What We Heard: Knowledge Exchange Series on Safer Supply

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Organization: Health Canada

Cat.: H134-32/2023E-PDF

ISBN: 978-0-660-48056-5

Pub.: 220822

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About safer supply and the overdose crisis

The overdose crisis continues to have devastating impacts on individuals, families, and communities. The number of overdose deaths is being driven by a highly unpredictable and toxic illegal drug supply. From January 2016 to September 2022, at least 34,455 lives were lost from substance use poisoning, where 1 or more of the substances involved was an opioid (also known as an "apparent opioid toxicity death"). According to the latest data, of all accidental apparent opioid toxicity deaths from January to September 2022, 81% involved fentanyl and 78% involved opioids that were non-prescription drugs.

In response, some Canadian health care providers have started safer supply programs. These programs provide an alternative to the toxic illegal drug supply by offering prescribed medications to people who use drugs, overseen by a health care practitioner, as a way to help prevent overdoses and connect people to other health and social services. These services are offered primarily as a harm reduction measure.

Overview of the Knowledge Exchange Series on Safer Supply

Safer supply is a relatively new intervention aimed at addressing the overdose crisis, and research is underway to evaluate and understand the effectiveness of these programs. In fall 2022, Health Canada hosted a 3-part, virtual Knowledge Exchange Series (KES) on Safer Supply, with key stakeholders. The purpose of the KES was to hear from a range of participants on the current evidence and knowledge around safer supply, share experiences of what is or isn't working well, and discuss how current research and knowledge can be used to design new models and services while reducing risks or unintended results from these programs.

Each session was 3 hours long and involved a mix of presentations and panel discussions, followed by small breakout discussion rooms. There were 20 to 30 participants at each session, with a range of invited presenters, panellists, and participants, including researchers, safer supply prescribers and clients, national drug policy organizations, and people with lived and living experience. A number of observers also attended from Health Canada's Expert Advisory Group on Safer Supply, the Federal-Provincial-Territorial Committee on Substance Use, the Canadian Centre for Substance Use and Addiction, Indigenous Services Canada, and the Canadian Institutes for Health Research.

This report summarizes findings from the 3 KES sessions, including the presentations, panel discussions, and participant discussions during the small breakout rooms.

What we heard

Session 1: Building and sharing the evidence on current models of safer supply

October 27, 2022

The objectives of the first KES session were to identify the gaps in knowledge and evidence around safer supply, key outcomes of interest, and indicators to measure success. At the start of the session, participants were presented with:

During the panel discussions and the small group break-out rooms that followed, participants discussed research and evidence gaps, research challenges, promising research results, and ideas around how to build the evidence base. Some key notions that came out of these discussions included:

Several KES participants said that it is crucial to keep the voices of people with lived and living experience (PWLLE) at the centre of discussions around program evaluation, and to include their personal experiences when measuring the effectiveness of safer supply. Participants also discussed how important it is to hear from a wide range of people when designing and evaluating safer supply, since different populations may have different experiences with substance use and different care needs. Participants pointed out, for example, that more voices from African, Caribbean and Black communities; First Nations, Inuit and Métis; and gender-diverse communities, should be part of these conversations. We also heard that there needs to be more research and data to understand the needs of people who only use drugs occasionally.

A number of participants mentioned that evaluating safer supply should go beyond measuring how many overdoses and deaths the programs prevent, and consider broader goals, such as asking clients what they want to get out of the programs. Other examples included how these programs impact quality of life, retention in care, and relationships with family members – including asking family members for their views. Participants also suggested that there needs to be more research around different service delivery models, and a better understanding of how safer supply fits into the range of medical and social services available to people who use drugs.

Several participants suggested that better data and evidence could help bring a broader community of prescribers and regulators on board with safer supply, and recommended more research to better understand why many prescribers are hesitant to offer safer supply services.

The challenges related to accessing and analysing data were also mentioned during the session. One example raised was the difficulty in establishing "denominators," such as the total number of people currently accessing the illegal drug supply and who may be at risk of overdose. Another challenge raised was the difficultly comparing data across different sites and areas, since data are collected and stored differently (such as administrative data, electronic medical records), and different program indicators are being measured. Some participants discussed the current lack of common indicators across federally-funded pilot projects as a key challenge to evaluating these services. Participants also discussed the need for more longitudinal studies (that is, data collection on the same individuals over time).

A few participants also commented that research around safer supply can be challenging because stakeholders are using different terms and definitions. For example, while some stakeholders use the term "safer supply" to describe an approach to stabilize people who are most at risk of overdose, others use the term to describe broader approaches, such as the regulation and legalization of controlled substances.

Finally, participants shared a number of different points of view on how to evaluate the risks associated with safer supply. For example, there was general agreement that there needs to be more research into the risk of substances being diverted from these programs, but opinions on how to study the issue varied. Some participants wanted to see more data on the scale of the issue (for example, how often is this happening? Is anyone experiencing harm as a result?) while others wanted to see more research into the reasons why people might sell or share their safer supply medications in the first place (for example, because the medications are not strong enough to help them stave off withdrawal or because they are sharing their safer supply with friends to help keep them alive).

Session 2: Optimizing current prescriber-led safer supply

November 8, 2022

The objectives of the second KES session were to understand what is working well with current safer supply models and what could be improved to meet the needs of people who use drugs, with a focus on the research that could help answer these questions. The session started off with presentations on the following:

During the panel discussion and the small group break-out rooms that followed, participants discussed the benefits and challenges of current prescriber-led models, and what tools, data and evidence would help improve the effectiveness of current models. Some suggested that these programs have contributed to better health and social stability for program participants, and better connections and trust between safer supply clients and the health care system.

Participants also shared ideas on how to improve and expand current prescriber-led models. For example, some participants suggested more team-based models of care (not a 1:1 prescriber to patient relationship; having prescribers supported by nurses and other health care professionals to be able to take on more clients). Others suggested expanding scopes of practice with additional training and support (such as, nurse prescribing), and ensuring linkages between safer supply programs, housing, and other social supports. A number of participants also spoke to the value of networks and communities of practice for care providers who would like more support in the absence of formal clinical guidance around safer supply.

One participant suggested that a "change management" approach could be one way to build broader safer supply capacity and access. This could include building substance use training into medical school programs, organizing a "coalition of the supportive," and finding ways to better engage with people who are cautious or opposed to safer supply to find common ground.

A range of ongoing challenges were also discussed, such as the lack of sustainable program funding, including federally-funded pilot programs. Some participants highlighted the risks of these programs ending abruptly (for example, people being cut off, experiencing withdrawal and having to resort to the illegal market). There were also some calls for the federal government to be more involved in safer supply, including calls for purchase and distribution of controlled substances, similar to what was done for COVID-19 vaccines. Some participants also suggested that federal health transfers should come with requirements for harm reduction funding. As was raised in the first KES session, a few participants spoke about the difficulty accessing the right kinds of medications for clients. In particular, they mentioned that people who are accessing the toxic illegal drug supply are consuming drugs that are extremely strong; however, many provincial and territorial drug formularies do not cover prescription-grade alternatives that would match the strength of these substances. Participants also stressed that the low number of prescribers is a major barrier to scaling up safer supply services.

Session 3: Using evidence to innovate: exploring future directions

November 22, 2022

The objectives of the third and final KES session were to discuss innovative new models of safer supply, and how these models could be evaluated to ensure they achieve their goals and reduce any potential unexpected consequences. Participants heard presentations on the following topics:

During the panel discussion and the small group break-out rooms that followed, participants discussed the kinds of safer supply models that should be implemented in Canada, how best to maximize benefits and minimize risks of these models, and what research and data would be needed to inform their design.

Several participants mentioned that more needed to be done to address the overdose crisis. Those participants felt it had not been treated as a public health emergency, and that it should be given the same level of response as the COVID-19 pandemic. Some participants stated that addressing both the toxic illegal drug supply and underlying factors (such as social determinants of health) are key to addressing the crisis. This included discussions around the need for more safer supply options (for example, broader range of substances, delivery models, consumption modes), and more supports (such as housing, food) within a continuum of care that is designed to meet individuals where they're at.

Some participants brought up the impacts of the ongoing stigma towards people who use drugs, including how it creates barriers to care, and emphasized that current programs are not meeting people's needs. Other participants discussed decriminalization as a critical tool to address the stigma.

A number of participants commented that a lot of the weight and responsibility of current approaches has fallen on prescribers. Some participants said that while prescriber-led models seem to be working for some people, they will never be able to be scaled up to meet the full demand for safer supply in Canada. To address this, several participants called for a "public health model" of safer supply (in other words, models of access to drugs that do not require an individual prescription).

Echoing comments from the first KES session, several participants noted the importance of having a wide range of views involved in the discussion on safer supply. Having people who use drugs involved at all stages of planning, design, and implementation of safer supply was also seen as important to help overcome some of the challenges related to scaling up safer supply. One participant indicated that conversations on safer supply are too siloed, and that there needs to be discussions among a broader range of stakeholders with different perspectives towards safer supply, including opportunities to raise and discuss concerns about the approach.

A few participants pointed out that current models of safer supply are mainly offered to people at highest risk of overdose (those with a chronic, severe substance use disorder and high exposure to highly potent illegal drug supply), and that there needs to be options and services for a broader population of people who use substances (that is, people who consume occasionally, or who work in the trades). One participant described the need to move beyond existing models of safer supply and develop a policy framework around regulated drug access, including a range of options, such as flexible prescribed models, non-medical co-operatives and compassion clubs, and regulated retail dispensaries. A few other participants raised the idea of developing a national safer supply strategy.

Moving forward: Key takeaways

The 3-part virtual KES provided Health Canada with an opportunity to bring together a wide range of experts across multiple disciplines in a collaborative discussion on the current state of research and evidence around safer supply in Canada the key factors needed to advance these approaches, and possible future directions.

There were a number of common themes across the 3 sessions. Participants shared important research developments, including some promising early findings from a number of published and in-progress studies on safer supply programs. Participants also shared valuable views and opinions on research and data challenges, including the need for more standardized data collection and analysis, and more studies on a broader range of research topics (such as delivery models, locations, and populations).

Participants spoke about people's experiences on the ground, delivering and receiving safer supply services, and how these programs are contributing to the health and social outcomes of their clients. These discussions included the identification of critical barriers to the success of current programs (such as, sustainable funding, access to medications, access to prescribers) and to the ability to expand and scale up approaches that are working.

Finally, participants imparted visions and goals for safer supply, including what new and innovative safer supply approaches could look like, and the need to explore different models. A common theme was the importance of continuing to have people who use drugs be at the centre of these conversations and ensuring that these conversations are open and accessible to a wider range of views and perspectives.

Health Canada would like to thank all of the presenters, panellists and participants who took part in the KES on Safer Supply and shared their research, ideas and perspectives. We hope that this KES has helped to generate new ideas, create new relationships, and spur new collaboration amongst participants and interested stakeholders. Moving forward, Health Canada will continue to engage with a range of stakeholders, including provinces and territories, regulators, people with lived and living experience, clinicians, program providers and others, on life-saving measures to respond to the overdose crisis in Canada. Health Canada is committed to closely monitoring all available evidence related to safer supply programs to better understand the potential benefits and risks, and to ensure that our response to the overdose crisis continues to be evidence-based and focused on saving lives.

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