Table 1 Descriptive summary of integrated safer supply pilot programs (n = 10)

#1

Program setting

Opioids

Some (25–50%)

Injectable hydromorphone, diacetylmorphine & fentanyl formulation

Physician Prescriber (n = 6PT); Clinical Nurse Lead (n = 1FT); Registered Nurse (n = 3FT); System Navigator (n = 2FT); PWLLE Support Worker (n = 4PT); Project Director (n = 1FT); Medical Office Administrator (n = 1FT)

Dependent on street/unregulated fentanyl and at high risk of drug poisoning; have not been able to reduce overdose risk via OAT or risk mitigation guidance; high tolerance to opioids; not already connected to a physician or nurse practitioner

Reduce fatal and non-fatal overdoses

 Stand-alone safer opioid supply clinic

 Non-observed:

Smokeable diacetylmorphine & fentanyl formulation

Connect people who are not being reached or retained by traditional substance use services and treatment programs

Other services provided

  Hydromorphone short acting (tablet); Hydromorphone controlled release (capsule); Oxycodone (tablet); Morphine sulfate (capsule, 12-h formulation)

Cocaine & methamphetamine

Generate evidence for safer supply

 Onsite primary care & referral; HIV/HCV testing; harm reduction equipment distribution; overdose prevention site/SCS; onsite & referral to social services; referral to specialized healthcare; individual/group support

 Observed:

  Morphine sulfate (capsule, 24-h formulation); Fentanyl (tablet); Sufentanil (injectable); Methadone (liquid); Buprenorphine (tablet)

Psychostimulants

 Non-observed:

  Dexedrine (tablet); Methylphenidate (tablet)

#2

Program setting

Opioids

Some (25–50%)

Injectable hydromorphone, diacetylmorphine & fentanyl formulation

Physician Prescriber (n = 1FT); Nurse Prescriber (n = 1FT, n = 1PT); Registered Nurse (n = 5FT); Social Worker (n = 1FT); Outreach Worker (n = 4FT); Patient Navigator (n = 1FT); Care Facilitator (n = 2FT); Clinic Manager (n = 1FT); Program Coordinator (n = 1PT); Clinic Assistant (n = 3FT); In-Reach Worker (n = 1FT); Infectious Diseases Care Program Team for HIV/HCV (n = 7FT); Lab Technician (n = 1FT); Community Paramedics (n = 2FT)

Dependent on street/unregulated fentanyl and at high risk of drug poisoning; previously tried multiple other forms of addiction treatment (abstinent based & pharmacological approaches); precariously housed; street-involved in terms of sex work; involved in criminal activity; has infectious diseases (uncontrolled HIV & HCV)

Pathway to care model to achieve medical and social stability

 Safer opioid supply embedded within an existing primary care clinic

 Non-observed:

Smokeable diacetylmorphine

Engage clients with primary care through a community health centre model

Other services provided

  Hydromorphone short acting (tablet); Fentanyl patch; Hydromorphone (injectable); Buprenorphine (tablet)

Stimulant options

 Onsite primary care; onsite HIV/HCV testing & treatment; harm reduction equipment distribution; onsite & referral to social services; referral to specialized healthcare; case management; individual/group support; cultural programming

 Observed:

  Methadone (liquid)

 Both observed & non-observed:

  Hydromorphone controlled release (capsule); Morphine sulfate (capsule, 12- & 24-h formulations)

Psychostimulants

 Non-observed:

  Methylphenidate (tablet)

Benzodiazepines

 Non-observed:

  Diazepam (tablet); Clonazepam (tablet)

#3

Program setting

Opioids

All/almost all (76–100%)

Smokeable diacetylmorphine

Physician Prescriber (n = 1PT); Nurse Prescriber (n = 1PT); Registered Nurse (n = 1PT); Outreach Worker (n = 4FT); Patient Navigator (n = 4FT); Program Coordinator (n = 1FT)

Current fentanyl use (daily)

Reduce reliance on street drugs to ultimately prevent overdose deaths

 Safer opioid supply biometric machine located in a housing unit and an existing overdose prevention site

 Non-observed:

Reduce criminal activity engagement and chaos in clients’ lives (achieve socioeconomic stabilization)

Other services provided

  Only providing Hydromorphone short acting (tablet), dispensed through biometric machine

Reduce overall drug use in the long-term

 Referral to primary health care and social services

#4

Program setting

Opioids

Few (less than 25%)

Injectable hydromorphone, diacetylmorphine & fentanyl formulation

Nurse Prescriber (n = 2FT); Registered Nurse (n = 4FT); Case Manager (n = 2FT); Clinic Manager (n = 1FT); Project Manager (n = 1FT); Staff Supervisor (n = 1FT)

Daily use of street/unregulated opioids (minimum 5 days per week)

Reduce overdose risk

 Safer opioid supply embedded within an existing primary care clinic

 Non-observed:

Smokeable diacetylmorphine

Reduce use of street/unregulated drugs

Other services provided

  Hydromorphone short acting (tablet); Morphine sulfate (capsule, 24-h formulation)

Higher potency medications

Increase stabilization for clients (anything related to social determinants of health)

 Onsite & referral to primary care; onsite HIV/HCV testing & treatment; harm reduction equipment distribution; overdose prevention site/SCS; onsite & referral to social services; referral to specialized healthcare; case management; individual/group support; cultural programming

 Observed:

Provide greater connection to primary care and social services

  Methadone (liquid)

Provide linkage to long-term, ongoing care

#5

Program setting

Opioids

Some (25–50%)

Smokeable diacetylmorphine

Nurse Prescriber (n = 1FT); Case Manager (n = 1FT); Registered Nurse (n = 1FT); Patient Navigator (n = 1FT, 2 PT); Office Administrator (n = 1FT); Program Manager (n = 1FT)

Diagnosis of opioid use disorder and at high risk of drug toxicity death

Reduce drug poisoning death

 Safer opioid supply embedded within an existing primary care clinic

 Non-observed:

Higher potency medications

Provide access to harm reduction care and harm reduction education

Other services provided

  Hydromorphone short acting (tablet); Oxycodone (tablet); Morphine sulfate (capsule, 24-h formulation); Methadone (liquid); Fentanyl patch

 Onsite primary care; onsite HIV/HCV testing & treatment; harm reduction equipment distribution; onsite & referral to social services; referral to specialized healthcare; case management; individual/group support

#6

Program setting

Opioids

Most (51–75%)

Injectable fentanyl formulation

Physician Prescriber (n = 1PT); Registered Nurse/Clinic Manager (n = 1FT); Licensed Practical Nurse (n = 6FT, n = 2PT); Case Manager/Social Worker (n = 2FT); Outreach Worker (n = 1FT, 1PT); Onsite Pharmacist (n = 1PT)

Intravenous opioid use; using for more than 6 months; have not been successful on oral replacement therapy

Enhance engagement with community services

 Stand-alone dedicated iOAT clinic

 Observed:

Injectable hydromorphone in formulations of 100mg/ml

Provide access to primary care, screening and treatment for HCV

Other services provided

  Hydromorphone short acting (tablet); Hydromorphone controlled release (capsule); Morphine sulfate (capsule, 12- & 24-h formulations); Hydromorphone (injectable); Methadone (liquid); Buprenorphine-Naloxone (tablet); Buprenorphine extended release (injectable)

Overdose prevention

 Referral to primary care; onsite HIV/HCV testing & treatment; harm reduction equipment distribution; onsite & referral to social services; case management; individual/group support

Psychostimulants

 Observed:

  Dextroamphetamine (tablet); Methylphenidate (tablet); Aripiprazole (tablet); Sertraline (tablet)

#7

Program setting

Opioids

Most (51–75%)

Smokeable diacetylmorphine

Physician Prescriber (n = 6FT, 12PT); Licensed Practical Nurse (n = 4FT, 8PT); Social Worker (n = 6FT, 6PT); Case Manager (n = 2FT, 2PT); Outreach Worker (n = 2FT, 2PT); Patient Navigator (n = 6FT, 6PT); Onsite Dietician (n = 1FT, 2PT); Clinic Manager (n = 2FT, 2PT); Program Coordinator (n = 2FT, 2PT); Clinic Assistant (n = 2FT, 2PT); Onsite Pharmacist (n = 2FT, 2PT)

Only criteria is if they are unattached to care

Reduce street/unregulated drug use

 Safer opioid supply and iOAT embedded within an existing primary care clinic and safe consumption site

 Non-observed:

Injectable fentanyl formulation

Provide linkage to primary care

Other services provided

  Hydromorphone short acting (tablet); Oxycodone (tablet)

Intranasal (inhale) diacetylmorphine

 Onsite primary care; HIV/HCV treatment; harm reduction equipment distribution; overdose prevention site/SCS; onsite social services

 Observed:

  Sufentanil (injectable); Buprenorphine (tablet)

 Both observed & non-observed:

  Morphine sulfate (capsule, 12- & 24-h formulations); Fentanyl patch; Hydromorphone (injectable); Diacetylmorphine (injectable); Methadone (liquid)

Psychostimulants

 Non-observed:

  Dexedrine (tablet); Methylphenidate (tablet)

Benzodiazepines

 Observed:

  Diazepam (tablet); Clonazepam (tablet); Alprazolam (tablet)

#8

Program setting

Opioids

Some (25–50%)

Injectable diacetylmorphine

Physician Prescriber (n = 2PT); Registered Nurse (n = 1FT); Licensed Practical Nurse (n = 3FT, 2PT); Harm Reduction/Mental Health Worker (n = 1FT, 2PT); Clinic Manager (n = 1PT); Program Coordinator (n = 1FT); Indigenous Community Support Worker (n = 1FT); Contingency Management Worker (n = 2PT)

Severe opioid use and at risk of overdose death confirmed via positive screen for fentanyl use

Reduce overdose death

 Stand-alone dedicated safer opioid supply program

 Observed:

Smokeable diacetylmorphine

Reduce use of street/unregulated drugs

Other services

  Morphine sulfate (capsule, 12- & 24-h formulations); Fentanyl patch; Methadone (liquid); Fentanyl powder

Smokeable fentanyl formulation (have this product but no designated space for clients to consume)

Provide wraparound care

 Onsite & referral to primary care; onsite HIV/HCV testing & treatment; onsite & referral to social services; referral to specialized healthcare; case management; individual/group support

Psychostimulants

 Non-observed:

  Dextroamphetamine (tablet)

#9

Program setting

Opioids

Most (51–75%)

Smokeable diacetylmorphine

Registered Nurse (n = 1PT); Licensed Practical Nurse (n = 1FT, 1PT); Harm Reduction/Mental Health Worker (n = 2PT)

Addiction to opioid injection drug use

Reduce overdose and eliminate cause of death

 Stand-alone TiOAT clinic

 Observed:

Achieve socioeconomic stability among clients

Other services provided

  Hydromorphone short acting (tablet); Fentanyl patch

Connect clients to the care they need

 Onsite primary care; harm reduction equipment distribution; overdose prevention site/SCS; referral to social services; referral to specialized healthcare

#10

Program setting

Opioids

Most (51–75%)

Injectable diacetylmorphine & injectable fentanyl formulation

Physician Prescriber (n = 1PT); Nurse Prescriber/Supervisor (n = 1FT); Registered Nurse (n = 4FT); Case Manager (n = 2FT); Clinic Manager (n = 1PT); Peer Support Worker (n = 1FT)

Using opioids in some way and willing to attend for daily visits

Reduce reliance on street/unregulated drugs

 iOAT embedded within an existing harm reduction program

 Observed:

Smokeable diacetylmorphine

Reduce overdose risk

Other services provided

  Morphine sulfate (capsule, 24-h formulation); Fentanyl patch; Hydromorphone (injectable); Sufentanil (injectable); Methadone (liquid)

Provide access to all kinds of other services (wraparound case management support, housing & mental health)

 Referral to primary care; onsite HIV/HCV testing & treatment; harm reduction equipment distribution; overdose prevention site/SCS; onsite & referral to social services; case management; individual/group support

Benzodiazepines

Increase connection with service system

 Non-observed:

Less reliance on safer supply in the long-term

  Clonazepam (tablet)