Overall, the proportion of HRCS respondents who received PSS is low, suggesting that PSS is not reaching all those in need in BC. PSS medications included in this study were prescribed opioids, stimulants, and benzodiazepines, which reflected alternatives to the substances that are commonly used by people who access the unregulated drug supply. In the present study, more than 70% of the sample reported the use of illegal opioids in the prior three days, and nearly 90% reported use of illegal stimulants in the prior three days. While interventions to reduce illegal drug toxicity deaths in BC have primarily been focused on opioid use (e.g. distribution of naloxone, increased opioid agonist treatment options)(11, 12), we found that stimulant use was even more prevalent than opioid use in this sample. Nevertheless, most of PSS prescriptions identified in this sample were for opioid PSS (68%) while a smaller proportion of people received a stimulant PSS prescription (33%). This highlights the need for increased attention to the health and service needs of people who use stimulants either alone or in combination with opioids. This attention must include considerations for expanding the available stimulant PSS options, and incorporating a range of PSS options that more closely match the preferences of people who use illegal stimulants(13).
This is particularly important where existing studies have demonstrated that the available PSS might not match patient preferences for the potency or route of administration(14, 15). As such, a broader range of medication sub-types might be required to be prescribed, and advocacy for such expansion is ongoing(15–18). However, in the absence of currently available alternatives, PSS medications available to date have been demonstrated to have benefits in several areas of clients’ lives. For example, studies have demonstrated that access to prescribed tablet hydromorphone for people using illegal opioids reduced overdose risk, provided improvements in health and well-being, improved pain management, and led to economic improvements (19).
While not implemented under the direct framework of PSS, medications being proposed for expansion as part of PSS have a plethora of evidence to support them, from which expectations of the potential benefits of expansion of the medications can be derived. For example, there is long-standing evidence that injectable diacetylmorphine is a safe and effective treatment for opioid use disorder, and is associated with improvements in health, crime, and psychosocial outcomes(20–23). It is important however to acknowledge that to date, evidence for this medication is derived from a clinical setting, where patients visit a clinic daily, which may be seen as a barrier to engagement for some people. Nevertheless, this treatment setting also comes along with shared decision-making, where patients have a choice regarding preferred medications and dose received(24), which are considerations that should be accounted for when considering the potential of PSS to meet the needs of those it is meant to serve.
While access to preferred versions of PSS is needed to support separation from the illicit drug supply, the rapid expansion of a wider range of medications to meet preferences via PSS has not yet occurred. In the absence of broadly available PSS options however, there may still be a role for currently available options. For example, in a study of patient preferences in injectable OAT, more than 80% of patients preferred diacetylmorphine over hydromorphone, but more than 80% also said they would still take hydromorphone if diacetylmorphine was not available (25). The lack of action on expansion of PSS options should not deter the broader implementation of currently available options for those who want them. This expansion can occur recognizing the limitations of these options, without sacrificing continued advocacy for a wider range of options, which could include injectable or inhalable versions of opioids to match growing rates of smoking among people who use drugs in BC (26).
Furthermore, in the absence of expansion of new medications, there are aspects of implementation of currently available medications that could be shifted to better meet needs. For example, a qualitative study of patients receiving dextroamphetamine (prescription psychostimulant) found that patients wanted to receive higher doses, with faster titration, and have access to take-home doses(27). There is growing evidence to support the safety and effectiveness of prescribed psychostimulants when provided in robust doses (> 60mg or more per day)(28). Emerging evidence suggests these doses are often not reached in practice, and some patients will need higher doses than listed in PSS guidance to achieve an effect(16). Prescription psychostimulants may not meet the needs of people who do not want to achieve abstinence, and who are seeking effects similar to those gained from the use of cocaine or methamphetamine, highlighting the urgency and need for expansion of alternative PSS options. Such alternatives could include medications like Desoxyn (prescribed methamphetamine) and drugs available through non-prescribed safer supply models.
We found that more than 60% of the sample reported the use of both opioids and stimulants, reflecting high rates of co-use of these substances, which have been reported more widely in population-level samples in BC, Canada, and North America(29–33). People are known to have a range of motivations for co-use (34) and to practice strategies to protect from harm (35), nevertheless the risk of harm persists given the rising toxicity of the unregulated drug supply in BC (36). Despite this co-use being common, only 30% of people who received an opioid PSS prescription in this study also received a stimulant PSS prescription. This highlights the need for increased resources for people who engage in polysubstance use and more efforts to determine how concurrent use of stimulants and opioids can be addressed through a combination of PSS and adjacent harm reduction and substance use treatment services that meet client goals. Harm reduction services and broader health system contact is particularly important for this population, given studies have identified elevated risk of a number chronic disease diagnoses for people with concurrent opioid and stimulant use disorders (37), and co-use of opioids and stimulants has been associated with increased risk of infectious disease (38).
In this study, we identified contact with DCS or OPS in the prior six months was associated with access to PSS. Prior studies have similarly identified that people who are more regularly engaged in services are more likely to access PSS. For example, a study of clients receiving opioid PSS identified that those who were receiving mental health medications, and those who were engaged in OAT had higher odds of PSS adherence (39). Similarly, OAT has been identified as a predictor of PSS awareness among people who use unregulated drugs in BC (40). Finding may reflect the important role people working at OPS and DCS sites play in connecting clients to ancillary harm reduction and treatment services such as PSS. The role of people with lived and living experience of substance use in overdose response in BC must be acknowledged, where many DCS and OPS services rely on the expertise and leadership of people working in what are often termed “Peer worker” roles(41–44). Studies have demonstrated that Peer workers rely on their informal roles and social networks to develop a sense of trust and safety that cannot be met by non-peer staff(45). Scaling up of programs that rely on Peer Workers may support increased harm reduction service connection and may support referral to and engagement with PSS.
Findings of this study suggest that additional outreach strategies and service models are needed to reach people who are not already connected to services and to improve the accessibility of harm reduction services (i.e. increased service hours, and reduced wait lists). In this study we found that rates of access to PSS were higher in Northern Health, as compared to other Health Authorities. Regional differences identified in this study are not representative of provincial trends; however they do highlight the efforts in specific communities to reach and engage people at harm reduction sites with access to PSS. For example, the high rates of PSS access in Northern Health are understood to be attributable to a peer-led model in this health region, in which a person with lived experience of substance use supports clients to connect to a PSS prescriber and facilitates medication access through a low-barrier medication delivery program (46).
Interventions such as this peer-led program can serve as a model that can be implemented in other settings across the province to adopt responses to better meet and reach the needs of people at risk of overdose. Such an approach would reflect responsiveness to the needs of the community during dual public health crises. A recent environmental scan of PSS programs in BC has reflected that such flexibility is possible and has identified that changes to service provision have been significant since PSS was first introduced in March 2020 (47). For example, the scan identified several examples of changes to staffing, physical spaces, program operations, and client protocols in PSS programs, with the primary goal of reducing COVID-19 infection and overdose risk. These high rates of adaptation demonstrate that health system changes are possible to promote client connections to PSS in BC. Such changes could be implemented to reach clients who remain the least engaged in care, including people accessing harm reduction services, where PSS rates remain low, and for people who are disconnected from both harm reduction and treatment services in in the province.