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Abstract

Since 2016, nearly 50,000 people who use drugs have died as a result of the toxic unregulated drug supply. Safer supply programs provide people who use drugs with daily access to pharmaceutical-grade prescription medication as an alternative to the toxic unregulated drug supply. We conducted a qualitative study with safer supply participants to better understand program discontinuation, re-engagement, and barriers to care from their perspective. Semi-structured interviews and surveys were completed with participants. Overall, 30 individuals participated in this study. Three major themes were brought up by research participants, which include: (1) safer supply program entry, (2) safer supply program experiences, and (3) the program restart process. Discussions with participants highlighted the importance of recognizing that times of crisis are inevitable and may potentially threaten participant program retention. Having clear program processes in place, increased wrap-around services, and flexibility when provisioning care are essential components of safer supply programs.

Keywords

safer supply harm reduction people who use drugs retention drug poisoning crisis toxic unregulated drug supply

Introduction

Canada is in the midst of a worsening drug poisoning crisis. People who use drugs (PWUD) are dying at increasing rates because of a toxic unregulated drug supply. Specifically, more than 50,000 people have died since surveillance of this crisis began in 2016 (Public Health Agency of Canada, 2024). In 2023, this was the equivalent of 22 people dying each day. Importantly, unregulated fentanyl continues to be a central driver of this crisis and was involved in 82% of apparent opioid deaths in Canada in 2023 (Public Health Agency of Canada, 2024). In Ontario, the vast majority of deaths related to accidental substance toxicity involved opioids (85.2%) and/or stimulants (60.2%), with the median age at death among PWUD in Ontario being 40 years old (Ontario Drug Policy Research Network, 2023a). Drug checking services available to PWUD have consistently indicated that the majority of unregulated drug samples submitted for testing are contaminated with substances other than what people intended to purchase. For example, unregulated fentanyl is often tainted with unexpected drugs, including fentanyl analogues, benzodiazepines, veterinary tranquilizers, and other harmful sedatives (Centre on Drug Policy Evaluation, 2023). This is of great concern, as it means PWUD are consuming unknown drug contaminates which can have harmful and dangerous side effects.

To directly address this, Health Canada’s Substance Use and Addiction Program provided funding for a number of safer supply pilot programs (Health Canada, 2020). Guided by principles of harm reduction, safer supply programs provide PWUD with daily access to pharmaceutical-grade prescription medication as an alternative to the toxic unregulated drug supply (Canadian Association of People Who Use Drugs, 2019; Haines et al., 2022). Though this program framework differs from traditional abstinence-based treatment, safer supply exists to support PWUD who may wish to use substances in a safer way. Many safer supply programs provide wrap-around care to clients, which may include housing support, program peers, case management, primary care, counselling, and other harm reduction services such as take-home naloxone. These additional supports can prove valuable for reducing morbidity and mortality overall, and, for those who have this end-goal, can help people achieve reduced and/or safer drug use. Importantly, a recent rapid review of safer supply evidence found that PWUD participating in these programs experienced lower rates of drug overdoses (Ontario Drug Policy Research Network, 2023b). A study in Ontario also found that one year after starting the program, safer supply participants had significant reductions in emergency department visits and hospitalizations (Gomes et al., 2022). Further, safer supply participants have self-reported mental health improvements, reductions in unregulated drug use, decreases in overdose events, and less frequent participation in criminalized behaviour since joining a safer supply program (Haines et al., 2023; National Safer Supply Community of Practice, 2023).

Understanding people’s retention in, and reasons for discontinuing, substance use programs is important to ensure services are tailored to the needs of PWUD. For example, within opioid agonist treatment (OAT) programs (which is the current gold standard treatment for individuals diagnosed with an opioid use disorder), a study in Ontario found that from 2014–2020, 58% of clients receiving OAT were not retained in treatment beyond 2 years, and nearly 20% were retained for less than 90 days. (Tahsin et al., 2022). Further, a randomized controlled trial in British Columbia, Canada found that participants receiving diacetylmorphine (pharmaceutical-grade heroin) remained in treatment at a statistically significantly greater rate than those receiving OAT (p < .001) (Oviedo-Joekes et al., 2009). These research studies indicate that while some substance use services may work for a subset of PWUD, a single program does not work for everyone. One size, in fact, does not fit all. Thus, information regarding safer supply program retention and re-engagement merits further investigation. To begin exploring this topic, we conducted a qualitative study to better understand program discontinuation and re-engagement from the perspective of safer supply Ottawa participants.

Methods

We completed a qualitative research study with safer supply participants in Ottawa, Canada. Participants were recruited at three safer supply Ottawa prescribing program sites. A separate manuscript provides an in-depth description of the programs (Haines & O’Byrne, 2023). Briefly, each of the programs offered a unique model of care within different facilities, which included a substance use clinic, a supervised consumption site within a shelter for people experiencing homelessness, and a community health centre. Altogether, the three programs served nearly 500 safer supply participants (Haines et al., 2023). The research team went in-person to the programs to ensure participation in the research study was as accessible and low-barrier as possible for participants. Safer supply program staff assisted the research team in recruiting participants through posters and word of mouth.

To participate in this research, participants had to be engaged in a safer supply program and must have stopped and restarted their safer supply program one or more times in the last year. Stopping their programs must have included a period when their safer supply medications were unavailable to them due to not having a valid prescription (due to their time away), followed by a check-in with safer supply staff to restart the program. While each safer supply program has its own policies and protocols, in general, prescriptions were placed on hold when a client was away from the program for 3 or more days (Bennett et al., 2022). As part of this program, clients had to check-in with their safer supply team before they restarted the program to assess their drug tolerance levels and other clinical information. Participants for this research study could be part of a safer opioid and/or stimulant supply program. Participants were recruited on a first-come, first-served basis. Participants and a member of the research team reviewed and signed consent forms together. Each participant was compensated $100 cash for their time and expertise.

Research ethics approval was provided by [REDACTED NAME OF INSTITUTION], H-03–22-7890. Funding for this research was provided by Health Canada’s Substance Use and Addictions Program (grant# 2021-HQ-000,059).

Data Collection

Data collection consisted of two parts and was completed in a private area at each of the safer supply program sites. First, a 5–10-min survey was completed with each participant. Participants could complete this independently or have the research team support them by reading the questions aloud; most participants opted to have the questions read to them. The survey included questions regarding socio-demographic information, substance use, substance use related complications, and harm reduction service usage. In addition, participants were asked a series of questions to assess the potential impact of safer supply on their lives through pre-/post- measures. Specifically, participants were asked to provide two answers reflective of the time (1) before they began safer supply, and (2) after (currently) being on safer supply.

Second, a 15–45-min audio-recorded semi-structured interview was conducted with each participant which provided the opportunity to discuss their experience of being on a safer supply program. Interview prompts were created prior to the interviews to ensure specific topics about the safer supply programs were addressed. These topics were uncovered through a review of the literature and clinical insights. Although these prompts were available to the interviewer, participants were encouraged to guide the conversation to ensure their personal experiences were captured.

Data Analysis

Data collected from the self-administered surveys were reported using descriptive statistics. Semi-structured interviews were audio-recorded with the permission of participants to ensure accurate transcription could occur afterwards. Qualitative data analysis occurred as per Smith, Flowers, and Larkin (Smith et al., 2009):

(1) Once an interview was completed, the audio recording was transcribed verbatim, including both interviewer and participant text.

(2) Three members of the research team read through the transcripts several times and listened back to audio recordings as needed to help nuance interpretations.

(3) Initial noting was completed, with notes and comments assigned to individual sections of data while maintaining contextual information. All authors maintained openness to what the data may bring forth, while also considering statements and descriptions which may be of particular importance as denoted by the participants.

(4) Notes and comments were clustered together to form larger codes within individualized interactions with participants.

(5) Codes were bunched together to create concrete themes and theoretical underpinnings which aimed to reveal the essence of the participant experience.

NVivo 1.7.1 software was used to complete data analysis. The research team met frequently throughout the analysis process to ensure there was a clear audit trail regarding findings. No major differences were found between participants at each of the three safer supply programs, and thus their results are reported together.

Results

Surveys

Overall, 30 participants were recruited to be part of this study (Table 1). Among this cohort, 11 (37%) participants were from the substance use clinic program, 11 (37%) were from the supervised consumption site/shelter program, and 8 (27%) were from the community health centre program. The participants’ median age was 38 years old, and the median time on a safer supply program was 20.5 months. Half of the participants were men and half were women. Self-reported gender of women and men include both cis and trans individuals. Given the small number of individuals who were trans within these programs, gender was grouped this way to protect privacy and confidentiality. Participants reported being restarted on their safer supply program a median of 2.5 times (IQR 1–4) over the past year. The vast majority (n = 21, 70%) of these participants reported that during their most recent safer supply program restart process they were away from the program for less than 7 days.

Table 1.

Baseline Demographic Characteristics of Research Participants.

Characteristics	Participants (n = 30)
Age (years)	38 (32–49)
Time on safer supply program (months)	20.5 (9–36)
Program site
Clinic	11 (37%)
Shelter/SCS	11 (37%)
Community health centre	8 (27%)
Self-identified gender
Female	13 (43.3%)
Male	17 (56.7%)
Number of times restarted on program in the last year	2.5 (IQR 1–4)
Time away from program before most recent restart
<7 days	21 (70%)
1–4 weeks	4 (13.3%)
1–5 months	3 (10%)
6–12 months	1 (3.3%)
12+ months	1 (3.3%)

Data are expressed as median (IQR) for continuous variables and number of participants (%) for categorical variables.

Interviews

Throughout the semi-structured interviews, all participants spoke in detail about the overall experience of being engaged in a safer supply program. This included the restart process of disengaging from the program for a period before being restarted. Overall, three themes associated with this restart process were brought up by research participants, which included: (1) safer supply program entry, (2) safer supply program experiences, and (3) safer supply program restart process. From these discussions, a figure was created to illustrate the cycle of program restarts, depicted by the overlapping themes and milestones described by participants (Figure 1).

Figure 1.

Cycle of safer supply program restarts.

Theme 1: Safer Supply Program Entry

All participants spoke about the challenges they faced as a PWUD prior to enrolling in a safer supply program. Common challenges amongst participants included poor mental and physical health (“I was suicidal and everything, man. It was horrible” [P23]), ongoing stigma (“people look at me, and think that automatically I’m a drug addict… it’s hurtful” [P19]), sexual and physical violence (“two times, I was raped” [P8]), participating in criminalized behaviour (“I was panhandling, doing sex work, and stealing” [P10]), isolation from the community (“I stopped caring about the community” [P13]), and frequent overdoses (”[I overdosed] quite a few times at the beginning…on [unregulated] fentanyl…43 times” [P15]). Given these challenges, for most participants, a primary driving force behind enrolling in a safer supply program was to reduce or halt their unregulated drug use and the associated consequences, even if only for a short period: “the day that I got on it, I was excited, because I knew I was going to get dilaudid [hydromorphone], and I knew that I’d get enough to get me off the [unregulated] fentanyl for a while” (P25). Another participant described this similarly: “I really want to just stop doing fentanyl. I really do, but it’s tough. It’s so tough… I would like to be off of everything” (P23).

Many participants also spoke about feeling hopeful that starting a safer supply program would provide them the support they needed to address these challenges. Additionally, while enrolling in the program was a personal decision, many participants expressed similar short-term and long-term goals for the program. Short-term goals typically addressed immediate needs associated with unregulated drug use, such as managing withdrawals, preventing injury (e.g., overdose, infections), reducing their reliance on the unregulated drug supply, and improving their mental and physical health. One participant stated “I hate being dope sick [withdrawal]. It’s the worst feeling ever.” [P30]. Long-term goals typically included securing housing, employment, and reconnecting with loved ones. One participant stated they wished to “find a place, and job hunt” (P19), while another “wanted to be more a part of my son’s life” (P11).

Participants vividly recalled being started on a safer supply program, as they reported this being a significant moment in their lives: “Honestly, it is winning the lottery” (P5). Another participant described similar feelings of happiness and hope for the future:

[I felt] excited… because there was something better that was going to happen. Well, hopefully, it [my unregulated drug use] was going to change, and I was very excited about that. And then, hopefully, getting closer to my family and not being that black sheep, and maybe actually showing them that I can do more than just what I was showing them (P11).

Many discussed how the entry point to the program was relatively simple and accessible, with one participant stating, “I feel like they took our needs into consideration, and then we were put on the program within sufficient time” (P1). Participants expressed appreciation for how people were prioritized based on risk factors: “for me, it felt pretty easy. It wasn’t like first come, first serve. It was who was more of a candidate, and I guess I was not doing good…. I overdosed probably 30 times here, so I don’t think I’d be around anymore without it” (P5). One participant reflected on the fact that safer supply “saved my life really. And I don’t know what I would do without it” (P8), while another noted the differences they have seen not only within themselves but also within their community:

This program has saved many lives. I don't care what anybody says. I've seen it. I've seen people that I didn't think would live to the next week that are still kicking around, that have gotten their shit together… there's still faith for them, there's still hope for them. And if it wasn't for this program, I'd probably fucking be dead (P7).

Overall, when starting safer supply, participants recalled feeling hopeful for the future and being excited for the possibility of having more control over their substance use: “oh my god, I was so happy… because I was getting tired of [unregulated] fentanyl” (P30); “I want to eventually, completely get clean. That’s my biggest goal” (P27).

Theme 2: Program Experiences

Participants spoke extensively about the personal impact safer supply had on their lives. Participants discussed how they felt safer supply improved their quality of life, with one participant stating “the program, it’s introduced me to a lot of helpful people around here… It’s pretty much changed my life for the better” (P11). While many participants described an end goal of abstinence from substances, others explored their personal substance use journey through different measures. This included participants who wished to reduce their drug use (“I went from a gram a day [of unregulated fentanyl to] maybe a gram once a month” [P23]), have safer drug use (“staying cleaner [and] using clean needles” [P12]), and using alternative methods for their drug use, such as inhaling or oral consumption of drugs rather than injection (“I barely use a needle anymore” [P1]). Participants also spoke about experiencing drug overdoses less frequently (“now I barely overdose at all. I overdosed once or twice in the last year or two, and that’s about it” [P14]), reductions in criminalized behaviour (“I was doing a lot of crime to get the drugs that I needed… armed robberies, robberies, dealing, theft. I don’t have to do that anymore… the [safer supply] drugs are taking care of my needs” [P17]), and improvements in mental health (“I wake up, and I’m actually happy” [P13]).

Participants explained that access to safer supply medications helped them address crucial goals, with one participant sharing how they were able to find housing, “When I was on safer supply, I didn’t have that constant worry [of obtaining unregulated opioids]. I could focus on other things and I got housing… I only had a backpack, and if it didn’t fit in there, I didn’t own it… Now I have power and I can own objects, and it’ll be there when I get back” (P5). Many participants echoed this finding, as safer supply allowed them to maintain a consistent daily schedule, “I don’t have to run around so much making money. I can rest assure that I’m going to get my pills at the beginning of the day, at the end of the day. So that makes it so much better” (P10). This consistently resulted in what participants described as a sense of normalcy in their lives, such as “having the routine gets you out… guess it just helped me make little changes to end up making big changes” (P20), as well as “I’m not on the nod all the time, so I’m able to make appointments, not be late for work, stuff like that” (P29). Participants spoke about their program involvement allowing them to refocus their energy on activities that were meaningful to them, with one participant stating “I smile more. I do Mandela colours, I crochet, I draw. I’m starting to draw again” (P30). Program participants described feeling an overall sense of hopefulness for their future: “you never know what could happen. Anything is possible” (P2). Further, they spoke about improvements to their sense of safety regarding their drug use. They attributed this largely to now knowing what they are consuming, and the fact that their safer supply medication would be ready for them each day at the pharmacy, “it’s the fact that you know when you wake up every day ,you have something that’s going to last you the day. Just that feeling is a stable feeling” (P13); “It [safer supply] makes me not have to worry as much about where my next fix is going to come from” (P28).

Theme 3: Restart Process

Given the focus of our research objectives, all participants were asked to speak about their experiences with the safer supply program restart process. We noted that despite each participant having a unique story, they all outlined a common trajectory for this restart process which consisted of 3 parts (sub-themes). First, participants described a period of crisis, which they defined as a difficult time in their lives where they were unable to engage with the safer supply program. Second, participants discussed their time away from the program, which commonly included distressing and harmful experiences during the time they were not engaged with the safer supply program. Lastly, participants spoke about their decision to return to the program and what the process of restarting safer supply was like.

Subtheme 1: Crisis

The first part of the restart process involved a crisis. Participants described this as a specific event, which ultimately resulted in them being unable to continue their safer supply program. Importantly, while unregulated substance use was discussed by some participants, oftentimes the crisis was not related to their unregulated drug use. Examples of crises disclosed by participants included:

• Incarceration

• Hospitalization

• Medication diversion

• Dope sickness

• Unexpected travel

• Struggling with daily medication pick-up

• Unregulated drug use

• Interpersonal stressors

• Environmental chaos

• Grief and loss

A few participants described how extended periods of hospitalization for other health concerns disrupted their safer supply program engagement. Participants spoke about feeling marginalized by hospital staff due to their drug use: “When I go to the hospital, I’m stigmatized already before they start helping me” (P10). Participants described feeling distressed while in hospital, with one participant noting that they needed to have unregulated drugs delivered to them in order to stay in the hospital: “People were bringing me drugs because they [the hospital] weren’t giving me what I needed” (P17). Another participant recounted having to leave the hospital to get their medication, as the hospital was not managing their drug withdrawal symptoms: “I would take off from the hospital and go to the pharmacy.” (P12). Similar experiences were disclosed by participants who had been incarcerated while on safer supply. Some reported not receiving medication in general (“Anytime I’ve been in jail, I never got my methadone, so I don’t know what’s wrong with the system there” [P4]), while other participants reported specifically having their short-acting safer supply medications suddenly stopped: “[I did not receive my hydromorphone]. Just the methadone” [P13]). A participant described feeling vulnerable and afraid while incarcerated, with limited support from healthcare staff:

I was sick [drug withdrawal]. I was unable to defend myself. was really scared and I was just worried because I didn't have any idea what was going on with the process of my [safer supply] prescription, if I was going to get it. Then when I did get medication, it wasn't enough, but it was better than nothing and I was able to sleep. I couldn't sleep for the longest time and I wasn't eating. It really affected me (P5).

Attending the pharmacy for daily medication pick-ups was a challenge for some participants, which led to program disengagement: “Most of the time I do come and pick them [safer supply medication] up, and there are days where I just feel tired and I just don’t feel like coming in” (P9). Participants emphasized that certain areas of the city can be dangerous, which can discourage them from regularly engaging in their program: “I don’t like downtown. It’s too rough… the drugs are bad most of the time, and so are the people. There’s too much violence” (P17). Participants disclosed how experiencing intense drug withdrawals impacted their ability to pick up their medication and attend check-in appointments: “I was so dope sick [withdrawal] I couldn’t get up” (P2). Lastly, during times of unexpected travel and with insufficient time to arrange medication transfers, participants missed their pick-ups: “I had to go to a funeral out of town. And where I had to go, there were no pharmacies around for me to get my methadone or to get my safer supply, so I had to go three days without it” (P8).

Sub-theme 2: Time Away

The second part of the restart process was time away from the safer supply program. Participants often described the time away from the safer supply program as an extremely stressful and overwhelming period. Several individuals became emotional when recounting this time during their interview. A number of participants recounted the impact of no longer having access to their safer supply medication. Participants described how rapidly their drug cravings and withdrawal symptoms escalated: “it was hard. I was craving my drugs” (P14). For some participants, this inevitably resulted in reverting to purchasing substances from the unregulated and toxic drug supply to manage cravings and withdrawals: “[when I got out of prison] I started using fentanyl again” (P13); “I felt like shit… because I couldn’t get my medication and I knew I was going to use fentanyl” (P25).

Given this, many participants reported experiencing increased rates of overdose during the period of program disruption. One participant stated:

For two weeks, I overdosed hard I think three times in one week and two times the next week, and it was bad all the time. It was like I went down immediately, and then with the fifth one being where I got a cut on my head downstairs, and that scared me (P1).

Participants described how being away from their safer supply program also worsened their mental health and overall sense of wellbeing. One participant said that during their time away from the program “all I did was sit there and lie there for three days. I couldn’t sleep, I couldn’t do anything because of the lack of drugs” (P15). Participants also noted that their time away from safer supply was a significant disruption in their lives that contributed to various interpersonal challenges, “it was really tough. I was sick a lot. I was fighting with my partner. We actually started staying at the shelter” (P1). Overall, participants conveyed feelings of isolation and hopelessness when recounting their time away from safer supply.

Subtheme 3: Return to Program

The third part of the restart process involved participants re-engaging with the safer supply team to restart the program. Participants typically reported that they felt supported by their safer supply team when restarting, and that the process was relatively quick and simple to complete: “they [safer supply Staff] luckily got me back on the program. Fairly quickly, too” (P1). Participants disclosed various reasons for deciding to re-engage with their safer supply program. As described, a number of participants spoke about how returning to unregulated drug use in their time away from safer supply resulted in increased overdoses. A desire to halt or minimize drug overdoses was a common reason for returning to the program. As well, participants recounted how losing access to their safer supply medication led them to return to previous means of survival, such as sex work and criminalized behaviour. In considering what their life would be like without safer supply, one participant stated “I’d have to go back to doing what I didn’t want to do in the first place. So this [safer supply] prevents that… it’d put me back, probably homeless, and I wouldn’t be able to pay my rent. I wouldn’t be able to pay for groceries, anything. It’d all go to dope [unregulated drugs].” (P26). This participant specifically described how engaging in a safer supply program allowed them to become housed and employed – and their main concern was to lose this during their disengagement. Many participants recounted similar experiences, speaking about how their safer supply program involvement supported them in meeting goals that they felt would not be possible without the program:

[Fentanyl] it just ended me pretty much, I would say, took everything from underneath me, everything. I didn't have much to start when I came here, but whatever I have now, I wouldn't have any more [without safer supply], guaranteed. No stability at all. It would be pointless because there would be way more overdoses and way more people using [unregulated drugs] on the streets and unsafe gear everywhere. Actually, when I first came here [to Ottawa] the streets were pretty bad. And all these programs are out there now. The street's pretty clean now actually. It's pretty clean out there (P5).

Overall, several participants spoke about how the chaos and distress they were experiencing led them to wanting to re-engage with the safer supply program: “I thought I could do it alone… But I realized quick enough that I needed the program” (P16).

While participants expressed an immense sense of gratitude for the safer supply program, part of the research interview specifically asked them to discuss some challenges they experienced during the restart process. Participants outlined how dose increases could at times be difficult to obtain when restarting the program, resulting in unmanaged drug withdrawals and cravings. One participant described unmanaged drug craving and withdrawal symptoms while their safer supply doses were titrated upon program restart: “they [safer supply staff] think they have to logically raise me slowly [when I am restarting my medication], but it’s not true because I’m using fentanyl [when I am off the program] anyways” (P4). Participants also expressed frustration with the pace of dose increases following program restart: “I’m disappointed because I was on 32 dilaudid tabs, now he’s increasing me two [hydromorphone 8 mg tabs] at a time each week. That’s ridiculous, I think” (P17). Further, a small number of participants recounted that there was some confusion about how to request medication increases. Because of this, participants stated that they could benefit from more ongoing communication from program staff about restart protocol and policies: “[I’d like a better understanding of how to ask for dose increases] without feeling like you’re a drug-seeking animal or whatever” (P1).

Discussion

In this paper, we reported on findings from surveys and interviews with 30 safer supply Ottawa participants who restarted their program one or more times in the last year. Participants revealed how involvement in a safer supply program resulted in considerable improvements in their lives, including reduced participation in criminalized behaviour, enhanced mental and physical health, safer/reduced drug use, and a general sense of hopefulness for the future. Participants emphasized how safer supply program participation allowed them to achieve a sense of routine and purpose, supported them in returning to meaningful social, work, and recreational activities, and enabled them to work towards major goals, including acquiring stable housing, reconnecting with loved ones, and engaging in to employment or volunteering While being away from safer supply highlighted a distressing and difficult time in participants’ lives, many participants spoke about how the overall restart process was often an unintentional or unavoidable part of being on a safer supply program. Ultimately, conducting this research revealed some important points for consideration.

First, PWUD face a heightened risk of experiencing various complex health issues, yet they also disclose experiences of marginalization, stigma, and other challenges when trying to access healthcare (Brar et al., 2021). Moreover, PWUD often face system fragmentation resulting in gaps in care, ultimately finding themselves lost in the healthcare system as well as other institutions (e.g., incarceration, confusion about how to find pharmacies to pick up medication) (Russell et al., 2021). Our discussions with participants indicated that the wrap-around care that is often available within the program framework is essential, especially during times of stress and crisis. Thus, increasing the availability and quality of wrap-around support for clients may be impactful in avoiding or minimizing program restarts, as many of the crisis events described by participants could potentially be mitigated through outside support (e.g., housing workers, primary care, etc.). Of importance, research has demonstrated that it can be difficult for PWUD to seek care in traditional healthcare models due to ongoing stigma and marginalization. This finding was frequently mentioned during participants’ interviews. Structural stigmatization embedded within services can result in PWUD being apprehensive when deciding if they will access essential care (Russell et al., 2021). Thus, meaningful and safe care embedded within safer supply programs may facilitate ongoing engagement in care. Further, participants described a clear need for consistency in the continuum of care across community organizations and institutions to avoid program interruptions.

A second point for discussion was the importance of increased transparency regarding policies and protocols within safer supply programs. Participants discussed how they occasionally felt confused about certain aspects of the safer supply program, specifically regarding medication changes and increases during restart processes. Participants expressed a desire for clearer communication about program procedures; however, they were apprehensive to ask questions, as they were concerned it could further contribute to the stigmatized perceptions of PWUD, such as the notion of being “drug-seeking”. These concerns aligned with research which explored how PWUD commonly report experiences of stigma and mistreatment within healthcare institutions (Biancarelli et al., 2019; Motavalli et al., 2021). Prioritizing open communication, encouraging and addressing questions, and offering choice wherever possible can help mitigate this challenge. If participants feel safe to express their questions, concerns, and preferences, safer supply programs may more adequately address the needs of PWUD. With regards to program restarts, intentional and ongoing communication regarding the process of (re)engaging in a safer supply program is necessary. It is important for program staff to inform participants that program restarts are an expected part of the program trajectory, and to discuss how to approach disengagement. Clearly outlined processes for participant program engagement in times of crisis may help mitigate this. This strategy is in line with providing care within a trauma-informed approach, wherein communication is open and ongoing, as well as inclusive of clients as active members in the decision-making process (Substance Abuse and Mental Health Services Administration, 2014). Similarly, supporting clients in being actively engaged in their program and care decisions would support the provision of individualized care to address the unique needs of each person. Participants highlighted the significance of tailoring and adjusting program requirements based on these individual care needs. Medication carries and home delivery options were suggested by participants as ways to mitigate accessibility and safety challenges. Participants also suggested that less frequent check-ins can support safer supply participants in gaining independence over time. Further work is required to determine how to maximize engagement and care outcomes with program safety and diligence.

Next, for the successes related to safer supply programs that our participants recounted to materialize, it is vital that there is education and awareness efforts across healthcare and social service systems. As discussed, institutional stigma within healthcare settings, such as hospitals and pharmacies, contributes to the apprehension of PWUD in seeking care (Paquette et al., 2018). Challenges that contributed to the restart process as outlined by participants included difficulties attending the pharmacy each day and concerns surrounding safety in certain areas of the city. While safer supply clients can obtain their prescription medications from any location that dispenses medication, the stigma associated with substance use and misconceptions of the program leads some participants to be apprehensive of going to pharmacies that safer supply program participants do not commonly use. Moreover, research supports the finding that pharmacists may be apprehensive and unwilling to serve PWUD, due to perceived stigma of their conditions and the medication they use (Dickson-Gomez et al., 2022). Pharmacy staff must be thoroughly trained and educated on the safer supply program, including why the program exists, who it is intended for, and how to dispense their medication. Considering the available research and our findings about improved mortality and morbidity, decreased criminalized behaviour, and increased engagement in social, work, and recreational activities, working to streamline safer supply programs could help maximize its individual and population-level outcomes.

In the same vein, institutions such as hospitals and prisons/jails could benefit from further education on safer supply programs, as many participants reported inconsistent and unclear care within these facilities. Advocacy efforts and purposeful education measures are crucial to bridge the gap between PWUD and care providers. Major gaps in the provision of safer supply programs that contribute to restarts must be addressed. Participants often spoke of not receiving their medications and a lack of communication regarding the process of receiving their medication in these facilities. Ultimately, it is well documented that PWUD are at increased risk of drug overdose in the initial weeks following their release from jail or prison (Butler et al., 2023). It is therefore essential that these gaps in care be addressed to ensure clients have access to safe, pharmaceutical-grade drugs rather than the toxic illicit drug supply. A recent study in Ontario found that safer supply participants described a sense of security and stability when they received their safer supply medication, as the substances they are using are of a known potency (Schmidt et al., 2023). When PWUD return to accessing the unregulated drug market, the substances they are purchasing can be much more powerful and unreliable. Moreover, during extended breaks from or decreases to substance use (e.g., when hospitalized or incarcerated), PWUD drug tolerance may decrease over time. This in turn also places them at heightened risk of overdose if they are forced to return to the unregulated toxic drug supply (Lewer et al., 2021).

Conclusion

As the ongoing drug poisoning crisis continues to escalate, it is essential to identify barriers to regular engagement in substance use programs and access to services that can support PWUD. In speaking with safer supply participants in Ottawa, Canada, our research findings revealed that program disruptions were often unavoidable and unrelated to unregulated substance use. Instead, participants spoke about challenges in accessing care during “crisis periods”, such as incarceration or hospitalization. Discussions with participants highlighted the importance of recognizing that times of crisis are largely inevitable and may potentially threaten participant program retention. Safer supply programs should seek to have clear program restart processes in place and increased wrap-around services to support participants in times of crisis. Further, improvements to continuity of care across institutions and increased education for other healthcare and social services on the topic of safer supply are needed. Overall, it is essential that safer supply and other programs which provide care for PWUD maintain flexibility given the multifaceted and complex nature of substance use in the context of the unregulated toxic drug supply.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This work was supported by the Health Canada 2021-HQ-000059.

Ethical Statement

ORCID iD

Marlene Haines

Author Biographies

Patrick O’Byrne NP PhD is a Full Professor of Nursing at the University of Ottawa and a Nurse Practitioner. His research and clinical practice focus on the prevention,diagnosis,and treatment of sexually transmitted infections,including HIV. He holds a research chair in public health and HIV prevention.

Emily Hill is a Bachelor of Social Work student at Carleton University. She is currently employed at OICH and works as a Case Manager within the organization.

Marlene Haines RN PhD is a researcher and nurse practitioner student in the School of Nursing at the University of Ottawa. Her program of research focuses on the drug poisoning crisis,harm reduction,and drug policy. She also has clinical expertise in safer supply programs,injectable opioid agonist therapy,and working with individuals who use substances as well as those who are homeless or unstably housed.

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