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.]
A 2022 Los Angeles Times piece advocates following Vancouver’s model of drug liberalization and treatment. Adam Zivo argues British Columbia’s model has been proven a failure.
By Adam Zivo
Oregon and British Columbia neglected to coerce addicts into treatment.
Ever since Portugal enacted drug decriminalization in 2001, reformers have argued that North America should follow suit. The Portuguese saw precipitous declines in overdoses and blood-borne infections, they argued, so why not adopt their approach?
But when Oregon and British Columbia decriminalized drugs in the early 2020s, the results were so catastrophic that both jurisdictions quickly reversed course. Why? The reason is simple: American and Canadian policymakers failed to grasp what led to the Portuguese model’s initial success.
Contrary to popular belief, Portugal does not allow consequence-free drug use. While the country treats the possession of illicit drugs for personal use as an administrative offense, it nonetheless summons apprehended drug users to “dissuasion” commissions composed of doctors, social workers, and lawyers. These commissions assess a drug user’s health, consumption habits, and socioeconomic circumstances before using arbitrator-like powers to impose appropriate sanctions.
These sanctions depend on the nature of the offense. In less severe cases, users receive warnings, small fines, or compulsory drug education. Severe or repeat offenders, however, can be banned from visiting certain places or people, or even have their property confiscated. Offenders who fail to comply are subject to wage garnishment.
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Throughout the process, users are strongly encouraged to seek voluntary drug treatment, with most penalties waived if they accept. In the first few years after decriminalization, Portugal made significant investments into its national addiction and mental-health infrastructure (e.g., methadone clinics) to ensure that it had sufficient capacity to absorb these patients.
This form of decriminalization is far less radical than its North American proponents assume. In effect, Portugal created an alternative justice system that coercively diverts addicts into rehab instead of jail. That users are not criminally charged does not mean they are not held accountable. Further, the country still criminalizes the public consumption and trafficking of illicit drugs.
At first, Portugal’s decriminalization experiment was a clear success. During the 2000s, drug-related HIV infections halved, non-criminal drug seizures surged 500 percent, and the number of addicts in treatment rose by two-thirds. While the data are conflicting on whether overall drug use increased or decreased, it is widely accepted that decriminalization did not, at first, lead to a tidal wave of new addiction cases.
Then things changed. The 2008 global financial crisis destabilized the Portuguese economy and prompted austerity measures that slashed public drug-treatment capacity. Wait times for state-funded rehab ballooned, sometimes reaching a year. Police stopped citing addicts for possession, or even public consumption, believing that the country’s dissuasion commissions had grown dysfunctional. Worse, to cut costs, the government outsourced many of its addiction services to ideological nonprofits that prioritized “harm reduction” services (e.g., distributing clean crack pipes, operating “safe consumption” sites) over nudging users into rehab. These factors gradually transformed the Portuguese system from one focused on recovery to one that enables and normalizes addiction.
This shift accelerated after the Covid-19 pandemic. As crime and public disorder rose, more discarded drug paraphernalia littered the streets. The national overdose rate reached a 12-year high in 2023, and that year, the police chief of the country’s second-largest city told the Washington Post that, anecdotally, the drug problem seemed comparable to what it was before decriminalization. Amid the chaos, some community leaders demanded reform, sparking a debate that continues today.
In North America, however, progressive policymakers seem entirely unaware of these developments and the role that treatment and coercion played in Portugal’s initial success.
In late 2020, Oregon embarked on its own drug decriminalization experiment, known as Measure 110. Though proponents cited Portugal’s success, unlike the European nation, Oregon failed to establish any substantive coercive mechanisms to divert addicts into treatment. The state merely gave drug users a choice between paying a $100 ticket or calling a health hotline. Because the state imposed no penalty for failing to follow through with either option, drug possession effectively became a consequence-free behavior. Police data from 2022, for example, found that 81 percent of ticketed individuals simply ignored their fines.
Additionally, the state failed to invest in treatment capacity and actually defunded existing drug-use-prevention programs to finance Measure 110’s unused support systems, such as the health hotline.
The results were disastrous. Overdose deaths spiked almost 50 percent between 2021 and 2023. Crime and public drug use became so rampant in Portland that state leaders declared a 90-day fentanyl emergency in early 2024. Facing withering public backlash, Oregon ended its decriminalization experiment in the spring of 2024 after almost four years of failure.
The same story played out in British Columbia, which launched a three-year decriminalization pilot project in January 2023. British Columbia, like Oregon, declined to establish dissuasion commissions. Instead, because Canadian policymakers assumed that “destigmatizing” treatment would lead more addicts to pursue it, their new system employed no coercive tools. Drug users caught with fewer than 2.5 grams of illicit substances were simply given a card with local health and social service contacts.
This approach, too, proved calamitous. Open drug use and public disorder exploded throughout the province. Parents complained about the proliferation of discarded syringes on their children’s playgrounds. The public was further scandalized by the discovery that addicts were permitted to smoke fentanyl and meth openly in hospitals, including in shared patient rooms. A 2025 study published in JAMA Health Forum, which compared British Columbia with several other Canadian provinces, found that the decriminalization pilot was associated with a spike in opioid hospitalizations.
The province’s progressive government mostly recriminalized drugs in early 2024, cutting the pilot short by two years. Their motivations were seemingly political, with polling data showing burgeoning support for their conservative rivals.
The lessons here are straightforward. Portugal’s decriminalization worked initially because it did not remove consequences for drug users. It imposed a robust system of non-criminal sanctions to control addicts’ behavior and coerce them into well-funded, highly accessible treatment facilities.
Done right, decriminalization should result in the normalization of rehabilitation—not of drug use. Portugal discovered this 20 years ago and then slowly lost the plot. North American policymakers, on the other hand, never understood the story to begin with.
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Experts warn surging THC levels are fuelling growing health risks — and say stronger regulation is urgently needed
More and more cannabis users are ending up in emergency rooms suffering from severe, repeated bouts of vomiting — a condition known as cannabis hyperemesis syndrome.
A new study found that emergency visits for cannabis hyperemesis syndrome increased 13-fold over eight years, accounting for more than 8,000 of the nearly 13,000 cannabis-related ER visits in that period.
Experts say the mounting health risks associated with cannabis use are due to rising THC levels in cannabis products. They urge stronger regulation, better labeling and more research — using Quebec’s approach as a potential model.
“I don’t think we have the perfect model in Quebec — there’s pros and cons,” said Dr. Didier Jutras-Aswad, a clinical scientist at the Centre hospitalier de l’Université de Montréal (CHUM) and a professor in the Department of Psychiatry and Addiction at Université de Montréal.
“But overall, the process of … progressively implementing changes, not wanting to be the first one in line to put all this new product on the market, I think is probably, in terms of public health, more prudent.”
THC levels
Tetrahydrocannabinol (THC) is the primary psychoactive compound in cannabis and what causes the “high.” It is one of more than 100 cannabinoids, or chemical compounds, naturally found in the cannabis plant.
Delta‑9‑THC is the most common and well-studied form, though other forms of THC exist and are less understood.
Federal drug laws place strict limits on delta-9-THC levels. They cap delta-9-THC at 10 milligrams per piece for edibles, and 1,000 milligrams per container for extracts and topicals. Dried cannabis flower and pre-rolled joints have no THC cap, but must disclose the THC level on their labels.
Other intoxicating cannabinoids — like delta-8-THC — are not regulated the same way. Some producers use these other cannabinoids to get around delta-9 limits to make their products more potent.
In 2023, Health Canada issued guidance warning against this practice, noting it could lead to inspections and regulatory action. Its guidance is not legally binding.
“Good weed”
Dr. Oyedeji Ayonrinde, a professor of psychiatry and psychology at Queen’s University, says “good weed” used to mean a product did not contain pesticides or contaminants. Now, it often means a product is high-THC — reinforcing the risky idea that stronger is better.
“We would say, Oh, man, that guy’s got good weed,’ because it’s 30 per cent [THC],” he said.
Today, THC levels average about 25 per cent — up from about four per cent in the 1960s. But some products go as high as 80 or 90 per cent THC.
“That’s ‘the good stuff,’” said Ayonrinde, referring to how consumers view products with these elevated levels of THC.
“One of the major [health] risk factors is the use of cannabis with higher than 10 per cent THC,” said Dr. Daniel Myran, a physician and Canada Research Chair at the University of Ottawa.
Myran led three Canadian studies this year linking heavy cannabis use to health risks such as schizophrenia, dementia and early death.
Chris Blair, a Canadian originally from Jamaica, says the cannabis he once smoked — natural, Jamaican, homegrown weed known as “sess” — was much milder than what is available through Ontario dispensaries today.
“We grew it, it was natural … the regular Mary Jane sess,” he said. “And then times changed … the sess was pushed to almost become the hydro[ponic] type of thing.”
Hydroponic growing methods produce more potent cannabis with higher THC levels. Blair says he could no longer go back to Jamaican sess, because he had built up a tolerance to it.
“Unfortunately, going back to sess was not the same, because it wasn’t the same high or same strength,” he said.
“Back when [I was] smoking [Jamaican sess] … I’d finished that spliff and we were ready to go hang out, we’re ready to party.
“Nowadays, after you smoke you’re mashed and you’re not doing anything.”
Greening out
Ayonrinde says higher THC levels can alter how the brain’s dopamine receptors work, which may induce paranoia.
“Being out of touch with reality, auditory hallucinogens, delusional thoughts, disorganized thinking — that’s part of the mechanism pathway for the development of a severe and enduring mental illness [like] schizophrenia,” he said.
High THC can also worsen anxiety, disrupt sleep, affect mood and trigger psychosis, he says. Other experts cited risks including cannabis use disorder, mental health issues, and dizziness or nausea — sometimes referred to as “greening out.”
Young people, whose brains are still developing until age 25, are most vulnerable to these harmful effects, Ayonrinde says.
During adolescence, the brain undergoes intense growth. “Think of the brain like a construction site,” he said. Frequent, high-dose THC use during this critical period can disrupt dopamine systems and increase the risk of building scaffolding for serious mental health conditions.
While some literature suggests that cannabidiol (CBD) — another major cannabinoid in most cannabis products — may act as a calming, non-psychoactive counterbalance to THC, Ayonrinde says this is only true at extremely high doses, around 6,000 mg.
Standard measurement
Experts say the diversity of cannabis products on the market is part of the challenge.
“When people say, ‘Weed helps me with my trauma,’ an example I often give is: cannabis is just like saying ‘dog’,” said Ayonrinde.
“What breed? Is it a chihuahua or a rottweiler or a great dane? Because without knowing exactly the THC, CBD … what are you talking about?
“There’s no single cannabis.”
Cannabis products lack clear dosage guidelines, and Ayonrinde says marketing messages push consumers to opt for high potency options.
Ruth Ross, a professor of pharmacology and toxicology at the University of Toronto, would like Canada to adopt a standard unit of measurement for THC levels, so consumers could easily understand what one unit means.
“Say a unit was one milligram; they could multiply that up — it’s easy math,” she said.
Myran agrees. “The way we sell alcohol in this country is not set up so that you pay the same amount for a litre of wine as you do for a litre of vodka,” said Myran.
“You have a minimum price per unit of ethanol … and there’s a really compelling reason to price cannabis according to its THC content … [to] financially discourage people from always moving to the highest potency THC products.”
Ross says there is also a need for more current cannabis research. Most cannabis research evaluates the effects of cannabis products with much lower THC levels than those seen on the market today. Long-term health effects can take decades to appear — similar to tobacco.
“Some of [the health harms] might emerge over many, many years, and we don’t know what those will be until data comes in,” she said.
Quebec’s approach
Ross points to Quebec as a unique model in cannabis regulation. It is the only province that caps THC potency and tightly controls how cannabis can be marketed. For example, edibles resembling candy or desserts are prohibited.
Jutras-Aswad, of the Université de Montréal, says overly strict rules can drive some consumers — especially those younger than the province’s legal age of 21 — to the black market.
Still, he says Quebec’s model offers benefits, including greater control over sales and a public health approach focused on harm reduction rather than profit.
Under Quebec’s Cannabis Regulation Act, the Société québécoise du cannabis (SQDC) is the only authorized cannabis retailer in the province.
SQDC employees are trained to offer science-based information, connect consumers with support services and promote safer use.
Researchers in Ontario are now studying how Quebec’s stricter THC limits may be affecting cannabis-related harms compared to other provinces.
“That’s going to be a really interesting within-Canada experiment,” said Ross.
Myran recommends adopting Quebec’s 30 per cent THC caps nationwide.
He also recommends better product labelling requirements and a pricing model that sets a minimum price per unit of THC — to discourage the purchase of high-potency products.
In a 2023 op-ed, Ross argued provinces should fund cannabis research to guide policy and public health.
In it, she notes that Quebec reinvested all $95 million of its 2022 revenue from cannabis sales into prevention and research. By contrast, Ontario set aside just 0.1% of its $170 million in cannabis revenue for a Social Impact Fund that has no clear public health focus.
“Canada can do so much better. We have world experts in cannabis research from coast-to-coast, and we are uniquely positioned to have high-quality, well-funded research on its medical use and potential harms,” she wrote.
“Five years from now, will we be dealing with major public health challenges that could have been avoided?”
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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