Addictions
“Safer supply” reminiscent of the OxyContin crisis, warns addiction physician
Dr. Lori Regenstreif, MD, MSc, CCFP (AM), FCFP, MScCH (AMH), CISAM, has been working as an addiction medicine physician in inner city Hamilton, Ontario, since 2004. She co-founded the Shelter Health Network in 2005 and the Hamilton Clinic’s opioid treatment clinic in 2010, and helped found the St. Joseph’s Hospital Rapid Access Addiction Medicine (RAAM) clinic.
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[This article is part of Break The Needle’s “Experts Speak Up” series, which documents healthcare professionals’ experiences with Canada’s “safer supply” programs] By: Liam Hunt
Dr. Lori Regenstreif, an addiction physician with decades of experience on the frontlines of Canada’s opioid crisis, is sounding the alarm about the country’s rapidly expanding “safer supply” programs.
While proponents of safe supply contend that providing drug users with free tablets of hydromorphone – a pharmaceutical opioid roughly as potent as heroin – can mitigate harms, Dr. Regenstreif expresses grave concern that these programs may inadvertently perpetuate new addictions and entrench existing opioid use.
She sees ominous similarities between safer supply and the OxyContin crisis of the late 1990s, when the widespread overprescribing of opioids flooded North American communities with narcotics, sparking an addiction crisis that continues to this day. Having witnessed the devastating consequences of OxyContin in the late 1990s, she believes that low-quality and misleading research is once again encouraging dangerous overprescribing practices.
Flashbacks to the OxyContin Crisis
Soon after Dr. Regenstreif received her medical license in Canada, harm reduction became the primary framework guiding her practice in inner-city Vancouver. This period coincided with Health Canada’s 1996 regulatory approval of oxycodone (brand name: OxyContin) based on trials, sponsored by Purdue Pharma, that failed to assess the serious risks of misuse or addiction.
Dr. Regenstreif subsequently witnessed highly addictive prescription opioids flood North American streets while Purdue and its distributors reaped record profits at the expense of vulnerable communities. “That was really peaking in the late 90s as I was coming into practice,” she recounted during an extended interview with Break The Needle. “I was being pressured to prescribe it as well.”
Oxycodone addiction led to the deaths of tens of thousands of individuals in the United States and Canada. As a result, Purdue Pharma faced criminal penalties, fines, and civil settlements amounting to 8.5 billion USD, ultimately leading to the company’s bankruptcy in 2019.
During the OxyContin crisis, patients would regularly procure large amounts of pharmaceutical opioids for resale on the black market – a process known as “diversion.” Dr. Regenstreif has seen alarming indications that safer supply hydromorphone is being diverted at similarly high levels, and estimated that, out of her patient pool, “15 to 20 out of maybe 40 people who have to go to a pharmacy frequently” have reported witnessing diversion.
Between one to two thirds of her new patients have told her that they are accessing diverted hydromorphone tablets – in many cases, the tablets almost certainly originate from safer supply.
Injecting crushed hydromorphone tablets pose severe health risks, including endocarditis and spinal abscesses. “I’ve seen people become quadriplegic and paraplegic because the infection invaded their spinal cord and damaged their nervous system,” said Dr. Regenstreif. While infections can be mitigated by reducing the number of times drug users inject drugs into their bodies, she says that safer supply programs do not discourage or reduce injections.
She further noted, “I’ve seen a teenager in [the] hospital getting their second heart valve replacement because they continue to inject after the first one.” The pill that nearly stopped the patient’s heart was one of the tens of thousands of hydromorphone tablets handed out daily via Canadian safe supply programs.
Her experiences are consistent with preliminary data from a scientific paper published by JAMA Internal Medicine in January, which found that safe supply distribution in British Columbia is associated with a “substantial” increase in opioid-related hospitalizations, rising by 63% over the first two years of program implementation — all without reducing deaths by a statistically significant margin.
While Dr. Regenstreif has worked in a variety of settings, from Ontario’s youth correctional system to Indigenous healing facilities in the Northwest Territories, her experiences in Australia, where she worked during a sabbatical year from 2013 to 2014, were particularly educational.
Australia has far fewer opioid-related deaths than Canada – in 2021, opioid mortality rates were 3.8 per 100,000 in Australia and 21 per 100,000 in Canada (a difference of over 500%). Dr. Regenstreif credited this difference to Australia’s comparatively controlled opioid landscape, where access to pharmaceutical narcotics is tightly regulated.
“Heroin had been a long-standing street opioid. It was really the only opioid you tended to see, because the only other ones people could get a prescription for were over-the-counter, low-potency codeine tablets,” she said. To this day, opioid prescriptions in Australia require special approval for repeat supplies, preventing stockpiling and street diversion.
No real evidence supports “safer supply”
Critics and whistleblowers have argued that Canadian safe supply programs, which have received over $100 million in federal funding through Health Canada’s Substance Use and Addictions Program (SUAP), were initiated without adhering to the rigorous evidentiary standards typically required to classify medication as “safe.”
Dr. Regenstreif shares these concerns and says that no credible studies show that safer supply saves lives, and that little effort is invested into exploring its possible risks and unintended consequences – such as increased addiction, hospitalization, overdose and illicit diversion to youth and vulnerable individuals.
Most studies which support the experiment simply interview recipients of safer supply and then present their answers as objective evidence of success. Dr. Regenstreif criticized these qualitative studies as methodologically flawed “customer satisfaction surveys,” as they are “very selective” and rely on small, bias-prone samples.
“If you have 400 people in a program, and you get feedback from 12, and 90% of those 12 said X, that’s not [adequate] data,” said Dr. Regenstreif, criticizing the lack of follow-up often shown safer supply researchers. “Nobody seems to track down the […] people who were not included. Did they get kicked out of the program? [Did they engage in] diversion? Did they die? We’re not hearing about that. It doesn’t make any sense in an empirical scientific universe.”
Safe supply advocates typically argue that opioids themselves are not problematic, but rather their unregulated and illicit supply, as this allows for contaminants and unpredictable dosing. However, studies have found that opioid-related deaths rise when narcotics, legal or not, are more widely available.
Dr. Regensteif is calling upon harm reduction researchers to build a more robust evidence base before calling for the expansion of safer supply. That includes more methodologically rigorous and transparent quantitative research to evaluate the full impact of Canada’s harm reduction strategies. Forgoing this evidence or adequate risk-prevention measures could lead to consequences as catastrophic as those resulting from Purdue’s deceptive marketing of OxyContin, she said.
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Critics propose solutions despite bullying
Dr. Regenstreif has faced pressure and exclusion for speaking out against safe supply. She estimates that while only a quarter of her local colleagues shared her doubts a few years ago, “now I would say more than half” harbor the same concerns. However, many are reluctant to voice their reservations publicly, fearing professional or social repercussions. “People who don’t want to speak out don’t want to be labeled as right-wing […] they don’t want to be labeled as conservative.”
While she acknowledges that safe supply may play a limited role for a small subset of patients, she believes it has been oversold as a panacea without adequate safeguards or due evaluation. “It doesn’t seem as if policymakers are listening to the people on the ground who have experience in doing this,” she said.
She contends that the solution to Canada’s addiction crisis lies in a more holistic, recovery-oriented approach that includes all four pillars of addiction: harm reduction, prevention, treatment, and enforcement. Her vision includes a national network of publicly-funded, rapid-access addiction medicine clinics with integrated counseling and wraparound services.
Additionally, Dr. Regenstreif stresses the importance of building upon established opioid agonist treatments (OAT), like methadone and buprenorphine, rather than solely relying on novel approaches whose social and medical risks are not yet fully understood.
At the core of Dr. Regenstreif’s advocacy lies a profound dedication to her patients and to the science of addiction medicine. “I like to think I kind of am fear-mongering with my patients, [by] trying to make them afraid of not getting better,” she explains. “I don’t want them to end up in the hospital and not come back out. I don’t want them to end up dead.”
[This article has been co-published with The Bureau, a Canadian media outlet that tackles corruption and foreign influence campaigns through investigative journalism. Subscribe to their work to get the latest updates on how organized crime influences the Canadian drug trade.]
From the Brownstone Institute
Cigarettes kill nearly half a million Americans each year. Everyone knows it, including the Food and Drug Administration. Yet while the most lethal nicotine product remains on sale in every gas station, the FDA continues to block or delay far safer alternatives.
Nicotine pouches—small, smokeless packets tucked under the lip—deliver nicotine without burning tobacco. They eliminate the tar, carbon monoxide, and carcinogens that make cigarettes so deadly. The logic of harm reduction couldn’t be clearer: if smokers can get nicotine without smoke, millions of lives could be saved.
Sweden has already proven the point. Through widespread use of snus and nicotine pouches, the country has cut daily smoking to about 5 percent, the lowest rate in Europe. Lung-cancer deaths are less than half the continental average. This “Swedish Experience” shows that when adults are given safer options, they switch voluntarily—no prohibition required.
In the United States, however, the FDA’s tobacco division has turned this logic on its head. Since Congress gave it sweeping authority in 2009, the agency has demanded that every new product undergo a Premarket Tobacco Product Application, or PMTA, proving it is “appropriate for the protection of public health.” That sounds reasonable until you see how the process works.
Manufacturers must spend millions on speculative modeling about how their products might affect every segment of society—smokers, nonsmokers, youth, and future generations—before they can even reach the market. Unsurprisingly, almost all PMTAs have been denied or shelved. Reduced-risk products sit in limbo while Marlboros and Newports remain untouched.
Only this January did the agency relent slightly, authorizing 20 ZYN nicotine-pouch products made by Swedish Match, now owned by Philip Morris. The FDA admitted the obvious: “The data show that these specific products are appropriate for the protection of public health.” The toxic-chemical levels were far lower than in cigarettes, and adult smokers were more likely to switch than teens were to start.
The decision should have been a turning point. Instead, it exposed the double standard. Other pouch makers—especially smaller firms from Sweden and the US, such as NOAT—remain locked out of the legal market even when their products meet the same technical standards.
The FDA’s inaction has created a black market dominated by unregulated imports, many from China. According to my own research, roughly 85 percent of pouches now sold in convenience stores are technically illegal.
The agency claims that this heavy-handed approach protects kids. But youth pouch use in the US remains very low—about 1.5 percent of high-school students according to the latest National Youth Tobacco Survey—while nearly 30 million American adults still smoke. Denying safer products to millions of addicted adults because a tiny fraction of teens might experiment is the opposite of public-health logic.
There’s a better path. The FDA should base its decisions on science, not fear. If a product dramatically reduces exposure to harmful chemicals, meets strict packaging and marketing standards, and enforces Tobacco 21 age verification, it should be allowed on the market. Population-level effects can be monitored afterward through real-world data on switching and youth use. That’s how drug and vaccine regulation already works.
Sweden’s evidence shows the results of a pragmatic approach: a near-smoke-free society achieved through consumer choice, not coercion. The FDA’s own approval of ZYN proves that such products can meet its legal standard for protecting public health. The next step is consistency—apply the same rules to everyone.
Combustion, not nicotine, is the killer. Until the FDA acts on that simple truth, it will keep protecting the cigarette industry it was supposed to regulate.
Author
By Adam Zivo
Both are shaped by radical LGBTQ activism and questionable evidence.
Over the past decade, North America embraced two disastrous public health movements: pediatric gender medicine and “harm reduction” for drug use. Though seemingly unrelated, these movements are actually ideological siblings. Both were profoundly shaped by extremist LGBTQ activism, and both have produced grievous harms by prioritizing ideology over high-quality scientific evidence.
While harm reductionists are known today for championing interventions that supposedly minimize the negative effects of drug consumption, their movement has always been connected to radical “queer” activism. This alliance began during the 1980s AIDS crisis, when some LGBTQ activists, hoping to reduce HIV infections, partnered with addicts and drug-reform advocates to run underground needle exchanges.
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In the early 2000s, after the North American AIDS epidemic was brought under control, many HIV organizations maintained their relevance (and funding) by pivoting to addiction issues. Despite having no background in addiction medicine, their experience with drug users in the context of infectious diseases helped them position themselves as domain experts.
These organizations tended to conceptualize addiction as an incurable infection—akin to AIDS or Hepatitis C—and as a permanent disability. They were heavily staffed by progressives who, influenced by radical theory, saw addicts as a persecuted minority group. According to them, drug use itself was not the real problem—only society’s “moralizing” norms.
These factors drove many HIV organizations to lobby aggressively for harm reduction at the expense of recovery-oriented care. Their efforts proved highly successful in Canada, where I am based, as HIV researchers were a driving force behind the implementation of supervised consumption sites and “safer supply” (free, government-supplied recreational drugs for addicts).
From the 2010s onward, the association between harm reductionism and queer radicalism only strengthened, thanks to the popularization of “intersectional” social justice activism that emphasized overlapping forms of societal oppression. Progressive advocates demanded that “marginalized” groups, including drug addicts and the LGBTQ community, show enthusiastic solidarity with one another.
These two activist camps sometimes worked on the same issues. For example, the gay community is struggling with a silent epidemic of “chemsex” (a dangerous combination of drugs and anonymous sex), which harm reductionists and queer theorists collaboratively whitewash as a “life-affirming cultural practice” that fosters “belonging.”
For the most part, though, the alliance has been characterized by shared tones and tactics—and bad epistemology. Both groups deploy politicized, low-quality research produced by ideologically driven activist-researchers. The “evidence-base” for pediatric gender medicine, for example, consists of a large number of methodologically weak studies. These often use small, non-representative samples to justify specious claims about positive outcomes. Similarly, harm reduction researchers regularly conduct semi-structured interviews with small groups of drug users. Ignoring obvious limitations, they treat this testimony as objective evidence that pro-drug policies work or are desirable.
Gender clinicians and harm reductionists are also averse to politically inconvenient data. Gender clinicians have failed to track long-term patient outcomes for medically transitioned children. In some cases, they have shunned detransitioners and excluded them from their research. Harm reductionists have conspicuously ignored the input of former addicts, who generally oppose laissez-faire drug policies, and of non-addict community members who live near harm-reduction sites.
Both fields have inflated the benefits of their interventions while concealing grievous harms. Many vulnerable children, whose gender dysphoria otherwise might have resolved naturally, were chemically castrated and given unnecessary surgeries. In parallel, supervised consumption sites and “safer supply” entrenched addiction, normalized public drug use, flooded communities with opioids, and worsened public disorder—all without saving lives.
In both domains, some experts warned about poor research practices and unmeasured harms but were silenced by activists and ideologically captured institutions. In 2015, one of Canada’s leading sexologists, Kenneth Zucker, was fired from the gender clinic he had led for decades because he opposed automatically affirming young trans-identifying patients. Analogously, dozens of Canadian health-care professionals have told me that they feared publicly criticizing aspects of the harm-reduction movement. They thought doing so could invite activist harassment while jeopardizing their jobs and grants.
By bullying critics into silence, radical activists manufactured false consensus around their projects. The harm reductionists insist, against the evidence, that safer supply saves lives. Their idea of “evidence-based policymaking” amounts to giving addicts whatever they ask for. “The science is settled!” shout the supporters of pediatric gender medicine, though several systematic reviews proved it was not.
Both movements have faced a backlash in recent years. Jurisdictions throughout the world are, thankfully, curtailing irreversible medical procedures for gender-confused youth and shifting toward a psychotherapy-based “wait and see” approach. Drug decriminalization and safer supply are mostly dead in North America and have been increasingly disavowed by once-supportive political leaders.
Harm reductionists and queer activists are trying to salvage their broken experiments, occasionally by drawing explicit parallels between their twin movements. A 2025 paper published in the International Journal of Drug Policy, for example, asserts that “efforts to control, repress, and punish drug use and queer and trans existence are rising as right-wing extremism becomes increasingly mainstream.” As such, there is an urgent need to “cultivate shared solidarity and action . . . whether by attending protests, contacting elected officials, or vocally defending these groups in hostile spaces.”
How should critics respond? They should agree with their opponents that these two radical movements are linked—and emphasize that this is, in fact, a bad thing. Large swathes of the public understand that chemically and surgically altering vulnerable children is harmful, and that addicts shouldn’t be allowed to commandeer public spaces. Helping more people grasp why these phenomena arose concurrently could help consolidate public support for reform and facilitate a return to more restrained policies.
Adam Zivo is director of the Canadian Centre for Responsible Drug Policy.
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