Addictions
“Safer supply” reminiscent of the OxyContin crisis, warns addiction physician
Dr. Lori Regenstreif, MD, MSc, CCFP (AM), FCFP, MScCH (AMH), CISAM, has been working as an addiction medicine physician in inner city Hamilton, Ontario, since 2004. She co-founded the Shelter Health Network in 2005 and the Hamilton Clinic’s opioid treatment clinic in 2010, and helped found the St. Joseph’s Hospital Rapid Access Addiction Medicine (RAAM) clinic.
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[This article is part of Break The Needle’s “Experts Speak Up” series, which documents healthcare professionals’ experiences with Canada’s “safer supply” programs] By: Liam Hunt
Dr. Lori Regenstreif, an addiction physician with decades of experience on the frontlines of Canada’s opioid crisis, is sounding the alarm about the country’s rapidly expanding “safer supply” programs.
While proponents of safe supply contend that providing drug users with free tablets of hydromorphone – a pharmaceutical opioid roughly as potent as heroin – can mitigate harms, Dr. Regenstreif expresses grave concern that these programs may inadvertently perpetuate new addictions and entrench existing opioid use.
She sees ominous similarities between safer supply and the OxyContin crisis of the late 1990s, when the widespread overprescribing of opioids flooded North American communities with narcotics, sparking an addiction crisis that continues to this day. Having witnessed the devastating consequences of OxyContin in the late 1990s, she believes that low-quality and misleading research is once again encouraging dangerous overprescribing practices.
Flashbacks to the OxyContin Crisis
Soon after Dr. Regenstreif received her medical license in Canada, harm reduction became the primary framework guiding her practice in inner-city Vancouver. This period coincided with Health Canada’s 1996 regulatory approval of oxycodone (brand name: OxyContin) based on trials, sponsored by Purdue Pharma, that failed to assess the serious risks of misuse or addiction.
Dr. Regenstreif subsequently witnessed highly addictive prescription opioids flood North American streets while Purdue and its distributors reaped record profits at the expense of vulnerable communities. “That was really peaking in the late 90s as I was coming into practice,” she recounted during an extended interview with Break The Needle. “I was being pressured to prescribe it as well.”
Oxycodone addiction led to the deaths of tens of thousands of individuals in the United States and Canada. As a result, Purdue Pharma faced criminal penalties, fines, and civil settlements amounting to 8.5 billion USD, ultimately leading to the company’s bankruptcy in 2019.
During the OxyContin crisis, patients would regularly procure large amounts of pharmaceutical opioids for resale on the black market – a process known as “diversion.” Dr. Regenstreif has seen alarming indications that safer supply hydromorphone is being diverted at similarly high levels, and estimated that, out of her patient pool, “15 to 20 out of maybe 40 people who have to go to a pharmacy frequently” have reported witnessing diversion.
Between one to two thirds of her new patients have told her that they are accessing diverted hydromorphone tablets – in many cases, the tablets almost certainly originate from safer supply.
Injecting crushed hydromorphone tablets pose severe health risks, including endocarditis and spinal abscesses. “I’ve seen people become quadriplegic and paraplegic because the infection invaded their spinal cord and damaged their nervous system,” said Dr. Regenstreif. While infections can be mitigated by reducing the number of times drug users inject drugs into their bodies, she says that safer supply programs do not discourage or reduce injections.
She further noted, “I’ve seen a teenager in [the] hospital getting their second heart valve replacement because they continue to inject after the first one.” The pill that nearly stopped the patient’s heart was one of the tens of thousands of hydromorphone tablets handed out daily via Canadian safe supply programs.
Her experiences are consistent with preliminary data from a scientific paper published by JAMA Internal Medicine in January, which found that safe supply distribution in British Columbia is associated with a “substantial” increase in opioid-related hospitalizations, rising by 63% over the first two years of program implementation — all without reducing deaths by a statistically significant margin.
While Dr. Regenstreif has worked in a variety of settings, from Ontario’s youth correctional system to Indigenous healing facilities in the Northwest Territories, her experiences in Australia, where she worked during a sabbatical year from 2013 to 2014, were particularly educational.
Australia has far fewer opioid-related deaths than Canada – in 2021, opioid mortality rates were 3.8 per 100,000 in Australia and 21 per 100,000 in Canada (a difference of over 500%). Dr. Regenstreif credited this difference to Australia’s comparatively controlled opioid landscape, where access to pharmaceutical narcotics is tightly regulated.
“Heroin had been a long-standing street opioid. It was really the only opioid you tended to see, because the only other ones people could get a prescription for were over-the-counter, low-potency codeine tablets,” she said. To this day, opioid prescriptions in Australia require special approval for repeat supplies, preventing stockpiling and street diversion.
No real evidence supports “safer supply”
Critics and whistleblowers have argued that Canadian safe supply programs, which have received over $100 million in federal funding through Health Canada’s Substance Use and Addictions Program (SUAP), were initiated without adhering to the rigorous evidentiary standards typically required to classify medication as “safe.”
Dr. Regenstreif shares these concerns and says that no credible studies show that safer supply saves lives, and that little effort is invested into exploring its possible risks and unintended consequences – such as increased addiction, hospitalization, overdose and illicit diversion to youth and vulnerable individuals.
Most studies which support the experiment simply interview recipients of safer supply and then present their answers as objective evidence of success. Dr. Regenstreif criticized these qualitative studies as methodologically flawed “customer satisfaction surveys,” as they are “very selective” and rely on small, bias-prone samples.
“If you have 400 people in a program, and you get feedback from 12, and 90% of those 12 said X, that’s not [adequate] data,” said Dr. Regenstreif, criticizing the lack of follow-up often shown safer supply researchers. “Nobody seems to track down the […] people who were not included. Did they get kicked out of the program? [Did they engage in] diversion? Did they die? We’re not hearing about that. It doesn’t make any sense in an empirical scientific universe.”
Safe supply advocates typically argue that opioids themselves are not problematic, but rather their unregulated and illicit supply, as this allows for contaminants and unpredictable dosing. However, studies have found that opioid-related deaths rise when narcotics, legal or not, are more widely available.
Dr. Regensteif is calling upon harm reduction researchers to build a more robust evidence base before calling for the expansion of safer supply. That includes more methodologically rigorous and transparent quantitative research to evaluate the full impact of Canada’s harm reduction strategies. Forgoing this evidence or adequate risk-prevention measures could lead to consequences as catastrophic as those resulting from Purdue’s deceptive marketing of OxyContin, she said.
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Critics propose solutions despite bullying
Dr. Regenstreif has faced pressure and exclusion for speaking out against safe supply. She estimates that while only a quarter of her local colleagues shared her doubts a few years ago, “now I would say more than half” harbor the same concerns. However, many are reluctant to voice their reservations publicly, fearing professional or social repercussions. “People who don’t want to speak out don’t want to be labeled as right-wing […] they don’t want to be labeled as conservative.”
While she acknowledges that safe supply may play a limited role for a small subset of patients, she believes it has been oversold as a panacea without adequate safeguards or due evaluation. “It doesn’t seem as if policymakers are listening to the people on the ground who have experience in doing this,” she said.
She contends that the solution to Canada’s addiction crisis lies in a more holistic, recovery-oriented approach that includes all four pillars of addiction: harm reduction, prevention, treatment, and enforcement. Her vision includes a national network of publicly-funded, rapid-access addiction medicine clinics with integrated counseling and wraparound services.
Additionally, Dr. Regenstreif stresses the importance of building upon established opioid agonist treatments (OAT), like methadone and buprenorphine, rather than solely relying on novel approaches whose social and medical risks are not yet fully understood.
At the core of Dr. Regenstreif’s advocacy lies a profound dedication to her patients and to the science of addiction medicine. “I like to think I kind of am fear-mongering with my patients, [by] trying to make them afraid of not getting better,” she explains. “I don’t want them to end up in the hospital and not come back out. I don’t want them to end up dead.”
[This article has been co-published with The Bureau, a Canadian media outlet that tackles corruption and foreign influence campaigns through investigative journalism. Subscribe to their work to get the latest updates on how organized crime influences the Canadian drug trade.]
The British Columbia Centre on Substance Abuse. (Photo credit: Alexandra Keeler)
News release from Break The Needle
By Canadian Affairs Editorial Board
Data released this week brought the welcome news that opioid-related deaths in Alberta have decreased substantially since last year. Opioid-related deaths have also decreased in B.C., although not as dramatically as in Alberta.
While the results are encouraging, more work needs to be done. And both provinces, which have taken very different approaches to the drug crisis, need to understand how their drug policies contribute to these results.
Fortunately, B.C. and Alberta both have research centres devoted to answering this very question. But we are disheartened to see that B.C.’s centre, the British Columbia Centre on Substance Abuse, accepts funding from pharmaceutical and drug companies.
As Canadian Affairs reported this week, the B.C. centre’s funding page lists pharmaceutical company Indivior, pharmacy chain Shoppers Drug Mart and cannabis companies Tilray and Canopy Growth as “past and current funders of activities at BCCSU — including work related to research, community engagement, and clinical training and education.”
This funding structure raises major red flags. Pharmaceutical and drug companies benefit from continued drug use and addiction. And in a context where B.C. has favoured harm-reduction policies such as safe consumption sites and safe supply, the risk of conflicts is especially high.
Indivior is the producer and manufacturer of Suboxone, a drug commonly prescribed to treat opioid-use disorder. Canada’s drug crisis has driven a surge in demand for prescription opioids to treat opioid-use order, with the number of Canadians receiving Suboxone and similar drugs up 44 per cent in 2020 from 2015, according to the Canadian Centre on Substance Use and Addiction.
Indivior is also the subject of at least two class-action lawsuits claiming the company failed to disclose adverse health effects associated with using Suboxone.
In 2021, Shoppers Drug Mart made a $2-million gift to the University of British Columbia to establish a pharmacy fellowship and support the education of pharmacist-focused addiction treatment at the British Columbia Centre on Substance Use. A conflict of interest exists here as well, with pharmacies benefiting financially from continued demand for drugs.
Consider, for example, if B.C.’s centre produced research showing pharmaceutical interventions were not effective or less effective than other policy measures. Would researchers feel pressure to not publish those results or pursue further lines of inquiry? Similarly, would Indivior or Shoppers Drug Mart continue to provide funding if the centre published research in this vein?
These are not the kinds of questions researchers should have to consider when pursuing research in the public interest.
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In response to questions about whether accepting drug industry funding could compromise the objectivity of their research, the British Columbia Centre on Substance Abuse referred Canadian Affairs to their website’s funding page. This page states their research is supported by peer-reviewed grants and independent ethical reviews to ensure objectivity.
We would argue such steps are not sufficient, not least because conflicts of interest are a problem whether they are real or perceived. Even if researchers at the centre are not influenced by who is funding their work, the public could reasonably perceive the objectivity of their research to be compromised.
It is for this reason that ethics laws generally require officeholders to avoid both actual conflicts of interest as well as the appearance of conflicts.
It is also why the government of Alberta, in launching their new addictions research centre, the Canadian Centre of Recovery Excellence (CoRE), has taken steps to safeguard the integrity of its work. The government has imposed legislative safeguards to ensure CoRE cannot receive external funding that could be seen to compromise its research, a spokesperson for the centre told Canadian Affairs.
It would be difficult to overstate the importance of the work done by the B.C. centre, CoRE and other centres like it. It is imperative that governments of all levels and stripes have quality, trusted research to inform decision-making about how best to respond to this tragic crisis.
The B.C. government and British Columbia Centre on Substance Abuse ought to implement their own safeguards to address these conflicts of interest immediately.
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
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B.C. parents say the province’s safer supply program and legal treatment framework leave them powerless to help their addicted teens
On Aug. 19, 2022, Kamilah Sword took a single hydromorphone pill, believing it to be safe. She overdosed and was found dead by her grandmother the next day. She was 14.
Kamilah believed the drug was safe — despite having bought it illicitly — because she was told it came from a government-run “safer supply” program, according to Kamillah’s best friend Grace Miller and her father.
“I’ll never get to see her get married, never have grandkids, never get to see her graduate,” said Kamilah’s father, Gregory Sword, lowering his chin to keep his voice steady.
“It’s a black hole in the heart that never heals.”
Sword faced significant challenges trying to get his daughter help during the year he was aware she was struggling with addiction. He blames British Columbia’s safer supply program and the province’s legal youth treatment framework for exacerbating his daughter’s challenges and ultimately contributing to her death.
“It’s a B.C. law — you cannot force a minor into rehab without their permission,” said Sword. “You cannot parent your kid between the ages of 12 and 18 without their consent.”
Sword is now pursuing legal action against the B.C. and federal governments and several health agencies, seeking accountability for what he views as systemic failures.
B.C.’s “Safe” supply program
B.C.’s prescribed safer supply program, which was first launched in 2020, is designed to reduce substance users’ reliance on dangerous street drugs. Users are prescribed hydromorphone — an opioid as potent as heroin — as an alternative to using potentially lethal street drugs.
However, participants in the program often sell their hydromorphone, in some cases to teenagers, to get money to buy stronger drugs like fentanyl.
According to Grace Miller, she and Kamilah would obtain hydromorphone — which is commonly referred to as Dilaudid or “dillies” — from a teenage friend who bought them in Vancouver’s Downtown Eastside. The neighbourhood, which is the epicentre of Vancouver’s drug crisis, is a 30-minute SkyTrain ride from the teenagers’ home in Port Coquitlam.
Sword says he initially thought “dillies” referred to Dairy Queen’s Dilly Bars. “My daughter would ask me for $5, [and say], ‘Yeah, we’re going to Dairy Queen for a Dilly Bar.’ I had no idea.”
He says he only learned about hydromorphone after the coroner informed him that Kamilah had three substances in her system: cocaine, MDMA and hydromorphone.
“I had to start talking to people to figure out what [hydromorphone] was and where it was coming from.”
Sword is critical of B.C.’s safer supply program for being presented as safe and for lacking monitoring safeguards. “[Kamilah] knew where [the drugs] were coming from so she felt safe because her dealer would keep on telling her, ‘This is safe supply,’” Sword said.
In February, B.C. changed how it refers to the program from “prescribed safer supply” to “prescribed alternatives.”
Grace says another problem with the program is the quantities of drugs being distributed.
“It would be a big difference if the prescriptions that they were giving out were dosed properly,” she said, noting addicts would typically sell bottles containing 14 pills, with pricing starting at $1 a pill.
‘Safer supply’
Sword estimates his daughter struggled with addiction for about 18 to 24 months before her final, fatal overdose.
After Kamilah overdosed for the first time on Aug. 21, 2021, he tried to get her into treatment. A drug counsellor told him that, because she was over 12, she would need to verbally consent. Kamilah refused treatment.
B.C.’s Infants Act allows individuals aged 12 or older to consent to their own medical treatment if they understand the treatment and its implications. The province’s Mental Health Act requires minors aged 12 to 16 to consent to addiction or mental health treatment.
While parents can request involuntary admission for children under 16, a physician or nurse practitioner must first confirm the presence of a mental disorder that requires treatment. No law specifically addresses substance-use disorders in minors.
When Kamilah was admitted to the hospital on one occasion, she underwent a standard psychiatric evaluation and was quickly discharged — despite Sword’s protests.
Ontario also has a mental health law governing involuntary care. Similar to B.C., they permit involuntary care only where a minor has been diagnosed with a mental disorder.
By contrast, Alberta’s Protection of Children Abusing Drugs Act enables a parent or guardian to obtain a court order to place a child under 18 who is struggling with addiction into a secure facility for up to 15 days for detoxification, stabilization and assessment. Alberta is unique among the provinces and territories in permitting involuntary care of minors for substance-use issues.
Grace, who also became addicted to opioids, says her recovery journey involved several failed attempts.
“I never thought I would have almost died so many times,” said Grace, who is now 16. “I never thought I would even touch drugs in my life.”
Grace’s mother Amanda (a pseudonym) faced similar struggles as Sword in trying to get help for her daughter. Amanda says she was repeatedly told nothing more could be done for Grace, because Grace would not consent to treatment.
“One time, [Grace] overdosed at home, and I had to Narcan her because she was dead in her bed,” Amanda said. “I told the paramedic, ‘Our system is broken.’ And she just said, ‘Yes, I know.’”
Yet Grace, who today has been sober for 10 months, would question whether she even had the capacity to consent to treatment when she was addicted to drugs.
Under B.C.’s Health Care (Consent) and Care Facility (Admission) Act, an adult is only considered to have consented to health care if their consent is voluntary, informed, legitimately obtained and the individual is capable of making a decision about their care.
“Mentally able to give consent?” said Grace. “No, I was never really mentally there.”
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System failure
Today, Sword is one of two plaintiffs leading a class-action lawsuit against several provincial and federal health authorities and organizations, including the B.C. Ministry of Health, Health Canada, Vancouver Coastal Health and Vancouver Island Health.
All four of these agencies declined to comment for this story, citing the ongoing court proceedings.
The lawsuit was filed Aug. 15 and is currently awaiting certification to proceed. It alleges the coroner initially identified safer supply drugs as a cause of Kamilah’s death, but later changed the report to omit this reference due to pressure from the province or for other unknown reasons.
It further alleges B.C. and Ottawa were aware that drugs prescribed under safer supply programs were being diverted as early as March 2021, but failed to monitor or control the drugs’ distribution. It points to a Health Canada report and data showing increased opioid-related problems from safer supply programs.
According to Amanda, Kamilah had wanted to overcome her addiction but B.C.’s system failed her.
“I had multiple conversations with Kamilah, and I know Kamilah wanted to get clean,” she says. “But she felt so stuck, like she couldn’t do it, and she felt guilty and ashamed.”
Grace, who battled addiction for four years, is relieved to be sober.
“I’ve never, ever been happier. I’ve never been healthier. It’s the best thing I’ve done for myself,” she said. “It’s just hard when you don’t have your best friend to do it with.”
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
Break The Needle. Our content is always free – but if you want to help us commission more high-quality journalism, consider getting a voluntary paid subscription.
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