A better strategy to reduce opioid deaths

Harmful measures such as mandatory confinement shouldn’t be part of the plan

Roughly 20 Canadians die each day from opioid toxicity, more than the number who die from breast cancer, liver disease or suicide daily. It’s clear there is a toxic drug-poisoning crisis in this country – one that we do not yet have a consensus on how to solve.

Should we decriminalize or even legalize drug use? Should we replace an opioid from the illicit market that people typically smoke or inject (e.g., fentanyl) with one that is prescribed and taken by mouth? Should we set up programs where people can receive a “safer supply” of an opioid that they will continue to inject and may occasionally share or sell?

We believe that a comprehensive approach should include all three of these strategies and more. We make this recommendation as co-chairs of the Toronto Opioid Overdose Action Network, as professionals who have been caring for people with substanceuse disorders and studying overdose deaths for more than 50 years collectively, and as people who have lost friends and patients to the overdose crisis.

Some options receiving attention right now, such as mandatory confinement, reflect a century of prohibition and criminalization, and should be rejected as health system responses. Mandatory confinement leads to mistrust of the health care system and the risk of fatal overdose is very high immediately after a period of forced abstinence.

Each person who uses drugs needs an evidence-informed, individualized approach that works for them and respects their autonomy. This would put harm reduction, treatment and care for substance use on the same footing as treatment for other health conditions such as cancer and heart disease.

Fifteen years ago, most opioid toxicity deaths in Canada were owing to prescription opioids. While it is possible to make connections between the prescription-driven OxyContin epidemic of the 1990s and 2000s and the illicitly manufactured fentanyl crisis of the late 2010s and early 2020s, the problems we face today are much larger than those we faced 15 years ago. In 2021, more than 2,500 people in Ontario died with fentanyl present in their bloodstream, compared with just 33 such deaths 15 years prior. In contrast, 145 people in Ontario died in 2021 with oxycodone present (the active ingredient in OxyContin and Percocet), compared with 168 such deaths 15 years earlier.

We need strategies that will reduce deaths from illicitly manufactured fentanyl. Ideally, these would be supported by high-quality evidence, such as the data obtained from randomized controlled trials.

Unfortunately, virtually all the randomized trials studying medications for opioid overdose prevention – a strategy known as oral opioid agonist treatment (OAT) – were conducted before fentanyl was in wide circulation. Despite lower rates of success in the current era, OAT should be offered to everyone who uses fentanyl.

Another treatment strategy supported by randomized trials that works for some patients is injection opioid agonist treatment (iOAT), but it requires a substantial infrastructure to deliver. In Canada’s largest city, there is just one clinic serving only a few dozen patients. With tens of thousands of people across the country using fentanyl every day, scaling up iOAT is a formidable task that will take time and significant resources.

In the absence of widespread availability of iOAT, a small number of physicians and nurse practitioners across Canada have started prescribing oral hydromorphone to patients who use fentanyl, providing people who use drugs with certainty that they are consuming a known drug and a known dose – a “safer supply.” Does this save lives? Early evidence is promising, especially when the provision of a safer opioid supply is coupled with additional support. One concern with this approach is that patients who are prescribed hydromorphone may sometimes share or sell their medication. Drug diversion is definitely a worry – as it is with OAT too – but in the context of the toxic drug supply in Canada, it is not obvious that the harms exceed the benefits. A report from the Ontario Drug Policy Research Network coming out in July will confirm that far more young people in Ontario are dying from illicitly manufactured fentanyl than from diverted hydromorphone (which should still only be prescribed with great care).

We should continue to adapt our approaches so that they are as up-to-date and evidence-based as possible. Anecdotes are useful for generating hypotheses, but they do not constitute the kind of evidence that should be used to drive major policy decisions. We also need to recognize that the health care system can only do so much to reduce the harms associated with substance use. A comprehensive approach that dramatically reduces the number of deaths from opioid toxicity will need to ensure that people who use drugs have a decent place to live and support for their physical and mental health.

Ultimately, we need different levels of government to work constructively with health care providers and people who use drugs to make transformative change.