Addressing the overdose crisis in North America with bold action

The unregulated drug supply is predominantly composed of fentanyl and responsible for accelerating the overdose crisis across North America. Scaling-up safer supply and implementing decriminalization of drug use are two major policy shifts needed to reduce overdose deaths and begin to displace frameworks focused on criminalization that have dominated health and drug policy. North America is facing a devastating public health crisis of unintentional drug poisoning overdose deaths driven by an unpredictable unregulated drug supply, which has significantly worsened since the onset of the COVID-19 pandemic. However, the volatility of the unregulated drug supply predates the pandemic, with fentanyl supplanting heroin over the last 5–7 years in much of Canada and the United States. It is this shift that has driven the acceleration in opioid-related death rates, with unregulated fentanyl responsible for 87% of opioid-overdose deaths in Canada in 2021 1. Historically, the overprescribing of pharmaceutical opioids has been implicated in increased opioid-related harms, and rates of opioid prescribing in North America remain elevated in comparison to other jurisdictions 2. Despite this, significant reductions in rates of opioid prescribing in North America have not led to decreases in opioid-related harms; in fact, multiple studies have found that decreases in pharmaceutical opioid prescribing have translated into increased rates of overdose from unregulated opioids such as heroin and fentanyl 3, 4. Although the preponderant contribution of fentanyl to overdose burden in North America is increasingly recognized, drug policy responses in many jurisdictions continue to focus on overprescribing, overlooking the decreasing contribution of pharmaceutical medications to the ongoing overdose crisis 5. This has led to a lack of adequate focus on how to effectively address overdose deaths caused by an unregulated drug supply composed primarily of fentanyl, in combination with an unpredictable array of fentanyl analogues, nitazenes and non-pharmaceutical benzodiazepines (including etizolam, flualprazolam and flubromazolam) 6, 7. This variability in the drug supply not only exposes people who use drugs to a higher risk of toxicity and overdose death, it complicates overdose response and has led to increasing numbers of non-fatal overdoses with unknown long-term health implications 8. Therefore, the response to the overdose crisis must be broad and multi-pronged, informed by both evidence of the drivers of opioid-related harm and the expertise of people who use drugs. This includes an urgent need to scale-up proven harm reduction interventions, incorporate novel approaches such as safer supply and acknowledge and redress the harms caused by laws that criminalize people who use drugs. Although opioid agonist therapy (OAT) has a strong evidence-base supporting reduced mortality among people retained in treatment, OAT discontinuation is high across much of North America, often resulting in a return to the unregulated drug supply 9. Therefore, although flexible models for OAT—including injectable OAT that uses diacetylmorphine or hydromorphone—are needed in the context of the current crisis, they will not be sufficient because of notable challenges to scale-up and expansion including restrictive eligibility and program requirements, a lack of political will to expand programming and lack of resources in small, rural and remote areas 7, 10, 11. Additionally, the unpredictability of the unregulated drug supply, ineffectiveness of OAT for many people and the often overlooked fact that many people dying of overdose do not have an opioid use disorder 12 means that the overdose response cannot be predicated entirely on broadened access to treatment. It must incorporate principals of harm reduction, including scale-up of supervised consumption sites and safer supply. Informed by a philosophy of harm reduction, the rationale underlying safer supply programs—where pharmaceutical opioids are prescribed to divert people from the unregulated drug supply and improve accessibility of health services—is that drug poisoning overdoses can be prevented by providing people who rely on the unpredictable unregulated supply with a known dose of pharmaceutical opioids. Safer supply can be distinguished from historical overprescribing of opioids as it is a targeted intervention aimed at people dependent on the unregulated drug supply who are at high risk of fatal overdose, while also providing wrap-around medical and social services to address concurrent needs. Although the Canadian government has funded a handful of pilot safer supply programs that include significant social supports and show positive initial findings 13, there remains a large unmet need for interventions for people who do not want, or have not had success on, traditional OAT programs across North America. Further, a continued over-reliance on the criminalization of drug use ignores its broad failure to reduce drug availability, potency or associated harms. In Canada, several jurisdictions have submitted applications to decriminalize drug possession, and people who use drugs are suing the Canadian government to remove criminal penalties associated with drug use 14. Although these actions may not have immediate, direct impacts on overdose rates, criminalization causes both health and social harms, while also contributing to the stigma and discrimination that drives negative treatment of people who use drugs within medical settings. The over-medicalization of drug use, tied to this stigma and discrimination faced by people who use drugs has led to resistance to incorporating their perspectives into programming and policy development that directly affect their lives. This is exemplified by the success of pandemic-related loosening of take-home dosing requirements in methadone programs—a change that has been highlighted as a core barrier to treatment retention by people who use drugs for years 15, 16. It is imperative that the perspectives of people who use drugs are equitably and meaningfully integrated into policy-making discussions, particularly when concerns are voiced about existing interventions. Given the failures of highly medicalized and criminalizing approaches, ensuring the expertise of people who use drugs is meaningfully included is necessary to ensure the healthcare system and response to the overdose crisis is effectively meeting their needs. It will also require openness to bold action and innovative responses like safer supply and decriminalization, rather than relying on incremental approaches, to effectively change the course of this crisis. T.G. has received grant funding from the Ontario Ministry of Health and is supported by a Canada Research Chair in Drug Policy Research and Evaluation. She has received stipends from Indigenous Services Canada for membership on their Drugs and Therapeutics Advisory Committee. G. K.is supported by funding from a Canadian Institutes of Health Research Banting Postdoctoral Researcher Award and a Canadian Network on Hepatitis C (CanHepC) Postdoctoral Fellowship. She has received fees for consulting to develop and conduct program evaluations for: Parkdale Queen West Community Health Centre, London Intercommunity Health Centre, The Neighbourhood Group, Street Health, and The Working Centre. She has also received fees for developing and conducting educational sessions for the Dr. Peter Centre and CATIE. N.T. is employed by the Canadian Association of People who Use Drugs, which receives funding from the Substance Use and Addictions Program, Health Canada. She has received research funds from the Canadian Research Initiative in Substance Misuse (CRISM) Quebec/Atlantic node and received funds to serve as an expert consultant as co-Chair of Health Canada's Task Force: Alternatives to Criminalization of Simple Possession. She also co-Chairs Health Canada's People with Lived and Living Experience Council and has received fees for developing and conducting educational sessions for the Dr. Peter Centre and CATIE. Gillian Kolla: Conceptualization, Drafting of manuscript. Natasha Touesnard: Conceptualization, Revision of manuscript. Tara Gomes: Conceptualization, Revision of manuscript.