The emerging practice of substance replacement therapy
Despite efforts by various societal actors to address the opioid crisis in recent years, fentanyl contamination of street drugs continues to cause many overdose deaths in Canada. Although no scientific studies have demonstrated the effectiveness of this practice in reducing overdoses, safe supply, the distribution of pharmaceutical grade psychoactive substances used on the street through various modalities, is seen as an additional tool to address this epidemic. Last July, the Canadian government issued a call for proposals and investments of $33 million for the development of safe supply programs. This article focuses on the medical component of this emerging practice in the management of opioid use disorders in disaffiliated populations or populations at high risk of overdose: opioid replacement therapy. This approach, in which we adapt treatment goals even further into a harm reduction perspective, attempts to address the needs of people for whom abstinence is not a realistic short-term goal, but who remains at risk of complications and overdose in the current context. The offer of this alternative treatment aims to promote contact between people who use drugs and health and social services, maximize retention in treatment and reduce the risks associated with consumption. Beyond the theoretical reflection, we illustrate through real cases the benefits observed of the medical prescription of safe supply in a low-threshold service for opioid use disorder in south-central Montreal and discuss the clinical and legal issues related to this approach.