"In 1997, Alan Leshner, the Director of the US National Institute on Drug Abuse (NIDA), proclaimed that addiction was a chronic, relapsing, brain disease (Leshner, 1997).

"Participants enrolled in the MySafe program described a variety of facilitators and barriers to program access and engagement. Facilitators included accessibility and choice, nonwitnessed dosing, a lack of consequences for missing doses, a judgment-free setting and an ability to accumulate doses as contingency plans (e.g., for travel). Barriers included technological issues with the machine, dosing challenges and prescriptions being tied to individual machines.

"The safety and efficacy of nurse prescribing of MOUD is well established, and its expansion can provide a range of advantages to people who are dependent on opiates.

"A study in Canada found that personal beliefs of NPs often pose a barrier to providing treatment, for example, views such as patients with OUD deserve less care than other patients [12], this was also reported as a barrier in the study by Spetz and colleagues [31].

"Several client- and provider-reported barriers to safer opioid supply program engagement were also identified.

"Diversion of safer opioid supply drugs was examined in six qualitative studies (Giang et al., 2023; Haines & O'Byrne, 2023a; Haines et al., 2022; Kalicum, 2023;

"Overall, the currently available evidence regarding health outcomes among safer opioid supply clients is generally favorable.

"From January–June 2020 to July–December 2022, the number of overdose deaths with evidence of smoking doubled, and the percentage of deaths with evidence of smoking increased across all geographic regions. By late 2022, smoking was the predominant route of use among drug overdose deaths overall and in the Midwest and West regions. Increases were most pronounced when IMFs were detected, with or without stimulants.

"This study is the first, to our knowledge, to document the clinical sequelae and naloxone administration for patients who were in the ED following confirmed NPO drug OD. The NPO group was administered a statistically significantly higher number of in-hospital naloxone boluses compared with the fentanyl group, which corresponded to a moderately large effect size. While these findings were based on limited sample sizes, we detected a large effect size for the association between increased naloxone doses and NPO overdose.

"Novel potent opioids (NPOs) are novel nonfentanyl opioids in the illicit opioid supply. Synthetic opioids are one of the fastest growing classes of opioids being detected in patients in the emergency department (ED) with opioid overdose (OD).1