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CPSO safer supply amendments (2026)
CPSO documents
CPSO. Special Board Meeting, October 13, 2026 – Board Packages.
CPSO. Professional Obligations – Obligations in Practice: Safer Supply Prescribing.
Letters and statements
2026 CPSO Special Board Meeting on Safer Supply – Public Letters to the Board Members. A Google folder of public letters to the CPSO and to the CNO.
ODPRN. October 30, 2026. CPSO’s safer supply amendments: what does the evidence say?
SUHN’s Letter to the CPSO.
SUHN’s Letter to the CNO.
Ontario Substance Use Health Providers (OSUHP): Press Statement and Open Letter to the CPSO.
Clinical guidance and protocols
Waraksa, M. (NP), Bond, N., Laurence, G., and Atkinson, A. 2022. Safer Opioid Supply Program Protocols. Parkdale Queen West Community Health Centre, Toronto, ON.
AVI Health and Community Services. 2022. Safer Supply Protocols.
Hales, J. (NP), Kolla, G. (PhD), Man, T. (MD), O’Reilly, E. (NP), Rai, N. (MD), Sereda, A. (MD). 2020. Safer Opioid Supply Programs (SOS): A Harm Reduction Informed Guiding Document for Primary Care Teams. Updated 2020.
Research
Evidence briefs, infographics, key reports and slide presentations
ODPRN. October 30, 2026. CPSO’s safer supply amendments: what does the evidence say?
SUHN/NSSCoP. 2025. Prescribed Alternatives Programs: Emerging Evidence.
NSSCoP. 2024. Prescribed Alternatives Programs in Ontario – Briefing Note.
Office of the Provincial Health Officer. 2023. A Review of Prescribed Safer Supply Programs Across British Columbia: Recommendations for Future Action.
Dr. Alice Viranyi. 2024 presentation: An Ethical Analysis of Prescribed Safer Supply in BC, and Dr. Daniel Buchman. 2024 presentation: Prescribed Safer Supply: A Public Health Ethics Framework.
Viranyi presentation (PDF) →Buchman presentation (PDF) →View webinar on ethics of safer supply →
ODPRN. 2023. Safer Opioid Supply: A Rapid Review of the Evidence.
Death Review Panel. 2023. BC Coroners Service Death Review Panel: An Urgent Response to a Continuing Crisis.
Key peer-reviewed research studies on safer supply, grouped by topic.
Clinical outcomes and prescribing
Kolla, G., Lewis, J-L., Guta, A., Schaff, A., Boyle, M., King, K., Strike, C., Karamouzian, M. (2026). Reduced risk of overdose among clients of a safer opioid supply program in Southwestern Ontario: A pre-post observational cohort study. International Journal of Drug Policy, 148, 105124. https://doi.org/10.1016/j.drugpo.2025.105124
Key findings
From data analyzed from a pre-post observational cohort of clients enrolled in an SOS program from 2021–2023:
- Overdose prevalence decreased significantly from 60% to 15%.
- Overdose incidence declined from 48.5 to 3.3 per 100 person-months.
- After adjusting for confounders, participants had 83% lower odds of overdose during follow-up (aOR 0.17, 95% CI: 0.08–0.38).
Gomes, T., McCormack, D., Kolla, G., Young, S., Bayoumi, A. M., Smoke, A., Li, P., & Antoniou, T. (2025). Comparing the effects of prescribed safer opioid supply and methadone in Ontario, Canada: A population-based matched cohort study. The Lancet Public Health, 10(5), e412–e421.
Key findings
- Matched 856 safer supply initiators to 856 methadone initiators.
- Safer supply clients were more clinically complex at baseline.
- Both groups had significant improvements after starting treatment. While on treatment, methadone recipients had lower rates of opioid toxicity and acute care use, but they discontinued treatment much sooner (median 103 vs. 268 days).
- When discontinuation was accounted for, differences largely disappeared except for opioid toxicity.
- The authors conclude the two are complementary options.
Xu, F., Wang, T., Kolla, G., Campbell, T., Watts, T., Ledlie, S., Koncz, D., Tadrous, M., and Gomes, T. (2025). Changing trends in safer opioid supply uptake, dose and hydromorphone volume in Ontario: A population-based cross-sectional study. International Journal of Drug Policy, 143, 104905. https://doi.org/10.1016/j.drugpo.2025.104905
Key findings
From a population-based repeated cross-sectional study of monthly trends in immediate-release hydromorphone prescribing for safer opioid supply, dosing patterns, and the proportion of oral hydromorphone dispensed for SOS in Ontario, 2016–2023:
- An estimated 2,730 safer opioid supply recipients in Ontario in 2023.
- Between 2016 and 2023, mean hydromorphone daily doses for SOS rose, reaching 171.9 mg.
- By December 2023, SOS accounted for one-fifth of all oral hydromorphone use (in mg) in Ontario.
Kolla, G., Fajber, K., Sereda, A., Morris, C., Deacon, P., & Cipriano, L. E. (2025). Opioid medication doses among safer supply clients: Current safer supply doses and previous OAT experience. Drug and Alcohol Dependence Reports, 15, 100338. https://doi.org/10.1016/j.dadr.2025.100338
Key findings
From a study of opioid medication doses among safer supply clients in London, ON:
- Previous OAT experience:
- 87% of SOS clients had previously received OAT.
- Mean highest methadone dose was 95 mg (range: 20–200 mg), with 39% reporting doses ≥120 mg.
- Current SOS medications:
- 95% received immediate-release hydromorphone; 28% as monotherapy.
- 68% received hydromorphone with one long-acting opioid.
- Total average morphine milligram equivalent (MME) doses of combination prescriptions (MME 1616) were similar to high-dose methadone (120 mg = MME 1440).
- Conclusion: Previous high-dose OAT experience was common among SOS clients. Results suggest SOS may complement existing OAT programs for people with high fentanyl tolerance.
Slaunwhite, A., Min, J.E., Palis, H., Urbanoski, K., Pauly, B., Barker, B., Crabtree, A., Bach, P., Krebs, E., Dale, L., Meilleur, L., Nosyk, B. (2024). Effect of Risk Mitigation Guidance for opioid and stimulant dispensations on mortality and acute care visits during dual public health emergencies: retrospective cohort study. BMJ, 384, e076336. https://doi.org/10.1136/bmj-2023-076336
Key findings
From a retrospective cohort study of 5,882 people with opioid or stimulant use disorder who received RMG prescriptions in British Columbia:
- There was a 61% lower rate of death from any cause the week after at least one day of opioid prescription, and a 55% lower rate of death from overdose.
- The effect increased with the number of prescription days; people who received four or more days of opioid prescription had a 91% lower rate of death from any cause and an 89% lower rate of death from overdose.
- Opioid prescription was not associated with acute care use. People prescribed stimulants used less acute care the following week. The effect of stimulant prescription on risk of death was unclear.
Nafeh, F., Mbichila, T., Bouck, Z., Scheim, A., Mitra, S., Bonn, M., Morris, F., Atkinson, K., Mason, K., Eeuwes, J., Strike, C., Gomes, T., Werb, D., Karamouzian, M. (2025). A Preliminary Assessment of Short-Term Social and Substance Use-Related Outcomes Among Clients of Integrated Safer Opioid Supply Pilot Programs in Toronto, Canada. International Journal of Mental Health and Addiction, 23(3), 2105–2115. https://doi.org/10.1007/s11469-023-01219-3
Key findings
- Overdoses dropped by about 80%. After enrolling in safer supply, participants’ self-reported overdose rate was one-fifth of what it had been before (incidence rate ratio 0.20; 95% CI 0.09–0.43).
- Less reliance on street drugs and less criminal activity. At follow-up, participants reported using less of the unregulated supply and less involvement in criminal activity, along with other positive social and substance use outcomes.
- Integrated model. The programs combined pharmaceutical alternatives with comprehensive support services, at five frontline providers in Toronto (2020–2023).
Gomes, T., Kolla, G., McCormack, D., Sereda, A., Kitchen, S., and Antoniou, T. (2022). Clinical outcomes and health care costs among people entering a safer opioid supply program in Ontario. Canadian Medical Association Journal, 194(36), E1233–E1242. https://www.cmaj.ca/content/194/36/E1233
Key findings
From a study of health outcomes among patients in London’s safer supply program:
- There was a rapid decrease in emergency department (ED) visits, hospital admissions, and health care costs (excluding primary care and medication costs) among individuals enrolled in the SOS program.
- Among people in the SOS program, there was also a significant decrease in ED visits, hospital admissions, admissions for incident infections, and health care costs (excluding primary care and medication costs) in the year following entry into the program compared to the year prior.
- No significant changes in these outcomes were found among a comparison group of London residents with opioid use disorder who were not clients of the SOS program.
Young, S., Kolla, G., McCormack, D., Campbell, T., Leece, P., Strike, C., Srivastava, A., Antoniou, T., Bayoumi, A., & Gomes, T. (2022). Characterizing safer supply prescribing of immediate release hydromorphone for individuals with opioid use disorder across Ontario, Canada. International Journal of Drug Policy, 102, 103601. https://doi.org/10.1016/j.drugpo.2022.103601
Key findings
From a study of patients receiving safer supply in Ontario and their prescribers:
- In Ontario, 447 individuals with opioid use disorder were started on safer supply of immediate-release hydromorphone (IRH) between January 2016 and March 2020.
- A total of 155 prescribers started at least one individual on safer supply in this period, with the most initiations occurring in mid-2019. Prescribing IRH safer supply is substantially less common than prescribing traditional opioid agonist therapy.
Brothers, T., Leaman, M., Bonn, M., Lewer, D., Atkinson, J., Fraser, J., Gillis, A., Gniewek, M., Hawker, L., Hayman, H., Jorna, P., Martell, D., O’Donnell, T., Rivers Bowerman, H., Genge, L. (2022). Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation shelters for people experiencing homelessness. Drug and Alcohol Dependence, 235, 109440. https://doi.org/10.1016/j.drugalcdep.2022.109440
Key findings
From a rapid implementation of an emergency safe supply program at a COVID-19 isolation hotel in Halifax:
- Residents participating in the emergency safe supply program had high rates of completing the mandatory 14-day isolation stay.
- No overdoses occurred during the implementation of this program.
Lew, B., Bodkin, C., Lennox, R., et al. (2022). The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study. Harm Reduction Journal, 19, 29. https://doi.org/10.1186/s12954-022-00614-8
Key findings
From a case study of an integrated harm reduction intervention at an emergency men’s shelter in Hamilton, ON:
- A significant reduction in non-fatal overdose rates, from 0.93 to 0.17 per 100 shelter bed occupancy nights, during a COVID-19 outbreak.
- The combination of a safer use space, safer supply programming, and opioid agonist treatment yielded zero overdoses within the designated safe space over 129 visits.
Impact of program closures
Ali, F., Sprakes, A., Mende-Gibson, J., et al. (2026). A continuum of disconnection: The impacts of safer supply program closures on continuity of care, transition, and total loss of service access. Harm Reduction Journal, 23, 107. https://doi.org/10.1186/s12954-026-01469-z
Key findings
From interviews with 30 former clients of Ontario’s SUAP-funded safer supply programs, after federal funding ended in March 2025:
- Harm increased with the degree of disconnection. People who kept their prescriber (n=10) stayed clinically stable. People who moved to a new prescriber (n=13) did worse, and people who lost access entirely (n=7) did worst.
- All reported overdoses were among people who lost access. 17% of participants (n=5) had at least one overdose after the closures, and every one of them had lost access to safer supply.
- Lost access meant more street drug use. 30% of participants (n=9) reported using more unregulated drugs, and 7 of those 9 had lost access entirely.
- Moving to a new prescriber often meant losing carries and more surveillance. Participants described revoked take-home doses, observed dosing, urine screening and the loss of trusted relationships. They said this undermined their stability and autonomy, and was hard to manage alongside work, caregiving and family.
- Losing access meant losing a whole ecosystem of care. Participants lost medication, primary care, harm reduction services and community. They described an immediate return to fentanyl, untreated infections, declining mental health, and survival strategies that led to criminalization.
- Northern Ontario was hit hardest. Every participant from Northern Ontario lost access completely, with no alternative prescribers or services in the region.
Ali, F., Sprakes, A., Mende-Gibson, J., Russell, C., Shaw, A., Bonn, M., Celinski, A., Kaminski, N., Karamouzian, M., Strike, C., and Rehm, J. (2025). ‘I won’t make it without this program’: The impact of safer opioid supply program closures in Ontario. Harm Reduction Journal, 22, 151. https://doi.org/10.1186/s12954-025-01298-6
Key findings
From interviews with 25 clients of six Ontario safer supply programs, conducted in January–February 2025, just before the programs closed:
- Safer supply reduced reliance on the street supply and overdose risk. Participants described stopping or reducing fentanyl use, and many moved from injecting to oral use. Over half (52%) had not overdosed at all since enrolling.
- Take-home doses were the norm. Nearly all participants (96%) received take-home doses, and most picked them up at a pharmacy once a day.
- The programs connected people to wraparound care. Most used harm reduction supplies, housing and social supports, and supervised consumption through their program (64% each). Participants valued trusting, non-judgmental relationships with staff, in contrast to past stigma in health care.
- Most had tried OAT and found it didn’t meet their needs. Participants described methadone and other OAT as rigid, punitive and invasive, citing frequent urine screening, witnessed dosing and loss of autonomy. Most saw a return to OAT as a last resort.
- Rapid tapers caused immediate harm. One participant’s dose was cut from 22 hydromorphone tablets to 2 within a few weeks. Participants described withdrawal, renewed fentanyl use, repeated hospital visits and a return to sex work to buy street drugs.
- Lower tolerance raises overdose risk. Long-term clients feared that after years on safer supply, a sudden return to street fentanyl would be especially likely to kill them.
- Quality of life improved. Participants described rebuilding family relationships, being able to work, and no longer needing to commit crimes to support their drug use.
Wilson, P., Colizza, K., and Hyshka, E. (2024). Safer supply and political interference in medical practice: Alberta’s Narcotics Transition Services.
Key points
From this commentary on Alberta’s 2022–2023 restrictions on safer supply prescribing:
- What Alberta did. Regulations announced in October 2022 and in force by March 2023 limited safer supply prescribing for opioid use disorder to six clinics, called Narcotic Transition Services, and required witnessed dosing. Prescribers and pharmacies faced fines of $10,000 a day for non-compliance.
- About 350 patients were affected. Anyone who couldn’t transfer to one of the clinics was cut off. Travelling to a clinic several times a day for witnessed doses was a major barrier for people with jobs or other commitments, no transportation, or reasons to avoid the clinic areas.
- The rules required people to go back to treatment that had already failed them. Patients had to have tried OAT unsuccessfully to qualify, but the standards then required clinics to move them back to OAT “as soon as reasonably possible.”
- No one tracked what happened to patients. No outcomes were monitored and no evaluation was published. Frontline workers described broken relationships with providers, declining health and hopelessness as patients returned to street opioids.
- Deaths rose. Comparing provincial data before and after the rules took effect showed a 28% average monthly increase in deaths from the unregulated supply. The authors say this likely reflects factors beyond the regulations alone, but that the ban did not make the crisis less severe.
- A court found a strong Charter case. A patient who couldn’t attend a clinic won a temporary injunction allowing her to keep her prescription. The judge found she had a strong case that her Charter rights were infringed and that she would suffer irreparable harm.
- Diversion concerns were out of proportion to the data. The authors note a lack of objective evidence of substantial diversion of safer supply, or of safer supply’s involvement in overdose deaths.
- Regulators stayed silent. Alberta’s health professional regulators did not publicly object to the government overriding clinical judgment. The authors suggest stigma, vilification of the physicians’ college during the government’s review, and lack of safer supply expertise among regulators as possible reasons.
Matzinger, L., et al. (2025). MySafe Final Evaluation Report: Impacts of Program Closure. Changemark Research and Evaluation.
Key findings
From an evaluation of MySafe, a biometric dispensing program in Vancouver and Victoria, based on interviews with 37 former clients and 6 service providers in March–June 2025, after the program’s Health Canada funding ended in 2024:
- What MySafe was. Clients picked up their daily hydromorphone from a palm-scan machine, often in their supportive housing, on their own schedule and without witnessed dosing. They were connected to primary care, OAT, harm reduction and social supports.
- Flexibility supported stability and work. Clients could time doses around their bodies, routines and jobs, without lining up or being watched. Participants described this as central to staying on their medication, keeping housing, and working.
- No toxic drug poisonings were reported while clients were in the program. Clients reported less withdrawal and fewer cravings, less reliance on street drugs, and less injecting. They also described better emotional and physical health, fewer evictions, more money for food and rent, and less crime and sex work.
- After closure, clients went back to rigid models. Many moved to daily pharmacy pickups or deliveries, and some were required to take their whole day’s dose at once under observation. Doses were often cut or medications changed with little discussion.
- Destabilization followed. Clients described more withdrawal and cravings and a return to the street supply, including using alone, and 5 reported overdosing again. At the time of the interviews, half (50%) were on no prescribed alternative or OAT at all, and 24% reported at least one poisoning in the past six months.
- Stigma returned. Clients described judgment at pharmacies, including a separate pickup window, and some (n=8) disengaged from care altogether.
Ali, F., Russell, C., Mende-Gibson, J., et al. (2025). The erosion of safer supply programs in Ontario, Canada: A dangerous step backward. Drug Science, Policy and Law. https://doi.org/10.1177/20503245251352845
Key points
From this commentary on Ontario’s 2024–2025 policy changes:
- Ontario was the centre of safer supply in Canada. It hosted more safer supply programs than any other province.
- Provincial policy forced closures. Under Bill 223, passed in December 2024, six federally funded programs had to close on March 31, 2025.
- The replacements exclude harm reduction. The government’s 27 Homelessness and Addiction Recovery Treatment (HART) Hubs exclude safer supply, supervised consumption and needle and syringe programs.
- The evidence points the other way. The authors summarize that safer supply has increased access to health and social services and reduced overdoses after people enrol.
- Closure carries predictable risks. Removing the programs will push people back to the toxic unregulated supply, break their connection to health care providers, and increase overdose risk.
- The authors call it a public health failure. They urge policymakers to prioritize evidence-based approaches to prevent unnecessary deaths.
Client experiences and outcomes
Michaud, L., Guta, A., Perri, M., Schaff, A., Boyle, M., King, K., Strike, C., & Kolla, G. (2026). “With this you’re not chained down to something”: Contrasting experiences of opioid agonist treatment and safer supply program participation among people receiving prescribed safer supply. Harm Reduction Journal, 23, 51. https://doi.org/10.1186/s12954-026-01409-x
Key findings
From qualitative interviews with 22 clients of a safer supply program in Kitchener-Waterloo, Ontario, comparing their experiences of safer supply with their earlier experiences of OAT:
- OAT had not managed withdrawal, tolerance or side effects for these clients. These were the biggest differences participants described between the two models.
- The model of care mattered as much as the medication. The safer supply program’s approach and philosophy of care built stronger therapeutic relationships than participants had experienced in OAT.
- More autonomy. Participants reported greater autonomy and better quality of life on safer supply than in their earlier OAT experiences.
- The authors call for individualized dosing in both OAT and safer supply. They conclude there is an urgent need for collaborative decision-making and comprehensive models of care for substance use.
Kolla, G., Pauly, B., Henderson, N., et al. (2026). “Safer supply is the thing that changes everything”: The role of prescribed safer supply in rebuilding trust following experiences of medical abandonment. BMC Public Health, 26, 2215. https://doi.org/10.1186/s12889-026-28140-3
Key findings
From interviews and focus groups in 2022 with 38 clients and 10 staff (including RNs, NPs and physicians) at two safer supply programs, in London, Ontario (LIHC) and Victoria, BC (AVI’s SAFER program):
- Participants described three kinds of medical abandonment before safer supply:
- Abrupt deprescribing. Many had been on high-dose, long-term opioids for chronic pain, injuries or surgeries and were stable, some working or in school. Then they were cut off, often “cold turkey,” once their prescriber reframed them as addicted, and turned to the street supply.
- Punitive OAT. Many had tried OAT several times over years. Some had it withdrawn as punishment for using other drugs, including one person with chronic pain cut off methadone after testing positive for cocaine.
- Stigma in health care. Participants described opioids being withheld or under-dosed in hospital, leading some to leave before completing treatment for serious conditions.
- Safer supply rebuilt trust and brought people back into care. Meeting clients’ opioid needs, and believing their accounts of pain and drug use, was the first step. Staff said clients then started seeing doctors, getting HIV and hepatitis C treated, and starting mental health medications, followed by less involvement in crime and sex work, and later reconnection with family.
- Pain was finally treated. Several clients said safer supply was the first time in years their pain had been managed.
- The authors warn against surveillance-based safer supply. They caution that punitive, surveillance-oriented practices in safer supply prescribing risk recreating the medical abandonment that made safer supply necessary in the first place.
Schmidt, R. A., Guta, A., Rai, N., Sereda, A., O’Reilly, E., Hales, J., Kolla, G., & Strike, C. (2025; online 2024). Safer Opioid Supply programs: Hydromorphone prescribing in Ontario as a harm reduction intervention to combat the drug poisoning crisis. Canadian Journal of Public Health, 116, 398–407. https://doi.org/10.17269/s41997-024-00979-2
Key findings
- The combination of safer supply, wraparound support, and harm reduction within primary care settings can lead to increased health care engagement, HIV/HCV prevention, testing, and treatment uptake, reducing the burden of infectious diseases and overdose risk.
- SOS programs have the potential to meaningfully reduce overdose rates, address the ongoing overdose crisis, and, if scaled up, influence population-level outcomes.
Schmidt, R. A., Kaminski, N., Kryszajtys, D. T., Rudzinski, K., Perri, M., Guta, A., et al. (2023). “I don’t chase drugs as much anymore, and I’m not dead”: Client reported outcomes associated with safer opioid supply programs in Ontario, Canada. Drug and Alcohol Review, 42(7), 1825–1837.
Key findings
From a qualitative study with 52 clients in 4 SOS programs in Ontario:
- Multifaceted pathways to improved self-reported health and wellbeing, including changes to drug use practices, fewer overdoses, reduced criminalized activity, improved trust and engagement in care, and increased social stability (e.g., housing).
- Clients reported that SOS saved their lives because of the reduced frequency of overdoses.
- Findings suggest that SOS programs improve clients’ health outcomes and increase opportunities for engagement in health and social services.
Gagnon, M., Rudzinski, K., Guta, A., Schmidt, R.A., Kryszatys, D.T., Kolla, G., Strike, C. (2023). Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduction Journal, 20, 81. https://doi.org/10.1186/s12954-023-00817-7
Key findings
From a qualitative study of 52 clients and 21 providers across four safer supply programs:
- Safer supply programs contribute to reducing injection-related health risks in addition to overdose risks.
- Three changes related to injection practices were identified: a reduction in the amount of fentanyl used and a decrease in injection frequency; the injection of hydromorphone tablets instead of fentanyl; and the cessation of injection altogether and taking safer supply medications orally.
- Safer supply programs have the potential to address disease prevention and health promotion gaps that stand-alone harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.
Fajber, K., Sereda, A., Warren, S., Morris, C., Nash, G., Pauly, B., Urbanoski, K., & Kolla, G. (2025). Comprehensive substance use services within primary care settings: The Safer Opioid Supply program at London InterCommunity Health Centre. Canadian Journal of Public Health, 116, 408–417. https://doi.org/10.17269/s41997-025-01006-8
Key findings
From interviews and focus groups with 20 clients and 5 staff of the London InterCommunity Health Centre (LIHC) Safer Opioid Supply program, the first formal safer supply program in Canada (started 2016):
- Safer supply is embedded in full primary care. All of the almost 300 clients (as of March 2024) are rostered as primary care patients, with care from physicians and nurse practitioners. They have access to HIV and hepatitis C treatment, wound care, sexual health, preventive care, housing support, income and disability applications, food programs, counselling and outreach.
- Safer supply brings people into care. Staff described clients who had never engaged with the health care system, and said safer supply was the “foot in the door” for treating serious conditions such as sepsis, abscesses and endocarditis.
- Clients reported few or no overdoses. Moving off the unregulated supply meant meeting the program’s main aim of preventing overdose deaths. Clients also stopped survival sex work, street hustles and small-scale crime to get drugs.
- Built-in safeguards. Long-acting opioids are given as witnessed doses at pharmacies, and hydromorphone as daily take-home doses. Clients are seen two to three times a week until stable, then weekly or every two weeks.
- The program prioritizes people with the greatest needs. Admission is triaged by acuity, with priority for women, people doing street-based sex work, people with untreated HIV, and people experiencing homelessness.
- Goals are set with the client. Some clients sought abstinence; others reduced street drug use, stabilized on medication, engaged in medical treatment, reconnected with family, returned to school or kept their jobs.
- Capacity and medications are limited. Eligible people were turned away for lack of capacity, and hydromorphone is often not strong enough for people with high fentanyl tolerance. Short-term federal funding made long-term planning difficult.
Strike, C., Rudzinski, K., Schmidt, R. A., Kolla, G., Kryszajtys, D., Perri, M., Kaminski, N., & Guta, A. (2025). A sea of need: Provider accounts of strategies used to manage admission demands to safer opioid supply programs in Ontario. Harm Reduction Journal, 22, 194.
Key findings
From interviews in 2021 with 21 providers (physician and nurse practitioner prescribers, nurses and allied health workers) at four Ontario safer supply programs, three in Toronto and one in London:
- Demand far outstripped capacity. After federal funding arrived, one program “pretty much doubled” its roster. Clinics were often staffed by just three people — one prescriber, one nurse and one community health worker — with no backup for sick days or vacation.
- Waitlists didn’t work. Waits reached two to three months, and people without phones were hard to reach when a spot opened. Programs closed their waitlists in favour of outreach and same-day intake.
- Programs moved to points-based admission to reach the most excluded. Early enrolment in Toronto skewed toward white men already connected to harm reduction services. Points went to recent and frequent overdose, homelessness, unmanaged HIV or hepatitis C, serious infections, sex work and pregnancy, and to women, 2SLGBTQ+, Black, Indigenous and racialized people. Pregnant people were often admitted the same day.
- This produced a very high-acuity client group. The most complex clients needed frequent, often weekly, check-ins, which slowed new admissions.
- Programs responded to medication sharing by admitting partners. Where clients were sharing medication with an intimate partner, programs admitted the partner too, even if the partner didn’t score high enough on the points system.
- People died waiting, and providers burned out. One physician reported that several people on the waitlist died of overdose. Providers described moral distress at turning people away, long hours, and feeling isolated from colleagues who refused to prescribe safer supply.
- The authors call it boutique care. Narrow admission criteria, forced by limited resources, limited the programs’ reach and population-level impact. Three of the four programs studied have since closed.
Scoping reviews and syntheses
Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence. International Journal of Drug Policy, 125, 104339. https://doi.org/10.1016/j.drugpo.2024.104339
Key findings
From a scoping review of peer-reviewed and grey literature published between January 1, 2012 and September 12, 2023:
- 24 papers met the inclusion criteria (client outcomes, client or provider perspectives).
- Findings included low rates of opioid toxicities, improved physical and mental health, and improved quality of life among clients.
- Findings also indicated a lack of access to adequate opioid doses and a limited range of opioid options. Clients and providers described these as a potential reason for diversion and a barrier to program access.
- Evidence suggests that safer opioid supply programs benefit clients through measurable outcomes; however, further research is needed.
SOS program evaluations
AVI Health and Community Services. (2025). Practice Brief: Expanding Prescribed Alternatives on Vancouver Island.
AVI Health and Community Services. (2025). “It helps me do things that are meaningful to me”: Prescribed alternatives for harm reduction workers.
Musa, S., McLean, A., and Kolla, G. (2025). Prescribed Alternatives and Outreach Program: Evaluation Report for Hamilton Urban Core Community Health Centre.
Matzinger, L., et al. (2025). MySafe Final Evaluation Report: Impacts of Program Closure.
Client Zine. (2025). Peterborough 360 NPLC Safer Supply Program: 3 years of Love and Radical Nonsense.
Sprakes, A., Rodericks-Schulwach, A., Murray, M., Kuhn, S., & Ambury, S. (2024). Safer supply program evaluation: A response to drug poisonings in Thunder Bay, Ontario. School of Social Work, Lakehead University.
Hardill, K. & King, C. (2024). Embedding a Safer Supply Program in a Small Urban Community: Peterborough 360 Degree Safer Supply Program (SSP) Evaluation, May 2022 through December 2023. Peterborough 360 Degree Nurse Practitioner-Led Clinic, Peterborough, ON.
Marris, J. & King, C. (2024). Peterborough 360 NPLC Safer Supply Program: The Participant Experience. Peterborough 360 Degree Nurse Practitioner-Led Clinic, Peterborough, ON.
Schmidt, R.A., Guta, A., Kaminski, N., Kryszajtys, D., Perri, M., Rudzinski, K., & Strike, C. (2023). A Prescription for Safety: A Study of Safer Opioid Supply Programs in Ontario. University of Toronto, Toronto, ON.
Haines, M., Tefoglou, & O’Byrne, P. (2023). Safer Supply Ottawa Evaluation: Spring 2023.
Haines, M., Hill, E., Kerwin, S., Tefoglou, A., O’Byrne, P. (2023). Safer Supply Ottawa Evaluation: Fall 2023 Report.
Atkinson, K. (2023). Safer Opioid Supply – 2023 Evaluation Report. Parkdale Queen West Community Health Centre.
Perri, M., Fajber, K., Guta, A., Strike, C., and Kolla, G. (2023). Outcomes from the Safer Supply Program in Kitchener-Waterloo.
Perri, M., Fajber, K., Guta, A., Strike, C., and Kolla, G. (2023). The Kitchener-Waterloo Safer Supply Program – A Collaborative Model of Care.
Kolla, G., Long, C., Perri, M., Bowra, A., and Penn, R. (2022). Safer Opioid Supply Program: Summary Report. London: London InterCommunity Health Centre.
Haines, M., Tefoglou, A., & O’Byrne, P. (2022). Safer Supply Ottawa Evaluation: Fall 2022 Report.
McMurchy, D., & Palmer, R. W. H. (2022). Assessment of the Implementation of Safer Supply Pilot Projects.
Ranger, C., Hobbs, H., Cameron, F., Stuart, H., McCall, J., Sullivan, G., Urbanoski, K., Slaunwhite, A., and Pauly, B. (2021). Co/Lab Practice Brief: Implementing the Victoria SAFER Initiative. Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada.
Sample SOS client profiles
Excerpt from NSSCoP (2024), Prescribed Alternatives Programs in Ontario – Briefing Note. Demographic information is drawn from the Safer Supply Ottawa (SSO) and London InterCommunity Health Centre (LIHC) program evaluation reports.
Webinars
2025“I Won’t Make It Without This Program”: Safer Supply Program Closures in Ontario
Speakers: Dr. Farihah Ali, Andrzej Celinski, and Andrew Shaw
2024Effect of Risk Mitigation Guidance on Mortality and Acute Care Visits
Speakers: Dr. Brittany Barker and Dr. Karen Urbanoski
2024The Ethics of Prescribed Safer Supply
Speakers: Dr. Alice Viranyi, Dr. Daniel Buchman, and Dr. Adrian Guta
2024The Ban on Safer Supply in Alberta
Speakers: Dr. Kate Colizza and Patty Wilson (NP)
2024Evidence for Safer Supply and Models for the Future
Speakers: Dr. Bernie Pauly (RN), Nancy Henderson (RN), Phoenix Beck McGreevy, Abby Hutchinson
2023Safe Supply: Current Perspectives and Evidence
Speakers: Dr. Gillian Kolla, Dr. Marie-Eve Goyer, Corey Ranger, Angela Robertson, Ashley Smoke, and Christopher Hoy
2023(Almost) Everything You’ve Heard About the “Opioid Epidemic” is “Wrong”
Speakers: Dr. Leo Beletsky (Northeastern University). CISUR
2022Clinical Outcomes and Health Care Costs Among People Entering a Safer Opioid Supply Program in Ontario
Speakers: Dr. Gillian Kolla, Dr. Tara Gomes, Dr. Andrea Sereda, and Ashley Smoke
2022Integrating Hepatitis C Care with Safer Supply Practice
Speakers: Jessica Nanni (NP), Angie Austin, Patty Wilson (NP), Dr. Tim O’Shea, Rivka Kushner, and Chris Hoy
