Needle Exchange & Safer Inhalation (NESI) Program

What is the program? 

The Needle Exchange & Safer Inhalation (NESI) program is housed within the Somerset West Community Health Centre (SWCHC) in Ottawa. The program uses community and harm reduction outreach workers to distribute safer inhalation and injection supplies and to collect and dispose of used equipment, and it provides peer support to people who use drugs. The program also provides harm reduction health education and referrals to services within the SWCHC and to other health and social service providers in the community.  

The SWCHC is a community-based health service organization that provides a variety of health and social services by removing barriers to accessing services for vulnerable populations (e.g., people who use drugs, isolated seniors, people who are homeless or precariously housed). Services offered include primary healthcare, harm reduction, health promotion and counselling. NESI is funded by the AIDS Bureau of the Ministry of Health and Long-Term Care (MOHLTC) in Ontario. 

Why was the program developed? 

The NESI program started in 2007. It was developed to provide a variety of harm reduction services under one roof to better meet the needs of people who use drugs. 

A core feature of the NESI program is the recognition that people with lived or living experience must play an integral role in the development and delivery of harm reduction services. This is because these individuals, called community workers in the program, have experienced what it is like to access services in the community and have an invaluable perspective on how to deliver these services effectively. In terms of delivery, community workers often are more successful at connecting with clients, building trusting relationships and increasing comfort among service users than professionals, who may not have personal experience with substance use themselves. 

How does the program work? 

The NESI program is part of the harm reduction department at the SWCHC. It includes three components: a gear room, day-time outreach and a regional NESI van. All programs meet clients where they are at and provide accessible, point-of-contact supports. 

The program is staffed by harm reduction outreach and community workers who work across the SWCHC harm reduction department in a variety of programs. A NESI program lead provides leadership to the program and supports front-line staff in their work. Community workers self-identify as having lived or living experience of using drugs and being from the drug using community. Harm reduction workers usually have more formal training and experience. They may also have lived or living experience that is relevant to the role, but this is not a required qualification for these positions. Community workers and harm reduction outreach workers take on roles in different components (e.g., gear room, day-time outreach) of the NESI program.

Gear room

The gear room is a space where community members can come and pick up harm reduction supplies (safer injection and inhalation kits, safer sex supplies). The gear room is run by community workers and operates from 9:00 a.m. to 4:00 p.m. Monday to Sunday. The gear room is also a safe space for community members to visit and get referrals to other services within the SWCHC and surrounding community (e.g., supervised consumption sites, primary care). Clients are normally followed up with by day-time outreach staff to ensure that they have connected to the services they need. There is regular communication between gear room and day-time outreach staff to ensure that clients are connecting to the services and not lost to follow up.

Day-time outreach

The day-time outreach component of NESI conducts outreach to people who use drugs in the SWCHC catchment area and is staffed by harm reduction outreach workers. Day-time outreach usually happens from 9:00 a.m. to 5:00 p.m., Monday to Friday. It includes services such as informal case management (e.g., navigating clients through systems of care), transportation support for clients, brief counselling and accompaniment to services. Staff also provide harm reduction education to clients, distribute and safely dispose of harm reduction supplies and connect clients to services within the community. 

Harm reduction outreach workers visit community members in encampments, their homes and local parks. During the COVID-19 pandemic, they have also engaged with respite centres to reach community members.

A variety of formal and informal partnerships have been established to reach clients and to provide referral pathways. The partnerships include rooming houses, the Salvation Army’s Street Outreach Team and Housing First Response Team and St. Luke’s Table (drop-in services). These partnerships facilitate referrals to programs and support better system navigation and collaboration for better client outcomes and connection points to engage in the community.

Day-time outreach staff provide training to staff at other organizations on harm reduction approaches both formally by request and through informal knowledge sharing.

NESI Van

The NESI van provides harm reduction supplies and HIV point-of-care testing. The van runs Monday to Saturday, 4:30 to 11:30 p.m. The van is staffed by one harm reduction outreach worker and one community worker who can also provide referrals and connection to other community services as needed. Point-of-care HIV testing is done in collaboration with the SWCHC’s anonymous HIV outreach testing worker across the city of Ottawa. A variety of resources and supports are provided if confirmatory testing is required.

Community workers

Community workers self-identify as having lived or living experience of using drugs and being from the drug-using community. They staff the gear room and NESI van. Community workers have a range of lived or living and professional experiences; some are new to working in healthcare, whereas others have prior educational and work experience in the field. Other lived experience that intersects with the social determinants of health (e.g., experience with homelessness, the justice system) is also valued. Some community workers have been previous service users of the organization and have a good understanding of how services at the SWCHC and broader community services work. 

Hiring process

Community worker applicants generally hear about the program through word of mouth and modelling by existing community workers. The program accepts paper applications, which it reviews for recruitment when new staff are required. Current community workers are included on the interview panel for new recruits. The interviews tend to be conversational (e.g., questions about judgement and boundary setting) and are related to applicants’ lived or living experience and readiness to work in a health centre setting. 

If a candidate is not ready for a staff role, they are encouraged to seek other paid opportunities, such as making harm reduction kits and participating in community needle clean-ups. The SWCHC helps individuals to complete a police record check (e.g., fee payment, accompaniment to complete required paperwork), which is a requirement to work at the SWCHC. The wage for community workers is based on a "livable income." Community worker staff, like all staff of SWCHC, are eligible for leave entitlements and other benefits.

Training, supports and accommodations 

A variety of trainings, supports and accommodations are provided to community workers to ensure success, health and growth for the SWCHC’s employees and the overall team. Community and harm reduction workers are provided training in: 

• naloxone use
• non-violence crisis intervention 
• suicide intervention
• HIV and hepatitis C
• CPR and basic first aid
• use of anti-racism and anti-oppression approaches
• confidentiality, assertive communication, understanding and managing aggressive behaviours, motivational interviewing, boundary settings and understanding dual relationships (client/staff)
• computer literacy (e.g., email writing)

In addition to this core training, SWCHC offers community workers ongoing training opportunities based on the needs (and requests) of staff, a community of practice specifically for community workers, and shadowing and mentoring opportunities from more experienced community workers. 

There is a need to recognize the trauma, grief, stress and potential burnout that community workers who are at the frontlines of the overdose and drug toxicity crisis may experience. SWCHC offers its community workers flexibility in scheduling and absenteeism, in addition to arranging for regular check-ins. Staff supervisors have training in trauma-informed care and operate from a frame of bridging the gaps between drug culture, street culture and health centre culture. The needs of community workers can change from the time they are hired and onboarded to the time they are established in their role. SWCHC strives to regularly adapt to best meet the needs of its staff and clients by normalizing regular support, supervision and response. All staff are also entitled to use SWCHC’s employee assistance program.

Required resources 

• Community workers
• Harm reduction outreach workers
• Program lead
• Safer drug use supplies (e.g., needles, pipes, stems) and safer sex supplies 
• Van
• Space for supply distribution (gear room)
• Connections to community health and social services for referrals 
• Funding source

Evaluation

The most frequently provided service from April 2020 to March 2021 through day-time outreach and NESI van was practical supports, which included helping clients acquire food, clothing, transit tickets, toiletries, as well as assistance with transportation and accompaniment to appointments and services, helping them with identification documents and completing forms (among other activities). This was followed by brief counselling (e.g., brief crisis intervention, ‘just listening’) and harm reduction education. (e.g., how to use the equipment).

For the period from April 2020 to March 2021, there were 2,362 client interactions through the NESI van. Locations where staff interacted with clients as part of day-time outreach included:

• needle exchange/syringe program (21,993)
• community agencies/services (e.g., out of the cold programs, shelters) (2,140 interactions)
• residences (e.g., client home, apartment/house, hotel/motel, friend’s place, (1,616 interactions)
• streets/parks (1,376 interactions)
• methadone maintenance/opioid agonist therapy clinics (218 interactions)

For the period of April 2020 to March 2021, referrals from the day-time outreach and NESI van to other programs and services included:

• harm reduction services (1,333 referrals)
• clinical service providers (e.g., HIV, urgent care, primary care and other providers) (310 referrals)
• addiction services (209 referrals)
• mental health service providers (163 referrals)
• hepatitis C testing and hepatitis C team (7 referrals)
• community-based HIV service providers (3 referrals)
• HIV/STI testing (2 referrals)
• other community-based service providers (e.g., faith-based services and spiritual support, social services, women-specific services, housing (784 referrals)

For the period of April 2020 to March 2021, the following harm reduction supplies were distributed through the day-time outreach and van included (among other supplies):

• 120,572 cookers
• 73,846 filters
• 267,912 needles
• 73,320 vitamin C and acidifiers
• 70,842 glass pipes and stems
• 23,681 mouthpieces
• 136,677 screens
• 21,996 crystal meth pipes
• 39,403 foils (for smoking)
• 19,991 condoms
• 8,169 lubricants
• 106 dental dams

Challenges

• Community workers may experience stigma within the organization and with clients because of their lived experience and other aspects of their identity.
• Community workers may not always be seen as staff when working in community (e.g., by police, other agencies, emergency medical services).
• Navigating boundaries in the workplace and when interacting with members of their community may be difficult, as well as potential triggers (e.g., drug use).

Lessons learned 

• Use an overstaffing scheduling model (i.e., scheduling more staff than needed) to support staff who are unwell or otherwise unable to work.
• Offer information in as many ways as possible (e.g., in different languages, in plain language, through technology, in print and in person). 
• Update relevant policies and create new ones: adapt organizational processes and structure to support peer staff hiring and retention.
• Emphasizing and normalizing skills such as critical self-reflection, debriefing and grounding within regular workplace routines leads to constructive feedback, continuous improvement and enhanced professional development for all staff.
• Ongoing scope reinforcement is needed to reduce the incidence of staff taking on activities that are outside of their roles and responsibilities. 

Program materials 

• Applications for community worker and peer harm reduction worker positions
• Staff onboarding and training logs
• Timesheets for hourly work
• Staff wellness care plans
• Harm reduction COVID-19 manual

Contact information 

Hana Haines
Manager of Operations, Harm Reduction
Somerset West Community Health Centre
55 Eccles St.
Ottawa, ON K1R 6S3
hhaines@swchc.on.ca