1 December 2022
One of the emerging themes from the 10th International Conference on Health and Hepatitis in Substance Users – INHSU 2022 – was the importance of safe supply as a life-saving intervention for people who use drugs.
Across the three days, we heard from experts based in Canada who have pioneered safe supply in the face of the overdose crisis. Speakers shared real-life examples of safe supply in action and discussed the ethics and practicalities of safe supply.
The call to action was clear; with unpredictable drugs like fentanyl saturating the illicit drug supply, other countries may soon begin to see the devastation it can cause, with Canada experiencing unprecedented levels of overdose deaths. Safe supply, alongside decriminalisation and harm reduction initiatives like drug consumption rooms, will be integral to saving lives.
Moving forward towards broader implementation of “Safer Supply”
Chairs: Marion Selfridge, Cool Aid Community Health Centre, Canada & Anne-Sophie Thommeret-Carrière, Université de Montréal, Canada. Speakers; Dr Andrea Sereda, London InterCommunity Health Centre, Canada Alexandra Holtom, Canadian Association of People Who Use Drugs (CAPUD), Canada, Marie-Ève Goyer, CIUSSS Centre-Sudde-l’Île-de-Montréal, Canada and Mattew Bonn, Canadian Association of People Who Use Drugs (CAPUD), Canada.
A fascinating glimpse into how Canada does safe supply — or safer supply — we heard from four speakers on topics including the deployment of safer supply, ethical considerations, and the need for decriminalisation.
The Canadian speakers put out a call for action for countries not yet affected by the deadly fentanyl crisis currently sweeping the US and Canada, to act now on safe supply, before it’s too late.
- What is killing people is not fentanyl; it is the unpredictability and unregulated street supply of fentanyl
- Safe supply in Canada has been a huge success with a 94% retention rate. This ability to retain is critical to keep people away from street supply but still enable them to inject drugs
- Safe supply is NOT and should never be seen as a pathway to OAT
- Safer supply reduces drug poisoning and overdose risk, reduces social inequities, reduces hospital admissions, reduces injecting drug use, contributes to better health, increases access to social services and health services, positively contributes towards family relationships, reduces illegal activity and reduces crime. Safer supply doesn’t just save lives, it enables living
- There are challenges though with concerns raised over diversion, the selling of their safe supply to obtain new substances, escalating doses, a lack of a framework of practice, etc which need to be addressed in the establishment of any safe-supply model
- There are three potential safe supply models; heroin-assisted treatment, medical safe supply and drug-user-run compassion clubs.
Safe supply must coexist with harm reduction and total decriminalisation
Safer Supply (SS) and HCV Micro-Elimination During COVID-19 – Prescribing Novel Opioid and Stimulant Alternatives to Toxic Illicit Drug Supply in Victoria, British Columbia
Marion Selfridge, Canadian Institute for Substance Use Research
Marion presented the findings from a study providing data on the first year of novel opioid and stimulant alternatives prescribed to 549 people who use drugs during the first year of the COVID-19 pandemic (March 2020-April 2021), at an inner-city health centre and connected multi-site outreach program in Victoria, Canada.
Chart reviews provided data on clients prescribed novel opioid and stimulant safer supply: half (50%) were provided COVID temporary shelter, and a quarter (25%) had an overdose in last 6 months. Clients who continued prescriptions were more likely to experience chronic pain, had an active OAT prescription, were older, housed, and given higher doses of opioid safer supply. Daily dispensed safer supply linked to outreach primary care in temporary COVID sheltering sites provided opportunities for HCV screening and linkage to care for high-risk populations which had not been previously engaged by HCV community outreach elimination work. Over 30 new HCV treatments were started with a total of 79% of total requiring HCV treatment now achieving SVR.
Further work is needed to understand the ways in which safer supply efforts can better engage highly marginalized populations.
The Nursing Perspective – overdose and safe supply
Chairs: Jan Tait, Ninewells Hospital and Medical School, UK & Mia Biondi Mia Biondi, York University, Canada. Presenters: Mary Munro, Scottish Ambulance Service, UK and Emmet O’Reilly, South Riverdale Community Health Centre, Canada
Organised by the INHSU Nurses Committee, this session welcomed Mary Munro from the Scottish Ambulance Service (SAS), who shared an innovative model where the SAS now carry take home naloxone. Since its launch in January 2021 there has been a roll out of a national training program for 2,500 paramedics and technicians who facilitate targeted distribution of naloxone.
- Since January 2021, 2,500 paramedics and technicians at SAS have been trained to distribute naloxone
- For 65% being provided take home naloxone by the SAS, it’s their first ever supply of naloxone
- 36% who receive naloxone are family and friends of people who use drugs
- The program identified that 40% of people who use drugs reached through the model have never accessed any type of alcohol and drug service — demonstrating a unique ability to reach new people
- The potential of within the SAS to deliver harm reduction services is endless; and could include delivery of the WAND method (wound care, assessment of injection risk, naloxone provision, and dried blood spot testing for BBVs)
Emmet O’Reilly then joined from South Riverdale Community Health Centre in Canada discussing Safe(r) Opioid Supply. Ontario has experienced double the number of overdose deaths compared to 2016 and it’s getting worse — safer supply is a way to tackle this at the source.
- The main drug causing poisonings is fentanyl, which can be cut with any number of substances. Words cannot describe the extent, better than the graph below can
- Safer supply is NOT a treatment program; the goal is to replace contaminated street drugs with prescription alternatives
- The model at South Riverdale includes various inclusion criteria such as daily use of illicit opiates, and failed trials of MMT/suboxone alongside a triage system to prioritize people most at risk such as those experiencing homelessness
- Emmet called for better drugs, more funding and more prescribers to move safer supply forward
This graph sums it up – absolute chaos.
Implications of using current mechanisms of Opioid Agonist Treatment (OAT) provision to access ‘Safer Supply’ in British Columbia
Marion Selfridge, Canadian Institute for Substance Use Research
In her second presentation of the day, Marion presented on the creation of the interim Risk Mitigation Guidance (RMG) in March 2020, as a response to dual public health emergencies — the COVID-19 pandemic and an ongoing toxic drug supply crisis linked to escalating drug overdose deaths. The guidance permitted prescribing medication alternatives to substances, including opioids, alcohol, stimulants and benzodiazepines, an intervention sometimes referred to as ‘safe(r) supply’.
Interviews with 55 people who use drugs across BC in 2020-21 revealed that access to RMG was limited, most often facilitated through urban prescribers, drug user groups and outreach teams. While it was seen as a step in the right direction, dosing was too low to stop withdrawal and not in a form to adequately replace current fentanyl or stimulant use.
Current policies and structures for Opioid Agonist Treatment (OAT) provision were used for RMG implementation: daily dispensing through pharmacy, often in tandem with witnessed OAT, and Urine Drug Screens.
Drug-related stigma, racism, discrimination, and surveillance acted as barriers to accessing RMG and reproduced distrust in their relationships with prescribers. The implementation of RMG through the same mechanisms as OAT prescriptions reduced access to RMG and reproduced structural vulnerabilities previously identified as barriers to OAT. The legacies of provincial policies around OAT provision also had a negative impact on the experience of RMG implementation.