In case of emergency: Expanding safe supply through supervised consumption services

Since 2016, 42,494 people have died from drug poisoning in Canada. This crisis is fueled by an unregulated drug supply contaminated with a deadly mix of synthetic opioids and non-opioid sedatives. Aiming to curb these drug poisoning deaths, the provision of pharmaceutical-grade alternatives to the unregulated, illegal drug supply, also known as safe supply, has demonstrated significant promise. However, despite its potential to save lives, this approach is currently mired in capacity constraints and accessibility barriers.

One opportunity for increasing access to safe supply is through supervised consumption services (SCS). In a new report produced by the HIV Legal Network, How to Innovate in an Emergency, we explored legal and policy options to scale up safe supply in this context, addressing barriers identified by research, people who use drugs, legal experts, policymakers and clinicians.

The current evidence on safe supply at SCS

Research on the co-location of safe supply programs within the low-barrier services of SCS shows participants’ willingness to consume substances in a monitored setting. Participants described the convenience of having a safe supply program integrated within a service they already use — notably in a setting they associate with safety, comfort and reduced exposure to “forces of structural oppression and marginalization operating within the local drug scene (for example, violence and police harassment).”

Community experts agreed that safe supply at SCS is pragmatic “low-hanging fruit” given that SCS are already designed to witness consumption, connect individuals to care and respond to critical situations, including drug poisonings. These built-in supervision safeguards allow prescribers of safe supply to reliably match participants’ dosing needs while mitigating risks when they have developed a higher tolerance. SCS are also spaces where trusting relationships have already been established, and where staff understand and subscribe to a harm reduction philosophy of practice.

In short, the infrastructure is already in place to scale up safe supply in these settings. However, there are several barriers, which include:

• a lack of available and willing prescribers,
• repeated audits by regulatory bodies,
• lack of clinical guidance,
• the requirement for an individual prescriber-patient relationship,
• lack of venues and sustainable funding,
• program rigidity,
• multiple barriers to participation, such as frequent urine testing,
• lack of de-medicalized safe supply models run by people who use drugs,
• inadequate safe supply options, especially for people who smoke drugs or use stimulants.

While each of these barriers deserves careful consideration, in this article, we will focus on the lack of available prescribers because this presents one of the main challenges to scaling up safe supply in SCS.

Legal and policy options to increase prescribed safe supply access at SCS 

The Controlled Drugs and Substances Act (CDSA) is the overarching federal legislation that controls and prohibits activities related to possessing, administering, or dispensing “controlled substances,” including drugs in safe supply programs. Under the CDSA, only “practitioners” can prescribe controlled drugs; those who currently prescribe safe supply are predominantly physicians and nurse practitioners.

The Narcotics Control Regulations (NCR), which were made under the CDSA, define a prescription as “an authorization given by a practitioner that a stated amount of a narcotic be dispensed for the person named in it” and allows practitioners to provide narcotics to a patient under their professional treatment if the narcotic is required for the treatment. Provincial and territorial governments also play a key role in the implementation of safe supply programs through laws that regulate healthcare professionals and define “controlled acts” or “restricted activities” such as prescribing.

Since prescriber hesitancy is a key barrier to scaling up safe supply, regulatory bodies could increase clinicians’ comfort and knowledge by offering training, as well as issuing public statements and clinical guidance explicitly endorsing prescribed safe supply in the context of SCS. This could be further encouraged through the influence and leadership of Health Canada.

Another option is to allow health professionals who are authorized to prescribe safe supply to pass that authority onto another healthcare provider (for example, a nurse). This can be done through directives, which are formal orders given in advance by an authorized prescriber to enable another healthcare provider to perform an activity without a direct assessment by the authorizer.

Because the NCR’s definition of a prescription could be interpreted as requiring orders for controlled substances to be client specific, an amendment to the NCR definition of “prescription” may be necessary to allow a medical directive for prescribed safe supply. In the context of SCS, a directive could be integrated into existing services. For example, an eligibility requirement that individuals be existing SCS participants (so that staff know they are already a person who uses opioids) and a requirement that consumption take place on site.

Given the limited number of practitioners available to prescribe safe supply, expanding the definition of a “practitioner” who is authorized to administer, prescribe, or sell narcotics under the NCR may be another route to address the shortfall. This would require engaging the federal government, provincial governments and health regulatory bodies to include other regulated professionals as practitioners, such as nurses and pharmacists.

Policy solutions

Parallel to the abovementioned efforts, governments need to take other urgent steps to stem the tide of deaths from the contaminated drug supply. Among other things, the federal government should:

• decriminalize drug possession;
• remove restrictions related to possessing, selling, splitting, sharing, dispensing, or otherwise administering the controlled substances that constitute safe supply;
• legalize and responsibly regulate controlled substances; and
• provide visible support for non-medical safe supply through buyers’ or compassion clubs.

Meanwhile, provincial and territorial governments should:

• guarantee sustained funding of SCS;
• support all SCS to provide inhalation services;
• adequately fund safe supply programs; and
• ensure all safe supply options are included at appropriate concentrations in public drug plans.

An unprecedented drug poisoning crisis demands novel and innovative approaches to meet the diverse needs of people who use drugs. Courts in Canada have repeatedly affirmed the right of people who use drugs to access health services, and governments have a legal and ethical obligation to ensure access to safe supply and SCS as necessary components of the rights to life and health. A diversity of tools is available for policy-makers to eliminate barriers to safe supply at SCS and to realize a continuum of options that honour the autonomy and human rights of people who use drugs. What we need now is political will.

 

Sandra Ka Hon Chu is the co-executive director at the HIV Legal Network. She works on HIV-related human rights issues concerning prisons, harm reduction, sex work, women and immigration. She has authored numerous publications, including an innovative legislative resource on women’s rights in the context of HIV, a compendium of affidavits describing prisoners’ experiences with injection drug use behind bars and briefing papers on sex work and HIV and the law in Canada and internationally.

Corey Ranger is a registered nurse working in harm reduction. He has worked in both Alberta and British Columbia as a frontline care provider and in the development, implementation and evaluation of harm reduction programs/services. He is the president of the Harm Reduction Nurses Association and works for AVI Health and Community Services supporting the scale up of safe supply programming in British Columbia.