Service delivery models for injectable opioid agonist treatment in Canada: 2 sequential environmental scans

Abstract

Background: Injectable opioid agonist treatment (iOAT) is an emerging evidence-based option in the continuum of care for opioid use disorder in parts of Canada. Our study objective was to identify and describe iOAT programs operating during the ongoing opioid overdose crisis. Methods: We conducted 2 sequential environmental scans. Programs were eligible to participate if they were in operation as of Sept. 1, 2018, and Mar. 1, 2019. Information was collected over 2–3 months for each scan (September–October 2018, March–May 2019). Programs that participated in the first scan and newly established programs were invited to participate in the second scan. The scans included questions about location, service delivery model, clinical and operational characteristics, numbers and demographic characteristics of clients, and program barriers and facilitators. Descriptive analysis was performed. Results: We identified 14 unique programs across the 2 scans. Eleven programs located in urban centres in British Columbia and Ontario participated in the first scan. At the time of the second scan, 2 of these programs were on hold and 2 of 3 newly established programs were in Alberta. The total capacity of all participating programs was 420 clients at most. Four service delivery models were identified; iOAT was most commonly integrated within existing health and social services. All programs offered hydromorphone, and 1 program also offered diacetylmorphine. In the first scan, 73% of clients (133/183) were male; the mean age of clients was 47 years. Limited capacity, pharmacy operations and lack of diacetylmorphine access were among the most frequently reported barriers. The most commonly reported facilitators included client-centred care, client relationships and access to other health and social support. Interpretation: Evidence indicates that iOAT can be successfully implemented using diverse service delivery models. Future work should facilitate scale-up of this evidence-based treatment where gaps persist in high-risk communities.

“COVID just kind of opened a can of whoop-ass”: The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada

“…iOAT/TiOAT programs with witnessed consumption are resource-intensive, which partially explains their gradual scale-up (from 11 in 2018 to 19 in 2020) ( Eydt et al., 2020 ). In contrast, the rapid and significant safer supply expansion over two months was likely enabled by lower operational costs (i.e., no requirement for observed dosing) and ease of tailoring to local contexts.…”

“…In contrast, the rapid and significant safer supply expansion over two months was likely enabled by lower operational costs (i.e., no requirement for observed dosing) and ease of tailoring to local contexts. Service delivery models for iOAT/TiOAT in Canada are currently limited to four discrete models, namely: 1) comprehensive, dedicated programs; 2) programs embedded in existing services (5 settings [see Table 3 ]); 3) pharmacy-based (no longer in operation); and 4) hospital-based ( Eydt et al., 2020 ). However, safer supply sites displayed a far broader range of community settings and medication options, as well as less demanding care frequency than iOAT, suggesting greater capacity for versatility in where and how services are provided provi (although this flexibility was only available after SARS-CoV2 exposure at some sites).…”

“…The 9-section survey (up to 61 questions depending on the site's service scope) was adapted from our iOAT scans (Appendix 1) ( Eydt et al., 2020 ) and emailed to participants as a Word document. Questions included requests for quantitative data, as well as open-text responses about program characteristics, changes in response to COVID-19, lessons learned, and barriers, gaps and strengths (see Appendix 1).…”

“…Members of our team from the Canadian Research Initiative in Substance Misuse network began conducting national environmental scans in 2018 to monitor the emergence of evidence-based iOAT for addiction ( Canadian Research Initiative in Substance Misuse [CRISM], 2019b ). iOAT involves supervised dosing of prescribed injectable hydromorphone or diacetylmorphine (i.e., pharmaceutical-grade heroin), typically with access to wrap-around health and social services, to reduce risk of overdose and death ( Eydt et al., 2020 ; Fairbairn et al., 2019 ). Our second scan (conducted in 2019) identified an emerging iOAT adaptation at one of the iOAT programs: supervised tablet-based (TiOAT) hydromorphone taken according to client preference (e.g., intravenously, orally) ( Eydt et al., 2020 ).…”

“…iOAT involves supervised dosing of prescribed injectable hydromorphone or diacetylmorphine (i.e., pharmaceutical-grade heroin), typically with access to wrap-around health and social services, to reduce risk of overdose and death ( Eydt et al., 2020 ; Fairbairn et al., 2019 ). Our second scan (conducted in 2019) identified an emerging iOAT adaptation at one of the iOAT programs: supervised tablet-based (TiOAT) hydromorphone taken according to client preference (e.g., intravenously, orally) ( Eydt et al., 2020 ). This 2020 scan adds safer supply (unsupervised take-home doses) ( Bonn et al., 2020 ) of a wide range of prescribed pharmaceutical medications and other substances (e.g., alcohol), for a more fulsome picture of the changing landscape.…”