Addictions
Canada’s ‘safer supply’ patients are receiving staggering amounts of narcotics
Image courtesy of Midjourney.
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How a Small Population Fuels a Black Market Epidemic, Echoing Troubling Parallels in Sweden
A significant amount of safer supply opioids are obviously being diverted to the black market, but some influential voices are vehemently downplaying this problem. They often claim that there are simply too few safer supply clients for diversion to be a real issue – but this argument is misleading because it glosses over the fact that these clients receive truly staggering amounts of narcotics relative to everyone else.
“Safer supply” refers to the practice of prescribing free recreational drugs as an alternative to potentially-tainted street substances. In Canada, that typically means distributing eight-mg tablets of hydromorphone, an opioid as potent as heroin, to mitigate the use of illicit fentanyl.
There is clear evidence that most safer supply clients regularly sell or trade almost all of their hydromorphone tablets for stronger illicit substances, and that this is flooding communities with the drug and fuelling new addictions and relapses. Just five years ago, the street price of an eight-mg hydromorphone tablet was around $20 in major Canadian cities – now they often go for as little as $1.
But advocates repeatedly emphasize that, even if such diversion is occurring, it must be a minor issue because there are only a few thousand safer supply clients in Canada. They believe that it is simply impossible for such a small population to have a meaningful impact on the overall black market for diverted pharmaceuticals, and that the sudden collapse of hydromorphone prices must have been caused by other factors.
This is an earnest belief – but an extremely ill-informed one.
It is difficult to analyze safer supply at the national level, as each province publishes different drug statistics that make interprovincial comparisons near-impossible. So, for the sake of clarity, let’s focus primarily on B.C., where the debate over safer supply has raged hottest.
According to a dashboard published by the British Columbia Centre for Disease Control, there were only 4,450 safer supply clients in the province in December 2023, of which 4,250 received opioids. In contrast, the 2018/19 British Columbia Controlled Prescription Drug Atlas (more recent data is unavailable) states that there were approximately 80,000 hydromorphone patients in the province that year – a number that is unlikely to have decreased significantly since then.
We can thus reasonably assume that safer supply clients represent around 5 per cent of the province’s total hydromorphone patients – but if so few people are on safer supply, how could they have a profound impact on the black market? The answer is simple: these clients receive astonishing sums of the drug, and divert at an unparalleled level, compared to everyone else.
Safer supply clients generally receive 4-8 eight-mg tablets per day at first, but almost all of them are quickly moved up to higher doses. In B.C., most patients are kept at 14 tablets (112-mg in total) per day, which is the maximum allowed by the province’s guidelines. For comparison, patients in Ontario can receive as many as 30 tablets a day (240-mg in total).
These are huge amounts.
The typical hydromorphone dose used to treat post-surgery pain in hospital settings is two-mg every 4-6 hours – or roughly 12-mg per day. So that means that safer supply clients can receive roughly 10-20 times the daily dose given to acute pain patients, depending on which province they’re located in. And while acute pain patients are tapered off hydromorphone after a few weeks, safer supply clients receive their tablets indefinitely.
Some chronic pain patients (i.e. people struggling with severe arthritis) are also prescribed hydromorphone – but, in most cases, their daily dose is 12-mg or less. The exception here is terminally ill cancer patients, who may receive up to around 100-mg of hydromorphone per day. However, this population is relatively small, so we once again have a situation where safer supply patients are, for the most part, receiving much more hydromorphone than their peers.
Not only do safer supply patients receive incredible amounts of the drug, they also seem to divert it at much higher rates – which is a frequently overlooked factor.
The clandestine nature of prescription drug diversion makes it near-impossible to measure, but a 2017 peer-reviewed study estimated that, in the United States, up to 3 per cent of all prescription opioids end up on the black market.
In contrast, it appears that safer supply patients divert 80-90 per cent of their hydromorphone.
These numbers should be taken with a grain of salt, as there have been no attempts to measure safer supply diversion – harm reduction researchers tend to simply ignore the problem, which means that we must rely on journalistic evidence that is necessarily anecdotal in nature. While this evidence has its limits, it can, at the very least, illustrate the rough scale of the problem.
For example, in London, Ontario, I interviewed six former drug users last summer who said that, of the safer supply clients they knew, 80 per cent sold almost all of their hydromorphone – just one interviewee placed the number closer to 50 per cent. More recently, I interviewed an addiction outreach worker in Ottawa who estimated that 90 per cent of safer supply clients diverted their drugs. These numbers are consistent with the testimony of dozens of addiction physicians who have said that safer supply diversion is ubiquitous.
Let us take a conservative estimate and imagine that only 30 per cent of safer supply hydromorphone is diverted – even this would be potentially catastrophic.
So we can see why any serious attempt to discuss safer supply diversion cannot narrowly focus on patient numbers – to ignore differences in doses and diversion rates is inexcusably misleading.
But we don’t need to rely on theory to make this point, because the recent parliamentary testimony of Fiona Wilson, who is deputy chief of the Vancouver Police Department and president of the B.C. Association of Chiefs of Police (BCACP), illustrates the situation quite neatly.
Wilson testified to the House of Commons health committee earlier this month that half of the hydromorphone recently seized in B.C. can be attributed to safer supply. As she did not specify whether the other half was attributed to other sources, or simply of indeterminate origin, the actual rate of safer supply hydromorphone seizures may actually be even higher.
As, once again, safer supply clients constitute roughly 5 per cent of the total hydromorphone patient population, Wilson’s testimony suggests that, on a per capita basis, safer supply patients divert at least 18 times more of the drug than everyone else.
This is exactly what one would expect to find given our earlier analysis, and these facts, by themselves, repudiate the argument that safer supply diversion is insignificant. When a small population is at least doubling the street supply of a dangerous pharmaceutical opioid, this is a problem.
The fact that so few people can cause substantial, system-wide harm is not unprecedented. In fact, this exact same problem was observed in Sweden, which, from 1965-1967, experimented with a model of safer supply that closely resembled what is being done in Canada today. A small number of patients – barely more than a hundred – were given near-unlimited access to free recreational drugs under the assumption that this would keep them “safe.”
But these patients simply sold the bulk of their drugs, which caused addiction and crime rates to skyrocket across Stockholm. Commentators at the time referred to safer supply as “the worst scandal in Swedish medical history,” and, even today, the experiment remains a cautionary tale among the country’s drug researchers.
It is simply wrong to say that there are too few safer supply clients to cause a diversion crisis. People who make this claim are ignorant of contemporary and historical facts, and those who wish to position themselves as drug experts should be mindful of this, lest they mislead the public about a destructive drug crisis.
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This article was originally published in The Bureau, a Canadian publication devoted to using investigative journalism to tackle corruption and foreign influence campaigns. You can find this article on their website here.
When it comes to addressing the national overdose crisis, the Canadian public seems ideologically split: some groups prioritize recovery and abstinence, while others lean heavily into “harm reduction” and destigmatization. In most cases, we would defer to the experts—but they are similarly divided here.
This factionalism was evident at the Canadian Society of Addiction Medicine’s (CSAM) annual scientific conference this year, which is the country’s largest gathering of addiction medicine practitioners (e.g., physicians, nurses, psychiatrists). Throughout the event, speakers alluded to the field’s disunity and the need to bridge political gaps through collaborative, not adversarial, dialogue.
This was a major shift from previous conferences, which largely ignored the long-brewing battles among addiction experts, and reflected a wider societal rethink of the harm reduction movement, which was politically hegemonic until very recently.
Recovery-oriented care versus harm reductionism
For decades, most Canadian addiction experts focused on shepherding patients towards recovery and encouraging drug abstinence. However, in the 2000s, this began to shift with the rise of harm reductionism, which took a more tolerant view of drug use.
On the surface, harm reductionists advocated for pragmatically minimizing the negative consequences of risky use—for example, through needle exchanges and supervised consumption sites. Additionally, though, many of them also claimed that drug consumption is not inherently wrong or shameful, and that associated harms are primarily caused not by drugs themselves but by the stigmatization and criminalization of their use. In their view, if all hard drugs were legalized and destigmatized, then they would eventually become as banal as alcohol and tobacco.
The harm reductionists gained significant traction in the 2010s thanks to the popularization of street fentanyl. The drug’s incredible potency caused an explosion of deaths and left users with formidable opioid tolerances that rendered traditional addiction medications, such as methadone, less effective. Amid this crisis, policymakers embraced harm reduction out of an immediate need to make drug use slightly less lethal. This typically meant supervising consumption, providing sterile drug paraphernalia, and offering “cleaner” substances for addicts to use.
Many abstinence-oriented addiction experts supported some aspects of harm reduction. They valued interventions that could demonstrably save lives without significant tradeoffs, and saw them as both transitional and as part of a larger public health toolkit. Distributing clean needles and Naloxone, an overdose-reversal medication, proved particularly popular. “People can’t recover if they’re dead,” went a popular mantra from the time.
Saving lives or enabling addiction?
However, many of these addiction experts were also uncomfortable with the broader political ideologies animating the movement and did not believe that drug use should be normalized. Many felt that some experimental harm reduction interventions in Canada were either conceptually flawed or that their implementation had deviated from what had originally been promised.
Some argued, not unreasonably, that the country’s supervised consumption sites are being mismanaged and failing to connect vulnerable addicts to recovery-oriented care. Most of their ire, however, was directed at “safer supply”—a novel strategy wherein addicts are given free drugs, predominantly hydromorphone (a heroin-strength opioid), without any real supervision.
While safer supply was meant to dissuade recipients from using riskier street drugs, addiction physicians widely reported that patients were selling their free hydromorphone to buy stronger illicit fentanyl, thereby flooding communities with diverted opioids and exacerbating the addiction crisis. They also noted that the “evidence base” behind safer supply was exceptionally poor and would not meet normal health-care standards.
Yet, critics of safer supply, and harm reduction radicalism more broadly, were often afraid to voice their opinions. The harm reductionists were institutionally and culturally dominant in the late 2010s and early 2020s, and opponents often faced activist harassment, aggressive gaslighting, and professional marginalization. A culture of self-censorship formed, giving both the public and influential policymakers a false impression of scientific consensus where none actually existed.
The resurgence in recovery-oriented strategies
Things changed in the mid-2020s. British Columbia’s failed drug decriminalization experiment eroded public trust in harm reductionism, and the scandalous failures of safer supply—and supervised consumption sites, too—were widely publicized in the national media.1
Whereas harm reductionism was once so powerful that opponents were dismissed as anti-scientific, there is now a resurgent interest in alternative, recovery-oriented strategies.
These cultural shifts have fuelled a more fractious, but intellectually honest, national debate about how to tackle the overdose crisis. This has ruptured the institutional dominance enjoyed by harm reductionists in the addiction medicine world and allowed their previously silenced opponents to speak up.
When I first attended CSAM’s annual scientific conference two years ago, recovery-oriented critics of radical harm reductionism were not given any platforms, with the exception of one minor presentation on safer supply diversion. Their beliefs seemed clandestine and iconoclastic, despite seemingly having wide buy-in from the addiction medicine community.
While vigorous criticism of harm reductionism was not a major feature of this year’s conference, there was open recognition that legitimate opposition to the movement existed. One major presentation, given by Dr. Didier Jutras-Aswad, explicitly cited safer supply and involuntary treatment as two foci of contention, and encouraged harm reductionists and recovery-oriented experts to grab coffee with one another so that they might foster some sense of mutual understanding.2
Is this change enough?
While CSAM should be commended for encouraging cross-ideological dialogue, its efforts, in this respect, were also superficial and vague. They chose to play it safe, and much was left unsaid and unexplored.
Two addiction medicine doctors I spoke with at the conference—both of whom were critics of safer supply and asked for anonymity—were nonplussed. “You can feel the tension in the air,” said one, who likened the conference to an awkward family dinner where everyone has tacitly agreed to ignore a recent feud. “Reconciliation requires truth,” said the other.
One could also argue that the organization has taken an inconsistent approach to encouraging respectful dialogue. When recovery-oriented experts were being bullied for their views a few years ago, they were largely left on their own. Now that their side is ascendant, and harm reductionists are politically vulnerable, mutual respect is in fashion again.
When I asked to interview the organization about navigating dissension, they sent a short, unspecific statement that emphasized “evidence-based practices” and the “benefits of exploring a variety of viewpoints, and the need to constantly challenge or re-evaluate our own positions based on the available science.”
But one cannot simply appeal to “evidence-based practices” when research is contentious and vulnerable to ideological meddling or misrepresentation.
Compared to other medical disciplines, addiction medicine is highly political. Grappling with larger, non-empirical questions about the role of drug use in society has always necessitated taking a philosophical stance on social norms, and this has been especially true since harm reductionists began emphasizing the structural forces that shape and fuel drug use.
Until Canada’s addiction medicine community facilitates a more robust and open conversation about the politicization of research, and the divided—and inescapably political—nature of their work, the national debate on the overdose crisis will be shambolic. This will have negative downstream impacts on policymaking and, ultimately, people’s lives.
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From the Brownstone Institute
Cigarettes kill nearly half a million Americans each year. Everyone knows it, including the Food and Drug Administration. Yet while the most lethal nicotine product remains on sale in every gas station, the FDA continues to block or delay far safer alternatives.
Nicotine pouches—small, smokeless packets tucked under the lip—deliver nicotine without burning tobacco. They eliminate the tar, carbon monoxide, and carcinogens that make cigarettes so deadly. The logic of harm reduction couldn’t be clearer: if smokers can get nicotine without smoke, millions of lives could be saved.
Sweden has already proven the point. Through widespread use of snus and nicotine pouches, the country has cut daily smoking to about 5 percent, the lowest rate in Europe. Lung-cancer deaths are less than half the continental average. This “Swedish Experience” shows that when adults are given safer options, they switch voluntarily—no prohibition required.
In the United States, however, the FDA’s tobacco division has turned this logic on its head. Since Congress gave it sweeping authority in 2009, the agency has demanded that every new product undergo a Premarket Tobacco Product Application, or PMTA, proving it is “appropriate for the protection of public health.” That sounds reasonable until you see how the process works.
Manufacturers must spend millions on speculative modeling about how their products might affect every segment of society—smokers, nonsmokers, youth, and future generations—before they can even reach the market. Unsurprisingly, almost all PMTAs have been denied or shelved. Reduced-risk products sit in limbo while Marlboros and Newports remain untouched.
Only this January did the agency relent slightly, authorizing 20 ZYN nicotine-pouch products made by Swedish Match, now owned by Philip Morris. The FDA admitted the obvious: “The data show that these specific products are appropriate for the protection of public health.” The toxic-chemical levels were far lower than in cigarettes, and adult smokers were more likely to switch than teens were to start.
The decision should have been a turning point. Instead, it exposed the double standard. Other pouch makers—especially smaller firms from Sweden and the US, such as NOAT—remain locked out of the legal market even when their products meet the same technical standards.
The FDA’s inaction has created a black market dominated by unregulated imports, many from China. According to my own research, roughly 85 percent of pouches now sold in convenience stores are technically illegal.
The agency claims that this heavy-handed approach protects kids. But youth pouch use in the US remains very low—about 1.5 percent of high-school students according to the latest National Youth Tobacco Survey—while nearly 30 million American adults still smoke. Denying safer products to millions of addicted adults because a tiny fraction of teens might experiment is the opposite of public-health logic.
There’s a better path. The FDA should base its decisions on science, not fear. If a product dramatically reduces exposure to harmful chemicals, meets strict packaging and marketing standards, and enforces Tobacco 21 age verification, it should be allowed on the market. Population-level effects can be monitored afterward through real-world data on switching and youth use. That’s how drug and vaccine regulation already works.
Sweden’s evidence shows the results of a pragmatic approach: a near-smoke-free society achieved through consumer choice, not coercion. The FDA’s own approval of ZYN proves that such products can meet its legal standard for protecting public health. The next step is consistency—apply the same rules to everyone.
Combustion, not nicotine, is the killer. Until the FDA acts on that simple truth, it will keep protecting the cigarette industry it was supposed to regulate.
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