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Key messages
- Health care providers care about the people and communities they serve. They use clinical guidance and research to decide how to provide care.
- If you have questions or concerns about safer supply programs, we want to know.
- What we know today:
- Prescribed safer supply is not contributing to opioid-related deaths.
- There are no indications that youth are experiencing harms from diverted prescribed safer supply drugs.
- Prescribed safer supply is saving lives and improving people’s quality of life.
- There is a lot of research being done on safer supply, including community impact.
- Currently, there are only 26 programs funded to provide safer supply across Canada and these programs serve only people who are at highest risk of harm from the unregulated drug supply.
- An expanded continuum of care that includes harm reduction-based safer supply and addictions treatment approaches will better serve the diverse needs of people who use drugs.
Contents
What is prescribed safer opioid supply?
What are the goals of prescribed safer supply?
Who gets prescribed safer supply?
What safer supply drugs are prescribed? How do they get them? Are they free?
How do people use their safer supply DilaudidⓇ?
Are there risks of infection from injecting tablets?
Why are Dilaudid® tablets prescribed if they aren’t meant to be injected?
What information do clients receive about how to use their medications?
How do programs try to prevent diversion?
What happens if diversion is suspected?
Is there evidence that diversion is creating harm in communities?
Doesn’t funding safer supply mean that there is less funding for addictions treatment?
Where can I find more information?
What is prescribed safer opioid supply?
People are prescribed Dilaudid® and long-acting morphine to replace street drugs.
- Doctors and nurse practitioners in the community prescribe opioids to replace the unpredictable street supply of drugs. They prescribe oral hydromorphone (Dilaudid®) pills and usually also a long acting ‘backbone’ slow-release oral morphine (Kadian® or M-Eslon®) or methadone.
- Emerging evidence shows that prescribed safer supply saves lives and improves quality of life.
What are the goals of prescribed safer supply?
The goals are to reduce people’s overdose risk from the unpredictable and very strong street supply, to reduce harms related to injection drug use and to improve the health of clients.
- The illegal street supply is unregulated. This means that the quality and strength of street drugs are unknown and therefore dangerous. This is why people are at high risk of overdose from street drugs.
- Prescribed safer supply uses long-established, evidence-based harm reduction models.
- Prescribed safer supply does not force people to use less drugs or to quit using drugs.
- Prescribed safer supply helps people stay well, stabilize, and work toward their own goals.
Who gets prescribed safer supply?
Safer supply is only for adults who are diagnosed as having opioid use disorder, who use street drugs, and who are at very high risk of overdose or other harms related to injection drug use.
- Prescribed safer supply is not for people who are new to opioids. It is a harm reduction approach for adults who already rely on the unregulated drug supply.
- People on prescribed safer supply have already tried other treatments and they didn’t work for them.
- There is no evidence that shows that prescribed safer supply is being sold to children.
What safer supply drugs are prescribed? How do they get them? Are they free?
People get both short-acting and long-acting opioids. Most people have drug benefits or they pay for them directly.
- Most prescribed safer supply clients receive short acting hydromorphone (Dilaudid®).
- Dilaudid® is dispensed daily. Most clients pick up a one day supply from the pharmacy to take home and use throughout the day and night. This means they do not have to go to the pharmacy many times each day. They have time to do other things, such as work, school, or hobbies.
- Some clients take all their Dilaudid® at the pharmacy. This happens when someone is at high risk of having their Dilaudid® lost or stolen or if there is concern about diversion. It also happens when someone has health problems that make taking opioids more dangerous.
- Most clients also get slow-release oral morphine (Kadian® or M-Eslon®) or methadone. These are both long acting opioids that last for 12-24 hours. They can help manage pain and prevent withdrawal.
- People take their methadone and / or slow-release oral morphine at the pharmacy each day. The pharmacist watches them take it.
How do people use their safer supply DilaudidⓇ?
Some people swallow their Dilaudid® pills. Some people inject them.
Are there risks of infection from injecting tablets?
- Yes, all injections - medical or recreational - have risks. Risks are minimized when people are taught safe injection practices and given proper sterile equipment.
- Potential health issues include:
- Skin and soft tissue injuries (e.g., skin ulcers, cellulitis)
- Lung, heart, and other conditions related to blood vessels (e.g., blood clots, endocarditis)
- Local and generalized infections (e.g., abscesses around injection site)
- Pills are not meant to be injected. They contain non-medicinal ingredients that can be harmful when injected – especially pills that contain gels or coatings, like time-released medications.
- Short acting hydromorphone tablets (i.e., not time released) have fewer and less harmful non-medicinal ingredients than long acting ones. Brand name Dilaudid® is prescribed because it has been found to have less residue when prepared for injection.
- Slow-release morphine (brand names Kadian® or M-Eslon®) is given to clients as an observed dose because it has higher risks of infection due to the ingredients that control the release of the drug over time. When clients achieve stability, these drugs are sometimes given as take-home doses.
- Current evidence shows that there was a decrease in hospitalizations for infectious complications among prescribed safer supply clients.
Why are Dilaudid® tablets prescribed if they aren’t meant to be injected?
- Most provincial or territorial drug benefit plans do not cover injectable hydromorphone at the necessary strengths. Dilaudid® (hydromorphone) tablets are covered.
- Short acting Dilaudid® tablets have less risk due to fewer non-medicinal ingredients than long acting medications. The risks of a prescribed medication is less than the risks associated with unregulated drugs which have unknown ingredients and unpredictable strength.
- We need drug benefit plans to include injectable high potency formulations of hydromorphone.
What information do clients receive about how to use their medications?
- Clients are taught the best and safest way to inject. They are provided with sterile injection equipment.
- They are taught about the warning signs of infection and the importance of seeing their health care provider immediately if they think they may have an infection.
- Clients are told about the dangers of opioids to people who have never used them before and the importance of keeping their medication safe.
- Clients sign a consent and agreement form to say that they understand the risks of injection and the expectations for being a client, including that they will be discharged if they divert (e.g., sell, share) their medications.
How does Dilaudid® (hydromorphone) compare to fentanyl from the unregulated street supply? Is it truly “safe”?
- No opioids are entirely safe. All opioids carry risks of overdose and risks of dependency.
- Dilaudids® are safer than street opioids because we know the strength of Dilaudid® and what’s in it.
- Dilaudid® provides similar pain relief and euphoria to heroin and fentanyl.
- How many Dilaudids® people take each day varies from client to client. Most programs have a maximum of 30 tablets per day, depending on the local unregulated drug supply
What about diversion?
Diversion is when someone shares or sells their medications to other people.
- There is no evidence that prescribed hydromorphone (i.e., Dilaudid®) is contributing to drug-related deaths (British Columbia Coroners Office, 2023; Public Health Ontario, 2023).
- There is no evidence that the diversion of prescribed hydromorphone is occurring in schoolyards or encouraging people to start using or re-using opioids. (British Columbia Coroners Office, 2023)
- Prescribed safer supply programs follow evidence. We know diversion happens (like with all medications) and so far, there is no evidence that diversion is causing harm in communities.
- If research shows that there are community harms, programs will develop new strategies to ensure community safety and wellness, as needed and indicated. Safer supply providers care about the community.
Why does diversion happen?
- Diversion happens with all medications, including methadone, suboxone, pain medications, antibiotics, ADHD medications, sleeping pills, etc. This is not unique to prescribed safer supply medications. Diversion frequently happens between friends and family members, often in the context of caring.
- Sometimes people share their medications to help someone in withdrawal or to prevent someone from using drugs from the toxic street supply. If more people could access safer supply, people might not need to share.
- Sometimes people sell or trade their medications for food, a place to sleep, or stronger drugs. By making sure that people have access to food, shelter, and the right medication and dose, diversion might not be necessary.
How do programs try to prevent diversion?
- All clients are told that diversion is a reason to require observed dosing or even discharge someone from the program because of the risks to the community.
- All clients do urine tests to make sure that they are taking the medications that they are prescribed.
- All clients are told how to keep their medications safe from loss or theft, like using lockboxes.
- Doctors and nurse practitioners try to make sure that people are getting the medication and dose that they need.
- Social services work with clients to help them get food, income, and a safe place to sleep, when possible. We need safe housing for people.
What happens if diversion is suspected?
- First, doctors and nurse practitioners talk to the client about why they are diverting medications and try to address the reason, when possible.
- The client might be required to have all of their medications observed at the pharmacy.
- If it is clear that someone is not taking their medications, they are discharged from the program.
Is there evidence that diversion is creating harm in communities?
- According to the BC Coroner’s Office:
- There is no evidence that prescribed hydromorphone is causing overdose deaths.
- There is no evidence that youth are experiencing harms from prescribed safer supply medications.
- There is no evidence that shows that prescribed safer supply medications are encouraging people to start using or re-using opioids.
- There are enormous amounts of evidence that shows that the powerful, unpredictable unregulated street supply is killing people.
Doesn’t funding safer supply mean that there is less funding for addictions treatment?
- Funding is a political decision and should never be a zero-sum game.
- We need increased funding for both harm reduction-based safer supply and addictions treatment. An expanded continuum of care that includes both will better serve the diverse needs of people who use drugs.
Where can I find more information?
- National Safer Supply Community of Practice
- Health Canada
- Canadian Association of People Who Use Drugs
Glossary
| Buprenorphine | Buprenorphine is a long-acting opioid medication used to treat pain and opioid dependency. Buprenorphine, when combined with naloxone, is usually provided as a pill that is absorbed under the tongue (i.e.: sublingual). The effects of buprenorphine can last for 12 to 36 hours. The most commonly prescribed brand name of buprenorphine is Suboxone®. |
| Dilaudid® | The most commonly prescribed brand name of hydromorphone is Dilaudid®. |
| Diversion | Diversion is when someone repurposes, shares, or sells their prescribed medications to other people. It can also occur if prescribed medications are lost or stolen. |
| Hydromorphone | Hydromorphone is an opioid medication that treats pain by blocking pain signals in the brain. It is in a class of medications called opioid analgesics. The most commonly prescribed brand name of hydromorphone is Dilaudid®. |
| Kadian® | The most commonly prescribed brand name of slow-release oral morphine is Kadian®, a 24-hour extended-release medication taken once daily. |
| Slow-release oral morphine (SROM) | Slow-release oral morphine (SROM) is extended-release, long acting opioid medication that treats pain by blocking pain signals in the brain. It is in a class of medications called opioid analgesics. SROM is available in twice-daily 12-hour and once-daily 24-hour extended-release formulations. |
| M-Eslon® | Another commonly prescribed slow-release medication is an oral morphine sulfate formulation known under the brand name M-Eslon®. This is a slow-release oral morphine 12-hour sustained-release medication taken twice-daily. |
| Methadone | Methadone is a long-acting opioid medication used to treat pain and opioid dependency. Methadone is available as a tablet or oral/liquid solution (often mixed in a flavored drink) generally taken once-daily. The effects of methadone can last for 12 to 36 hours. |
| Observed dose | An observed dose refers to a dose of medication that is consumed (e.g., ingested, injected) in the presence of a registered health care provider (i.e.: witnessed or observed dose). |
| Opioid | Opioids are a family of drugs that are prescribed to relieve pain, control coughs and diarrhea, and treat dependency to other opioids. |
| Overdose | Overdose happens when a toxic amount of a drug, or combination of drugs, overwhelms the body. Opioid overdoses happen when there are too many opioids or a combination of opioids and other drugs in the body that the person is not responsive to stimulation and/or breathing is inadequate. |
| Prescribed safer supply | Prescribed safer supply extends long established harm reduction models and aims to provide an alternative to the unpredictable unregulated street supply. Doctors and nurse practitioners in the community prescribe opioids to replace the unpredictable street supply of drugs. They prescribe oral hydromorphone (Dilaudid®) pills and usually also slow-release oral morphine (Kadian® or M-Eslon®) “backbones,” to replace the toxic supply that people must otherwise rely on. |
| Regulated drug supply | This refers to the establishment, regulation, management, and distribution of drugs of known quantity, quality, and potency by the government and/or by a regulated supplier. Regulated drug supply provides an alternative to the unpredictable unregulated street supply. Alcohol and prescription medications are examples of substances that are available through a regulated supply. |
| Street supply | This refers to the unregulated drug supply circulating communities. It is also known as the illegal, illicit, or black drug market. |
| Suboxone® | The most commonly prescribed brand name of buprenorphine is Suboxone®. |
| Take home dose(s) | Take home doses or “carries” refer to doses of prescribed medications provided to clients to take as needed throughout the day. |
| Unregulated drug supply | This refers to the unpredictable street supply currently circulating communities, also known as the illegal, illicit, or black drug market. Because the street supply is not regulated, the unregulated supply often contains lethal contaminants, harmful fillers/buffers, and other toxins, causing overdose and death. |
| Withdrawal | Withdrawal from opioids, stimulants, and other drugs and medications can occur any time long-term use is stopped or cut back. Opioid withdrawal is a life-threatening condition resulting from opioid dependence. Withdrawal symptoms include insomnia, muscle aches, nausea, fever, sweating, vomiting, and diarrhea. |
References cited
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About this document
This FAQ was developed by the National Safer Supply Community of Practice (NSS-CoP). Please visit https://www.nss-aps.ca/ to learn more.
Contributors: Rebecca Penn (concept, writing, editing), Alexandra Holtom (writing, editing), Robyn Kalda (writing, editing)
Suggested Citation: National Safer Supply Community of Practice. (2023). Prescribed Safer Supply: Frequently Asked Questions. Canada. https://www.nss-aps.ca/pss-faq
Version: 13 June 2023
Production of this document has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada.
Released under a Creative Commons – Attribution – Noncommercial license
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