Promoting a safer drug supply through controlled access to regulated drugs is controversial but has the potential to reduce overdose risk and improve public health. This study outlined perspectives of participants in a safer supply program to determine whether the program met their needs.
l
Innovative harm reduction strategies have major potential to reduce the burden of opioid and other drug use disorder through reduced overdoses and improved public health (e.g., reducing infectious disease that can be transmitted through needle sharing). This was especially true during the beginning of COVID-19 pandemic, when overdose rates increased greatly. One novel harm reduction approach is safer supply programs, which were increased in Canada during the pandemic to help address the upsurge in overdose deaths.
Safer supply programs (used interchangeably with “safe supply” programs) provide typically illegal substances with known doses and compositions to people who use drugs, who otherwise obtain drugs from unregulated markets. This access to a regulated version of the substance decreases exposure to drugs contaminated with a substance they do not wish to consume (e.g., fentanyl) or has an unknown dose, thereby decreasing risk of accidental overdose. These programs range from versions that are medicalized with a provider prescribing the drugs to non-medicalized, characterized by “grassroots” efforts. Examples of non-medicalized programs include “compassion” or “buyer’s” clubs, where substances of known compositions are distributed to its members. However, only medicalized programs have been scaled up in Canada, since non-medicalized programs are not yet legal. Medicalized programs have been associated with several positive outcomes, including reductions in overdose and unregulated drug use, improved health, and improved social outcomes (e.g., housing stability).
The Victoria Safer Alternatives for Emergency Response (SAFER) program is strongly grounded in the perspectives of people who use drugs. This community-based program is operated by a local health organization (AVI Health and Community Services) and a local organization of people who use drugs (SOLID Outreach). The program provides prescriptions for safer opioids and stimulants along with primary care and social services. Researchers in this study explored the experiences and opinions of people participating in the SAFER program during its year of implementation, which coincided with the beginning of the COVID-19 pandemic. Such research can help identify strengths and opportunities of safer supply programs, especially at a time when overdose risk is elevated.
In this qualitative study, the research team interviewed participants enrolled in the SAFER program. Participants were asked about their experiences with and opinions of the SAFER program to determine whether the program met their needs.
A community-based participatory research approach was used in this study. This means that people who use drugs were involved in every step of the research process, from its initial conceptualization through reporting of the results. Such an approach centers concerns of the affected community and program participants, in addition to those of researchers, service providers, and decision-makers.
Interviews were conducted in-person and by telephone between December 2020 and June 2021. When the interview was in-person, they were conducted in homeless encampments to meet people where they were. Interviews lasted 45-60 minutes and were audio recorded. Participants were compensated 30 Canadian dollars for their time.
Recordings of the interviews were transcribed and then imported into a qualitative software program (NVivo) to help facilitate coding. Members of the research team coded data from the transcripts by reviewing transcripts, developing initial codes, and creating a coding framework. The analysis was guided by the 6 core components from the prior study that was conducted to inform the development of the SAFER program, which was led by people who used or are using drugs, in partnership with local organizations and researchers from the University of Victoria.
Participants were recruited from a larger study that evaluated the implementation and impact of prescribing drugs to reduce overdose risk (i.e., “risk mitigation prescribing”) throughout Canadian provinces. This larger study included 55 people who use drugs and were trying to obtain a prescription for drugs to mitigate their overdose risk. These people were interviewed about their experiences. Among them, 16 participants reported being involved in the SAFER program, which formed the sample for the current study.
Of the 16 participants, 14 identified as men and 2 identified as women. The majority did not disclose their race/ethnicity, though 6 identified as Indigenous. The vast majority (14) reported unstable housing conditions, which included living in homeless encampments, shelters, and staying with friends or family. For education, 6 participants reported that they completed high school, 4 did not, and 3 reported that they had some college education. Finally, 8 participants reported using opioids only, 3 reported using stimulants only, and 5 reported using both opioids and stimulants.
Perspectives varied on the program’s ability to meet their substance use needs
Participants varied in their responses regarding whether the type of medication, dose, strength, administration route, and formulations provided by the program were effective. Overall, the variety of medications available seemed important to meeting participants’ individual needs, but participants expressed concerns that without more variety of medications and administration routes, the program would not be able to entirely replace substance use from unregulated markets.
Some participants reported the dose and amount of medications provided was “perfect” and were “very satisfied” with it. Others reported that fentanyl patches were an effective addition to the pills, as they helped to manage pain and withdrawal. However, others expressed that the oral route of administration “took a while … to kick in.” Participants also identified a need for smokeable medications and a safer supply of stimulants.
Participants were able to have input on their dose, which gave them the flexibility to find what might be most effective for them. For example, some participants reported needing a combination of short- and long-term acting opioids to effectively alleviate their withdrawal symptoms. Another reported that they knew they had the option to ask for a higher dose, but did not want to for health reasons. Participants also expressed issues with obtaining a strength of medications that were strong enough to replace substances from unregulated markets.
All participants felt the quality of the generic version of hydromophone was inferior to that of the brand name, questioning its effectiveness.
Participants felt the program was welcoming and respectful, expressed concerns about consequences of program discontinuation
The majority of participants reported that the care they received through the SAFER program was compassionate and non-stigmatizing, which made them feel welcomed and respected. They experienced it as distinct from other healthcare settings that were negative, where staff were “just really rude.” In addition, participants appreciated that SAFER staff would locate them if they missed their medications and that “it’s nice to have the help. And have someone there that it actually feels like somebody cares to help.” Participants also reported feeling respected when interacting with staff and appreciated how they went beyond what was required.
The program’s ability to provide a safe and welcoming experience was in large part a result of participant feedback that was used for quality improvement. Participants felt that feedback from people who use drugs gave people a voice to express what aspects of the program are important to its design and implementation, as well as what is working well. Participants also commented that rapport with caring staff facilitated their positive experiences with the program.
Participants expressed fear about what they would do if the program was cancelled and were concerned about not having any other option but to return to the unregulated supply of drugs. For instance, one participant stated that without the SAFER program, “it’s going to be a hell of a lot worse,” and another said, “I guess I’d be stuck to the fentanyl … Completely depressed. And, stuck to the thing that I want to get rid of.”
Participants appreciated active outreach, though accessibility remains a barrier
Participants reported that outreach workers coming to them, wherever they were living (e.g., homeless encampments, shelters, etc.) was important for them to learn about the program and connecting them with other health services. This removed the barriers of transportation and navigating complex systems of care. For example, one participant commented that “It’s great for people who are like living on the street and that don’t have nothing left.” Another commented that, because the outreach came to them “… it makes it easier if you’re homeless. You don’t have to take a chunk out of your day, just figuring out how that’s all going to work.”
Similarly, participants appreciated that the outreach workers were able to connect them with a variety of other healthcare services through one provider. Program staff worked together to coordinate care for participants, such as SAFER nurses facilitating access to prescriptions. Outreach workers were also able to help participants with other social needs, including finding housing, obtaining food, getting IDs, and facilitating personal supports (e.g., reconnecting with family members).
Although many participants expressed that the SAFER program was able to effectively remove barriers to access the program, others commented how they did not know where to go to access the program or learn more about it. One participant suggested that accessing the program was by chance, since they learned about it when an outreach worker happened to pass by their tent. These barriers stem from budget constraints that limits the capacity of the program and prescribers’ inability or unwillingness to take on patients.
Other barriers included difficulty making it to the pharmacy every day, since participants had to pick up their medications daily at a pharmacy. This difficulty was attributed to mobility problems, health conditions, and fear of having their items confiscated by police if they left their encampment. Some participants also expressed that they felt stigmatized when picking up their prescriptions by pharmacy staff. However, some participants appreciated the structure of going to the pharmacy and how it helped them regulate the amount of medication they possessed. Delivery of medications was also an option, but there were mixed feelings about it, with some appreciating it and others expressing the risk of missing the drop-off meant that they could not get their dose that day.
Participants’ quality of life was improved
Many participants reported that the SAFER program reduced their reliance on drugs from unregulated markets. There were mixed reports however about the effects of this, with one participant reporting that while their fentanyl use decreased by half, “it doesn’t have that same sensation of euphoria or actually feeling high,” but another who had previously been smoking fentanyl appreciating the transition to oral medication and stating that it still resulted in euphoria. This safer supply of drugs resulted in fewer overdoses.
Participants also reported that having access to a safer supply of drugs allowed them to manage their withdrawal symptoms and cravings, which helped them feel better in their daily lives. However, chronic pain remained a challenge, with several participants reporting that they had to supplement the prescribed drugs with street drugs to adequately relieve their pain. Additionally, some participants reported that the program both reduced criminal activity and increased prosocial activity, by reducing natural incentives for illegal behaviors (e.g., robbery) to obtain money for drugs. Other participants reported that the program sparked motivations to eventually quit using drugs and how it helped to improve their mood and energy levels.
The research team interviewed participants enrolled in the SAFER drug supply program during its first year of implementation to understand their experiences with the SAFER program and determine whether the program met their needs. Several strengths and opportunities were identified. Key strengths of the program included: a reduction in participants’ use of drugs from unregulated markets, resulting in fewer overdoses; effective management of withdrawal symptoms and cravings; program accessibility due to outreach staff coming to where participants are; connecting participants with other medical and social services; program staff treating participants with respect; and improved quality of life. Key opportunities included: a need for a greater variety of medication options, formulations, and administration routes; improvements to accessibility (e.g., not making participants come to the pharmacy every day and greater outreach efforts to improve awareness of the program); and a need for program sustainability.
In accordance with the principles of harm reduction, one SAFER program strength identified by many participants was its ability to “meet people where they are”. Outreach was conducted by staff directly in homeless encampments, increasing its accessibility to vulnerable populations that are not being served through traditional health care or social services. This was critical for reducing overdoses, since there is an increased risk of drug overdoses among this population, which was even higher during the COVID-19 pandemic.
Although the qualitative nature of this study does not allow the researchers to conclude that the SAFER program caused a reduction in overdoses, the results of this study provide evidence that participants did not rely as much on unregulated drugs, which led to reports of fewer overdoses among participants. At the same time, another recent study suggests a safer supply program was associated with increased opioid use related hospitalizations – an iatrogenic effect. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations. Overall, these results add to the growing number of harm reduction strategies that, when implemented along with a broader, multi-level public health strategy, could achieve population-wide reductions in overdoses and improved health.
Participant experiences with a safer drug supply program during its first year of implementation were generally positive, including a perceived reduction in the use of drugs from unregulated markets, enhanced ability to manage withdrawal and cravings, connections to medical and social services, rapport with program staff, and improved quality of life. Opportunities remain, however, for the program to provide a greater variety of medication options, formulations, and administration routes, to improve accessibility and to sustain the program for the long-term. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations.
Kolla, G., Pauly, B., Cameron, F., Hobbs, H., Ranger, C., McCall, J., Majalahti, J., Toombs, K., LeMaistre, J., Selfridge, M., & Urbanoski, K. (2024). “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. Harm Reduction Journal, 21(111). doi: 10.1186/s12954-024-01029-3.
l
Innovative harm reduction strategies have major potential to reduce the burden of opioid and other drug use disorder through reduced overdoses and improved public health (e.g., reducing infectious disease that can be transmitted through needle sharing). This was especially true during the beginning of COVID-19 pandemic, when overdose rates increased greatly. One novel harm reduction approach is safer supply programs, which were increased in Canada during the pandemic to help address the upsurge in overdose deaths.
Safer supply programs (used interchangeably with “safe supply” programs) provide typically illegal substances with known doses and compositions to people who use drugs, who otherwise obtain drugs from unregulated markets. This access to a regulated version of the substance decreases exposure to drugs contaminated with a substance they do not wish to consume (e.g., fentanyl) or has an unknown dose, thereby decreasing risk of accidental overdose. These programs range from versions that are medicalized with a provider prescribing the drugs to non-medicalized, characterized by “grassroots” efforts. Examples of non-medicalized programs include “compassion” or “buyer’s” clubs, where substances of known compositions are distributed to its members. However, only medicalized programs have been scaled up in Canada, since non-medicalized programs are not yet legal. Medicalized programs have been associated with several positive outcomes, including reductions in overdose and unregulated drug use, improved health, and improved social outcomes (e.g., housing stability).
The Victoria Safer Alternatives for Emergency Response (SAFER) program is strongly grounded in the perspectives of people who use drugs. This community-based program is operated by a local health organization (AVI Health and Community Services) and a local organization of people who use drugs (SOLID Outreach). The program provides prescriptions for safer opioids and stimulants along with primary care and social services. Researchers in this study explored the experiences and opinions of people participating in the SAFER program during its year of implementation, which coincided with the beginning of the COVID-19 pandemic. Such research can help identify strengths and opportunities of safer supply programs, especially at a time when overdose risk is elevated.
In this qualitative study, the research team interviewed participants enrolled in the SAFER program. Participants were asked about their experiences with and opinions of the SAFER program to determine whether the program met their needs.
A community-based participatory research approach was used in this study. This means that people who use drugs were involved in every step of the research process, from its initial conceptualization through reporting of the results. Such an approach centers concerns of the affected community and program participants, in addition to those of researchers, service providers, and decision-makers.
Interviews were conducted in-person and by telephone between December 2020 and June 2021. When the interview was in-person, they were conducted in homeless encampments to meet people where they were. Interviews lasted 45-60 minutes and were audio recorded. Participants were compensated 30 Canadian dollars for their time.
Recordings of the interviews were transcribed and then imported into a qualitative software program (NVivo) to help facilitate coding. Members of the research team coded data from the transcripts by reviewing transcripts, developing initial codes, and creating a coding framework. The analysis was guided by the 6 core components from the prior study that was conducted to inform the development of the SAFER program, which was led by people who used or are using drugs, in partnership with local organizations and researchers from the University of Victoria.
Participants were recruited from a larger study that evaluated the implementation and impact of prescribing drugs to reduce overdose risk (i.e., “risk mitigation prescribing”) throughout Canadian provinces. This larger study included 55 people who use drugs and were trying to obtain a prescription for drugs to mitigate their overdose risk. These people were interviewed about their experiences. Among them, 16 participants reported being involved in the SAFER program, which formed the sample for the current study.
Of the 16 participants, 14 identified as men and 2 identified as women. The majority did not disclose their race/ethnicity, though 6 identified as Indigenous. The vast majority (14) reported unstable housing conditions, which included living in homeless encampments, shelters, and staying with friends or family. For education, 6 participants reported that they completed high school, 4 did not, and 3 reported that they had some college education. Finally, 8 participants reported using opioids only, 3 reported using stimulants only, and 5 reported using both opioids and stimulants.
Perspectives varied on the program’s ability to meet their substance use needs
Participants varied in their responses regarding whether the type of medication, dose, strength, administration route, and formulations provided by the program were effective. Overall, the variety of medications available seemed important to meeting participants’ individual needs, but participants expressed concerns that without more variety of medications and administration routes, the program would not be able to entirely replace substance use from unregulated markets.
Some participants reported the dose and amount of medications provided was “perfect” and were “very satisfied” with it. Others reported that fentanyl patches were an effective addition to the pills, as they helped to manage pain and withdrawal. However, others expressed that the oral route of administration “took a while … to kick in.” Participants also identified a need for smokeable medications and a safer supply of stimulants.
Participants were able to have input on their dose, which gave them the flexibility to find what might be most effective for them. For example, some participants reported needing a combination of short- and long-term acting opioids to effectively alleviate their withdrawal symptoms. Another reported that they knew they had the option to ask for a higher dose, but did not want to for health reasons. Participants also expressed issues with obtaining a strength of medications that were strong enough to replace substances from unregulated markets.
All participants felt the quality of the generic version of hydromophone was inferior to that of the brand name, questioning its effectiveness.
Participants felt the program was welcoming and respectful, expressed concerns about consequences of program discontinuation
The majority of participants reported that the care they received through the SAFER program was compassionate and non-stigmatizing, which made them feel welcomed and respected. They experienced it as distinct from other healthcare settings that were negative, where staff were “just really rude.” In addition, participants appreciated that SAFER staff would locate them if they missed their medications and that “it’s nice to have the help. And have someone there that it actually feels like somebody cares to help.” Participants also reported feeling respected when interacting with staff and appreciated how they went beyond what was required.
The program’s ability to provide a safe and welcoming experience was in large part a result of participant feedback that was used for quality improvement. Participants felt that feedback from people who use drugs gave people a voice to express what aspects of the program are important to its design and implementation, as well as what is working well. Participants also commented that rapport with caring staff facilitated their positive experiences with the program.
Participants expressed fear about what they would do if the program was cancelled and were concerned about not having any other option but to return to the unregulated supply of drugs. For instance, one participant stated that without the SAFER program, “it’s going to be a hell of a lot worse,” and another said, “I guess I’d be stuck to the fentanyl … Completely depressed. And, stuck to the thing that I want to get rid of.”
Participants appreciated active outreach, though accessibility remains a barrier
Participants reported that outreach workers coming to them, wherever they were living (e.g., homeless encampments, shelters, etc.) was important for them to learn about the program and connecting them with other health services. This removed the barriers of transportation and navigating complex systems of care. For example, one participant commented that “It’s great for people who are like living on the street and that don’t have nothing left.” Another commented that, because the outreach came to them “… it makes it easier if you’re homeless. You don’t have to take a chunk out of your day, just figuring out how that’s all going to work.”
Similarly, participants appreciated that the outreach workers were able to connect them with a variety of other healthcare services through one provider. Program staff worked together to coordinate care for participants, such as SAFER nurses facilitating access to prescriptions. Outreach workers were also able to help participants with other social needs, including finding housing, obtaining food, getting IDs, and facilitating personal supports (e.g., reconnecting with family members).
Although many participants expressed that the SAFER program was able to effectively remove barriers to access the program, others commented how they did not know where to go to access the program or learn more about it. One participant suggested that accessing the program was by chance, since they learned about it when an outreach worker happened to pass by their tent. These barriers stem from budget constraints that limits the capacity of the program and prescribers’ inability or unwillingness to take on patients.
Other barriers included difficulty making it to the pharmacy every day, since participants had to pick up their medications daily at a pharmacy. This difficulty was attributed to mobility problems, health conditions, and fear of having their items confiscated by police if they left their encampment. Some participants also expressed that they felt stigmatized when picking up their prescriptions by pharmacy staff. However, some participants appreciated the structure of going to the pharmacy and how it helped them regulate the amount of medication they possessed. Delivery of medications was also an option, but there were mixed feelings about it, with some appreciating it and others expressing the risk of missing the drop-off meant that they could not get their dose that day.
Participants’ quality of life was improved
Many participants reported that the SAFER program reduced their reliance on drugs from unregulated markets. There were mixed reports however about the effects of this, with one participant reporting that while their fentanyl use decreased by half, “it doesn’t have that same sensation of euphoria or actually feeling high,” but another who had previously been smoking fentanyl appreciating the transition to oral medication and stating that it still resulted in euphoria. This safer supply of drugs resulted in fewer overdoses.
Participants also reported that having access to a safer supply of drugs allowed them to manage their withdrawal symptoms and cravings, which helped them feel better in their daily lives. However, chronic pain remained a challenge, with several participants reporting that they had to supplement the prescribed drugs with street drugs to adequately relieve their pain. Additionally, some participants reported that the program both reduced criminal activity and increased prosocial activity, by reducing natural incentives for illegal behaviors (e.g., robbery) to obtain money for drugs. Other participants reported that the program sparked motivations to eventually quit using drugs and how it helped to improve their mood and energy levels.
The research team interviewed participants enrolled in the SAFER drug supply program during its first year of implementation to understand their experiences with the SAFER program and determine whether the program met their needs. Several strengths and opportunities were identified. Key strengths of the program included: a reduction in participants’ use of drugs from unregulated markets, resulting in fewer overdoses; effective management of withdrawal symptoms and cravings; program accessibility due to outreach staff coming to where participants are; connecting participants with other medical and social services; program staff treating participants with respect; and improved quality of life. Key opportunities included: a need for a greater variety of medication options, formulations, and administration routes; improvements to accessibility (e.g., not making participants come to the pharmacy every day and greater outreach efforts to improve awareness of the program); and a need for program sustainability.
In accordance with the principles of harm reduction, one SAFER program strength identified by many participants was its ability to “meet people where they are”. Outreach was conducted by staff directly in homeless encampments, increasing its accessibility to vulnerable populations that are not being served through traditional health care or social services. This was critical for reducing overdoses, since there is an increased risk of drug overdoses among this population, which was even higher during the COVID-19 pandemic.
Although the qualitative nature of this study does not allow the researchers to conclude that the SAFER program caused a reduction in overdoses, the results of this study provide evidence that participants did not rely as much on unregulated drugs, which led to reports of fewer overdoses among participants. At the same time, another recent study suggests a safer supply program was associated with increased opioid use related hospitalizations – an iatrogenic effect. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations. Overall, these results add to the growing number of harm reduction strategies that, when implemented along with a broader, multi-level public health strategy, could achieve population-wide reductions in overdoses and improved health.
Participant experiences with a safer drug supply program during its first year of implementation were generally positive, including a perceived reduction in the use of drugs from unregulated markets, enhanced ability to manage withdrawal and cravings, connections to medical and social services, rapport with program staff, and improved quality of life. Opportunities remain, however, for the program to provide a greater variety of medication options, formulations, and administration routes, to improve accessibility and to sustain the program for the long-term. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations.
Kolla, G., Pauly, B., Cameron, F., Hobbs, H., Ranger, C., McCall, J., Majalahti, J., Toombs, K., LeMaistre, J., Selfridge, M., & Urbanoski, K. (2024). “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. Harm Reduction Journal, 21(111). doi: 10.1186/s12954-024-01029-3.
l
Innovative harm reduction strategies have major potential to reduce the burden of opioid and other drug use disorder through reduced overdoses and improved public health (e.g., reducing infectious disease that can be transmitted through needle sharing). This was especially true during the beginning of COVID-19 pandemic, when overdose rates increased greatly. One novel harm reduction approach is safer supply programs, which were increased in Canada during the pandemic to help address the upsurge in overdose deaths.
Safer supply programs (used interchangeably with “safe supply” programs) provide typically illegal substances with known doses and compositions to people who use drugs, who otherwise obtain drugs from unregulated markets. This access to a regulated version of the substance decreases exposure to drugs contaminated with a substance they do not wish to consume (e.g., fentanyl) or has an unknown dose, thereby decreasing risk of accidental overdose. These programs range from versions that are medicalized with a provider prescribing the drugs to non-medicalized, characterized by “grassroots” efforts. Examples of non-medicalized programs include “compassion” or “buyer’s” clubs, where substances of known compositions are distributed to its members. However, only medicalized programs have been scaled up in Canada, since non-medicalized programs are not yet legal. Medicalized programs have been associated with several positive outcomes, including reductions in overdose and unregulated drug use, improved health, and improved social outcomes (e.g., housing stability).
The Victoria Safer Alternatives for Emergency Response (SAFER) program is strongly grounded in the perspectives of people who use drugs. This community-based program is operated by a local health organization (AVI Health and Community Services) and a local organization of people who use drugs (SOLID Outreach). The program provides prescriptions for safer opioids and stimulants along with primary care and social services. Researchers in this study explored the experiences and opinions of people participating in the SAFER program during its year of implementation, which coincided with the beginning of the COVID-19 pandemic. Such research can help identify strengths and opportunities of safer supply programs, especially at a time when overdose risk is elevated.
In this qualitative study, the research team interviewed participants enrolled in the SAFER program. Participants were asked about their experiences with and opinions of the SAFER program to determine whether the program met their needs.
A community-based participatory research approach was used in this study. This means that people who use drugs were involved in every step of the research process, from its initial conceptualization through reporting of the results. Such an approach centers concerns of the affected community and program participants, in addition to those of researchers, service providers, and decision-makers.
Interviews were conducted in-person and by telephone between December 2020 and June 2021. When the interview was in-person, they were conducted in homeless encampments to meet people where they were. Interviews lasted 45-60 minutes and were audio recorded. Participants were compensated 30 Canadian dollars for their time.
Recordings of the interviews were transcribed and then imported into a qualitative software program (NVivo) to help facilitate coding. Members of the research team coded data from the transcripts by reviewing transcripts, developing initial codes, and creating a coding framework. The analysis was guided by the 6 core components from the prior study that was conducted to inform the development of the SAFER program, which was led by people who used or are using drugs, in partnership with local organizations and researchers from the University of Victoria.
Participants were recruited from a larger study that evaluated the implementation and impact of prescribing drugs to reduce overdose risk (i.e., “risk mitigation prescribing”) throughout Canadian provinces. This larger study included 55 people who use drugs and were trying to obtain a prescription for drugs to mitigate their overdose risk. These people were interviewed about their experiences. Among them, 16 participants reported being involved in the SAFER program, which formed the sample for the current study.
Of the 16 participants, 14 identified as men and 2 identified as women. The majority did not disclose their race/ethnicity, though 6 identified as Indigenous. The vast majority (14) reported unstable housing conditions, which included living in homeless encampments, shelters, and staying with friends or family. For education, 6 participants reported that they completed high school, 4 did not, and 3 reported that they had some college education. Finally, 8 participants reported using opioids only, 3 reported using stimulants only, and 5 reported using both opioids and stimulants.
Perspectives varied on the program’s ability to meet their substance use needs
Participants varied in their responses regarding whether the type of medication, dose, strength, administration route, and formulations provided by the program were effective. Overall, the variety of medications available seemed important to meeting participants’ individual needs, but participants expressed concerns that without more variety of medications and administration routes, the program would not be able to entirely replace substance use from unregulated markets.
Some participants reported the dose and amount of medications provided was “perfect” and were “very satisfied” with it. Others reported that fentanyl patches were an effective addition to the pills, as they helped to manage pain and withdrawal. However, others expressed that the oral route of administration “took a while … to kick in.” Participants also identified a need for smokeable medications and a safer supply of stimulants.
Participants were able to have input on their dose, which gave them the flexibility to find what might be most effective for them. For example, some participants reported needing a combination of short- and long-term acting opioids to effectively alleviate their withdrawal symptoms. Another reported that they knew they had the option to ask for a higher dose, but did not want to for health reasons. Participants also expressed issues with obtaining a strength of medications that were strong enough to replace substances from unregulated markets.
All participants felt the quality of the generic version of hydromophone was inferior to that of the brand name, questioning its effectiveness.
Participants felt the program was welcoming and respectful, expressed concerns about consequences of program discontinuation
The majority of participants reported that the care they received through the SAFER program was compassionate and non-stigmatizing, which made them feel welcomed and respected. They experienced it as distinct from other healthcare settings that were negative, where staff were “just really rude.” In addition, participants appreciated that SAFER staff would locate them if they missed their medications and that “it’s nice to have the help. And have someone there that it actually feels like somebody cares to help.” Participants also reported feeling respected when interacting with staff and appreciated how they went beyond what was required.
The program’s ability to provide a safe and welcoming experience was in large part a result of participant feedback that was used for quality improvement. Participants felt that feedback from people who use drugs gave people a voice to express what aspects of the program are important to its design and implementation, as well as what is working well. Participants also commented that rapport with caring staff facilitated their positive experiences with the program.
Participants expressed fear about what they would do if the program was cancelled and were concerned about not having any other option but to return to the unregulated supply of drugs. For instance, one participant stated that without the SAFER program, “it’s going to be a hell of a lot worse,” and another said, “I guess I’d be stuck to the fentanyl … Completely depressed. And, stuck to the thing that I want to get rid of.”
Participants appreciated active outreach, though accessibility remains a barrier
Participants reported that outreach workers coming to them, wherever they were living (e.g., homeless encampments, shelters, etc.) was important for them to learn about the program and connecting them with other health services. This removed the barriers of transportation and navigating complex systems of care. For example, one participant commented that “It’s great for people who are like living on the street and that don’t have nothing left.” Another commented that, because the outreach came to them “… it makes it easier if you’re homeless. You don’t have to take a chunk out of your day, just figuring out how that’s all going to work.”
Similarly, participants appreciated that the outreach workers were able to connect them with a variety of other healthcare services through one provider. Program staff worked together to coordinate care for participants, such as SAFER nurses facilitating access to prescriptions. Outreach workers were also able to help participants with other social needs, including finding housing, obtaining food, getting IDs, and facilitating personal supports (e.g., reconnecting with family members).
Although many participants expressed that the SAFER program was able to effectively remove barriers to access the program, others commented how they did not know where to go to access the program or learn more about it. One participant suggested that accessing the program was by chance, since they learned about it when an outreach worker happened to pass by their tent. These barriers stem from budget constraints that limits the capacity of the program and prescribers’ inability or unwillingness to take on patients.
Other barriers included difficulty making it to the pharmacy every day, since participants had to pick up their medications daily at a pharmacy. This difficulty was attributed to mobility problems, health conditions, and fear of having their items confiscated by police if they left their encampment. Some participants also expressed that they felt stigmatized when picking up their prescriptions by pharmacy staff. However, some participants appreciated the structure of going to the pharmacy and how it helped them regulate the amount of medication they possessed. Delivery of medications was also an option, but there were mixed feelings about it, with some appreciating it and others expressing the risk of missing the drop-off meant that they could not get their dose that day.
Participants’ quality of life was improved
Many participants reported that the SAFER program reduced their reliance on drugs from unregulated markets. There were mixed reports however about the effects of this, with one participant reporting that while their fentanyl use decreased by half, “it doesn’t have that same sensation of euphoria or actually feeling high,” but another who had previously been smoking fentanyl appreciating the transition to oral medication and stating that it still resulted in euphoria. This safer supply of drugs resulted in fewer overdoses.
Participants also reported that having access to a safer supply of drugs allowed them to manage their withdrawal symptoms and cravings, which helped them feel better in their daily lives. However, chronic pain remained a challenge, with several participants reporting that they had to supplement the prescribed drugs with street drugs to adequately relieve their pain. Additionally, some participants reported that the program both reduced criminal activity and increased prosocial activity, by reducing natural incentives for illegal behaviors (e.g., robbery) to obtain money for drugs. Other participants reported that the program sparked motivations to eventually quit using drugs and how it helped to improve their mood and energy levels.
The research team interviewed participants enrolled in the SAFER drug supply program during its first year of implementation to understand their experiences with the SAFER program and determine whether the program met their needs. Several strengths and opportunities were identified. Key strengths of the program included: a reduction in participants’ use of drugs from unregulated markets, resulting in fewer overdoses; effective management of withdrawal symptoms and cravings; program accessibility due to outreach staff coming to where participants are; connecting participants with other medical and social services; program staff treating participants with respect; and improved quality of life. Key opportunities included: a need for a greater variety of medication options, formulations, and administration routes; improvements to accessibility (e.g., not making participants come to the pharmacy every day and greater outreach efforts to improve awareness of the program); and a need for program sustainability.
In accordance with the principles of harm reduction, one SAFER program strength identified by many participants was its ability to “meet people where they are”. Outreach was conducted by staff directly in homeless encampments, increasing its accessibility to vulnerable populations that are not being served through traditional health care or social services. This was critical for reducing overdoses, since there is an increased risk of drug overdoses among this population, which was even higher during the COVID-19 pandemic.
Although the qualitative nature of this study does not allow the researchers to conclude that the SAFER program caused a reduction in overdoses, the results of this study provide evidence that participants did not rely as much on unregulated drugs, which led to reports of fewer overdoses among participants. At the same time, another recent study suggests a safer supply program was associated with increased opioid use related hospitalizations – an iatrogenic effect. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations. Overall, these results add to the growing number of harm reduction strategies that, when implemented along with a broader, multi-level public health strategy, could achieve population-wide reductions in overdoses and improved health.
Participant experiences with a safer drug supply program during its first year of implementation were generally positive, including a perceived reduction in the use of drugs from unregulated markets, enhanced ability to manage withdrawal and cravings, connections to medical and social services, rapport with program staff, and improved quality of life. Opportunities remain, however, for the program to provide a greater variety of medication options, formulations, and administration routes, to improve accessibility and to sustain the program for the long-term. More rigorous research is needed to understand the benefits and risks and safer supply programs to inform clinical and public health recommendations.
Kolla, G., Pauly, B., Cameron, F., Hobbs, H., Ranger, C., McCall, J., Majalahti, J., Toombs, K., LeMaistre, J., Selfridge, M., & Urbanoski, K. (2024). “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. Harm Reduction Journal, 21(111). doi: 10.1186/s12954-024-01029-3.
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