Early findings from safer supply pilot projects

As the overdose crisis worsened during the COVID-19 pandemic, health care experts and people who use drugs called for greater access to a safer supply of prescription medications as an alternative to the toxic illegal drug supply.

In 2020, the Substance Use and Addictions Program at Health Canada funded ten time-limited safer supply pilot projects in three provinces (British Columbia, Ontario, and New Brunswick). Health Canada then contracted a four-month qualitative assessment, from December 2020 to March 2021, of these projects to capture early learnings, including effective strategies for program delivery.

This is a summary of an independent assessment report prepared by Dale McMurchy Consulting based on information gathered through surveys and interviews with safer supply program leads, staff and participants. While this assessment was funded by Health Canada, the information summarized herein does not necessarily represent the views of Health Canada.

Impact on participants’ lives

Participants said:

• My whole lifestyle improved
• Got my life back
• My life has improved drastically
• It saved my life
• I function productively in society
• My life is getting better
• Frees time to do more constructive things
• More energy and confidence to focus on my art
• Opened a whole new outlook and positive way of living
• Positive influence on what else you do
• Enabled me to move forward in my life and not be at a standstill
• Life is so much better
• There’s a lot less edge on my day
• Allowed me to focus on more positive direction
• 100% more stable than I have ever been
• My life has been a hardship, a mountain, but I now know happiness
• I can devote time hunting for and keeping job, going to appointments

Participants and staff say having access to a safer supply of drugs has resulted in improvements to the lives of many participants. They reported that participants:

• Have improved health, wellbeing and quality of life
• Have decreased overdose risk and decreased use of street drugs
• Have addressed health issues related to drug use, mental health and chronic diseases
• Have reduced stress
• Have more energy and are more active
• Are eating and sleeping better
• Are becoming housed and employed
• Have more time in the day and can pursue hobbies and interests   
• Have increased stability in their life
• Have more money and no longer have to hustle for drugs
• Experience greater safety and interact less often with the street (such as dealers, violence, crime, police)
• Are no longer engaged in survival sex work
• Have improved or improving relationships with family and friends
• Feel hopeful for their future

Medications offered by safer supply programs

In terms of the medications offered by safer supply programs, as an opioid replacement, most participants receive tablet hydromorphone. Fewer receive injectable hydromorphone, fentanyl patches or oxycodone. Many also take a longer-acting opioid (sometimes called a “backbone”), such as methadone or slow-release oral morphine. Some programs also prescribe stimulant replacements (such as methylphenidate and dextroamphetamine).

Participants have effectively developed their own goals and processes for managing their medications. For example, they combine injections and tablets, take their medications as needed throughout the day, and reserve enough to get them through until the next day. Most still struggle to manage withdrawal symptoms, but few have overdosed. While many participants have stopped using street drugs, others still use them, but at a progressively decreasing rate. From the perspective of program staff, it is anticipated that this downward trend will continue with increased participant time in the program and as prescriptions are adjusted to match their needs.

Services offered by safer supply programs

Participants receive a wide range of services in addition to prescription medications through the safer supply programs or referrals to partner organizations. In addition to primary care services (acute, chronic and preventative care), many of the 10 safer supply programs looked at through this evaluation were also offering some combination of the following services:

• Outreach and support in the community
• Harm reduction supports
• Case management to support all of a participant’s needs
• Advocating for participants
• Medication delivery
• Crisis support
• Housing supports
• Assistance getting income support and drug coverage
• Assistance getting personal documents such as health cards and IDs
• Referrals to other services
• Cultural programming
• Legal support

The safer supply program team

Participants receive support and care from a dedicated and responsive team. The core team often includes a:

• physician or nurse practitioner;
• registered nurse, licensed practical nurse, or registered practical nurse; and
• case, social, community health, harm reduction or peer support worker. Peers play many roles and are considered by many to be important to success.

According to staff,
“key successes related to staffing have included the benefits of a multidisciplinary team where team members have diverse perspectives and common goals. The team is well-rooted in community harm reduction practice, has a keen social justice analysis, and have established open modes of communication and support.”

Challenges experienced by safer supply programs

The top challenge for programs is the high level of tolerance to fentanyl experienced by participants due to its high potency.

According to program staff,
“for those who have been using fentanyl, their tolerance is such that even maximal doses of Dilaudid [hydromorphone] have little effect except withdrawal management. This leads people to continue to use street fentanyl, as the Dilaudids do not approximate the effect they get from fentanyl.”

Additional challenges met by the programs include:

• Shortages and supply interruptions of medications
• Limited types of medications available or approved for use for opioid use disorder and the extent of provincial or territorial coverage of medications used by programs, including injectable hydromorphone and diacetylmorphine, as well as other safer supply medications
• Participant time requirements
• Participants missing doses and having to reduce their dosage or restart
• Diversion (such as participants selling, trading or giving their prescribed medications to someone else)
• Staff shortages and resistance by some professionals
• COVID-19 challenges (such as increased isolation, fewer community services, spacing requirements at program sites)

Demand for a safer supply

Respondents stated that the overdose crisis is not improving and the current safer supply services available across the country are not meeting demand. Many programs have reached capacity or are too busy to take new participants. Broad access to these services, whether through primary care, harm reduction services or other modalities, is needed to meet demand and help address this crisis by providing the necessary services (medications and comprehensive health and social services) to people with substance use disorder.

Programs and staff that continue to innovate based on participants’ experiences, evolving needs and feedback are most effective.

To ensure program success, staff say:

• "Position people who use drugs as the experts in their own health and wellbeing."
• "The staff here listen to participants, adapt accordingly, and have seen amazing results."
• "Participants are the experts in their experience with drug use.  We meet people where they are at and support them with their individual goals."

Key features for effective program design and delivery

The programs reported that the following are important when designing and implementing safer supply services.

Employ a community-centred approach

• Engage the community
• Involve people with lived and living experience throughout

Take a harm reduction approach

• Base service delivery on the principles of harm reduction
• Offer a range of service delivery models to ensure participants feel at ease
• Apply strengths-based approaches

Focus on the participant

• Tailor services to promote individual health and wellbeing, understanding the needs of stigmatized, racialized and marginalized populations
• Create a welcoming, culturally-safe, judgement-free, trauma-informed environment
• Empower participants in their health and wellbeing; acknowledge their skills
• Collaboratively set individual goals

Ensure effective management

• Clearly define the governance, leadership and management structure
• Develop human resources, partnership and communication protocols
• Provide team building, capacity building, and mental health and wellness supports           
• Establish financial management systems
• Outline technology, equipment and storage requirements
• Embed quality improvement processes

Understand professional scopes of practice

• Engage professionals (pharmacists, physicians and nurses) early to develop working relationships, protocols and care pathways

Develop service processes and procedures

• Review needs assessments, research and expert input
• Conduct process mapping and create work plans, workflow and participant pathways
• Develop and document processes, protocols and guidelines, including details on eligibility criteria, intake processes, prescribing, titration, dispensing methods, frequency of visits, and missed doses and appointments

Ensure access and retention

• Plan to meet demand and for growth and expansion
• Provide an accessible location, with adequate and functional space
• Ensure hours of operation meet participants’ needs
• Develop innovative methods for appointments, such as reminder systems; drop-in and group appointments, and various entry points, such as satellite and mobile clinics, outreach, in-home and virtual services, medication delivery, vending machines