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."