Addictions
Safe supply opioids based more on ideology than evidence?
From the Frontier Centre for Public Policy
Those who advocate for them always claim the moral high ground because of ‘evidence-based studies.’ But such studies appear to be in short supply.
That’s probably why 72 BC doctors recently signed a letter that argues against safer supply, saying the evidence underlying the philosophy is “weak or inadequate.”
Almost three years into the experimental opiate “safer supply” program in British Columbia and no one, including those handing out the pills, seems to know if it is working or making the problem worse. There are no shortage of opinions arguing on either side of the debate, but recent reports suggest that the facts remain in short supply.
Safe supply initiatives fall under the broad category of harm reduction programs. For opiate addiction, the program typically involves the prescription and distribution of pills like hydromorphone, a medical-grade opioid that is as potent as heroin, to addicts. The underlying hope is that addicts will then forgo possibly-tainted, illicit street drugs in favour of the ‘safer’ government-provided pills.
More than 40,000 Canadians have lost their lives to opioid overdoses since 2016 and British Columbia is one of the world’s first jurisdictions to take the ‘safer supply’ route in an effort to quell opioid overdoses.
But BC’s Auditor General just released a report on the trial program and, so far, it remains unclear as to whether the program has made any progress. Opioid deaths are still increasing and, while the report doesn’t criticize the underlying philosophy of ‘safer supply,’ it does note “deficiencies in key areas.”
According to the report, the government is conducting the program in a rather haphazard way. BC health authorities failed to maintain basic standards for administering an experimental trial and neglected their obligation to publish data on how the program is doing. The data was supposed to be publicly available by September 2022, more than 18 months ago.
Instead, the report found that health authorities are overly reliant on incomplete and out-of-date fact sheets about the program’s performance. It also cited authorities for major failings in the management and delivery of the program.
The bureaucrats in charge claim that they have the data to support their claims about the success of the program, yet one has to wonder why — three years in — no data is available to support those claims.
A similar dearth of data has been noted in Ottawa where the House of Commons Health Committee has been exploring the opioid epidemic and toxic drug crisis. One doctor who leads a safer supply program in London, Ontario, appeared to be a strong advocate for safer supply programs, claiming that safe supply clinicians “rely on good research and published evidence.”
But Dr. Marcus Powlowski, a Liberal MP and medical doctor who also has a master’s degree in health law and policy from Harvard, had apparently looked at the papers that she proclaimed as evidence, and soundly renounced the studies as “basically a bunch of anecdotes.”
So where is this rigorous scientific evidence for safer supply programs?
Those who advocate for them always claim the moral high ground because of ‘evidence-based studies.’ But such studies appear to be in short supply.
That’s probably why 72 BC doctors recently signed a letter that argues against safer supply, saying the evidence underlying the philosophy is “weak or inadequate.” They called for all safer supply programs to be “tightly controlled, rigorously monitored, and meticulously documented.”
A lack of medical evidence is likely related to another major issue outlined in the Auditor General’s report – “prescriber hesitancy.” That is, there are only a limited number of doctors who are willing to write prescriptions for the potent opioids used in safer supply.
However, there is plenty of evidence for one disturbing aspect of this program – diversion. This is a practice whereby safer supply pills (primarily hydromorphone) given to addicts are subsequently sold (or diverted) to drug traffickers and/or organized crime groups to obtain more potent and illicit drugs like fentanyl.
In early March, the RCMP in Northern BC revealed that thousands of safe supply opiate pills had been seized as part of organized crime busts in Prince George and Campbell River. It was considered to be solid evidence that diversion of safer supply drugs was occurring. According to the RCMP spokesperson, “Organized crime groups are actively involved in the redistribution of safe supply and prescription drugs,” and “what has been deemed safe is not being kept safe.”
It is simply not realistic to expect that such practices are not occurring in our major cities. The National Post, the CBC and an independent filmmaker have all previously published evidence of diversion occurring in London, Ottawa and Vancouver, respectively.
Drug policies such as safe supply have long bypassed appropriate scientific scrutiny because they supposedly save lives. But the question still remains – do they? And at what cost to addicts and the rest of society?
Susan Martinuk is a Senior Fellow with the Frontier Centre for Public Policy and author of Patients at Risk: Exposing Canada’s Health-care Crisis.
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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