Safe supply improved most health outcomes for people who use opioids as effectively as methadone, found a new study out of Ontario, Canada—when recipients were more likely to stick with it.
The study, published in the Lancet in May, contributes to a growing body of research showing how safe opioid supply (SOS) reduces harms. However, it is the first of its kind to directly compare the benefits of SOS with those of conventional medications for opioid use disorder, also known as opioid agonist therapies (OAT).
Particularly since the start of the COVID-19 pandemic, there have been several federally-funded SOS programs operating in Ontario. Outside of these programs, some physicians have also chosen to prescribe SOS to their patients. The first SOS program in the province—and the first formal program in Canada—launched in 2016 at London InterCommunity Health Centre. SOS, as the researchers note, “typically involves prescribing short-acting opioids (eg, hydromorphone) to individuals at high risk of overdose for take-home, unsupervised use.”
In contrast, medications like methadone and buprenorphine are long-acting opioids that work to prevent withdrawal symptoms and reduce cravings and risk of overdose without typically causing the person to get high. Available in Canada since the 1960s, these medications can also—unlike in the United States—be picked up from pharmacies with a prescription. Supported by much evidence, they’re considered gold-standard treatments for opioid use disorder.
“We found that for both groups there were significant improvements across all the outcomes that we looked at.”
“One of the gaps that we had identified was that studies hadn’t typically compared safer supply to alternative options like OATs,” lead author Dr. Tara Gomes, of the Ontario Drug Policy Research Network, told Filter. “We found that for both [groups] there were significant improvements across all the outcomes that we looked at … [including] reduced opiate toxicities, all-cause emergency department visits, admissions to hospital, new infections … and deaths [from opioid toxicity].”
After comparing over 900 SOS recipients with over 25,000 methadone recipients in a population-based matched cohort study, the researchers narrowed their sample size to 856 people from each group who met the eligibility criteria. They then assessed the health of these groups, based on several clinical outcomes, for a year following treatment initiation.
The two groups were kept as similar as possible in terms of socioeconomic demographics, which parts of the province people lived in, and numbers of prior overdoses and health-care interactions.
“[We found that] people who were receiving safer supply were [relative to most methadone recipients] quite complex in terms of high rates of [past] overdoses and health-care interactions and diagnoses [like HIV and hepatitis C] in the years before they started safer supply,” Gomes said. “For our study, to have a reliable comparison, we needed … to be sure we were comparing apples to apples in terms of the types of people who were starting these programs.”
Gomes said she did not find the fact that SOS contributed to overall improved health outcomes surprising. But one finding in particular stood out to her and her team: The group prescribed SOS had much higher retention rates than the group on methadone.
The researchers found that overall health improvements “were more pronounced among methadone recipients.” However, “Importantly, the benefits of methadone over SOS on clinical outcomes were largely removed after accounting for higher rates of discontinuation among methadone recipients.”
For people commencing SOS, the median time to discontinuation was 268 days—compared with 103 days for those on methadone.
The one exception was with “opioid toxicity” (overdose), for which rates among methadone recipients remained slightly better after adjustment. That’s significant. But people’s differing needs and the better retention rate for SOS means that both options “have important, complementary roles in addressing Canada’s ongoing drug toxicity crisis,” the researchers concluded.
For people commencing SOS, the median time to discontinuation was 268 days, or almost nine months—compared with 103 days, or just over three months, for those on methadone.
“This is likely reflecting that, for people who are very [medically] complex, who may have tried OATs … frequently in the past, who are highly reliant on the unregulated drug supply and have developed a high tolerance to that supply, methadone is not working particularly well right now,” Gomes said.
Although methadone has been the medical standard for decades, Gomes said that clinical guidance documents seem to recognize this evolving issue, and now allow for greater flexibility, suggesting that higher doses of methadone be prescribed for certain patients.
But she added that methadone alone may not be the most effective tool for everyone. Due to the potency of the fentanyl-dominated unregulated opioid market in Canada, “there is this recognition that people are just simply not able to stay on methadone as long anymore, it’s likely contributing to their withdrawal and people are having to go back to the unregulated drug supply…”
“In contrast, these safer supply programs really try to be designed to meet people where they’re at,” she continued, “and to recognize that people still might use the unregulated drug supply but that they can still have access to a regulated form of an opioid.”
Despite its demonstrated benefits, many people on safe supply face losing access to treatment in Ontario and nationwide.
Many of the SOS recipients surveyed in this study were pooled from community health centers and programs that largely received funding through federal Substance Use and Addiction Program (SUAP) grants.
The temporary funding for the majority of these programs expired in March and thus far, has not been renewed. Without this funding or any additional provincial support, Gomes said that many of the most vulnerable people will lose access to treatment options that work for them.
“Safer supply programs are in a position right now where they’re trying to adapt and determine if they continue to prescribe safer supply in some way to their patients or if they try to transition those patients to [OAT],” Gomes said. SOS recipients who aren’t interested in OAT are “simply losing access to services.”
“The longer we keep people engaged in treatments, the more likely they are to—number one—stay alive. Number two, they’re also getting all those other health concerns addressed.”
Dr. Andrea Sereda, who leads the SOS program at London InterCommunity Health Centre and was not involved in the new research, said that, particularly for highly medically complex groups, keeping safer supply options and the longer retention time associated with them is vital.
“The longer we keep people engaged in treatments, the more likely they are to—number one—stay alive,” she told Filter. “Number two, knowing they’re more complex, [SOS recipients] are also getting all those other health concerns addressed… instead of just receiving treatment for opioid use disorder, they’re also getting their HIV and hepatitis C addressed, and that’s really important to people.”
The expiry of SUAP funding comes at a time when political backlash against harm reduction is arguably at an all-time high.
British Columbia has rolled back many of its more progressive drug policies over the last few years, including restricting safer supply dispensing and requiring that all patients now be witnessed by a pharmacist when taking medication.
Alberta recently announced its plan to expand involuntary drug treatment legislation, and in Ontario, the provincial government is in the process of expanding its Homelessness and Addiction Recovery Treatment (HART) Hub model at the expense of its supervised consumption sites, many of which are being forced to shut down. The HART Hubs are explicitly barred from providing any “drug consumption services,” sterile syringes or safe supply.
“Right now it feels as if political parties are really under the sway of public opinion, and that’s not the best way to provide correct therapies and treatments to human beings,” Sereda said. “We’re in a time where evidence-based medicine isn’t being treated with the level of respect [considering the] level of expertise that is involved in it.”
For Sereda, safe supply should not be considered specialty care, when it should be just one of many tools, alongside methadone and buprenorphine, available to help people.
“Clinicians should be able to make decisions based on the research and based on what is best for their patients,” she said, “without fear of political or public backlash for doing what is best for the person in front of them.”
Photograph (cropped) by Mike Mozart via Flickr/Creative Commons 2.0
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