How Bad Is Opioid Diversion?
A look at the numbers
The CBC recently ran a story about opioid diversion in London, Ontario. According to London police, roughly half of the opioids they’ve seized in the last year have been prescription pills, which means that, somehow, drugs intended for legal distribution are ending up on the street. Predictably, this has led some to blame London’s safe supply program, which prescribes pharmaceutical-grade opioids to 276 people who otherwise would use unregulated drugs. In this post, I want to answer two questions. First, what is the evidence that the safe supply program is driving diversion? And second, what should we think about 50 percent of seized pills being prescription opioids?
When it comes to fentanyl and other opioids, the biggest problem is that people are taking them and then dying. In Canada last year, there were 8,049 opioid-related deaths. In the United States in 2022—2023 data isn’t available—there were 81,806 opioid-related deaths. There’s some evidence that overdoses in the U.S. are declining slightly, though those data are provisional.
Despite the attention the overdose crisis receives, it’s still misunderstood. An overwhelming number of overdose deaths are caused by unregulated opioids, especially unregulated fentanyl. In Canada, 88 percent of overdose deaths last year involved unregulated opioids. In the U.S., as the figure shows, of the 81,806 deaths caused by opioids, only roughly 6,000 of them were caused by prescription drugs. (I’m using ‘prescription drugs’ to mean ‘pharmaceutical-grade’. Someone can take a prescription drug without having a prescription.)
The reason prescription drugs make up such a small percentage of overdose deaths is partly availability. Over the years, unregulated fentanyl has become much more common. But even when opioid prescribing was at its peak in the U.S., the number of overdose deaths due to prescription opioids was still relatively low (~13,000 in 2011).
The more important reason prescription drugs make up such a small percentage of overdose deaths is that they’re safer. Most opioid overdoses occur because the person taking the drug doesn’t know that it contains fentanyl or doesn’t know how much fentanyl it contains. As the numbers show, the problem is largely due to drugs being of unknown strength and composition.
These facts are the basic justification for safe supply programs, which involve prescribing people pharmaceutical-grade opioids to replace the unregulated ones they buy on the street. I have argued for such programs with colleagues here and in this newsletter here.
In discussions about safe supply, people often worry about diversion, which occurs when people who didn’t get a prescription for pharmaceutical-grade opioids, either through a safe supply program or for pain relief, access the drugs. Sometimes drugs are stolen from pharmacies, as in a recent case of $4 million worth of opioids going missing from an Ontario pharmacy. Safe supply programs can also contribute: sometimes people sell or trade their prescriptions.
In a recent article, Adam Zivo, a columnist at the National Post and director of the Centre for Responsible Drug Policy, who has written many articles criticizing safe supply, blames London’s opioid diversion rates on its safe supply program.
In the article, Zivo quotes correspondence with London’s Deputy Chief Paul Bastien. (Zivo helpfully includes a link to a document of their correspondence, which includes the many, many messages he sent to the London Police to get answers to his questions about a police seizure of drugs in April.) Bastien eventually responded to Zivo as follows:
With respect to the case at hand, most of the tablets seized were found packaged in bulk. However, a small quantity of tablets was found in bottles affixed with labels suggesting they were prescribed through a safer supply program.
Based on this, Zivo writes that “[Bastien’s] email confirmed that, for years, the LPS had access to evidence validating the existence of widespread safer supply diversion but had done nothing with it.”
I don’t see it. It’s a leap to go from “a small quantity of tablets was found in bottles affixed with labels suggesting they were prescribed through a safer supply program” to “widespread safer supply diversion”, and I see nothing else in the exchange that verifies Zivo’s claim that safe supply programs are the main contributor over other forms of diversion.
A couple days later, Zivo tweeted a CBC article, which Zivo says shows that “roughly half of the hydromorphone seized in the city can be confidently attributed to the program.”
In fact, the CBC article only says that half of the seized drugs were prescribed opioids, not that the drugs came from the safe supply program. The article is clear that their provenance is hard to determine:
But Deputy Chief Paul Bastien said safer opioid supply (SOS) programs aren’t the only source of opioids being diverted for other uses. He said it’s hard to quantify how much they contribute to the redistribution of prescribed drugs because of how police find them.
“Sometimes a drug is seized in bulk packages,” he told CBC’s London Morning on Friday. “If it’s seized in a bottle by a physician who is prescribing safe supply, that’s clearly an indication [of diversion to street use]. The bulk of what we have seized over the past several years is not found in that form.”
This is consistent with Bastien’s email to Zivo. Bastien only claims that prescription opioids make up half the drugs seized by police. He also says that it’s hard to know where the drugs are coming from and that only a small quantity can be confidently attributed to safe supply. Zivo claims that the jump in seized prescription drugs is due to London’s safe supply program, which is possible, but Bastien doesn’t say that and Zivo doesn’t give other evidence to support his claim.
Zivo has misread the deputy chief’s email and the CBC article—neither says that half the diverted opioids are due to the safe supply program. Still, the police drug seizure raises the question: How should we feel about 50 percent of the seized drugs being prescription opioids?
The two most pressing facts are that the overdose crisis is killing lots of people and that unregulated drugs are predominantly responsible for these deaths. The main problem is that the drugs are toxic, not that they’re opioids. As I described earlier, this is a causal connection. It isn’t a coincidence that prescription drugs cause fewer overdoses. People are far less likely to overdose when they know the composition and strength of the drugs they’re taking.
When these drugs are diverted, it means that people take them instead of unregulated drugs, which means fewer people are likely to die from an overdose. Proportionally, the more pharmaceutical-grade drugs, the better.
Now, diversion, regardless of the source, causes problems. Bastien, the deputy chief, says that criminal groups take advantage of policy changes such as safe supply. It isn’t good that criminal groups are stealing and selling pharmaceutical-grade drugs, but, all things considered, it’s better than them manufacturing and selling non-pharmaceutical-grade fentanyl.
Overdose deaths will stop when people stop doing drugs or when the drugs they’re taking become safer. People aren’t going to stop doing drugs, which means we have to create a safer supply.