Prescribed Safer Supply Programs: Emerging Evidence

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Contents

What is prescribed safer supply?

Objectives and scope of this document

Context

Who can access prescribed safer supply?

What does the evidence show?

Success factors for prescribed safer supply programs

Program challenges

What clients have said about prescribed safer supply

For further information

References cited

About this document

What is prescribed safer supply?

Safe supply refers to regulated pharmaceutical drugs of known content, quantity, quality, and potency that provide the mind/body altering properties of drugs that are currently only available through illegal markets and not available through traditional opioid agonist therapies (CAPUD, 2019).

“[Prescribed] safe opioid supply programs are a promising intervention to address North America’s ongoing overdose crisis by providing people at high risk of fatal overdose an alternative to the toxic drug supply” (Ivsins et al., 2020b)

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Objectives and scope of this document

This document is a brief summary of the current evidence about prescribed safer supply for lay audiences, political briefings, and the media. It draws on findings from peer-reviewed research articles and commentaries, as well as all program evaluation reports that have been published to date.  For a more in-depth review of the evidence, please see ODPRN's Safer Opioid Supply: A Rapid Review of the Evidence.

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Context

The appearance of fentanyl in the unregulated drug supply in recent years has made the illegal drug supply increasingly unpredictable and toxic. As a result, there were 34,455 opioid toxicity related deaths in Canada between January 2016 and September 2022 (Special Advisory Committee, 2022). Fentanyl is overwhelmingly responsible for drug-related deaths in Canada, contributing to 89% of drug-related deaths in Ontario and 86% of drug-related deaths in BC in 2021 (British Columbia Coroners Service, 2023; Gomes, Murray et al., 2022).

Health Canada currently funds 25 pilot programs which use medical models of safer supply. The most common settings for prescribed safer supply are community health settings, such as community health centres and primary care clinics, and onsite pharmacies (Glegg et al., 2022). There are also unfunded programs and individual health care providers who prescribe safe supply. Unsanctioned buyer’s club models are being explored.

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Who can access prescribed safer supply?

Around 5% of adults around the world use illegal drugs, and nearly 90% of them are occasional or recreational users (Schlag, 2020). Anyone who uses opioids procured from the illegal drug supply – either recreationally or routinely – needs access to a safer supply. At this time, safer supply is only accessible through medicalized programs (i.e., “prescribed safer supply”) due to the current legislative and regulatory context in Canada.

However, prescribed safer supply programs have very limited capacity. One program estimated 6000 people in their region would benefit from prescribed safer supply, but they are only able to serve 300 people (McMurchy & Palmer, 2022). Prescribed safer supply programs currently prioritise those who are at the highest risk of death from overdose (Young et al., 2022), who are experiencing serious medical complications from their drug use (Gomes, Kolla, McCormack et al., 2022; Haines, Tefoglou, & O'Byrne, 2022; McMurchy & Palmer, 2022; Selfridge et al., 2020), and who are marginalized from health care services, including traditional opioid agonist therapies (ESCODI, 2022).

“[N]ot all people who use opioids are interested in treatment, nor is conventional treatment suitable for all people who use opioids” (Ivsins et al., 2020a).

Prescribed safer supply programs are not accessible to those who use opioids recreationally. Typical prescribed safer supply inclusion criteria include DSM V defined opioid use disorder and previous unsuccessful experience with methadone, buprenorphine or SROM, or disinterest in methadone, buprenorphine, or SROM  (Hales et al., 2020). Individual prescribed safer supply programs add criteria such as a history of overdose and high risk of overdose, complications related to injection drug use (infections, etc.), and social factors such as being unhoused or precariously housed, being disengaged from health care and social services, or being involved in crime or sex work. Retention rates in prescribed safer supply programs are very high (Atkinson, 2023; McMurchy & Palmer, 2022; Kolla et al., 2022; Haines, Tefoglou, & O'Byrne, 2022;  ESCODI, 2022; Selfridge et al., 2022).

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What does the evidence show?

Initiators of prescribed safer supply in Canada have drawn on the extensive literature on international OAT studies, European Heroin Assisted Treatment (HAT) studies and Canadian iOAT. There are many research and evaluation studies underway. Peer-reviewed scientific studies and evaluations of prescribed safer supply programs show:

  • Prescribed hydromorphone is not contributing to drug-related deaths: Data from coroners in both BC and Ontario have found no link between prescribed hydromorphone and drug-related overdose deaths: “There is no indication that prescribed safe supply is contributing to illicit drug deaths” (British Columbia Coroners Service, 2023). In Ontario, despite the increasing use of immediate-release hydromorphone during the early pandemic period, both the percentage and overall number of hydromorphone-related deaths actually decreased (Gomes, Murray et al., 2022).
  • Reduced risk of death and/or overdose: Both drug-related deaths and deaths from any cause among people receiving prescribed safer supply were rare (Young et al., 2022; Gomes, Kolla, McCormack et al., 2022) and they had fewer overdoses (Atkinson, 2023; Bardwell et al., 2023; ESCODI, 2022; Haines, Tefoglou, & O'Byrne, 2022; Lew et al., 2022; McNeil et al., 2022; Selfridge et al., 2020).
  • Engagement and retention in programs and care: Increased access to health and social services, including primary care, COVID-19 quarantine, OAT, counselling, and housing support; and improved relationships with providers (Atkinson, 2023; Brothers et al., 2022; Haines & O'Byrne, 2023; Haines, Tefoglu, & O'Byrne, 2023; Hong, Brar & Fairbairn, 2022; Kalicum 2023; Kolla et al., 2022; McMurchy & Palmer, 2022; Selfridge et al., 2020; Selfridge et al., 2022).
  • Improvements in physical and mental health: Improved chronic and/or infectious disease management, medication adherence, pain management, sleep, nutrition, and energy level (Haines & O'Byrne, 2023; Kolla et al., 2022; Kolla & Fajber, 2023; Klaire et al., 2022; Ivsins et al., 2021; McMurchy & Palmer, 2022; Haines, Tefoglou, & O'Byrne, 2022; Selfridge et al., 2020; Gomes, Kolla, McCormack et al., 2022).
  • Fewer emergency department visits and hospitalizations: Significantly fewer Emergency Department visits and inpatient hospital admissions after entering the safer supply program compared to the year prior, with no change in these outcomes among a matched group unexposed to safer supply in the same time period (Gomes, Kolla, McCormack et al., 2022).
  • Decrease in hospitalizations for infectious complications: In the year after beginning a safer supply program, there was a significant decrease in hospitalizations for infectious complications among safer supply clients; hospitalizations dropped from 26 in the year before program entry to 13 in the year following entry to a safer supply program (Gomes, Kolla, McCormack et al., 2022). There was no change in these outcomes among a matched group unexposed to safer supply in the same time period (Gomes, Kolla, McCormack et al., 2022). Increasing infection rates overall among people who inject drugs since 2016 align with the shifts in the unregulated drug market towards nonprescription fentanyl (Gomes, Kitchen et al., 2021). Many clients credited safer supply programs for reducing the frequency at which they injected, providing an alternative to injecting fentanyl, and allowing them to stop injecting by providing safer supply medications that are dosed properly and can be taken orally (Gagnon et al., 2023).
  • Reduced use of drugs from the unregulated street supply (thereby reducing overdose risk) and, in some cases, reducing drug use overall or ceasing the use of drugs by injection (Atkinson, 2023; Bardwell et al., 2023; Haines, Tefoglu, & O'Byrne, 2023; Kalicum 2023; Kolla et al., 2022; Kolla & Fajber, 2023; McNeil et al., 2022; ESCODI, 2022; Haines, Tefoglou, & O'Byrne, 2022; Selfridge et al., 2020; Ivsins et al., 2020b).
  • Improved control over drug use: The flexibility and autonomy of prescribed safer supply programs, coupled with certainty about dose strength, enabled participants to avoid withdrawal symptoms and manage pain (Bardwell et al., 2023; Haines & O'Byrne, 2023; McNeil et al., 2022; Ivsins et al., 2020b, Selfridge et al., 2020).
  • Improvements in social well-being and stability: Economic improvements (Ivsins et al., 2020b; Selfridge et al., 2020;  Haines, Tefoglou, & O'Byrne, 2022), reduced inequities stemming from the intersection of drug use and social inequality (Ivsins et al., 2021), better control over time leading to engagement in employment, hobbies, and interests (Atkinson, 2023; McMurchy & Palmer, 2022; Haines, Tefoglou, & O'Byrne, 2022), decreased involvement in and exposure to violence, criminal activities and legal issues (Haines & O'Byrne, 2023; Kolla et al., 2022; McMurchy & Palmer, 2022; Haines, Tefoglou, & O'Byrne, 2022; Ivsins et al., 2020b), improved general social stability (ESCODI, 2022), improved housing access (Atkinson, 2023; Haines, Tefoglou, & O'Byrne, 2022) and improved relationships with family members and friends (Kolla et al., 2022; McMurchy & Palmer, 2022; Selfridge et al., 2020 ).
  • Decline in health care costs: Prescribed safer supply program participants had lower costs for healthcare not related to primary care or outpatient medications in the year after program initiation, with no corresponding change observed in a matched group of individuals who did not access the program (Gomes, Kolla, McCormack et al., 2022).

Overall, the emerging evidence supports prescribed safer supply as a critical option on the continuum of treatment and harm reduction services for people who have not been successful with traditional approaches to care and who are at high risk of drug poisoning.

Research involving health administrative data provides a measure of reassurance regarding the safety of safer supply programs: Gomes, Kolla et al. (2022) found a significant decline in health services utilization among clients on prescribed safer supply alongside no change in infection rates, opioid-related deaths, or all-cause mortality.

More research is needed, including longitudinal studies to monitor changes in access to and delivery of prescribed safer supply in the country, determine which models are most effective, and identify the impact of programs on the health, well-being and safety of  individuals and communities.

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Success factors for prescribed safer supply programs

  • Comprehensive ancillary services: populations served by prescribed safer supply benefit from health and social supports delivered alongside safer supply (Gomes, Kolla, McCormack et al., 2022; Haines, Tefoglou, & O'Byrne, 2022; Kolla & Fajber, 2023; Mansoor et al., 2023; Selfridge et al., 2020).

“Safer supply is just one part of more equitable access to health and wellbeing. Providing safer supply is a harm reduction entry-point to addressing other basic needs and priorities. Secure housing, livable income, access to health care, and a caring community to feel a part of, are all necessities." (McMurchy & Palmer, 2022)

  • Program flexibility (Bardwell et al., 2023; Ivsins et al., 2020b; Haines, Tefoglou, & O'Byrne, 2022; McMurchy & Palmer, 2022) and adaptability (Glegg et al., 2022; McMurchy & Palmer, 2022)
  • Low-barrier, client-centred design (Ivsins et al., 2020b; McMurchy & Palmer, 2022; Ranger et al., 2021)
  • Ability to provide pharmaceuticals that meet people’s needs (dose, formulation, type) (Giang et al., 2023; Kalicum 2023; Ranger et al., 2021; Selfridge et al., 2022)
  • Community-centred approach, foregrounding the leadership and engagement of people who use drugs (Ranger et al., 2021; Haines & O'Byrne, 2023) and considering the perspectives of professional stakeholders (Foreman-Mackey et al., 2022).

“The overarching approach to providing safer supply services should be grounded in the community and centred on input from people with lived experience in program co-design, planning and implementation” (McMurchy & Palmer, 2022)

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Program challenges

Safer supply programs and models do have challenges. Current models are time-consuming for participants, require extensive staffing, and cannot provide safer supply medications of the kind (e.g. smokable formulations or stimulants) and strength that people prefer or require (Foreman-Mackey et al., 2022; Giang et al., 2023; Haines & O'Byrne, 2023; Kalicum 2023; Kolla et al., 2022; Kolla & Fajber, 2023; Mansoor et al., 2023; McMurchy & Palmer, 2022). Current regulations and policies are limiting and conventional addiction medicine has not generally been supportive (Foreman-Mackey et al., 2022; Kalicum 2023; Kolla et al., 2022; Mansoor et al., 2023; McMurchy & Palmer, 2022) .

Diversion (the sharing, exchanging, and selling of prescribed safer supply drugs) is reflective of unmet individual and community needs. It is not unique to safer supply medications (Haines & O'Byrne, 2023). It can be understood as a harm reduction practice rooted in mutual aid that saves lives and improves quality of life. It has social and structural contexts and motivators: barriers to medicalized safer supply programs often necessitate diversion practices. Programs address diversion through providing comprehensive care, urine drug screens, patient contracts, and observed doses. According to coroners reports in Ontario and BC, there is no evidence that hydromorphone is contributing to drug related deaths (British Columbia Coroners Service, 2023; Gomes, Murray et al., 2022). For more information, please see Reframing Diversion for Health Care Providers: Frequently Asked Questions (NSSCoP, 2022).

Next steps for safer supply include developing and exploring other models, including nonmedical models and supports for individual prescribers, and moving towards decriminalization and regulation.

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What clients have said about prescribed safer supply

Quotes from prescribed safer supply program evaluations:

  • "Once I was a client of this program, I knew I was safe." (Haines, Tefoglou & O’Byrne, 2022)
  • "I haven't had an overdose since I've been on the program. I had a couple shortly before where I had to be defibrillated." (Atkinson, 2023)
  • "It's been a miracle...it's made me love life. It's given me a reason to get out of bed. It's changed my whole perspective on life." (Haines, Tefoglou & O’Byrne, 2022)
  • "I'm not in the hospital so much getting my abscesses drained, because I'm actually swallowing my medication. I find it more effective." (Atkinson, 2023)
  • "It makes me actually happy to be part of it, because it gave me the opportunity to feel like I have a family." (Haines, Tefoglou & O’Byrne, 2022)
  • “I don’t use street drugs anymore. I never thought it was possible.” (McMurchy & Palmer, 2022)
  • The best part is the freedom. It just gives me a lot of freedom, more freedom than I had before, more options than I had before. That's a beautiful thing. And the support that comes around with it." (Atkinson, 2023)
  • "There are people that are on this program that started off in tents and now they've actually got themselves to a position where they're renting an apartment. That doesn't happen without safer supply." (Haines, Tefoglou & O’Byrne, 2022)
  • “It’s done nothing but been good for me. I’ve got my family, I’ve been housed for [the] first time in 10 years, I’m volunteering at [organization]. I’m doing things that I just, didn’t care about, had no motivation to before.” (Kolla et al., 2022)
  • "I got a job, got stable housing, stopped using, connected with kids again, I'm in school." (Atkinson, 2023)
  • “It’s not yet perfect, but it saved my life" (McMurchy & Palmer, 2022)

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For further information

National Safer Supply Community of Practice resources

Reports

Protocols and Guiding Documents

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References cited

Atkinson, K. (2023). Parkdale Queen West Community Health Centre Safer Opioid Supply Program Evaluation Report. Toronto, Canada. https://pqwchc.org/wp-content/uploads/PQWCHC_SOS_EvaluationReport-Final… ➤ Surveys, semi-structured interviews and EMR data.

Bardwell, G., Ivsins, A., Mansoor, M., Nolan, S., & Kerr, T.  (2023). Safer opioid supply via a biometric dispensing machine: a qualitative study of barriers, facilitators and associated outcomes. Canadian Medical Association Journal, 195(19) e668-e676. https://doi.org/10.1503/cmaj.221550 ➤ Semi-structured interviews with 46 MySafe program participants.

British Columbia Coroners Service. (2023). Illicit Drug Toxicity Deaths in BC: January 1, 2012 to December 31, 2022. Government of British Columbia. https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-div…

Brothers, T.D., Leaman, M., Bonn, M., Lewer, D., Atkinson, J., Fraser, J., Gillis, A., Gniewek, M., Hawker, L., Hayman, H., Jorna, P., Martell, D., O'Donnell, T., Rivers-Bowerman, H., & Genge, L. (2022). Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug and Alcohol Dependence 235, Article 109440. https://doi.org/10.1016/j.drugalcdep.2022.109440 ➤ Reviewed medical records of all 77 COVID-19 isolation hotel shelter residents during May 2021.

Canadian Association of People Who Use Drugs. (2019). Safe Supply Concept Document. Canada: Canadian Association of People Who Use Drugs.
https://zenodo.org/record/5637607#.YwUxcezML0p

Drug User Liberation Front & Vancouver Area Network of Drug Users. (2023). The DULF and VANDU Evaluative Compassion Club: A Strategic Framework for Preventing Overdose Deaths due to the Unpredictable Illicit Drug Supply, Revision 3.2. British Columbia: DULF and VANDU. https://www.dulf.ca/framework

L'Équipe de soutien clinique et organisationnel en dépendance et itinérance (ESCODI). (2022). A First Survey on Safer Supply in Québec. Québec: L'Équipe de soutien clinique et organisationnel en dépendance et itinérance. https://dependanceitinerance.ca/wp-content/uploads/2022/11/Safer-Supply… ➤ Survey of 20 prescribers and 16 pharmacists in Québec.

Foreman-Mackey, A., Pauly, B., Ivsins, A., Urbanoski, K., Mansoor, M., & Bardwell, G. (2022). Moving towards a continuum of safer supply options for people who use drugs: A qualitative study exploring national perspectives on safer supply among professional stakeholders in Canada. Substance Abuse Treatment, Prevention, and Policy (17): Article 66. https://doi.org/10.1186/s13011-022-00494-y ➤ 17 qualitative interviews.

Gagnon, M., Rudzinski, K., Guta, A., Schmidt, R.A., Kryszajtys, D.T., Kolla, G., & Strike, C. (2023). Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduction Journal 20, Article 81. https://doi.org/10.1186/s12954-023-00817-7

Giang, K., Charlesworth, R., Thulien, M., Mulholland, A., Barker, B., Brar, R., Pauly, B., & Fast, D. (2023). Risk mitigation guidance and safer supply prescribing among young people who use drugs in the context of COVID-19 and overdose emergencies. International Journal of Drug Policy 115, Article 104023. https://doi.org/10.1016/j.drugpo.2023.104023 ➤ Interviews with 30 young people who use drugs and 10 addiction medicine physicians

Glegg, S., McCrae, K., Kolla, G., Touesnard, N., Turnbull, J., Brothers, T.D., Brar, R., Sutherland, C., Le Foll, B., Sereda, A., Goyer, M.-È., Rai, N., Bernstein, S., & Fairbairn, N. (2022). “COVID just kind of opened a can of whoop-ass”: The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada. International Journal of Drug Policy 106, Article 103742. https://doi.org/10.1016/j.drugpo.2022.103742 ➤ Mixed methods national environmental scan at two time points.

Gomes, T., Kitchen, S. A., Tailor, L., Men, S., Murray, R., Bayoumi, A. M., Campbell, T., Young, S., & Kolla, G. (2021). Trends in Hospitalizations for Serious Infections Among People With Opioid Use Disorder in Ontario, Canada. Journal of Addiction Medicine, 16(4), 433-439. https://doi.org/10.1097/ADM.0000000000000928 ➤ Analysis of inpatient hospitalizations for serious infections from 2013-2019.

Gomes, T., Kolla, G., McCormack, D., Sereda, A., Kitchen, S., & Antoniou, T. (2022). Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario. Canadian Medical Association Journal, 194(36), e1233-e1242. https://doi.org/10.1503/cmaj.220892 ➤ Interrupted time series analysis with 82 exposed individuals demographically and clinically matched to 303 unexposed individuals.

Gomes, T., Murray, R., Kolla, G., Leece, P., Kitchen, S., Campbell, T., Besharah, J., Cahill, T., Garg, R., Iacono, A., Munro, C., Nunez, E., Robertson, L., Shearer, D., Singh, S., Toner, L., & Watford, J.. on behalf of the Ontario Drug Policy Research Network, Office of the Chief Coroner for Ontario and Ontario Agency for Health Protection and Promotion (Public Health Ontario). (2022) Patterns of medication and healthcare use among people who died of an opioid-related toxicity during the COVID-19 pandemic in Ontario. Toronto, ON: Ontario Drug Policy Research Network; 2022. https://odprn.ca/research/publications/opioid-related-deaths-and-health…

Haines, M., & O'Byrne, P. (2023). Safer opioid supply: qualitative program evaluation. Harm Reduction Journal, 20(53). https://doi.org/10.1186/s12954-023-00776-z ➤ Semi-structured interviews and surveys with 30 participants

Haines, M., Tefoglu, A., & O’Byrne, P. (2022). Safer Supply Ottawa Evaluation: Fall 2022 Report. Ottawa, Canada. https://safersupplyottawa.com/research/ ➤ Chart review for all safer supply program participants (n=425) plus a qualitative study including interviews (n=30) and surveys

Haines, M., Tefoglu, A., & O’Byrne, P. (2023). Safer Supply Ottawa Evaluation: Spring 2023 Report. Ottawa, Canada. https://safersupplyottawa.com/research/ ➤ Chart review for all safer supply program participants (n=460) and stimulant safer supply participants (n=28)

Hales, J., Kolla, G., Man, T., O'Reilly, E., Rai, N., & Sereda, A. (2020) Safer Opioid Supply Programs (SOS): A Harm Reduction Informed Guiding Document for Primary Care Teams-April 2020 update. Canada. https://bit.ly/3dR3b8m

Health Canada. (2019). Toolkit for Substance Use and Addictions Program Applicants: Stream 2 - Increasing Access to Pharmaceutical-Grade Medications. Government of Canada. https://drive.google.com/file/d/1gOxsb6LNVmrEyeU3CBwr7XPYSPHG9S8L/view

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Hong, R.H., Brar, R., & Fairbairn, N. (2022). Supporting Self-isolation for COVID-19 With “Risk Mitigation” Prescribing and Housing Supports for People Who Use Drugs: A Case Report. Journal of Addiction Medicine 16(5), 592-594. https://doi.org/10.1097/ADM.0000000000000954 ➤ Case study.

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Kalicum, J. (2023). “We need all the help we can get”: A Qualitative Examination of Service Provider Perspectives on the Barriers and Facilitators to the Implementation of The Emergency Risk Mitigation Guidelines [Master’s thesis, University of Victoria]. https://dspace.library.uvic.ca/bitstream/handle/1828/15052/Kalicum_Jere… ➤ 24 qualitative interviews.

Kasper, K. J., Manoharan, I., Hallam, B., Coleman, C. E., Koivu, S. L.,  & Weir, M. A. (2019). A controlled-release oral opioid supports S. aureus survival in injection drug preparation equipment and may increase bacteremia and endocarditis risk. PloS ONE 14(8): e0219777. https://doi.org/10.1371/journal.pone.0219777 ➤ Examined used injection drug preparation equipment (n=87).

Klaire, S., Sutherland, C., Kerr, T., & Kennedy, M. C. (2022). A low-barrier, flexible safe supply program to prevent deaths from overdose. Canadian Medical Association Journal, 194(19), e674-e676. https://doi.org/10.1503/cmaj.211515 ➤ Case study.

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Lew, B., Bodkin, C., Lennox, R., O'Shea, T., Wiwcharuk, G. & Turner, S. (2022). The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study. Harm Reduction Journal 19, Article 29. https://doi.org/10.1186/s12954-022-00614-8 ➤ Case study

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About this document

This evidence brief was developed by the National Safer Supply Community of Practice (NSS-CoP). Please visit https://www.nss-aps.ca/ to learn more.
 
Contributors: Rebecca Penn (concept, writing, editing), Robyn Kalda (writing, editing), Alexandra Holtom (editing)

Suggested Citation: National Safer Supply Community of Practice. (2023). Prescribed Safer Supply Programs: Emerging Evidence. Canada. https://www.nss-aps.ca/evidence-brief

Version: 27 September 2023

Production of this document has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.

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