- Many people who use drugs have fatally overdosed due to the poisoned drug supply
- Researchers reviewed a pilot program that provided supportive housing with supervised drug use and other services
- Combining those services had a positive impact on the health of people who use drugs
In the past eight years, increasing contamination of the supply of street drugs has led to a massive and sustained increase in overdoses, many of which are fatal.
A community-based agency called Ottawa Inner City Health provides services related to healthcare, housing and psychosocial needs of people experiencing homelessness.
In 2017, the agency established a pilot program of supervised injectable and oral opioids, using hydromorphone (Dilaudid). The program also included supportive housing and other services.
Researchers at the University of Ottawa and other academic institutions in Canada and the U.S. evaluated the health and other outcomes of people who were enrolled in the first year of the pilot program.
A total of 26 participants were enrolled, all of whom had a history of severe opioid use disorder and ongoing mental health issues. In addition, many participants used other substances such as alcohol and stimulants.
While in the program, none of the participants overdosed or died. One year after participants entered the program, researchers found the following:
- the use of non-prescribed opioids fell significantly
- about 96% of participants connected to psychological support services
- 31% of participants became employed or entered a training or educational program
After the first year, 77% of participants continued on in the program.
The study has found encouraging results on the health of people with severe opioid use disorder when supervised provision of opioids was combined with supportive housing and additional care.
Study details
People who were eligible for entering the program fit the following criteria:
- had severe opioid use disorder
- had previously used prescribed opioid substitution medicines such as buprenorphine and/or methadone and/or slow-release oral morphine
- were injecting non-prescribed opioids
- were experiencing homelessness
The average profile of the 26 participants upon study entry was as follows:
- age – 36 years
- 46% men, 54% women
- major ethno-racial groups: White – 85%; Indigenous – 12%
- 96% had stimulant use disorder
- 31% had alcohol use disorder
- 73% experienced complications from injecting drugs
- 92% had hepatitis C virus infection (HCV)
- 31% had HIV infection
Results
The dose of prescribed opioids was gradually increased over time; this was a planned outcome.
The researchers stated that “most participants started on oral extended-release hydromorphone rather than slow-release oral morphine.”
The researchers noted that one participant “was prescribed only oral hydromorphone and chose to crush and inject his tablets, under observation, rather than take them by mouth or use the injectable hydromorphone formulation offered.”
Survival
None of the participants died while enrolled in the program. Two people died two weeks after leaving the program. Most people (nearly 60%) who left the program did not experience overdoses within 12 months of leaving. The researchers stated that based on records of overdoses in Ottawa in the year prior to entering the study, this reduction in overdoses during the pilot program was significant.
Changes in use of non-prescribed opioids and other drugs
Over the course of the study, the percentage of people using non-prescribed opioids decreased to 55% (by month 12). However, the researchers noted that there was no parallel reduction in the use of stimulants. This latter finding should not be surprising, as other studies have found a similar trend among people who use both opioids and stimulants.
Treatment and prevention of chronic viral infections
In addition to providing prescription opioids and supportive housing, the program also provided referrals for other aspects of health and well-being. For instance, the researchers found that most (seven out of eight) of the participants with HIV were able to start or restart HIV treatment.
Three other people were given HIV post-exposure prophylaxis (PEP) to prevent chronic HIV infection.
There were 24 people with hepatitis C virus who entered the program. No other people became infected with this virus while in the program. Six people with HCV initiated treatment for this virus.
Mental health treatment
The researchers stated that while in the program, 88% of participants started (or restarted) treatment for mental health conditions and 65% were connected to psychological support services.
Other outcomes
The researchers found that after participants entered the program and stabilized their health and lives, 42% of them “reconnected with estranged family and 31% started a work, volunteer or educational program.”
For the future
The results of the present study are in line with published results from other studies that assess drug treatment and/or harm reduction programs. In some cases, the present study’s findings of retention in care are better because of the combination of housing, drug treatment and other services provided.
However, much more needs to be done to help reduce harm from drug use. The researchers encouraged other supervised drug treatment programs to “consider integrating evidence-based approaches for stimulant use disorder treatment.”
The researchers found that prescribing opioids is safe and effective in a setting of comprehensive care, supportive housing and other services. They stated:
“Given the ongoing, rising overdose crisis globally and particularly across North America, countries whose policies prohibit offering injectable opioid agonist treatment should urgently move to liberalize opioid use disorder treatment options.”
They added that “further policy changes needed to facilitate access within Canada include increasing the availability of high-concentration hydromorphone formulations, and treatment coverage under provincial drug benefits. Additionally, the housing-first approach of the [Ottawa program] demonstrates the utility of combining housing with substance use treatment and other wrap-around services […]. Policy makers should prioritize increasing housing-first models that include prevention services, such as embedded supervised consumption spaces or injectable opioid treatment programs.”
—Sean R. Hosein
REFERENCE:
- Harris MT, Seliga RK, Fairbairn N, et al. Outcomes of Ottawa, Canada’s Managed Opioid Program (MOP) where supervised injectable hydromorphone was paired with assisted housing. International Journal of Drug Policy. 2021 Dec; 98:103400.
- Fischer B, O’Keefe-Markman C, Lee AM, et al. ‘Resurgent,’ ‘twin’ or ‘silent’ epidemic? A select data overview and observations on increasing psycho-stimulant use and harms in North America. Substance Abuse Treatment, Prevention, and Policy. 2021 Feb 15;16(1):17.
- Imtiaz S, Shield KD, Fischer B, et al. Recent changes in trends of opioid overdose deaths in North America. Substance Abuse Treatment, Prevention, and Policy. 2020 Aug 31;15(1):66.