CATIE News

3 November 2020 

Estimated number of people who inject drugs and coverage of harm reduction programs in Canada

  • An estimated 171,900 people in Canada injected drugs in 2016, an increase since 2011
  • Two-thirds of people in Canada who injected drugs received opioid agonist therapy in 2016, also an increase since 2011
  • Nearly 50 million needles and syringes were distributed in 2016, below recommended Canadian targets

People who use injection drugs have an increased risk of acquiring hepatitis C virus and HIV infections through sharing and/or re-using drug use equipment. Both opioid agonist treatment (OAT) and needle and syringe distribution are associated with a reduced risk of hepatitis C, HIV and other related harms. Retention in OAT is also associated with a reduction in overdoses and deaths among people who are dependent on opioids.

Given the importance of providing harm reduction services for people who use drugs, the World Health Organization (WHO) has recommended that countries provide OAT for at least 40 per 100 people who inject drugs and that they distribute at least 200 needles and syringes annually to each person who injects drugs.

Collecting and reporting data on people who inject drugs is a key part of public health surveillance, policy and programming planning, and resource allocation to support the health of people who use drugs. A recent study produced estimates of the number of people who inject drugs in Canada as well as coverage of OAT and needle and syringe distribution. The study provided national estimates along with provincial/territorial estimates, making it the most up-to-date data of its kind on injection drug use prevalence and OAT and needle and syringe coverage in Canada.

Study details

The researchers used several data sources to estimate both the number of people who inject drugs and harm reduction coverage in Canada. This included provincial/territorial data on the number of people who received methadone, survey data of the proportion of people who inject drugs who reported receiving methadone, and the number of needles and syringes provided in each province/territory. Eleven out of 13 provinces and territories were included in the study; data for Nunavut and the Northwest Territories was not available.

Results

In Canada, an estimated 171,900 people injected drugs in 2016, which represents a prevalence rate of 0.7% (0.7 people per 100 people aged 16 to 64 years injecting drugs). This number is an increase from the estimated 130,000 people who injected drugs in 2011 (prevalence rate of 0.55%). Prevalence varied significantly across the country, with rates from 0.16% in Alberta to 1.48% in B.C.

In 2016, an estimated 113,381 people across Canada received OAT. This represents a coverage rate of 66 people on OAT per 100 people who inject drugs. The coverage increased from 55 people on OAT per 100 people who inject drugs in 2011. Provincial/territorial coverage ranged from 29 to 163 people on OAT per 100 people who inject drugs in Manitoba and Alberta, respectively.

Service providers and government agencies distributed 49,958,381 needles and syringes across Canada in 2016. This was an increase in needle and syringe distribution since 2011—from 193 to 291 needles and syringes per person who injects drugs. Provincial/territorial coverage in 2016 ranged from 134 to 883 needles and syringes per person who injects drugs, with the lowest coverage in Newfoundland and Labrador and the highest coverage in Alberta.

Comparing OAT and needle and syringe coverage with WHO guidelines

This study indicates that, on average, Canada met the WHO guidelines for coverage of OAT, with 66 people on OAT per 100 people who injected drugs in 2016. The WHO recommends that countries provide OAT to at least 40 people for every 100 people who inject drugs each year. On a provincial/territorial level, one province, Manitoba, failed to meet this standard in 2016.

On average, Canada met needle and syringe distribution guidelines set out by the WHO, with about 291 needles and syringes distributed per person who injected drugs in 2016. The WHO target is for more than 200 needles and syringes distributed per person who injects drugs each year. However, only eight out of 11 provinces/territories met this guideline, with coverage in Newfoundland and Labrador, Quebec and Yukon falling short.

Recent analysis in the Blueprint to Inform Hepatitis C Elimination in Canada suggests that needle and syringe distribution in Canada should be higher than the WHO guidelines, increasing to 750 needles and syringes distributed for every person who injects drugs each year. In 2016, only two provinces/territories, Alberta and Saskatchewan, exceeded this Canadian target.

Implications for service providers

Since 2011, an increasing number of people are injecting drugs in Canada. There has also been an alarming increase in the number of deaths from opioid overdose from 2011 to present day, with more than 4,000 people dying of an opioid-related overdose in 2017 alone. Furthermore, although this study was conducted prior to the emergence of the SARS-CoV-2 virus, the complex health, social and system-level challenges faced by people who inject drugs may contribute to adverse health outcomes associated with the COVID-19 illness. This could further exacerbate the negative health outcomes that are already disproportionately experienced by this community. Together, these factors indicate a strong need for high coverage of harm reduction services and resources to support people who use drugs.

This study demonstrates that coverage of both OAT and needle and syringe distribution increased in each reported province and territory between 2011 and 2016, which suggests an increasing trend in harm reduction service provision over time. Sustaining and increasing access to and coverage of OAT and needle and syringe distribution in Canada is necessary to further reduce the harms associated with injection drug use and to prevent new HIV and hepatitis C infections, accidental overdose deaths and other harms associated with injection drug use. 

The initial dataset used in this study may be limited and will therefore not provide a complete picture of OAT coverage and needle and syringe distribution in Canada. Further, this data does not illustrate service coverage within a province or territory. There may be inaccuracies in the estimates that are a result of the limitations of the initial dataset. A more detailed dataset would provide a clearer picture of OAT and needle and syringe distribution within urban, rural and remote locations that may indicate gaps in local coverage. More detailed information should be used to inform policy and decision-making for program delivery.

A comprehensive package of harm reduction and support interventions and services is necessary to support the health of people who use drugs. In addition to OAT and needle and syringe distribution, this includes the distribution of equipment for smoking drugs, naloxone, overdose prevention sites and support services for people who use drugs.

—Rivka Kushner

Resources

Best Practice Recommendations for Canadian Harm Reduction Programs – Working Group on Best Practice for Harm Reduction Programs in Canada

Everything new every time you use – CATIE postcard

Coping with COVID-19: Insight from the front lines of HIV, hepatitis C and harm reduction – CATIE Webinar

REFERENCES:

  1. The Canadian Network on Hepatitis C Blueprint Writing Committee and Working Groups. Blueprint to Inform Hepatitis C Elimination Efforts in Canada. Montreal, QC: Available from: https://www.canhepc.ca/sites/default/files/media/documents/blueprint_hcv_2019_05.pdf
  2. Jacka B, Larney S, Degenhardt L, et al. Prevalence of injecting drug use and coverage of interventions to prevent HIV and hepatitis C virus infection among people who inject drugs in Canada. American Journal of Public Health. 2020;110(1):45–50.
  3. World Health Organization. WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. 2009. Available from: https://www.unaids.org/sites/default/files/sub_landing/idu_target_setting_guide_en.pdf
  4. Vasylyeva TI, Smyrnov P, Strathdee S, Friedman SR. Challenges posed by COVID‐19 to people who inject drugs and lessons from other outbreaks. Journal of the International AIDS Society. 2020 Jul;23(7):e25583.