Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 — Safer Supply Evaluation
Midpoint Knowledge Exchange Forum: What We Heard Report

Introduction

On May 10, 2023, the Canadian Institutes of Health Research (CIHR) hosted a virtual midpoint knowledge exchange forum for an evaluation project funded through the Operating Grant: Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 funding opportunity. This research project is evaluating Safer Supply Pilot Projects supported by Health Canada through their Substance Use and Addictions Funding Program (SUAP). This report comprises a synthesis of progress and current findings presented by the research team and a summary of knowledge user and audience perspectives shared during a panel reflections and discussion session.

Disclaimer

The following information intends to summarize what we heard at the workshop. CIHR has made every effort to share this text with project participants for their review. Any errors or omissions are unintentional. This report should not be taken as a definitive account of research results. Readers are advised to follow up directly with grant recipients for the most current information on their projects.

The meeting book for this workshop is available upon request. Requests can be directed to the CIHR Contact Centre: support-soutien@cihr-irsc.gc.ca.

Message from the Scientific Director

Countless Canadians and their loved ones have been grappling with a nation-wide overdose crisis over the past several years, one that shows no signs of slowing down. A large number of lives continue to be lost each year, due to an illegal drug supply increasingly contaminated with toxic and potent drugs.

Unfortunately, the COVID-19 pandemic has exacerbated the effect of the overdose crisis on Canadian communities. There has been a clear increased risk of harm to people who use drugs or who have a substance use disorder. Targeted investments to expand access to pharmaceutical-grade medications as safer alternatives to the illegal supply (safer supply) that may provide people with pathways to care are urgently needed.

To address this investment gap, Health Canada has been supporting Safer Supply Pilot Projects (SSPP) through their Substance Use and Addictions Funding Program (SUAP). These pilot intervention projects offer safer supply services and contribute to the evolving evidence base on harm reduction interventions. The Canadian Institutes of Health Research Institute of Neurosciences, Mental Health and Addiction (CIHR-INMHA) supported research to evaluate these innovative programs as part of the Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 funding opportunity (FO) launched in late 2020. The ‘Safer Supply Evaluation’ component of the FO supports critical implementation science research on the outcomes of the SSPPs, conducted by a dedicated research team comprised of members drawn from the Canadian Research Initiative in Substance Misuse (CRISM) network.

This midpoint knowledge exchange forum presented a significant opportunity in the mobilization of research into real-world evidence informing policy and practice decisions on harm reduction. The interim research findings shared at this forum will be invaluable to the countless lives touched by the ongoing overdose crisis nationally. CIHR-INMHA is grateful to the research team and knowledge users for their participation in this important knowledge exchange event, and to the Honourable Carolyn Bennett, Minister of Mental Health and Addictions and Associate Minister of Health, for her opening remarks.

Samuel Weiss, CM, PhD, FRSC, FCAHS
Scientific Director, CIHR Institute of Neurosciences, Mental Health and Addiction

Summary of Research Team Progress Update

Presenters: Daniel Werb, Centre on Drug Policy Evaluation, St. Michael’s Hospital (Nominated Principal Investigator), and Mohammad Karamouzian, Centre on Drug Policy Evaluation, St. Michael's Hospital

• Overview of safer supply pilot projects (SSPP) in Canada

  This project is evaluating 11 safer supply pilot projects (SSPPs) in Canada (six in British Columbia [BC], four in Ontario, one in New Brunswick), funded by Health Canada’s Substance Use and Addictions Program (SUAP).

  The sites vary based on the services they provide and the study is reviewing different models of safer supply, including:

  • Injectable opioid agonist therapy (iOAT): Observed doses in clinical settings requiring more than one visit per day
  • Safer opioid supply (SOS): Unobserved, take-home tablets dispensed daily at the pharmacy and a low barrier vending machine model (MySafe)
  • Risk mitigation prescribing (in BC only): Take home prescriptions for unobserved dosing

  Data for this midpoint progress update comes from SSPP progress reports that sites are required to submit to Health Canada as a condition of their funding, organizational assessment interviews of SSPP leadership and management, self-reported qualitative data from SSPP clients, preliminary quantitative data from iOAT and SOS clients in Toronto, and urinalysis and administrative data from the MySafe Project.

  Since this midpoint knowledge exchange forum, the following paper has been published: Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

• Implementation and sustainability challenges

  A thematic analysis of 45 progress reports from the 11 SSPP sites between February 2020 and March 2022 highlighted several challenges, including:

  • Organizational challenges: Sites reported physical space constraints and staff shortages partly due to the intersection of the COVID-19 pandemic and the drug toxicity crisis.
  • Limited funding: The short-term funding mechanism makes building relationships among staff and clients difficult, threatens the programs’ sustainability, and affects staff job security and client care continuity.
  • Structural inequities: The lack of affordable housing is an ongoing challenge not limited to BC or Ontario. This severely impacts clients, especially during the winter months.
  • Community opposition: While this was not found to be a major issue, particularly where programs are embedded within an existing service, it was raised as a concern by a few programs.
  • Unmet medication needs: High-potency opioids, such as fentanyl in the unregulated drug supply generate client tolerance, making safer supply dosages inadequate to meet needs. Provincial availability varies due to regulations that restrict access to diacetylmorphine and high-dose opioids, leading to withdrawal symptoms and continued substance use. Many clients also prefer inhalation to injection and there is a need for prescribed opioid medications that are smokeable.
  • Pandemic-related challenges: COVID-19 resulted in inadequate programs and services for highly marginalized people. Safer supply programs provide increased time and stability for people to engage in programming and services that address social determinants of health. However, these programs and services are severely limited.
  • Overly medicalized and high-barrier models: Despite efforts to make services accessible, some models were overly medicalized and not sufficiently client-centred. Physicians’ capacity to provide safe supply prescriptions remains limited, primarily due to physicians’ concerns with offering a non-witnessed safe supply.

  This analysis highlighted two key actionable recommendations:

  • Long-term funding is needed to ensure staff job security and client care continuity.
  • Expansion of access to a range of medications is needed to meet client needs and reduce reliance on the unregulated drug supply.
• Facilitators of program success

  Organizational assessment interviews with leadership and management of SSPPs revealed several factors that supported program success, including:

  • Wraparound care models: Comprehensive and holistic approaches to providing support to safer supply clients help address unmet health and wellness needs (see more wraparound services in the discussion summary).
  • Community buy-in: Most sites did not receive significant opposition from the community. Some used creative approaches to engage with the community (e.g., inviting the deputy chief of police to visit the facility, engage with staff and address concerns).
  • Client-centred and flexible care: Seeking client feedback and incorporating their suggestions into programs and services helps care providers better meet clients’ needs.
  • Staff excellence and culture: A healthy work culture and a team approach contribute to sustainability and growth.
  • Foregrounding people with lived and living experience (PWLLE): Engaging with PWLLE in a genuine way from the early stages of brainstorming ideas and including PWLLE as staff members is key to the success and sustainability of programs and services.
• Client experiences, outcomes and perceptions

  A review of published or soon-to-be-published research studies undertaken by different researchers and care providers noted several client experiences, outcomes and perceptions of SSPPs:

  • An evaluation of the London InterCommunity Health Centre Safer Opioid Supply program found a significant decline in rates of emergency department visits, hospital admissions, and health care costs after entry into the SOS program^{Footnote 1}. This suggests that safer opioid supply programs can increase the range of medication options available to better meet the needs of individuals who use drugs who are at a high risk of drug poisoning.
  • Preliminary findings suggest that the safer supply program offered at the Peterborough 360 Degree Nurse Practitioner-Led Clinic, that offers take-home doses of immediate-release hydromorphone tablets, has resulted in increased quality of life and access to primary care, social supports and harm reduction services. There has also been decreased involvement in criminalized activities, overdose risk, drug use and experiences of pain/withdrawal. The researchers note there is a need for increased take-home doses and diversity of medications, as well as increased programming that offers connection, employment, and access to basic needs, including housing.
  • A review of qualitative data from two programs offering take-home medications (London InterCommunityHealth Centre, London, Ont.) and a mixed model of take-home and in-clinic observed doses (SAFER, Victoria, BC) found a rapid decrease in overdose risk and less involvement in criminalized activities and that take-home dosing allows for client autonomy and for people to stay away from drug scenes. The researchers noted a strong need for more medication options, including heroin and smokeable options.
  • Preliminary qualitative findings from four programs in Ontario providing wraparound primary care show a reduced risk of overdose death and many clients reported they had reduced or stopped using unregulated drugs and reduced, or stopped, injecting drugs^{Footnote 2}. Clients re-engaged with health care and addressed previously unattended health problems and had increased access to HIV/Hepatitis C treatment and care. Through reduced unregulated substance use, they also decreased criminal activity and increased their uptake of social services, resulting in increased social stability and improvements in housing and food security.
  • A qualitative study on tablet injectable opioid agonist therapy (TiOAT) programs in BC found factors that improved access to TiOAT in rural settings included living close to the clinic, reliable transportation to the clinic and availability of take-away doses. Barriers to care included limited clinic hours, dosing interruptions due to hospitalizations and/or incarcerations and witnessed ingestion requiring multiple prolonged visits (i.e., 20 minutes) to the clinic per day^{Footnote 3}. The researchers note that TiOAT is not necessarily considered safer supply but this method is a unique program for rural communities and therefore was deemed relevant.
  • Preliminary findings from a fentanyl patch program within a wraparound care model (Hope to Health, Vancouver, BC) demonstrated a positive short-term impact, as reported by clients. This included improved psychosocial health and well-being, improved physical health and changes in substance use patterns such as reduced craving, reduced spending on street drugs, reduced criminal activity and recovery feeling more feasible.
• Short-term client health and social outcomes

  Preliminary quantitative data from a cohort of 27 participants of The Works iOAT program and 26 participants of a few SOS programs in Toronto revealed a reduction in illegal income-generating activities, decreased spending on drugs, decreased unregulated opioid use, increased food security, fewer arrests, improvements in participants’ housing situations and decreased self-reported overdoses.

  The researchers note that these results are preliminary and based on a small sample size but the trends are insightful.

• Client preferences and retention (Mysafe)

  Preliminary quantitative administrative records obtained from the MySafe program (secure hydromorphone dispensing machine) found that most clients accessed medications from the dispensing machine between 5 p.m. and 11 p.m.

  Urinalysis data is limited but shows that exposure to benzodiazepines has increased over time, cocaine use decreased over time, and clients accessing medications through MySafe are also consuming other drugs (e.g., amphetamines, fentanyl, oxycodone). The researchers note that it is important to consider these results in context, as the goal of the MySafe program is not to reduce or stop drug use, rather to provide people with a safer, regulated supply of opioids to prevent drug overdoses.

  During the follow-up period, urine screening tests were conducted on 66 clients who had been prescribed hydromorphone, resulting in 85 urine tests. It was found that eight unique individuals tested negative for hydromorphone based on their urine samples. There could be different explanations for this, and researchers caution that this data is preliminary and from a small sample size. While the absence of medication detected in a urine drug screen could indicate some clients are diverting their medication to others. These results could also indicate that clients’ needs are not being met. If they are selling their medications to purchase higher-potency opioids on the unregulated market, prescribing higher doses through safer supply could contribute to better retention in the program. This is a complex issue that requires more research and data to gain a better understanding.

  The researchers expect to publish results of a qualitative study on the MySafe program in the coming months^{Footnote 4}.

• Work in progress

  The research team’s next steps include creating a Safer Supply Models “Blueprint,” analyzing administrative clinical health data from Ontario, collecting and analyzing longer-term cohort data from Toronto SSPPs, conducting a qualitative analysis of client experiences, perceptions and outcomes across Canada, conducting systematic reviews of qualitative and quantitative evidence, an analysis of ongoing organizational assessment interviews with SSPP leadership and staff, evaluation of an Indigenous-led safer supply model (Kilala Lelum Urban Indigenous Health and Healing Cooperative) and a policy analysis of the role of safer supply in ending the overdose crisis.

• Big picture from early findings

  In summary, the researchers conclude that safer supply appears to be effective for highly marginalized clients. Programs vary in the services they provide and the resources available to them. The sustainability and scale-up of complex safer supply models require dedicated support to ensure their effectiveness.

  Further evidence (including longitudinal analyses) is being generated on a range of measures of sustainability, adaptability, and impact across Canada.

  CIHR expects to hold the next knowledge exchange meeting with the research team in spring 2024.

Summary of Discussion

Following the research team’s progress update, a moderated discussion was held for meeting participants (including policy makers, service providers, other researchers and knowledge users) to share their reflections on the research findings and discuss potential implications and applications. Below is a thematic summary of the discussion.

• Diversion of safer supply

  While safer supply programs aim to provide individuals with a safer alternative to street drugs, the issue of diversion has emerged as a potential problem.

  The public health impact of diversion remains unknown. More research is necessary to better understand the dynamics surrounding diversion and its implications, including whether medications are being diverted to youth or being found in schools.

  Qualitative data emphasized that sharing of safer supply medications primarily occurs between family members or friends in need, to prevent loved ones from accessing the toxic street drug market. In some cases, people share medications when they are unable to fill their prescriptions.

  A survey in BC found that over 50% of respondents did not receive enough medication through safer supply to manage withdrawal symptoms, leading them to seek additional supply from the illicit market.

  To prevent diversion of safer supply medications, addressing barriers to accessing sufficient and holistic substance use health care is crucial. Broad availability of appropriate medications and integrated patient-oriented programs are needed to meet complex care needs.

  Many of the mechanisms of diversion are a consequence of inadequate access to care and the need for improved safer supply and opioid agonist therapy (OAT) programs.

  Surveillance measures like urine drug screening were criticized for being dehumanizing and creating additional barriers. Research during the COVID-19 pandemic showed that loosening restrictions on take-home doses of medications like methadone improved treatment retention without increasing harm or overdoses.

  Researchers stressed the importance of utilizing substantial data from buprenorphine and methadone literature when considering the issue of diversion. Studies have shown the term "diversion" may not accurately capture the circumstances, for example, many individuals receiving these medications may share their supply to help a friend or family member.

  A report conducted in BC found that hydromorphone, one of the safer supply medications, had minimal involvement in overdose deaths.

  There is a need for accurate population-level estimates of the number of people using drugs. Without this information, it is premature to conclude that diversion is widespread and increasing the number of individuals at risk of overdose.

  Reading recommendations provided in MS Teams chat:

  • “People need them or else they’re going to take fentanyl and die”: A qualitative study examining the ‘problem’ of prescription opioid diversion during an overdose epidemic
  • Reframing Diversion for Health Care Providers: Frequently Asked Questions
  • Methadone diversion as a protective strategy: The harm reduction potential of ‘generous constraints’
• Community opposition to safer supply programs

  Most safer supply programs did not encounter community opposition. In the current study to date, the level of opposition was minimal, with only two sites experiencing issues. These sites were attempting to introduce a new program or service.

  Most people in the community cannot discern the nature of the services offered at sites. The addition of OAT to safer supply programs has generally been well-received, while other services may encounter some opposition.

  It is important to consider each community’s unique circumstances and dynamics when implementing prevention strategies. By understanding and addressing potential concerns, it is possible to foster greater acceptance and support for safer supply programs and related initiatives.

• Safer supply considerations for rural settings

  Various structural barriers and unique challenges exist in rural settings, including privacy concerns and stigma.

  Engaging with communities and seeking their feedback and guidance is crucial to begin to address barriers. By working closely with communities, safer supply programs can be tailored to address the unique circumstances and requirements of different populations and settings, promoting better outcomes.

• Big picture from early findings

  Safer supply medications are only one component within a larger approach. The term "wraparound" is sometimes used as a buzzword to imply well-resourced programs, when in reality, these services are often understaffed.

  The nature of wraparound services depends on the individual’s specific needs and should aim to prevent individuals from being bounced around between different service providers.

  A program administrator from a community health centre shared their perspective on wraparound services, emphasizing the importance of a multidisciplinary team that acts as various touchpoints. The team includes professionals from nursing, physiotherapy, social work, psychiatry, infectious disease, and HIV-AIDS, among others. The goal is to address both social and medical concerns together.

  The discussion also highlighted the need for social navigators, access to Elders and Knowledge Keepers, cultural wellness supports, traditional medicines, Western counseling models, outreach programs, assistance with chronic pain, housing, legal matters, and mobile health services.

  Experiences shared from New Brunswick revealed challenges within the health care system. Efforts are being made to provide wraparound services. The program is elevating the voices of participants and raising awareness through organizing community events. Addressing dental care issues has been a challenge. Partnerships with community organizations (e.g., local library) have facilitated an employment support program.

  The importance of having sufficient staff and resources to provide wraparound services was stressed.

• Supervised consumption sites (SCS)

  Although these interventions have proven effective in meeting clients’ needs, additional requirements are often imposed without an increase in resources.

  The focus should extend beyond making referrals; there is a need to ensure that people can access the necessary services. Stable housing was identified as a critical service often lacking in many communities. While SCS can save lives, it is essential to consider the holistic needs of individuals.

• General remarks

  The opportunity to scale up initiatives was lost when the fentanyl crisis emerged.

  While diversion of safer supply medications receives significant media attention, positive aspects and outcomes of harm reduction programs should be emphasized more. It is important to counter ongoing disinformation campaigns and move towards implementation and scaling up of programs that have demonstrated effectiveness.

  Evidence supporting these programs needs must continue to be built, and any confusion surrounding them should be addressed.

  It is important to have clear definitions and understanding of what is meant by "safer supply."

  It is unfair to place the burden of advocating for basic rights solely on vulnerable individuals. Communities need to come together and take action to protect those at risk immediately.

  Legislation change may take decades while people’s lives are in immediate danger. In Alberta, there are barriers to opening overdose prevention sites, preventing people from accessing life-saving care.

  Both medical and community models for safer supply programs are needed. Legalization may play a role in enabling these initiatives to be implemented effectively.

  Thank you to all who participated in this midpoint knowledge exchange forum.

For more information

Since this midpoint knowledge exchange forum, the following paper has been published: Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

The meeting book for this forum is available to the public upon request. Requests can be directed to the CIHR Contact Centre: support-soutien@cihr-irsc.gc.ca.

More information on CIHR’s Research in Substance Use initiative can be found online at: Research in Substance Abuse.

For more information on CIHR’s Institute of Neurosciences, Mental Health and Addiction, visit the INMHA homepage or email INMHA-INSMT@cihr-irsc.gc.ca.

Date modified:

2023-11-01