Safer Supply Prescribing

In response to troubling trends, more stakeholders calling for harm reduction strategies

While the country’s public health conversation has been largely focused on COVID-19, the opioid crisis not only remains deeply concerning, but has been exacerbated by the disruptions imposed by the pandemic. 

The challenges presented by the pandemic have introduced new risks to a vulnerable patient population, which has led to a spike in opioid-related deaths. In the first two months of the pandemic, there was a 25% increase in overdose deaths in Ontario when compared to the same period last year. The Office of the Chief Coroner estimates around 55 people are dying weekly due to overdoses. In an October 15 drug alert, Toronto Public Health reported Toronto paramedics responded to an estimated 132 suspected opioid-related OD deaths between April 1 and September 30, 2020. During this same period in 2019, there were 59 such fatalities.

For those battling addiction, quarantine and physical distancing measures have taken a toll — resulting in disruptions of treatment and recovery services and limited access to mental health services, and peer support. For those actively using drugs, the risk of a fatal overdose increases when using while alone. 

Compounding the crisis is an increasingly toxic street supply which has grown only more unpredictable as global supply chains break down, leading to potentially deadly combinations of drugs that contain unknown amounts of fentanyl, benzodiazepines and, increasingly, carfentanil. 

The current toxic drug supply is responsible for the vast majority of the country’s overdose fatalities. Seventy-six percent of all opioid-related overdose deaths in Canada in 2018 were related to fentanyl or fentanyl analogues, such as carfentanil, including 74% in Ontario, 84% in Alberta, and 87% in BC.

In fact, safe supply experts say that most deaths can be attributed to poisoning, not overdosing.  

In response to the troubling trends, Patty Hajdu, federal Minister of Health, announced in September funding support of nearly $9.5 million for four safer supply projects for people at risk of overdose in Ontario. The four Ontario safer supply projects will provide people who have not responded to other forms of treatment for opioid use disorder with a medical alternative that keeps them from resorting to the use of street drugs. The initiatives will also provide “wrap-around care,” connecting them with health and social services, including treatment, which may be more difficult to access during the COVID-19 outbreak.

Safer supply opioid prescribing is an emerging area of clinical practice that is grounded in the principles of harm reduction. It refers to the direct delivery (prescribing) of pharmaceutical-grade opioids to patients with opioid use disorder as an alternative to the toxic street supply of illicit opioids. 

While it can take many forms, safer supply opioid prescribing often involves the prescribing of hydromorphone tablets that are consumed by patients, and often without direct supervision by a health-care professional.

The College has developed expectations permissible enough to allow harm reduction strategies, including safer supply prescribing.

Providing low barrier access to a consistent supply of unadulterated opioids, say safer supply advocates, will not only prevent overdose events, but also potentially reduce drug-related harms (e.g., violence related to the illicit drug market), and improve overall health and well-being with access to wrap-around care.  

Ms. Hadju called upon relevant health regulators, such as CPSO, to do all that can be done to help provide people who use drugs with a full spectrum of options for accessing medication in order to avoid the street supply.

For its part, the College has developed expectations — as articulated in our Prescribing Drugs policy — permissible enough to allow harm reduction strategies, including safer supply prescribing, while ensuring all opioid practices are safe and appropriately regulated.

In our Advice to the Profession document that accompanies the policy, the College acknowledges the growing interest in exploring emerging or alternative means of treating and supporting this population with an aim to minimize opioid-related overdoses and deaths. The document states “that providing pharmaceutical-grade alternatives to the toxic street supply, both in the context of a comprehensive treatment plan or as a standalone harm reduction strategy, can enable physicians to support patients with opioid use disorder and reduce their risk of overdose and death.”

CPSO Registrar, Dr. Nancy Whitmore, elaborated on the College’s position. “We recognize that some of the most marginalized patients feel alienated from traditional models of care. And for some of these people, recovery may not be the goal or maintenance may not be feasible, and that minimizing harm might itself be the best goal in that scenario,” she said.

“We also recognize the pandemic has further exacerbated the risks and potential for harm among patients with opioid use disorder. Taking all of this into account, we believe people should be provided with the services and supports that best meet their needs,” said Dr. Whitmore. Our expectation, she said, is that all care be delivered within a patient safety framework that minimizes the risk of unintended consequences for the patient and the public. 

As the pandemic continues and overdose deaths climb, more mainstream stakeholders — including several levels of government — have advocated for safer supply prescribing. But the practice also continues to have its critics — addiction specialists worried about diversion, misuse, and abuse. There is also concern that these practices disincentivize patients from pursuing more traditional — albeit stricter — addiction treatment programs, which focus on reducing dependency.

CPSO has not advocated for one model of care over another, preferring instead to keep the focus on the measures that need to be taken to ensure patient and public safety, as befitting our mandate. 

“As with all opioid prescribing, it is essential that safer supply strategies be implemented in a manner that minimizes the risk of harm and the introduction of unintended consequences that may negatively impact patients (e.g., misuse, abuse) or the public more broadly (e.g., diversion). The need for caution is heightened in the absence of clinical practice guidelines or strong clinical evidence demonstrating the risks and benefits of a particular approach,” states the advice document. 

If considering safer supply opioid prescribing, physicians are reminded of the following expectations of the Prescribing Drugs policy:

• Practise within the limits of your clinical competence and/or scope of practice; 
• Demonstrate sound clinical judgment, taking into account the individual needs of each patient;
• Consider and apply relevant practice standards, quality standards, and clinical practice guidelines, where they exist; 
• Where relevant practice standards, quality standards, and clinical practice guidelines do not exist, or in areas of medicine that are less developed, consider the best available indirect evidence, including clinical trials and evidence-based research to help inform consensus protocols or best practices;
• Review previous interventions the patient has undergone; and
• Develop a comprehensive treatment plan that can help the patient while minimizing risks and unintended consequences (e.g., the risk of diversion).

Physicians are further reminded the importance of careful documentation increases as care departs from recommended guidelines and/or moves into areas of medicine that are less developed.