On the streets of Hamilton, Ontario, the sale and exchange of prescription hydromorphone pills—used in safer supply programs to combat opioid addiction—has become a visible and contentious issue. These powerful painkillers, intended to reduce harm by providing regulated alternatives to illicit fentanyl, are increasingly appearing in the local drug market, sparking debate among healthcare professionals, law enforcement, and community members.

The safer supply approach, developed over the past decade, offers prescribed medications like hydromorphone to people with opioid use disorder to mitigate the risks associated with contaminated and unpredictable street drugs. Initially seen as a harm-reduction strategy, the program expanded across Canada, with British Columbia and Ontario among the provinces adopting it. At its peak, thousands were authorized for safer supply pills, and some clinics even introduced vending machines for dispensing medication.

However, recent investigations and firsthand observations reveal widespread diversion, where prescribed pills are sold or traded on the street for fentanyl or cash. In Hamilton, hydromorphone pills sell for as little as $2 apiece, cheaper than common consumer goods, fueling an open market around addiction-focused pharmacies. Police reports confirm substantial seizures of these pills, alongside fentanyl and methamphetamine, with arrests targeting local dealers connected to addiction medication diversion. Similar situations have been reported in other Ontario cities such as North Bay, London, Ottawa, and Toronto, as well as in Indigenous communities, where diverted pills fetch higher prices.

Critics, including Dr. Lori Regenstreif, a Hamilton addiction specialist, argue that the program has deviated from its original intent. She contends that the easy availability of hydromorphone pills has contributed to ongoing addiction, open drug use, and criminal activity rather than recovery. Dr. Regenstreif, who announced her departure from addiction care in frustration, says the model has become profit-driven, with pharmacies and clinics benefiting financially from high patient volumes through dispensing fees. Pharmacists in Hamilton estimate earnings of up to $40 per day per patient, pointing to a system they describe as transactional and lacking comprehensive patient support.

Conversely, proponents of safer supply assert that it remains a crucial tool for managing opioid dependence amid a lethal drug market. Dr. Chris Cavacuiti, founder of the True North Medical clinics, states that safer supply prescriptions are paired with other addiction treatments and that patients identified as diverting medication are removed from the program. David D’Souza of New Dawn Medical acknowledges challenges such as diversion and “lax prescribing” but argues that with proper regulation, safer supply can pragmatically address current drug realities.

Pharmacies involved in the program emphasize their role in dispensing medications prescribed by physicians and assert that they follow protocols to reduce diversion, including urine drug testing and supervised dosing. However, observations in Hamilton suggest these measures have had limited success in curbing the illicit trade of hydromorphone.

In response to growing concerns, regulatory bodies have introduced stricter guidelines. The College of Physicians and Surgeons of Ontario recently proposed new rules that would require in-person patient assessments before and during safer supply treatment, limit prescriptions to eight weeks, mandate concurrent use of standard opioid agonist therapies, and restrict patients from taking pills off-site. The College of Pharmacists has signaled an intent to tighten opioid dispensing practices, though details remain forthcoming.

Provincial and federal governments have also taken steps, including Ontario’s 2024 Safer Streets, Stronger Communities Act, which prohibits new safer supply programs, and British Columbia’s move toward witnessed dosing protocols to prevent medication removal from clinics.

Despite these efforts, opioid overdose deaths remain high. Hamilton alone recorded 165 suspected opioid overdose fatalities last year, highlighting the ongoing public health crisis. While safer supply programs were designed to reduce harm, the complex realities of diversion, addiction, and economic incentives have raised questions about their long-term efficacy and management. Stakeholders continue to seek a balance between accessible treatment options and measures to prevent unintended consequences affecting communities across Ontario and Canada.