- Researchers analysed the outcomes of a safer opioid supply program in London, Ontario
- Participants had 32% fewer hospital emergency visits and 54% fewer inpatient visits
- Certain annual healthcare costs decreased significantly
Safe supply is a harm reduction approach that provides people who use drugs with access to medications that are an alternative to unregulated drugs. It aims to reduce harms related to the unregulated drug supply, including the risk of drug poisoning deaths.
Canada’s first formal safer opioid supply program
The safer opioid supply program at the London Intercommunity Health Centre (LIHC) started in 2016 in London, Ontario. It was initially offered to LIHC service users who were experiencing multiple health issues related to injecting drugs (e.g., infectious complications like endocarditis, HIV, hepatitis C) and were believed to be at risk of death due to these health issues. Many had previously attempted traditional opioid agonist treatment (OAT) but found it was not effective for them. As the program expanded, formal eligibility criteria were developed. These criteria and more information about the program can be found in a CATIE evidence brief.
In the LIHC safer opioid supply program, immediate-release hydromorphone (primarily Dilaudid branded tablets due to their ease of dissolution into solution) is the main medication prescribed as an alternative to unregulated opioids. These tablets are usually dispensed every day from a pharmacy of the participants’ choice as take-home doses. Participants can consume them how (e.g., orally, snorting or by injecting), when and where they like, to achieve the effects they desire (e.g., for a euphoric effect, to manage withdrawal and cravings). Slow-release oral morphine is often also prescribed to program participants, who generally consume it orally once a day at their pharmacy. This medication is longer acting and can help prevent withdrawal between doses.
The safer opioid supply program is offered at a community health centre where participants are also provided with comprehensive primary care. Comprehensive primary care can include a range of health and social services that help participants meet their needs. It can include treatment for health issues such as HIV, hepatitis C, asthma or diabetes; sexual health care; vaccinations; and screenings for cancer. It can also include access to harm reduction supplies and education, assistance with meeting basic needs such as food and housing, and other supports.
Researchers analysed the healthcare records of participants in the safer opioid supply program between January 1, 2016, and March 31, 2019, to understand their patterns of healthcare use before and after accessing the program. These trends were compared with those from a matched group of people who lived in the same area and who had similar demographic and health characteristics. This matched group included people who lived in London, Ontario during the study period and had been diagnosed with an opioid use disorder (OUD). The two groups were also matched on the basis of age, sex, eligibility for public drug benefits, neighbourhood income, hospital visits for opioid poisoning in the past year and hospital admission for endocarditis in the past year. This matching process was done to help the researchers determine if changes in program participants’ outcomes over the study period were associated with participating in the program or caused by other factors.
Of 94 people who were part of the safer opioid supply program during the study period, records from 82 program participants were matched with those of 303 people from the group who were not exposed to the program. The two groups were similar in a number of ways, including:
- average age of 41 years
- 40% were male
- 87% were eligible for public drug benefits
- 8.5% had been to hospital because of opioid poisoning in the previous year (i.e., had experienced an overdose that was treated in hospital)
However, there were differences between the groups. Before entering the program, participants in the safer opioid supply program were more likely to have experienced a range of health challenges than people in the matched group. Participants were more likely to have:
- been diagnosed with HIV (34% of safer opioid supply participants, compared with 8% of people in the matched group)
- been diagnosed with hepatitis C (70% of safer opioid supply participants, compared with 25% of people in the matched group)
- visited the hospital in the previous year because of a substance use disorder (18% of safer opioid supply participants, compared with 10% of people in the matched group)
- visited the hospital in the previous year because of a skin or soft-tissue infection (18% of safer opioid supply participants, compared with less than 6% of people in the matched group)
These differences suggest that the safer opioid supply program was successful in its goal of engaging a group of people who were experiencing more health issues related to their drug use.
Primary study findings
Researchers analysed healthcare outcomes in different ways to explore the effectiveness and safety of the safer opioid supply program. The first analysis was a time series analysis that looked at healthcare outcomes every 30 days for the five years before participants entered the safer opioid supply program and every 30 days for one year after they entered the program. Researchers conducted the same analysis for the matched group over the same period of time.
This analysis showed that there were significant and rapid changes in the healthcare outcomes of safer opioid supply program participants in the year after they entered the program, including decreases in the monthly rate of:
- emergency department visits
- admissions to inpatient hospital care
- healthcare costs (not related to primary care or outpatient medication)
This analysis also found that there was no significant change for program participants in the rate of hospital admission for new infections that can be related to injecting drugs (e.g., endocarditis, skin and soft-tissue infections, osteomyelitis).
For the matched group, there were no significant changes in any of these four outcomes.
Researchers conducted a second analysis to compare healthcare outcomes one year before and one year after participants entered the program. This analysis was repeated for the matched group over the same period of time. They found significant changes among safer opioid supply program participants, including the following:
- Emergency department visits significantly decreased (from 250 in the year before, to 170 in the year after entering the program).
- Hospital visits for inpatient care significantly decreased (from 74 in the year before, to 34 in the year after entering the program).
- Hospital admissions for new infections that can be related to injecting drugs significantly decreased (from 26 in the year before, to 13 in the year after entering the program).
- Healthcare costs (not related to primary care or outpatient medication) significantly decreased (from an average of $15,635 per person in the year before, to an average of $7,310 per person in the year after entering the program).
For the matched group, there were no significant changes in these outcomes.
Researchers analysed a range of additional outcomes for both groups. They found that deaths from all causes were rare in both groups. There were no opioid-related deaths among participants in the safer opioid supply program in the year after they entered the program. There were fewer than five opioid-related deaths among people in the matched group.
In the year after participants entered the safer opioid supply program, their total publicly funded medication costs increased significantly, from an average of $12,840 to $21,119 per person. Prescription opioids (e.g., OAT and safer supply medications) accounted for 15% of these costs. The majority of the remaining costs were probably the result of improved access to medications for treating health issues such as HIV and hepatitis C. For people in the matched group, total publicly funded medication costs did not increase significantly.
This research demonstrates that safer opioid supply can help expand treatment and harm reduction options for people who use drugs who are at high risk of drug toxicity death. It adds to a growing body of evidence about the effectiveness and safety of safer opioid supply programs. The reduced use of hospital services and reductions in certain healthcare costs among safer opioid supply participants demonstrate that these programs can play an important role in reducing harms for people who use drugs.
The rising medication costs also suggest that being part of the safer opioid supply program provided participants with improved access to care for complex health issues such as HIV and hepatitis C. Receiving treatment for these health issues is likely to benefit individual health and well-being, and it may also reduce healthcare system costs over time. This is because treatment for these infections can prevent them from being passed on.
There have been concerns raised that prescribing immediate-release hydromorphone tablets for people to inject (if they wish) may lead to increased infections among people who use drugs. However, this study found that among participants in the safer opioid supply program there was no change in the rate of new infections that can be related to injecting drugs after they entered the program. It also found a reduced rate of hospital admissions for these infections a year after they entered the program. These findings provide evidence for the safety of safer opioid supply programs.
For the future
It is important to note that safer opioid supply program participants were provided with comprehensive primary care and access to a range of social and health services alongside their safer supply of opioids. It is difficult to separate the effects of different aspects of the program from each other. Further research is needed to evaluate the roles of different aspects of safer opioid supply programs in reducing harms and improving health.
Gomes T, Kolla G, McCormack D et al. Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario. Canadian Medical Association Journal. 2022;194:E1233-42.