Victoria SAFER Initiative

What is the program? 

The Victoria SAFER Initiative (SAFER) provides pharmaceutical alternatives to the unregulated drug supply to prevent and reduce the incidence of ‘overdose’/drug poisoning. SAFER is a flexible, community-based model of safe supply that is grounded in harm reduction policy and practice and utilizes a social justice lens. The SAFER program is run by a multidisciplinary staff team (e.g., support workers, systems navigators, nurses, physicians) and provides support and referrals to other community services. The program offers safe supply (e.g., opioids, stimulants) in a variety of formats (e.g., tablets, patches, liquid).

AVI Health & Community Services (AVI) launched SAFER in July 2020 during the COVID-19 pandemic with funding from Health Canada’s Substance Use and Addictions Program (SUAP).

Why was the program developed? 

SAFER was developed to address the number of drug toxicity overdoses and deaths happening in Victoria, British Columbia (BC). Over 9,600 people died of toxic drug poisoning in BC between January 2016 and March 2022. In 2022, almost six people per day died of unregulated drug toxicity in BC. Victoria has consistently been among the top three townships in terms of the rate of overdose deaths.

During the COVID-19 pandemic, the BC Ministry of Mental Health and Addictions (MMHA), with the BC Centre on Substance Use (BCCSU), released a clinical document entitled “Risk Mitigation in the Context of Dual Public Health Emergencies” (known as Risk Mitigation Guidance or RMG) on March 26, 2020. This document was developed to support the prescribing of pharmaceutical alternatives to the toxic drug supply to prevent overdose among people using drugs during the COVID-19 pandemic. The RMG informed the development of SAFER’s clinical protocols and service delivery model, along with direct input from the community. SAFER started delivering services in 2020 with a two-pronged approach where safe supply services were delivered alongside a community engagement process. SOLID Outreach Society, a local harm reduction organization run by and for people who use drugs, provided input, as did community health and social service providers, people who use drugs and academics (among others). These groups helped to inform the development and implementation of the program.

How does the program work? 

SAFER provides pharmaceutical alternatives to the unregulated drug supply. Services can be accessed through community pharmacies and outreach support, or through the SAFER clinic where drugs are dispensed on-site.

Initially the program was entirely outreach based. Staff (e.g., support workers, nurses, systems navigators) conducted intakes via outreach with people sheltering at homeless encampments where the overdose rate was rapidly increasing. For those who could not attend a pharmacy, daily safe supply medications were delivered to wherever participants were sheltering (e.g., tents, local shelters, supported or market housing).

In February 2021, initial funding for SAFER was renewed and in June 2021, the program was able to open a clinic to offer a broader range of safe supply options in different forms (e.g., patches, injectable) to better meet the needs of people using the program. With the addition of the clinic and the associated need to redirect staff, the program stopped delivering safe supply and transitioned all participants to either a community pharmacy of their choice or the SAFER clinic. However, during episodic COVID-19 outbreaks and when individuals have needed to isolate owing to COVID-19 infection, the program has been able to temporarily deliver safe supply or work with other service providers (e.g., pharmacy delivery) to ensure that people can continue to access safe supply while they isolate and recover from COVID-19.

The current eligibility criteria for the program includes:

• dependency on unregulated drugs and therefore high risk of toxic drug poisoning/overdose
• lack of access to a willing safe supply prescriber
• inadequate safe supply through other options (e.g., typical opioid agonist treatment [OAT] approaches not being effective enough to significantly reduce risk or current safe supply dose under the RMG are not matching current opioid tolerance)
• an interest in prescribed fentanyl options and a willingness to have doses witnessed (i.e., used in the presence of staff) at the SAFER clinic

Participants are typically referred to the program by the SAFER physician team. For example, all SAFER physicians also work in other local programs and have patients who need a broader range of safe supply options. Referrals can also come from other SAFER staff (e.g., support workers, nurses) or other service providers outside of the SAFER program, or people can self-refer.

Typically, the intake process includes a meeting between the potential participant and members of the staff team (e.g., a nurse and support worker team) in the community. Staff provide information about the program and what the person can expect. The person’s goals related to safe supply are discussed and an intake form is completed. The intake form includes:

• demographic information
• a substance use assessment (e.g., what substances the person is using, how much, mode of consumption)
• recent history of overdose
• vital signs and initial health assessment (e.g., respiratory conditions, allergies, chronic health conditions)
• any social supports or other needs as determined by the potential participant

The potential participant signs a consent form. For those who will be attending the SAFER clinic, the team describes the clinic and discusses the SAFER Community Safety Agreement. The agreement outlines expectations for how staff and program participants conduct themselves at the SAFER clinic, including expectations around mutual respect.

Once participants are connected to the program, they can receive their safe supply prescription either from the SAFER clinic or from a community pharmacy of their choice. Approximately half of the program participants regularly attend the SAFER clinic to access their safe supply, and half access their safe supply at their pharmacy.

SAFER currently has a capacity of 75–100 participants. The program’s waitlist is kept at no more than 10–15 people, as maintaining a longer list can cause distress for both participants and staff. There are priority spots on the waitlist for women and gender-diverse and/or Indigenous individuals, including people who are pregnant, to increase equity in safe supply access.

Safe supply medications

SAFER uses its own clinical protocols and prescriber guidance, which include prescriptions that fall outside of the BC RMG, to better address the opioid tolerances of participants and to reduce their reliance on the toxic unregulated supply. The program strives to provide pharmaceuticals that best meet each person’s needs, including the dosage and form of consumption (e.g., oral, injection) that works best for them. Depending on which options they are prescribed, participants may need to attend the SAFER clinic. For example, consumption of fentanyl options is currently witnessed at the SAFER clinic. The program currently offers four options for safe supply:

*SAFER is able to access fentanyl buccal tablets, marketed as Fentora, and fentanyl patches via Special Authority approval from the Province of BC.

Prescribed safe supply through a community pharmacy

Participants who primarily access their prescribed safe supply through a community pharmacy are provided their safe supply medications by a pharmacist. SAFER support staff (e.g., nurses, systems navigators) maintain connection with them via outreach visits, phone calls and text messages. If a participant needs to speak with their SAFER physician (or vice versa), this can be arranged via phone call or the participant may be encouraged to attend the SAFER clinic to see a physician on duty. Registered participants who do not typically access the SAFER clinic for their safe supply are still welcome to attend the clinic should they need harm reduction supplies or naloxone, or to connect with a team member for support.

Prescribed safe supply through the SAFER clinic

Participants who primarily access their prescribed safe supply through the SAFER clinic are provided their safe supply medications by a nurse. Depending on what options they are prescribed, they may attend the clinic multiple times per day. For example, someone prescribed sufentanil may come to the clinic for up to four doses per day, someone prescribed fentanyl buccal tablets (e.g., Fentora), may come for up to two doses per day, and someone prescribed fentanyl patches may come three times per week to have patches changed. Ongoing care and assessment of participants is completed on-site by nurses who collaborate with other healthcare providers (e.g., physicians, systems navigators).

Participants who access their safe supply at the clinic may also use their personal supply of other drugs (in addition to their safe supply) during their visit, as they would at a supervised consumption and overdose prevention site. The SAFER clinic does not currently offer safer inhalation services because of lack of available space. The clinic is not open to the public and does not provide this service to individuals who are not registered program participants.

SAFER has a partnership with a local pharmacy (Cridge Family Pharmacy), which delivers all medications that are dispensed by the SAFER clinic on a daily basis; this pharmacy is a key part of the care team.

Primary care, support and navigation services

SAFER is a harm reduction program and as such it provides support and information to participants related to safer drug use, as well as referral and connection to other community health and social services. While the SAFER staff team is not a case management or primary care team specifically, staff members prioritize building trusting, respectful relationships with program participants to learn about their unique goals and priorities and to support them to pursue those.

Owing to program capacity limits, SAFER physicians prefer to collaborate with other primary care providers and facilities to ensure that participants have access to more comprehensive care and so that SAFER can focus primarily on the provision of safe supply. Participants who do not have another primary care provider can be offered primary care services by SAFER at the clinic or via outreach when necessary.

In addition to safe supply medications, participants may access the SAFER clinic to:

• connect with support workers for peer support
• see a SAFER physician on duty (physicians are on-site twice per week) for follow-ups related to their safe supply medications or other healthcare needs
• work on other referrals to other health or social supports (e.g., supported housing, income assistance, cultural supports [e.g., Indigenous-led counselling], legal supports, detox and treatment) with a systems navigator
• access accompaniment to medical, legal and housing appointments

Staffing

SAFER services are provided by a multidisciplinary staff team:

• Support workers have lived/living experience and provide peer support. They collaborate with the team to provide accessible care. There are also two team leads with similar qualifications who take on added responsibility for scheduling and helping to coordinate daily tasks at the clinic. Support workers and team leads currently work in the clinic; however, they have previously worked in the community on outreach and may do so when there are enough staff members in the clinic. The staffing priority is to maintain an adequate number of staff on-site at the clinic.
• Systems navigators provide psychosocial support and practical support to increase participants’ connections to community-based care. They help to bridge connections to other supports that might be needed including shelter, housing, income supports and so on. They work both on outreach and in the clinic.
• A medical office assistant (MOA) supports the team by performing administrative tasks including managing the electronic medical record (EMR) system, assisting the clinical staff with medical follow-up and referral, and helping to coordinate daily tasks at the clinic.
• Nurses (registered nurses, licensed practical nurses) use SAFER clinical guidelines and decision support tools to inform their assessment, medication dispensing, recommendations and communications with physicians on the care of and follow-up with participants. They provide some primary care including wound care, ongoing monitoring and collaboration with other healthcare providers on-site at the SAFER clinic. The team includes a full-time outreach nurse.
• Physicians (SAFER MDs) work either off-site (e.g., from home or via another worksite) or on-site at the SAFER clinic to provide ongoing assessment and prescriptions of safe supply options, including OAT.
• Street ambassadors are hired by SOLID Outreach Society. There are a number of services offered in the building from which the SAFER clinic operates, including SOLID’s administrative offices, their outreach programs and their Cannabis Substitution Program. Street ambassadors are a welcoming and reassuring presence outside and around the larger building that houses the SAFER clinic. They are able to direct people to various programs, attend to overdoses when needed and liaise with neighbours who may have questions or concerns regarding programs in the building.

Leaders in the program include a medical director (one of the SAFER physicians), a program manager and a clinical nurse lead.

Required resources 

• Human resources
  • Support workers
  • Team leads
  • Systems navigators
  • Medical office assistant
  • Nurses
  • Physicians
  • Medical director
  • Program manager
  • Clinical nurse lead
  • Street ambassadors
• Pharmacy partner to dispense medications through the SAFER clinic
• Community pharmacies to provide access to safe supply medications for those who are accessing medications outside of the SAFER clinic
• Pharmaceuticals, including safe supply options and any other medications that might be required on the basis of services offered
• A clinic space that also functions as a supervised consumption and overdose prevention service for participants, as well as administrative space for staff
• Harm reduction supplies for safer sex and safer drug use
• An EMR system to chart ongoing participant care and dispensation of medications

Evaluation

SAFER works with the Canadian Institute for Substance Use Research (CISUR), including the Co/Lab project, and SOLID Outreach Society as key research and evaluation partners.

SAFER also routinely collects point-in-time feedback from its participants; a summary of the most recent round of feedback collection is included in the SAFER Impacts infographic (see Program materials below). For example, in September 2022:

• Over 85% of program respondents said that access to SAFER has improved their mental health
• 90% of program respondents said that access to SAFER has reduced their use of unregulated drugs
• Almost 80% of program respondents said that access to SAFER has increased their connection to social supports

SAFER is involved with a number of research projects including a provincial evaluation of prescribed safe supply and a national evaluation of the safer supply pilot projects.

See the Program materials section below for a list of publications and online resources about SAFER.

Challenges

• There is limited physical space at the current clinic location (e.g., number of booths, waiting area, storage, staff space).
• Recruitment and retention of staff is difficult, particularly because of the overburdened state of the healthcare system (e.g., availability of nurses) and the impact of ongoing trauma related to poverty, criminalization and deaths from toxic drug policy and unregulated drugs.
• Prescriber workload is a challenge because SAFER’s physicians also work in other practices and typically have high patient loads and other professional responsibilities.
• Expectations related to addiction medicine models such as urine drug screens and witnessed dosing (related to clinicians’ concerns about diversion). The requirement for confirmatory urine drug screening means that program staff spend a lot of time reminding and tracking down participants to provide urine samples. Requiring dispensation and witnessed dosing by nurses at a clinic means that there is much less flexibility for participants (i.e., “carries”), and there is less ability for the program to support more participants via community pharmacies.
• Contempt, discrimination, stigma and paternalism continue to be major barriers to the survival and well-being of people who use drugs.

Lessons learned 

• Drugs must match the need of participants, and the fact that individuals have different drug tolerances must be considered when designing a safe supply program: offering options is key.
• The goals of participants should be self-determined, and measures of the program’s success need to include the benefits reported by participants. Participants’ goals may include less reliance on the unregulated drug market, more stability in their life and fewer experiences of cravings or withdrawal, as well as matching euphorigenic impacts sought out by participants.
• Decision-making with people who use drugs is essential as they are the experts of their own experience and relationship with substances. Flexible models that are led by people with lived or living experience are integral to building connections to people and to connecting people to care.
• An addiction medicine model of providing pharmaceutical alternatives often clashes with the goals and values of harm reduction and has limited reach and impact. Restrictions such as urine drug screening, OAT as a condition of safe supply, short prescription durations and framing all drug use as addiction are barriers to access.
• Safe supply is not the only answer to the toxic drug poisoning crisis and will not address other needs such as secure housing and access to healthcare, although it can act as a bridge to these services. Safe supply must be considered with other interventions including the decriminalization and legalization of drugs.

Program materials 

• A Practice Brief: Implementing the Victoria SAFER Initiative
• Safer Supply Checklist
• SAFER’s Top Ten: A working document by SAFER staff
• SAFER Impacts infographic
• Clinical protocols – available upon request
• Pauly B, McCall J, Cameron F et al. 2022. A concept mapping study of service user design of safer supply as an alternative to the illicit drug market. International Journal of Drug Policy. 2022;110:103849.
• That’s SAFER YouTube channel including a playlist of SAFER presentations such as “Building Capacity Among Prescribed Safe(r) Providers”
• @SaferVic Twitter account
• Visionary harm reduction in Victoria, British Columbia – video series

Contact information 

Carissa Pozzi, RN
SAFER Clinical Nurse Lead
carissa.pozzi@avi.org

Corey Ranger, RN
SAFER Knowledge Translation and Exchange Project Manager
SAFERkte@gmail.com