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Macdonald-Laurier Institute

Moving the needle: How “safe supply” became Canada’s answer to the opioid crisis, why it failed, and how we can do better

Safe supply, as implemented, not only fails to reduce overdose deaths, but exacerbates the diversion of opioids for illicit use and undermines proven treatments.

May 29, 2025
in Domestic Policy, Latest News, Papers, Health, Social Issues
Reading Time: 5 mins read
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Moving the needle: How “safe supply” became Canada’s answer to the opioid crisis, why it failed, and how we can do better

By Lori Regenstreif
May 29, 2025

PDF of paper

Executive Summary | Sommaire (le français suit)

Canada’s opioid crisis has spiralled from relatively rare heroin usage in the 1990s to a nationwide epidemic of overdose deaths. This new epidemic is driven by synthetic fentanyl and a terribly misguided policy response: “safe supply” programs that distribute opioids in the form of Dilaudid, or hydromorphone (HM) tablets.

Because safe supply was meant to curb overdoses, health officials initially framed these programs as “harm reduction.” Yet, they morphed into a social justice experiment detached from clinical evidence – epitomized by the dispensing of 8 mg Dilaudid tablets (the strongest dose available) for unsupervised use. For context, Dilaudid is as potent as heroin and – assuming most of us are “naïve” to opioids – a 1 or 2mg tablet would be enough to knock a typical adult out for several hours, say, after breaking a bone or having surgery.

Safe supply, as implemented, not only fails to reduce overdose deaths, but exacerbates the diversion of HM tablets for illicit use and undermines proven treatments like opioid agonist therapy (OAT), which rely on methadone or buprenorphine – well[1]known, safe, and effective medications.

The crisis demands a return to evidence-based policy. Overdose deaths in Canada surged to more than 7,328 in 2021 despite the expansion of so-called safe supply (Public Health Agency of Canada 2018; Health Canada 2023). By comparison, 3,023 Canadians died in 2016 of opioid overdoses (Health Canada 2019). Qualitative studies touting the benefits of safe supply programs – self-evaluations by program advocates – lack rigour. HM tablets are being widely diverted (sold or traded), flooding the streets at prices that compete with the street supply. Meanwhile, OAT, which is supported by decades of data showing mortality reductions, has been side-lined.

Safe supply’s proponents argue that it respects user autonomy and reduces stigma, likening it to regulated alcohol. Yet opioids’ acute toxicity – unlike alcohol’s incremental harms – renders this analogy meaningless and fallacious.

We need a better path.

This new approach should:

• Prioritize opioid agonist therapy and a full suite of wrap-around services over the distribution of opioid tablets alone.

• Be genuinely evidence-based – in other words, “follow the science.”

• Balance the well-being of individuals and communities.

• Reintegrate the “four pillars” of drug strategy – prevention, treatment, harm reduction, and enforcement – so that it addresses not only the harms of opioid use but also the root causes and contributing factors that perpetuate this crisis.

By shifting the focus back to a legitimate drug strategy model, Canada can ensure that we do not pursue harm reduction in isolation but instead link it to pathways of recovery and long-term stability. It’s time to move the needle toward recovery and away from accepting the perpetual use of opioids. Only then can we hope to create a system that truly reduces harm and fosters healthier communities.


Au Canada, la crise des opioïdes a pris des proportions telles qu’elle constitue désormais une épidémie nationale de décès par surdose, alors qu’au cours des années 1990, l’usage de l’héroïne était relativement rare. Cette récente épidémie est attribuée au fentanyl synthétique, ainsi qu’à la réponse profondément inappropriée des gouvernements, qui ont mis en place des programmes d’« approvisionnement sécuritaire » en opioïdes sous forme de comprimés de Dilaudid ou d’hydromorphone.

Ces programmes ont initialement été introduits pour « réduire les risques », dans l’espoir que leur mise en œuvre contribuerait à prévenir les surdoses en assurant un approvisionnement sécuritaire. Malgré l’intention, ils se sont métamorphosés en une initiative de justice sociale exempte de fondement clinique, concrétisée par la distribution de comprimés de Dilaudid de 8 mg (la dose la plus forte disponible) pour un usage non supervisé. Pour le contexte, le Dilaudid est aussi puissant que l’héroïne et, pour beaucoup d’entre nous très peu familiers avec le sujet, précisons qu’un simple comprimé de 1 ou 2 mg suffit pour induire chez un adulte moyen une somnolence de plusieurs heures, par exemple à la suite d’une fracture ou d’une opération chirurgicale.

L’approvisionnement sécuritaire, tel qu’il est actuellement déployé, est non seulement inefficace pour réduire le nombre de décès par surdose, il exacerbe le détournement des comprimés d’hydromorphone à des fins illégales et sape les efforts de traitement éprouvé, par le biais, notamment, des agonistes opioïdes (TAO) comme la méthadone ou la buprénorphine – des médicaments reconnus pour leur sécurité et leur efficacité.

La crise nécessite de revenir à une politique fondée sur des données probantes. Le Canada a enregistré plus de 7 328 décès par surdose en 2021 malgré l’élargissement du programme d’approvisionnement soi-disant sécuritaire (Agence de la santé publique du Canada, 2018; Santé Canada, 2023). En comparaison, en  2016, 3  023 personnes sont décédées à la suite d’une surdose (Santé Canada, 2019). Les études qualitatives qui vantent les mérites des programmes d’approvisionnement sécuritaire – des auto[1]évaluations réalisées par les défenseurs des programmes – manquent de rigueur. Les comprimés d’hydromorphone sont fréquemment détournés (vendus ou troqués) et inondent nos rues à un prix avantageux par rapport au marché. Parallèlement, le TAO, appuyé sur des décennies de données qui démontrent ses effets sur la réduction de la mortalité, a été écarté.

Les défenseurs de l’approvisionnement sécuritaire soutiennent qu’il préserve l’indépendance de l’utilisateur et réduit la stigmatisation, en le comparant à l’alcool réglementé. Pourtant, la toxicité aiguë des opioïdes – contrairement aux dommages progressifs de l’alcool – rend cette analogie dénuée de sens et trompeuse.

Il nous faut une meilleure voie.

Cette nouvelle méthode doit :

• Privilégier le recours au traitement par agonistes opioïdes et à un ensemble complet de services d’accompagnement plutôt qu’à la simple distribution de comprimés d’opioïdes.

• Reposer véritablement sur des preuves tangibles – en d’autres termes, « s’appuyer sur la science ».

• Fixer un équilibre entre le bien-être des individus et celui des collectivités.

• Remettre en avant les « quatre piliers » de la politique antidrogue – prévention, traitement, réduction des risques et répression – pour s’attaquer non seulement aux conséquences néfastes de la consommation d’opioïdes, mais aussi aux origines profondes de la crise actuelle et aux facteurs qui la perpétuent.

Si le Canada se recentre sur une stratégie défendable de lutte contre les drogues, il aura la possibilité de dépasser l’approche strictement axée sur la réduction des effets néfastes en la liant aux voies de la guérison et de la stabilité à long terme. Il est temps de changer les choses en favorisant le rétablissement plutôt qu’en se résignant à accepter l’utilisation continuelle d’opioïdes. Ce n’est qu’à cette condition que nous pourrons espérer créer un système qui réduit réellement les préjudices infligés et promeut des collectivités plus saines.

 

Tags: Lori Regenstreif

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