Operating Grant: Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 – Safer Supply
End-of-Grant Report Summary – March 2025

Introduction

The Operating Grant: Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 funding opportunity was designed to evaluate harm reduction approaches representing critical evaluation needs that have been heightened by the COVID-19 pandemic: safer supply and supervised consumption sites. This report is from the Safer Supply Evaluation funding pool.

Health Canada (HC) supported Safer Supply Pilot Projects (SSPP) through their Substance Use and Addictions Program (SUAP) to expand access to pharmaceutical-grade medications as safer alternatives to the toxic illegal drug supply (referred to as "safer supply"), that may also provide people with pathways to care.

Disclaimer

This End-of-Grant Report Summary includes information as provided by the research team. Some information has been edited for length and clarity. Any errors or omissions are unintentional. This report should not be taken as a definitive account of research findings. Readers are advised to follow up directly with the research team for the most current information on their project.

Project summary

Project Title: A proposal to evaluate safer supply pilot programs in Canada

Nominated Principal Investigator: Dan Werb, Centre on Drug Policy Evaluation, Unity Health Toronto

Key outcomes

The team evaluated integrated safer supply pilot programs across Canada. These programs provide low-barrier access to prescribed doses of pharmaceutical alternatives, most commonly opioid formulations, to individuals accessing the unregulated toxic drug supply and at high risk of adverse harms, such as overdose.

The research team has collected comprehensive qualitative and quantitative data and established collaboration agreements for nationwide client and service provider interviews. The evaluation included analyzing narrative data from SUAP reports, completing two rounds of organizational assessment interviews with safer supply program managers, conducting group interviews with program staff across various roles, and exploring clinical outcomes using administrative health datasets. They have also evaluated the substance use care and safer supply program at an Indigenous-led organization in B.C.

This work builds essential infrastructure for understanding how safer supply initiatives, as well as other low-barrier clinical and frontline responses, can reduce overdose deaths across diverse Canadian communities.

Potential implications

This evaluation identifies the range of existing safer supply programs and determines which approaches most effectively meet client needs. The findings highlight how safer supply programs can fit within Canada's overdose prevention and harm reduction strategies.

The evaluation outlines barriers affecting equitable access to programs, challenges in service delivery, clinical limitations of currently available medications, and local factors affecting how programs work. The team has identified key elements affecting long-term program sustainability.

These findings provide critical evidence to help policy makers, health care practitioners, and program administrators develop, implement and expand effective safer supply programs across diverse Canadian communities.

Key accomplishments toward objectives

Best practices identified for safer supply interventions

This evaluation identified best practices for operating effective safer supply programs and provides a foundation for expanding effective interventions as part of comprehensive substance use care across diverse Canadian communities.

Wraparound service models

Wraparound models that combine safer supply medications with housing supports, primary care, mental health services, and social connection opportunities are the most sustainable and lead to the best client outcomes.

Low-barrier medication approaches

Novel approaches like the MySafe dispensing machine show promise for reaching specific client subgroups, including those who may be hesitant to engage with traditional healthcare services. These models offer minimal interaction with care providers but greater flexibility and autonomy for clients.

Sustainable funding

Longer-term funding commitments are essential to retain qualified staff, build trust with clients, and develop meaningful community relationships.

Medication flexibility

Programs need access to a wider range of medications and dosing options to meet diverse client needs, particularly given the high potency of fentanyl in the unregulated supply.

Diverse and client-centred models

Different service delivery models can meet the needs of different populations, suggesting diversified approaches to safer supply are best. Successful programs developed collaborative relationships with other health care providers, housing services, and community organizations, creating seamless referral pathways. Programs that involve people who use drugs (PWUD) in their design and evaluation, ensure services truly meet community needs.

Addressing the evidence needs of decision makers and knowledge users

The team has identified benefits and risks experienced by safer supply programs to date, while considering the impact of the COVID-19 pandemic and the local context.

Key benefits identified

reduced opioid toxicity events
decreased unregulated drug use
fewer emergency department visits and hospitalizations
lower rates of serious infections like endocarditis
improved client outcomes across physical and mental health, quality of life, stability, stigma experiences, and criminal involvement

Risks and challenges

diversion sometimes occurs for various reasons (e.g., compassionate sharing, unmet medication/financial needs)
inadequate prescribed dosing and limited medication options sometimes led some clients to continue using unregulated drugs to manage withdrawal symptoms
existing prescribed opioid medications may not meet the needs of clients with high-frequency fentanyl use

Barriers to service access

requirements for multiple daily visits (particularly for injectable opioid agonist treatment)
operating hours
insufficient program capacity

COVID-19 impacts

catalyzed rapid expansion through emergency Risk Mitigation Guidance and new policies like B.C.'s "Prescribed Safer Supply"
created implementation challenges as restrictions limited client access and enrollment capabilities

Local context matters

programs varied considerably in structure, available medications, access requirements, and integration with wraparound services
programs should be tailored to local needs while ensuring adequate medication options and doses

Remaining knowledge gaps

long-term safety and effectiveness comparisons with standard opioid agonist treatments
optimal program designs for different contexts
specific client profiles that would most benefit from safer supply interventions

Impacts of local contexts, biological and social determinants and sub-populations on harm reduction interventions

The evaluation revealed significant variations in how local contexts and population characteristics shape safer supply implementation and effectiveness. Programs must adapt to diverse settings while addressing specific needs of vulnerable populations.

Geography and rural access

In rural communities, distance from services, limited transportation options, and restrictive dispensing policies created significant access barriers. Despite these challenges, rural tablet injectable opioid agonist therapy clinics successfully created supportive, friendly environments that contrasted with typically stigmatizing health care experiences elsewhere.

Cultural appropriateness and equity gaps

There are concerning gaps in culturally appropriate, equitable approaches.

Indigenous Populations: Culturally informed approaches that recognize historical trauma and Indigenous-specific contexts are needed, but little evidence is available regarding whether these have been effectively implemented.
African, Caribbean and Black Communities: There is limited evidence addressing how safer supply programs respond to the needs of African, Caribbean, and Black PWUD, despite their disproportionate substance-related harms in settings such as Toronto. This mirrors broader patterns where marginalized communities face both higher risks and reduced access to innovative interventions.

Gender-specific needs

Research has not sufficiently examined gender-specific considerations and outcomes, despite well-documented differences in substance use patterns, treatment barriers, and service engagement between men and women.

Housing status and wraparound services

Evidence shows improved outcomes when safer supply programs integrated housing supports. Programs offering wraparound services addressing social determinants demonstrated higher retention rates and improved health outcomes than medication-only approaches.

Considerations for strengthening future harm reduction intervention evaluations

Population estimates

Developing accurate population size estimates of PWUD is essential for effective policy planning. Despite growing recognition of drug-related harms, Canada lacks precise data on the number and composition of PWUD nationwide. These estimates could help evaluate intervention effectiveness, identify key sub-populations requiring targeted approaches, and inform resource allocation.

Early standardization of metrics

It is critical to establish standardized metrics and evaluation outcomes from the very beginning of harm reduction implementation. Standardization efforts were initiated only in the last year of the evaluation, after programs had already established diverse tracking systems and were considering potential closures. This delayed approach made pivoting toward standardized data collection exceedingly difficult and created substantial challenges for meaningful cross-program and cross-provincial comparisons. Programs collected different outcome measures using varied methods, making it difficult to determine whether observed differences reflected actual effectiveness. Without early agreement on core metrics, some programs missed opportunities to track outcomes that later proved essential, and complicated resource allocation decisions, as funders lacked comparable data to identify promising approaches. Future initiatives would benefit from early investment in the collaborative development of standardized evaluation frameworks, co-created with program implementers, researchers, people with lived and living experience (PWLLE), and policy makers.

Advancing evidence-informed practices through knowledge dissemination activities

Adaptive knowledge synthesis

To keep up with the fast-changing evidence in this field, the team has developed an adaptive knowledge synthesis framework. This tool captures emerging findings from various programs across Canada, translating research into practice using strategic communication approaches for diverse interest-holder groups.

Knowledge dissemination activities

Using approaches tailored to the needs and engagement styles of specific audiences, knowledge dissemination activities for this project have included:

Open-access peer-reviewed publications
Scientific conference presentations
Program-specific reports summarizing noteworthy safer supply findings as they emerge
Establishment of direct engagement channels with policy makers and practitioners
Presentation of safer supply outcomes data to diverse audiences, including the public, health care providers, PWLLE, policy makers, and researchers
Working with the National Safer Supply Community of Practice, which is a vital platform for sharing findings with frontline safer supply practitioners across Canada. This partnership helped create collaborative networks to accelerate the adoption of evidence-informed approaches in real-world settings and ensure that emerging best practices reached those implementing safer supply programs across diverse communities.

Cross-disciplinary collaborations and engagement with decision makers to inform drug policy

The team worked across all Canadian regions where evaluated programs operated, ensuring that research and analysis remained grounded in diverse local contexts.

Interdisciplinary approach

Team members brought a wide range of complementary expertise in quantitative and qualitative methods, administrative data analysis, policy analysis, community-based research, implementation science, and knowledge mobilization. This mix enabled a broad and comprehensive examination of safer supply initiatives through multiple lenses.

Centring lived and Indigenous expertise

The team integrated established and emerging researchers with people who had lived experience of substance use and safer supply, as well as Indigenous scholars and leaders. Combining lived experiences with academic expertise strengthened the project's ability to analyze complex issues while keeping the work relevant to the communities most affected by drug policies.

Policy engagement

Ongoing dialogues with key policy makers helped ensure research findings informed real-time policy discussions. Policy makers that were engaged included: Toronto Public Health, Ontario Ministry of Health, BC Auditor General's office, Canadian Centre on Substance Use and Addiction, BC Centre on Disease Control, BC Centre on Substance Use, Ontario Drug Policy Research Network, Canadian Research Initiative on Substance Matters, and provincial mental health ministries.

International contributions

Internationally, the team's work contributed to global dialogue through policy briefs to the United Nations documenting the impacts of Canadian safer supply initiatives as well as safer supply panels in international harm reduction and substance use conferences.

Selected knowledge mobilization

For more information

Additional information about this project can be found on the knowledge mobilization page of CIHR's Research in Substance Use initiative.

More information on CIHR's Research in Substance Use initiative can be found online or email rsu-rst@cihr-irsc.gc.ca.

For more information, visit CIHR's Institute of Neurosciences, Mental Health and Addiction or email inmha-insmt@cihr-irsc.gc.ca.

Date modified:: 2025-05-26