Participant perspectives on a safe supply program in Vancouver, Canada: impacts, satisfaction and improvement priorities

Abstract

Objectives

The ongoing toxic drug crisis in Canada, driven largely by fentanyl proliferation, has led to ever-escalating overdose rates. The Safer Alternatives for Emergency Response (SAFER) program was launched in Vancouver, British Columbia (BC) in 2021 to reduce overdose risk by offering prescribed pharmaceutical alternatives, including fentanyl medications. This study aimed to evaluate satisfaction and the program’s perceived impact on health and social outcomes among SAFER participants.

Methods

Data were collected from 78 SAFER participants through baseline interviewer-administered questionnaires. The primary outcome was self-reported changes in drug use, health status and social outcomes. Descriptive statistics summarized participant characteristics and outcomes.

Results

Among 78 participants, with 22 (28%) identifying as women or gender diverse, 76% reported reduced drug use, while 71% experienced reductions in drug cravings/withdrawal and overdose risk, respectively. Safer drug-use behaviours were also reported: 56% reported that they were more likely to use sterile equipment, 37% said they were more likely to check their drugs, and 35% said they were more likely to carry naloxone. Improvements in overall physical health (58%), mental health (63%), financial stability (55%), and social connections (49%) were also noted. High satisfaction with services was reported (78%), although 71% suggested improvements, including extended hours, easier access to carry doses, and expanded medication options.

Discussion

These findings indicate that the SAFER program is perceived as effective in reducing overdose risk and improving health and social outcomes. However, barriers such as service accessibility and limited medication options remain. Addressing these concerns could enhance program outcomes. Further large-scale research is recommended to confirm these results and explore long-term impacts.

Introduction

The toxic drug crisis in North America continues to have devastating consequences. The Canadian province of British Columbia (BC), has been particularly hit hard, reaching an annual rate of 40.1 deaths per 100,000 population in 2024 [1]. Strategies such as opioid agonist therapy, naloxone distribution, drug checking services, and supervised consumption sites have expanded [2–4]. While the scale-up of these interventions reduced drug toxicity deaths and provided critical support [5], overdose deaths continued to increase in the wake of their expansion.

In response, the provision of prescribed pharmaceutical opioids and stimulants as safer alternatives to the unregulated drug supply—known as prescribed safer supply or prescribed pharmaceutical alternatives—has been introduced in Canada. Safer supply programs were initiated in Canada in 2016 on a very small scale but were dramatically scaled-up in 2020, partially in response to the COVID pandemic [6]. These programs were implemented in a variety of clinical settings, in particular those that were already dispensing opioid agonist treatment. These programs operated legally under existing medical regulations allowing physicians and nurse practitioners to dispense medications. Such programs aim to reduce reliance on the unregulated drug supply and lower overdose risk, particularly in the context of a toxic and unpredictable illicit market [6]. These programs often provide pharmaceutical alternatives such as hydromorphone or stimulants like dextroamphetamine, and in some cases may be integrated with opioid agonist therapies. While models vary, some programs include daily dispensed or observed doses, with some availability of take-home doses depending on program structure and patient circumstances [6].

Studies show that safer supply programs reduce non-fatal opioid toxicities [7–9] and one has documented reductions in fatal overdoses [10]. Long-term evaluations have also documented reductions in infections like infective endocarditis and osteomyelitis, as well as fewer hospital admissions [8]. Qualitative assessments suggest improvements in self-perceived health, better access to care for chronic conditions, highlighting broader benefits of safer opioid supply programs [11–14]. However, a number of challenges and barriers to safer supply programming have been identified. Karamouzian et al. [15] pointed to limited reach and issues with retention due to physical space constraints, staff shortages, unsustainable funding models, unmet medication needs, and heavily medicalized, high-barrier models of delivery. Further, concerns regarding the diversion of safer supply medications have been raised by law enforcement and others [16].

Most safer supply programs have primarily offered oral hydromorphone, but inadequate dosing, drug preferences, and a lack of alternative medications are known barriers to care [12, 17]. This prompted the development of programs that address a greater diversity of drug use behaviour and needs, such as the Safer Alternatives for Emergency Response (SAFER) program launched in Vancouver in 2021, which provides various prescribed psychostimulants and opioids, including fentanyl.

Building on existing research on safer supply programs, we sought to evaluate participant satisfaction with and the perceived impacts of the SAFER program on psychosocial well-being, health, and drug use behaviours.

Methods

Study setting

The Safer Alternatives for Emergency Response (SAFER) program is run by PHS (Portland Hotel Society) Community Services Society in partnership with Vancouver Coastal Health and is funded by Health Canada. The program operates out of a clinic in the Downtown Eastside neighbourhood of Vancouver, and is overseen by a multidisciplinary team, including physicians, nurses, pharmacists, social workers, and individuals with lived/living experience of substance use. The program offers various prescribed opioids, including hydromorphone and fentanyl formulations, as well as psychostimulants such as methylphenidate and dextroamphetamine [18]. SAFER allows participants to choose between titration schedules or fixed doses [18], and the medications offered include those with psychoactive effects that people who use drugs usually only find in unregulated drugs. These are available in various forms, including injectable, oral, and transdermal options, and are consumed onsite (i.e., no “take-home” dosing) via witnessed ingestion. Eligibility for SAFER is based on ongoing substance use and vulnerability to related harms. Clients can self-refer and be assessed for program admission. SAFER follows between 20 and 30 clients at any time, and all medications are dispensed onsite. SAFER clients are able to access a range of harm reduction supplies onsite.

Study design

Data were derived from a prospective cohort study of SAFER program participants [18]. Study eligibility criteria included: being at least 18 years of age, able to communicate in English, and enrolled in the SAFER program or having discontinued the program in the last 3 months. Between December 2021 and February 2025, participants were recruited via referrals from SAFER staff and print materials, including flyers and posters, placed within the SAFER clinic. After providing informed consent, participants completed an interviewer-administered baseline questionnaire and up to three subsequent semi-annual follow-up questionnaires. The questionnaires solicited information on socio-demographic characteristics, drug use and other behavioural patterns, medications for substance use, health outcomes, experiences with SAFER program, and engagement with other services. The questionnaires were administered onsite by trained research assistants. Participants received a $40 CAD cash honorarium at each study visit. Ethics approval was received from the University of British Columbia Clinical Research Ethics Board.

Study variables and analysis

This analysis was restricted to participants who completed a baseline questionnaire between December 2021 and December 2023. This study assessed perceived impacts of the SAFER program on drug use and associated behaviours, as well as various health and social outcomes. Pre-determined domains considered included: the extent to which participants felt the SAFER program had helped them reduce their use of their preferred drug, manage drug cravings and withdrawal symptoms, lower their overdose risk, increase the use of sterile drug use equipment (e.g., syringes), and adopt safer drug consumption practices (e.g., using drugs slowly). They were also asked whether the program had made them more likely to carry naloxone and have their drugs checked (e.g., via local drug checking services using Bruker ALPHA and ALPHA II Fourier Transform Infrared spectrometers and/or BTNX fentanyl immunoassay strips). Further areas of inquiry included the program’s impact on reducing participants’ reliance on illegal activities (e.g., drug selling), improving income (e.g., reduced drug spending, increased paid work), enhancing housing stability, and reducing the likelihood of violence. Participants were asked about the program’s influence on decreasing contact with police, strengthening connections with family/friends, increasing use of other health or social services, and improving pain management, physical and mental health. Participants responded on a Likert scale that was categorized as: strongly agree/agree, neither agree nor disagree/too soon to know, and strongly disagree/disagree.

Participants were also asked about their satisfaction with: the SAFER program, the dose level of their safe supply medication, as well as overall satisfaction with medications (very satisfied or satisfied vs. neither satisfied, unsatisfied, or very unsatisfied). Additionally, participants were asked to rate the quality of service at SAFER (excellent/good vs. fair/poor). Further, participants were asked if the SAFER program needs to be improved (yes vs. no) and, if yes, how it could be improved. A list of possible responses was read and participants were also invited to provide other responses not included in the list. Descriptive statistics were used to summarize the data. The analysis included calculations of frequencies and percentages. Missing values did not exceed “2” for any variables, with the exception of one question regarding program impacts on pain management (for which 5 responses were missing), and therefore no imputations were performed to address missing data.

All analyses were conducted with SAS version 9.4.

Results

The study included 78 participants with a median age of 45 years (1st−3rd quartile: 38–52). Fifty-five participants (71%) self-identified as men, 22 (28%) as women or gender diverse, and 1 (1%) did not disclose their gender. Regarding ethnicity/ancestry, 45 (58%) identified as White, 27 (34%) as First Nations/Aboriginal/Inuit/Metis, and 3 (3%) as Black and other People of Colour (BPOC). Unstable housing in the last 6 months was reported by 59 (76%) participants. Participants reported their unregulated drug use in the previous six months when completing their baseline survey, with 63 (81%) reported daily opioid use, 36 (46%) reporting daily crystal methamphetamine use, 35 (45%) reporting any cocaine use, and 19 (24%) reporting any benzodiazepine use. Participants had been enrolled in the SAFER program for a median time of 4.8 months.

In the past six months, 24 participants (31%) were prescribed fentanyl powder, 23 (29%) were prescribed Fentora, and 27 (35%) were prescribed a fentanyl patch. Additionally, 14 (18%) were prescribed sufentanil, 16 (21%) were prescribed injectable opioid agonist therapy (iOAT), and 20 (26%) were prescribed tablet iOAT (TiOAT).

Participants reported various program impacts. As shown in Figs. 1, 2 and 3 and a majority, 59 (76%), agreed or strongly agreed that SAFER helped them reduce their use of their preferred drug, while 55 (71%) reported reductions in drug cravings/withdrawal and risk of overdose, respectively. Forty-four participants (56%) stated that the program made them more likely to use sterile drug equipment. In terms of drug-use behaviour, 29 (37%) felt the program prompted them use drugs more slowly or taste drugs first, and 27 (35%) felt more inclined to carry naloxone. Moreover, 29 (37%) reported being more likely to have their illicit drugs checked, and 45 (58%) noted a reduction in reliance on illegal activities. Furthermore, 43 (55%) agreed or strongly agreed that the program helped them improve their income, and 21 (27%) reported improvements in housing stability, while 34 (44%) felt less likely to experience physical violence. Additional positive impacts included less contact with the police (n = 37, 47%), improved connections with family/friends (n = 38, 49%), increased use of health/social services (n = 45, 58%), and better pain management (n = 55, 71%). Furthermore, participants reported improved physical (n = 45, 58%) and mental health (n = 49, 63%).

Fig. 1.

Being in the SAFER Program Has… (Drug Use Patterns)

Fig. 2.

Being in the SAFER Program Has… (Socioeconomic Outcomes)

Fig. 3.

Being in the SAFER Program Has… (General Health Outcomes)

Fig. 4.

How Do You Think the Safer Program Could Be Improved? (n=55)

Most participants rated the quality of service at SAFER as “excellent” or “good” (85%), with 78% reporting being satisfied or very satisfied with the program. With regard to their most recent medication from the SAFER program, 54% reporting being satisfied/very satisfied with their dose, and 64% reported being satisfied overall.

Regarding quality improvement, 55 (71%) participants felt that SAFER could be improved. Of those 55 participants, 38 (69%) suggested longer operating hours, 31 (56%) expressed interest in easier access to carry doses, and 21 (38%) advocated for more medication options, 4 (19%) of whom were seeking expanded access to fentanyl and 9 (43%) of whom were seeking heroin (Fig. 4). Additionally, sixteen (29%) participants wanted to be able to smoke/inhale drugs on site, 15 (27%) wanted shorter wait times, 12 (22%) requested closer clinics/reduced travel time, 11 (20%) wanted more time to use drugs on-site, and six (11%) suggested offering higher doses.

Discussion

This study suggests that the SAFER program, by providing pharmaceutical alternatives to the toxic drug supply, had a positive impact on participants’ self-reported well-being and drug-use behaviour, with approximately three quarters reporting reduced drug use and decreases in cravings/withdrawal, and overdose risk. Further, the SAFER program, unlike most other safer supply programs, offers a range of medications, including fentanyl-based products. Participants also cited benefits not reported in previous evaluations of safer supply programs, including that the program increased their safe drug practices, with over half reporting being more likely to use sterile equipment, and with over a third being more likely to report having their drugs checked and being more likely to carry naloxone. Many participants experienced broader improvements, including better physical and mental health, financial stability, and social connections. Also unique to this evaluation was noted benefits related to less engagement in illegal activities and fewer interactions with police. These improvements in social functioning likely reflect reduced reliance on street-based drug markets and the income-generating activities typically undertaken to acquire them. However, 71% of participants suggested program improvements, including longer operating hours, easier access to carry doses, and more medication options.

The perceived reduction in overdose risk and improvements in safer drug-use behaviour align with findings from other safer opioid supply programs in London, Ontario and Halifax, Nova Scotia, such as those generated by Gomes et al. [8] and Brothers et al. [7]. Our findings also align with the scoping review by Leddie et al. [6] which also reported on reduced opioid toxicity and improvements in mental health among safer supply clients.

However, SAFER’s focus on a wider range of medication options, including several fentanyl formulations and psychostimulants, addresses some gaps identified in earlier research, which highlighted the limitations of programs offering only hydromorphone [12]. Participants’ suggestion that SAFER expand medication options reflects the diversity of drug preferences among people who use drugs [19]. This further aligns with research by Kolla et al. [12], who recommended that future safer supply programs offer heroin for patients who smoke fentanyl, as well as the work by Leddie et al. [6] indicating that a lack of medication options and low dosing in safer supply programs were reported by clients as areas in need of improvement. Policymakers should therefore consider the need for flexible, individualized safer supply programs that offer multiple opioid and psychostimulant options as a means of increasing access to and retention in programming. Furthermore, logistical factors, such as extending operating hours, improving geographic accessibility, and permitting smoking on site should be addressed, as participants cited these as program barriers. Such barriers have also been documented in previous research by Ivsins et al. [17] in the context of a hydromorphone distribution program. Concerning carry doses, which was noted as an area for improvement by 31 (40%) of participants, this would likely not be feasible in the current model given the documented risks of diversion [16], such as diversion to opioid-naïve individuals.

This study had several limitations. The convenience sample was small and may not represent the broader population of people who use drugs in Vancouver, and some selection effects may have occurred whereby those who had negative experiences with the program were more likely to withdraw, thus resulting in more positive reporting. The majority of participants were from the Downtown Eastside (DTES) and reported unstable housing, which may limit the generalizability of the findings to populations with different housing circumstances. Additionally, self-reported data could introduce bias, as participants may over- or under-estimate program impacts. The study also lacked a comparison group and was cross-sectional in nature, thus limiting attributions of impact. Future research with larger samples and objective measures of program outcomes is warranted.

The SAFER program demonstrates considerable participant-perceived success in improving health outcomes, reducing illicit drug use, and promoting safer behaviour among participants. However, challenges remain, particularly in the areas of medication variety and service accessibility. Future efforts should focus on expanding medication options to better meet preferences and reduce barriers to access. Larger-scale studies should be conducted to identify long-term outcomes, including how safer supply programs can be adapted to diverse populations across different regions.

Author contributions

Kennedy and Kerr designed the larger evaluation from which this study was derived. Kerr, Mawani and Kennedy designed this particular analysis. Kennedy conducted the descriptive statistical analysis. Mawani and Kerr drafted the manuscript and Kennedy, Holliday, and Sutherland provided critical feedback on the initial and subsequent drafts.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due given the small. number of vulnerable participants who were included in sth study. However, some data may be made available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.