Nurse Practitioner
Parkdale Queen West Community Health Centre
Dr. Duncan Webster, MD, FRCPC
Physician
Associate Professor, Dalhousie University
Prof. Sheila Wildeman
Associate Professor
Dalhousie University, Schulich School of Law
Patty Wilson, NP
Nurse Practitioner
Hanqing Yang
Nurse Practitioner
Dr. Samantha Young, MD, FRCPC
General Internist
PhD candidate
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