Abstract
Canada is currently grappling with an unprecedented addiction crisis, with one of its most prominent facets being the alarming rise in overdose fatalities. This overdose fatality crisis, a severe public health concern, has been exacerbated by the onset of the COVID-19 pandemic, especially impacting individuals who use drugs (PWUD).
In response to the evolving landscape of opioid use disorder (OUD) treatments, including interventions like opioid agonist therapy (OAT), a spectrum of innovative strategies have been conceived to address various aspects of OUD care, including prevention, harm reduction, and improving care accessibility for PWUD. 1
Against this backdrop, a coalition of healthcare professionals, advocates, and individuals with lived experience have promoted the implementation of an initiative called prescribed safer opioid supply (SOS). This entails prescribing pharmaceutical-grade opioids to PWUD to replace unpredictably toxic non-pharmaceutical grade opioids and fentanyl analogs, typically for unwitnessed consumption. 2
Qualitative evidence supports the benefits of safe supply programs for PWUD, 3 but concerns remain about risks like diversion and associated harms such as tablet hydromorphone injection, new-onset opioid use disorder, and overdose. The need for quantitative studies to objectively assess the impact of safe supply interventions on overdose deaths and health outcomes is increasingly recognized. An important addition to the discourse on safe supply programs comes from the retrospective cohort study by Slaunwhite et al. 4 This study provides valuable insights into the effects of risk mitigation guidance (RMG) opioid and stimulant dispensations on mortality and acute care visits among individuals with OUD. Notably, the study identified a short-term reduction in risk following the administration of supervised SOS, albeit primarily among individuals already receiving OAT. However, caution is warranted in interpreting these findings, as the study's exclusion of individuals not on OAT from the analysis raises questions about whether the observed benefits are driven solely by SOS or influenced by OAT as well. Moreover, the study's limitations, such as potential selection bias due to the absence of randomization, the lack of standardized case definitions for RMG medications, and the assessment of outcomes at a very short-term interval of one week, underscore the need for further research to objectively assess the impact of safe supply interventions on overdose deaths and health outcomes.
Furthermore, another recent study by Nguyen et al. contested the benefits of safe supply, 5 reporting that the SOS policy in British Columbia was associated with higher rates of safer supply opioid prescribing but also with a significant increase in opioid-related poisoning hospitalizations. These findings underscore the complexity and evolving nature of the literature on safe supply programs. It is crucial to contextualize these findings within the broader public health framework. While the short-term benefits of SOS are notable, the potential for diversion and its impact on the larger population, particularly those not receiving OAT, must be carefully considered. A thorough risk-benefit analysis, encompassing the potential negative externalities and long-term sustainability of safe supply programs, is imperative for informed policy decisions and effective harm reduction strategies.
Many SOS programs in Canada have been led by community health centres in response to the unmet needs of PWUD. Psychiatrists may work with individuals receiving SOS depending on their involvement with PWUD and where they work. Notably, most Canadian psychiatrists do not typically prescribe opioids or OAT. However, awareness and education are essential even if they are not involved in the prescribing. Given their training and skill sets, psychiatrists can greatly support individuals who participate in SOS programs.
First, psychiatrists should address psychiatric comorbidity in SOS patients. 6 While data are lacking specifically among PWUD who engage with SOS, individuals with OUD often have comorbid trauma, mood, or anxiety disorders, and the benefit of concurrent psychiatric care with OAT has been established, leading to decreased hospitalizations, ER visits, and, all-cause mortality. 7
Second, psychiatrists may interface with individuals who receive SOS and present to the hospital for various reasons. Psychiatrists working in consultation-liaison and addiction consultation settings may receive requests about how to provide care for patients receiving SOS. Psychiatrists working on inpatient units may also treat patients on a SOS program admitted to psychiatric units. Managing opioid withdrawal symptoms can decrease suffering and increase engagement in assessments and management plans. Unfortunately, many patients are discharged before medically advised or disengage from psychiatric teams when their needs are unmet around their OUD. 8 In the ER and inpatient settings, providers should ensure that individuals are provided with relief from symptoms of opioid withdrawal safely. For individuals receiving SOS who are admitted to the hospital, treatment goals encompass relieving the suffering and distress of individuals experiencing opioid withdrawal, allowing patients to remain in the hospital for medically necessary care, and maintaining tolerance to opioids for individuals likely to resume using opioids. 9 To this end, providers can help relieve opioid withdrawal symptoms using short-acting opioids or methadone/buprenorphine/slow-release oral morphine. 9 However, psychiatrists without addiction training often lack the clinical expertise to provide an appropriate dose of standard OAT for individuals with OUD, let alone safer supply dosing. We encourage providers to continue to obtain further competency in working with patients with substance use disorders and to collaborate with addiction consult services and ambulatory safer supply programs to help provide optimal care for patients receiving SOS.
Third, when patients show interest in SOS or seek psychiatrists as prescribers, it's vital for psychiatrists to thoroughly inform them about available options and provide a clear explanation of indications, potential risks, and anticipated benefits. Understanding opioid pharmacology and OAT is essential for prescribing SOS, but uncertainties persist about potential interactions with psychotropic drugs. Caution and vigilance are crucial, as it's unclear if SOS medications may elevate the risk of serotonin syndrome or additive sedation, possibly masking or exacerbating mental health symptoms. Psychiatrists must exercise careful prescription management and monitor side effects as required.
Fourth, psychiatrists should listen non-judgmentally to patients receiving SOS. In addition to providing psychiatric care, psychiatrists should ensure the provision of harm reduction strategies, including take-home naloxone and address, to the extent possible, deficiencies in social determinants of health, such as access to safe housing, food security, financial aid, and social capital. Psychiatrists play a vital role in providing essential care, including smooth transitions for SOS patients and collaborating closely with outpatient clinicians.
Furthermore, it is worth acknowledging the potential role of wrap-around care in the context of SOS studies. 6 SOS programs often provide a range of support services to participants, including comprehensive healthcare and interventions addressing social determinants of health. However, wrap-around care can complicate study outcomes in SOS interventions. Understanding the distinct impact of wrap-around care and SOS within this broader context requires careful consideration and may pose challenges in drawing definitive conclusions about the sole effectiveness of SOS. This complexity highlights the importance of rigorous study design and methodology when evaluating SOS programs and the need for further research to elucidate the nuanced relationships between various components of care in achieving positive outcomes for individuals with OUD.
Raising awareness among psychiatrists about SOS is crucial in addressing individuals with OUD. The current literature on SOS is still in its early stages, and an ongoing review of practice should consider the most up-to-date literature. Patients enrolled in SOS programs should always receive take-home naloxone and be provided with harm minimization guidance concerning consumption. Additionally, when appropriate, approved OAT should be offered. Regardless of the ongoing debates surrounding safe supply, psychiatrists must stay informed about this practice and continue offering psychiatric care to patients considering or receiving SOS.
Footnotes
Acknowledgements
Declaration of Conflicting Interests
Funding
ORCID iDs
