Doctors Nova Scotia working on strategy to offer safe drug supply for patients with addictions

This is the conclusion of a two-part series on the relatively new harm reduction technique known as safe supply, in which doctors prescribe the same drugs some people have become dependent on to reduce overdose deaths from toxic street drugs. Proponents say it is also a way to manage health and allow patients to focus on social aspects of their lives.

Not all doctors agree that providing people with a safe supply of the drugs they have become dependent on is an effective treatment for some people who are addicted.

It is increasingly being seen as an option and studies are starting to show its effectiveness, but it is only available to a small number of patients in Nova Scotia, partly because very few doctors are willing to prescribe a safe supply.

But that may be changing.

Dr. Margaret Fraser, a family physician and emergency doctor in Sydney, said there are medical, legal and regulatory problems with prescribing a safe supply of drugs.

"If I prescribed a high dose of narcotic to a patient who subsequently overdosed, I could be held medico-legally responsible for that person's death, either by the patient's family or the regulatory bodies and could lose my licence over that," she said.

"You can lose your licence to prescribe narcotics altogether if you're viewed as a problem prescriber. That's happened to several physicians in our area.

"We're being pulled in two directions and honestly at times it feels like we're going to be torn in half by the demands of the regulatory bodies and the demands of the patients. There's absolutely no middle ground when it comes to narcotics and other controlled substances and it's a very difficult position to be in as a physician."

Many people who have become addicted have also become tolerant to drugs and need high doses, which can be dangerous, and that can leave doctors exposed to increased liability, Fraser said.

Doctors would also have little control over the cleanliness and safety of unsupervised injection, which could increase transmission of diseases and lead to illness or death from sepsis, she said.

In addition, doctors want to avoid conflict with the college of physicians and surgeons and the province's prescription monitoring program regarding overprescribing.

Fraser said she would need to see "significant" safeguards in place before considering safe supply for a patient, including changes by the regulators, access to safe consumption sites and collaboration with other health-care and social-care providers.

Dr. Leisha Hawker is a family physician who works part-time at an addiction clinic in Halifax and is president of Doctors Nova Scotia.

Like other doctors, she prescribed safe supply to some patients in Halifax during the pandemic in order to slow the spread of COVID-19.

Doctors Nova Scotia is working on a harm reduction strategy that includes safe supply, Hawker said, with results expected over the next few months.

But for now, she prefers to prescribe a replacement for addictive drugs.

"In our current state, we need to focus on what has best evidence for patients with addiction and specifically with opioid use disorders, the best evidence is for opiate agonist therapy, meaning methadone or Suboxone," Hawker said.

Doctors Nova Scotia is pushing for primary care reform to make collaborative practices much more widely available, something that Hawker said helps addictions patients with a broader range of medical and social issues.

"There's a few patients that have failed other opiate agonist therapies that I might then consider for safe supply, but it would be something that I'd be doing quite carefully and I'd want to know the patient well and discuss all the risks with them and with their other providers and kind of collaborate with the pharmacist just to do it in a way that minimizes as much risk as possible," she said.

Increasing training options for doctors

Until recently, there weren't many opportunities for training in addiction medicine, Hawker said, but those are increasing.

Dalhousie's School of Medicine has added addiction medicine to the curriculum and doctors are helping train medical residents at the Ally Centre of Cape Breton's collaborative clinic. The facility has a safe consumption site and its organizers are working to find a prescriber for safe supply.

Last year, 39 Nova Scotians died of confirmed or probable opioid toxicity. So far this year, 38 people have died.

Janet Bickerton, a registered nurse and health services co-ordinator with the Ally Centre, said the health clinic has everything in place to offer safe supply, including support counselling, drug testing, safe consumption materials and a safe location for users to take drugs.

But it still needs a physician willing to prescribe for the small number of patients who have no other alternative.

"Across the country, we're starting to recognize the research is pretty clear that this is an option for a certain segment of the population who use drugs," said Bickerton.

"It's not talking [about] having a party and 'Whoopee, we're going to get all high and have fun.' This is talking about just being able to put your feet on the floor in the morning."

The centre has two part-time doctors, one of whom has prescribed safe supply to "very small" number of clients, said Bickerton.

"At the time, the physician thought that she could kind of take that on, but realized after a few clients that this is a lot ... and that we'd have to put the brakes on and that was about all we could manage," she said.

"That population in and of itself is not for everyone. The physicians that we've been able to recruit ... are special. They really are and they really want to work with this population. They see the value. They find it rewarding, but it's taxing."

Giulia DiGiorgio, executive director of Cape Breton Association for People Empowering Drug Users, has been trying for years to have a safe supply available on the island.

CAPED is run by people with lived experience using illicit drugs and has Health Canada funding to offer programs to reduce the stigma from criminalizing people who need medical help in order to lead productive lives.

The group had been approved to take part in the MySafe program, which dispenses opioids to approved users from a secure vending machine designed for that purpose.

Like the Ally Centre, DiGiorgio was unable to find a doctor who would prescribe for the program, but she hasn't given up.

Access lacking in rural communities

She said the machines work well in urban settings with large concentrations of people who use drugs, but they would also be helpful in Cape Breton.

"While Halifax does have access, all of our especially rural communities don't have access and I feel that every community could potentially have a peer-led, low-barrier model of safe supply with the MySafe vending machine in every community, in Glace Bay, in New Waterford, in Sydney, in Inverness," DiGiorgio said.

"Wherever the population of people who need it, there could potentially be a service offered by people with lived experience, so that people could get an alternative to the toxic illicit supply of drugs that people are getting so sick from and dying from."

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