Promising Practice: Safer opioid supply

Safer opioid supply: An interview with Rebecca Penn

Rebecca Penn works with the Safer Opioid Supply teams at Street Health, Parkdale Queen West, Regent Park and South Riverdale Community Health Centres in Toronto, Ontario. Rebecca also co-facilitates the Safer Opioid Supply Community of Practice (SOS-CoP).

This interview was conducted in December 2020. Please email safersupplyon [at] gmail [dot] com for additional and updated information about the content below.

What problem are you trying to solve?

Ontario is experiencing an opioid and overdose crisis that is driven by a tainted drug supply. The COVID-19 pandemic has only worsened this crisis in many ways. We want to reduce preventable deaths and keep people connected to care. Our ultimate goal is to integrate a community-based model of safer supply delivery into standard care for people who use drugs.

What does your intervention look like?

In June 2020, Health Canada’s Substance Use and Addictions Program (SUAP) granted funding for a 10-month pilot test of two safer opioid supply (SOS) interventions at community health centres in Toronto. This type of intervention provides wrap-around support to people who are daily opioid users with medical complications and lived experience with structural factors that lead to a high risk of overdose (such as homelessness, BIPOC identity or LGBTQ+ identity). By “wrap-around support” we mean access to a safer opioid supply, as well as full medical and social assessments, and access to primary care, housing supports, care navigators and care coordinators.

This is what providing a safer opioid supply looks like: Clients are offered prescriptions to a backbone opioid to prevent withdrawal. This comes in the form of either slow-release oral morphine (Kadian) or methadone dispensed by a community pharmacy and consumed under observation. We are just starting to integrate the use of fentanyl patches as another option for a backbone.

We also prescribe 8 mg of hydromorphone (Dilaudid) tablets on a daily basis to clients who still want to attain a feeling of “euphoria,” to reduce the chances that they will resort to illegal drugs. The number of tablets prescribed matches an individual’s tolerance levels. These tablets can be supplied to a client who can take them away and use them without observation. When a client first starts the program they see their SOS provider once or twice a week while they titrate their dose to one that is working well for them. Together with their prescriber, they decide on the frequency by which they are seen. The program at Parkdale Queen West Community Health Centre offers an observed option for clients who are not eligible for daily dispensed Dilaudid, but who would greatly benefit from a safer supply. These clients come to the SOS room at Parkdale to get their medications and have all their Dilaudid doses observed by registered practical nurses. The wrap-around supports are available to help clients meet their other goals.

What are the remaining challenges?

There are so many challenges that accompany this work.

For one, there are remaining barriers to care in our model that are difficult to avoid in the current climate. We can still only provide Kadian and methadone under observation, so we are only seeing clients who are willing and able to show up during the day at a pharmacy. There is also some tension around who is eligible for our services. Although the highest opioid-related death rates are among White men, our programs focus on women, people of colour, Indigenous people and those who are experiencing homelessness or who live alone. This is because not only are these populations at high risk of overdose and criminalization, they also face greater barriers to accessing primary care, social services and treatment services. As a sector, we need to figure out how to make SOS available to White men and other groups who do not fit our current criteria. 

Secondly, the treatments we are prescribing are just not strong enough to match the highs that our clients are getting from using illegal drugs. For example, some people require 30 tablets of hydromorphone a day to match their tolerance levels (and this becomes 60 tablets if the pharmacies run out of 8 mg tablets and need to give out 4 mg tablets). We know some people are still using other drugs in addition to the prescription drugs they are receiving from us. And we do worry about the risk of overdose in these scenarios.

Finally, one of the biggest challenges is navigating conflicting perspectives. We work with care providers who have a harm reduction approach to opioid use as well as those with a preference for abstinence-based or traditional opioid-agonist therapy approaches. I still see a lot of stigma-based assumptions and fear. There are still many care providers who mistrust drug users and who, for example, fear that clients will sell their prescription tablets for cash or fentanyl. A large part of the work I do involves building relationships and trust between people.

Why is this a “promising practice”?

This safer supply intervention is evidence-informed, and there are many people and organizations doing this kind of work across Canada with positive results. However, it is important to recognize we are very much still in a trial phase.

Providing unobserved dosing is a new practice in substitution therapy, as is the use of tablets. Most of the evidence base for this type of intervention comes from studies in which heroin is prescribed, but this is difficult to do in Canada.

It’s exciting to see doctors learning what works directly from people who use drugs, the people for whom we are all doing this work. It’s also very exciting that this intervention is helping to build a new evidence base that will increase the potential for this type of care model to be scaled up. Many evaluation studies are underway to look at the impact of safer supply on individuals as well as on health systems.

I’m looking forward to what we can accomplish with the Safer Opioid Supply Community of Practice, which is an initiative currently offered through a partnership among SUAP-funded SOS programs in Ontario, the Alliance for Healthier Communities, the Ontario branch of the Canadian Mental Health Association, and Addictions and Mental Health Ontario. The goal of the Safer Opioid Supply Community of Practice is to support new prescribers and programs to scale up the safer supply care model and make it more broadly accessible.