"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.

"From 2016–2017 to 2020–2021, the average annual number of U.S. deaths from excessive alcohol use increased by more than 40,000 (29%), from approximately 138,000 per year (2016–2017) to 178,000 per year (2020–2021). This increase translates to an average of approximately 488 deaths each day from excessive drinking during 2020–2021.

"In conclusion, we found that areas where SCS were implemented in Toronto subsequently had significant reductions in overdose mortality incidence, although other areas in the city did not. Furthermore, we found an inverse spatial association between SCS and overdose mortality incident locations, and this association increased in magnitude over time. This finding suggests that the implementation of SCS could contribute to reductions in overdose mortality in proximal areas.

"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.

"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).

"In 1997, Alan Leshner, the Director of the US National Institute on Drug Abuse (NIDA), proclaimed that addiction was a chronic, relapsing, brain disease (Leshner, 1997).

"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.

"The safety and efficacy of nurse prescribing of MOUD is well established, and its expansion can provide a range of advantages to people who are dependent on opiates.

"A study in Canada found that personal beliefs of NPs often pose a barrier to providing treatment, for example, views such as patients with OUD deserve less care than other patients [12], this was also reported as a barrier in the study by Spetz and colleagues [31].

"Several client- and provider-reported barriers to safer opioid supply program engagement were also identified.