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“Safer supply” reminiscent of the OxyContin crisis, warns addiction physician

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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.

[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.]

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Addictions

There’s No Such Thing as a “Safer Supply” of Drugs

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By Adam Zivo

Sweden, the U.K., and Canada all experimented with providing opioids to addicts. The results were disastrous.

[This article was originally published in City Journal, a public policy magazine and website published by the Manhattan Institute for Policy Research. We encourage our readers to subscribe to them for high-quality analysis on urban issues]

Last August, Denver’s city council passed a proclamation endorsing radical “harm reduction” strategies to address the drug crisis. Among these was “safer supply,” the idea that the government should give drug users their drug of choice, for free. Safer supply is a popular idea among drug-reform activists. But other countries have already tested this experiment and seen disastrous results, including more addiction, crime, and overdose deaths. It would be foolish to follow their example.

The safer-supply movement maintains that drug-related overdoses, infections, and deaths are driven by the unpredictability of the black market, where drugs are inconsistently dosed and often adulterated with other toxic substances. With ultra-potent opioids like fentanyl, even minor dosing errors can prove fatal. Drug contaminants, which dealers use to provide a stronger high at a lower cost, can be just as deadly and potentially disfiguring.

Because of this, harm-reduction activists sometimes argue that governments should provide a free supply of unadulterated, “safe” drugs to get users to abandon the dangerous street supply. Or they say that such drugs should be sold in a controlled manner, like alcohol or cannabis—an endorsement of partial or total drug legalization.

But “safe” is a relative term: the drugs championed by these activists include pharmaceutical-grade fentanyl, hydromorphone (an opioid as potent as heroin), and prescription meth. Though less risky than their illicit alternatives, these drugs are still profoundly dangerous.

The theory behind safer supply is not entirely unreasonable, but in every country that has tried it, implementation has led to increased suffering and addiction. In Europe, only Sweden and the U.K. have tested safer supply, both in the 1960s. The Swedish model gave more than 100 addicts nearly unlimited access through their doctors to prescriptions for morphine and amphetamines, with no expectations of supervised consumption. Recipients mostly sold their free drugs on the black market, often through a network of “satellite patients” (addicts who purchased prescribed drugs). This led to an explosion of addiction and public disorder.

Most doctors quickly abandoned the experiment, and it was shut down after just two years and several high-profile overdose deaths, including that of a 17-year-old girl. Media coverage portrayed safer supply as a generational medical scandal and noted that the British, after experiencing similar problems, also abandoned their experiment.

While the U.S. has never formally adopted a safer-supply policy, it experienced something functionally similar during the OxyContin crisis of the 2000s. At the time, access to the powerful opioid was virtually unrestricted in many parts of North America. Addicts turned to pharmacies for an easy fix and often sold or traded their extra pills for a quick buck. Unscrupulous “pill mills” handed out prescriptions like candy, flooding communities with OxyContin and similar narcotics. The result was a devastating opioid epidemic—one that rages to this day, at a cumulative cost of hundreds of thousands of American lives. Canada was similarly affected.

The OxyContin crisis explains why many experienced addiction experts were aghast when Canada greatly expanded access to safer supply in 2020, following a four-year pilot project. They worried that the mistakes of the recent past were being made all over again, and that the recently vanquished pill mills had returned under the cloak of “harm reduction.”

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Most Canadian safer-supply prescribers dispense large quantities of hydromorphone with little to no supervised consumption. Patients can receive up to 40 eight-milligram pills per day—despite the fact that just two or three are enough to cause an overdose in someone without opioid tolerance. Some prescribers also provide supplementary fentanyl, oxycodone, or stimulants.

Unfortunately, many safer-supply patients sell or trade a significant portion of these drugs—primarily hydromorphone—in order to purchase more potent illicit substances, such as street fentanyl.

The problems with safer supply entered Canada’s consciousness in mid-2023, through an investigative report I wrote for the National Post. I interviewed 14 addiction physicians from across the country, who testified that safer-supply diversion is ubiquitous; that the street price of hydromorphone collapsed by up to 95 percent in communities where safer supply is available; that youth are consuming and becoming addicted to diverted safer-supply drugs; and that organized crime traffics these drugs.

Facing pushback, I interviewed former drug users, who estimated that roughly 80 percent of the safer-supply drugs flowing through their social circles was getting diverted. I documented dozens of examples of safer-supply trafficking online, representing tens of thousands of pills. I spoke with youth who had developed addictions from diverted safer supply and adults who had purchased thousands of such pills.

After months of public queries, the police department of London, Ontario—where safer supply was first piloted—revealed last summer that annual hydromorphone seizures rose over 3,000 percent between 2019 and 2023. The department later held a press conference warning that gangs clearly traffic safer supply. The police departments of two nearby midsize cities also saw their post-2019 hydromorphone seizures increase more than 1,000 percent.

The Canadian government quietly dropped its support for safer supply last year, cutting funding for many of its pilot programs. The province of British Columbia (the nexus of the harm-reduction movement) finally pulled back support last month, after a leaked presentation confirmed that safer-supply drugs are getting sold internationally and that the government is investigating 60 pharmacies for paying kickbacks to safer-supply patients. For now, all safer-supply drugs dispensed within the province must be consumed under supervision.

Harm-reduction activists have insisted that no hard evidence exists of widespread diversion of safer-supply drugs, but this is only because they refuse to study the issue. Most “studies” supporting safer supply are produced by ideologically driven activist-scholars, who tend to interview a small number of program enrollees. These activists also reject attempts to track diversion as “stigmatizing.”

The experiences of Sweden, the United Kingdom, and Canada offer a clear warning: safer supply is a reliably harmful policy. The outcomes speak for themselves—rising addiction, diversion, and little evidence of long-term benefit.

As the debate unfolds in the United States, policymakers would do well to learn from these failures. Americans should not be made to endure the consequences of a policy already discredited abroad simply because progressive leaders choose to ignore the record. The question now is whether we will repeat others’ mistakes—or chart a more responsible course.

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Should fentanyl dealers face manslaughter charges for fatal overdoses?

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Tyler Ginn prior to his death from a fentanyl overdose in 2021. [Photo credit: Gayle Fowlie]

By Alexandra Keeler

Police are charging more drug dealers with manslaughter in fentanyl overdose deaths. But the shift is not satisfying everyone

Four years ago, Tyler Ginn died of a fentanyl overdose at the age of 18. Tyler’s father found his son unresponsive in the bedroom of their Brooklin, Ont., home.

For Tyler’s mother, Gayle Fowlie, the pain of his loss remains raw.

“He was my kid that rode his bike to the store to buy me a chocolate bar on my birthday, you know?” she told Canadian Affairs in an interview.

Police charged Jacob Norn, the drug dealer who sold Tyler his final, fatal dose, with manslaughter. More than three years after Tyler’s death, Norn was convicted and sentenced to six years in prison.

“I don’t think you can grasp how difficult going through a trial is,” Fowlie said. “On TV, it’s a less than an hour process. But the pain of it, and going over every detail and then going over every detail again … it provides details you wish you didn’t know.”

But Fowlie is glad Norn was convicted. If anything, she would have liked him to serve a longer sentence. Lawyers have told her Norn is likely to serve only two to four years of his sentence in prison.

“My son’s never coming back [and] his whole family has a life sentence of missing him the rest of our lives,” she said. “So do I think four years is fair? No.”

Norn’s case reflects a growing trend of drug dealers being charged with manslaughter when their drug sales lead to fatal overdoses.

But this shift has not satisfied everyone. Some would like to see drug dealers face harsher or different penalties.

“If we say that it was 50 per cent Tyler’s fault for buying it and 50 per cent Jacob’s fault for selling it … then I think he should have a half-a-life sentence,” said Fowlie.

Others say the legal system’s focus on prosecuting low-level drug dealers misses the broader issues at play.

“[Police] decided, in the Jacob Norn case, they were going to go one stage back,” said Peter Thorning, who was Norn’s defence lawyer.

“What about the person who gave Jacob that substance? What about the person who supplied the substance to [that person]? There was no investigation into where it came from and who was ultimately responsible for the death of that young man.”

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Manslaughter charge

At least 50,000 Canadians have died from drug overdoses since 2016. Last year, an average of 21 individuals died each day, with fentanyl accounting for nearly 80 per cent of those deaths.

Fentanyl, a synthetic opioid, is up to 50 times stronger than heroin and 100 times stronger than morphine. A dose as small as a few grains of salt can be lethal.

Given its potency, police and prosecutors have increasingly turned to manslaughter charges when a dealer’s product results in a fatal overdose.

A recent study in the Canadian Journal of Law and Society found that the number of manslaughter charges laid for drug-related deaths in Canada surged from three cases in 2016 to 135 in 2021.

Individuals can be convicted of manslaughter for committing unlawful, reckless or negligent acts that result in death but where there was no intention to kill. Sentences can range from probation (in rare cases) to life.

Murder charges, by contrast, require an intent to kill or cause fatal harm. Drug dealers typically face manslaughter charges in overdose cases, as their intent is to distribute drugs, not to kill those who purchase them.

Joanne Bortoluss, a spokesperson for the Durham Regional Police, which charged Norn, said that each of their investigations follows the same fundamental process.

“Investigators consider the strength of the evidence, the dealer’s level of involvement, and applicable laws when determining whether to pursue charges like manslaughter,” she said.

The Canadian Journal of Law and Society study also found that prosecutions often target low-level dealers, many of whom are drug users themselves and have personal connections to the deceased.

Norn’s case fits this pattern. He struggled with substance abuse, including addiction to fentanyl, Xanax and Percocet. Tyler and Norn were friends, the judge said in the court ruling, although Fowlie disputes this claim.

“[Those words] are repulsive to me,” she said.

The Crown argued Norn demonstrated “a high degree of moral blameworthiness” by warning Ginn of the fentanyl’s potency while still selling it to him. In a call to Ginn, he warned him “not to do a lot of the stuff” because he “didn’t want to be responsible for anything that happened.”

Fowlie’s outrage over Norn’s lenient sentencing is compounded by the fact that Norn was found trafficking fentanyl again after her son’s death.

“So we’ve killed somebody, and we’re still … trafficking? We’re not worried who else we kill?” Fowlie said.

Trafficking

Some legal sources noted that manslaughter charges do not necessarily lead to harsh sentences or deterrence.

“If you look at how diverse and … lenient some sentences are for manslaughter, I don’t think it really pushes things in the direction that [victims’ families] want,” said Kevin Westell, a Vancouver-based trial lawyer and former chair of the Canadian Bar Association.

Westell noted that the term “manslaughter” is misleading. “Manslaughter is a brutal-sounding title, but it encapsulates a very broad span of criminal offences,” he said.

In Westell’s view, consistently charging dealers with drug trafficking could be more effective for deterring the practice.

“What really matters is how long the sentence is, and you’re better off saying, ‘We know fentanyl is dangerous, so we’re setting the sentence quite high,’ rather than making it harder to prove with a manslaughter charge,” he said.

Trafficking is a distinct charge from manslaughter that involves the distribution, sale or delivery of illicit drugs. The sentencing range for fentanyl trafficking is eight to 15 years, Kwame Bonsu, a media relations representative for the Department of Justice, told Canadian Affairs.

“Courts must impose sentences that are proportionate to the gravity of the offence and the degree of responsibility of the offender,” Bonsu said, referencing a 2021 Supreme Court of Canada decision. Bonsu noted that aggravating factors such as lack of remorse or trafficking large quantities can lead to harsher sentences.

‘Head of the snake’

Some legal experts noted the justice system often fails to target those higher up in the drug supply chain.

“We don’t know how many hands that drug goes through,” said Thorning, the defence lawyer.

“Are the police going to prosecute every single person who provides fentanyl to another person? Jacob [Norn] was himself an addict trafficker — what about the person who supplied the substance to him?”

Thorning also questioned whether government agencies bear some responsibility. “Is some government agency’s failure to investigate how that drug came into the country partly responsible for the young man’s death?”

Westell, who has served as both a Crown prosecutor and criminal defence lawyer, acknowledged the difficulty of targeting higher-level traffickers.

“Cutting off the head of the snake does not align very well with the limitations of the international borders,” he said.

“Yes, there are transnational justice measures, but a lot gets lost, and as soon as you cross an international border of any kind, it becomes incredibly difficult to follow the chain in a linear way.”

Bortoluss, of the Durham police, said even prosecuting what appear to be obvious fentanyl-related deaths — such as Tyler Ginn’s — can be challenging. Witnesses can be reluctant to cooperate, fearing legal consequences. It can also be difficult to identify the source of drugs, as “transactions often involve multiple intermediaries and anonymous online sales.”

Another challenge in deterring fentanyl trafficking is the strong financial incentives of the trade.

“Even if [Norn] serves two to four years for killing somebody, but he could make a hundred thousand off of selling drugs, is it worth it?” Fowlie said.

Thorning agreed that the profit incentive can be incredibly powerful, outweighing the risk of a potential sentence.

“The more risky you make the behaviour, the greater the profit for a person who’s willing to break our laws, and the profit is the thing that generates the conduct,” he said.

A blunt instrument

Legal experts also noted the criminal justice system alone cannot solve the fentanyl crisis.

“Most people who have [lost] a loved one [to drug overdose] want to see a direct consequence to the person that’s responsible,” said Westell. “But I think they would also like to see something on a more macro level that helps eliminate the problem more holistically, and that can’t be [achieved through] crime and punishment alone.”

Thorning agrees.

“These are mental health .. [and] medical issues,” he said. “Criminal law is a blunt instrument [that is] not going to deal with these things effectively.”

Even Fowlie sees the problem as bigger than sentencing. Her son struggled with the stigma associated with therapy and medication, which made it difficult for him to seek help.

“We need to normalize seeing a therapist, like we normalize getting your eyes checked every year,” she said.

“Pot isn’t the gateway drug, trauma is a gateway drug.”


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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