Theme: Clinical Research Year: 2025
Background:
While the driver of North America’s overdose epidemic is illicit fentanyl, the toxic drug crisis impacts users of substances beyond opioids. Posthumous toxicology testing in unregulated drug deaths in British Columbia (BC) shows that cocaine (48%) and methamphetamine (42%) are the second and third mostdetected substances after fentanyl (85%). Detection does not necessarily mean contribution to death; however, to reduce exposure to the unpredictable illicit supply, interventions must include stimulants. Provincial prescribed safer supply (PSS) clinical guidelines allow for pharmaceutical stimulants commonly used for ADHD treatment to be provided to illicit stimulant users—however, less than 10% of PSS patients receive them. Prescribers have decried a lack of evidence, citing randomized clinical trials (RCTs) for stimulant replacement therapy (SRT) showing minimal to no efficacy. However, are the tested outcomes in these RCTs congruent with conceptualizations of success for SPSS patients?
Methods:
Ten SPSS users in BC were recruited using a maximum variation strategy to participate in semi-structured qualitative interviews, which focused on each participant’s perception of what it meant for SPSS “to work.” Transcribed interviews were coded using thematic analysis. Results: For most participants, using SPSS in preferred formulation, dosage, and route of administration resulted in significant increases in quality of life, such as improved functionality, mental wellness, family connection, and paid employment, as well as reduced illicit stimulant use. Notably, despite these changes, almost none would be successful RCT participants, as even occasional illicit stimulant use would disqualify them from the primary measure of evaluation: drug cessation within the study period.
Conclusion:
This study reveals patterns and strategies of successful SPSS use that contradict the design of SRT RCTs and challenge their relevancy as evidence against SPSS. Moreover, it interrogates the methodological appropriateness of RCTs for PSS for myriad reasons, including the impossibility of blinding psychoactive substances for participants.
Disclosure of Interest Statement:
No pharmaceutical grants, nor any grants, were received to fund this study, which was a thesis research project. Author received a $400 transfer from her thesis supervisor’s UNBC faculty research start-up funds to compensate research study participants
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