When it comes to addressing the national overdose crisis, the Canadian public seems ideologically split: some groups prioritize recovery and abstinence, while others lean heavily into “harm reduction” and destigmatization. In most cases, we would defer to the experts—but they are similarly divided here.

This factionalism was evident at the Canadian Society of Addiction Medicine’s (CSAM) annual scientific conference this year, which is the country’s largest gathering of addiction medicine practitioners (e.g., physicians, nurses, psychiatrists). Throughout the event, speakers alluded to the field’s disunity and the need to bridge political gaps through collaborative, not adversarial, dialogue.

This was a major shift from previous conferences, which largely ignored the long-brewing battles among addiction experts, and reflected a wider societal rethink of the harm reduction movement, which was politically hegemonic until very recently.

Recovery-oriented care versus harm reductionism

For decades, most Canadian addiction experts focused on shepherding patients towards recovery and encouraging drug abstinence. However, in the 2000s, this began to shift with the rise of harm reductionism, which took a more tolerant view of drug use.

On the surface, harm reductionists advocated for pragmatically minimizing the negative consequences of risky use—for example, through needle exchanges and supervised consumption sites. Additionally, though, many of them also claimed that drug consumption is not inherently wrong or shameful, and that associated harms are primarily caused not by drugs themselves but by the stigmatization and criminalization of their use. In their view, if all hard drugs were legalized and destigmatized, then they would eventually become as banal as alcohol and tobacco.

The harm reductionists gained significant traction in the 2010s thanks to the popularization of street fentanyl. The drug’s incredible potency caused an explosion of deaths and left users with formidable opioid tolerances that rendered traditional addiction medications, such as methadone, less effective. Amid this crisis, policymakers embraced harm reduction out of an immediate need to make drug use slightly less lethal. This typically meant supervising consumption, providing sterile drug paraphernalia, and offering “cleaner” substances for addicts to use.

Many abstinence-oriented addiction experts supported some aspects of harm reduction. They valued interventions that could demonstrably save lives without significant tradeoffs, and saw them as both transitional and as part of a larger public health toolkit. Distributing clean needles and Naloxone, an overdose-reversal medication, proved particularly popular. “People can’t recover if they’re dead,” went a popular mantra from the time.

Saving lives or enabling addiction?

However, many of these addiction experts were also uncomfortable with the broader political ideologies animating the movement and did not believe that drug use should be normalized. Many felt that some experimental harm reduction interventions in Canada were either conceptually flawed or that their implementation had deviated from what had originally been promised.

Some argued, not unreasonably, that the country’s supervised consumption sites are being mismanaged and failing to connect vulnerable addicts to recovery-oriented care. Most of their ire, however, was directed at “safer supply”—a novel strategy wherein addicts are given free drugs, predominantly hydromorphone (a heroin-strength opioid), without any real supervision.

While safer supply was meant to dissuade recipients from using riskier street drugs, addiction physicians widely reported that patients were selling their free hydromorphone to buy stronger illicit fentanyl, thereby flooding communities with diverted opioids and exacerbating the addiction crisis. They also noted that the “evidence base” behind safer supply was exceptionally poor and would not meet normal health-care standards.

Yet, critics of safer supply, and harm reduction radicalism more broadly, were often afraid to voice their opinions. The harm reductionists were institutionally and culturally dominant in the late 2010s and early 2020s, and opponents often faced activist harassment, aggressive gaslighting, and professional marginalization. A culture of self-censorship formed, giving both the public and influential policymakers a false impression of scientific consensus where none actually existed.

The resurgence in recovery-oriented strategies

Things changed in the mid-2020s. British Columbia’s failed drug decriminalization experiment eroded public trust in harm reductionism, and the scandalous failures of safer supply—and supervised consumption sites, too—were widely publicized in the national media.¹

Whereas harm reductionism was once so powerful that opponents were dismissed as anti-scientific, there is now a resurgent interest in alternative, recovery-oriented strategies.

These cultural shifts have fuelled a more fractious, but intellectually honest, national debate about how to tackle the overdose crisis. This has ruptured the institutional dominance enjoyed by harm reductionists in the addiction medicine world and allowed their previously silenced opponents to speak up.

When I first attended CSAM’s annual scientific conference two years ago, recovery-oriented critics of radical harm reductionism were not given any platforms, with the exception of one minor presentation on safer supply diversion. Their beliefs seemed clandestine and iconoclastic, despite seemingly having wide buy-in from the addiction medicine community.

While vigorous criticism of harm reductionism was not a major feature of this year’s conference, there was open recognition that legitimate opposition to the movement existed. One major presentation, given by Dr. Didier Jutras-Aswad, explicitly cited safer supply and involuntary treatment as two foci of contention, and encouraged harm reductionists and recovery-oriented experts to grab coffee with one another so that they might foster some sense of mutual understanding.²

Is this change enough?

While CSAM should be commended for encouraging cross-ideological dialogue, its efforts, in this respect, were also superficial and vague. They chose to play it safe, and much was left unsaid and unexplored.

Two addiction medicine doctors I spoke with at the conference—both of whom were critics of safer supply and asked for anonymity—were nonplussed. “You can feel the tension in the air,” said one, who likened the conference to an awkward family dinner where everyone has tacitly agreed to ignore a recent feud. “Reconciliation requires truth,” said the other.

One could also argue that the organization has taken an inconsistent approach to encouraging respectful dialogue. When recovery-oriented experts were being bullied for their views a few years ago, they were largely left on their own. Now that their side is ascendant, and harm reductionists are politically vulnerable, mutual respect is in fashion again.

When I asked to interview the organization about navigating dissension, they sent a short, unspecific statement that emphasized “evidence-based practices” and the “benefits of exploring a variety of viewpoints, and the need to constantly challenge or re-evaluate our own positions based on the available science.”

But one cannot simply appeal to “evidence-based practices” when research is contentious and vulnerable to ideological meddling or misrepresentation.

Compared to other medical disciplines, addiction medicine is highly political. Grappling with larger, non-empirical questions about the role of drug use in society has always necessitated taking a philosophical stance on social norms, and this has been especially true since harm reductionists began emphasizing the structural forces that shape and fuel drug use.

Until Canada’s addiction medicine community facilitates a more robust and open conversation about the politicization of research, and the divided—and inescapably political—nature of their work, the national debate on the overdose crisis will be shambolic. This will have negative downstream impacts on policymaking and, ultimately, people’s lives.