The safer opioid supply (SOS) program launched at the London InterCommunity Health Centre (LIHC) in 2016. The program includes prescriptions for pharmaceutical opioids as an alternative to the unregulated drug supply for people who meet certain eligibility criteria. The program also provides clients with health and social supports within a primary care setting. The program led to significant decreases in hospital emergency department visits, inpatient hospital admissions, hospital admissions for infections that can be related to injecting drugs and health costs (not primary care or medication related) for those enrolled. The results show that the program decreased harms related to drug use and can play an important part in the harm reduction services offered to people at risk of drug poisoning.
The SOS program is guided by a harm reduction philosophy and the voices of people who use drugs. The program prescribes pharmaceutical opioids as an alternative to the unregulated drug supply for eligible participants, in addition to providing comprehensive primary care. People who are at risk of death because of conditions associated with injecting drugs (e.g., recurrent endocarditis, untreated HIV, overdose) are prioritized in the program. Also prioritized are people whose needs may not be met by traditional healthcare (e.g., people who are homeless or street involved). The program attempts to engage, or reengage, people in healthcare services.
Eligibility criteria include:
- patterns of opioid use consistent with opioid use disorder
- long-term experience injecting drugs (more than two years)
- self-report of regular street-acquired drug use
- complications of injecting drugs (e.g., endocarditis, abscess, HIV)
- high risk of death without intervention
- positive result on a urine drug screen for opioids (to confirm recent use)
- capacity for informed consent (to understand potential risks and benefits of treatment)
- challenges related to psychosocial functioning and connecting to, or engaging in, traditional healthcare (e.g., homelessness, involvement in criminal activity to support drug use, involvement in sex work)
If there is capacity within the SOS program and a person meets the above criteria, they can be enrolled as a client. The first step is for the client to meet with a systems navigator who helps to assess their needs. Clients are then provided with or referred to both health and social services to address their needs, in addition to being provided with safer opioid supply medications.
Health and social services can include:
- comprehensive primary care (e.g., treatment for HIV, hepatitis C, asthma or diabetes)
- sexual healthcare and screenings
- broader preventive care such as cancer screenings and vaccinations
- access to harm reduction equipment and supplies and harm reduction education
- assistance with access to food programs or services to meet other basic needs (e.g., hygiene supplies)
- support to find and maintain housing
- assistance with transportation to appointments and accompaniment for appointments
- advocacy (e.g., with respect to income, housing, or the justice system) or counselling services
- referrals to more specialized services as needed
The main medication prescribed in the SOS program is immediate-release hydromorphone tablets (usually Dilaudid branded tablets as they can dissolve easily into a solution that can then be injected if the client chooses to). Hydromorphone can be used by clients for its euphoric effect, and for some clients it can be used to manage symptoms of withdrawal as needed. The prescription can be filled at the client’s pharmacy of choice as a take-home dose, and clients can choose where, when and how (i.e., oral or injection) they administer the dose.
Slow-release oral morphine is often prescribed alongside immediate-release hydromorphone to help to manage withdrawal symptoms (sometimes called the “backbone”). Slow-release oral morphine is generally taken as an observed dose once a day at a pharmacy.
The medications used in the program are ones that are covered by the public formulary in Ontario. Diacetylmorphine (heroin), fentanyl formulations (tablets or injectable) and high-dose injectable formulations of hydromorphone are not covered and therefore are not prescribed in the program, although clients have indicated an interest in having more medication options.
Between January 2016 and March 2019, 94 individuals entered the SOS program. A study considered the following primary outcomes to explore the effectiveness and safety of the SOS program:
- emergency department visits
- hospital admissions
- hospital admissions for new infections that can be related to injecting drugs (e.g., endocarditis, septic arthritis, spinal infections, skin and soft-tissue infections)
- healthcare costs (other than primary care and medication costs)
The study compared 82 SOS program participants for whom data were available before and after entry to the program and 303 people from London, Ontario, who had an opioid use disorder but were not enrolled in the SOS program during the study timeframe. These individuals were matched to SOS participants on demographic (e.g., age) and clinical characteristics (e.g., previous healthcare utilization and medication dispensing).
Many of the characteristics of those who participated in the SOS program and those who did not were similar (e.g., average age was 41 years, 40% were male). However, those enrolled in the SOS program were more likely to have experienced healthcare challenges (e.g., diagnosed with HIV or hepatitis C, having been in the hospital in the previous year because of substance use disorder or soft-tissue infection) before starting the program compared with the matched group. This is consistent with the SOS program’s eligibility criteria, which are designed to enable to the program to reach people with serious medical complications from their drug use. Further details related to the analysis can be found in the article entitled “Ontario research finds that a safer opioid supply program led to reduced hospital visits and reduced healthcare costs.”
Researchers conducted two analyses. In the first, they measured outcomes in 30-day intervals in the five years before entry and one year after entry to the SOS program. This analysis found a rapid and significant decrease in the rates of emergency department visits, hospital admissions and healthcare costs for people enrolled in the SOS program (82 participants). No significant change was found in the rate of hospital admissions for new infections for people enrolled in the SOS program. In the matched group of people who were not enrolled in the SOS program (303 participants), no significant changes were found in any of these outcomes.
In the second analysis, which compared participants in the SOS program (82 participants) one year before and after program entry, the following significant decreases were found:
- 32% decrease in emergency department visits
- 54% decrease in hospital admissions
- 49% decrease in hospital admissions for new infections
- healthcare costs decreased from $15,635 to $7,310 per person-year
In the matched group of people who were not enrolled in the SOS program (303 participants), there were no significant changes in these outcomes.
There were no opioid-related deaths among those enrolled in the SOS program in the year after entry into the program and low all-cause mortality in this group. In the matched group not enrolled in the SOS program, there were fewer than five opioid-related deaths and low all-cause mortality.
Costs associated with the SOS program
Medication costs related to public drug benefits significantly increased from $12,840 to $21,119 per person-year for those enrolled in the SOS program. About 15% of this increase in cost is attributed to prescribed opioids. The majority of the costs are probably the result of improved access to treatments for conditions such as HIV and hepatitis C. These costs may lead to long-term cost savings and may represent an overall health benefit to those enrolled in the program.
What does this mean for service providers?
The SOS program aimed to serve people who were experiencing multiple health conditions related to injecting drugs and for whose needs were not being met by traditional health services. Results indicate that the program was successful at reaching people who were experiencing greater health issues probably related to their drug use (e.g., HIV, hepatitis C, infections), as seen in the baseline characteristics of SOS program participants versus the matched group.
The results show that the SOS program was effective at reducing harms for people who use drugs. This was shown through reductions in emergency department visits, reductions in hospital admissions and reductions in hospital admissions for new infections. A reduction in healthcare costs associated with emergency department visits or other healthcare visits (not including primary care and medication costs) was found for those enrolled in the SOS program, indicating potential healthcare savings from similar programs. The increase in costs seen in public drug benefits is probably a result of better access to medications for conditions such as HIV and hepatitis C, signalling the program’s ability to better meet the overall healthcare needs of clients and potentially improve their health.
Although more research is needed, this study provides preliminary information on how safer supply programs can be effective and safe for people who use drugs. Previous concerns surrounding the potential for increased rates of overdose deaths and infections in people using safe supply were not supported in this study, as no opioid-related overdose deaths were seen in SOS program participants in the year after enrolment in the program, alongside decreased hospital admissions for infections among SOS program participants in the year after enrolment.
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.