Prescribing safer-supply drugs helps people with addictions — but also pits some doctors against each other

NOTE: This is the second in a two-part series on the call for stricter rules around prescribing safer-supply drugs in Ontario. You can read the first part here.

Amid police concerns over what they say is an increase in diverted prescribed opioids, some doctors are also calling for stronger regulations around safer-supply prescribing.

Dr. Robert Cooper, a physician based in Toronto and Orillia, Ont., sits on the board of Addiction Medicine Canada and has worked in addiction medicine since 1997. He said the organization was formed partly in response to what its members consider inappropriate prescribing of short-acting opioids to people dealing with addiction.

He said he doesn’t support safer-supply prescribing, but noted that previous programs once funded by the federal government provided useful wraparound support — such as connection to housing resources and mental health services — before they shut down.

“Instead, what we have now is programs where people with active drug addictions are given drugs that they sell, and they use the money to purchase other drugs.”

Safer-supply prescribing, which gained traction as the overdose crisis was worsening during the COVID-19 pandemic, involves putting patients on legal opioids in the form of tablets. The hope is it’ll prevent them from getting illegal drugs from the streets and elsewhere that could potentially be more dangerous for them, including being laced with other, unsafe drugs.

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For example, earlier this month, there was a surge of more than 60 drug poisonings in the Kenora area over two days.

Dr. David Marsh, vice-president of research and graduate studies at the Northern Ontario School of Medicine University (NOSM), said safer supply encompasses several different models of addiction care and treatment.

One of the first models started with supervised injectable treatment, said Marsh, also research chair in mental health and addiction at the Health Sciences North Research Institute.

He was involved in some of the first heroin prescription trials in Canada during the early to late 2000s. They were built on research out of the United Kingdom, Switzerland and other European countries that have made safer-supply prescribing standard care in the treatment system.

During the heroin prescription trials, patients would typically attend a clinic three times a day, seven days a week to receive their medication under supervision, according to Marsh.

“That model of care has been shown to be very effective for reducing the risk of death, but also improving people’s physical and social health, and helping them to get re-engaged in things like employment and school,” Marsh said, adding the goal would be to get patients to switch to oral treatments like methadone.

In 2020, Health Canada started funding 31 programs across the country that offered prescribed alternatives to opioids and provided wraparound supports, including mental health and housing supports. But those programs lost their funding in 2025. 

“Some physicians have tried to come up with the best alternative, which does benefit some people, but clearly has potential for risks,” Marsh said.

He said the take-home safer supply option has a less established evidence base than supervised injectable treatments, although research over the past decade suggests some people receiving pharmaceutical opioids may benefit and may be less likely to die from an overdose.

In Ontario, prescribing guidelines are governed by the College of Physicians and Surgeons (CPSO), which regulates physicians and sets professional expectations, and a doctor’s individual judgment. That means any physicians in the province can prescribe opioids to someone struggling with addiction as an alternative to street drugs.

British Columbia is the only province that has a formal government-sanctioned framework around safer-supply prescribing. In 2025, the province mandated that the consumption of safer-supply medications must be observed by a health-care professional. 

That’s one of the changes Cooper hopes is implemented in Ontario.

Cooper said he believes the term safer supply can be misleading when it refers to short-acting opioids. He pointed to eight-milligram hydromorphone tablets that are used in some programs as particularly potent.

“We’re putting a pharmaceutical-grade opiate on the street that’s twice as strong as heroin and we’re pretending that this is somehow doing a service to our communities.”

He distinguishes those medications from long-acting opioid treatments such as methadone and suboxone that can reduce withdrawal and cravings without producing the same highs and lows.

Patients who begin treatment with methadone or suboxone are required to take the medication under supervision. Some can eventually take it home, but if they test positive for an illegal drug, they’re required to resume supervised dosing.

“If we give people these long-acting medications, it normalizes their behavior, normalizes their lives, allows them to go back to school and get back to work, get stable housing, get away from street drugs,” Cooper acknowledged.

By contrast, safer-supply opioids are often provided without supervised consumption.

“The information I get from patients is that most if not all of the medication is being sold,” Cooper said.

He said people may be less likely to overdose on pharmaceutical opioids such as hydromorphone and Percocet than on some illegal drugs, but argued that patients can subsequently transition to stronger drugs such as fentanyl.

That transition to stronger street drugs is something Dr. Lori Regenstreif has seen among young people struggling with addiction.

Regenstreif works at the Rapid Access Addiction Medicine (Raam) Clinic in downtown Hamilton and at a male juvenile correctional facility in southern Ontario, where she’s responsible for intake questions.

She said the young people being held at the facility are from various parts of the province, sometimes even outside the province, to prevent gang-related conflict.

“I’ve always said that they’re the canaries in the coal mine. They’re the first ones that face whatever is hitting the streets.”

Regenstreif said that starting around 2022, there was an uptick in the amount of young people between ages 15 and 25 telling her that they were buying “D8’s,” which are eight-milligram hydromorphone tablets.

She added that one hydromorphone tablet is equivalent to roughly five Percocet pills.

“I’ve seen kids get in trouble with Percocets, but because they’re not so potent, they’re not as addictive. With the D8’s, they’re taking five Percocets in one. And if they do that for a few days in a row, suddenly they’re having withdrawal if they don’t take them.”

She said her patients often tell her that they opt for the cheapest drugs available, and right now, the eight-milligram hydromorphone tablets are extremely cheap because they’ve flooded the market.

“It’s whatever is the cheapest and most available. And unfortunately, the next most available cheapest is fentanyl. And so when they’re desperate, and they’re in withdrawal, and withdrawal is a terrible, terrible thing, they’ll take anything and that might be fentanyl,” Regenstreif said.

“Once they take fentanyl, as my patients tell me, you never go back. You can’t go back to hydromorphone after you’ve had fentanyl. It’s way more potent.”

Regenstreif said that when young people come to her with hydromorphone dependence, she generally aims to transition them to another opioid-agonist treatment, often buprenorphine. For some patients, she said, that can include injectable buprenorphine, followed by a slow taper when the patient wants to eventually come off treatment.

She doesn’t consider supplying short-acting opioids on its own to be treatment.

Cooper said Addiction Medicine Canada is calling on the CPSO and Ontario’s Ministry of Health to make two changes when it comes to safer-supply prescribing. 

The recommendations include requiring all doses to be consumed under observation and establishing a maximum quantity of medication that can be prescribed at one time.

“If they observe all the doses, then much of the risk of diversion and much of the risk to other members of the public is gone,” Cooper said, adding that people who benefit from the prescription would still be able to continue treatment. 

CBC reached out to the Ministry of Health requesting a response to the recommendations outlined by Cooper. A spokesperson didn’t respond to most of the questions, including if it tracks the number of Ontarians on safer-supply prescriptions and if it’s considering additional regulatory changes. 

“To be absolutely clear, our government does not and will never support the distribution of tools to use illegal drugs, including the predatory prescribing of addictive drugs that violates a physician’s obligations as set out by the College of Physicians and Surgeons of Ontario,” Lily Barnes said in an emailed statement. 

“Our government has moved to replace the failed model of drug injection sites with Homelessness and Addiction Recovery Treatment (HART) Hubs, helping people break the cycle of addiction through comprehensive treatment and support. Across the province, we have invested $560 million to create 29 new HART Hubs.” 

The CPSO says safer supply is a complex and evolving area of medicine.

In June 2026, the college amended its prescribing policy to clarify expectations around safer-supply prescribing. 

The changes require physicians to conduct an in-person assessment before starting safer supply, offer medications like methadone and suboxone, and conduct in-person assessments at least every three months when it’s prescribed on an ongoing basis.

The CPSO doesn’t currently require all safer-supply medications to be consumed under observation.

In a statement to CBC, the CPSO said it is aware of the recommendations being discussed by some physicians and law enforcement representatives, regarding observed dosing and limits on the quantity of safer-supply medications prescribed at a time. 

The regulator said daily dispensing and/or observed dosing during the initial period of treatment can help mitigate risks, but it doesn’t currently mandate supervised consumption for all safer-supply prescriptions.

It also doesn’t set a specific maximum quantity of safer-supply medication that physicians can prescribe.

“Physicians are expected to prescribe in a manner that minimizes the risk of harm and unintended consequences to patients and the broader public,” Laura Zilke, a CPSO spokesperson, said in an emailed statement.

The issue is now before the college’s board of directors. The CPSO has scheduled a special meeting for Oct. 13 to consider proposed amendments related to safer-supply prescribing.