MONTREAL — The Workforce cohort, an initiative that provides prescribed alternatives (PA) for harm reduction workers who themselves have a substance use disorder (SUD), is being piloted by AVI Health and Community Services in Victoria, British Columbia. Early results from this program were presented at Public Health 2026, the annual meeting of the Canadian Public Health Association (CPHA).

The session was moderated by Greg Penney, director of programs at the CPHA. He spoke with Medscape News Canada about the important role that PA play in managing SUD. “If you look at anyone who has a substance use disorder, what is the pathway for them? It’s always been kind of binary: You have to quit, so you’re not using. There is no transition. If we look at a different health issue, like tobacco, we don’t think of it that way. We give people a pathway to quit smoking, [such as] nicotine patches. We’re not actually taking away the thing that’s addicting, we’re taking away the mechanisms that are harmful.”

The support provided by PA programs is particularly important for healthcare workers in harm reduction. “We know, especially with healthcare providers, that [in] high-stress environments, people can have substance use issues,” continued Penney. “How do you keep [those] people working and thriving and yet provide them with an opportunity to maintain their health, especially [given that] people with lived experience bring a great value that’s necessary?” The program gives those people an opportunity to help others with SUDs, he added. 

Laura Cartwright, program coordinator for AVI Health and Community Services Knowledge Translation and Exchange Program, and Emily Clayton, a clinical nurse educator with the same program, described the Workforce PA cohort initiative and its early results at Public Health 2026. 

Clayton noted that PA programs are essential in a province like British Columbia, where the provincial health officer declared the toxic drug crisis to be a public health emergency in 2016. In that year, 997 deaths resulted from unregulated drugs. Since then, over 19,000 people have died in the province from the same cause.

Workforce Cohort 

“Traditionally, people with SUDs who are not completely abstaining have been excluded from working in settings that support people with an SUD,” said Clayton. “They are also frequently ineligible for the very PA programs they help support. This eliminates important contributions from people with lived experience.” Harm reduction initiatives are increasingly informed by the knowledge of people with criminalized drug use, whose perspectives help ensure that the initiatives are contextually relevant and respectful, she added. 

The Workforce cohort was launched in spring 2024 as an extension of the SAFER Knowledge Translation & Exchange clinic in Victoria. The proximity of harm reduction workers with SUD to PA prescribers necessitates certain safeguards. For the Workforce cohort, these safeguards include having prescribers work off site with nurse-mediated clinical intake and follow up, delivering medications largely in community pharmacies, and conducting dual position reviews for complex clinical cases. In addition, staff of AVI Health and Community Services PA programs are not eligible for the Workforce program. The Workforce clinic room acts as a service hub, as it includes a drop-in space and overdose prevention room.

The Workforce care pathway starts with self-referral forms that are distributed to local harm reduction organizations in Victoria. Triaging is informed by scores obtained using equity and acuity criteria. Once they are received into the program, participants meet with a systems navigator to discuss their needs. The navigator then collaborates with the Workforce prescriber and nurse. 

Medications offered include opioid agonists, fentanyl patches, and dissolvable fentanyl tablets. The nurse conducts a substance use and a pre-dose assessment before providing medications. A post-dose observation period confirms dose tolerance and safety. After the dose is titrated upward over several days to a maintenance dose, participants typically receive future doses from a community pharmacy.

The systems navigator connects participants with external resources, such as income, housing, and identification services. He or she also advocates for the participant’s access to primary care and tertiary care. Follow-up consists of at least monthly check-ins with the program physician and nurse.

Multiple Benefits 

Surveys and interviews conducted with seven Workforce participants and three staff members in March and April of 2025 revealed the success of the program. The positive outcomes included a lack of drug poisoning deaths, reduced use of unregulated drugs (with complete abstinence in some cases), improved employment stability, better ability to focus on work duties, improvement in mental health and participation in daily activities, and better access to healthcare. Participants also reported use of more social supports, improved relationships with family, and improved parenting ability.

In addition to its other benefits, PA programs like Workforce help reduce the stigma of SUDs, said Penney. When people receive prescriptions for maintenance drugs rather than buying them on the street, it legitimizes their medical need. This principle is especially true if they receive it from a community pharmacy like any other medication.

Political Barriers 

“Workforce outcomes are positive. However, delivering care within a medical model of care limits the flexibility and the autonomy that AVI aims to provide for participants receiving twice-daily dosing,” said Clayton. “This requires two trips to the pharmacy, creating a barrier for accessing medications.” Some participants have accessed unwitnessed or take-home doses after having proven their adherence to medication. This access enhanced participants’ flexibility and autonomy, while allowing them to use their prescriptions when they need them, Clayton added. 

But in December 2025, the BC Ministry of Health announced that all PA prescriptions must transition to witnessed dosing, which creates “significant barriers for those participants already receiving take-home doses,” she said. “This hinders accessibility to one’s meds and may result in one accessing the unregulated supply to meet one’s needs. This poses significant risk to one’s safety and could ultimately result in death.”

The policy recognizes exceptional circumstances in which participants who have been receiving take-home doses may continue to do so if witnessed dosing poses vocational barriers. “It’s hoped that workforce participants who meet this exceptional circumstance criteria are able to continue with take-home doses,” said Clayton. 

This research was funded through AVI Health and Community Services, which itself has multiple government and community funders. Penney, Cartwright, and Clayton reported no relevant financial relationships.