Case Studies from Four Canadian Clinics - The Urgent Need for Expanded Response Options
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Exploring Expanded
Response Options to
Opioid Harms
Canadian Centre on Substance Use and Addiction | www.ccsa.ca | June 2020
Case Studies from Four Canadian Clinics
The Urgent Need KEY MESSAGES
for Expanded • The COVID-19 pandemic continues to compound the ongoing
public health crisis related to high rates of opioid overdoses
Response Options and deaths.
• Access to a greater range of pharmaceutical treatment options
for opioid use can substantially improve the likelihood that
clients remain in treatment, improve the quality of life for people
Canada is facing an urgent challenge who use opioids and help reduce deaths from a contaminated
to reduce the harms associated illicit opioid supply.
with the problematic use of opioids.
• Fully responding to opioid harms requires addressing
More than 14,700 lives were lost
fundamental problems of regulated and safer supply and mental
to deaths apparently related to
opioids between January 2016
health, trauma and the social determinants of health.
and September 2019. During that • Recent legislative changes in Canada have increased the
same period, there were 19,490 availability of diacetylmorphine and hydromorphone, two
hospitalizations for poisoning pharmaceutical treatment options for opioid use disorder.
related opioid to opioids (Special Additional class exemptions issued by Health Canada in the
Advisory Committee on the Epidemic context of COVID-19 have further reduced barriers to accessing
of Opioid Overdoses, 2019). The pharmaceutical options.
COVID-19 pandemic compounds this
ongoing public health crisis. There • Response needs to involve collaborative decision making involving
is a heightened need to reduce people with lived or living experience of opioid use, who are well
avoidable pressures on healthcare positioned to anticipate unintended consequences and identify
systems and support people who effective solutions.
use opioids who may be at increased
• There is a need to support physician and pharmacist competency
risk or unable to self-isolate during
and engagement, as they play a pivotal role in moving toward
the pandemic.
broader implementation of expanded options.
Individuals using opioids need a
range of comprehensive, accessible,
quality services to support them if opioids to be made available to treat There is evidence that injectable
they choose to reduce or stop, but persons with opioid use disorder hydromorphone or diacetylmorphine
available treatment options are (OUD), and to stem the deaths therapies are viable treatment
limited. Many individuals with lived occurring from the contaminated options for patients with severe OUD
or living experience, as well as public illicit opioid supply (Canadian (Fairbarin et al., 2019). Further,
health and medical professionals, Community Epidemiology Network on administering these therapies in
are calling for pharmaceutical-grade Drug Use, 2020). primary care clinics and designatedControlled Drugs and Substances
“I don’t think harm reduction is different than Act that increases the accessibility
recovery. It’s all about someone just living of controlled substances for
their best life and being happy and meeting therapeutic purposes (Health
their goals and whether or not they use Canada, 2020), and British
drugs I think is irrelevant. … we want people Columbia has issued interim
to be alive, not get HIV, and live with joy in clinical guidance for putting these
their life with other human connections, and exemptions into place (British
that’s what these programs do. And whether Columbia Centre on Substance
or not you call that recovery is up to you.” Use, 2020).
— Christy Sutherland, MD, Portland Hotel
This resource provides case
Society, Vancouver and Victoria
studies of the expanded response
options to opioid harms used by
pharmacies is feasible and cost While these case studies highlight
injectable OAT options, providing an four Canadian clinics in 2019.
efficient. This integration can
array of flexible options for delivery These case studies are intended
provide the opportunity to address
additional primary care needs and administration of treatment to share information and generate
in parallel, potentially leading during the pandemic can support discussion about alternative
to positive short-term outcomes people who use opioids by reducing complementary measures for
such as stopping illicit opioid use, the risk of overdose, infection and improving the quality of life of
reducing criminal activity and withdrawal while they maintain people who use opioids, especially
transitioning into stable housing physical distancing or must those with severe OUD, and the
and employment (Wilson, Brar, self-isolate. Health Canada has value of implementing expanded
Sutherland, & Nolan, 2020). recently issued a class exemption responses to reducing opioid
under subsection 56(1) of the harms. The resource is intended
Comprehensive efforts have
been made across the country
to address the multiple factors “We try to optimize their treatment as best
contributing to the opioid crisis and we can, but some participants really feel like
minimize ongoing harms, with some substance use is a part of who they are and
strategies more widely implemented at this moment they are not going to stop the
than others. For example, naloxone, use, and that’s okay, too. So, they can still
an emergency measure that can come here, it’s not that they are going to be
reverse an overdose, has become stigmatized or removed from the program
widely available across Canada because of their ongoing substance use and
(Moustaqim-Barrette et al., 2019). it’s sort of like trying to have harm reduction
In contrast, the availability of opioid and treatment coincide with each other, that
agonist therapies (OAT) can vary by they are not these opposing ideas, that they
jurisdiction and region, as well as can actually exist together.”
with physician competence (Herring, — Tara O’Mara, NP, Alberta Health Services,
Lefebvre, Stewart, & Selby, 2014; Edmonton
Taha, 2018).
ACKNOWLEDGEMENTS
We are grateful to the following participants who offered their time and shared their experience for the
case studies:
• Scott MacDonald, MD, Providence Healthcare, Vancouver
• Tara O’Mara, NP, Alberta Health Services, Edmonton
• Christy Sutherland, MD, Portland Hotel Society, Vancouver and Victoria
• Jeffrey Turnbull, MD, Ottawa Inner City Health, Ottawa
2 Exploring Expanded Response Options to Opioid Harms Canadian Centre on Substance Use and Addictionfor a broad audience including
mental health and addiction
Key Learnings for across Canada was not equal
and the findings may not be
service providers, harm reduction
service providers, primary care and
Injectable Opioid representative of experiences
in all regions. Nevertheless, the
clinic physicians and nurses, first
responders, pharmacists, policy
Therapy case studies shine a spotlight on
Canadian examples of current
makers, researchers and people practice for expanded options to
who use drugs. The case studies address OUD. The findings from
were conducted before the onset practice were supplemented with
of the COVID-19 pandemic. Since those from the literature:
The four clinics that provided
then, in response to the need for information for this report are • The case study participants
social isolation, a greater flexibility profiled below. The small sample identified low-barrier access to
in response options is being means it is not possible to draw treatment, open-ended time
explored in Canada and many other general conclusions. Furthermore, for physician engagement and
countries around the world. the distribution of participants ongoing evaluation of treatment
CLINIC PROFILES
Four clinics were contacted for this study. Three are outpatient clinics and one is a residential program.
Clinics are located in Alberta, British Columbia and Ontario. Their treatment services integrate harm reduction
approaches and place them on a single continuum of care. Some patients use the clinics or program as an
avenue for “safer supply.”
Each clinic or program supports 20–150 individuals, The clinics offer the following additional services:
depending on capacity. Patients of the clinics or • Primary care
program must meet the following criteria: • HIV and hepatitis C treatment
• Use drugs intravenously • Women’s health
• Be diagnosed with OUD • Chronic disease management (e.g., chronic
• Be at risk of overdose obstructive pulmonary disease, hypertension)
• Psychiatry
• Have a history of unsuccessful oral treatment
• Social work
Patients enter the clinics and programs via: • Peer support
• Self-referral • Nutrition education
• Pharmacy
• Referral from other clinics and programs
• Connections
• Connection through supervised consumption sites
◦ Housing
The clinics and programs offer a variety of medical ◦ Employment services
response options to opioid harms that include: Clinics report the following outcomes:
• Preloaded syringes of hydromorphone provided • Improved health, hygiene and nutrition
for client to inject while supervised or for nurse to • Reconnection with family
assist (80–630 mgs over 3–6 doses per day) • Employment
• Hydromorphone tablets crushed by nurses and • Engagement in leisure activities
sterile injectable equipment provided to patients to • Decreased criminality
administer (16 mgs, up to five times per day) • Fewer or no overdoses
• Preloaded syringes of diacetylmorphine provided • Connections with other services
to client for supervised injection or for a nurse to ◦ Psychiatry
assist (up to 400 mg in three doses per day to a ◦ Initiation of HIV or hepatitis C treatment
maximum daily dose of 1,000 mg) ◦ Housing support
Canadian Centre on Substance Use and Addiction Exploring Expanded Response Options to Opioid Harms 3“We already have evidence that injectable
Practice
hydromorphone is safe, and both more
effective and more cost-effective in that
Implications
population that continues to inject despite
attempting oral treatments. But now we also
know that it reduces mortality. It needs to be
available and it will be available.”
Considerations for
— Scott MacDonald, MD, Providence
Healthcare, Vancouver Implementation
The social distancing required as
programs as key factors designated community pharmacy part of the response to the COVID-19
for success. upon dose stabilization (Wilson pandemic has forced policy
• An additional success factor et al., 2020). makers to create new guidelines
of including people with lived • Challenges to program delivery to ensure programs continue to
or living experience in decision identified by the case study support people with lived and living
making to determine appropriate participants include reliable experience while respecting these
responses, identify effective funding for medications and requirements. These new practices
solutions and anticipate staffing, harms to clients who will need to be revisited and
unintended consequences is use substances other than evaluated to identify practices to
supported by the literature (Taha, opioids and opposition to using continue post-pandemic.
Maloney-Hall, & Buxton, 2019). expanded response options from
The case study participants
The case studies demonstrate colleagues, other healthcare
• proposed the following
that quality of life for people who services or correctional facilities.
considerations for implementing
use opioids can be substantially • The case study respondents expanded response options,
improved across multiple reported that men tended to depending on the needs of the
dimensions by providing access to access the clinics and programs community:
a greater range of pharmaceutical more than women. Some women,
particularly those involved in the • Family doctors could work with
treatment options.
sex trade, or those who prefer their community pharmacy to
• It remains essential to address ensure expanded response
assisted injection or want to inject
underlying problems related to options are available at
in an area that they do not want to
mental health conditions, trauma their clinics.
expose (such as their chest), are
and the social determinants of
uncomfortable or feel threatened • After developing a relationship
health in support of the response
in the presence of men. with a person who uses opioids,
to opioid harms (Canadian
Centre on Substance Use and
Addiction, 2017).
“We need to know what the values, goals
• Policy levers, such as and individual plans are for each patient. It
those addressing physician does need to be individualized, and there
remuneration and billable time needs to be opportunity for shared care.
for engagement, can help move That may include, well, which drug do you
the identified factors for success want? Would you prefer diamorphine or
forward (Childerhose, Atif, & hydromorphone? We should be respecting
Fairbank, 2019). people’s decisions. When somebody is
• Participants noted that addressing ready to transition to oral, then, how would
privacy restrictions that inhibit you like to do that? Do you want to do micro
information sharing among clinics dosing with Suboxone? Do you want to try
and programs could be a further methadone? A taper or Kadian? We give
contributor to success. people choice.”
• Injectable opioid agonist therapy — Scott MacDonald, MD, Providence
can be safely transitioned to a Healthcare, Vancouver
4 Exploring Expanded Response Options to Opioid Harms Canadian Centre on Substance Use and Addictioncare providers may wish to of the outcomes achieved by people urgent need to respond to
consider if there are opportunities accessing these clinics and programs the COVID-19 pandemic and
to connect them to additional is necessary to propel discussion evaluating the impact of these
external services. about the value of implementing changes in practice to determine
• Specialized services may be expanded responses to opioid harms. what could be sustained after the
needed in some communities pandemic;
to address particular
population concerns. Conclusion and • Supporting the implementation
of identified good practices and
Participants noted additional solutions
to help improve quality of care:
Next Steps trialing solutions to recognized
problems, including finding ways
to address fundamental problems
• Provide women-only programs;
related to underlying mental
• Produce diacetylmorphine health conditions, trauma and the
domestically to improve access; social determinants of health;
• Increase the capacity of programs These case studies profile the
expanded response options to opioid • Supporting physicians to develop
to accommodate more patients; competence in delivering these
and harms used by four Canadian clinics.
The intent is to fuel discussion treatments through literature
• Develop take-home programs to about alternatives for improving the reviews, training, point of care
minimize the toll on patients’ and quality of life for people who use models, and mentorship and
services providers’ time. opioids and the value of expanded specialist supports;
Supports for Physician responses to reducing opioid harms. • Rigorously investigating the
Competence This discussion is particularly effectiveness of these types of
important during the COVID-19 programs and the improvements
The case study participants noted pandemic, which is compounding the they claim through randomized
that physicians might not feel fully ongoing public health crisis of opioid control trials and program
confident in this aspect of their overdoses and deaths. The lessons evaluation; and
practice because of the need learned from these case studies
for holistic skills encompassing • Broadly sharing new knowledge
can inform efforts to implement with policy makers, researchers,
addiction, mental health and public expanded response options for opioid
health expertise. They explained the full range of potential service
harms. These efforts could include:
that physician competence typically providers, and persons who use
develops over time, but also • Expanding the scope of treatment substances and their supporters
suggested the following supports options available due to the and allies.
for physicians to improve their
competence: “In a supervised injection site, the immediate
• Regularly review the literature; goal is safety, getting the chaos out of their
life, connecting with other things that are
• Respond to calls for change in
important for their addiction management,
practice;
such as a psychiatrist, counselling, family,
• Attend physician training courses; employment, leisure.… we watch them
• Use point-of-care modules; and inject, and they overdose, and we give them
• Find opportunities for mentorship Narcan, and we send them on their way,
and access to specialist supports. only to do it again. If we [can] stabilize them,
keep them alive, and then work on their
Evaluation and Knowledge addiction, that seem[s] to be a much more
Mobilization effective strategy. And yeah, if we could get
Evaluation of the impact of these them to oral, that would be fantastic. If we
programs, including a focus on could get them abstinent, working, all of
unique implementation needs for those things, that would be fantastic too. But
particular populations and programs, really, it’s not my objectives. It’s theirs.”
will contribute to the evidence base. — Jeffery Turnbull, MD, Ottawa Inner City
Continued knowledge mobilization Health, Ottawa
Canadian Centre on Substance Use and Addiction Exploring Expanded Response Options to Opioid Harms 5Additional Resources
• Canadian Centre on Substance Use and Addiction, Impacts of COVID-19 on
Substance Use
• Canadian Centre on Substance Use and Addiction, Opioids
• Health Canada, Subsection 56(1) class exemption for patients, practitioners and
pharmacists prescribing and providing controlled substances in Canada during the
coronavirus pandemic
• Health Canada, Opioid Symposium: What We Heard Report
• Health Canada, Toolkit for Substance Use and Addictions Program Applicants. Stream
2 — Increase access to pharmaceutical grade medications. Available upon request from
hc.SUAP-PUDS.sc@canada.ca with “Safe Supply Tools” in the subject line.
• Canadian Research Initiative in Substance Misuse (CRISM), National Guideline for the
Clinical Management of Opioid Use Disorder
• CRISM, COVID-19 Pandemic — National Rapid Guidance. CRISM provides six national
guidance documents that address the urgent needs of people who use substances,
service providers and decision makers in relation to the COVID‑19 pandemic. (Some
documents forthcoming and yet to be provided in French.)
• Centre for Health Evaluation and Outcome Sciences, Evidence Summary:
Dextroamphetamine Sulfate (Dexedrine spansule) for the Treatment of Stimulant
Use Disorder
• Public Health Ontario, Effectiveness of Supervised Injectable Opioid Agonist Treatment
(SiOAT) for Opioid Use Disorder
• Safer Opioids Supply Programs, A Harm Reduction Informed Guiding Document for
Primary Care Teams
• British Columbia Centre on Substance Use, Guidance for Injectable Opioid Agonist
Treatment for Opioid Use Disorder
• CRISM, Injectable Opioid Agonist Treatment Guideline
• Health Canada, Toolkit: COVID-19 and Substance Use. Available upon request from
hc.cdss-scdas.sc@canada.ca
• Canadian Association of People Who Use Drugs, Safe Supply Concept Document
• Canadian Family Physician Clinical Practice Guidelines, Managing Opioid Use Disorder in
Primary Care: PEER Simplified Guideline
6 Exploring Expanded Response Options to Opioid Harms Canadian Centre on Substance Use and AddictionReferences
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ISBN 978-1-77178-677-5 © Canadian Centre on Substance Use and Addiction 2020
CCSA was created by Parliament to provide national leadership to address substance
use in Canada. A trusted counsel, we provide national guidance to decision makers by
harnessing the power of research, curating knowledge and bringing together
diverse perspectives.
CCSA activities and products are made possible through a financial contribution
from Health Canada. The views of CCSA do not necessarily represent the views of
Health Canada.
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