SAFER SUPPLY

by the Opioid Poisoning Committee

October 4, 2023

View All Our Policy Recommendations Here

QUESTION

How could safer supply models be implemented in Alberta?

summary

Prescribed safer supply programs, developed in partnership with people who use drugs and prescribers, should be implemented in Alberta as an urgent measure to prevent the escalating number of drug poisoning injuries and deaths. Programs should include consideration of how potential unintended harms can be monitored and mitigated. They should be implemented with robust evaluation to add to the existing evidence-base in this area.

WHAT IS SAFER SUPPLY?

Safer supply is a public health strategy to reduce the exposure of people who use drugs to the possibility of drug poisoning resulting from a toxic drug supply. It involves the provision of a known quantity of a pharmaceutical substance that people can consume instead of substances of unknown potency and quality. It is not intended as addiction treatment and should not be confused with withdrawal management or opioid agonist treatment for substance use disorders (these separate interventions, however, must also be available for when people request them).

ACTION:

1.       Acknowledge that the context of substance use (e.g., potency and predictability of the illegal drug supply) is rapidly evolving and that updated, contextually relevant guidance is needed. The evidence base and experience of current Canadian safer supply models and the extensive literature on injectable opioid agonist treatment (diacetylmorphine and hydromorphone) should be used to inform planning.

2.       Local jurisdictions and/or individual providers who identify a need for safer supply models in their communities should be provided with resources and funding to develop a flexible and adaptive model tailored to local needs and substance use patterns and grounded in current and emerging evidence. This includes involving and reimbursing people who use drugs in the design, implementation, and monitoring of the program.

3.       Universities and researchers should provide program evaluation support and monitoring via an urgent call for scientifically reviewed provincial or national funding. Ideally, evaluation is ongoing, standardized, and coordinated across the province to allow adaptive programming and continuous improvement.

4. The College of Physicians and Surgeons of Alberta, Alberta College of Pharmacists, and College and Association of Registered Nurses of Alberta, alongside experienced opioid agonist prescribers, dispensing pharmacists, and people who use drugs, should develop an Alberta guidance document for prescribers and pharmacists. The document should provide practical guidance on implementing safe supply in their practice and how to balance the benefit of immediate risk reduction due to a toxic drug supply and the potential unintended harms at an individual and societal level. If barriers to implementation are identified at the legislative, federal, provincial, or local level, the organizations above should take the lead on convening efforts to address and remove obstacles to care. A National Safer Supply Community of Practice is also available to prescribers (https://www.nss-aps.ca).

5.       Prescribed safer opioid supply is an immediately feasible initial action that should precede further exploration of lower-threshold models where barriers to more medical models exist. Recognizing that polysubstance use consumed via a variety of routes is common, models must also be adapted for people who primarily use stimulants and for people who consume drugs primarily via inhalation/smoking.[i]

EVIDENCE:

  • Published literature remains limited given the novel nature of safer supply but is rapidly growing and expected to increase substantially in the coming years. Emerging evidence briefs on prescribed safer supply were released in May and July 2023.[ii],[iii]

  • There is no evidence to date that safer supply models are contributing to deaths due to drug poisoning [iv[,[v]

  • Flexible safer supply programs that involve some or all the following are currently being implemented and evaluated across Canada:

    • Prescription of drugs manufactured for oral consumption for intravenous use [vi]

    • Unsupervised use of prescription drugs (dispensed via a pharmacy or via a vending machine that uses biometric identification) [vii]

    • Formation of compassion clubs – legally sanctioned cooperative models of procuring substances for use [viii]

  • Emerging evidence [ii],[iii] from Canadian safer supply programs demonstrates overall benefit and low risk of harm. The preliminary evidence demonstrates the following signals:

    • Reduced risk of death and/or drug poisoning

    • Engagement and retention in programs and care

    • Improvements in physical and mental health

    • Fewer emergency department visits and hospitalizations

    • Decrease in hospitalizations for infectious complications

    • Reduced use of drugs from the unregulated street supply

    • Improved control over drug use

    • Improvements in social well-being and stability

    • Decline in health care costs

CONTEXT:

  • Drug poisoning deaths in Alberta increased dramatically during the COVID-19 pandemic and remain above pre-pandemic levels (from 800 in 2019 to 1498 in 2022) [ix]. This increase far outpaces population growth (1.6% population growth vs 87% rise in poisoning deaths).

  • This is in large part due to increasing toxicity in the illegal drug market [x]. Most deaths in the past five years did not involve a prescription; instead, recent observed reductions in opioid prescribing correspond with an increase in poisoning deaths as people have been driven to obtain drugs from the illegal market [vi],[vii].

  • Moreover, approximately one third of people presenting with a drug poisoning event to acute care do not meet the criteria for an opioid use disorder [vii], suggesting that approaches beyond addiction treatment alone must be considered.

  • Safer supply interventions are NOT addiction treatment. Safer supply is a distinct and complementary strategy intended to use a public health and morally neutral approach to prevent deaths and serious outcomes, including hospitalization, due to the current toxic drug supply [xi]. It should be implemented in parallel with a range of proven addiction treatment options accessible to people who request it.

  • A regulated supply of pharmaceutical grade opioids (with a known potency) is expected to mitigate the risk of using unregulated opioids from the illegal market which have an unknown and variable potency [xii].

  • A legacy of chemical control exists for many people who use drugs, in particular the racialized and colonized; people who use drugs should share in any decision-making about the models implemented to address this legacy (self-determination) [xiii].


References:

[i] Parent S, Papamiali K, Graham B, Buxton JA. Examining prevalence and correlates of smoking opioids in British Columbia: Opioids are more often smoked than injected. Substance Abuse Treatment, Prevention, and Policy 2021;16. DOI 10.1186/s13011-021-00414-6

[ii] National Safer Supply Community of Practice. (2023). Prescribed Safer Supply Programs: Emerging Evidence. Canada. https://www.nss-aps.ca/evidence-brief

[iii] The Ontario Drug Policy Research Network. Safer opioid supply: A rapid review of the evidence. Toronto, ON: Ontario Drug Policy Research Network; 2023.

[iv] BC Coroners Service. Unregulated Drug Deaths in B.C. (to April 30, 2023) https://www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports  Accessed June 19, 2023

[v] Gomes T, Murray R, Kolla G, Leece P, Kitchen S, Campbell T, et al. Patterns of medication and healthcare use among people who died of an opioid-related toxicity during the COVID-19 pandemic in Ontario. 2022: Ontario Drug Policy Research Network.

[vi]Ivsins A, Boyd J, Mayer S, Collins, Sutherland C, Kerr T, McNeil R. Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: A qualitative study. Drug Alcohol Depend 2020;216:108202. DOI 10.1016/j.drugalcdep.2020.108202

[vii] Bardwell G, Ivsins A, Mansoor M, Nolan S, Kerr T. Safer opioid supply via a biometric dispensing machine: a qualitative study of barriers, facilitators and associated outcomes. CMAJ 2023 May 15;195:E668-76. doi: 10.1503/cmaj.221550

[viii] British Columbia Centre on Substance Use. Heroin Compassion Clubs. 2019. https://www.bccsu.ca/wp-content/uploads/2019/02/Report-Heroin-Compassion-Clubs.pdf Accessed June 19, 2023.

[ix] Government of Alberta. Alberta Substance Use Surveillance System https://www.alberta.ca/substance-use-surveillance-data.aspx  Accessed June 19, 2023

[x] Canadian Centre on Substance Use and Addiction. 2020. https://www.ccsa.ca/changes-related-covid-19-illegal-drug-supply-and-access-services-and-resulting-health-harms  Accessed June 19, 2023.

[xi] Canadian Association of People Who Use Drugs. Safe Supply Concept Document. 2019. https://www.capud.ca/capud-resources/safe-supply-projects  Accessed June 19, 2023.

[xii] Rolles S, Schlag AK, Measham F, Phillips L, Nutt D, Bergsvik D, Rogeberg O. A Multi Criteria Decision Analysis (MCDA) for evaluating and appraising government policy responses to non medical heroin use. Int J Drug Policy 2021;91. DOI 10.1016/jdrugpo.2021.103180.

[xiii] Halseth R, Murdock L. Supporting Indigenous self-determination in health: Lessons learned from a review of best practices in health governance in Canada and internationally. 2020: National Collaborating Centre for Indigenous Health.