Calls for more 'safer opioid' access in Nova Scotia as drug supply increasingly toxic

As the illicit drugs that have devastated Western and Central Canada become more prevalent in Nova Scotia, a Halifax physician is renewing calls to expand access to "safer opioid supply" treatment to prevent overdoses and deaths.

Opioids sold and consumed in Nova Scotia are increasingly unpredictable and often contaminated, Dr. Mike Gniewek, a family and addictions physician with Halifax's Mobile Outreach Street Health unit, said in a recent interview.

To save more lives, more doctors in the Atlantic region should be trained on how to treat some patients with pharmaceutical-grade opioids — known as safer supply opioids — a medical approach in which drug users are prescribed what's considered a safer alternative to what they are consuming. The approach, he said, comes with ongoing monitoring and primary health-care support.

"Is it perfectly safe? No. But it is much, much, much safer than the illicit market, because people have a labelled amount of an opioid that's known to them with a predictable effect," Gniewek said.

The problem right now, he said, is that he knows of only three doctors in the province willing to prescribe patients with a safer supply of an opioid — and he is one of them.

'Worrying more and more'

Since before 2017, Gniewek and his colleagues have been monitoring the devastating effects of these drugs in Western Canada, hoping that the eastern part of the country would be less affected.

"I definitely started worrying a year or two ago, and I'm worrying more and more with each passing day," he said.

Gniewek, part of a team that provides primary health care, harm reduction and addiction treatment to patients who are homeless or unstably housed, said fentanyl has become a "prominent player" in Halifax's drug market.

"And that's only increased lately. Even over the last month we've seen a little spike in overdose-related harms. We've seen more drug testing with contaminants in the drug supply, and we're seeing more fentanyl and fentanyl analogs," he said, which have a similar but not identical chemical structure to fentanyl.

The patients best suited to be prescribed opioids as a treatment plan include people with severe addictions, those who are overdosing weekly or using fentanyl or fentanyl analogs, he said. Currently, he and two other doctors at his clinic prescribe a dosage of an opioid to patients in Halifax on a "very small scale."

"And that definitely needs to increase," he said, adding that all safe-supply prescribing must be accompanied with adequate training, support and patient monitoring.

Illicit drug warnings

Since 2016, Health Canada has recorded 38,514 opioid-related overdose deaths, most of them in B.C., Alberta and Ontario. Between January and March of last year, there were more than 1,900 apparent opioid overdose deaths in the country, an average of 21 a day.

Nova Scotia saw a record of 63 opioid toxicity deaths in 2023, the same number as in 2022. In 2021, there were 40 reported toxicity deaths, down from 49 in 2020.

RCMP in Nova Scotia issued a warning on Dec. 8 about illicit drugs after two fatal suspected overdoses on the same day — involving a 31-year-old man and a 35-year-old man — in Springhill, a town of about 2,700 people in Cumberland County.

Mounties issued a similar warning in October following the suspected overdose death of someone under the age of 18 at a home in Cole Harbour, a suburb outside of Dartmouth, on Oct. 15; two other people under 18 were taken to hospital in an ambulance. Later that evening RCMP responded to another suspected overdose and administered naloxone — which reverses the effects of opioids — to a 34-year-old man.

Evidence shows that giving drug users a prescribed dose of a drug that's similar to what they're addicted to can save lives and improve health outcomes, said Gillian Kolla, a collaborating scientist with the Canadian Institute for Substance Use Research and assistant professor at Memorial University's faculty of medicine.

Decrease in ER visits

A September 2022 report in the Canadian Medical Association Journal co-authored by Kolla found that in Ontario there was a rapid decrease in emergency department visits and hospital admissions among individuals enrolled in a safer opioid supply program.

The basis for safer supply is simple, Kolla said, and is aligned with how Canada regulates alcohol and cannabis to ensure that clients know what they are purchasing.

"Across Canada, different places have many different drug markets, so the toxic drug crisis is playing out differently in different provinces, even different cities," Kolla said in a recent interview.

British Columbia and Alberta first began seeing overdose rates dramatically increase between 2015 and 2016, and the same happened in Ontario in 2017, she said, adding, "This is when the unregulated drug supply switched from heroin to fentanyl."

Heroin has become extremely difficult to find in many areas, Kolla said, adding that drug users in Ontario say they have not been able to access heroin since 2017, forcing them to turn to different drugs such as fentanyl, which is synthetic.

Whenever a certain drug becomes hard to get, suppliers "have to get creative" and develop different opioid mixtures, sometimes adding other drugs, including sedatives like benzodiazepine.

"So it actually leads to this game of Whack-A-Mole, where one [drug] precursor gets regulated, people can't get it anymore or it's difficult to get it, then [drug supply] switches to a different mix," she said.

Kolla said Canada's long-standing focus on using police enforcement to manage illicit drugs has "has no good outcomes. In fact, the main outcome is we have a much more potent and dangerous supply."

She was one of 131 addictions researchers, doctors and nurse practitioners who on Dec. 14, issued a letter to the federal government calling for continued support and the scaling-up of safer supply programs. Funding from Ottawa for 21 safer supply programs in Canada is set to expire at the end of March.