Canada is experiencing an overdose crisis caused by a toxic illicit drug supply. As overdose deaths from fentanyl and other synthetic drugs have increased, interventions such as supervised consumption sites (SCS), overdose prevention sites (OPS) and naloxone distribution have expanded across parts of Canada. Together, these interventions have saved many lives;¹ however, they do not address the fundamental problem of a toxic drug supply.^2,3 They prevent overdose deaths but do not necessarily prevent overdoses from happening.

Many advocates, including people who use drugs, health care professionals, researchers, policy makers and politicians, argue that a “safe supply” of drugs is urgently needed to address the toxic illicit drug supply. Providing a legal and regulated supply of drugs has the potential to support people who use drugs to stay alive and to live safe and healthy lives. This article will explain what “safe supply” means, discuss developments within the Canadian context and describe some examples of safe supply programs in Canada.

Canada’s drug toxicity crisis

People in Canada are dying from drug overdoses at unprecedented rates. More than 17,600 Canadians died from an overdose between January 2016 and June 2020.⁴ The main driver of the overdose crisis is the fact that the illicit drug supply is toxic and unpredictable.⁵ The dangers associated with the illicit drug supply have been caused by drug prohibition, which is meant to stop the production, transport, sale and possession of certain drugs.^6,7 However, prohibition has not reduced drug use, and it has increased multiple health and social harms.⁸ Because of prohibition, drugs have become more concentrated. Prohibition creates incentives to make and sell drugs that are smaller and stronger so that production and transportation volumes can be reduced and profits can be increased. ⁶ Prohibition is why fentanyl and fentanyl analogues, drugs that are many times stronger than heroin in much smaller doses, have severely contaminated the illicit drug supply and have been linked to the increases in overdose deaths.^4,9

The COVID-19 pandemic has made the overdose crisis even worse. Border closures appear to have made the illicit drug supply even more toxic and unpredictable.^10,11 In addition, physical distancing measures to reduce community transmission of COVID-19 have resulted in reduced access to harm reduction services (e.g., SCS), increased social isolation and more people using drugs alone. Numerous provinces have reported increases in overdose deaths since the COVID-19 pandemic began in March 2020.^10,12,13 This has shone a spotlight on the overdose crisis and further increased the urgency of the need for a safe supply of drugs.

What is safe supply?

The term “safe supply” is relatively new, but the concept is not. People who use drugs have been calling for safe and regulated drugs for decades.^14,15 The Canadian Association of People Who Use Drugs (CAPUD) defines safe supply as “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.”¹⁴ This covers many drugs that are currently illegal, including heroin, fentanyl, cocaine, methamphetamines and MDMA.^14,16 The goal of safe supply is to enable people who use drugs to access regulated substances from a legal source, rather than toxic versions from illicit markets — ultimately saving lives.

As a concept and approach, safe supply is informed by evidence from drug treatment programs but is considered distinct from these approaches. There are a range of treatment approaches for a person with a diagnosed substance use disorder, including opioid agonist therapy (OAT) and injectable OAT (iOAT), which involve providing people with medications that are a substitute for the illicit drugs they are using. Most notably, safe supply is informed by evidence from iOAT approaches. These approaches involve providing people for whom oral OAT does not work with diacetylmorphine (heroin) or injectable hydromorphone to inject in a supervised setting. Decades of research from six countries, including Canada, has demonstrated that these approaches are effective at reducing people’s exposure to the illicit drug supply and are associated with other health and social benefits.^17–19

Generally, safe supply is considered distinct from treatment approaches for the following reasons:

• Treatment aims to medically treat an individual, often with the goal of reducing or eliminating their drug use. Safe supply aims to reduce the harms caused by the illicit drug supply.²⁰
• Many drug treatment medications do not provide the mind/body altering effects that people seek from substance use. Safe supply includes drugs with mind/body altering effects.¹⁴
• Medications used in drug treatment often have to be taken under medical supervision. Safe supply aims to reduce barriers to access, and the drugs are often envisioned as being taken unsupervised.²⁰ Approaches to dispensing safe supply can range from more to less controlled.¹⁴
• There are limited treatment options available for people who use stimulants and other non-opioids.²¹ Safe supply includes access to regulated stimulants and other drugs.¹⁴

Safe supply comes out of a harm reduction model and is centred on the safety, human rights, agency and leadership of people who use drugs.¹⁴ It can be considered the next step in a human rights-based approach to drug policy.¹⁴ Safe supply can fit alongside other harm reduction interventions, such as OPS, SCS and naloxone distribution. While harm reduction interventions seek to reduce the harms caused by the criminalization of drug use, safe supply would help reduce the criminalized contexts of drug use.¹⁴ However, there are differing opinions on the ultimate goals of safe supply. Some see safe supply primarily as a way of reducing the risk of overdose death; others see it as a way to reduce or end a broader range of harms related to the criminalization of drug use and believe it should be available to anyone who currently uses illicit drugs. Another term that has been used is “safer supply,” which is meant to recognize that even regulated drugs are not risk free. However, some people who use drugs argue that this term can cause confusion. It can shift attention away from the fact the illicit drug supply is toxic and causing extreme harm.¹⁶

What is happening with safe supply in Canada?

Owing to the severity and scale of the overdose crisis, the federal government has indicated its support for safe supply interventions. Since 2019, Health Canada has provided pilot funding for multiple opioid safe supply projects that aim to save lives and help support research and ongoing practice.^22,23 Federal support for safe supply has increased during the COVID-19 pandemic. At the beginning of the pandemic, Health Canada issued temporary changes to the Controlled Drugs and Substances Act²⁴ to increase flexibility in prescribing opioids and other controlled substances.²⁵ Additionally, the federal minister of health has written an open letter in support of safe supply, urging provinces and territories across Canada to take actions that enable people who use drugs to access safe supply.²⁵ Health Canada has also compiled a COVID-19 and Substance Use Toolkit that provides resources and information about safe supply and related topics (e.g., a list of relevant exemptions from the Controlled Drugs and Substances Act). It is intended to help healthcare providers and people who use drugs to understand the range of options that may be available during the pandemic.

Multiple prescribing guidelines have been developed that aim to enable prescribers to provide safe supply to people who use drugs.^26–29 Many of these guidelines are intended to help people who use drugs stay safe during the COVID-19 pandemic. In fact, doctors and nurses in British Columbia have been explicitly encouraged to prescribe regulated substances to people who are at risk of overdose and COVID-19.^26,30

Several approaches to safe supply have been proposed in Canada. So far, safe supply has been happening through a medical model where a person needs to obtain a prescription for a regulated substance from a healthcare provider. This is because, in the context of drug prohibition, a prescription is the only legal way to access many substances with mind/body altering effects. Some of the prescriptions for safe supply are provided within primary care-based programs, which involve ongoing assessments, monitoring and engagement in healthcare and case management services.²⁹ To provide safe supply, hydromorphone can be prescribed as an alternative to illicit opioids such as fentanyl. Hydromorphone is commonly chosen because it is legal, it is covered by most provincial and territorial public drug plans and it is acceptable to people who use opioids.^31,32 Other drugs that may be used as safe supply include methylphenidate (a stimulant), diazepam (a benzodiazepine) and diacetylmorphine (heroin).^20,26

However, approaches that rely solely on a medical model may create barriers (e.g., rigid protocols, limited clinical capacity, and stigma associated with drug use) and may be unable to meet everyone’s needs.^14,32–35 MySafe is a program that seeks to address some of these barriers. This program uses MySafe machines – secure, 800lbs vending machines with biometric identification technology – to dispense safe supply.³² It aims to be low barrier, to support participants’ autonomy, and allow people to access safe supply without judgement or stigma.³² Another model that has been proposed for consideration is a public health dispensing model.³² This approach could involve providing eligible participants with direct access to regulated substances, without requiring individual physician prescribing.³² Heroin compassion clubs have been proposed as another way of securing access to safe supply.^36,37 These co-op based models would allow eligible individuals to purchase regulated opioids without legal sanctions.^36,37 Safe supply could also be provided without prescriptions at social and entertainment venues, or through licensed shops and dispensaries.¹⁴

Despite federal support, guidelines and many potential models of safe supply, uptake has been limited across Canada. Barriers to safe supply differ across the country. Political will and funding have been the largest barriers in some regions where provincial governments have been reluctant to support safe supply measures.^38,39 Even in areas where governments have supported safe supply, public drug plans do not cover all potential substances (e.g., diacetylmorphine and injectable hydromorphone) and implementation has been limited.^40,31 Regulatory bodies have been slow to provide guidance and many prescribers seem to have concerns because safe supply goes against their traditional practice.^20,40 Physicians have expressed concerns about their professional liability, the health of their patients and other factors.^37,40 Some of these concerns, however, may not be supported by evidence.^5,37,41 For example, doctors have expressed concerns that safe supply will become preferable to traditional treatments.³⁷ However, this concern is hypothetical and advocates note that many people would benefit from access to both safe supply and treatment options.^14,37

What do we know about safe supply programs in Canada so far?

Safe supply programs are a relatively new harm reduction intervention in Canada. They have only recently been implemented as emergency responses to the toxic illicit drug supply.⁴² As a result, there is limited evidence on the effectiveness of these programs. However, preliminary evidence is very promising.

One safe supply program has been operating in Ontario at the London InterCommunity Health Centre (LIHC) since 2016.^29,43 Participants in the safe supply program are people who have found that OAT does not work for them and who have injected opioids for many years.⁴³ Participants are given a prescription for immediate release hydromorphone tablets. To meet participants’ needs, the physician and the individual decide together what the daily dose will be. People can pick up their doses daily and use them wherever they choose.⁴⁴ This program is embedded in primary care and includes case management (e.g., connection to outreach teams, housing support) and harm reduction education.⁴³

 Preliminary evidence suggests that this model has been effective at preventing overdose deaths, improving participants’ health and helping them to meet other important health and social needs.⁴³ Over four years, the LIHC safe supply program has reported a 90% retention rate and zero fatal overdoses among 118 participants. ⁴³ Numerous other positive outcomes include:⁴³

• increased engagement in primary care (e.g., cancer screening, managing chronic conditions, accessing mental health care)
• increased engagement in HIV and hepatitis C testing and treatment (e.g., all participants with HIV are engaged in care and 90% have an undetectable viral load). There have been no new cases of HIV
• reduction in homelessness, from 62% to 38% of participants
• reduction in survival sex work (from 68% to 20% among women) and criminal activity to pay for drugs (from 48% to 12%)

In Vancouver, British Columbia, the Molson Overdose Prevention Site combines an OPS, drug checking and safe supply in one place. The Molson OPS is run by the Portland Hotel Society, a housing and social service agency. The Molson’s safe supply program started in 2019.⁴⁵ Participants of the safe supply program are people who are not currently involved or interested in drug treatment approaches. People can pick up hydromorphone tablets from a nurse up to five times a day.^45,46 They must consume their safe supply on site at the OPS, by swallowing, injecting or snorting it.

A 2020 study used ethnographic observation and interviews with program participants to examine the effects of the safe supply program.^45,47 The study found that the safe supply program provides multiple benefits, including:⁴⁷

• reduced illicit drug use and overdose risk
• improvements in health and well-being (e.g., improved nutrition, sleep and access to wound care)
• improvements in pain management
• economic improvements (i.e., people did not need engage in criminal activity to buy drugs, and they also did not need to spend as much money on drugs, which meant that they could purchase food and other basic necessities)

Although the co-location of a safe supply program within an OPS helped to facilitate low-barrier access to safe supply, researchers concluded that requiring participants to use all doses in the OPS may create additional barriers to engagement.⁴⁵

How can service providers help to advance safe supply?

The toxic illicit drug supply has caused an overdose crisis in Canada. This crisis has been made even worse by the COVID-19 pandemic. Conventional harm reduction interventions, such as OPS, SCS and naloxone distribution, are effective and urgently needed. But they are unable to address the root causes of this crisis. A combined approach that includes scaling up safe supply options and programs could significantly help to address the overdose crisis. It also has the potential to address many other harms, including reducing HIV and hepatitis C transmission. Action to address related factors that affect people who use drugs, such as criminalization, poverty, ongoing legacies of colonialism, lack of housing, trauma and stigma, are also urgently needed.^9,48–50

In areas where safe supply has faced political barriers or is not currently available, service providers can help to advocate for safe supply programs and to educate the prescribers they work with about safe supply.

Service providers can also play critical roles within existing safe supply programs, including assisting in the further development of the programs and related supports, and connecting people who use drugs to safe supply and supporting them to navigate the process. It is also crucial that people who use drugs be involved in the design and evaluation of safe supply programs to ensure that they meet people’s needs. Finally, there is an urgent need to make sure that safe supply programs continue after the COVID-19 pandemic. Safe supply will be needed as long as prohibition and the criminalization of people who use drugs continue.

Related resources

Safe Supply: Hydromorphone Tablet Distribution Program at the Molson Overdose Prevention

Lessons Not Learned: The Overdose Crisis in Canada

Responding to an Opioid Overdose, Responding to Stimulant Overuse and Overdose

The Ontario overdose crisis and the impact of COVID-19 (webinar)

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