Slowly Dying: '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

An anti-gang unit seized fentanyl, cocaine, guns and cash in a London, Ontario investigation in July 2023.

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 resumes 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,” Dr. Koivu said.

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 are now procuring them for $2 each. On the street these tablets are called D8s.

“It’s now cheaper to buy a D8 than it is to buy a tallboy beer,” Dr. Koivu said.

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,” Dr. Koivu added. “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 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.