Ontario is moving backward in its opioid harm-reduction policies, restricting access to drugs that help users fight addiction. Regulators argue that these restrictions will reduce diversion—the sale, sharing, or transfer of prescribed drugs to others. However, restricting access to pharmaceutical opioids risks driving patients back to the dangerous illicit market these programs seek to help them avoid.
On Oct. 13, Ontario’s medical regulator, the College of Physicians and Surgeons, approved new restrictions on what’s referred to as “safer supply” opioid prescribing—providing access to pharmaceutical drugs of known strength and composition to people who would otherwise obtain them from the black market. Physicians must prescribe safer-supply opioids only in conjunction with opioid-agonist therapy—long-acting opioids that reduce craving and withdrawal symptoms, such as methadone or buprenorphine. They must prohibit take-home doses and assess patients in person at least once a month. The regulator expects physicians to comply by Nov. 16.
Ontario’s first formal safer-opioid-supply program began in London, Ontario, in 2016. Programs have typically prescribed immediate-release hydromorphone—sold under the brand name Dilaudid—which patients collect daily from pharmacies and take home. Clinicians often also prescribe a longer-acting opioid, e.g., methadone, and programs provide primary care and social support. The goal is to reduce exposure to unpredictable street drugs without requiring patients to abstain from opioids.
Ontario has long allowed patients with opioid use disorder to obtain it from community pharmacies, including take-home doses when clinically appropriate. Canada allows physicians to prescribe methadone through community pharmacies, whereas the United States generally restricts access to specialized opioid treatment programs regulated by the Drug Enforcement Administration.
Ontario’s new safer-supply restrictions deny clinicians comparable discretion. Its revised prescribing policy requires physicians to mark these prescriptions “safer supply” and “no carries”—meaning no take-home doses. The regulator explicitly intends this requirement to ensure that all safer-supply medication is consumed under supervision. This restriction applies only to safer-supply prescriptions; it does not impose a blanket prohibition on take-home methadone or buprenorphine prescribed as opioid-agonist therapy. Thus, under the new rules, a patient receiving both methadone and hydromorphone could take the methadone home while having to appear for supervised consumption of the hydromorphone.
Ontario permits clinicians to individualize take-home methadone decisions, yet it now denies them comparable discretion in prescribing safer-supply medications. The Ontario College of Pharmacists has even highlighted research linking expanded access to take-home methadone with lower risks of overdose and treatment interruption or discontinuation. Although these findings do not establish that take-home doses are appropriate for every safer-supply patient, they reinforce the need to weigh the dangers of restricting access against the risks of diversion.
Prohibiting take-home doses creates practical barriers. Patients must arrange transportation and fit supervised consumption into their daily schedules. Rural residents may live far from a participating pharmacy. Employed patients may struggle to attend during operating hours without missing work. Caregiving responsibilities, disabilities, and unreliable transportation can make repeated visits even harder. A prescription that patients cannot obtain in practice offers little protection.
The rationale for safer supply draws on lessons from the U.S. crackdown on prescription pain pills, as I explain in Your Body, Your Health Care. For example, many states operate prescription drug monitoring programs (PDMPs) that track and trend prescriptions and impose state statutory limits on the number and dose of opioids that doctors may prescribe, based on the belief that over-prescribing opioids was the main cause of the overdose crisis. In response, many nonmedical opioid users migrated to illicit heroin and then to fentanyl as pharmaceutical opioids became harder to obtain. The crackdown also harmed patients receiving legitimate pain treatment.
As I have written previously, some chronic pain patients, cut off from their medications by physicians fearing law-enforcement scrutiny, turned to the illicit market for relief. There, patients and non-medical users alike risk encountering counterfeit pain pills containing fentanyl or other adulterants. Pharmaceutical opioids carry risks, but knowing what is in a drug and its dose makes those risks more predictable.
Research offers encouraging, though incomplete, evidence supporting safer supply. A 2022 study of London’s program found that emergency department visits and hospital admissions declined after patients enrolled in safer supply programs, while those outside of the program saw no significant improvements. A larger 2025 Ontario study associated safer-supply enrollment with fewer hospital-treated opioid poisonings and less health care use.
The researchers also examined a separate comparison group: those who started methadone treatment. Both groups improved. The methadone comparison group had lower poisoning rates, while safer-supply recipients were less likely to discontinue their programs. Because some safer-supply patients also received opioid agonist therapy, these findings should not be read as a comparison of hydromorphone alone against methadone alone.
Both studies were observational as opposed to controlled studies, meaning that many outside factors might have influenced the outcomes. They cannot conclusively separate the effects of pharmaceutical opioids from those of accompanying medical and social services. But these findings support keeping safer supply available as an option while researchers continue to evaluate its benefits and risks. They do not demonstrate that requiring patients to accept opioid-agonist therapy as a condition of receiving safer supply improves outcomes.
The problem of drug diversion deserves attention. Prescribed opioids can reach people for whom clinicians did not prescribe them, including recreational users. But acknowledging that risk does not prove that blanket restrictions will reduce fatal and non-fatal overdoses. Regulators must also consider what happens to patients who can no longer meet the conditions for obtaining their prescriptions. Reducing diversion while driving patients back to illicit fentanyl would hardly constitute a public health success.
The same distinction applies to any mandates that users participate in opioid-agonist therapy. Methadone and buprenorphine can help people manage opioid use disorder and reduce overdose risk. Clinicians should offer these medications and explain their benefits and risks. However, evidence supporting a treatment does not establish that making it compulsory as a condition of another prescription produces better outcomes.
Rather than physically forcing patients to take medication or confining them in treatment facilities, Ontario makes access to safer supply conditional on accepting opioid-agonist therapy. A competent patient who declines that treatment loses access to a pharmaceutical alternative to street fentanyl, even when the prescribing physician considers safer supply appropriate. This regulatory requirement pressures patients to accept treatment they would otherwise refuse and prevents clinicians from tailoring care to their patients’ needs and preferences.
Repeated pharmacy visits may make safer supply impractical for some patients, increasing their reliance on illicit drugs. Researchers will need to assess whether Ontario’s new restrictions lead to that outcome. Regulators should track whether patients remain in care, retain access to pharmaceutical alternatives, and experience more or fewer overdoses.
Ontario still offers patients a pharmaceutical alternative to illicit opioids that U.S. policymakers have yet to permit. U.S. policymakers should consider that harm-reduction approach while preserving the patient choice and clinical discretion Ontario is now curtailing. Clinicians should assess risks on a case-by-case basis, offer treatment voluntarily, and tailor prescribing and supervision to each patient’s circumstances. Regulators should judge restrictions by their effects on overdose rates, access, and retention in care. Counting fewer diverted pills tells us little if the policy leaves more people dependent on an unpredictable illicit market.
Harm reduction starts with helping people reduce the risks they face, even when they decline the treatment others would choose for them. Making that help conditional on accepting the government’s preferred treatment risks defeating its purpose.