Methods: We conducted semi-structured interviews with purposively sampled healthcare providers and clients across 4 SOS programs in Ontario, Canada from February to October 2021. Interviews examined SOS implementation and adaptation, with HIV and HCV-specific questions (e.g., testing and treatment). Participants filled out a questionnaire with demographic, employment and health information. Thematic analysis was conducted in MAXQDA and descriptive statistics in SPSSv28.
Results: We interviewed n=80 participants across all sites, comprised of n=27 providers [physicians, nurses, community health workers, pharmacists; cis woman 62%/cis man 29%/nonbinary 9%; white 71%, with 29% racial diversity] and n=53 clients [cis man 57%/cis woman 43%; white 77%, Indigenous 19%, Black 2%, Latino 2%; HIV+ (13%); HCV+ (77%); 89% had ever injected drugs, 87% had ever tried methadone, mean age 47 (SD 9.5; range 29-62)]. SOS programs were expanded during the COVID-19 pandemic and prioritized clients living with HIV and/or HCV, women (especially pregnant women), sexual and gender diverse, Black, Indigenous, racialized, and homeless clients. Clients typically received daily observed oral slow-release morphine and hydromorphone tablets to take with them (i.e., to crush and inject later). Providers described SOS as a mechanism to engage clients in HIV/HCV testing and treatment, and shared examples of clients who were homeless/virally unsuppressed at intake becoming housed/virally suppressed through these programs. Clients reported that SOS reduced overdoses, increased access to HIV/HCV care (e.g., by combining daily dispensed opioids with HIV medications), and reduced their need to engage in criminalized activities (e.g., theft, sex work). Many providers expressed variations on the sentiment that SOS programs were designed to offer clinical services, but once clients' doses were established the work shifted to addressing their psychosocial and material needs. Clients identified reconnecting with their children, family and community as priorities. While popular with providers and clients, these programs are very resource intensive and provide limited drug options which keeps some clients dependent on the unregulated drug market to supplement their needs.
Conclusions: In this qualitative study, respondents described SOS as a life-saving intervention for people who use drugs who have not benefited from traditional opioid-assisted treatment options. The protocols used across the 4 sites reflect trauma-informed care principles and have implications for improving care and outreach for diverse people who use drugs. Social workers can have important roles to play in SOS service delivery and by advocating for these programs. Future quantitative research is needed to explore the integration and adaptation of SOS beyond these pilot programs.