Putting the Horse Before the Unicorn: A Safe Supply Strategy Should Begin With Partial Agonists—A Commentary on Bonn et al. (2020).

Preliminary evidence suggests that the social and economic disruptions of COVID-19 have put people with opioid use disorder at a markedly greater risk of fatal overdose. In response, Bonn et al. (2020) advocate for the introduction and scaling up of safe supply. Defining it as the prescribing of pharmaceutical-grade opioids for unsupervised recreational use, it is an intervention explicitly intended not to be a form of treatment. They argue that the practice would reduce overdose deaths by giving people with opioid use disorder a safer alternative to illicit opioids, which are unpredictably adulterated and likely to contain potent fentanyl analogs.

This definition places safe supply at harm reduction’s pinnacle, as one of its elusive unicorns. Overdose prevention sites, which have yet to be scaled up and face perpetual obstruction in the United States, require people to provide their own drugs but supervise consumption to prevent fatal overdose. Naloxone distribution allows people who encounter overdoses to effectively reverse them in unsupervised settings. Safe supply goes further: It is licensed prescribers giving less risky opioids to people with opioid use disorder for deliberate unsupervised recreational use.

That such use can be characterized as misuse is a source of concern for many. As off-label use of a prescription medication, safe supply does not correspond to an established standard of care. It is not a treatment, it does not reduce many behavioral risks of opioid use disorder, and it does not alleviate pain (apart from withdrawal), which is the clinical purpose of the medicine. Safe supplies may contribute to the same increased tolerance and escalating use as illicit opioids, implicating prescribers in increasing the risk of harm to their patients. In a system in which providers worry about being held accountable for patients’ misuse of addiction treatment medicines, supplying full agonist opioids for recreational use is a quantum leap. Bonn et al.’s (2020) response is logical: COVID-19 has combined with opioid overdose dangers and the spread of infectious diseases to form a truly unprecedented syndemic for people who use drugs (PWUD), justifying bold interventions. Viewed through a population-level lens, safe supply stands to save lives by reducing PWUD’s exposure to dangerous street drugs.

Supporting safe supply because its harms are fewer than its lifesaving benefits is taking a utilitarian approach to public health. It is compelling because it intuitively reframes prescribing pharmaceutical-grade opioids to PWUD as overdose prophylaxis, in effect creating a new standard of care for at-risk populations. However, in basing an argument for safe supply on its utility as overdose prophylaxis, one is making an even stronger case for distributing partial agonists such as buprenorphine outside of traditional treatment channels, in advance of safe supply efforts.

It is true that many PWUD do not see themselves as ready for treatment, but we should still do what we can to protect their lives. There is evidence that the unsupervised consumption of diverted buprenorphine does so, as would prescribing it to people with opioid use disorder for overdose prevention alone. It is less risky to consume without supervision than full agonists, and more frequent illicit use is associated with fewer reported overdoses (Carlson et al., 2020). It may also make people more amenable to formal treatment (Kenney et al., 2018). Decoupling partial agonist medicines from treatment and prescribing them without the expectation that patients will be closely monitored will show PWUD that a partial agonist can be both a type of safe supply and a standard of care for preventing overdose. Some authorities have already legitimized buprenorphine’s use in this way by declaring that they will not arrest or prosecute people who possess it illegally (del Pozo et al., 2020). Prescribing guidelines in the United States have recently been loosened to allow induction into partial agonist treatment by telemedicine and to permit 28 days of take-home buprenorphine with very little supervision (Davis & Samuels, 2020). The systems-level ingredients for such a decoupling are falling into place.

In “meeting people where they are,” safe supply allows PWUD to use a safer version of their recreational substance of choice, unsupervised and on their own terms. It not only helps protect them, but also validates the idea that pleasureinducing substances can have a role in people’s lives. This is a critical shift in norms if we intend to replace the failed War on Drugs’ “zero tolerance” approach with less draconian laws and policies that reduce decades of harms (del Pozo & Beletsky, 2020). We should not pursue this unicorn, however, without first taking advantage of the workhorse that is ready to go and can quickly make a population-level difference during the present syndemic. We can recast buprenorphine as a non–treatment-based overdose prophylaxis and distribute it widely among the populations at the greatest risk. This will set the conceptual, legal, and medical stages for considering and evaluating the more controversial intervention of full agonist safe supply.

Acknowledgment

Brandon del Pozo was supported by National Institute on Drug Abuse Grant T32DA013911 and National Institute of General Medical Science Grant P20GM125507. The institutes had no role in the preparation of this article, and the opinions expressed are the authors’ alone.

Conflict-of-Interest Statement

The authors have no conflicts to disclose.