In 2020, AVI Health & Community Services (AVI) launched its prescribed alternatives (PA) program with the Victoria SAFER Initiative, and in 2022, it expanded the program to serve communities across Vancouver Island. For more information, see the Victoria SAFER Initiative case study. Building on this work, AVI further expanded the program in 2024 to include harm reduction workers (HRWs) in Victoria, providing them with access to pharmaceutical grade alternatives to the toxic unregulated drug supply, along with wraparound health and social supports.
AVI increases health equity by providing highly responsive, harm reduction-based HIV, hepatitis C, substance use, sexual health, mental health and other community health services and is informed by the voices of people with living and lived experience.
Why was the program developed?
The 2024 expansion of the program was designed to support HRWs to stay safe, healthy and stable while doing frontline work and in their daily lives, and to address several gaps and inequities:
- HRWs are too often excluded from programs they help deliver: Many HRWs meet the eligibility criteria for PA programs yet cannot access them because of conflict-of-interest policies, prescriber restrictions, and ethical and legal concerns around treating one’s colleagues. The incongruence of programs asking HRWs to support participants who have access to PA options but denying this access to the HRWs themselves creates frustration, confusion and inequity. Such exclusion fosters an exploitative environment that deepens divisions within the workforce, stigmatizes HRWs and further marginalizes those supporting their own communities.
- HRWs face the same risks of overdose and other drug-related harms as other community members: Many HRWs rely on the toxic unregulated drug supply to manage pain, withdrawal symptoms and trauma symptoms while working. This causes fear, instability and exhaustion, especially as the unregulated drug supply becomes increasingly unpredictable and volatile.
- Workplace stability is consistently at risk: Accessing the unpredictable and toxic unregulated drug supply can make it difficult for HRWs to maintain employment, attend appointments and manage daily life.
In response to these barriers and inequities, AVI expanded its PA program by engaging existing AVI prescribers, mobilizing community pharmacies and establishing thorough ethical safeguards to allow HRWs to safely access PA without compromising clinical and ethical boundaries. Staff advocacy, partnerships with local organizations and consultation with regulatory bodies all informed this expansion.
The program is built around AVI’s commitment to health equity, dignity, safety and person-centred care. It acknowledges that HRWs play a critical role in overdose response, harm reduction program development and improvement, outreach and peer support and that they deserve access to the same harm reduction and healthcare services they help to provide to others in the community.
How does the program work?
The program provides access to PA to people employed in harm reduction roles (i.e., HRWs) who have living experience of substance use. In addition, an interdisciplinary healthcare team provides wraparound care and connections to health and social supports to help them stay safe, healthy and stable. Medication options include, but are not limited to, opioid agonist treatment (OAT) and prescribed alternative medications such as hydromorphone, fentanyl patches and fentanyl buccal tablets.
The program is staffed by:
- two physician prescribers who work remotely to lead clinical assessments, dosing and titration plans
- one program nurse who manages clinical intake and follow-up
- one systems navigator who is the primary contact for participants, supporting them with social service navigation, healthcare access, case management and advocacy
HRW participants are typically more independent and require less intensive support than those in other AVI PA programs, so staffing for this group is scaled back.
HRWs are only eligible to participate if they are not currently employed by AVI PA programs, to avoid ethical and legal conflicts of interest. Staff from other AVI programs and community partner organizations (e.g., SOLID Outreach) are eligible to participate because they do not interact directly with the program’s prescribers and therefore do not face the same risks. The program can currently provide services to 10 HRWs. Eligibility is assessed using AVI’s equity and acuity scales and prioritizes HRWs who:
- identify as Black, Indigenous and people of colour
- identify as women and gender-diverse
- are actively experiencing homelessness
- have recently experienced overdose(s)
- have high levels of emergency medical service use (emergency department visits, ambulance calls, etc.)
Medication options and dispensing protocols
PA medication options include standard OAT medications and safer opioid formulations such as hydromorphone, fentanyl patches and fentanyl buccal tablets. PA medications and dosages are tailored to each participant’s specific needs and goals. Participants work closely with program staff during dosing, titration and stabilization. Participants access their medications through community pharmacies, typically by directly witnessed ingestion (DWI). Under DWI, a healthcare professional (e.g., nurse or pharmacist) observes the ingestion of each dose to confirm administration and to prevent repurposing or off-label usage. Some participants are unable to take their medication via DWI because their employment schedules limit their ability to access community pharmacies daily or multiple times daily as required by their dosing schedule. As a result, some participants have received take-home doses (“carries”) with careful clinical assessment and observation. Recent provincial policy changes have made take-home doses less accessible; however, in accordance with the policy, some HRW participants may qualify to continue to receive take-home doses because they are clinically stable and their employment obligations prevent the use of DWI.
Ethical and legal considerations
To uphold privacy and clinical boundaries, address ethical and legal considerations and comply with provincial regulations, AVI developed several safeguards in consultation with the College of Physicians and Surgeons of British Columbia:
- PA prescribers must work off-site, and contact with HRW participants must be mediated by nursing staff who manage intake and follow-up
- PA medications are dispensed primarily through community pharmacies rather than the program clinic
- PA medications are provided mainly through DWI with a pharmacist or nurse
- Dual-physician case reviews are conducted when clinical decisions are complex
These safeguards allow HRWs to access care without compromising professional relationships.
Evaluation and outcomes
Participant characteristics
Between March and April 2025, AVI’s Knowledge Translation and Exchange team conducted three participant interviews, four participant surveys and three AVI staff interviews.
Of the seven HRW participants included in the interviews and surveys:
- five identified as cisgender men, one as a cisgender woman and one as a non-binary person
- six identified as white/of European descent
- one identified as Indigenous
Key outcomes
There were no overdose deaths among the HRW program participants. Among program participants and program workers that participated in program evaluation surveys (4 people) and interviews (6 people) the following outcomes were most commonly reported:
- reduced use of the unregulated drug supply (with several participants reporting full abstinence from the street supply)
- improved mental health and reduced stress
- better access to healthcare (including access to family doctors)
- better access to social supports (through wraparound care)
- greater employment stability
- increased ability to complete daily activities (including parenting)
Additional outcomes reported included stronger family connections, improved sense of control, autonomy and dignity, reduced withdrawal symptoms, improved sleep and reduced encounters with policing.
Interviews with HRW participants highlighted the impacts and outcomes of the program:
"I was struggling so much with my pain medication and… my GP at the time was dismissive. The amount of stigma that I had to deal with was astronomical… And then finally, the support that the program was offering…I didn't even know that it existed. It was such a such a life-saving thing” (Participant-2).
"It's the only reason why I'm able to do my job. If it wasn't for this program, I definitely wouldn't be working… I don't even know if I'd be here to be honest, you know? Sorry, it’s a little emotional, talking about it… just to be able to just finish my tasks, my job duties. I would never have been able to before…. And to not have those stresses and worries” (Participant-2).
"I can't even describe how much of a difference that makes…To actually feel again some semblance of control again is just huge, you know? And what it, what it does for my mental health is, is astronomical" (Participant-2).
“It just kind of helps me live my life. That’s essentially it... It helps me do things that are meaningful to me. And especially my work… I just really wanted stability and...[PA] has just been really so helpful...making it so my life does not get worse. And that is really important... And it's really good to have something that makes me feel like I'm valued and...like nobody is judging me” (Participant-1).
Challenges
- Restrictive provincial policies on take-home doses: If participants currently receiving take-home doses are directly impacted by the new guidelines requiring DWI, this will make it harder for them to continue with the program, especially for those working irregular shifts.
- Significant demand with limited capacity: Minimal funding and the limited number and availability of PA prescribers reduces program capacity, leaving many HRWs who are eligible unable to participate.
- Political and media scrutiny: PA programs continue to be politicized, which creates misinformation, disinformation and program instability. AVI PA participants have voiced significant anxiety about the potential for their medication access to change or for the program to close because of public discourse and media coverage.
- Ethical complexities: Ensuring prescribers do not treat their colleagues requires additional coordination and restricts which HRWs are eligible to participate.
Lessons learned
- HRWs benefit greatly from access to prescribed alternatives: Participants consistently reported that PA improved their health, stability and ability to remain employed.
- PA acts as a bridge to other supports: PA helps people stabilize enough to access housing, healthcare or substance use treatment (if that is their goal).
- Flexible, person-centred care is essential: Individualized dosing, wraparound support and trusting relationships contribute to improved outcomes.
- Evidence-based policy reforms are urgently needed: Barriers related to criminalization, stigma and restrictive take-home dose policies limit the effectiveness of PA programs.
- Programs must “walk the talk”: Integrating and supporting HRWs with living and lived experience strengthens the harm reduction workforce and demonstrates the humanity and normalcy of PA. HRWs with living and lived experience bring valuable insights to their work and can foster meaningful trust and rapport with the participants they work with.
- All new and existing PA programs should incorporate policies and practices that ensure access to PA for HRWs. Employment during the ongoing drug poisoning crisis can exacerbate existing harms for HRWs because of increased stress, stigma and limited organizational capacity to provide adequate support. Integrating PA for HRWs proactively can help mitigate these risks, promote well-being and sustain workforce resilience.
Program materials
- Prescribed alternatives at AVI
- SAFER Knowledge Translation & Exchange (KTE) Initiative publications
- Workforce PA outcomes summary
Contact information
Corey Ranger
Clinical Director
AVI Health & Community Services
3rd Floor – Access Health Centre
713 Johnson Street
Victoria, BC V8W 1M8
corey.ranger@avi.org