The Canadian Mental Health Association (CMHA) network consists of 28 branches across the province that provide community-based clinical and social services to Ontarians living with mental health and substance-use issues. All CMHA branches work from a harm-reduction framework that aims to support individuals with substance-use concerns and connect them with services. Some of our branches offer comprehensive supports, including Rapid Access Addiction Medicine clinics, youth addictions programming, managed alcohol programs, and a broad range of harm reduction and outpatient substance-use counselling and supports.
It is with this perspective in mind that our network of CMHA branches in Ontario wish to voice our support for safer opioid supply approaches in Ontario.
Ontario has been in a state of opioid overdose crisis for several years, as the number of lives lost has steadily increased. In 2019, our province experienced the worst effects of this when we recorded the highest number of opioid-related overdose deaths in the country: 1,509.1 Furthermore, with this pandemic we are seeing compounding public health emergencies: the wide-ranging and deadly health impacts of COVID-19, plus a significant increase in overdoses due to opioids, largely due to an increasingly toxic drug supply. Since the onset of the COVID-19 pandemic in March until June, there has been a nearly 40 per cent increase in opioid-related deaths. If the current data trends continue, 2,271 opioid-related deaths are expected in 2020, making it the most tragic year on record.2
It is essential that substance use and harm reduction approaches, including safer opioid supply initiatives, are scaled up, in order to provide services and support for people who use drugs (PWUD) in Ontario.
Safer opioid supply (SOS) is an approach that focuses on saving lives through the provision of safe doses of opioid medication, provided by a health care practitioner, as an alternative to the contaminated sources of unregulated drugs currently available on the street.3 SOS provides people who may not have responded to other forms of treatment with a safer medical alternative from a licensed prescriber. These programs also aim to connect individuals with health and psychosocial services, which may be more difficult to access during the COVID-19 outbreak.4 Safe supply and other harm reduction initiatives exist on a broad continuum of substance-use programming that aims to support Ontarians who use substances by minimizing their risks and providing low-barrier access to support. In Ontario, several SOS models currently exist and are predominantly located within Community Health Centres, where in addition to primary care, clients can also be connected to a broad range of psychosocial supports. While the evidence in support of these models is emerging, preliminary data shows that SOS programs have been successful in mitigating harms and supporting people who are at imminent risk of death due to a toxic drug supply.5,6
While there are several factors contributing to the overdose crisis, exposure to toxic substances in an unregulated (illicit) market is the primary driver of overdose deaths in Ontario. Fentanyl and its analogues have been found to be the major cause of opioid-related overdoses and deaths. Individuals purchasing substances on the street may consume fentanyl without their knowledge, causing overdoses among people who may be unaware that they were consuming high-strength opioids.7 Research shows that the vast majority of deaths (87 per cent) are attributable to fentanyl and nearly all deaths (96 per cent) are accidental.8 As such, what is widely referred to as an overdose crisis, is in fact better described as a drug-poisoning crisis.9
Advocates for safer supply approaches reference the way in which the government controls and distributes alcohol, tobacco and cannabis, for example, and suggest that treating other substances similarly – by providing a regulated safe supply – has the potential to reduce overdose deaths.10 The purpose of safer supply is to provide a less risky way for people to access what they are seeking when using street drugs, while reducing the risk of death and engaging in wraparound health and social supports. This is increasingly important as we know that PWUD continue to be stigmatized and criminalized which can lead to marginalization from the health care system that may make them especially vulnerable to health and social harms, especially during a pandemic.11
As the data continues to emerge during this time it is clear that the pandemic is contributing to an increase in overall substance use among vulnerable populations. Homeless youth report a 69 per cent increase in substance use since the beginning of the pandemic and there is a 37 per cent increase in overdoses with this population.12 In addition, closures of services have led PWUD to unsafe consumption practices such as using alone.13 We are seeing this clearly with evidence indicating that 75 per cent of overdose deaths during this pandemic were people who were alone, with no one available to intervene or administer naloxone.14
The pandemic and overdose crisis are not only intersecting public health emergencies taking place in Ontario, but COVID-19 is exacerbating harms and placing people who use drugs at higher risk of negative health outcomes including opioid poisoning. We know that the overdose crisis, in conjunction with COVID-19, has disproportionately impacted marginalized communities contributing to further lives lost. There are greater rates of opioid poisonings in communities with higher ethno-cultural diversity and lower socioeconomic status. This parallels the communities that are also experiencing higher rates of COVID-19 infection and deaths.15 While a toxic and unpredictable drug supply is the main driver, physical distancing, disruption to services, and self-isolation protocols have further elevated risks.16 Each region in our province was already experiencing this overdose crisis, and COVID-19 has only accelerated the need for action and alternative approaches.
It is crucial that during this time of dual public health emergencies, expanded access to a range of low-barrier interventions be both available and accessible. We need immediate action from government and the health care system to prevent further deaths. Overdose prevention interventions like safer supply models are essential in addressing the imminent risk of death for people who use substances in Ontario. CMHA has been actively engaged in responding to the opioid crisis across the province and are strong supporters of harm-reduction approaches. We also support the programs and health-care practitioners that are providing greater access to safer, pharmaceutical grade alternatives to the toxic street supply. It is crucial that organizations and health-care practitioners feel supported and equipped to do so during this time. In addition, we urge the Ontario government to work with leaders in our sector to ensure that harm-reduction services are scaled up and support is available for prescribers and community organizations providing SOS.