The Safer Alternatives for Emergency Response (SAFER) program is a safer supply program that offers a range of prescribed pharmaceutical-grade medication alternatives of known content, quantity, quality and potency (e.g., short-acting hydromorphone, fentanyl patches) as an alternative to the toxic unregulated drug supply. Findings from a recent qualitative study with individuals who have used prescribed fentanyl patches through this program demonstrate that it reduces exposure to the toxic unregulated drug supply, subsequently decreasing overdose risk and drug-related harms. The results suggest that there is value in integrating fentanyl patch safer supply into the spectrum of substance use services.1
Program description1,2
SAFER is a prescribed safer supply program based in the Downtown Eastside neighborhood of Vancouver, BC, operated by PHS Community Services Society in partnership with Vancouver Coastal Health. The main goal of the program is to reduce overdose risk and drug-related harms by decreasing people’s reliance on the unregulated drug supply, as well as to serve as a low-barrier point of access to wraparound health and social services and supports. The program strives to acknowledge participant autonomy and to facilitate access to a robust continuum of substance use services aligned with participant-defined goals.
The SAFER program is run by an interdisciplinary team of physicians, nurses, pharmacists, social workers and people with living and lived experience of substance use. As a collaborative team, they provide integrated harm reduction, public health, substance use treatment and social services to program participants. The program is embedded within health and social services, offering participants access to on-site primary care from staff trained in substance use care and medicine. Also available on-site is a low-barrier overdose prevention site where participants can access harm reduction materials (e.g., syringes, cookers, pipes), take-home naloxone kits and drug checking services.
The SAFER program is designed for participants who are diagnosed with opioid use disorder (OUD), who use toxic unregulated drugs and who are at very high risk of overdose or other drug-related harms. Eligibility for the SAFER program is based on a participant’s ongoing substance use and their vulnerability to associated drug-related harms. To be eligible for a fentanyl patch, participants must be diagnosed with OUD and must have previously tried at least two substance use treatment interventions (e.g., oral and/or injectable opioid agonist treatment [OAT], other safer supply medications) but were unable to stabilize because these options did not adequately meet their needs.
The intake process assesses participants to determine appropriate medication options and dosages, to identify other factors that increase the precariousness of their lives and their susceptibility to overdose, infection and other drug-related harms (e.g., pregnancy, young age) and to evaluate their use of multiple substances (e.g., alcohol, stimulants) that may require additional supports and counselling. If an individual is eligible, the SAFER program provides them with no-cost adhesive transdermal fentanyl patches, which can be used alongside or as a replacement for OAT and other safer supply medications (e.g., methadone, slow-release oral morphine, hydromorphone tablets). To minimize risk of mixing and potentially dangerous interactions with other long-acting opioids, doses of oral OAT medications are tapered down, with the aim of prescribing the fentanyl patch alone if it is clinically appropriate for the individual.
Fentanyl patch titration for participants is gradually adjusted on the basis of their previous use of unregulated fentanyl. A gradual titration process is the slow and intentional addition (or decrease) of a substance of a known concentration (i.e., a “titrant”) into a person’s body. While progressing through the titration process, some participants require some short-acting opioids (e.g., tablet hydromorphone, fentanyl powder) to reduce discomfort, cravings and withdrawal symptoms. Generally, the adhesive skin patches are applied and changed by a nurse or pharmacist every three days (e.g., Monday, Wednesday, Friday), with the option of having a patch changed on a Sunday or every two days if requested. Patches are returned at each dose change and examined for damage and tampering.
Results1
The current study was part of a larger ongoing evaluation of the SAFER program. Between February 2022 and May 2023, qualitative interviews were completed with 17 SAFER participants who were actively or previously prescribed the fentanyl patch for any duration of time.
Participants were 35 to 65 years old, with an average age of 47. Twelve participants identified as white, four identified as Indigenous and two identified in another way (participants could select more than one response). Of the 17 participants, 10 identified as men, five identified as women and two identified by another gender. At the time of the study, nine people (53%) were currently accessing fentanyl patch prescriptions. Eight people (47%) had discontinued their fentanyl prescription and had transitioned to other fentanyl or fentanyl analogue alternatives including fentanyl powder (six people), sufentanil (one person) and tablet fentanyl (one person). As per eligibility criteria, all participants were diagnosed with an OUD and had tried at least two other substance use interventions (e.g., OAT, other safer supply medications) in the past three years.
Three main themes emerged through qualitative thematic analysis.
1. Program accessibility and flexibility
Participants described the SAFER program as more flexible and less taxing than OAT and other safer supply programs. The SAFER fentanyl patch program required fewer clinic visits for witnessed (observed) doses. Additionally, the SAFER program’s flexible missed-dose protocols for fentanyl patches were noted as an important facilitator for participant engagement and retention (e.g., up to 16 days could pass before a titration restart was required). Participants reported that this greater flexibility and convenience made it easier for them to follow the program, enhancing their continued participation and autonomy.
2. Improved stability, health and well-being
Having dependable access to a safer pharmaceutical-grade fentanyl alternative allowed participants to reduce their reliance on the toxic unregulated drug supply and their overdose risk. Participants reported that the program facilitated substantial reductions in withdrawal symptoms and cravings and that they felt safer and more in control of their drug use. Participants also reported that access to a prescribed safer supply reduced their exposure to other contaminants and substances in the unregulated drug supply (e.g., benzodiazepines).
“And in this program, at least I know I’m taking fentanyl and not benzo fentanyl, you know what I mean? And that I know that what I’m taking is not going to kill me, or lie to me and say that, like, you know, like benzo dope, and get myself addicted to benzo also, you know?...It’s a nice feeling when you can control what’s going on in your body.”
By having consistent access to an effective and no-cost prescribed substitute, participants reported they engaged in fewer criminalized activities and decreased their need to purchase unregulated drugs, allowing them to spend their money on other expenses (e.g., housing, food, bills, debts). Several participants reported positive changes in their formal employment (e.g., increased stability while at work) and others shared that they were better able to manage their own health and well-being (e.g., scheduling and attending medical appointments, improved sleep, healthier skin and veins, effective pain management).
3. Program challenges and limitations
Skin irritation and adhesion issues: All participants who left the fentanyl patch program cited skin irritation and adhesion issues as one of their primary reasons for leaving. Participants reported damp skin, yellow and red areas, rashes and a sensation of “claustrophobic” skin that could not “breathe.” Adhesion issues caused by perspiration, especially during warmer months, caused patches to sometimes detach from the skin, significantly decreasing the effects of the patch. This sometimes resulted in accusations of patch diversion by program staff.
Finding the right dose: Participants reported difficulties in finding a comfortable, balanced dose because of the extended length of gradual titration. Some participants reported a gradual titration period of anywhere between five to eight months before reaching an adequate dose while on the patch — much longer than other safer supply medications they had tried. For most participants, finding the right dose meant balancing euphoric effects while effectively managing pain, withdrawal symptoms and cravings.
“Well my street consumption is way down, and yeah, so yeah, that’s good...Before [the patch] any day of the week I was...doing a million tons of drugs in one day and so I’m all over the place. Versus here I — you know, consistent and steady.”
Operational challenges: The main challenge noted by participants was the three-day patch change wait-time between Friday and Monday. Some participants reported that the patches started to lose effect by Sunday, sometimes resulting in increased use of unregulated drugs to manage discomfort and withdrawal symptoms. Some participants were able to request an additional patch change on Sundays and/or to move to a schedule where patches were changed every two days, which helped address this discomfort.
What does this mean for service providers?1
The researchers recommend that to better meet participant needs and support program retention, service providers should consider:
- extending program operating hours to facilitate participant access, avoid missed doses and increase access to wraparound health and social services and supports
- encouraging participant/provider communication about dosing and titration challenges
- exploring the development and provision of high-concentration fentanyl patches that reduce skin discomfort and difficulties with diminishing patch effects between three-day patch change wait-time schedules
- developing flexible dosing schedules for each individual participant and facilitating early and ongoing communication between staff and participants
- pursuing and evaluating other safer supply options (e.g., fentanyl powder) that may better suit the needs and drug consumption mode preferences of program participants (e.g., smoking, injecting, ingesting) to increase the effectiveness of these programs
- considering the importance of pleasure and euphoria in program design, implementation and evaluation to ensure retention
Related resources
CATIE statement on safer supply – CATIE statement
Victoria SAFER Initiative – case study
Safer supply: Current perspectives and evidence – webinar
Prescribed Safer Supply Protocols: Fentanyl Patch – British Columbia Centre on Substance Use (BCCSU)
References
- Norton A, Ivsins A, Holliday E et al. A qualitative evaluation of a fentanyl patch safer supply program in Vancouver, Canada. International Journal of Drug Policy. 2024;131:104547. https://doi.org/10.1016/j.drugpo.2024.104547
- Klaire S, Sutherland C, Kerr T et al. A low-barrier, flexible safe supply program to prevent deaths from overdose. Canadian Medical Association Journal. 2022;194(19):E674-E676. https://doi.org/10.1503/cmaj.211515