Safe Supply / Safer Supply Programs

1. Public Health Crisis from Acute Drug Toxicity Fatalities

"Since the Early 2000s, Canada and the United States have been experiencing an unprecedented public health crisis from acute drug toxicity fatalities (“drug death crisis”) that is estimated to have claimed well beyond 1 million lives. Although initially driven mostly by fatalities from potent prescription opioids, over the past decade this crisis has changed to being propelled mostly by highly potent and toxic illicit/synthetic opioids (ISOs; e.g., fentanyl and analogues) (Ciccarone, 2021; Fischer, 2023). In 2021, Canada recorded 8,006 opioid-toxicity deaths, for an age-adjusted rate of 21.2/100,000 population (Federal, Provincial, and Territorial Special Advisory Committee on the Epidemic of Opioid Overdoses, 2023). During the same year, there were 106,699 drug overdose deaths (32.4/100,000) in the United States (Spencer et al., 2022). Although this death toll in absolute numbers and rates is even graver in the United States than in Canada, it has been shown to adversely affect life expectancy in both countries.

"In Canada, comprehensive intervention efforts have been implemented and expanded over time to address this drug death crisis. These have included, for example, extensive scale-up of supervised consumption (or “overdose prevention”) services, naloxone distribution (for opioid overdose reversal), and treatment availability (including different opioid agonist therapy [OAT] formulations/modalities) for opioid use disorder (OUD) (Antoniou et al., 2020; Kennedy et al., 2022; Papamihali et al., 2020; Piske et al., 2020). These measures, however, have not been able to stem the rising tide of drug deaths. The levels of drug toxicity deaths in Canada have continuously increased (up to and including 2021), and more recent indicators suggest no significant changes moving forward (Federal, Provincial, and Territorial Special Advisory Committee on the Epidemic of Opioid Overdoses, 2023)."

Benedikt Fischer and Tessa Robinson. “Safer Drug Supply” Measures in Canada to Reduce the Drug Overdose Fatality Toll: Clarifying Concepts, Practices and Evidence Within a Public Health Intervention Framework. Journal of Studies on Alcohol and Drugs 2023 84:6 , 801-807.

2. Development of Prescribed Safer Supply in Canada

"The extremely potent and toxic nature of ISOs [Illicit/Synthetic Opioids] has rendered them the primary cause of overdose fatalities while consequently presenting major challenges for the menu of available interventions. Many existing interventions have mostly aimed at either manipulating the drug use environment to be safer (e.g., supervised consumption) or reactively treating underlying drug use disorders (OAT) or overdoses (naloxone). These approaches, however, have limited direct impact on the primary vector of highly potent and toxic ISO drugs causing overdose deaths (Fischer et al., 2019, 2020b). For illustration: More than half of recent overdose fatalities in British Columbia have occurred from inhalation rather than injection drug use—a mode of use traditionally viewed as substantially safer and protective against overdose-related death (BC Coroners, 2023; Fischer, 2023;Thiblin et al., 2004).

"The search for more effective interventions has thus increasingly focused on the need for safer drug supply provision as an emergency measure to address and reduce the risk of deaths caused by ISO exposure (Ivsins et al., 2020; Tyndall, 2020). Conceptually and practically, safer supply measures provide a form of vector intervention toward reducing the drug consumer's exposure to highly potent/toxic ISO drugs and therefore the consequential risk of overdose death (Fischer et al., 2020b). Based on this premise, the first Canadian small-scale safer supply programs began operating in Ontario from 2017 onward, initially providing prescribed pharmaceutical-grade hydromorphone to small numbers of at-risk drug consumers. Similar programs were subsequently implemented in other locations, with some offering alternative opioid formulations and/or dispensing modes. Safer supply programs became officially supported by the federal government of Canada as of 2020 (Government of Canada, 2023; Harris et al., 2021; Tyndall, 2020; Young et al., 2022). In 2021, the province of British Columbia phased in its formal prescribed safer supply policy for regulatory guidance (Ministry of Mental Health and Addictions, 2021)."

3. Safer Opioid Supply Outcomes

"Overall, the currently available evidence regarding health outcomes among safer opioid supply clients is generally favorable. Specifically, when reported, most studies found reductions (Brothers et al., 2022; Haines & O'Byrne, 2023a; Lew et al., 2022) or a lack of change (Gomes et al., 2022) in the occurrence of opioid toxicity events, along with a reduction in the frequency of unregulated opioid use among clients of safer opioid supply programs (Bardwell et al., 2023; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020, 2022; McNeil et al., 2022). Other health outcomes were also shown to improve among safer opioid supply clients, including increased access to the healthcare system (Gomes et al., 2022; Kolla & Fajber, 2023; Kolla et al., 2021), infectious complications (Gomes et al., 2022), and improvements to clients’ mental health (Gomes et al., 2022; Haines et al., 2022; Kolla & Fajber, 2023; Kolla et al., 2021). Also, participants of qualitative studies expressed that safer opioid supply program participation improved their access to healthcare and other wraparound services (Foreman-Mackey et al., 2022; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020; McMurchy & Palmer, 2022), allowing them to address health issues such as HIV and hepatitis C (Kolla et al., 2021). Additionally, safer opioid supply program clients and providers interviewed in qualitative studies expressed that safer opioid supply recipients were afforded a greater sense of stability as clients were less preoccupied with concerns related to drug procurement (Foreman-Mackey et al., 2022; Giang et al., 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020, 2022; McNeil et al., 2022), or engagement in criminal activity as a means of income generation for drug related purchases (Atkinson, 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Ivsins et al., 2020, 2021, 2022; Kolla et al., 2021; McNeil et al., 2022)."

Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. The International journal on drug policy, 125, 104339. Advance online publication. doi.org/10.1016/j.drugpo.2024.104339

4. Safer Supply of Opioids and Diversion

"Diversion of safer opioid supply drugs was examined in six qualitative studies (Giang et al., 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Kalicum, 2023; Kolla et al., 2021; McMurchy & Palmer, 2022) and one quantitative study (Brothers et al., 2022). These studies found that diversion does occur (Brothers et al., 2022; Haines et al., 2022; Kolla et al., 2021; McMurchy & Palmer, 2022), although the extent of diversion remains unknown. Importantly, safer opioid supply programs include measures and protocols to prevent and address diversion, including urine drug screens, lock boxes and observed dosing (Atkinson, 2023; Kalicum, 2023; Kolla et al., 2021; McMurchy & Palmer, 2022; Selfridge et al., 2022; Waraksa et al., 2022). Despite concerns regarding the diversion of hydromorphone from safer opioid supply programs, unregulated fentanyl remains the largest contributor of death in both Ontario (Public Health Ontario, 2023) and British Columbia (British Columbia Centre for Disease Control, 2021; Owens, 2023), Canada with no substantial changes in occurrence of deaths related to prescription opioids use, including hydromorphone. These factors indicate that diversion in the context of safer opioid supply requires further study, and ongoing refinement and sharing of protocols to address diversion within safer opioid supply programs is likely the most effective response."

5. Prescribed Safer Supply Models in Canada

"Within Canada, there are various prescribed safer supply models each with the goal of reducing unregulated opioid overdose without requiring cessation of substances. While some programs offer non-opioid safer supply options including stimulants and benzodiazepines, the primary focus remains opioids. These programs range in medications offered, clinical setting, and witnessed or unwitnessed ingestion (Health Canada, 2023b; Ledlie, Garg, et al., 2024).

"Some prescribed safer supply models require patients to consume the medication onsite, under the supervision of staff. Other models provide short-acting opioids as take-home doses (often via daily dispensing) but may require witnessed ingestion for long-acting opioid agonist treatment. Opioid medications offered include oral hydromorphone tablets (the most commonly), injectable hydromorphone, long-acting morphine (M-Eslon ®), oxycodone tablets, fentanyl powder, and fentanyl patches (Klaire et al., 2022; Ledlie, Garg, et al., 2024).

"Program settings are diverse, from dispensing at a pharmacy or biometrically controlled dispensing machine to integration within supervised consumption services, addiction treatment clinics, primary care clinic, or harm reduction housing. Models have also included temporary spaces such as dispensing within COVID-19 isolation spaces (Kolla et al., 2024; Ledlie, Garg, et al., 2024). While the majority of research has focused on dedicated safer supply clinics or those receiving federal funding, a notable proportion of safer supply prescribing has occurred in existing primary care clinics, although in British Columbia (BC) much of the scale-up was driven by specialized addiction medicine providers (Glegg et al., 2022).

"Policies that necessitate witnessed ingestion multiple times a day pose a substantial barrier for many patients, and can lead to return to use of toxic drugs (Bardwell et al., 2023). However, witnessed dosing remains a common practice due to concerns of diversion, which is the selling or sharing of safer supply medication to/with others."

Patty Wilson, Kate Colizza, Elaine Hyshka, Safer supply and political interference in medical practice: Alberta's Narcotics Transition Services, International Journal of Drug Policy, Volume 133, 2024, 104600, ISSN 0955-3959, doi.org/10.1016/j.drugpo.2024.104600.

6. Barriers to Implementation of Safer Supply Programs

"Several client- and provider-reported barriers to safer opioid supply program engagement were also identified. Provider identified barriers to prescribing opioids for the purposes of safer supply primarily reflected a perceived lack of guidance and training with the introduction of the Risk Mitigation Guidance in British Columbia (Giang et al., 2023; Kalicum, 2023; Mansoor et al., 2023), and the limited evidence base regarding the effectiveness and safety of safer opioid supply. For providers, some facilitators to safer opioid supply programs were also identified and included belonging to a team (Foreman-Mackey et al., 2022), as well as strong communication between providers (Mansoor et al., 2023). Barriers reported by clients included challenges accessing safer opioid supply prescribed drugs when program policies mandated multiple visits throughout the day to obtain the complete daily dose (Atkinson, 2023; Haines & O'Byrne, 2023a; Ivsins et al., 2020), and lack of familiarity with the program by non-safer opioid supply providers (Haines et al., 2022; Kolla et al., 2021). The mismatch between the potency of the unregulated drug supply and what was prescribed to safer opioid supply clients was also identified as a limitation of safer opioid supply programs (Atkinson, 2023; Bardwell et al., 2023; Giang et al., 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Ivsins et al., 2020; Karamouzian et al., 2023; Kolla et al., 2021; McNeil et al., 2022). In particular, the lack of availability of higher potency opioids and multiple formulations that allow for consumption by either injection or inhalation was described in some studies as leading to continued use of unregulated drugs, which may undermine the effectiveness of safer opioid supply programs for prevention of toxicity events. This aligns with a recent study conducted in Ontario, which found a shift in the mode of drug use toward inhalation, contributing significantly to opioid toxicity deaths (MacDonald et al., 2023). A survey conducted among people who use drugs in British Columbia also found that half of respondents would prefer smokeable options if they were provided by safer opioid supply program. Kamal et al., 2023). Furthermore, as the opioid toxicity crisis continues to evolve across North America, polysubstance use is increasingly associated with substance-related deaths (Konefal et al., 2022; Park et al., 2022). In addition to the availability of higher potency opioids, provision of non-opioid prescription medication should continue to be implemented. This is supported by findings generated from interviews conducted with people who use drugs highlighting the need for access to a regulated supply of stimulants and benzodiazepines for people currently accessing these substances from the unregulated supply and to help prevent non-opioid related withdrawal symptoms when transitioning to safer supply programs (Canadian Community Epidemiology Network on Drug Use., 2021; Xavier et al., 2023). Together, identified barriers, facilitators, and suggestions for the improvement of safer supply programs may help to inform the implementation, scale-up and operation of current and future safer supply programs."

7. Considerations for Implementing Safe Supply

"In British Columbia, a new policy directive—termed “prescribed safer supply”—has recently been announced that will extend prescribing practices outlined in the risk mitigation guidelines beyond the pandemic,²⁹ although the original guidelines remain in effect and have since been revised with a more explicit focus on mitigating COVID-19 risk. However, although the recent policy directive has been broadened to include fentanyl patches and sublingual fentanyl, it does not presently support stimulant prescriptions and thus raises concerns for people who have been accessing stimulants. As the overdose crisis continues, it is imperative that safe supply be extended to all PWUD while being continuously modified to maximize access, efficacy, and equity.

"Finally, our findings draw attention to the tensions surrounding safe supply approaches primarily oriented toward managing withdrawal and drug cravings versus the desire of PWUD to experience enjoyment from drug use.³⁴ There is a need to account for pleasure in the design and implementation of safe supply approaches—something seldom examined in North American research and policy discussions on drug use. Better aligning safe supply approaches with the real-world experiences and desires of PWUD will likely necessitate expanding the options available to include regulated versions of criminalized drugs that they are accustomed to using, such as methamphetamine, cocaine, heroin, and even fentanyl. With growing support for drug decriminalization and strides being made in Oregon and elsewhere,^35,36 it is time that these discussions be broadened to also consider what a regulated drug market might look like in North America."

Ryan McNeil, Taylor Fleming, Samara Mayer, Allison Barker, Manal Mansoor, Alex Betsos, Tamar Austin, Sylvia Parusel, Andrew Ivsins, and Jade Boyd. (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, doi.org/10.2105/AJPH.2021.306692

8. Risk Mitigation Prescribing of Safer Supply

"The risk-mitigation prescribing guidelines were a harm reduction approach in response to the evolving risk environment during COVID-19—namely, continued drug market changes and increasing socioeconomic marginalization—that facilitated reliable access to opioids and stimulants of known contents and potency. Access to no-cost pharmaceutical alternatives enabled participants to exercise greater control over their drug use and reduced vulnerability to overdose. Participants emphasized that, although they had experienced more sporadic drug use patterns characterized by frequent periods of withdrawal and cravings at the outset of the pandemic because of supply shortages, rising prices, and reduced income, they remained uninterested in addiction treatment and yet wanted greater control over their drug use. This was often attributable to past negative experiences with medication-based treatment and recovery services. Prescription opioids and stimulants made available at no cost through the risk mitigation guidelines were positioned as a way to exercise greater agency over drug use and thereby avoid withdrawal and cravings amid deepening socioeconomic marginalization, drug market changes, and escalating overdose deaths."

9. Few Stimulant-Specific Harm Reduction Responses Implemented Globally

"Few stimulant-specific harm reduction responses are implemented globally. Though NSPs and drug consumption rooms (DCRs) can be accessed by people who use stimulants, existing harm reduction services might not always be adequate for their needs.^[34] For example, stimulant use is associated with more frequent injection than opioids, but limits in NSPs on the number of syringes that can be acquired at any one time represent a particular barrier for those injecting stimulants. Stimulants are also more likely to be smoked or inhaled than opioids, but not all DCRs permit inhalation on premises, and smoking equipment is rarely distributed. However, safer smoking kits for crack cocaine, cocaine paste and ATS are distributed in several territories, including Portugal^[5][35] and harm reduction programmes for people who use non-injectable cocaine derivatives are in place in several countries in Latin America. There have been promising pilot programmes in Asia focusing on people who use methamphetamine, including outreach programmes distributing safer smoking kits, plastic straws, harm reduction education, and access to testing and treatment for HIV, hepatitis C, TB and other sexually transmitted diseases (see page 75 in Asia Chapter 2.1).

"Drug checking (services that enable people to voluntarily get the contents of their drugs analysed) is an important harm reduction intervention for people who use stimulants. These services are implemented in at least nine countries in Western Europe³, are available in the United States, Australia and New Zealand, and are increasingly available in Latin America⁴. Eight countries in Eurasia⁵ have some form of drug checking services through distribution of reagent test kits at music festivals and nightlife settings. Other methods of drug checking include the use of mobile testing equipment to determine the contents of what is sold using tiny samples of the product, allowing for identification of both drugs and contaminants. Though availability of drug checking is growing globally from a low baseline, implementation faces serious legal barriers in many countries as it involves handling controlled substances, and drug checking services often require formal exemption from drug laws in order to operate legally.

"No approved substitution therapy for ATS exists, although pharmacologically-assisted treatment with methylphenidate for ATS users was authorised by the government in Czechia during the COVID-19 pandemic, and in Canada, the British Columbia Centre on Substance Use released interim clinical guidance recommending the prescription of dexamphetamine and methylphenidate to people who use stimulants.^[36]"

Harm Reduction International (2020). Global State of Harm Reduction 2020. London: Harm Reduction International.

10. The Drug User Liberation Front and the Compassion Club Model

"After losing a year-long battle to secure a federal exemption to operate, in August 2022, the Drug Users Liberation Front (DULF), a community-level non-profit in the Downtown Eastside, piloted an Evaluative Compassion Club for individuals who use cocaine, heroin or methamphetamine, live in Vancouver's Downtown Eastside, and were at high risk of overdose (Canadian Broadcasting Corporation, 2022). Over fourteen months, eligible individuals enrolled as members, granting them the ability to purchase, at cost, up to fourteen grams of cocaine, heroin, and methamphetamine per week at a fixed storefront space in Vancouver's Downtown Eastside (Drug Users Front Liberation, 2023). All substances were tested via paper spray mass spectrometry, nuclear magnetic resonance spectroscopy, fourier transform infrared spectroscopy and high-performance liquid chromatography prior to sale to ensure quality and a lack of potentially fatal contaminants, and labeled so that participants were aware of the contents (see Fig. 1, Fig. 2 for example) (Drug Users Front Liberation, 2023). The club's operations spanned four days per week, totaling twenty-four hours, and the Club's physical space included an on-site overdose prevention site (Drug Users Front Liberation, 2023). Compassion clubs of this kind are novel, and there appears to be no evidence specific to this form of intervention focused on ensuring access to a safe supply of heroin, cocaine and methamphetamine. This type of collective initiative does bear some similarities to other types of compassion or “buyers” clubs, including those focused on providing access to medicinal cannabis or antiretroviral therapy for HIV disease (Kent, 1999; Rhodes and van de Pas, 2022), but it represents a highly novel form of safe supply programming."

Jeremy Kalicum, Eris Nyx, Mary Clare Kennedy, Thomas Kerr, The impact of an unsanctioned compassion club on non-fatal overdose, International Journal of Drug Policy, 2024, 104330, ISSN 0955-3959, doi.org/10.1016/j.drugpo.2024.104330.

11. Implementation of Safer Supply

"Early implementation issues and tensions included prescriber concerns about safer supply prescribing in a highly politicized environment, accessibility challenges for service users such as stigma, encampment displacement, OAT requirements, program capacity and costs, and tensions between addiction medicine and harm reduction. Navigating these tensions included development of clinical protocols, innovations to reduce accessibility challenges such as outreach, wraparound care, program coverage of medication costs and prescribing safer supply with/without OAT. These findings contribute important insights for the development of prescribed safer supply programs."

McCall, J., Hobbs, H., Ranger, C. et al. Prescribed safer supply during dual public health emergencies: a qualitative study examining service providers perspectives on early implementation. Subst Abuse Treat Prev Policy 19, 19 (2024). doi.org/10.1186/s13011-024-00598-7

12. MySafe: Safer Opioid Supply Via Biometric Dispenser

"Participants enrolled in the MySafe program described a variety of facilitators and barriers to program access and engagement. Facilitators included accessibility and choice, nonwitnessed dosing, a lack of consequences for missing doses, a judgment-free setting and an ability to accumulate doses as contingency plans (e.g., for travel). Barriers included technological issues with the machine, dosing challenges and prescriptions being tied to individual machines. Participants reported reduced use of illicit drugs, decreased overdose risk, financial improvements and improvements to health and well-being. Taken together, these findings illustrate promising aspects of, and areas for improvement to, the MySafe model of safer supply.

"Our findings add to a small but emerging body of research on safer supply programs in Canada that reports how these programs have the potential to reduce overdose risk by limiting illicit opioid exposure,3,15,29–31 with 1 study reporting no opioid-related deaths among program participants3 and another reporting 0 overdoses among program participants.31 As most participants in this study reported using fewer illicit drugs and described reductions in overdose risk since enrolling in MySafe, our findings provide further support of the potential that safer supply programs may offer to address overdose risk. Our findings also illustrate how the MySafe program provides secondary benefits beyond the intended program outcomes (e.g., reduction in overdose risk), addressing physical, mental and social well-being. Given the known associations between sociostructural factors and overdose risk,32–35 our findings underscore the importance of addressing issues attendant to drug use and overdose vulnerability, and are in line with previous research showing the feasibility of safer supply programs to address matters at the intersection of drug use, drug market volatility and social determinants of health.3,13,15,36

"Little research has examined barriers and facilitators to engagement in and adherence to safer supply programs.13,37 A recent study reported benefits of accessing pharmaceutical alternatives, including increased agency regarding how participants consumed their drugs and when they chose to attend the clinic.13 However, participants also described barriers, including limited hours of operation, the need to attend the clinic several times a day and nurse-witnessed ingestion.13 These findings are similar to studies on opioid agonist therapy that report how stigma and programmatic restrictions constrain initiation and retention.2,38–41 Our study findings suggest that the MySafe program circumvents these barriers by providing 24-hour access (or 13-hour access, for the overdose prevention site) and not requiring witnessed ingestion. Integrating the MySafe program in supportive housing allowed greater ease of access to residents, which is particularly important, given the reported links between housing and overdose42,43 and calls for targeted interventions in housing environments where people are most at risk.26,34,44 In addition, this program appears to have potential to limit exposure to violence that is associated with procuring drugs from the illegal market, although further research is needed to confirm such impacts.45

"The MySafe program was not without its issues. Technological issues were described by most participants, resulting in some having withdrawal symptoms and others seeking illicit opioids when unable to access medications from the machine. However, many participants reported accumulating their prescriptions for circumstances when they were not able to use the machine, such as when away on vacation or when technological issues arose. A lack of takeaway doses has been described as a barrier in studies on access to opioid agonist therapy.40,46–48 In the case of the MySafe program, however, patients should not have to stockpile their medications because of technological issues; this could lead to intentional or unintentional diversion of medications.

"A problem confronting all programs of safer supply and opioid agonist therapy in the current era of high-potency illicit drugs is addressing illicit fentanyl-induced withdrawal and the inability of previously sufficient dosages of pharmaceutical opioids to provide appropriate withdrawal management or anti-craving effects. Similar to our results, insufficient dosing of opioid agonist therapy has been found to shape continued use of illicit drugs.49,50 A recent study on adherence to safer supply opioids found that 60-day adherence was higher for those receiving higher daily doses.37 Dosing challenges therefore need to be addressed, which may include increasing the maximum daily dose or providing medications other than hydromorphone, such as prescription fentanyl or diacetylmorphine.4,51,52 However, this limitation speaks more to available medications and less of the MySafe model itself. Clinical guidelines that detail how to address dosing challenges in safer supply programs are urgently needed, including how and when to increase the maximum daily dosages of hydromorphone or provide access to alternative opioid medications.

"Our findings suggest that the MySafe model could be beneficial in other settings, particularly in jurisdictions with challenges in accessing safer supply, including rural and remote communities with geographical and transportation barriers and in pharmacies that are under-resourced and have limited hours of operation. 53,54 In addition, this model shows promise for medication delivery beyond safer supply and could include opioid agonist therapy, direct-acting antiviral tablets or other medications that are commonly accessed by marginalized groups. This would be especially beneficial for structurally vulnerable populations who have compounding barriers when accessing services related to substance use (e.g., Indigenous and racialized communities, sex workers, gender and sexual minorities). Future research is needed to assess the feasibility of the MySafe program in other communities, as well as to explore opportunities to emulate this model for the safe supply of other medications."

Geoff Bardwell, Andrew Ivsins, Manal Mansoor, Seonaid Nolan, Thomas Kerr. Safer opioid supply via a biometric dispensing machine: a qualitative study of barriers, facilitators and associated outcomes. CMAJ May 2023, 195 (19) E668-E676; DOI: 10.1503/cmaj.221550.

13. Safe Supply and Non-Fatal Overdose

"In this study involving 47 individuals who were admitted to an unsanctioned compassion club, we found that enrolment in the program was associated with a reduction in any type of non-fatal overdose as well as non-fatal overdose involving naloxone administration. These findings, suggesting that enrollment in DULF's intervention likely decreased overdose rates, appear to be amongst the first in a growing body of research on the impacts of a safer drug supply that does not employ the medical system.

"Our findings are aligned with previous evaluations of safer supply programs that have found positive outcomes associated with program engagement, as well as the findings of the scoping review of safer supply programs published in this issue (Ledlie et al. 2024). A previous quantitative study investigating a medicalized and prescriber-based model of safer supply found that enrolment in such programming reduced use of emergency departments, hospital admissions and healthcare costs (Gomes et al., 2022). In addition, several qualitative investigations of safer supply programs, involving prescriber- and vending machine-based programs, have found that such programs help reduce illicit drug use, overdose risk, and led to other improvements in health, social and financial well-being (Bardwell, Ivsins, Mansoor, Nolan, & Kerr, 2023; Ivsins, Boyd, Beletsky, & McNeil, 2020; Ivsins, Boyd, Mayer, et al., 2020; Ivsins et al., 2021; Ledlie et al. 2024; Schmidt et al., 2023). Perhaps most relevant to the current study, a recent quantitative study of a prescriber-based opioid safer supply program in Toronto reported an 80% reduction in non-fatal overdose among participants after 8 months of program engagement (Nefah et al, 2023). However, such programs are known to often suffer from low enrolment and retention rates, attributed in part to inability of such programs to accommodate a large number of individuals and a lack of desirable options and dose for people who use drugs (May, Holloway, Buhociu, & Hills, 2020). This problem may be further compounded by the medical system's inability to prescribe or allow access to illegal drugs (Tyndall, 2020). This in turn has prompted calls for the implementation of more community-based compassion club models operating outside of the medical system as a means of increasing access to safer supply (Thomson et al., 2019). Indeed, some physician leaders have expressed that they would rather not to be responsible for ensuring access to safer supply given the associated ethical issues and the current state of the overburdened healthcare system (Bach, 2022). Our study contributes to the existing literature by describing the impact of a non-medicalized safer supply program on non-fatal overdose.

"People who use drugs, and other experts in the field, have long expressed a demand for a stable, predictable, and easy to access supply of drugs to prevent overdose in the context of the current overdose crisis (Bonn et al., 2020; Health Canada, 2023a; BC Coroners Service, 2023a; Tyndall, 2020). Despite its limited scope, this study has implications for research and policy development specific to safer supply and overdose prevention. The lack of active studies in the field of de-medicalized safer supply distribution highlights the need for more research. Given the recent arrest of DULF's co-founders (Greer, 2023), pathways for exemptions to Canada's Controlled Drugs and Substances Act are needed to enable institutions to run programs and track relevant statistics that can assist policymakers in making decisions (Bonn et al., 2021), as well as revisions to existing policy frameworks, specifically the Special Access Program, the Controlled Drugs and Substances Act, and Food and Drugs Act, which limit the implementation of compassion clubs as a response to Canada's public health crisis (Bonn et al., 2021). This policy hurdle is further compounded by a lack of available licit substances for such a program; there are currently no appropriate approved drugs in Canada's Drug Product Database (Health Canada, 2023b). This further underscores the need for policy changes that facilitate a deeper understanding of the effectiveness of compassion clubs as a means of optimizing support for individuals who are at risk of overdose. Further, additional prospective study of effectiveness is needed, alongside qualitative studies focused on implementation issues and cost-effectiveness research to further uncover the impacts and limitations of this unique approach to safe supply programming."

14. Safe Supply Works

"Among residents of a COVID-19 isolation hotel shelter for people experiencing homelessness, we found that an emergency, provisional safe supply program (i.e., prescribing pharmaceutical-grade medications and beverage-grade alcohol) was associated with low rates of adverse events and high rates of successful completion of the 14-day isolation period. No shelter residents experienced an overdose during their stay. We identified medication dosage ranges that generally fell within those recommended in “risk mitigation” prescribing guidelines, which were urgently produced in response to evolving risks of COVID-19."

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, 109440. doi.org/10.1016/j.drugalcdep.2022.109440

15. Safe Supply

"The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings (Bonn et al., 2021; Brothers et al., 2022; Tyndall, 2020; Hales et al., 2020; Bonn et al., 2021). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder (Oviedo-Joekes et al., 2016; Fairbairn et al., 2019). Qualitative studies have evaluated the benefits of witnessed hydromorphone tablet consumption, which is more flexible and less resource-intensive than witnessed iOAT (Ivsins et al., 2021; Ivsins et al., 2020). A recent study from Ottawa, Canada, describes positive outcomes for people with severe opioid use disorder who are provided hydromorphone iOAT along with supported housing (Harris et al., 2021). Benefits of managed alcohol programs are also clearly established for people with severe alcohol use disorder, and particularly people who drink non-beverage alcohol (Stockwell et al., 2021; Stockwell et al., 2018; Crabtree et al., 2018). Some existing managed alcohol programs include once-daily alcohol dispensing and/or unwitnessed ingestion (Pauly et al., 2018)."

16. Overdose Crisis In Canada

"Canada is in the midst of a devastating overdose crisis that has been further exacerbated by the COVID-19 pandemic and, in particular, the subsequent increased toxicity of the drug supply [1]. Between January 2016 and June 2022, close to 33,000 people died from an overdose in Canada, with the provinces of British Columbia, Ontario, and Alberta accounting for 88% of those deaths [2]. Fentanyl, and to a lesser extent fentanyl analogues, have contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses [2]. Between January and June 2022, fentanyl was detected in 76% of overdose deaths in Canada [2]. In Ontario, fentanyl is involved in 88% of fatal overdoses [3]. In Toronto, this number rises to 93% [3]."

Gagnon, M., Rudzinski, K., Guta, A. et al. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J 20, 81 (2023). doi.org/10.1186/s12954-023-00817-7

17. Development of Safer Supply Programs In Canada

"Scaling-up interventions such as naloxone distribution programs, supervised consumption services, and opioid agonist treatment have averted thousands of overdose-related deaths in Canada, but the persistent predominance of fentanyl in the unregulated drug supply continues to fuel overdose-related deaths [4]. To complement existing interventions, many have pointed out that providing an alternative to the unregulated toxic drug supply in the form of safer supply is critical to preventing overdose-related deaths and addressing the needs of people for whom current treatment models do not work or are not a good fit [5,6,7,8,9,10,11]. This approach builds on the premise that harms caused by the unregulated drug supply can be averted by providing access to a regulated drug supply [12].

"Over the past few years, there has been a rapid scale up of safer supply programs in Canada [13]. Ontario is home to a dozen safer supply programs where primary care physicians and/or nurse practitioners work with other health care and service providers to embed safer supply prescribing within a broader model of care and supports for clients with complex health and social needs [14]. At the time of the study, safer supply medications in this province consisted of take-home hydromorphone tablets and directly observed slow-release morphine tablets, dosed and titrated to meet clients’ needs. Some programs required both medications to be directly observed for high-risk clients, such as those who report high-volume alcohol consumption or benzodiazepine use. Early evidence suggests that clients enrolled in safer supply programs have significantly reduced emergency room visits and hospitalizations, improved health care engagement, fewer overdoses and overdose-related deaths, reduced drug-related harms, and improved health and social outcomes [14,15,16,17,18,19,20,21,22]."

18. Safer Supply and Injection Practices

"Safer supply programs are not designed or implemented with the explicit goal of changing injection practices. However, the experiences of clients and providers help us understand how a structural intervention, such as safer supply, can impact other aspects of IDU (e.g., frequency of injection) and its associated health risks (e.g., HIV, HCV, etc.). As Perlman and Jordan [37] point out, structural interventions are important because “structural factors contribute potently to creating the context that renders individuals and areas vulnerable to the syndemic of [overdose, HCV, and HIV]” (p.109). These interventions work upstream, to change the “risk environment” [38, 39], rather than solely focusing on mitigating the downstream consequences at the level of the individual. Our study findings suggest that changing the “risk environment,” by providing an alternative to the toxic drug supply, creates more opportunities for risk reduction. Changes in injection practices identified in this analysis offer a compelling example.

"Our findings suggest that clients enrolled in safer supply programs changed their injection practices in three intersecting ways: (1) they changed how often they injected, (2) they changed what they injected, and (3) they changed their mode of consumption (from injecting to swallowing or snorting). These findings add to existing research [16,17,18] by providing a more dynamic understanding of injection practices in the context of safer supply programs and further supporting the idea that safer supply can contribute to reducing injection-related health risks in addition to overdose risks [40]. We posit that safer supply programs have the potential to address disease prevention and health promotion gaps that other stand-alone downstream harm reduction interventions (e.g., needle and syringe programs) cannot address, by working upstream and providing a safer alternative to fentanyl. As Rhodes [38] reminds us, harm reduction interventions such as needle and syringe exchange programs are crucial, but their effectiveness at preventing injection-related health risks can be undermined by a particular “risk environment.” For example, if a particular shift in the drug supply results in people injecting more frequently, such is the case with fentanyl, an HIV outbreakFootnote1 could occur even in jurisdictions where needle and syringe exchange programs are available [38].

"It is important to note, however, that not all changes in injection practices could be attributed directly to safer supply programs. We identified several indirect factors, such as poor venous access and having to inject hydromorphone tablets not intended for intravenous administration (for more on this, see study by Ivsins and colleages [17] and guidance by the British Columbia Centre on Substance Use [42]), which shaped the decision to stop injecting. Having the option of taking safer supply medications orally made this decision possible, but it is unclear if all clients who stopped injecting would have done so if they had access to a range of injectable safer supply medications and/or had better venous access. Moreover, it is unclear to what extent clients continued to inject because the safer supply medications dosage/potency was not meeting their needs, as suggested by clients who spoke of the need to supplement with fentanyl, and/or because they wanted to continue injecting. Future research should aim at exploring these nuances because safer supply programs are not intended as interventions to stop clients from injecting. If clients want to inject, they should be able to do so and access injectable safer supply medications (including injectable hydromorphone) as well as sterile supplies and supervised safer consumption services—a priority echoed in a recent report on substance use patterns and safer supply preferences of PWUD in British Colombia [43]."

Safe Supply / Safer Supply Programs

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