Adapting Approaches to the Toxic Street Drug Overdose Crisis

Addiction medicine continues to confront the toxic street drug overdose crisis daily. Many of the submissions in this issue of Canadian Journal of Addiction directly discuss evolving approaches to the crisis, including the use of opioid agonist therapies (OATs), prescribed alternatives, needle exchange, and the complexities inherent to the toxic street drug overdose crisis. As “people who use drugs” (PWUDs) represent an increasingly heterogeneous population, considering more individualized approaches and barriers to engagement and retention in care is required.1 Initiation of OAT at the initial point of contact in an emergency department or acute care setting can improve initial OAT retention rates, rather than waiting for OAT start-up through addiction referral.2 The paper by Liu et al3 adds further nuance in their qualitative study where they emphasize that perceptions of PWUD about buprenorphine/naloxone can influence acceptance of emergency room initiation as does ready access to follow-up care that is supportive and comprehensive in nature. Initial dosing of OAT may also be particularly important in the era of fentanyl as identified in the letter by Bawa et al4 not only in emergency department and acute care settings, but also in withdrawal management ones. Fentanyl and its analogs represent the majority of the current toxic street supply cut with various agents to prolong the effects of fentanyl or other contaminants, increasing overall lethality5,6 and likely requires a different approach. Those using fentanyl and who previously tolerated moderate to high dose methadone well may need a more rapid up-titration of methadone for improved retention and outcomes, although more post-discharge safety evaluation is required. Needle exchange is an effective harm reduction approach,7 as are safe consumption sites (SCS).8 With potential SCS closures, decreased needle exchange may occur and greater needle debris. The article by Jackson et al9 identifies the complexities of why needle debris occurs, particularly when services as designed more for convenience of pick-up rather than accessibility to PWUD and their needs. The article by Kim et al10 also speaks to the alarmingly frequent use of substances in hospital settings by people with methamphetamine use disorders and the need for more effective hospital-based harm reduction strategies to address the issue. Some have argued that safer, predictable, pharmaceutical-grade substances could keep PWUD from continued use of and exposure to the toxic drug supply,11 but many of the social and economic antecedents for opioid and stimulant use disorders, including experiences of trauma, economic insecurity, being unhoused, social isolation, lack of social supports, stigma as well as urban and rural disparities would likely drive continued toxic street supply use.1,12 The debate over prescribed alternatives (safer supply) as opposed to more traditional OAT provision remains a point of division in addiction medicine, but Canadian Journal of Addiction aims to help provide a forum for meaningful discussion about the varied evidence-based approaches to addiction and to promote conciliation. Some approaches, like prescribed alternatives and SCS, may be better for some PWUD, particularly those with more severe substance use disorders, less motivation to change, and greater barriers to care, whereas more classic addiction treatment and recovery options may be better for others. The exchange in the Letters to the Editor with Wilson et al13 and Kahan14 reflects the ongoing discussion and adds to the other articles in this edition of the Journal, which emphasize the complexities and need for continually updating the complex approaches to care required. Recent data suggest a reduction in drug overdose deaths across Canada,15 but it is too early to know if this is a sustained trend. Progress is being made on the toxic street drug overdose crisis, and hope that insights from the articles in this issue of the journal add further nuance and individualization to approaches for those susceptible. David Crockford, MD, FRCPC Editor-in-Chief, CJA

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