The tennis player Arthur Ashe once said that to take on a challenge, “start where you are, use what you have, do what you can.” In the face of Canada’s national crisis of illicit drug poisoning, physicians and nurse practitioners who care for people who use drugs could consider Ashe’s advice.
As overdose deaths skyrocket, associated with even higher concentrations of illicitly-produced fentanyl in the street drug supply, it’s time for physicians and nurse practitioners across Canada to step up and start prescribing a replacement “safe supply” of pharmaceutical-grade drugs. We can use the tools we already have, within models that meet our patients’ needs, while we advocate for decriminalization of drugs and access to a legal, regulated, non-toxic supply.
Canadian drug users are effectively facing two pandemics. COVID-19 has dramatically changed every facet of life for this community. Borders have hardened, altering the global drug trade and increasing the deadly toxicity of the drug supply. Social distancing and quarantine measures are the new norm, ushering in a wide range of negative impacts on mental health. Many harm reduction programs and healthcare services have limited access or hours, or even shut down.
As a result, the overdose death crisis is getting even worse. In Ontario, chief coroner Dr. Dirk Huyer told reporters that about 55 people per week are dying from overdose, up from an already staggering 44 people per week pre-pandemic. In British Columbia, May and June 2020 successively broke records for highest number of overdose deaths in a month—a record last set in December 2016. In Saskatoon, data is sparse, but this month paramedics responded to more than 100 overdose calls in one week for the first time ever. Despite all this, people who use drugs continue to care for each other while fighting and organizing for their lives.
We currently have access to the only non-toxic opioid supply in the country.
It is clear that the status quo is not enough. So how can physicians start where we are, use what we have, and do what we can to respond to these dual crises?
While we advocate for systems-level changes to reduce risks of death, including a legalized, regulated supply of drugs and housing for all, we currently have access to the only non-toxic opioid supply in the country.
Traditional evidence-based treatments for opioid use disorder, including methadone and buprenorphine maintenance therapy, just don’t work for everyone. Prescribing a safe supply of regulated opioids, including hydromorphone tablets, can allow people to know how much they’re taking, decrease their reliance on the poisoned illicit drug supply, and decrease involvement in illegal activities to procure drugs from a criminalized market.
We wish that diacetylmorphine was widely available, and that high-concentration injectable hydromorphone was on government drug formularies across the country to help meet the needs of more people with higher tolerance. Yet as physicians or certified prescribers, we can all prescribe some form of legal opioid today while advocating for access to other opioids.
We are resident doctors involved in safe supply initiatives in our respective Canadian cities. We’re also part of a research team looking at how a safe supply of drugs is being mobilized during COVID-19, and exploring the barriers and facilitators to safe supply prescribing and distribution.
The Canadian Association of People Who Use Drugs defines safe supply as a “legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.” Some safe supply models involve simply providing prescriptions (to people who are eligible, and above and beyond standard evidence-based treatments for substance use disorders), while others involve a more holistic approach including case managers, primary care and/or urine drug screening (in part to assess for possible diversion).
There is a disconnect between what prescribers and researchers think are barriers to safe supply, in contrast to people who use drugs.
The research is ongoing, but our team of health professionals, scientists, lawyers and people who use drugs has identified some key themes. Restrictive laws and fear of discipline by professional bodies (whether real or imagined) appear to deter prescribers and limit access to safe supply. Facilitators such as regulatory exemptions to the Controlled Drugs and Substances Act are insufficient by themselves to improve access.
There is also a disconnect between what prescribers and researchers think are barriers to safe supply, in contrast to people who use drugs. Members of our expert advisory group of people who use drugs felt that over-medicalized safe supply programs prevent some people from accessing the program, and may limit patient or client autonomy and agency if there are lots of conditions to receiving a prescription.
Our advisory group identified that safe supply initiatives would be more accessible and promote dignity if they are designed with and by community members, offer take-home dosing, require fewer (or zero) urine drug screening tests, and are generally more flexible.
Safe supply prescribing is not easy or straightforward for those of us with medical licenses, but people who use drugs are asking us to be brave and step up. “Off-label” prescribing of medical-grade opioids as a replacement for the toxic illicit drug supply is not something that we learned in medical school, and goes against current messaging to limit opioid prescribing as much as possible. We are trying to use an imperfect tool in response to an overwhelming crisis of death.
We have relationships with patients, some of whom we’ve known for years, who are doing everything they can to stay alive. We have training in building therapeutic alliances, assessing patients, offering treatment, and monitoring outcomes. We can lean on overwhelming evidence of benefit for oral and injectable opioid agonist treatment as we seek new solutions.
We know that there are many types of evidence, and that when serving this patient population with highly specific needs we often operate in clinical grey zones without a randomized control trial or systematic review to guide the way. We know how to take the evidence and apply it to the patient in front of us. We know how to listen and how to learn from our patients, and how to change our practice to better meet their needs.
We also have relationships with social service providers, allied health professionals, and community groups. We are scholars, ready to implement and evaluate and refine. Working alongside people who use drugs, including the Canadian Association of People Who Use Drugs, we will push to influence policymakers, regulatory bodies and the public.
Some physicians and nurse practitioners may argue that we should not have a role in safe supply—that this is a public health and policy problem that requires a public health and policy response. But these overdose deaths are happening to patients, and until that policy response comes, we need to prescribe safe supply as an urgent stopgap now.
There is so much we can do, and should do, in the face of enormous death and suffering.