A Call for an Evidence-Based Strategy Against the Overdose Crisis

Introduction

The current overdose crisis is one of the most devastating public health challenges in the field of mental health and substance use disorder care in history. Globally, about 1 in 5 deaths is attributable to substance use, with more than 70% attributable to opioids.1 The dramatic increase in mortality in Canada and the USA since 2015 is primarily due to changing drug markets and related patterns of substance use, and an ill-prepared system of care.2 In the USA, the economic cost of drug abuse is estimated to be $193 billion dollars annually, which includes healthcare costs, loss of productivity and criminal justice costs.3

Fentanyl now dominates the pattern of use in most regions of North America and has become the drug of choice among many people who use drug (PWUD).4 This shift towards high-potent synthetic opioids has not stopped at fentanyl, with ultra-potent synthetic fentanyl derivatives such as carfentanil as well as non-fentanyl-derived ultra-potent synthetic opioids such as Nitazene now becoming readily available.5,6 The latter, from a drug class known as benzimidazole-opioids, is several times more potent than fentanyl and is undetectable using currently available fentanyl test strips.5

As a result, the climb in overdose deaths in North America have been dramatic, and one that is seemingly impervious to previous response measures developed by public health agencies.7 For instance in BC, there were 2,306 and 2,272 overdose deaths in 2021 and 2022, respectively, almost 25% more than the previous record set only in 2020 (1,774).8 These numbers have set off alarms among healthcare leaders in the province, leading to the adoption of initiatives intended to mitigate the harms associated with the illicit toxic drug supply. The most recent has been the provision of a ‘safe supply’ – the prescription of high-potent psychotropic substances outside of a therapeutic context in the hope of reducing overdose risk due to increased toxicity of the illicit drug supply.9 While the logic of providing ‘clean’ drugs to protect PWUD from exposure to a ‘tainted’ illicit drug supply is irrefutable, the ‘devil’ is very much in the details. Should this approach be viewed simply as a short-term intervention or as a strategy that over the long-term will curb mortality significantly? In the latter case, how will safe supply be integrated into a long-term therapeutic context in contrast to defaulting into a stand-alone option? A vigorous debate over these questions, along with concerted and well-supported research efforts to secure much needed objective data, remains the only evidence-based approach to develop a clear path forward devoid of wishful thinking borne out of desperation.