Hydromorphone pills prescribed under the name Dilaudid and known informally as ‘dillies’. They are meant to treat severe pain but have become part of the street drug trade in such places as Hamilton.Sammy Kogan/The Globe and Mail
One hot morning this summer, a group of weary-looking men and women gathered outside the door of a Hamilton pharmacy, waiting for opening time. Just before 9, they started filing through the door to collect the medicines they take for their various addictions. The meds are designed to help them fend off the agony of withdrawal and perhaps even get on the road to recovery.
But within minutes of emerging, one of them, a bearded man in a baseball cap, was emptying his bottle of pills into the palm of another guy, who in return gave him a small handful of a yellowish powder: fentanyl, the potent opioid that causes most drug overdoses.
Transactions like this are commonplace on the streets of Hamilton, so routine that those involved hardly bother to conceal them. This one took place just around the corner from the pharmacy on James Street South, a busy avenue in the heart of the city. The two men exchanged their drugs right in front of me, after I explained who I was and what I was writing about.
The pills were a potent painkiller called hydromorphone. Sold under the commercial name Dilaudid, they are normally used to treat severe pain from cancer, bone fractures or burns.
About a decade ago, some doctors began prescribing them to people with addictions. They reasoned that, with fentanyl flooding the streets, it was safer for patients to satisfy their need with a regulated, prescription medication than a dangerous, illegal drug. Health authorities sanctioned the practice, which became known as safe supply or safer supply.
Before long, though, evidence started to mount that many patients were selling or exchanging the pills, which became popular street drugs in their own right.
In 2021, Hamilton police seized a total of just eight hydromorphone pills. Last year, they seized 1,639. The price has dropped as the supply has increased, until a pill cost less than a can of beer.
Authorities eventually woke up to the problem – known as drug “diversion” – and governments began imposing more controls. But in Ontario at least, safer supply continued to thrive.
A group of 36 alarmed physicians wrote to the Ontario government in July demanding action. One of them, Lori Regenstreif, 63, used to work at a clinic just a few steps away from the James Street pharmacy where the pills-for-powder trade happened. She told me her “blood boils” over what the mass dispensing of safer-supply drugs is doing to her patients.
Hamilton addiction physician Lori Regenstreif says safer supply policies have promoted harm, not reduced it.Sammy Kogan/The Globe and Mail
Because hydromorphone pills are so easy to get, some of them are falling back into using street drugs after years of stability on the standard addiction medicines she prescribes.
“You are turning people into criminals instead of patients,” she says. “They’re trying to move forward, and you’re pulling them back in.”
With doctors like her raising a fuss and the media asking more and more questions, regulators began moving this week to further tighten the rules on safer supply. But not before the program caused what she calls “horrible” damage in cities like Hamilton.
Dr. Regenstreif took me on a tour of its downtown, pointing out the addiction pharmacies that dot the city and the struggling people who congregate outside them. Over the next few weeks, I spoke with doctors, pharmacists, addiction experts, police, community leaders and drug users on the streets.
What emerged was a picture of a well-intentioned policy gone wildly off course. Though federally funded clinics supplying safer-supply drugs closed down, and the provincial government banned new ones, individual doctors kept prescribing large quantities of hydromorphone pills.
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A network of pharmacies and clinics sprang up to distribute them. Taking advantage of a billing system that rewards them for the heavy traffic they get from addiction medicine, they collect fees from the health system and send their customers out the door with bottles of highly addictive medicines, which then make their way into the street-drug market.
The spread of the pills echoes the origins of the opioids crisis, which began with the mass prescribing of addictive pain pills. Ontario neighbourhoods from North Bay to downtown Toronto are coping with the side effects, which include open drug use and dealing. Dr. Regenstreif says she is seeing more and more young people turning to the pills, some of them in their early teens. Indigenous communities are seeing more of them, too.
A Hamilton police cruiser passes a downtown pharmacy bearing a True North addiction program sign in late July.Sammy Kogan/The Globe and Mail
Safer supply sprang from the best of motives. When drug overdoses started soaring a decade ago, advocates argued that we should treat the opioids crisis as a health, not a crime, problem.
To reduce the spread of diseases such as AIDS and hepatitis C, they handed out clean needles. To reduce the toll of overdoses, they offered people supervised places to take their drugs, with trained staff on hand to revive them in case they collapsed.
Harm reduction was the goal and safer supply was the next step. At the program’s peak, 5,000 people were approved for the drugs in British Columbia, ground zero of the opioid crisis. B.C. even introduced vending machines where selected users could get their pills.
From the start of Canada’s safer-supply experiment, though, many patients were selling the pills to give themselves some pocket money or to buy more powerful drugs. In London, Ont., police said the number of prescription hydromorphone pills they were discovering in drug busts had soared from 1,000 in 2019 to 30,000 in 2023.
In Prince George, B.C., police seized 10,000 prescription pills in a single raid in 2024. They said safer-supply drugs were being trafficked by organized criminals and deployed by drug users “as a form of currency to purchase more potent, illicit street drugs.”
A series of articles in the National Post shone a spotlight on the issue. The pharmacies dispensing the pills began coming under scrutiny. A Globe and Mail investigation in 2024 found that some B.C. pharmacies were paying prohibited cash incentives to patients so that they would go to those pharmacies to get their prescriptions filled.
A leaked B.C. Ministry of Health document last year confirmed the practice, saying that more than 60 pharmacies were being investigated for offering kickbacks. It also said that a “significant portion” of prescription opioids are sold – trafficked provincially, nationally and internationally.
As a result, since the end of 2025 British Columbia has been prohibiting most safer-supply patients from taking their addiction medications out of the pharmacy, insisting they take the meds on site, under observation – a system known as “witnessed dosing.” Meanwhile, the federal government quietly halted its funding for safer-supply programs last year. In 2024 the Ontario government brought in a law, the Safer Streets, Stronger Communities Act, that bars new safer-supply programs.
But Canadian doctors have wide latitude to prescribe drugs as they see fit, if they believe their patients will benefit from them. Many have continued to approve daily doses of hydromorphone pills to patients with serious addictions.
“There is no way anyone can tell me this is harm reduction,” Dr. Regenstreif said. “It is harm promotion.”
The daughter of a Winnipeg city planner, she studied genetics and molecular biology at university, then went into medicine. She moved to Hamilton in 2004, started treating the homeless and the mentally ill and gravitated to addiction treatment.
I think there is a level of patient care that is missing. It’s very transactional.
— Priya Sandhu, Hamilton pharmacist
She has seen wave upon deadly wave of the drug crisis roll over Hamilton since, but nothing has left her as discouraged as the chaos wrought by safer supply. In the last few years, she says, the clinics and pharmacies offering the program have spread “like wildfire.”
The facilities can be found everywhere from Niagara Falls to the Toronto suburb of Pickering to Elliot Lake in Northern Ontario.
True North Medical has more than 100 addiction-medicine clinics, from Red Lake in the northwest of the province to Kingston in the southeast. Arrow Medical, established in 2023, offers “urgent, compassionate, evidence-based care for people living with opioid use disorder, without judgment, barriers or delay.” It has 11 locations around Southern Ontario, as well as a virtual clinic.
The James Street pharmacy in Hamilton, Wellkare, offers “fast, friendly” service and short wait times. “We are accepting new patients!” an ad on the outside wall says.
Wellkare is one pharmacy that takes urine samples from patients to ensure traces of prescribed hydromorphone show up in their system.Sammy Kogan/The Globe and Mail
Visitors can come out of the door with their pills in minutes. Many pharmacies have doctors on site to write prescriptions. If a doctor is not there, clients can often talk to one by video.
Hamilton pharmacist Priya Sandhu says such outfits have discovered that specializing in addiction medicines can be a money maker. Many of their clients are on multiple medications. Along with hydromorphone, they might be receiving addiction meds such as methadone, Suboxone and Kadian, as well as drugs for anxiety, insomnia, infections and high blood pressure. The pharmacies can charge dispensing fees for each, plus another charge for observing the taking of the drugs, if that is required.
Ms. Sandhu figures they can make $40 a day off some customers. That means that, in theory, a pharmacy could earn nearly $15,000 a year from a single person.
“It’s a great business model,” she says. But “I think there is a level of patient care that is missing. It’s very transactional.”
Defenders of safer supply insist it is a vital service. Arrow Medical’s founder, Joshua Fletcher, says traditional addiction meds such as methadone and Suboxone may calm patients’ drug cravings but they don’t provide the high that some of them seek. Better that they should get it from fast-acting hydromorphone pills than street fentanyl laced with dangerous additives, says Dr. Fletcher, who is affiliated with North York General, a Toronto hospital.
The founder of True North, addiction doctor and University of Toronto professor Chris Cavacuiti, told me by e-mail that his clinics prescribe safer-supply pills only in combination with more standard addiction meds and that “any patient identified as diverting medication is discontinued from the program.” He said the program’s aim is “to reduce reliance on street drugs and keep patients connected to health care providers.”
David D’Souza, the founder of another chain, New Dawn Medical, acknowledges that diversion and “lax prescribing” happens. But in an Aug. 27 paper for the Macdonald-Laurier Institute, an Ottawa think tank, he wrote that safer supply “properly targeted and rigorously regulated, can be a pragmatic response to the new realities of today’s illicit-drug market.”
The pharmacies, too, defend their practices. They stress their job is to dispense addiction medications, not prescribe them. That is up to the doctors.
The pharmacies also say they have strict protocols in place to prevent diversion, such as taking urine samples from patients to make sure they have traces of the prescribed drug in their bodies and requiring them to take at least some of their meds in front of pharmacy staff.
Staff at the Wellkare pharmacy showed me the small washroom where patients go to produce a sample. It has a video camera inside to discourage them from tampering with their samples. A sign warns visitors it is there. The owner declined to speak to me on the record.
None of these measures seem to do much to prevent the buying and selling of the pills. I visited four different Hamilton pharmacies over several days this summer and often found people waiting outside to buy hydromorphone pills. They had no problem finding sellers.
Downtown Hamilton from above.Sammy Kogan/The Globe and Mail
A steady stream of people came out of the pharmacies, holding white plastic bags containing their meds. Some told me they would take only one or two of their pills so that the drug showed up in their urine test at the pharmacy, but trade the rest for fentanyl or sell them for cash.
Jesse Steingart, 44, said pill selling and trading is a fact of life in Hamilton. He used to sell his hydromorphone to get fentanyl “because that’s a hard drug to afford.” Now, he says he sells them just once or twice a week, “whether it’s to get laundry done or to get a pizza in my stomach.” With the pills in his pocket, “it’s just inevitable.”
Joshua Gordyn told me he sells or trades the pills he gets daily from his pharmacy. The eight-milligram pills go for about $2 on the street in Hamilton – more in communities where they are less common. Mr. Gordyn said he could get $10 a pill if he took them to a nearby Indigenous reserve, Six Nations of the Grand River.
Police there confirm that outsiders bring pills to the reserve. Detective Sergeant Rob Monteforte of the Six Nations drug squad said that, in a bust last year, they seized more than 1,000 from suspected Toronto-area traffickers.
Locals on safer supply sometimes sell their meds, too, he said. If police find a pill bottle with a name on it, they call the prescribing doctor and ask him or her to cut the patient off.
Brett Stubbs works as a security guard at a church soup kitchen across the street from a well-known Hamilton addiction pharmacy. He told me that, once, when he was reviving someone who had suffered an overdose, he had to cut open the man’s pants to give him a life-saving injection. About 70 pills tumbled out of his pockets.
“It’s so blatant, it’s frightening,” said Regan Anderson, head of Wayside House of Hamilton, a live-in addiction-treatment centre. He sees people using and dealing pills right on the steps of a nearby pharmacy.
It would be one thing, he told me, if the array of drugs that people get at such places was helping them get better. Instead, “they’re staying unwell, and to the point of being basically publicly intoxicated or paralyzed on the street, without a real strong road map to change or to recovery.”
Dr. Regenstreif has done lots of work with youth who have run afoul of the law. They told her hydromorphone pills are cheap and easy to find. For those with limited experience using opioids, and thus a low tolerance, they pose a serious threat.
The eight-milligram Dilaudid pills, or D8s, are so strong they are not often used in ordinary medicine. Yet some safer-supply patients are walking out of the pharmacy door with 10 or 20 D8s at a time.
Though the death rate from opioids has been trending downward in Canada, 165 people died in Hamilton last year of suspected overdoses, a staggering number for the Southern Ontario city of about half a million. The victims of this 21st-century plague can be seen all over downtown, passed out of the sidewalk or bent over, swaying, in the half-conscious state that comes from consuming opioid drugs.
Critics of safer supply like Dr. Regenstreif say the practice is contributing to the problem, by giving drug users a marketable commodity that produces ready cash on a daily basis – just what they need to support their habit.
Hamilton police say that although fentanyl is still the main threat, they know prescription pills are being sold on the streets. This July, they carried out a two-week investigation of suspected drug dealing around a local pharmacy. They arrested nine people and seized 284 hydromorphone pills, along with quantities of fentanyl, methamphetamine and other drugs.
Police officers search a suspect’s belongings during an arrest in July in Hamilton.Sammy Kogan/The Globe and Mail
Hamilton is far from the only Ontario city struggling with the fallout from safer supply. In North Bay, drug-squad officer Brad Reaume said the Northern Ontario city was blindsided by the spread of diverted safer-supply drugs, hit when “we had our backs turned.” He said some pills end up in Indigenous communities farther north, where they are less numerous and fetch a higher price.
In London, downtown business owners have complained about open drug use, vandalism and other problems around pharmacies that specialize in addiction meds. In April, city council voted unanimously to ask the provincial government to review what one councillor, David Ferreira, called the “variety-store” model of dispensing them.
In Ottawa, merchants and residents complained about similar issues around a clinic in the Chinatown district. “It’s creating a very visible, very active and I would say dangerous open-air drug market,” city councillor Ariel Troster said. “It’s just the absolute Wild West with these private clinics.”
Even at one of Toronto’s trendiest intersections, Dundas and Ossington, residents have been complaining on social media about open drug use outside an addiction pharmacy. In a scene much like that outside the Hamilton pharmacies, a collection of people gather in the morning to wait for it to open.
Province-wide, the Ontario Provincial Police say they seized 12 times as much hydromorphone in 2025 as they did in 2022, though they cannot say for certain how much came from diverted safer supply.
Regulators are aware of the diversion issue.
Lily Barnes, press secretary for Ontario Health Minister Sylvia Jones, said that “to be absolutely clear, our government does not and will never support the distribution of illegal drugs,” though it was up to the bodies that oversee pharmacists and doctors to make sure their members were following the rules about opioids.
The Ontario College of Pharmacists said it was looking into complaints about certain addiction pharmacies and “reviewing standards, policies, guidelines and other requirements.”
Inside Wellkare pharmacy, patients are greeted by harm reduction signs and information.Sammy Kogan/The Globe and Mail
The College of Physicians and Surgeons of Ontario brought in new rules this May requiring doctors to see patients in person (rather than just online) before starting them on safer-supply drugs, to offer them other addiction medicines first and to assess patients in person every three months.
Then, this week, it went much further. It said it would direct doctors not to prescribe safer supply except in combination with other more standard addiction drugs; to limit prescribing of the drugs to eight weeks; and to require patients on safer supply to undergo “a comprehensive in-person clinical assessment” at least monthly. Most significantly, it would direct doctors to specify that patients should not take their pills out of the pharmacy or clinic.
The new directive will go to the college’s directors for approval on Oct. 13 and, provided they give the green light, take effect on Nov. 16. “These amendments would not prohibit safer supply prescribing,” said Laura Zilke, a spokeswoman for the college. “Rather, they would strengthen clinical oversight of prescribing, while minimizing the risks associated with diversion and supporting a short transition for patients from safer supply to OAT,” she said, referring to opioid agonist therapy, the blanket term for treatment with standard addiction meds.
The college of pharmacists is also considering change. Without specifying what it would do, its board voted Tuesday to make it a priority “to strengthen pharmacy practice related to opioid dispensing for safe supply.”
The change of tack comes too late for Dr. Regenstreif. In an emotional open letter in August, she said she was leaving her addiction practice after 15 years, fed up with “a business model bent on making a profit for doctors and pharmacies by keeping people on the addictive opioids that got them into trouble in the first place.”
Some of her patients cried when she told them, but she said that, as much as she cared for them, she could not keep working in a system “that has lost sight of recovery as a goal.”