In Ontario, about a dozen programs offer stabilization treatment through substitute drugs (safe supply), which is considered the first step towards proper treatment. In theory, safe supply reduces the risk of overdose on opioids by providing uncontaminated drugs, especially when administered by a professional. Today, the program is justified by its advocates as necessary to deal with the opioid crises, namel fentanyl, but this program was never meant to dead with the potent opioid.
Dr. Sharon Koivu, a strong advocate of this concept, is a specialist in addiction at LHSC and STEGH, an assistant professor at Western University, and a researcher at Lawson Health Research Institute. However, for the past few years, she has been denouncing the negative effects of the program.
« Wherever we see a safe supply program, such as in Ottawa and Hamilton, the number of overdoses has increased. Of course, correlation does not imply causation, but we can’t ignore this correlation and conclude that the Safe Supply program is working. » The London clinic in Ontario offers 40 pills per day of Dilaudid, a substitute opioid used for withdrawal treatment and considered safer than fentanyl. « That’s an outrageous amount of opioids. On average, people can’t tolerate more than 12 pills. There’s no medical reason to justify this much medication in the program. » A study published in The Lancet in 2010 suggested that half of opioid overdose deaths were caused by prescribed medication.
Safe Supply : Not So Safe After All
As a result, harm reduction clinics are directly exacerbating the crisis by flooding the streets with prescription opioids. Since no one needs that many opioids, these pills are abundant on the streets and sold at reduced prices. Dilaudid used to cost nearly $20 in pharmacies. Today, you can buy a pill for nearly $2 at injection sites.
This phenomenon is doubly harmful, according to Dr. Koivu, because these cheap pills also attract organized crime. « Half of the drugs seized by London police contain prescription opioids, and that’s probably just the tip of the iceberg because police seizures are only a small fraction of the drugs in circulation. We can’t fight the opioid crisis if we keep adding opioids to the streets. »
We did the math: in the city of London, about 300 people receive 40 pills per day, 365 days a year. Assuming only one-third of these pills end up being sold on the streets, that would equal 1,438,000 pills reaching the black market each year.
If we extend this figure to the three programs in place across Ontario, we arrive at the frankly staggering number of 4,793,300. And yet, as Dr. Koivu points out, no one seems to care about verifying the « clients’” identities. « These programs are neither supervised nor regulated. Anyone can walk in and claim these pills. There’s no verification. »
In 2019, London police seized about 850 hydromorphone pills, which was about 10% of the Dilaudid 8 pills provided through the safe supply program. By 2023, this number increased to over 30,000 hydromorphone pills seized, with about half being Dilaudid 8 pills. By 2024, more than 12,000 hydromorphone pills had been seized, almost all Dilaudid 8 mg, except for 675 pills.
In Ontario and British Columbia, harm reduction has received far more public support—and therefore more resources—than treatment, which Dr. Koivu laments. « If we put all our resources into the first pillar and nothing into treatment, we’re only perpetuating the crisis. Without sustained and well-regulated treatment, we’re just prolonging the addiction of opioid users. »
What is Dilaudid?
Dilaudid is the brand name for hydromorphone, a painkiller used to treat patients with a high tolerance to opioids, and its prescription is legal. Stronger than OxyContin but less potent than fentanyl, Dilaudid is often prescribed in Ontario in quantities that far exceed the tolerance of non-users, around 2 milligrams. In excess, the pills are sold either for money or to obtain fentanyl.
However, the situation in Ontario is no less complex than in British Columbia, with a decentralized approach that also emphasizes treatment. In addition to safe supply programs, Ontario has a broad range of addiction treatment services.
The province funds over 200 addiction treatment programs, ranging from outpatient services to residential programs. According to data from the Ontario Ministry of Health, there are about 2,000 beds dedicated to addiction treatment, spread across short-term detox centers and longer-term rehabilitation programs.
The Crisis That Makes Other Crises Boil Over
If the crisis is so difficult to understand, it’s because it highlights many issues that have been swept under the rug for far too long. « There isn’t one solution to the crisis because there isn’t just one crisis, » says Paxten Bach from British Columbia. « In 80% of cases, » says Dr. Gosch, « opioid addiction is compounded by mental health issues. »
Every year, dozens of new synthetic fentanyl-related products enter the illegal market, becoming more elusive and more deadly each time. Yet fentanyl is far from the only culprit: nearly 80% of overdoses are due to a combination of at least two drugs, including alcohol.
This complexity is reminiscent of other social crises whose root causes are numerous and intertwined. For example, the housing crisis, although often reduced to a simple lack of affordable housing, is actually the result of a web of factors: real estate speculation, growing economic inequality, job insecurity, and lack of access to social services.
Similarly, the opioid crisis cannot be addressed solely from the perspective of drug trafficking or law enforcement. « In British Columbia, we’ve tried this approach for years, » laments Dr. Bach. « It would be surprising if a repressive approach could stand in the way of new synthetic drugs. »
A parallel can also be drawn with the epidemic of gun violence, which is not limited to the availability of weapons, but is also rooted in deep social dynamics: the marginalization of certain communities, lack of mental health resources, economic despair, and lack of opportunities. Like opioid addiction, gun violence is often a symptom of a broader malaise, of a social fabric in distress. In both cases, simplistic responses—banning a substance or restricting access to weapons—are not enough to stem the problem if they aren’t accompanied by comprehensive policies that tackle the underlying structural causes.
What about solutions?
To curb the crisis, the four-pillar approach reminds us of the need for a united front involving the entire community, starting with the often overlooked pillar in the fight against opioids: prevention. While new medications are excellent for stabilizing cognitive balance and reducing withdrawal effects, different regulations can also help balance repressive approaches with harm reduction.
1: Safe Supply : Regulate and Monitor
Let’s start with the simplest solution: « controlled » supply must be done on-site and under supervision. Whether one believes in the benefits of harm reduction or not, one thing is clear: the drugs administered on-site will not end up on the black market. For Dr. Koivu, all clinics and injection centers must be regulated, and injections must be supervised. « Before even addressing this issue, we should control who can claim Dilaudid pills in Ontario. Right now, no ID is asked. Anyone can, in theory, go up to 40 pills. »
Vincent Lam, a doctor specializing in addiction treatment, fears that safer fentanyl supply could encourage addiction. By not requiring patients to use their prescriptions on-site, some might sell or trade pills on the black market to obtain fentanyl, which is much stronger but deadly.
2: Distribute Naloxone – Everywhere – Especially in Pharmacies
Although the idea of collaboration between the police and local services may raise some eyebrows, it is in fact a fairly common approach that has proven successful. In the 1980s, the Dutch city of Needjik faced a heroin crisis. Public daytime injections, abandoned building squats, police-ignored ghettos, etc. The solution: a community-based approach combining repression, prevention, and treatment. Addicts received treatment, entered methadone substitution programs (pharmacologically similar to heroin but controlled), and were given a place in a shelter. Additionally, each user benefited from a long-term medical plan tailored to their needs.
Another solution comes from pharmacies. Between 24% and 30% of overdoses in Canada are caused by a prescription opioid. Pharmacies are therefore key players in the fight against overdoses. More and more pharmacies are able to participate in the effort. We must continue this progress. The most effective solution is to equip the largest number of pharmacies with naloxone, a drug that can reverse the effects of an overdose in moments, provided it is administered in time. For a long time, naloxone’s presence was taboo, but today, the new toxicity crisis makes it more necessary than ever.
3: Facilitate Access to Treatment
No matter the province, experts agree on one point: access to treatment for the at-risk population must be made easier.
Whether someone seeks care at a luxury rehab center or a community facility, the treatment journey for a person struggling with addiction is often a true labyrinth, plagued by siloed approaches and a lack of consistency in service delivery.
A structural reform is necessary to simplify access to treatment, harmonize approaches between provinces, and ensure continuity of care for patients.
This could include implementing integrated care pathways, better coordination between harm reduction services, treatment, and rehabilitation, and broader access to substitution medications such as methadone and buprenorphine, without excessive administrative barriers.
See longer, original article in French.
Resources
- Data, surveillance, and research on opioids and other substances, Government of Canada
- National Guidelines of the Canadian Substance Abuse Research Initiative (ICRAS) on the clinical management of opioid use disorder
- National Report: Deaths Apparently Related to Opioid Consumption in Canada (published March 2018), Government of Canada
- Dr. Sharon Koivu: ‘Safe supply’ has only worsened the addiction crisis in London, The National Post
- Erika Naomi Gertz: From the rise of fentanyl to disastrous ‘safe supply’ policies: The long, sad story of how Canada’s drug crisis spiralled into an epidemic, The Hub.ca
Pierre-Olivier Bussières is the Editor-in-Chief of Hoppy History and Uber Optimized. He is the Sales and Marketing Director at Uberflix Studio. He also writes about travel, geopolitics, and alcohol markets, and has published articles in The Diplomat, Reflets, The Main, Go Nomad, Global Risk Insights, and Diplomatie.
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