We spoke to two service providers about the issues relating to the operation of supervised consumption services (SCS) and overdose prevention sites in Canada.
- Lorraine Barnaby, Supervised Consumption Service Manager, Parkdale Queen West Community Health Centre (PQWCHC), Toronto, Ontario
- Kira Haug, Harm Reduction Coordinator, ASK Wellness Society, Kamloops, British Columbia
Why was a supervised consumption site needed in your community?
PQWCHC’s Queen West site has been delivering harm reduction services in the community for over 20 years. There is an ongoing demand for harm reduction services in our community; Queen West is the third busiest needle distribution program in Toronto. In 2015, we had over 15,000 client visits and distributed almost 300,000 needles. We serve a significant number of people who inject drugs, including people who lack stable housing, inject alone, frequently and in public.
Compared to Toronto overall, there are disproportionately high numbers of people who inject drugs within our catchment area, as well as higher rates of emergency department visits due to drug use. Fatal and non-fatal overdoses are at crisis levels in Toronto. PQWCHC and its community have been deeply impacted by the current overdose crisis. A 2012 study of Queen West harm reduction clients found that 11% had experienced an overdose (in the past six months), over a third reported public injecting, 42.5% had evidence of a current or past infection with hepatitis C, and 51% did not have stable housing. Queen West clients told researchers and us that they wanted and would use an integrated SCS.
How did you implement the supervised consumption site? What were the keys to success or major barriers you encountered? What types of services are provided?
We had been planning and gathering input on this service for many years. We worked with our board members, staff, potential service users and the other proposed SCS sites in Toronto, and we also consulted with Insite and Dr. Peter Centre in Vancouver to develop the service model, policies and protocols. Extensive community consultations were conducted. Approval from the Board of Health and Toronto City Council was needed. It took many years to complete the Health Canada exemption application requirement and get official approval to operate a SCS. It took over a year to get Ontario Ministry of Health and Long-Term Care funding approval.
Key factors in implementation of the SCS included:
- local community support
- collaboration with the other Toronto sites
- organizational readiness
- a communication strategy
- involvement of people who use drugs
Challenges in implementing the SCS included:
- the Health Canada exemption application process
- delays in receiving funding
- completing building renovations
An ongoing challenge is existing Health Canada service restrictions (assisted injection and drug splitting/sharing is not permitted). We are working with other SCS across Canada to advocate for change.
As well, due to the stigma associated with injection drug use there has been a slow uptake of clients using the service. To overcome this, we have:
- done outreach to people who inject drugs, community agencies and our local police division
- recruited SCS ambassadors
- formed a community liaison committee
- adjusted the service model, intake process and physical space to increase accessibility and create a more welcoming environment
Core SCS services include:
- supervision of injections
- emergency response to overdoses
- nursing care
- counselling and case-management
- harm reduction supplies and education
- naloxone kit distribution and training
- drug checking
- referrals to internal and external services and supports
Clients also have access to the Centre’s full range of services and supports. We plan to expand this service to also allow for intranasal and oral consumption of drugs.
What was the outcome/impact of the supervised consumption site for your clients and community?
The opening of our SCS created a welcoming, safe and legal space to inject drugs, get harm reduction supplies and learn about safer injection techniques. During the first three months, the SCS has seen over 225 visits and almost 100 unique clients have accessed services. The service has responded to six medical emergencies/overdoses, as well as reduced the risk of overdose among other clients by encouraging them to use slowly and to test their drugs.
The service has also had an impact on delivering front-line harm reduction, case management, health and counselling services to individuals who use drugs. Additional impacts on clients include:
- connection to primary care services, both internal to PQWCHC and external providers
- referrals to community and social services
- advocacy for clients to access housing supports offered by the City of Toronto (Streets to Homes)
- provision of basic wound care and triage for referral to additional medical services, if required.
The service has led to increased community awareness about harm reduction and the SCS. We’ve connected with several community partners and agencies, including local shelters, social assistance offices, drop-ins and health providers. In addition, we are delivering seven presentations to platoons of the local Toronto Police Division to increase awareness of the service among front-line police.
What can we do to tackle the contaminated drug supply in Canada?
We need to change the system that currently exists. The drug war has been a failure. It is driving overdose deaths and is the direct cause of the contaminated supply. We need to decriminalize all substances and make a safe legal supply available to those who need it. While it will take time to research what decriminalization would look like in Canada, an immediate moratorium could be called on all drug arrests. This would finally allow people who use drugs to access healthcare and call for emergency services when overdoses happen without fear of arrest, assault, stigma or discrimination.
Moving to a decriminalized system would also free up millions of dollars currently spent by police to target and arrest people who use drugs. This could instead be used to fund greater harm reduction programming and services, which will further bring down overdose, HIV and hepatitis C rates.
We can also begin to address the overdose deaths by creating diacetylmorphine and hydromorphone replacement and maintenance programs. We need these programs to be low threshold and built around the needs of people who use drugs. By offering take-home doses, people can build increased stability in their lives and maximize the ease with which people can work, volunteer or spend time doing things other than procure their drugs.
Why was an overdose prevention site needed in your community?
Kamloops, like other parts of B.C., is experiencing an increase in overdose fatalities due to opiate consumption and poisoning. The hardest hit by this epidemic were people who were “living rough” or homeless. ASK Wellness Society provides housing and social services to these vulnerable populations. Each day we would pray that we hadn’t lost another client in the night. Soon, we began to realize the risk extended to all populations of people who use drugs. Folks were going down after ingesting opiates by accident, including tainted supplies of other drugs like cocaine.
When this first began just over two years ago, we were scrambling to get access to naloxone and to be trained to reverse an overdose. Over the past two years, naloxone has become readily available to all people who might witness an overdose, allowing us to implement an overdose prevention program.
How did you implement the overdose prevention site? What were the keys to success or major barriers you encountered? What types of services are provided?
ASK Wellness Society partnered with Interior Health in British Columbia to launch a mobile supervised consumption service in 2016. The facility is a bus retrofitted to be a mobile clinic. The bus parks outside of our two locations in Kamloops and offers a place where people who use drugs can be safely monitored and treated if they overdose.
We have also converted a small space in our building to provide other overdose prevention services. We provide peer-delivered services and programming including:
- needle retrieval and community engagement
- outreach services
- naloxone training and provision
- overdose first response
- harm reduction programming
- referrals to wrap around services.
Once a week we also have street nurses who can do wound care, HIV/HCV/STI testing, and support to begin methadone or Suboxone (buprenorphine/naloxone) replacement therapies.
The most challenging barrier has been around public support for homelessness and drug use in our community. Stakeholders in the business and residential sectors are tired, frustrated and angry about litter, loitering and crime that has been occurring. Discarded needles and other paraphernalia has led to an overall sense of empathy fatigue from the community.
We have been creative in our response to this issue. We distribute contact cards to community members that list our partners and phone numbers for services such as outreach services and needle retrieval. We also have weekly meetings with multiple partners, including the police, Canadian Mental Health Association and local shelters to discuss hot spots, concerns and solutions for individuals with problematic behaviours.
Another barrier is reaching folks who are living alone, using alone, or are scared to reach out for supports because of stigma and discrimination.
What was the outcome/impact of your overdose prevention site for your clients and community?
Impacts for our community and stakeholders have been profound. Our overdose prevention services have improved access to programming and education for people who use drugs and family members or friends of people who use drugs. Regular contact with clients for access to harm reduction services and tools creates opportunities to build trust and rapport. This contact can help connect them to further wrap around services including supports for:
- mental health
- chronic health
- income assistance
- replacement therapies for opiate dependence
- access to the food bank.
Within the community of people who use drugs, we have also noted that folks are taking more care of each other. Our clients have saved dozens of lives by having and knowing how to use naloxone.
However, although we are saving lives, local community members have also been impacted. Residents, business owners and other groups see a real or perceived increase in open drug use; overdoses and the overdose response; and an increase in crime, discarded syringes and homelessness. We are often on the receiving end of community concerns, anger and fear surrounding this epidemic. This has been a frustrating and dismaying situation for our frontline workers, however we try to use these interactions to educate about harm reduction, trauma and poverty.
What can we do to tackle the contaminated drug supply in Canada?
Tackling a contaminated drug supply is extremely challenging. Many of our folks who use opiates actually seek out fentanyl and may not consider the supply to be contaminated. However, there are also many concerning reports of non-opiate drugs (such as cocaine) that are contaminated with fentanyl. Because of this, drug testing should be widely available for all people to access.
Prevention education should also be offered to youth early on so they know the harms before ever having to be in a high-risk environment. Medical morphine programs may also be useful as folks could have access to safe opiates prescribed and overseen by a physician.