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Daily supervised Opioid Agonist Treatment (OAT) medication has been identified as a barrier to treatment retention. Canadian OAT guidelines outline take-home dose (THD) criteria, yet, OAT prescribers use their clinical judgement to decide whether an individual is 'clinically stable' to receive THD. There is limited information regarding whether these decisions may result in inequitable access to THD, including in the context of updated COVID-19 guidance. The current Canadian OAT THD guideline synthesis and systematic review aimed to address this knowledge gap. This systematic review included a two-pronged approach. First, we searched available academic literature in Embase, Medline, and PsychINFO up until October 12th, 2022, to identify studies that compared characteristics of individuals on OAT who had and had not been granted access to THD to explore potential inequities in access. Next, we identified all Canadian national and provincial OAT guidelines through a semi-structured grey literature search (conducted between September-October 2022) and extracted all THD 'stability' and allowances/timeline criteria to compare against characteristics identified in the literature search. Data from both review arms were synthesized and narratively presented. A total of n = 56 guidelines and n = 7 academic studies were included. The systematic review identified a number of patient characteristics such as age, sex, race/ethnicity, marital status, housing, employment, neighborhood income, drug use, mental health, health service utilization, as well as treatment duration that were associated with differential access to THD. The Canadian OAT THD guideline synthesis identified many of these same characteristics as 'stability' criteria, underscoring the potential for Canadian OAT guidelines to result in inequitable access to THD. This two-pronged literature review demonstrated that current guidelines likely contribute to inequitable OAT THD access due primarily to inconsistent 'stability' criteria across guidelines. More research is needed to understand differential OAT THD access with a focus on prescriber decision-making and evaluating associated treatment and safety outcomes. The development of a client-centered, equity-focused, and evidence-informed decision making framework that incorporates more clear definitions of 'stability' criteria and indications for prescriber discretion is warranted. [ABSTRACT FROM AUTHOR]

• Prescribed safer opioid supply programs continue to expand across Canada. • We conducted a scoping review of client outcomes and client/provider perceptions. • Generally, program participation is associated with beneficial client outcomes. • Large population level studies are required to study rarer outcomes and diversion. • More research is needed for program adaption and to address unique regional needs. Safer opioid supply programs provide prescription pharmaceutical opioids, often with supportive services, to people at high risk of experiencing harms related to substance use. However, questions regarding the effectiveness and safety of this practice remain. We conducted a scoping review of literature describing client outcomes from formal opioid supply programs providing prescriptions for pharmaceutical opioids, and the perceptions of involved clients/providers. We performed a scoping review of peer-reviewed studies and grey literature published between January 1, 2012, to September 12, 2023. We included articles reporting either safer opioid supply client outcomes or clients/providers perspectives. Extracted data included study objectives, substance use patterns, client outcomes, client/provider perspectives, and estimates of effectiveness and/or harm. Our search yielded 1,597 articles. Following removal of duplicates and application of exclusion criteria, 24 publications comprising 17 peer-reviewed and seven grey literature publications were included in our study. We generated eight themes summarizing topics in the available literature: opioid-related toxicities, infectious complications, other clinical outcomes, client-reported outcomes, program access barriers, diversion, program retention, and costs to the healthcare system. Specific findings included low rates of opioid toxicities, improved physical and mental health, and improved quality of life among clients. A lack of access to adequate opioid doses and the limited range of opioid options offered within safer opioid supply programs was described by clients and providers as a potential reason for diversion and a barrier to program access. Generally, evidence suggests that safer opioid supply programs are beneficial to clients through measurable outcomes. However, the available literature has important limitations, including limited inferences about the effectiveness, safety, and potential for diversion within safer opioid supply programs. Further research is needed to support the ongoing evaluation of safer opioid supply programs as one component of a multifactorial response to escalating rates of substance-related harms. [ABSTRACT FROM AUTHOR]

Opioid use and related harms have been of growing concern in North America and elsewhere. In Canada, while policies and programs intended to mitigate opioid-related harms have been introduced by public health agencies, the medical profession, and different levels of government, there remains a paucity of evidence regarding the unintended consequences of these initiatives, including their impacts on people with chronic pain, a population often treated with opioids. This institutional ethnography investigated how opioid-related policies and programs are developed, deployed, and translated into practice in Ontario, Canada. Semi-structured interviews were conducted with people with chronic pain and practitioners to trace the institutional relations organizing opioid prescribing and use. Data analysis proceeded through an iterative process of identifying and mapping social relations, as well as textual analysis. Participants identified two policies that have been particularly impactful for people with chronic pain and clinicians: Ontario's Narcotics Monitoring System and the 2017 Guideline for Opioids for Chronic Non-Cancer Pain. Both interventions have contributed to fear among physicians that they will be investigated and disciplined by their licensing college for 'overprescribing' opioids. In the face of pressure to adhere to more conservative opioid prescribing practices, physicians have taken up strategies including rapidly tapering patients' doses and refusing to prescribe opioids. These changing work practices have had significant repercussions for people with chronic pain, such as increased pain, reduced quality of life, greater risks of harm, and the erosion of the physician–patient relationship. Policies intended to mitigate opioid-related harms by reducing the number of opioids prescribed have had repercussions for people with chronic pain and for practitioners. There is an urgent need to investigate the unintended and unanticipated impacts of drug policies, which may only be uncovered through explorations of people's everyday lives and experiences. [ABSTRACT FROM AUTHOR]

Background: Opioid agonist therapy (OAT) has been shown to reduce opioid use and related harms. However, many young people are not accessing OAT. This study sought to explore how young people navigated OAT over time, including periods of engagement, disengagement, and avoidance.Methods: Semi-structured, in-depth qualitative interviews were conducted between January 2018 and August 2020 with 56 young people in Vancouver, Canada who reported illicit, intensive heroin and/or fentanyl use. Following the verbatim transcription of longitudinal interviews, an iterative thematic analysis was used to extrapolate key themes.Results: Young people contemplating OAT expressed fears about its addictiveness. Many experienced pressure from providers and family members to initiate buprenorphine-naloxone, despite a desire to explore other treatment options such as methadone. Once young people initiated OAT, staying on it was difficult and complicated by daily witnessed dosing requirements and strict rules around repeated missed doses, especially for those receiving methadone. Most young people envisioned tapering off OAT in the not-too-distant future.Conclusions: Findings underscore the importance of working collaboratively with young people to develop treatment plans and timelines, and suggest that OAT engagement and retention among young people could be improved by expanding access to the full range of OAT; updating clinical guidelines to improve access to safer prescription alternatives to the increasingly poisonous, unregulated drug supply; addressing treatment gaps arising from missed doses and take-home dosing; and providing a clear pathway to OAT tapering. [ABSTRACT FROM AUTHOR]