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).
“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)
The illegal drug supply is unpredictable, contaminated, and toxic. As a result, there were 30,843 opioid toxicity related deaths in Canada between January 2016 and March 2022 (Special Advisory Committee, 2022).
Health Canada currently funds 22 pilot programs which use medical models of safer supply. The most common settings for 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.
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 safer supply.
However, safer supply programs have very limited capacity. One program estimated 6000 people in their region would benefit from safer supply, but they are only able to serve 300 people (McMurchy & Palmer, 2022). 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, 2022; Haines et al., 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).
Typical 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 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 safer supply programs are very high (McMurchy & Palmer, 2022; Kolla et al., 2022; Haines et al., 2022; ESCODI, 2022; Selfridge et al., 2022).
Initiators of 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, with evidence emerging to show:
- Reduced risk of death: Short-term deaths among people receiving safer supply were rare (Young et al., 2022; Gomes & Kolla, 2022) and they had fewer overdoses (ESCODI, 2022; Haines et al., 2022; McNeil et al., 2021; 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 (Brothers et al., 2022; 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 (Kolla et al., 2022; Klaire et al., 2022; Ivsins et al., 2021; McMurchy & Palmer, 2022; Haines et al., 2022; Selfridge et al., 2020; Gomes & Kolla, 2022).
- Fewer hospital visits: Fewer Emergency Department visits, inpatient hospital admissions, and mental-health-related and substance-use-disorder-related hospital visits (Gomes & Kolla, 2022).
- 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 (Kolla et al., 2022; McNeil et al., 2021; ESCODI, 2022; Haines et al., 2022; Selfridge et al., 2020; Ivsins et al., 2020b).
- Improved control over drug use: The flexibility and autonomy of safer supply programs, coupled with certainty about dose strength, enabled participants to avoid withdrawal symptoms and manage pain (McNeil et al., 2021; Ivsins et al., 2020b, Selfridge, 2020).
- Improvements in social well-being and stability: Economic improvements (Ivsins et al., 2020; Selfridge et al., 2020; Haines et al., 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 (McMurchy & Palmer 2022; Haines et al., 2022), decreased involvement in and exposure to violence, criminal activities and legal issues (Kolla et al., 2022; McMurchy & Palmer, 2022; Haines et al., 2022; Ivsins et al., 2020b), improved general social stability (ESCODI, 2022), improved housing access (Haines et al., 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: 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, 2022).
- Comprehensive ancillary services: populations served by safer supply benefit from health and social supports delivered alongside safer supply (Gomes & Kolla 2022; Haines et al., 2022; 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 (Ivsins et al., 2020b; Haines et al., 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)
- Ability to provide pharmaceuticals that meet people’s needs (dose, formulation, type) (Selfridge et al., 2022)
- Community-centred approach, foregrounding the leadership and engagement of people who use drugs (Ranger et al., 2021).
“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)
National Safer Supply Community of Practice resources
- Reframing Diversion for Health Care Providers: Frequently Asked Questions (2022)
- Safer Supply for Health Care Providers: Frequently Asked Questions (2022)
- Safer Supply: A Review of the Literature (2022)
- Safer Supply, Opioid Agonist Treatment & Harm Reduction: National Advocacy Toolkit (2022)
- Assessment of the Implementation of Safer Supply Pilot Projects - Full Report (McMurchy & Palmer, 2022)
- London InterCommunity Health Centre's Safer Opioid Supply Program Evaluation - Full Report (Kolla et al., 2022)
- Cool Aid Community Health Centre Report on Risk Mitigation Guidance Prescriptions: Providing “Safer Supply” in CAMICO Sheltering Sites, Outreach and Primary Care Practice (Selfridge et al., 2020)
Protocols and Guiding Documents
- Safer Opioid Supply Programs (SOS): A Harm Reduction Informed Guiding Document for Primary Care Teams-April 2020 update (Hales et al., 2020).
- Safer Opioid Supply Program Protocols. Parkdale Queen West Community Health Centre (Waraksa et al., 2022)
- Victoria SAFER Initiative: Safer Supply Protocols (AVI Health and Community Services, 2022)
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.
Drug User Liberation Front & Vancouver Area Network of Drug Users. (2022). The DULF and VANDU Evaluative Compassion Club: A Strategic Framework for Preventing Overdose Deaths due to the Unpredictable Illicit Drug Supply, Revision 2.1. British Columbia: DULF and VANDU. https://www.dulf.ca/_files/ugd/fe034c_d16d82483593406da4d4459d6f7aa63e…
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.
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., 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.
Haines, M., Tefoglu, A., & O’Byrne, P. Safer Supply Ottawa Evaluation: Fall 2022 Report. (2022). Ottawa, Canada. https://safersupplyottawa.com/research/ ➤ Chart review for all safer supply participants (n=425) plus a qualitative study including interviews (n=30) and surveys
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
Health Canada. (2022). Interactive map: Canada's response to the opioid overdose crisis. Health Canada. https://health.canada.ca/en/health-canada/services/drugs-medication/opi…
Ivsins, A., Boyd, J., Beletsky, L., & McNeil, R. (2020a). Tackling the overdose crisis: The role of safe supply. International Journal of Drug Policy 80, Article 102769. https://doi.org/10.1016/j.drugpo.2020.102769
Ivsins, A., Boyd, J., Mayer, S., Collins, A., Sutherland, C., Kerr, T., & McNeil, R. (2020b). Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study. Drug and Alcohol Dependence 216: Article 108202. https://doi.org/10.1016/j.drugalcdep.2020.108202 ➤ 42 qualitative interviews plus 100 hours of ethnographic observations.
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.
Kolla, G., Long, C., Perri, M., Bowra, A., & Penn, R. (2022). Safer Opioid Supply Program: Summary Report. London, Ontario: London InterCommunity Health Centre. https://www.nss-aps.ca/sites/default/files/resources/2022_LIHC_SOS_Prog… ➤ Findings from a mixed-methods evaluation examing the scale up of the safer supply program at LIHC from 112 to 248 clients.
McMurchy, D., & Palmer, R. W. H. (2022). Assessment of the Implementation of Safer Supply Pilot Projects. Ottawa, Ontario: Dale McMurchy Consulting. https://www.nss-aps.ca/sites/default/files/resources/2022-03-safer_supp… ➤ Qualitative assessment of 10 time-limited safer supply pilot projects in British Columbia, Ontario, and New Brunswick.
McNeil, R., Fleming, T., Mayer, S., Barker, A., Mansoor, M., Betsos, A., Austin, T., Parusel, S., Ivsins, A., & Boyd, J. (2022). Implementation of Safe Supply Alternatives During Intersecting COVID-19 and Overdose Health Emergencies in British Columbia, Canada, 2021. American Journal of Public Health 112, s151-s158. https://doi.org/10.2105/AJPH.2021.306692 ➤ 40 qualitative interviews.
Ranger, C., Hobbs, H., Cameron, F., Stuart, H., McCall, J. Sullivan, G., Urbanoski, K., Slaunwhite, A., & Pauly, B. (2021). Co/Lab Practice Brief: Implementing the Victoria SAFER Initiative. Victoria, British Columbia: Canadian Institute for Substance Use Research.
Schlag, A. K. (2020). Percentages of problem drug use and their implications for policy making: A review of the literature. Drug Science, Policy and Law 2020;6. https://doi.org/10.1177/2050324520904540 ➤ Literature review.
Selfridge, M., Heaslip, A., Nguyen, A., Card, K., & Fraser, C. (2020). Cool Aid Community Health Centre Report on Risk Mitigation Guidance Prescriptions: Providing “Safer Supply” in CAMICO Sheltering Sites, Outreach and Primary Care Practice. Victoria, British Columbia: Cool Aid Community Health Centre. https://coolaid.org/wp-content/uploads/2021/03/CACHC_RMG_March-August20… ➤ Chart review (n=313)
Selfridge, M., Card, K., Kandler, T., Flanagan, E., Lerhe, E., Heaslip, A., Nguyen, A., Moher, M., Pauly, B., Urbanoski, K., & Fraser, C. (2022). Factors associated with 60-day adherence to “safer supply” opioids prescribed under British Columbia's interim clinical guidance for health care providers to support people who use drugs during COVID-19 and the ongoing overdose emergency. International Journal of Drug Policy 105, Article 103709. https://doi.org/10.1016/j.drugpo.2022.103709 ➤ Chart review (n=286).
Silverman, M., Slater, J., Jandoc, R., Koivu, S., Garg, A. X., & Weir M. A. (2020). Hydromorphone and the risk of infective endocarditis among people who inject drugs: a population-based, retrospective cohort study. The Lancet Infectious Diseases 20(4): 487-497. https://doi.org/10.1016/S1473-3099(19)30705-4 ➤ Retrospective cohort study (n=60 529) using linked health administrative databases.
Special Advisory Committee on the Epidemic of Opioid Overdoses. (2022). Opioid- and stimulant-related harms in Canada. Ottawa: Public Health Agency of Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimu… (accessed 2022 Sept 27).
Young, S., Kolla, G., McCormack, D., Campbell, T., Leece, P., Strike, C., Srivastava, A., Antoniou, T., Bayoumi, A. M., Gomes, T. (2022). Characterizing safer supply prescribing of immediate release hydromorphone for individuals with opioid use disorder across Ontario, Canada.International Journal of Drug Policy 102, Article 103601. https://doi.org/10.1016/j.drugpo.2022.103601 ➤ Using provincial health data, examined 534 initiations of safer supply (447 distinct individuals) from 155 prescribers
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: 17 January 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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