Abstract
Keywords
Introduction
In 2016, the unregulated drug supply in Canada and other countries rapidly became increasingly dangerous. This was largely due to the contamination of heroin with fentanyl, resulting in increased rates of overdose and death among people who use drugs (PWUD) (Hayashi et al., 2018). Since then, nearly 50,000 PWUD have died in Canada as a result of the unregulated toxic drug supply (Public Health Agency of Canada, 2024). While accurate and rapid community drug checking is not available in most communities, some larger cities in Canada have drug checking programs. Results from these programs are often publicly distributed to provide some insight into the worsening state of the poisoned unregulated drug supply in those regions. For example, drug checking results in Toronto, Ontario show that the vast majority of unregulated drugs tested are consistently tainted with substances other than what the recipient intended to purchase and use, including fentanyl analogues, benzodiazepines, and other sedatives (e.g., xylazine) (Centre on Drug Policy Evaluation, 2023). Results from these community drug checking sites also demonstrate that the unregulated drug market fluctuates rapidly, with new and different substances detected each week. It is important to note then that most individuals purchasing unregulated substances have no way of knowing what may be in the drugs they are consuming, increasing their risk of overdose and death.
While fentanyl is involved in the majority (81%) of drug toxicity deaths (Public Health Agency of Canada, 2024), it is becoming more common for harms related to polysubstance use to involve a combination of opioids (e.g., fentanyl) and stimulants (e.g., cocaine, crystal methamphetamines). In 2022, Health Canada reported that 48% of opioid toxicity deaths also involved a stimulant drug and that 79% of stimulant-related deaths also involved an opioid drug (Public Health Agency of Canada, 2024). In Ontario specifically, a report released by the Ontario Drug Policy Research Network found that stimulants played a direct role in nearly 60% opioid-related deaths during the COVID-19 pandemic (Gomes et al., 2022). These findings highlight the need for comprehensive polysubstance use services and programs for PWUD. Currently, individuals who use unregulated stimulants have very few evidence-based resources available to address their stimulant use. For example, there is no gold standard medication for treating stimulant use disorder, and most interventions focus on psychosocial (e.g., counselling, outpatient therapy) approaches which are often rooted in abstinence (Kampman, 2022). While abstinence from drugs may be a goal for some people who use stimulants, PWUD are a heterogeneous group with different needs and circumstances. For example, for PWUD who may be seeking to use stimulant drugs more safely or may be seeking to reduce their stimulant use slowly over time, there exist very few programs or service options.
While certain substances are regulated in Canada, such as alcohol and cannabis, the vast majority of people who use unregulated drugs do not have access to a regulated supply of drugs. Specifically, the most recent Canadian Alcohol and Drug Survey found that over one million people in Canada reported using an illegal drug in the past year (Health Canada, 2021). To address this, 26 Safer Supply pilot programs were opened in a select number of cities across Canada with the support of Health Canada's Substance Use and Addictions Program (Health Canada, 2023; National Safer Supply Community of Practice, 2023). Overall, Safer Supply programs seek to reduce harms related to the toxic unregulated drug supply by providing PWUD with pharmaceutical-grade prescription medication (Canadian Association of People Who Use Drugs, 2019; Haines & O’Byrne, 2023). To date, the majority of Safer Supply programs have focused on providing opioid medication to people who use unregulated fentanyl. However, it is important to note that the concept of Safer Supply is not synonymous with opioids, and instead can be understood as “a broad term which includes offering someone an alternative, safer version of a substance in contrast to the toxic illicit drug supply” (Haines et al., 2022, p. 8).
In Ottawa, Canada, a Safer Stimulant Supply program was opened to support people who use unregulated stimulants given the scarcity of programs available to this group and the increasing harms associated with stimulant and polysubstance use. Currently, there is no gold standard medication for treating stimulant use disorder, with most interventions focusing on psychosocial (e.g., counselling, outpatient therapy) approaches which are often rooted in abstinence (Kampman, 2022). Further, for individuals who may not be seeking treatment for their stimulant use – but perhaps instead, increased safety with the drugs they are consuming – services are exceptionally scarce and difficult to access (Fleming et al., 2020). Overall, Safer Stimulant Supply programs seek to provide a replacement for the toxic unregulated stimulant supply, often including, but not limited to, crystal methamphetamines, cocaine, and/or crack cocaine. People who use unregulated stimulants who wish to be considered for the program may self-present to the substance use clinic or community health centre currently offering a Safer Stimulant Supply program. A care team consisting of physicians, nurses, and peers completes a detailed clinical intake form with the person who uses unregulated stimulants to assess if they are an appropriate candidate. At a minimum, typically program patients must be diagnosed with a stimulant use disorder (DSM-5) and they must have attempted and were not successful in contingency-based management, or have social and/or medical barriers to accessing traditionally recommended management.
Typically, both short-acting (e.g., methylphenidate immediate-release 10 mg tablets) and/or long-acting (e.g., methylphenidate long-acting capsules) prescription stimulant medication is used within Safer Stimulant Supply programs. Decisions regarding stimulant medication prescriptions are tailored to the individual needs of each patient by their prescriber. Patients most often pick up their medication from a pharmacy daily. Long-acting medication is typically taken orally and observed by a pharmacy staff member. Short-acting medication is usually dispensed “to go” for patients to use over the course of the day via their preferred route of administration (e.g., oral, injection) for harm reduction. Patients complete weekly check-ins with their Safer Stimulant Supply teams, where they discuss individual patient goals, including topics such as their mental health, physical health, and substance use. While goals for the Safer Stimulant Supply program are created and implemented by program patients and their care teams, common goals include: 1) decreased or discontinued unregulated stimulant use; 2) decreased risk of drug-induced psychosis; 3) decreased risk of cardiovascular morbidity due to illicit stimulant use; 4) decreased risk of infectious disease transmission; 5) decreased participation in criminalized behaviours; and 6) improved mental and physical health (Haines et al., 2023).
Given the paucity of research and evaluation regarding Safer Stimulant Supply programs, in this paper, we describe the results of Safer Stimulant Supply patient medical chart reviews. Our goal was to better understand patient outcomes and complete a more in-depth exploration of the impact of Safer Stimulant Supply programs.
Methods
Study design
This retrospective review of medical charts focused on data collected by Safer Stimulant Supply program clinical teams in Ottawa, Canada. In total, 28 patient medical charts were eligible to be included in this evaluation. Only the medical charts of patients actively engaged in a Safer Stimulant Supply program in Ottawa at the time of data collection were included.
Data collection
All Safer Stimulant Supply program patients complete initial intake forms as well as check-ins with their care teams on a regular basis. Data from these forms was collected and anonymized by the care team prior to being given to the research team to protect patient confidentially. Specifically, the data collected included patient demographics, information regarding substance use, wrap-around service and support access, urine drug screen results, and program intake information. Data collection was performed from January – March 2023.
Of note, self-reported gender of women and men include both cisgender and transgender individuals. Given the small number of individuals who were transgender within these programs, gender was grouped this way to protect privacy and confidentiality.
Data analysis
Data collected from the medical chart reviews were reported on using descriptive statistics. This included means and standard deviations for normally distributed variables, medians and interquartile ranges for skewed variables, and proportions and percentages for categorical variables.
Ethics and funding
This study was approved by the University of Ottawa. Funding was provided by Health Canada's Substance Use and Addictions Program (grant # 2021-HQ-000059).
Results
Sociodemographic information
A total of 28 Safer Stimulant Supply patient medical charts were reviewed. There were 22 (79%) men and 6 (21%) women actively engaged in a Safer Stimulant Supply program at the time of chart reviews. Patients had a median age of 37 years old, with the oldest being 61 and the youngest being 20. Current patients had a median of 9.5 months on a Safer Stimulant Supply program. During the intake process, patients reported starting to use drugs at an average age of 14 years old and reported beginning to inject drugs at an average age of 21 years old (among the n = 16 who reported that they inject drugs). Patients’ levels of education were as follows: less than high school (36%, n = 10), high school (32%, n = 9), university (18%, n = 5), and college (14%, n = 4). Most patients reported their income source as Ontario Disability Support Program (57%), followed by Ontario Works (21%), and other (21%).
Behavioural assessments
As part of the Safer Stimulant Supply intake process, program patients complete a behavioural assessment with staff members. This assessment includes an overview of risk factors and other behaviours directly associated with unregulated substance use. The majority (71%, n = 20) of patients reported experiencing some form of abuse (e.g., physical, sexual, emotional, mental) over their lifespan – this was the most commonly reported risk factor. Nearly two-thirds (n = 18) of patients reported experiencing a drug overdose associated with their unregulated substance use. Half (n = 14) of the patients had used a supervised consumption site at some point, and half reported having shared drug use equipment with peers before. Less than half (46%, n = 13) of patients reported injecting drugs. More than one-third (39%, n = 11) of patients were engaged in criminalized behaviour as a result of their unregulated substance use, and 29% (n = 8) of patients reported an emergency room visit in the past month. A full 25% (n = 7) of patients reported having been diagnosed with Hepatitis C, while 7% (n = 2) reported having been diagnosed with HIV.
Pre-/post-measures
Safer Stimulant Supply program staff regularly asked patients a series of questions to help assess the possible impact of the program on their lives through pre-/post-measures at program intake and subsequent check-in meetings. At program intake, 39% (n = 11) of patients reported living in a shelter, and 61% (n = 17) were housed. During their most recent check-in, 29% (n = 8) of patients reported still living in a shelter, and 71% (n = 20) reported being housed. Of note, no patients went from being housed to living in the shelter while being enrolled in the Safer Supply stimulant program. Several different types of wrap-around supports were also made available to Safe Stimulant Supply program patients. This included housing workers, primary care services, and infectious diseases programming. With regards to housing, nearly one-third (32%, n = 8) of patients formally met with a housing worker for support during their time on a Safer Stimulant Supply program.
At Safer Stimulant Supply program intake, the majority (71%, n = 20) of patients reported having no access to primary care services. At follow-up, nearly 90% (n = 24) of patients reported accessing primary care services since starting their Safer Stimulant Supply program. Many (75%, n = 21) patients also utilized the in-house, wrap-around primary care services offered. In addition, ten patients (36%) were being prescribed medication unrelated to their substance use (e.g., mental health, infectious diseases, and other health concerns) along with their Safer Stimulant Supply medication. All program patients were offered a Hepatitis C program, which includes support surrounding prevention, testing, diagnosis, and treatment. Most (68%, n = 19) patients accepted the offer to engage with this Hepatitis C program, and among those with engaged, 17 opted to complete Hepatitis C testing with a nurse. Of the patients who completed testing, 8 (47%) were Hepatitis C negative, 6 (35%) were Hepatitis C positive, and 3 (18%) had results pending at the time of chart reviews. Two of the patients who tested positive immediately started Hepatitis C treatment concurrent to their Safer Stimulant Supply medication.
Substance use and medication
Over the course of the program, patient stimulant medication prescriptions were titrated to address ongoing unregulated stimulant use, as well as ongoing stimulant cravings and withdrawal symptoms. An overview of prescriptions is provided in Table 1, which describes how patient prescriptions changed from their initial intake doses to their most recent check-in doses (reported as median daily dose). It should be noted that at their most recent check-in, patients who were prescribed a long-acting stimulant medication (68%, n = 19) were only prescribed a single type. Further, patients were asked to report the amount of unregulated stimulants they had consumed at program intake and at each subsequent check-in to assess the impact of Safer Stimulant Supply over time. Before starting the program, patients reported using a median of 10 points (1 gram) (IQR 0–20) of cocaine and 1.5 points (IQR 0–10) of crystal methamphetamines each day. At their most recent check-in, patients reported using a median of 0 points (IQR 0–1) of cocaine and 0 points (IQR 0-0) of crystal methamphetamines each day.
Prescription Stimulant Medication Doses.
Discussion
In this paper, we described the results of medical chart reviews from a Safer Stimulant Supply program in Ottawa, Canada. Overall, patients reported decreased use of unregulated stimulants as well as improved access to wrap-around services, such as housing support, primary care, and infectious diseases services. Given the lack of literature and formal guidelines surrounding Safer Stimulant Supply programs, our results present some nascent data on this topic and raise several interesting points for discussion.
First, despite Safer Stimulant Supply program goals being individualized based on each patient's unique needs, the vast majority of patients reported decreasing their unregulated stimulant use throughout their time on the program. Strikingly, while average cocaine use at intake was 10 points/day, and average crystal methamphetamine use at intake was 1.5 points/day, the average use for both substances at patients’ most recent check-in appointments had decreased to 0 points/day. It is important to further contextualize this result within the understanding that this decrease occurred over the span of a median time of 9.5 months on the program. As well, while unregulated stimulant use decreased, prescription stimulant medication doses increased over time. Indeed, medications must be titrated to manage stimulant cravings and withdrawals appropriately and effectively (Haines et al., 2023). These findings suggest that, ultimately, the prescription of high-dose stimulant medication can be impactful for certain groups of PWUD who are looking to decrease or stop their unregulated stimulant use altogether. While some guidelines regarding Safer Stimulant prescribing exist(British Columbia Centre on Substance Use, 2022), there continues to be a gap in widespread clinical knowledge at this time. Thus, in the absence of formalized guidelines, expertise from people with lived experience and harm reduction-based clinicians must be used to direct medication dosing.
Second, in considering the socio-demographic data collected on this group at program intake, there are a few noteworthy findings. Patients reported starting to use drugs in their adolescence, specifically at an average of 14 years old. The youngest age a patient reported starting to use drugs was 10 years old. This finding reinforces the understanding that a spectrum of youth substance use-based services must be available to address potential harms related to unregulated substance use from a very young age. Concerningly, a recent report found that there has been a steady decline over the past 5–10 years in youth accessing opioid agonist treatment, while emergency department visits, hospitalizations, and opioid toxicity deaths associated with unregulated drug use continue to escalate among youth(Iacono et al., 2023). This is particularly worrisome given the previously mentioned increasing rates of polysubstance use, the state of the toxic unregulated drug supply, and the limited substance use-related programming available to address stimulant use. Also of note, the majority of program patients self-identified as male (n = 22, 79%), while a minority reported their gender to be female (n = 6, 21%). While this may be due to a small sample size, it may also be impacted by women historically being underserved in substance use and harm reduction-based spaces (Collins et al., 2020; Pinkham & Malinowska-Sempruch, 2008). Despite substance use programming placing a clear focus upon cis-men (Aldous et al., 2023; Public Health Agency of Canada, 2024; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2022), results from the most recent Canadian Alcohol and Drug Survey (Health Canada, 2021) show that men and women have a similar prevalence of past-year use of unregulated drugs. Further, this survey found that there was no difference in the prevalence of self-reported harms as a result of drug use between men and women (Health Canada, 2021). This suggests that women continue to be an underserved group of people in need of further investigation to better understand their substance use needs within harm reduction services such as Safer Supply programs.
Third, our findings demonstrate the importance of pairing Safer Supply programs with comprehensive and targeted wrap-around supports. Patients regularly accessed these services alongside their Safer Stimulant Supply program. Further, our previous research with Safer Supply patients found that wrap-around supports were integral to stabilizing on a Safer Supply and completing goals (Haines et al., 2022; Haines & O’Byrne, 2023). Many patients (75%, n = 21) utilized the in-house walk-in primary care services being offered by their program, and overall engagement in primary care among patients rose from 29% at intake to 90% at their most recent check-in. This is important for two main reasons. First, PWUD remain an important group for primary care services to engage with given their ongoing risk factors (e.g., infectious diseases transmission) and harms (e.g., drug overdose) associated with the toxic unregulated drug supply. Second, only 34% of people in Ontario have access to same or next-day appointments with a primary care provider (Health Quality Ontario, 2022). In contrast, 75% of Safer Stimulant Supply program patients were engaged in same-day walk-in primary care services through their program. Further, and importantly, many patients successfully engaged with housing workers to initiate finding stable housing, and most patients engaged with a Hepatitis C program. These findings suggest that wrap-around service access is an essential component of offering a Safer Supply program and caring holistically for PWUD.
Limitations
One limitation of this research is the use of self-report data to assess program outcomes. In particular, self-reports are used to track the quantity of unregulated stimulants being consumed by patients at program intake and during each check-in meeting. It is important to note that at intake and check-ins, rapid urine drug screens (UDS) are also completed and tracked with patients. Further, urine samples are periodically sent to a laboratory for more detailed and specific results; however, depending on laboratory capacity, these results can take days or weeks to be processed. However, self-reported data remain essential for two main reasons. Firstly, UDS or laboratory results do not quantify the amount of a substance (for a Safer Stimulant Supply program, this would typically be crystal methamphetamine or cocaine) being consumed each day by the patient. Thus, self-reported is necessary to track quantities over time. Secondly, given the state of the toxic unregulated drug supply, UDS and lab testing are not clinically useful to see if someone has decreased or stopped using substances. For example, if a patient reports not using crystal methamphetamines, but they report that they are still using fentanyl, it is possible for a positive methamphetamine result to occur if the fentanyl they are consuming was contaminated with crystal methamphetamine without their knowledge. Anecdotally, clinicians instead often use UDS to simply confirm that an individual is consuming their prescribed program medication (e.g., confirming there is methylphenidate in a Safer Stimulant Supply patient's UDS results). Laboratory testing may be clinically useful to validate patient's experiences (e.g., blackouts, unusual behaviour) when using the unregulated drug supply. Ultimately, Safer Stimulant Supply programs exist to reduce harms – abstinence is not required to be engaged in this type of program.
Conclusion
With 22 people in Canada dying each day as a result of the toxic unregulated supply of drugs, a spectrum of services and programs are required to address this crisis. In particular, people who use unregulated stimulants are increasingly at risk for harms surrounding their drug use and have limited services and programs available to address their drug use. Safer Stimulant Supply programs seek to support PWUD through the provision of pharmaceutical-grade stimulant medication as a replacement for the toxic unregulated stimulant drugs supply. We have presented patient outcomes related to Safer Stimulant Supply programs, which included decreased use of unregulated stimulant drugs, increased access to primary care and infectious disease programs, and improvements to housing status. Further, explicit examples of prescription stimulant medications at program intake and at later check-in appointments were provided. Overall, Safer Stimulant Supply programs remain an underutilized but important harm reduction tool to address the drug poisoning crisis.
Footnotes
Data availability statement
Declaration of Conflicting Interests
Funding
ORCID iD
