“Safe Supply” Initiatives: Are They a Recipe for Harm Through Reduced Health Care Input and Supply-Induced Toxicity and Overdose?

ABSTRACT

Within the addiction field, some advocates support a suite of de-regulatory policies that aim to reduce harm by providing people who use drugs with a “safe supply” of pharmaceutical-grade medications. Such initiatives have commenced without the evidence standards normally used to label medication provision as “safe.” This perspective suggests that continued debate and research in this area acknowledge the potential toxicity of any provided safe supply medications and highlights that these initiatives could result in an unhelpful reduction in interactions between people who use drugs and health care professionals.

One of The Fundamental changes upon graduation from medical school or accreditation to certain health care professions is the legal ability to prescribe specific medications. Although this power is in many instances uncontroversial (e.g., few if any members of society believe that they should be able to access chemotherapy without medical consultation; Wazaify et al., 2005), discourse surrounding what medications should and should not be available without the need for professional consultation, supervision, and/or formal prescription can often be contentious.

In the past decade many areas of health care have seen legally sanctioned shifts away from the need for medical consultation or formal prescription to access certain licensed medications. Examples include pharmacy provision of progestogen-only oral contraceptive pills (POP; Michie et al., 2016) and websites such as “www.iwantprepnow.co.uk,” which enable consumers to directly purchase anti-retroviral pre-exposure prophylaxis (PrEP). Indeed, a recent United Kingdom Secretary of State for Health and Social Care even suggested relaxing antibiotic prescribing guidance, allowing dispensing by pharmacists without prior medical consultation (Mahase, 2022). In each of the above examples, the reasons behind the desire for regulatory relaxation are multifactorial and stem from both issues concerning the medications themselves and the conditions they treat. However, the influence of advocacy groups, often aiming to expand access to specific products for specific populations, can also be a pivotal driver of policy change (Mitchell, 1986).

Within the addiction field, some advocates endorse a suite of deregulatory policies that aim to reduce harm by providing people who use drugs with a “safe supply” without necessarily following the evidence standards normally used to label such medication provision as safe (Bonn et al., 2020; Tyndall, 2020). Although the term safe supply lacks a universally accepted definition, it typically refers to the provision of pharmaceuticalgrade medications as a putatively safer alternative to supply via an adulterated illicit drug market, particularly to people who are at high risk of overdose. Opioid agonist treatments (OAT; e.g., methadone, buprenorphine, and, in some circumstances, diamorphine) are mainstays of evidence-based addiction treatment and apply this principle under medical supervision. In contrast, safe supply initiatives embrace a reduced need for health care professional consultation, supervision, and/or the need for a formal prescription to directly provide people who use drugs with pharmaceutical-grade medications including opioids, benzodiazepines, cocaine, and/or methamphetamine (Connock et al., 2007). As an example, a recent safe supply proposal in Canada suggested providing up to a month of short-acting opioid medication based on an individual's self-reported consumption pattern (Government of Canada, 2022).

Ironically, this perceived need to move away from the current level of health care professional medication oversight may have been accelerated from within the addiction field itself, owing to the dramatic de-regulatory changes associated with naloxone (McAuley et al., 2015). Several jurisdictions worldwide no longer require a trained health care professional consultation or a formal prescription to access naloxone, supplies often can be provided directly to members of the public, and there has been a removal of any legal consequences to people administering naloxone for the purpose of saving a life (Government of the UK, 2019). Indeed, naloxone—in both its intranasal and injectable formulations—is, to our knowledge, the only such example of a licensed medication that holds such a status. The deregulatory success story of naloxone, in which health care professionals were a key advocate group alongside people who use drugs, may have fueled perspectives that other licensed medications used in the treatment of addiction should be treated similarly—that is, access expanded, barriers to provision lowered, and a reduction in the role of health care professionals in their supply and supervision.

But we would caution about generalizing from a drug whose potential harms are very minimal to drugs that can induce addiction and overdose. Debate and research into safe supply initiatives (which is, after all, a term not currently backed up by evidence of safety) needs to acknowledge and monitor for potential toxicity and overdose from drugs distributed into communities. We also wish to highlight that these initiatives could have the potential to reduce therapeutic interactions between people who use drugs and health care professionals.

Potential for supply-induced toxicity and overdose

Discussion of the removal or relaxation of elements of consultation, supervision, or the need for a formal prescription are often accompanied by the laudable aims of reducing drug-related harm via the removal of potentially harmful unknown constituents within illicit drug supplies and provision of accurate knowledge of product potency. However, although naloxone has no potential to cause addiction or overdose, opioids, benzodiazepines, and other safe supply medications do (Tyndall, 2020). The contribution to potential toxicity and overdose of safe supply medications is substantial—both to the individual provided with the medication and to any others to whom the safe supply medication may become diverted. As noted, more Americans and Canadians have died from legally produced, clearly labeled opioids than died in World Wars I and II combined (Humphreys et al., 2022). Diversion of distributed drugs could be accidental (e.g., the evidence that recreational cannabis legalization has led to a spike in child poisonings), or it could be intentional (once people who do or do not use drugs become aware that medication with significant financial value may be available on request; Aldabergenov et al., 2022; Myran et al., 2023). In the event of a fatal overdose caused by the provided safe supply medications and issued without supervision or prescription, would blame be attached to the local jurisdiction for its de-regulatory approach, to the provider of the safe supply of drugs, or to individuals using drugs for failing to use their provided supply correctly? If there were an accidental death or a new case of addiction attributed to diverted medication supply, whom would the media, society, and concerned others hold responsible, and would any level of fatal overdose in any population be tolerated?

Programs to distribute addictive drugs to community members are also vulnerable to prolific and careless actors, whether because of venality (e.g., the “pill mills” of Florida) or ideological commitments (e.g., the case of Lady Isabella Frankau in Britain; Shapiro, 2021), and the regulatory relaxation necessary for safe supply initiatives may increase this vulnerability. The experience of the North American opioid crisis shows that even a fraction of 1% of such physicians can trigger dramatic increases in addiction and overdose. Research has consistently demonstrated that greater availability of addictive substances within communities can contribute to greater rates of substance use disorder and overdose (Babor et al., 2010), with evidence to suggest an increased risk if the substances in question are sanctioned as safe by those in positions of authority. Data have also shown magnified risks of addiction developing following consumption of diverted prescription medications in substance-naive populations with particular vulnerabilities—including people with lower incomes and those with concurrent mental health challenges (Compton et al., 2016). Regional-level medication-specific mortality has also been shown to increase in line with increases in per capita medication prescription (Gladstone et al., 2015; Hall et al., 2021) and when consultation, supervision, and/or formal prescription regulations are relaxed, such as during the COVID-19 pandemic (Aldabergenov et al., 2022).

Potential for reduced therapeutic contact between health care professionals and people who use drugs

Although advocacy for continued health care professional consultation, supervision, and prescription of medications may reasonably be viewed as paternalistic, decisions related to medication supply in all health care contexts should be the result of a risk–benefit analysis discussion conducted between the prescriber and the individual in receipt of medication in the context of broader prescribing regulation. This is particularly important in the addiction treatment context because the health care professional in question may be well situated to provide other interventions that go beyond the prescription pad, and too often individuals in addiction settings may have limited or unhelpful interactions with other parts of the health care system (McCurry et al., 2022). Efforts to make it as easy as possible for people who use drugs to access health care professionals should be supported, and flexible, personalized arrangements based on an individual's needs should be the hallmark of addiction care. A non–evidence-based blanket reduction in health care professional oversight of prescribing would be a case of providing a stigmatized population a lower quality of care than would be considered ethical for other patients.

The landscape of addiction treatment service provision has changed dramatically across the globe over the last decade, particularly in the United States and the United Kingdom. The former has increased integration of addiction within the wider health care landscape, and the latter has experienced a significant shift away from provision by the health care sector to provision by voluntary, community, and social enterprise (VCSE) organizations (Roberts, 2021). Within the United Kingdom, this move away from the potentially stigmatizing term medical model has been accompanied by a significant reduction in the numbers of trained health care professional staff, including addiction psychiatrists, psychologists, and nurse practitioners. Although some of these changes have been driven by reductions in funding and/or commissioning practices, continued advocacy for de-medicalization of addiction treatment, which some safe supply initiatives have the potential to perpetuate, may further reduce access to health care expertise for people with addiction disorders and stymie research (Lembke, 2020).

Conclusions

Safe supply is a promotional term, when what is needed is careful evaluation of the risk of such initiatives to increase addiction, toxicity, and overdose. Furthermore, the importance of health care professional consultation, supervision, and formal prescriptions for some individuals in the course of their recovery journey should not be forgotten. Too often prescribers are colloquially referred to as “the medication person” within broader mental health care settings (Angermeyer et al., 2017). The safe supply debate should not assist in perpetuating this unhelpful professional stigma.