The Victoria SAFER initiative: A community-based prescribed safer supply program using fentanyl formulations in Victoria, BC

BACKGROUND: In response to the severe mortality impacts of the shift in the North American unregulated drug supply to unregulated fentanyl and fentanyl analogues, the provision of pharmaceutical fentanyl formulations as part of prescribed safer supply programs has been piloted in a limited number of settings. The Victoria SAFER Initiative is a community-based prescribed safer supply program providing pharmaceutical alternatives; in 2021, they began offering multiple fentanyl or fentanyl-analogue formulations (buccal, injectable, transdermal) to individuals at high risk of opioid overdose. METHODS: Qualitative interviews and focus groups were completed with program staff (n = 10) and participants (n = 40) between May 2022 and April 2024. Guided by the Consolidated Framework for Implementation Research (CFIR), data was analyzed thematically to identify strengths and challenges in program implementation, including benefits and drawbacks of prescribing fentanyl products. RESULTS: Thematic analysis elicited three major themes linked to CFIR domains regarding the provision of prescribed fentanyl options: Fentanyl products provided a better substitute for the unregulated supply than other available medications (innovation domain); different formulations of fentanyl enabled individualized care and participant autonomy (innovation and implementation domains); and requirements for observed dosing of fentanyl options presented challenges for clients and providers (outer setting and implementation domains). CONCLUSION: This program provides a model for the prescription of multiple fentanyl or fentanyl-analogue formulations to complement other medications offered in prescribed safer supply programs. Primary barriers to innovation are the outer setting of the unregulated drug supply and government policies, while inner context factors and individuals implementing the innovation were facilitators.