As the cofounder of the Canadian Association for Safe Supply, and an administrator on the safesupply.ca website, I receive email from people across Canada who are at risk of overdose. Frequently, these are people seeking a prescribed safe supply, and the subject lines are heart-wrenching: “Need help. At risk of overdose” or “Please help me, looking for a prescriber.” All too often the people emailing have already been denied a prescription and are using illicit fentanyl and risking their lives.
Last weekend, Dr. Vincent Lam, an addictions medicine physician and an author, wrote in the Globe and Mail about how instead of using the commonly prescribed hydromorphone to treat opioid disorder, he prefers prescribing traditional treatments in the form of opioid substitution therapies like methadone and buprenorphine. “I urge these patients to instead take treatments for opioid use disorder that are supported by medical science,” he writes.
Lam, who is also the medical director of Coderix Medical Clinic, an addictions clinic in Toronto, additionally points out the discrimination and stigma facing Canadians at risk of overdose. “Patients of mine are rightly angry when — as often occurs — they seek general medical care and are belittled, condescended to, or refused pain management because they are a person who uses drugs,” he writes. “… The result is that people who suffer from substance-use disorders who are admitted for other urgent medical reasons often leave because they are suffering the agony of withdrawal, and therefore do not receive other essential medical services. In this way, they are denied what is promised by the Canada Health Act — universal access to health care.”
Fortunately, most Canadians don’t experience the systemic healthcare discrimination that Lam illustrates. But for people at risk of overdose, seeking a compassionate prescriber for a safe supply (meaning legal and regulated drugs with the non-medicinal properties sought in the illicit market) is often one experience of discrimination after another.
Prescribers are often dismissive of those seeking a safe supply. Lam’s reference to using traditional opioid substitution therapies is a clear omission of evidence that indicates injectable heroin and hydromorphone-assisted treatments have actually been shown to produce “significantly greater retention in treatment, reduction in illicit drug use, reduction in criminal activities, and fewer convictions and imprisonments” for those who have been unsuccessful with traditional opioid substitution therapies, according to a recent review by the Canadian Agency for Drugs and Technology in Health (CADTH). The study concludes that “based on incremental cost-effectiveness ratios, it was found that both injectable treatments dominated methadone.”
Systemic discrimination starts with the government, not with the prescriber. Attitudes from prescribers often mirror discriminatory policies set by the government.
Even if a person finds a willing prescriber, the provincial pharmacare programs that financially reimburse Canadians for prescription drug costs do not cover — or only cover in very few cases — preparations used for injection or inhalation by people who use drugs, despite the proven safety and effectiveness.
Instead, people are prescribed opioid tablets like oral hydromorphone as an off-label alternative. People can crush and inject these tablets, at their own risk — risks that are very well established in medical literature. Health complications from tablet injection include excipient lung disease, blood viruses, and blood clots. Lam’s criticism in this case is valid, but misplaced. He writes, “Within a Medicare system that funds physicians and often pills – but less often provides multidisciplinary management of chronic pain – oxycodone was the go-to for pain for almost a decade. Stingy sick leave policies make it difficult for injured workers to recover from painful injuries. Many who suffered in non-physical ways – from trauma to untreated mental illness – also discovered that opioids helped to ease their suffering temporarily. In addition to being swallowed, oxycodone tablets like Percocet were sometimes sold, chewed and snorted.”
But it’s not the fault of the prescriber or the patient that the only options covered by pharmacare are tablets. “Safe supply” means providing drugs regulated for injection and inhalation use — using tablets for these purposes does not meet this definition.
So what is the alternative for Canadians at risk of overdose who are denied a prescription?
The most obvious alternative comes in the form of the unpredictable illicit market. When Canadians at risk of overdose are systemically discriminated against, they risk their lives with an unpredictable illicit supply. These are people who could otherwise thrive in life if they had a safe supply.
Ironically, Lam’s past authorship includes a biography of Tommy Douglas, the Saskatchewan Premier who introduced the first single payer universal healthcare program in North America, leading the way for the Canadian healthcare system so many of us hold up as a foundational value of this country. At its best, our healthcare system is inclusive, responsive, and representative of the values Douglas espoused so many decades ago.
But at its worst, you have the systemic healthcare discrimination that denies so many people at risk of overdose in Canada a prescription.