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Access to safer supply prescribing rapidly increased during COVID-19: Study

Dr. Stephanie Glegg

The number of programs and prescribers offering safer supply to reduce risk of overdose increased dramatically during COVID-19, according to a study looking at services across Canada published this month in the International Journal of Drug Policy. The findings suggest capacity for further rapid scale-up of flexible safer supply prescribing to address the increasing toxic drug supply.

Researchers conducted surveys and interviews as part of a national environmental scan. They documented that 60 new sites were prescribing safer supply in May 2020, a 285% increase from the 21 sites where safer supply was available just two months earlier in March 2020. Through interviews with healthcare providers, the study authors found that the COVID-19 pandemic was a driving force behind this rapid scale-up in prescribing services.

Measures to limit COVID-19 spread have been cited as contributing to an increase in fatal drug poisonings and substance use related hospitalizations in regions across Canada, which led to disruptions to the global illicit drug supply chain, a reduction in the availability of harm reductions services, and more isolation to reduce risk of infection.

“Many public health experts anticipated that the early response to COVID-19 in March 2020 could lead to an increase in overdose and substance use related harms,” says Dr. Stephanie Glegg, lead author of the study and a researcher with the BC Centre on Substance Use and University of British Columbia. “Safer supply was identified as an option to reduce those risks and with new clinical guidance and policy changes introduced to support prescribing we witnessed a dramatic increase in both access and availability.” 

More access to safer supply but barriers still exist

Safer supply refers to providing prescribed medications as an alternative to the toxic illegal drug supply to people who are at high risk of overdose. During COVID-19 the illicit drug supply has become increasingly toxic – as fentanyl concentrations increase – and unpredictable – with the emergence of contaminants such as benzodiazepines.

“We saw people who were able to access a safer supply avoid overdose death, avoid infections related to the unregulated fentanyl street supply, regain their physical health, decrease their involvement in criminalized survival behaviours like theft or sex work, reconnect with family and their community …. It was nothing short of joyful to see people who have been marginalized most of their lives regain their footing,” says Dr. Andrea Sereda, a physician operating a large safer supply program at London Intercommunity Health Centre in London, ON. “But the flip side of that is we saw what happened to the people who didn’t have access to a safer supply. And what happened to thousands of them is, they died. Thousands of people died.”

Researchers documented that the most common substances prescribed were opioids, made available mostly through addiction treatment programs, community health centres and primary care clinics, outreach and home delivery services, and onsite pharmacies models – relatively flexible program settings able to quickly adapt practices based on community need.

“In Halifax, Mobile Outreach Street Health (MOSH) was already leading COVID testing and supporting people in hotel isolation shelters,” says Dr. Thomas Brothers, a co-author of the study and a physician with Dalhousie University. “The providers working with MOSH saw the need to offer safe supply (as well as managed alcohol) to keep people safe and allow them to isolate and quarantine. We were able to organize a group of prescribers to support each other as a community of practice, and really relied on the infrastructure, relationships, and trust MOSH had already built with the community over the past decade.”

Despite the rapid increase in services, access is still limited and barriers to scaling up prescribed safer supply persist. Access in rural and remote settings remains mostly non-existent and 79% of safer supply services were unfunded.

Fears of diversion remain a barrier to prescribing

Concerns related to the risk of diversion have also been cited as barrier to a broader scaling up of safer supply prescribing.

A perceived over-prescribing of pharmaceutical opioids in the early 2000s is often cited as a factor in the increase of opioid-related overdoses. However, data from various provincial coroners services indicates that prescription opioids have not been a key contributor to fatal overdose. Additionally, recent research has found that diverted prescription opioids can have a protective effect on community, as people become less reliant on the toxic illicit drug supply.

“As clinicians, we have a duty and an obligation to keep people safe even if it’s not within a treatment framework,” says Dr. Nadia Fairbairn, an addiction medicine clinician and senior author of the study. “It can be complex and challenging, to balance that obligation with the potential for opioid-naïve people to access diverted prescription opioids. The reluctance that many clinicians have about prescribing safer supply speaks to the need for other models of delivery.”

Other approaches to safer supply include public health prescribing models and community-led non-prescriber based models.

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