Letter from the Minister of Health regarding treatment and safer supply

This letter has been sent to Provincial and Territorial Ministers of Health and regulatory colleges to encourage action at all levels to better provide people who use drugs with a full spectrum of options for receiving care from practitioners. This includes increasing access to safer, pharmaceutical-grade alternatives to the contaminated illegal drug supply for people at risk of overdose.

August 24, 2020

Dear Colleagues:

I am writing to you today to express my deepest concern about the ongoing and increasing harms experienced by Canadians who are suffering from problematic substance use. I am seeking your support to take concrete action to help address these increasing harms and to better protect the health, safety and lives of these Canadians.

As you know, the overdose crisis has been one of the most significant public health crises in recent Canadian history. Between January 2016 and December 2019, nearly 15,400 Canadians lost their lives from apparent opioid-related causes.

Tragically, in many regions of the country, the 2019 novel coronavirus (COVID-19) pandemic is worsening the overdose crisis, as well as other acute substance use-related harms. There are numerous indications that the street supply is growing even more unpredictable and toxic as supply channels are disrupted. The risks this poses to people who use drugs are further exacerbated by the current strain on support services during the COVID-19 pandemic.

We are now seeing the devastating impact of these compounding crises. For example, in June 2020, the British Columbia Coroners Service reported 175 illegal drug toxicity deaths, the highest number of fatalities ever recorded for a single month in that province's history. To put this in perspective, this is the same amount of people who have died in British Columbia from COVID-19 over the past six months. In Ontario, there was a 25 percent increase in overdose deaths from March to May 2020 compared with the same period last year. Alberta Health Services has also reported a major increase in the number of calls for opioid-related emergencies in May of this year. There are daily news reports of an increase in overdoses in communities across the country.

We need immediate action from all levels of government and health care practitioners to prevent further deaths from the contaminated illegal drug supply and COVID-19.

I am reaching out to you, Ministers of Health, regulators of health professions and organizations representing health care practitioners, to ask you to do all you can to help provide people who use drugs with a full spectrum of options for accessing medication, depending on their individual circumstances, that will help them avoid the increased risks from the toxic drug supply. This includes your support for programs that provide greater access to a safer, pharmaceutical-grade alternative to the toxic street supply.

Established best practices for treating problematic opioid use involve a variety of oral medications, including buprenorphine/naloxone, methadone and slow-release oral morphine. For patients who do not respond well to these traditional opioid agonist therapies, prescription injectable hydromorphone and diacetylmorphine (pharmaceutical-grade heroin) have been successful in helping to stabilize and support the health of some patients with opioid use disorder in a clinical context.

Evidence from these programs in Canada, Switzerland, Germany and the United Kingdom has shown significant beneficial health outcomes through improvements in the physical and mental health of patients. The Canadian Research Initiative in Substance Misuse (CRISM) has developed guidance on injectable opioid agonist treatment, and the Canadian Agency for Drugs and Technologies in Health has published a Rapid Review of clinical evidence and cost effectiveness of injectable opioids agonist treatment for patients with opioid dependence.

Health Canada has moved to make these medications more accessible. In May 2019, the Department approved the use of injectable hydromorphone by qualified health care practitioners as a treatment for adults with severe opioid use disorder. In April 2019, upon the recommendations of Canada's Chief Public Health Officer, Dr. Theresa Tam, diacetylmorphine (prescription-grade heroin) was added to the List of Drugs for an Urgent Public Health Need, making it possible for all provinces and territories to import this drug for the treatment of opioid use disorder. Diacetylmorphine has been approved for treatment in a number of countries, including Switzerland, the United Kingdom, Germany and the Netherlands.

Providing a pharmaceutical-grade alternative to the toxic street supply (i.e. a safer supply), both in the context of treatment or as a harm reduction measure, can support people who use drugs by reducing their risk of overdose, infection and withdrawal. At the start of the pandemic, Health Canada issued a temporary exemption to the Controlled Drugs and Substances Act to facilitate prescribing with flexible treatment options (e.g. allowing prescribers to use verbal prescriptions for narcotics and allowing pharmacists to extend and renew prescriptions) to help patients adhere to social distancing and self-isolation guidance. Originally set to expire at the end of September 2020, I am pleased to inform you that Health Canada has extended this exemption to September 30, 2021, given the ongoing nature of the COVID-19 pandemic.

The Department is also funding a number of safer supply pilot projects across the country through the Substance Use and Addictions Program. These innovative projects will be evaluated to build the safer supply evidence base to support the scaling up of effective models.

Despite the foregoing efforts, the Department still hears from many stakeholders that barriers remain to accessing pharmaceutical-grade alternatives to the toxic street drug supply, whether it be for treatment or harm reduction purposes. Many people who use drugs are not able to find practitioners to provide them with the treatment or access to a safer supply. Some physicians indicate they do not feel supported by their regulatory colleges or sufficiently informed, and medication costs can be a barrier to some.

I encourage you to look at your sphere of influence and work to remove barriers to implementing a safer supply during this unprecedented time. Consider steps you could take to allow service providers in your jurisdiction to take advantage of the regulatory flexibility that is in place at the federal level and improve access to pharmaceutical-grade alternatives for people who use drugs. I know important measures have been put in place to curtail unnecessary opioid over-prescribing, which are commendable and needed. However, we must balance this objective with the needs of people at a high risk of overdose, by ensuring health professionals feel equipped and supported to prescribe medication for treatment or harm reduction without fear of reprisal.

There are many resources available to guide providers as they move into this area, such as the CRISM guidance documents noted above and their six national rapid guidance documents developed to address the urgent needs of people who use substances, service providers and decision makers in relation to the COVID-19 pandemic. Health Canada has also assembled a toolkit to provide clarity on prescribing for the treatment of substance use disorder and/or to provide a safer supply.

It is vital that we recognize substance use disorder is a health and social issue, and that we treat people who use drugs with compassion and give them the support that they need. Please be assured that I am ready to work collaboratively to advance these issues so that we can achieve the common goal of saving lives and preventing harm. Please accept my best wishes.

Yours sincerely,

The Honourable Patty Hajdu, P.C., M.P.

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