"If it wasn't for them, I don't think I would be here": experiences of the first year of a safer supply program during the dual public health emergencies of COVID-19 and the drug toxicity crisis.

BACKGROUND: In response to the devastating drug toxicity crisis in Canada driven by an unregulated opioid supply predominantly composed of fentanyl and analogues, safer supply programs have been introduced. These programs provide people using street-acquired opioids with prescribed, pharmaceutical opioids. We use six core components of safer supply programs identified by people who use drugs to explore participant perspectives on the first year of operations of a safer supply program in Victoria, BC, during the dual public health emergencies of COVID-19 and the drug toxicity crisis to examine whether the program met drug-user defined elements of an effective safer supply model. METHODS: This study used a community-based participatory research approach to ensure that the research was reflective of community concerns and priorities, rather than being extractive. We interviewed 16 safer supply program participants between December 2020 and June 2021. Analysis was structured using the six core components of effective safer supply from the perspective of people who use drugs, generated through a prior study. RESULTS: Ensuring access to the 'right dose and right drugs' of medications was crucial, with many participants reporting success with the available pharmaceutical options. However, others highlighted issues with the strength of the available medications and the lack of options for smokeable medications. Accessing the safer supply program allowed participants to reduce their use of drugs from unregulated markets and manage withdrawal, pain and cravings. On components related to program operations, participants reported receiving compassionate care, and that accessing the safer supply program was a non-stigmatizing experience. They also reported receiving support to find housing, access food, obtain ID, and other needs. However, participants worried about long term program sustainability. CONCLUSIONS: Participants in the safer supply program overwhelmingly appreciated it and felt it was lifesaving, and unlike other healthcare or treatment services they had previously accessed. Participants raised concerns that unless a wider variety of medications and ability to consume them by multiple routes of administration became available, safer supply programs would remain unable to completely replace substances from unregulated markets.

Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada.

OBJECTIVES: Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. METHODS: The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. RESULTS: We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. CONCLUSION: Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.

Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario.

BACKGROUND: London InterCommunity Health Centre (LIHC) launched a safer opioid supply (SOS) program in 2016, where clients are prescribed pharmaceutical opioids and provided with comprehensive health and social supports. We sought to evaluate the impact of this program on health services utilization and health care costs. METHODS: We conducted an interrupted time series analysis of London, Ontario, residents who received a diagnosis of opioid use disorder (OUD) and who entered the SOS program between January 2016 and March 2019, and a comparison group of individuals matched on demographic and clinical characteristics who were not exposed to the program. Primary outcomes were emergency department (ED) visits, hospital admissions, admissions for infections and health care costs. We used autoregressive integrated moving average (ARIMA) models to evaluate the impact of SOS initiation and compared outcome rates in the year before and after cohort entry. RESULTS: In the time series analysis, rates of ED visits (-14 visits/100, 95% confidence interval [CI] -26 to -2; p = 0.02), hospital admissions (-5 admissions/100, 95% CI -9 to -2; p = 0.005) and health care costs not related to primary care or outpatient medications (-$922/person, 95% CI -$1577 to -$268; p = 0.008) declined significantly after entry into the SOS program (n = 82), with no significant change in rates of infections (-1.6 infections/100, 95% CI -4.0 to 0.8; p = 0.2). In the year after cohort entry, the rate of ED visits (rate ratio [RR] 0.69, 95% CI 0.53 to 0.90), hospital admissions (RR 0.46, 95% CI 0.29 to 0.74), admissions for incident infections (RR 0.51, 95% CI 0.27 to 0.96) and total health care costs not related to primary care or outpatient medications ($15 635 v. $7310/person-year; p = 0.002) declined significantly among SOS clients compared with the year before. We observed no significant change in any of the primary outcomes among unexposed individuals (n = 303). INTERPRETATION: Although additional research is needed, this preliminary evidence indicates that SOS programs can play an important role in the expansion of treatment and harm-reduction options available to assist people who use drugs and who are at high risk of drug poisoning.

Spotting as a risk mitigation method: A qualitative study comparing organization-based and informal methods.

OBJECTIVES: To explore the similarities and differences of organization-based and informal spotting (remote supervision of substance use) from the perspectives of spotters and spottees across Canada. METHODS: Spotters and spottees who spot informally and for organizations were recruited across Ontario and Nova Scotia. We interviewed 20 informal and 10 organization-based participants by phone using semi-structured interviews between 08/2020 and 11/2020. Participants were asked about each methods benefits and limitations. Interviews were audio-recorded, transcribed, and analyzed thematically. RESULTS: Benefits of informal spotting included its ability to strengthen social connections and foster autonomy in overdose response planning. The lack of support for informal spotters created stress and burnout. Organization-based spotters enjoyed the spotting training and support provided. However, regulations surrounding having to call ambulance in overdose events deterred many people from wanting to work for or call these services. CONCLUSIONS: Both organization-based and informal spotting have a role in mitigating harms associated with the overdose crisis. Moving forward, further research is needed on how to optimize these services for all people who use drugs in varying jurisdictions internationally.

Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

BACKGROUND: Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS: We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS: We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS: Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.

"COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada.

OBJECTIVES: In the context of the ongoing overdose crisis, a stark increase in toxic drug deaths from the unregulated street supply accompanied the onset of the COVID-19 pandemic. Injectable opioid agonist treatment (iOAT - hydromorphone or medical-grade heroin), tablet-based iOAT (TiOAT), and safer supply prescribing are emerging interventions used to address this crisis in Canada. Given rapid clinical guidance and policy change to enable their local adoption, our objectives were to describe the state of these interventions before the pandemic, and to document and explain changes in implementation during the early pandemic response (March-May 2020). METHODS: Surveys and interviews with healthcare providers comprised this mixed methods national environmental scan of iOAT, TiOAT, and safer supply across Canada at two time points. Quantitative data were summarized using descriptive statistics; interview data were coded and analyzed thematically. RESULTS: 103 sites in 6 Canadian provinces included 19 iOAT, 3 TiOAT and 21 safer supply sites on March 1, 2020; 60 new safer supply sites by May 1 represented a 285% increase. Most common substances were opioids, available at all sites; most common settings were addiction treatment programs and primary care clinics, and onsite pharmacies models. 79% of safer supply services were unfunded. Diversity in service delivery models demonstrated broad adaptability. Qualitative data reinforced the COVID-19 pandemic as the driving force behind scale-up. DISCUSSION: Data confirmed the capacity for rapid scale-up of flexible, community-based safer supply prescribing during dual public health emergencies. Geographical, client demographic, and funding gaps highlight the need to target barriers to implementation, service delivery and sustainability.

Critical studies of harm reduction: Overdose response in uncertain political times.

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada.

BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender. METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender. RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men. CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

'It's our safe sanctuary': Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario.

BACKGROUND: Overdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada. METHODS: We used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model. RESULTS: The OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs. CONCLUSION: The unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.