Diversion in Safer Opioid Supply Programs

"We interviewed 25 clients of an SOS [Safer Opioid Supply] program in Toronto to explore their motivations for and perspectives of SOS medication diversion. We found that diversion of SOS medications reportedly occurred via a complex interplay of personal motivations coupled with structural factors, such as the volatility of the unregulated drug market, limited access to safer supply programs, adverse social determinants of health, and a narrow range of available prescribed medications.

"Building on the findings of previous SOS program evaluations (Haines & O'Byrne, 2023; Haines et al., 2022; Henderson et al., 2024), we found that participants reported diverting medications to fellow SOS program clients and non-clients to manage withdrawal symptoms or chronic pain. However, the criminalization of selling unregulated drugs, along with other societal and structural factors (e.g., systemic discrimination, poverty, racism, and classism) that contribute to the negative perception of selling unregulated drugs as predatory, make it challenging to study the acts of mutual support and care involved in sharing SOS medications (Kolla & Strike, 2020; National Safer Supply Community of Practice, 2022). Diversion of SOS medication was also reportedly driven by insufficient potency and medication availability for an individual entering the program after having high tolerance from an increasingly potent drug supply, reported here and elsewhere (Haines et al., 2022; McMurchy & Palmer, 2022).

"Factors influencing diversion may be addressed by increasing the capacity of SOS programs and increased control over the unregulated drug supply by public health organizations (Bardwell et al., 2021; Henderson et al., 2024). For example, expanding the range of opioid medications available on the provincial drug formulary to better match client preferences and tolerances is likely to reduce instances of diversion stemming from client dissatisfaction and/or withdrawal (Bardwell et al., 2021; Ferguson et al., 2022). Moreover, providing higher potency medications that are preferred but not received by a large number of SOS clients (Speed et al., 2024) through programs, such as those prescribing fentanyl patches (Norton et al., 2024) would be hepful. Additionally, diversion reportedly occurred to meet basic survival and subsistence needs including procuring food, clothing, shelter, or supporting friends and family, consistent with previous research (Bardwell et al., 2021; Giang et al., 2023; Henderson et al., 2024). These findings underscore the urgent need to address systemic poverty and provide comprehensive support, including expanded income assistance programs, as part of a holistic and integrated care approach for clients of SOS programs (Van Draanen et al., 2020). As explored in the current study and discussed elsewhere (Haines et al., 2022), diversion of medication from SOS programs can allow for non-clients to also access opioids of a known potency and lower their risk of overdose, and can allow an individual to access a safer alternative supply before they enter an SOS pilot program (McMurchy & Palmer, 2022). However, this perspective warrants caution given the complex dynamics of the unregulated drug markets. Large-scale diversion of SOS medications might theoretically increase the overall supply and accessibility, potentially leading to plummeting prices of hydromorphone tablets in the Canadian unregulated drug market (Mathew et al., 2021). This contrasts with rising prices in the United States, where higher demand and decreased access to high-potency opioids during the COVID-19 pandemic drove prices up (Mutter et al., 2023). Moreover, the experiences of clients who were harassed or faced violence from others attempting to acquire their medication highlighted the complex interplay between harm reduction programs and the potential unintended consequences of inequitable access to regulated substances within marginalized communities."