I do use Suboxone for some of the patients I look after downtown, but that's a patient autonomy issue. Lots of people don't want to be on Suboxone because they don't necessarily want to stop their drug use entirely. I don't want to stop taking a single shot of whisky on a Saturday night, but I want to use it responsibly. As long as they have capacity and turn down Suboxone, I can't force that treatment on them.
I understand the value of Suboxone because there are some patients who take it and do well on it. If the goal is to get them completely off any opioid, whatever substance they're using, and the patient wants to do that, then I agree with you that we should look at alternatives other than safe supply. However, often the only way to get the patients to trust us, as an infrastructure of people at the front lines looking after patients, is to start them off on Dilaudid and get them into the fold. You have to remember—and as a physician, you know that building trust is crucial—that lots of the patients who end up on the street have substance use disorders and have gone through horrible life journeys where the people they wanted to trust let them down, so for us to develop trust takes time.
I wish I could start everybody on Suboxone and see how they do, but the reality is I can't because of an individual's situation.