Safe Supply: Hydromorphone Tablet Distribution Program at the Molson Overdose Prevention Site
The Molson Overdose Prevention Site (OPS) in Vancouver co-locates a supervised consumption service, a drug-checking service, a service for injectable opioid agonist treatment and a hydromorphone tablet distribution program. The hydromorphone tablet distribution program is a safe supply program that provides a regulated alternative for people at high risk of overdose from the fentanyl-contaminated, illicit opioid supply. Factors that facilitate engagement in the safe supply program include its low-threshold model, co-location within the OPS and the flexibility and choice that the program offers to participants. Barriers to engagement include the OPS’ limited operating hours, dosage restrictions, wait times to access the OPS and clients’ potential discomfort in accessing an OPS. Overall, the program has been well received by participants and provides learnings that can inform the implementation of other safe supply and harm reduction programs in Canada.
The hydromorphone tablet distribution program is located at the Molson OPS in the Downtown Eastside of Vancouver, Canada. The program was started in 2019 by the Portland Hotel Society (PHS), a housing and social service agency that operates the Molson OPS. The goal of this safe supply program is to provide a regulated alternative to illicit opioids to decrease the risk of overdose.
The Molson OPS is a provincially sanctioned harm reduction site. In addition to the hydromorphone distribution program, the Molson OPS offers a supervised consumption service, a drug-checking service (to determine what is present in a sample of drugs) and a service for injectable opioid agonist treatment (provided via an adjacent PHS clinic). The Molson OPS is considered an especially low-threshold model as it allows for the sharing of drugs and peer-assisted injection.
The program is delivered by the PHS primary care clinic, which is linked to the OPS. It serves people who are at high risk of fatal overdose and not currently enrolled in or interested in drug treatment programs such as opioid agonist therapy. Program participants access the program via the OPS, during operating hours (1:30 p.m. to 10:30 p.m. daily). The hydromorphone tablets are dispensed to program participants by nurses through a sliding window that connects the OPS to a nursing station on the other side. Participants are allowed to pause their involvement in the program at any time and return without having to be put back on the waitlist.
Participants are enrolled in the program through PHS clinic primary care physicians, who also visit the OPS twice per week. Participants are prescribed a weekly amount up to 80 milligrams per day. Participants can receive up to two eight-milligram tablets at a time and can come back for additional dosages up to five times per day, with a minimum one-hour waiting period in between.
To avoid diversion of tablets into the illicit market, participants are supervised while consuming the tablets onsite (whether they take them orally, snort them or inject them). However, since April 2020, “take-home” doses have been permitted under emergency COVID-19 pandemic prescribing guidelines in British Columbia. A small subset of participants receive an injectable, liquid hydromorphone formulation instead of tablets because of personal preference, including participants who have transitioned from an injectable opioid agonist treatment program.
As of February 2020, 69 participants were enrolled in the program.
This study was a combination of interviews with 42 program participants and ethnographic observation at the OPS throughout 2019. The goal was to identify key barriers and facilitators to participant engagement with the hydromorphone tablet program.
The study found that key facilitators to program engagement included the following:
- Having access to a reliable, regular source of opioids enables participants to exert more control over their drug use, greatly reduces their fear of overdose and reduces their involvement in illicit behaviours to purchase drugs on the street.
- The program is located in the Molson OPS, a central, low-threshold, safe space where many participants were already accessing other harm reduction services.
- Participants are offered flexibility and choice in how to use the program, including varied consumption methods (e.g., oral, intranasal, injection) and flexibility in terms of when and how often to access the program.
The study found that key barriers to program engagement included the following:
- The limited operating hours of the program, particularly in the morning, when withdrawal may begin, meant many participants reverted to illicit opioid sources outside of program hours. (However, this issue may be less significant now that take-home doses are available).
- Co-location with the OPS meant potentially long wait times for people to access the program, especially during peak hours.
- The hourly-dose limits also meant participants could not receive their full daily dose without returning several times throughout the day. Very few participants received the maximum of five daily doses.
- The OPS, which participants must enter to access the program, may also be a triggering or uncomfortable environment for individuals who are attempting to reduce their drug use, or for those who did not use supervised consumption services before joining the program.
- There were complaints about lower potency and difficulty injecting a generic brand of the hydromorphone tablets that was used for a period when the brand-name hydromorphone tablets were unavailable.
What does this mean for service providers?
This study demonstrated a number of key facilitators and barriers for engaging users of the hydromorphone tablet distribution program. This information can be applied to the planning and delivery of other safe supply programs and, more generally, other low-threshold harm reduction programs. In particular, the co-location with other services and the flexibility of the program creates a lower threshold approach, especially for those who are most marginalized.
A number of barriers were also directly or indirectly tied to individual, social and structural factors such as housing, mobility and poverty. The intersection of these factors should be taken into account when designing and implementing other safe supply and overdose prevention programs.
Despite this, the study shows that safe supply programs can be a feasible public health intervention to address the overdose crisis. Although barriers exist, these can be addressed via considerations of how the program is delivered. The authors noted that overall, the program was very well received among program participants. Taking into account high enrolment numbers and long waitlists, they expressed the need for scale-up of safe supply programs.
- Ivsins A, Boyd J, Mayer S et al. Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: a qualitative study. Drug and Alcohol Dependence. 2020 Sep 15: 108202.
- Olding M, Ivsins A, Mayer S et al. A low-barrier and comprehensive community-based harm-reduction site in Vancouver, Canada. Public Health Practice. 2020; 110(6): 833-5.