In 2019, Canada funded an expansion of safe supply and put out a call for pilot programs. Of particular interest to the federal health department was an emerging approach it identified as a “flexible” model: community-based, low-threshold public health initiatives that suggested a “strong potential for scaling up” and reaching people left out by more structured programs. It would still be a medicalized model, but as removed from addiction medicine as possible without breaking any laws.
In June 2020, the federal Substance Use and Addictions Program (SUAP) funded the Victoria SAFER Initiative to design a flexible safe supply program in British Columbia, implement it and quantify that it worked. An entirely new safe supply protocol has resulted, developed in collaboration with the people using it—with higher doses, lower barriers and a trio of fentanyl products, including one that’s injectable.
SAFER started outreach to encampments immediately, connecting unhoused people to the safe supply options that already existed. BC’s Risk Mitigation Guidance (RMG), a clinical protocol developed early in the pandemic, supported “extraordinary measures” to reduce harms to people at risk of overdose. Simultaneously, SAFER began an evolving community engagement process asking people who use drugs—all kinds of people, using all kinds of drugs in all kinds of ways—what would make a safe supply program work for them.
The team SAFER has assembled looks a lot more like a syringe service program than an addiction treatment clinic. In addition to physicians and nurses, SAFER employs systems navigators to connect participants to social supports including housing, and peer workers with lived and living experience to lead outreach and ensure that services center participants’ needs.
Larry, a SAFER peer worker in her 50s, uses her lived experience of substance use and homelessness to build relationships with participants whose previous health care experiences might not have involved anyone they could relate to or trust, who didn’t ask them to stop using drugs.
“They know that this is their space,” Larry told Filter. “They know we want to see them, and that we care what happens when we don’t see them.”
Larry’s been doing frontline harm reduction work around Victoria and Vancouver for the past decade. She sees participants engage with SAFER services more fully because they don’t feel policed, and do feel they’re among peers and allies who recognize their right to dignity, autonomy and basic needs. (SAFER peer workers are unionized, with benefits and hourly pay above BC’s living wage.)
“RMG completely failed to acknowledge that people use drugs for a whole host of reasons, not just avoiding dopesickness.”
RMG opened the door to expanded safe supply, but it was fundamentally a withdrawal management tool, and the risk being mitigated was more COVID than the toxic supply.
“The belief back then was, ‘Everyone’s gonna get COVID, and they’ll need to isolate, and when they isolate they won’t be able to access regular supply of drugs, so let’s provide a maximum of 14 tablets of Dilaudid 8mg every day to keep them from going through withdrawal,’” Clinical Nurse Lead Corey Ranger told Filter. “And it completely failed to acknowledge the fact that people use drugs for a whole host of reasons, not just avoiding dopesickness.”
SAFER’s physicians wrote a new guidance document, which Filter has reviewed. It uncouples safe supply from pandemic response, and adapts RMG protocols to a flexible model. It moves services closer to harm reduction not just by reducing medical barriers, but by adding something that was missing: choice.
SAFER’s guidance states explicitly that participants are not required nor expected to access medications for opioid use disorder (MOUD), like methadone. The original RMG had been ambiguous. But many SAFER participants still choose MOUD, especially because they can be prescribed in combination with other options the program offers.
Despite lots of fanfare about government-authorized safe supply, the supply itself left a lot to be desired. If you take out the MOUD (not really safe supply) and m-eslon, (a less-slow version of the slow-acting morphine approved as MOUD in Canada) the only opioid you’re left with is oral hydromorphone (Dilaudid).
While hydromorphone is one of the more accessible pharmaceutical opioids to dispense, it’s an inadequate option for keeping most people off street supply, at least at the RMG doses. Plus, if it’s not the name-brand Dilaudid, it can’t really be injected; generic hydromorphone has too much filler to properly dissolve, and can actually combust.
SAFER raised the hydromorphone maximum from 14 tablets a day to 30. Participants responded well, and also suggested oxycodone because they needed an option that could be smoked. Oxycodone isn’t in the RMG at all, but 20 mg tablets are equivalent to 8 mg hydromorphone and already covered by public insurance, so SAFER started offering those too.
But while the new options were holding some of the participants, others were still clearly being underdosed. Which left them continuing to rely on street supply to make up the difference, and still suffering its harms.
“People come in poisoned. They can’t even lift their head,” Larry said. “It’s not just that we provide safe alternatives—people can’t walk, can’t stand up because of the benzos, because the drugs are so adulterated.”
In Victoria, where SAFER is based, the supply is saturated with fentanyl, so fentanyl tolerance is very high. If someone’s using their prescribed medication and also still using street supply, it might mean they need a higher dose. But it often means the medication itself just isn’t right for the job.
“To try to make an impact on this drug poisoning crisis, we were going to fight fentanyl with fentanyl.”
In June 2021, SUAP renewed funding. SAFER opened a clinic, put in private injection booths and informed government health authorities it would be expanding beyond tablet safe supply.
“We needed something outside the box, compared to what people were using,” Ranger said. “To try to actually make an impact on this drug poisoning crisis, we were going to fight fentanyl with fentanyl.”
SAFER now offers three fentanyl products. Fentora tablets can be smoked or dissolved under the tongue, sort of like a fizzy Suboxone. Prescribers can dose up to 2,000 mcg twice a day; potentially higher if needed.
Fentanyl patches function as a long-acting backbone, like MOUD. But they can be administered three times a week rather than daily, which means participants who use only the patches regain the freedom to go out of town for a few days, or just have more time for life.
Sufentanil injections are prepared by program nurses using participants’ preferred-gauge needle, then handed to them to self-administer. Participants can get up to four doses a day if that’s what fits them, but can also miss up to 30 days without their prescription being changed. SAFER is the only program in Canada to offer sufentanil injections.
All three products require consumption and the 20 or so minutes after to be supervised. But this can be done by a systems navigator or peer worker like Larry, rather than being restricted to clinical staff.
Participants can combine the MOUD or fentanyl patches with either of the other two fentanyl products, or combine a fentanyl product with a tablet medication, or use all three—just not more than one from each category at the same time. The sufentanil injections are a fixed dose of 100 mcg each, but the others don’t really have maximums; providers can increase to whatever dose is helpful.
SAFER is now prescribing to around 100 patients. The sufentanil injections have been a particularly effective entry point for new participants, who agree to come into the program because they’re curious about sufentanil, and who go on to build relationships and connect to other services.
“Probably the most morally distressing thing is knowing we have a finite capacity.”
Over 90 percent of SAFER participants are engaged with systems navigators, who work with them on social supports including but not limited to housing applications, income assistance, primary care, documentation, legal support and Indigenous cultural supports. The clinic includes an overdose prevention site where people can use both regulated and unregulated supply, and a shared common area where participants and staff can relax.
But working inside a medicalized model means most of the problems SAFER’s been encountering can’t necessarily be solved.
Aside from the concern that a patient overdosing on prescribed drugs could be legally inconvenient for the prescriber, Health Canada’s main worry when it first identified flexible models was the potential for “diversion.” SAFER’s team strongly objects to the misrepresentation of diversion as harmful to the community, but still can’t offer carries for anything. And because part of the program’s job is to produce retention data supporting a flexible model, that means urine drug screens about once a month.
“We have had to include UDS for now, but we try and mitigate it by offering as many options as we can,” Project Manager Heather Hobbs told Filter. “So if one option is not working for someone in our program, we listen to them and can try them on something else, rather than taking a punitive approach and cutting them off.”
The provincial government commissioned an ethical analysis on safe supply, which concluded last year that it was a breach of medical ethics to restrict access to medications based on assumptions about how people will use them. But that doesn’t mean anything changes.
“We are practicing harm reduction, and we’re also limited by addiction medicine prescribing practices,” Hobbs said.
One agenda item for this year is lowering some of the barriers around the fentanyl products, including making the patches accessible through community pharmacies so participants don’t always have to come into the clinic. Another is piloting smokable opioid options. A third is expanding stimulants beyond the original RMG options: methylphenidate (Ritalin) and dextroamphetamine (one of the main active ingredients in Adderall), which aren’t meeting the overall need but have been a useful Band-Aid for some participants when street supply isn’t an option.
For a time, the team was conducting outreach deliveries. There’s constant demand, especially among participants facing mobility barriers, but SAFER hasn’t had the staffing resources to keep it up.
“Probably the most morally distressing thing is knowing we have a finite capacity, and that we could help more people if we could reach more people,” Ranger said.
The data bear out that SAFER’s flexible model is reducing illicit drug use, which is good for building an evidence base but doesn’t say much about the actual people. More representative is participant feedback, which shows quality-of-life improvements from housing to wound care to mental health, regardless of whether someone’s stopped using illicit drugs entirely.
“They’re all doing well and they’re not dying, so it’s pretty hard to argue with what we’re doing here at this point,” Ranger said. “The only real issue—which all of us will be open about—is finding ways to make it more accessible.”
Top photograph of generic fentanyl patch packages via Wikimedia Commons/Public Domain. Inset photograph of booths at Victoria SAFER Initiative courtesy of SAFER.