Safer Opioid Supply Program in Canada Helps Those Who Face Overdose Risks

Carolyn Crist

September 27, 2022

The Safer Opioid Supply (SOS) Program near Toronto, Canada, appears to be a safe and effective harm-reduction initiative, according to new data.

An analysis indicates that the program is associated with a reduction in emergency department visits, hospitalizations, and overall healthcare costs. In addition, there were no opioid-related deaths among participants who were at high risk of overdose.

Dr Tara Gomes

"Not only did hospital engagements decline immediately after starting SOS programs, but also the risk of overdose did not change, and there were no opioid-related deaths in the 1-year follow-up," study author Tara Gomes, PhD, an assistant professor of health policy, management, and evaluation at the University of Toronto and a scientist at the Li Ka Shing Knowledge Institute of St. Michael's Hospital in Toronto, told Medscape Medical News.

Gomes is the lead principal investigator of the Ontario Drug Policy Research Network, a collaboration between researchers and drug policy decision-makers in the province.

"These changes were not seen in a group of similar individuals who lived in the same city — so were exposed to the same illicit drug supply — but who were not part of this program, helping to reinforce that these changes are specific to SOS participation," she said.

The study was published in the Canadian Medical Association Journal on September 19.

Hospital Admissions Declined

More than 29,000 opioid-related toxicity deaths occurred in Canada between 2016 and 2021, often as a result of high levels of fentanyl in the drug supply, according to the investigators. In response, SOS programs have been launched in several provinces, including the first formal SOS program at the London InterCommunity Health Centre in Ontario. As part of the program, clients are prescribed pharmaceutical opioids as an alternative to the fentanyl-adulterated drug supply and are given health and social supports.

Gomes and colleagues conducted an interrupted time series analysis of residents in London, Ontario, who had received a diagnosis of opioid use disorder and had had a healthcare encounter related to the diagnosis between January 2016 and March 2019. They followed 82 participants who entered the SOS program, as well as a comparison group of 303 people who were matched on the basis of demographic and clinical characteristics but who did not participate in the program.

The research team focused on the population's numbers of emergency department visits, hospital admissions, infection rates, and healthcare costs. They used autoregressive integrated moving average models to evaluate the effect of starting the SOS program and to compare the population's outcome rates in the year before and after entering the program.

For participants who entered the program, the rate of emergency department visits declined by about 14 visits per 100 people. In addition, hospital admissions declined by about five admissions per 100 people. Healthcare costs that weren't related to primary care or outpatient medications declined by about $922 per person. The rate of hospital admission for infections remained about the same; the investigators observed a decline of about 1.6 infections per 100 people.

In the year after entry into the program, emergency department visits, hospital admissions, infection-related admissions, and total healthcare costs declined significantly among SOS clients, compared with the year before.

Conversely, there were no significant changes in any of the measured outcomes among the 303 people who didn't participate in the program.

Medication Costs Increased

Gomes and colleagues noted that the findings provide preliminary evidence that SOS programs can play a role in the harm-reduction options available to those who are at high risk of drug poisoning and overdose. At the same time, many questions remain.

For instance, although total healthcare costs declined among those enrolled in the program, the medication-related costs increased. About 34% of participants had HIV, 69.5% had hepatitis C virus infection, and 28% had infectious complications in the year before entering the program. This finding may indicate that the participants had serious medical complications resulting from their drug use and were able to seek healthcare services.

"We interpret that to be a positive finding, because of the very high prevalence of HIV and hepatitis C in the SOS clients. Treatments for HIV and hepatitis C are lifesaving but expensive," said Gomes. "Therefore, these higher medication costs are likely reflective of improved access to treatments for these infections, which can greatly improve people's health and quality of life but also save the healthcare system money over the longer term."

Gomes and colleagues are now beginning to evaluate other SOS programs across Ontario. They hope to better understand the various approaches that are available and determine which models can best support people who face high risks because of drug use.

A Limited Solution?

Commenting on the study for Medscape, Andrew Ivsins, PhD, a postdoctoral fellow in social medicine at the University of British Columbia in Vancouver and a research scientist at the British Columbia Centre on Substance Abuse, said, "This is an important study and one of the first to show how safe supply can help by building connections to the healthcare system that didn't exist previously."

Dr Andrew Ivsins

Ivsins, who wasn't involved with this study, has researched safe supply programs around Vancouver. He and colleagues found that among participants in these programs, the use of illicit street-purchased drugs decreased, which led to improved health and wellness.

"Safe supply is fundamentally, at the most basic level, a response to the highly toxic drug supply and out-of-control poisoning crisis in North America," he said. "It's a contentious issue, but it makes so much sense that if what's killing people is highly toxic drugs, we need to find a way to provide an option that doesn't kill them."

Dr Marie-Eve Goyer

"Up to now, safer supply has mostly been used to reduce harms, including mortality and morbidity, in persons using illicit opioids. But if we really want to lower the risk linked to heavy contamination of the unregulated drug supply, safer supply programs will have to be extended to all substances potentially sold illegally," Marie-Eve Goyer, MD, an assistant professor of family medicine at the University of Montreal, told Medscape Medical News.

Goyer, who wasn't involved with this study, has conducted research about substance replacement therapy in Quebec. She found that many provinces are now reporting on new potent designer benzodiazepines that are being used or that are contaminating fentanyl, which calls for a broader approach to address the drug overdose crisis.

"Let's realize that safer supply prescription is a very medicalized (and limited) solution to an epidemic that is made of stigma, criminalization, and repressive public policies," she said. "Without true changes in the law, we will continue to see our people dying every day."

The study was funded by grants from the Ontario Ministry of Health and the Canadian Institutes of Health Research. Gomes has received grants to support the research of both groups, and other authors has received support or fees related to the London InterCommunity Health Centre. Ivsins and Goyer have disclosed no relevant financial relationships.

CMAJ. Published September 19, 2022. Full text

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape, MDedge, and WebMD.

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