'They left their homes to live in tents near the drug store'

Canadian doctor describes how flood of cheap 'safer supply' tablets paved way for fentanyl gangs in London, Ontario

Dr. Sharon Koivu never expected to be thrust into the national spotlight. Yet, over the past few months, her outspoken opposition to the federal government’s “safer supply” programs has made her a well-known figure in Canadian addiction policy.

These programs, which have been widely available in Canada since 2020, claim to reduce overdoses and deaths by providing free, government-supplied drugs as alternatives to potentially tainted illicit substances. In Canada, that typically means distributing hydromorphone, an opioid as powerful as heroin, to mitigate fentanyl use.

Like many addiction experts, Dr. Koivu claims that these programs are being widely defrauded and that most, if not the majority, of the hydromorphone distributed by the government is being resold on the black market, fuelling a new wave of addictions.

Though Dr. Koivu’s views are mainstream within the addiction medicine world, colleagues have largely been too afraid to publicly speak up. They fear harassment from safer supply advocates, who are known to bully opponents with ruthless zeal, as well as retaliation from a federal government that is keen on downplaying its failures.

These critics are neither obscure nor wackos. Most of them have worked in addiction medicine for many years, if not decades, and have formidable CVs and good reputations. Dr. Koivu, for example, has practiced palliative care and addiction in London, Ontario, since the early 2000s.

But amid a climate of fear and censorship, even the well-credentialled can be muted.

Dr. Koivu never considered silence an option, because it would mean abandoning her patients. When we first spoke this January, she exclaimed, “I am seeing people who are suffering! Why are they not worthy of compassion? Why is their pain meaningless? Why are their lives forgotten? These patients have to matter.”

These strict principles have made her a leading voice among the small group of physicians who have had the courage to openly criticize safer supply. And while this has earned praise from many colleagues, it has also made her a target for activists who have tried to smear her, inaccurately, as a right-wing provocateur.

Dramatic rise in infections

Though safer supply was scaled up across Canada in 2020, it was first piloted in 2016 in London, Ontario, through a program run by the London Intercommunity Health Centre (LIHC). As Dr. Koivu worked at a nearby hospital, she was able to observe the community impacts of safer supply years before other physicians.

“At first, the main driver around safer supply was to give it to street-level women who were selling their bodies for drugs – either directly or for money to buy drugs. The thought was that if they could be given the drugs directly, they wouldn’t have to sell their bodies,” said Dr. Koivu.

After the pilot project launched, though, it was quickly promoted as a tool to reduce harms among all drug users, not just sex workers.

Dr. Koivu initially thought that safer supply could benefit her patients. Much of her workload revolves around treating people with infections related to intravenous drug use, and she believed that safer supply, by distributing oral-use hydromorphone tablets, could reduce injections and related infections.

But the opposite happened – the frequency and severity of her patients’ infections rose dramatically.

Before safer supply launched in London, patients typically abused diverted Hydromorph Contin which had originally been prescribed for pain management. Diversion, in addiction medicine circles, means people legally acquiring opioids and then distributing or illegally reselling them to other drug users or traffickers.

Hydromorph Contin is just hydromorphone administered through a slow-release pill filled with small beads, and, as drug users typically want their entire opioid payload immediately, they would nullify the slow-release coating by crushing and injecting the pills.

Dr. Koivu noticed that patients who injected Hydromorph Contin often developed heart valve infections – so she involved herself in several studies between 2016 and 2022 which formally proved this connection. She concluded that Hydromorph Contin beads, when crushed, produce large particles that do not dissolve well and, when injected, appear to scratch and physically damage users’ heart valves.

As safer supply distributes immediate-release hydromorphone tablets, which have no slow-release coating, Dr. Koivu hoped that patients would have fewer reasons to inject and would consume their new tablets orally – but she was wrong. Patients still injected the tablets to get a stronger effect.

According to Dr. Koivu, crushing and dissolving the immediate-release tablets created smaller particles that, while less dangerous for the heart, apparently blocked or damaged very small blood vessels in users’ spines. Heart valve infections decreased as immediate-release safer supply hydromorphone displaced Hydromorph Contin, but other infections relating to injection drug use rose dramatically, often causing horrific suffering and disfigurement.

“I was seeing spine infections and epidural abscesses (abscesses of the spine) which were causing severe suffering and pain – infections that could lead to paraplegia. I also saw gangrene, sepsis. I hadn’t seen many of those infections previously.”

Though safer supply programs now commonly distribute “recipes” on how to best inject hydromorphone, Dr. Koivu says that none of her patients have been warned that intravenous use of this “safe” drug can lead to debilitating harms.

Addicted youth and decaying communities

Through speaking with her patients, Dr. Koivu learned that safer supply diversion was ubiquitous. As the drug flooded into her community, its street price collapsed – whereas an 8mg tablet used to sell for $20, her patients can now procuring them for $2 each.

“It’s now cheaper to buy a D8 than it is to buy a tallboy beer. And when a drug is readily available and cheap, more people use it. When I started my work, the vast majority of people I saw had started with a legal script (prescription) from a physician – or had significant childhood trauma, or both. That changed.”

Teenagers often underestimated the dangers of the drug, and were more likely to experiment with it, because it was doctor-prescribed, marketed as “safe,” and lacked the stigma associated with other substances, such as heroin.

“I started seeing a real shift in the people I was seeing, Much younger populations. Young people for whom this was now an early drug that they were experimenting with, and developing an addiction to.  More young people are buying diverted drugs and developing an addiction. More people are moving up from D8s (the street term for 8mg tablets of hydromorphone) to something stronger. More people are dying of overdoses.”

Advocates often argue that safer supply is needed to combat the fentanyl crisis, as traditional addiction medications are less effective with fentanyl users. Yet, for Dr. Koivu, this narrative has always been strange because, in London, fentanyl only became popular years after safer supply was introduced.

In fact, based on her patient interactions, safer supply seemed to fuel fentanyl abuse.

Individuals who abuse opioids quickly develop a physical tolerance that requires them to consume more of the drug to achieve the same effect. This often pushes users to graduate to using more potent substances, such as fentanyl, which means that increased hydromorphone abuse within a community can easily spur a darker crisis.

“Patients have certainly told me this – that they start with D8s and need something stronger and stronger to get the same euphoric effect. These patients, who started with D8s, would then step up to fentanyl. People selling fentanyl started coming to the community, and now fentanyl is a huge problem in London.”

Once patients became trapped in a cycle of safer supply diversion and opioid abuse, their lives would spiral into oblivion.

“I have had patients tell me that they were housed and that they left their homes to live in tents near the drug store, which is near LIHC, where a large amount of diversion takes place. It added to the homeless crisis – people were literally leaving their homes to be near the action.”

At the tent city, which hadn’t existed before safer supply, people were living “in squalor, with a lack of sewage and toilets, which also increases the risk of infection.” 

Some of Dr. Koivu’s patients were vulnerable women who were being pressured to secure as much hydromorphone as possible, so that their spouses or pimps could confiscate the drugs for resale. According to some patients, criminals would wait outside safer supply pharmacies and then intimidate vulnerable people, such as the geriatric or disabled, into handing over their hydromorphone.

Flashbacks to the OxyContin Crisis

Several addiction physicians and drug policy experts say that Canada’s safer supply experiment is like a reincarnation of the OxyContin crisis.

In the late 1990s, Purdue Pharma, an American pharmaceutical company, released a powerful opioid called OxyContin. To boost sales and obtain approval for wider prescribing, Purdue fraudulently downplayed OxyContin’s addictiveness and potential for abuse – and, while this made the company billions, it precipitated a continent-wide, ongoing opioid crisis which has taken hundreds of thousands of lives so far.

Before OxyContin, opioids were sparingly used and typically reserved for individuals experiencing significant pain, such as cancer patients. To change this, Purdue invested enormous sums of money into popularizing the idea that the United States was suffering from an epidemic of untreated chronic pain, Among other things, the company sponsored low-quality studies and networks of quasi-independent advocacy groups to push its narratives.

This fostered an environment where opioid overprescribing was normalized and healthcare professionals who showed caution were deemed callous and “opioiphobic.” Some unscrupulous doctors set up highly-profitable “pill mills” that doled out OxyContin prescriptions like candy to anyone who wanted them.

Lawsuits filed in the 2000s and 2010s eventually exposed Purdue’s malfeasances, but, by the time regulators clamped down on prescribing in the mid 2010s, it was too late – the opioid crisis was roaring.

While it is currently trendy to criticize Purdue, that wasn’t always the case. Early on in the crisis, only a minority of “opiophobic” doctors spoke up – Dr. Koivu was one of them.

“I was pretty critical of Purdue very early on in the opioid crisis, and gave talks criticizing them. At the time there was a real belief, similar to now, that people who were suffering needed our compassion and care, and that we could give them a better life if we gave them more opioids. It was certainly embraced by a lot of the medical profession.”

For Dr. Koivu, safer supply feels like deja vu. The pill mills of yesterday have returned as safer supply programs. Once again, low-quality research and questionable appeals to “compassionate” are justifying opioid overprescribing. Even the tactics for fraud, such as driving around homeless people to secure more drugs, are the same.

But, this time, one thing is crucially different.

“When I criticized Purdue, people questioned whether I felt that I was putting myself at risk – but I was never at risk. No one tried to destroy me and my career. But now, people who come forward and criticize safer supply are at risk of being bullied.”

But when Dr. Koivu spoke up about what she was witnessing among her patients, safer supply advocates harassed her and accused her of fear mongering. They claimed that she profited from undermining safer supply, even though the program actually increased her patient load and income.

“Disheartening isn’t even a word that can describe it. I have never felt this kind of harassment in my entire medical career – despite the fact that I have been a very forward-thinking advocate for years.”

The poison of politics

Dr. Koivu was raised in a progressive family where social justice was paramount – her father ran for the NDP federally in 1974 and, throughout her life, she has always considered herself very left-wing. But when she raised her concerns about safer supply to progressive politicians, whether they be Liberals or the NDP, she found herself ignored.

Frustrated by her own marginalization, she decided that she would talk to anyone who would listen – so she eventually found herself, somewhat to her own bewilderment, collaborating with conservative stakeholders. Alberta’s United Conservative Party invited her to participate in their Clinical Addiction Treatment Expert Panel, and conservative politicians reached out to her to learn from her experiences.

 “I was not expecting to feel silenced by many who claim to be left-wing and so supported by conservatives. This was not at all what I was expecting – it was quite a surprise,” she wrote to me in an email.

Her new connections occasionally put her outside of her comfort zone.

When she was approached by conservative filmmaker Aaron Gunn, who wanted to interview her for his 2023 documentary, “Canada is Dying,” she was unsure of what to do. Though Gunn is considered a far-right extremist by his opponents, she decided to work with him. In the end, she felt that her views were accurately portrayed.

Similarly, when I first reached out to her, she deliberated about working with me, a National Post columnist, and asked one of her adult sons, who had almost been destroyed by addiction in his 20s, for advice. He encouraged her to speak with me.

In May, the National Post published a 10,000 word investigative story of mine which thoroughly detailed safer supply’s disastrous failings. The response was explosive. My findings were debated in parliament, and, shortly after, the Conservatives introduced a motion to defund safer supply (it failed).

Later that month, Gunn released his documentary, which was watched by millions online.

These two high profile exposės garnered significant attention – and, as Dr. Koivu had been an important figure in both of them, she was thrust into the spotlight. The London Free Press published a highly critical article wherein Dr. Andrea Sereda, who leads the LIHC’s safer supply program, dismissed Dr. Koivu’s testimony as “unfounded anecdotes.”

Yet, as Dr. Koivu and I met for another interview over the summer, she was content.

She had received only positive feedback at her workplace, which was a surprising but welcome development. The Canadian Society of Addiction Medicine had also just appointed her as one of its two regional directors for Ontario.

She laughed about the “hit piece,” and said that it had been written with such an obvious bias that it had offended any colleagues and community members, pushing them to rally around her. After that blowback, the same journalist interviewed Dr. Koivu and wrote a more balanced article that gave her space to highlight her concerns.

“It was the best thing that could’ve happened,” she said.

Safer supply activists had tried to undermine her reputation and erase the suffering of her patients – but their efforts were failing in my view, because, ultimately, the truth was on her side. And after conducting dozens of interviews, I can assert it was a truth that many of her colleagues had witnessed, too. A truth witnessed in other hospitals and clinics across Canada.

Safer supply is failing and people are suffering. No amount of bullying can hide that forever, because, in the end, suffering makes itself known.

---

This article was originally published in The Bureau, a Canadian publication devoted to using investigative journalism to tackle corruption and foreign influence campaigns. You can find this article on their website here.