Between January 2016 and June 2021, 24 626 people died from opioid toxicity in Canada. (1) A key driver of this ongoing public health crisis has been the infiltration of illicitly manufactured fentanyl and other dangerous adulterants into the unregulated drug supply. Although a range of educational, harm reduction and substance use disorder (SUD) treatment interventions have been implemented and expanded in response, these efforts have not been sufficient, and the number of deaths from drug poisoning continues to rise. Furthermore, a substantial proportion of people do not access conventional treatments; for instance, only a minority of patients with opioid use disorder regularly receive treatment medications. (2) Emerging evidence also suggests that the changing drug supply has negatively affected the effectiveness of these medications, including the efficacy of buprenorphine among people using fentanyl compared with those using heroin. (3) An additional concern is unintentional exposure to fentanyl among people who use substances such as stimulants and the emergence of other contaminants such as benzodiazepines.
This reality has prompted calls for the provision of a legal and regulated source of psychoactive substances, known as "safe supply," particularly low-barrier, flexible options that meet the diverse needs and goals of people who use drugs. (4)
What is the Safer Alternatives for Emergency Response program?
Operating in Vancouver since April 2021, Safer Alternatives for Emergency Response (SAFER) is a safe supply program that provides substitutes to the toxic drug supply in the form of medications that are prescribed off label. The program is operated by a nonprofit organization (PHS Community Services Society) in partnership with Vancouver Coastal Health, and is funded through Health Canada's Substance Use and Addiction Program. A multidisciplinary team of physicians, nurses, pharmacists, social workers and people with lived or living experience of substance use oversees the program. The approach adopted at SAFER can be viewed as an extension of the use of medications as treatment for SUDs, such as opioid agonist therapy (OAT). However, in contrast to OAT, which is often prescribed with a goal of abstinence, the primary goal of SAFER is to prevent overdose and other harms by decreasing reliance on the unpredictable, unregulated drug market. Medications provided at SAFER include those with mind- and body-altering effects that are often desired by people who use drugs but are typically accessible only via unregulated drugs and are not provided by conventional treatments such as OAT. (5)
Who is eligible?
Eligibility for SAFER is based on ongoing use of substances and vulnerability to their associated harms. At intake, participants are assessed to determine appropriate medication options and potential need for precautions owing to medical conditions that affect tolerability of SAFER medications, factors that confer additional vulnerability (such as pregnancy or young age) and concurrent use of substances such as alcohol that require additional counselling. Although there are no absolute contraindications to participation, the program emphasizes identifying the appropriateness of the intervention, recognizing participant autonomy and facilitating connection to evidence-based treatment for SUDs when this is aligned with participant-defined goals.