Preventing deaths & supporting wellbeing
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In April 2016, The Provincial Health Officer declared a public health crisis with respect to opioid overdoses in British Columbia. The primary cause of these deaths is a contaminated drug supply. At least 13,112 people in BC and over 34,000 in Canada died from this toxic drug supply between 2016 and 2023. These numbers are high and climbing. Drug toxicity, often referred to as overdose, is now the leading cause of death among people aged 10-69 in British Columbia. Perhaps surprisingly, most of those deaths occur indoors, not on the street.1
Provision of a regulated supply of drugs of known content and quality, a safer supply, is one way to address the drug toxicity crisis. There is much confusion, misunderstanding, and inconsistent information around what a Safer Supply program is about, why such a program is offered and why providing this service is important to individual and community health. This situation is made more complex by the social environment we live in.
Some historical context
People have used psychoactive substances for thousands of years to feel better, do better, explore thinking and feeling, celebrate important milestones and as part of religious or cultural ceremonies. Many people use psychoactive substances regularly. A daily coffee or two, or a cup of tea (caffeine) are part of many morning rituals. Others drink alcohol, smoke cigarettes (nicotine), vape (nicotine or THC2) or use cannabis to relax, reduce anxiety or socialize after a day at work. Still others use opioids or stimulants to feel good or reduce emotional and physical pain. Use for the latter reasons can leave people more vulnerable to harmful impacts from drugs they may obtain through unregulated sources.
Several factors contribute to the challenges agencies face trying to reduce overdose deaths by supplying a safer alternative to the toxic street supply of drugs. For example, social conditions can make certain groups of people, including those who are homeless or Indigenous peoples, more vulnerable to harms from adulterated and toxic drugs. Such conditions include a lack of affordable housing and supports for people living in poverty, a lack of services related to drug use, various barriers to accessing existing services, systemic racism, and colonialism. These issues can make it difficult for people who use drugs to address their daily life needs, let alone their health needs.
Policies at federal, provincial, and municipal levels that moralize and criminalize people who use drugs are also relevant to the provision of a safer supply. These policies may in part be rooted in a belief stemming from mid-1500s England still evident in Victorian times that there were two types of people experiencing poverty: those deserving of public support and those not.3 The deserving poor lived in poverty through no fault of their own. This included elders, orphans or people who were ill or disabled. The undeserving poor were seen as physically able to work, but not doing so due to laziness or unwillingness to seek employment, and therefore able to look after themselves. People who use drugs are often viewed in the latter category, regardless of their circumstances. These beliefs can stay below social awareness yet can still influence the actions of policymakers and the public. For example, you might ask, "Why is it okay for people in hospice care to have unlimited access to a safe supply of opioid pain relievers, but not others who use drugs to address the pain in their daily lives?" With moralized and punitive thinking potentially contributing to a range of policies, people who use drugs may be viewed as second-class citizens, not worthy of the same rights and freedoms as the remainder of the population.
Thus, the conditions in which people live and the challenges they experience may be attributed to the persons themselves, suggesting they may be lazy, immoral, dishonest, or criminal, rather than disproportionately affected by housing, income, and healthcare systems that do not and currently cannot meet their needs. These disparities are made worse by Indigenous heritage and the colonial legacy of racism still clear in Canada. This is stigma. Stigma associated with drug use separates people who use drugs from the rest of society, often leaving them to cope with health or personal challenges on their own or within their circle of friends. Using drugs alone is one response to stigma, and given the toxic drug supply, one that can lead to a greater incidence of overdose and death.
Public spaces
For some people, such as those who are unhoused or who spend much of their time accessing inner-city social services, using drugs in public is something they cannot easily avoid. People would not generally choose to consume drugs in public. No one really wants people they do not know to see them in such a vulnerable circumstance. This is in part why folks take drugs in public bathrooms. If a member of the public sees any used needles, pipes, or other supplies, they should not touch them but instead call an agency that provides collection/disposal services or the municipal hall.
Many people are without safe, affordable, adequate housing. Increasing numbers are forced to take refuge either within the shelter system or outside in building alcoves, under trees or in tents. Living outside means that people do things in public or semi-public places. This includes eating, sleeping, urinating, defecating, having sex, arguing, and using drugs, things housed people do indoors. Folks who live outside would prefer not to be seen doing these activities as much as you might wish not to see them. Though you may feel uncomfortable, there is little danger to you. Living outside, especially in harsh weather conditions, is extremely difficult. It is important to remember that people would not live outdoors if they had a safe space, a home they could enter, lock the door, and have privacy.
What is Safer Supply and how does it work?
The Canadian Association of People Who Use Drugs (CAPUD) developed the concept of safe supply, defining it as "a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market. Drugs include opioids such as heroin, stimulants such as cocaine and crystal methamphetamine, hallucinogens such as MDMA and LSD, and marijuana."4
The main contaminant in the illicit drug supply is fentanyl, a potent synthetic opioid. More recently, xylazine, a tranquilizer used in veterinary practices, metonitazine (a synthetic opioid) and several novel benzodiazepines such as bromazolam and etizolam5 have surfaced in illegal drug supplies. Though Safer Supply is a form of harm reduction in that it can reduce the likelihood of death or significant problems that may occur due to drug toxicity, it goes beyond harm reduction in that it is based on the belief that people who use drugs are entitled to access medications that will not hurt them.6 Though Safer Supply was introduced primarily as a harm reduction initiative in British Columbia to aid in reducing the risk of spreading COVID-19 and of death from a toxic drug supply, the concept predates the pandemic.7
With a three-year mandate from the federal government beginning in 2021, safer supply in British Columbia is often administered through a closely monitored program under the Risk Mitigation Guidance (RMG)8 developed by the Ministry of Mental Health and Addictions, Ministry of Health, and Office of the Provincial Health Officer of British Columbia.
Clients must live in British Columbia to be part of the RMG Prescribed Safer Supply program. The program is offered through social service agencies in major centers including Vancouver and Victoria, as well as Kelowna, Abbotsford, White Rock, and Nanaimo. Smaller areas also provide the service through individual prescribers, though not at the same level available in larger communities.
Clients are assessed by a physician, referred to the program and, upon acceptance, seen on a regular basis by a nurse or nurse practitioner and, where available, an outreach team. The nurse monitors the amount of drug offered to a client, evaluates the individual's response to the program and provides ongoing support to participants including referral to other health and social supports.9 Nurse Practitioners (NPs) may also prescribe and provide services under this program. Some safer supply prescribers have developed programs outside of the RMG. The Ministry of Health also closely monitors these efforts.
The drug most often prescribed is hydromorphone (Dilaudid), though fentanyl and sufentanil are now available to clients as well as diacetylmorphine and Fentora.10 Some stimulants are also available within the safer supply initiative. Twelve thousand people have accessed Safer Supply in British Columbia since the program began in 2021 though less than five thousand people currently receive their medication this way.
Key to Safer Supply (and harm reduction efforts) is the ongoing involvement of people with lived and living experience of drug use in the development, monitoring, and evaluation of programming. They are experts in the experience of drug use and the local setting in which it takes place. Their knowledge of the drugs used, effects on their bodies and lives, and the health, social service and policing environment is critical to ensuring the program is delivered in ways that work for the people who use it.
Participants in Safer Supply program evaluations11 have noted benefits such as:
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Fewer toxic events from use of opioids
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Greater access to the health care and support systems
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Improvements in mental health
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Greater sense of personal safety as they no longer need to access drugs through criminal behaviour
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Decrease in criminal behaviour related to obtaining drugs
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Development of a mutually respectful and supportive community with program staff
Participants also experienced challenges in the programs. These included restrictive procedures that required them to be observed taking their drugs and the inability to either take drugs with them (carries) or obtain them in another province should the person wish to travel elsewhere, which could result in a lack of medication and the need to purchase what they need illicitly. Providers mentioned a lack of guidance and training options as well as a limited evidence base as their concerns around provision of safer supply to clients.
Diversion
One of the most often heard concerns about Safer Supply is the potential for diversion of prescribed medications for sale on the street. Diversion of prescribed drugs is not new, having long predated the toxic drug crisis. For example, hydromorphone diverted from pain prescriptions, the most common source of the drug, has been available illicitly for many years.1
People who use drugs (PWUD) have noted that the dose of hydromorphone available through Safer Supply programs does not cover their level of need, particularly for those using street-acquired fentanyl, which is much stronger. When the dose of hydromorphone is not strong enough to curb withdrawal and cravings, people must access the street supply, which puts them at risk of death from toxic drugs. Providing ineffective medications can also lead to sharing or selling of medicines in attempts to help friends and family members avoid withdrawal or reduce pain. Individuals may also sell a part of their medication to aid with meeting their daily life needs such as food or shelter.
Some recent evaluations of Safer Supply programs indicate that though diversion occurs, it was not found to be a problem. In her review of Safer Supply programs in British Columbia Dr. Bonnie Henry observes that although it happens frequently, "Diversion should be understood as indicating unmet needs for PWUD (both medical and social needs) and therefore efforts to mitigate diversion should begin with efforts of the health and social service system to better meet those needs."2
Tyndall, M. (2023). Diversion of ‘safer supply’: A growing problem or urban myth?
Office of the Provincial Health Officer (2023). A Review of Prescribed Safer Supply Programs Across British Columbia: Recommendations for Future Action, p.11.
Is there more than one type of Safer Supply program?
Safer Supply provided in British Columbia under the RMG policy of the provincial government is one of several arrangements possible for this health service.
CAPUD suggests that Safer Supply services should be provided in ways that consider the nature of the drugs offered through the program, the needs and wants of program users and the ability to deliver the program within relevant constraints such as cost, location, and prevailing legal and policing climates. Potential alternatives to current models in British Columbia include:
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Drugs are dispensed without prescription but are administered in a supervised setting under the care of health professionals and/or peer workers.
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Drugs could be dispensed at entertainment venues or social settings that are licensed to do so (e.g., MDMA, alcohol, powdered cocaine).
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Drugs can be made available without prescription in dispensaries and shops (e.g., cannabis, hallucinogenic mushrooms, poppy seed tea, and opium bulbs).12
Other provinces, for example Ontario, have implemented models of Safer Supply different from those of British Columbia.13 Along with the British Columbia Safer Supply service, many of these programs are currently under evaluation.
In her November 2023 report, the Coroner of British Columbia recommended adoption of the compassion club model, similar to #1 above, but this was rejected by the Ministry of Mental Health and Addictions. Further, in her December 2023 review of Safer Supply programs in British Columbia, Provincial Health Officer Dr. Bonnie Henry recommended continuation and expansion of Safer Supply programs through enhanced prescription and delivery options.14
While much attention around drug use and deaths due to toxic drugs focuses on people living unhoused, the reality is that most deaths related to the drug toxicity crisis have occurred indoors. Due in part to stigmatization and criminalization, many people use drugs alone, without anyone to watch over them. If they overdose, there is no one to check on them, ensure they are breathing, administer naloxone or call 911. This is a singular tragedy of the drug toxicity crisis and, like many aspects of this emergency, need not occur.
Safer Supply—Health promotion in practice
The United Nations International Covenant on Economic, Social and Cultural rights, to which Canada is a signatory, states under Article 12 that each signer must "recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health." Although only the right to housing is law in Canada (since 2019), a majority of federal, provincial, and municipal governments and political parties champion the spirit of this agreement. Yet, many services that support the health and wellbeing of people who use drugs, such as Safer Supply, remain underfunded, politicized, and controversial, with many barriers to implementation.
While needle exchange, naloxone distribution, overdose prevention sites, drug checking, and supervised consumption sites have gained a significant level of acceptance across Canada, these services have not been fully implemented. They are increasingly under attack and potentially at risk of defunding. The pilot Health Canada exemption to decriminalize drugs in BC (January 31, 2023, to January 31, 2026) is a measure towards addressing the drug toxicity crisis; however, this exemption was implemented without first increasing access to these necessary services to help prevent drug-related harms and death. Without adequately addressing the contaminated and toxic drug supply, people who use these drugs will continue to die in large numbers.
Health promotion focuses on both healthy public policy and community action, rather than just preventing or "fixing" problems at the individual level. Policy and institutional failures at all levels, combined with societal issues such as widespread stigma around substance use, and a lack of substance use support services for those who wish them, together contribute to the difficulty in providing a safer supply to people who use drugs.
The provision of a safer supply of drugs to people who need them is a health service. Like many other health services, the primary goal is preventing deaths. In the same way that providing clean water to those who drink from sources infested with coliform bacteria (that can spread disease and cause death) saves lives, a safe supply of drugs can greatly reduce the number of deaths of people from a contaminated and toxic drug source. Individuals in safer supply programs report significant improvements in their health and greater stability in their lives. Over time, individual health improvements multiply and—along with appropriate supports—foster improved community health.
Safer Supply is one aspect of equitable access to care and services that enable wellbeing for all. Extreme poverty, lack of affordable housing and other barriers to health call for widespread public action in pursuit of social justice and the common good. Participation is needed in many forms from a range of contributors at various levels. Dialogue among the parties will be crucial for progress in arriving at sound policies and practices that include all voices.
Drug use and criminalized behaviour
People will use drugs regardless of whether it is legal. People continued to find sources of alcohol during Prohibition and cannabis before legalization in Canada in 2018. Providing a clean and regulated supply of a drug to someone who uses drugs on a regular basis has many positive effects for both the individual and the community. Deaths due to toxins in the drug supply decrease. People who use drugs report decreased involvement in criminal activities as they have less need to obtain illicit drugs. Health improves as participants' lives begin to stabilize. Program participants also report increased self-esteem and connection to caring others as well as a greater sense of personal agency in managing their lives.
There are few services currently available in BC for those who wish any form of treatment. Accessing available services can be difficult, especially for those who are unhoused or living in unstable conditions.
Many Safer Supply programs offer access to other supports. As a connection between the participant and program staff builds over time, participants may utilize a greater range of program offerings. For example, initially a person may accept only medications, but as time passes or need dictates, they may access food or income assistance services or become interested in services to address other health issues. Appointments also provide an opportunity for contact with a caring professional and a space to talk about one's life. These conversations are in themselves beneficial as well as giving opportunity to discuss potential referral to supports to address other life concerns.
Drug use is influenced by many personal and contextual factors. This recognition allows us to act alone and with others to address a shared responsibility. We can strive together to maximize benefits, minimize harms, and enhance wellbeing through healthier relationships with drugs, reflecting a mutual intent to collaborate in cultivating more inclusive, equitable, cohesive, caring communities.15
One thing we can do, to start with, is change the way we think about people who use drugs. Changing our language is one way to address the stigma that currently exists around drug use, especially opioids and stimulants. If as a society we can learn to see that using drugs is not just the problem of a few but something most of us do for a range of reasons, then we have gone some distance in creating a foundation for the healthy and health-promoting communities we all wish to live in.
Changing our language
Our words affect others and influence how we think about and act toward other people. Changing our language can help end stigma and discrimination. We are all people first, and experience a range of things in our lives.
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❌substance abuse |
✔️substance use, substance-related harms |
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❌addict |
✔️person/someone who uses/injects drugs |
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❌the poor |
✔️person/people living in poverty |
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❌overdose crisis |
✔️drug toxicity crisis |
Footnotes
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BC Coroner's Service (2023). BC Coroner's Service Death Review Panel: An urgent response to a continuing crisis.
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Tetrahydrocannabinol (THC) is the main psychoactive ingredient in cannabis.
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The English Poor Law of 1834 made this distinction. Although the law was repealed in 1948 and replaced with the National Health Service Act that became the National Health Service, remnants of the thinking that was part of the original law remain today. See Raphael (2007) and Moeller (1995) for further discussion of these concepts in Canadian and United States policy directions.
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Canadian Association of People Who Use Drugs [CAPUD] (2019). Safe Supply: Concept Document, p.4.
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BC Coroner's Service (2023). Illicit Drug Toxicity, Type of Drug Data, Data to December 21, 2022.
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Canadian Association of People Who Use Drugs [CAPUD] (2019). Safe Supply: Concept Document.
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Ibid.
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Ministry of Mental Health and Addictions, Ministry of Health (2021). Access to Prescribed Safer Supply in British Columbia: Policy Direction.
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Please see: Health Canada (2023). Safer supply.
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The MySafe program in Vancouver is a pilot project where biometrically secured machines dispense hydromorphone tablets daily to registered users meeting specific criteria.
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Ledlie et al. (2024). Prescribed safer opioid supply: A scoping review of the evidence. International Journal of Drug Policy, 125, p.14.
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Canadian Association of People Who Use Drugs [CAPUD] (2019). Safe Supply: Concept Document, p.9.
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Public Health Ontario (2022). Environmental Scan: Scan of Evidence and Jurisdictional Approaches to Safer Supply.
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Office of the Provincial Health Officer (2023). A Review of Prescribed Safer Supply Programs Across British Columbia: Recommendations for Future Action.
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15 Norman, T. & Reist, D. (2022). Understanding Substance Use.
References
BC Coroners Service (2023). BC Coroners Service Death Review Panel: An Urgent Response to a Continuing Crisis. https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/death-review-panel/an_urgent_response_to_a_continuing_crisis_report.pdf. Accessed 11/14/23.
BC Coroner's Service (2023). Illicit Drug Toxicity, Type of Drug Data, Data to December 21, 2022. https://www2.gov.bc.ca/ assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf.
Canadian Association of People Who Use Drugs (2019). Safe supply: concept document. Dartmouth, NS. https://www.capud.ca/capud-resources/safe supply-projects.
Health Canada (2023). Safer supply. https://www.canada.ca/en/health-canada/services/opioids/responding-canada-opioidcrisis/ safer-supply.html#a2.
Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, G., Bouck, Z., Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. International Journal of Drug Policy, 125, 104339.
Ministry of Mental Health and Addictions, Ministry of Health (2021). Access to prescribed safer supply in British Columbia: Policy direction. https://www2.gov.bc.ca/assets/gov/overdose-awareness/prescribed_safer_supply_in_bc.pdf.
Norman, T. & Reist, D. (2022). Understanding substance use. Victoria, BC: Canadian Institute for Substance Use Research, University of Victoria. https://www.heretohelp.bc.ca/sites/default/files/understanding-substance-use-2022.pdf.
Office of the Provincial Health Officer (2023). A Review of Prescribed Safer Supply Programs Across British Columbia: Recommendations for Future Action. Victoria, BC. https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-caresystem/office-of-the-provincial-health-officer/reports-publications/special-reports/a-review-of-prescribed-safer-supplyprograms- across-bc.pdf.
Public Health Ontario (2022). Environmental Scan: Scan of Evidence and Jurisdictional Approaches to Safer Supply. https://www.publichealthontario.ca/-/media/Documents/S/2022/safer-supply-environmental-scan. pdf?rev=7c5662c193514367bd43ca2057a224df&sc_lang=en.
Tyndall, M. (2023). Diversion of 'safer supply': A growing problem or urban myth? https://calgaryherald.com/uncategorized/diversion-of-safer-supply-a-growing-problem-or-urban-myth.
Other sources
British Columbia Centre on Substance Use (2021). Prescribed Safer Supply. https://www.bccsu.ca/clinical-care-guidance/ prescribed-safer-supply/. Accessed 10/17/23.
Haines, M. & O’Byrne, P. (2023). Safer opioid supply: qualitative program evaluation. Harm Reduction Journal, 20(1), pp.53-64.
Moeller, S. (1995). The cultural construction of urban poverty: Images of poverty in New York City, 1890-1917. Journal of American Culture, 18, 1-16.
Ontario Drug Policy Research Network (2023). Safer Opioid Supply: A Rapid Review of the Evidence. Toronto, ON. Ontario Drug Policy Research Network. https://odprn.ca/wp-content/uploads/2023/07/Safer-Opioid-Supply-Rapid-Review.pdf.
Province of British Columbia (2022). Decriminalizing people who use drugs in BC. https://www2.gov.bc.ca/gov/content/ overdose/decriminalization.
Province of British Columbia (2023). BC Coroners Service death review panel urges expanded access to safer supply. https://news.gov.bc.ca/releases/2023PSSG0076-001700.
Ranger, C., Hobbs, H., Cameron, F., Stuart, H., McCall, J. Sullivan, G., Urbanoski, K., Slaunwhite, A., & Pauly, B. (2021). “Co/ Lab Practice Brief: Implementing the Victoria SAFER Initiative.” Victoria, BC: Canadian Institute for Substance Use Research, University of Victoria. https://www.uvic.ca/research/centres/cisur/assets/docs/colab/practice-brief-safer.pdf.
Raphael, D. (2007). Poverty and policy in Canada: Implications for health and quality of life. Toronto: Canadian Scholar's Press.
About the author
The Canadian Institute for Substance Use Research, formerly CARBC, is a member of the BC Partners for Mental Health and Substance Use Information. The institute is dedicated to the study of substance use in support of community-wide efforts aimed at providing all people with access to healthier lives, whether using substances or not. For more, visit www.cisur.ca.
