Safer pharmaceutical alternatives to unregulated drug supply: A scoping review and concept analysis.
Background: Providing pharmaceutical-grade medications as an alternative to the unregulated drug market (i.e., safer supply) has emerged as a harm reduction strategy in response to elevated overdose mortality in Canada. The principles and implementation of this approach can vary widely. We aimed to summarize the literature and describe models of safer supply for people with substance use disorder or at high risk of drug-related harms.
Methods: We searched five major online databases and the gray literature for articles on safer supply. Models of safer supply were characterized based on their specific features, including delivery setting, medications offered, intended population, and outcomes assessed. Using Walker and Avant’s concept analysis methodology, we extracted definitions and descriptions surrounding the concept of safer supply. Intervention characteristics and unique attributes from the definitions were thematically organized into dimensions, leading to a framework that clarifies boundaries between the different models.
Results: We included 234 articles: 167 (71%) empirical and 67 (29%) non-empirical (i.e., perspectives, commentaries) works on safer supply. Of the empirical articles, 117 (70%) evaluated alternative substance use treatments (e.g., injectable opioid agonist treatments), 42 (25%) focused on harm reduction-oriented substance use management (e.g., standard OAT with short acting opioids), and 8 (5%) on harm reduction strategies (e.g., fentanyl patch, vending machine, buyers’ club). Of the 50 empirical works on harm reduction-oriented substance use management and strategies, 23 (46%) employed qualitative research methods. Twenty-five unique safer supply interventions were identified, predominantly in North America, of which 24 (96%) involved a prescriber and 16 (64%) involved short-acting opioids prescribed in tandem with long-acting opioid agonists. Characteristics and attributes extracted from the safer supply interventions were grouped into the following dimensions: 1) Philosophy of care (i.e., alternative substance use treatment vs. harm reduction-oriented substance use treatments vs. harm reduction strategies), 2) Accessibility points (i.e., via a prescriber or from a compassion club), 3) Intervention protocol (i.e., settings and medications offered), 4) Continuity of care (i.e., level of engagement in comprehensive care), and 5) Indications (i.e., for people with substance use disorder and/or people who use drugs).
Conclusions: This scoping review and concept analysis of safer supply facilitates a nuanced understanding of the various dimensions and implications surrounding the philosophy of care and delivery of this intervention, offering valuable contributions to the ongoing discourse on this topic. In summary, this work is a needed step toward the integration of this promising strategy into future evidence-based research strategies, guidelines, and policy decisions on substance use management.
