Harm Reduction Services in Ottawa

• Anyone can overdose (first time and long time users, youth and older adults).
• Fentanyl is often made as a powder and mixed with other drugs. It is also being pressed into pills. It is around 50 to 100 times more toxic than morphine. This makes the risk of accidental overdose much higher.
• There is an increased risk of overdose after a period of non-use (like being released from prison, hospital, or a treatment facility) or from a lack of access to drugs.

• Avoid using alone. Fix with a friend and leave the door unlocked.
• Avoid mixing drugs with prescription and over the counter drugs, alcohol, benzodiazepines, other opiates and/or uppers like cocaine or crack.
• Use one drug at a time if you are mixing and take a break between drugs.
• Inject, snort, or smoke a very small amount first to test its strength.
• Illicit fentanyl is much more toxic than other pharmaceutical opioids
• There is no easy way to know if fentanyl is in your drugs. You can't see it, smell it or taste it
• Fentanyl is being cut (mixed) into both opioid and non opioid drugs
• If you are feeling sick or under the weather, use less and be more careful.
• Use less when your tolerance is low (like when you haven't used in three or more days).
• Let your community agency know if you notice any changes with your drugs.
• An overdose is a medical emergency! If you or someone else is overdosing, do not hesitate to CALL 9-1-1.

• Education about the drug Naloxone.
• Overdose risk and myth information.
• Overdose prevention training.
• Steps on how to respond to an overdose.

You can also visit the Province of Ontario's web page to find the nearest naloxone distribution partner near you.

On September 22, 2017, under Section 56.1 of the Controlled Drugs and Substances Act, Health Canada provided an exemption to Ottawa Public Health via the Sandy Hill Community Health Centre authorizing the operation of Supervised Injection Services (SIS) on an interim basis by Ottawa Public Health at 179 Clarence Street. On May 10, 2018, OPH was granted an exemption from the Controlled Drugs & Substance Act (CDSA) to operate a Supervised Consumption Site under the section 56.1 of the CDSA, valid for one year.

The Health Canada exemptions allow OPH to offer health services that provide a hygienic environment for people to either inject, swallow or inhale pre-obtained drugs under supervision. The supervised consumption service (SCS) is staffed with public health employees with experience in harm reduction and trained and authorized to provide supervised consumption services.

While SCS is an important component of any comprehensive approach to working with people who inject, swallow or snort drugs, it will not solve all the issues related to the current opioid crisis.

OPH is working closely with Ottawa Police Services (OPS), the City of Ottawa's Corporate Security Services and Ottawa Community Housing to ensure safety for staff, clients, and the surrounding community and is committed to continuing an ongoing dialogue with the community.

OPH will continue to monitor the situation and work alongside and in support of partners, including local shelters, other local harm reduction service providers, peer-led services and the Ottawa Overdose Prevention and Response Task Force, who all share a common goal of saving lives from potential overdoses.

OPH has enhanced its existing harm reduction services by adding a supervised consumption service (SCS) to its existing services for people who inject, swallow or snort drugs (OPH's Site program at 179 Clarence Street). Supervised consumption services are health services that provide a hygienic environment for people to inject pre-obtained drugs under supervision.

Supervised consumption services have four (4) main goals [1] [2]

1. To reduce spread of infectious diseases (HIV and hepatitis C);
2. To reduce the number of drug overdose deaths;
3. To bring people who inject, swallow or snort drugs into contact with other health and social and treatment services; and,
4. To reduce issues in the community such as drug use in public places, and discarded needles.

In addition to supervised consumption, individuals are provided with sterile injection supplies, clean inhalation supplies, education on safer consumption, overdose prevention and intervention, medical and counselling services, and referrals to drug treatment, housing, income support and other services.

The permanency and range of services offered at each site are the main differences between the two.

Overdose Prevention Services (OPS):

Overdose Prevention Services are an extension of existing harm reduction programs that provide easy-to-access, life-saving harm reduction services in a stigma-free environment, to help reduce the growing number of opioid-related overdose deaths. The sites will provide:

        •Supervised injection

        •Harm reduction supplies, including disposal of used supplies

        •Naloxone

Sites may also provide additional services based on local need and capacity, including supervised oral and intranasal drug consumption and fentanyl test strips as a drug checking service.

OPS that meet the necessary criteria will be approved to operate on a time-limited basis, usually three to six months (with the possibility of extension), by the Province of Ontario. OPS may act as “interim” services as they are set-up rather quickly (only a few weeks) to address an immediate need in the community while waiting to establish Supervised Consumptions Services.  For more information on OPS criteria and application process please visit http://www.health.gov.on.ca/en/news/bulletin/2018/hb_20180111.aspx. 

Supervised Consumption Services (SCS):

A SCS is tailored to be a permanent site with integrated support services. As such, the application process to Health Canada for a SCS is more complex and involves several steps. The process can take months as it includes fulsome consultations with the community, partners and participants along with selecting and renovating a permanent location. Health Canada grants a one-year exemption and once expired a renewal application is reviewed for another year exemption. SCS must have registered nurses on staff working under medical directives in order to provide medical intervention such as administering oxygen. Another requirement for SCS is to have a network of support services at their sites for individuals, such as addiction treatment programs, counselling and support for permanent housing. At 179 Clarence, the SCS offers direct links to these kinds of services and allows injection, oral or intranasal forms of consumption. 

Research has concluded that Ottawa would benefit from multiple supervised consumption services (SCS) that are integrated into health services already working with people who use drugs. Conditions in Ottawa support the need for SCS.

Rates of HIV (10%) and hepatitis C (70%) infection among people who inject drugs in Ottawa are higher than for the general population.[3] In addition, twenty-five percent of people who inject drugs usually or always inject in public places and 19% report sometimes injecting in a public place [4].

A total of 48 Ottawa residents died from unintentional drug overdose in 2015, 29 (60%) of which were due to opioids such as fentanyl, oxycodone, and morphine. [5]  Between 2000 and 2015, the rate of death due to unintentional drug overdose from any drug increased 23% in Ottawa. Unintentional overdose deaths due to opioids were 2.7 times higher during 2009-2015 (24 per year) compared to 2003-2008 (9 per year). For more drug use and overdose statistics, see OPH's website.

Recent anecdotal information from community groups and service agencies are reporting increased numbers of overdoses and deaths. Even though many of these overdoses are not seen in emergency departments, there were nearly 700 drug overdose-related Emergency Department visits during the first half of 2017.

Currently there are three other supervised injection sites in Ottawa:

• Ottawa Inner City Health - Trailer
• Sandy Hill CHC
• Somerset West CHC

All of the above are operating under exemptions from the federal Controlled Drugs and Substances Act (CDSA). 

OPH works with over 20 community agencies to provide harm reduction services in Ottawa and is actively working with municipal and community agencies to address the opioid crisis in our community, which includes increasing overdose peer support in the community and ensuring naloxone is readily available to prevent overdoses.

Supervised consumption services will improve harm reduction services that are currently offered in Ottawa. SCS provide a safe, clean, indoor, supervised environment for people to inject, swallow or snort illicit drugs with an opportunity for safer drug use teaching, overdose prevention support, and referral to counselling, withdrawal management, and addiction and other health care services. Without a safe place to use illicit drugs, people may use in isolation thereby increasing the risk of overdose death and/or may inject, swallow or snort in public spaces. Using illicit drugs in public is not only an issue for people who are homeless, but people living in shared accommodation or shelters may be afraid of losing their accommodation if they use on the premises, so they turn to public spaces. [6]Research has found that people who inject drugs will only travel short distances (i.e. a few city blocks) to use health services, including supervised injection services.[7] [8] The SCS will allow OPH to address the ever-growing public health issue and the continued need for opioid overdose prevention services.

A number of people who use the services are already existing clients of OPH's Site program.

Clients arrive at the program with pre-obtained drugs. Each person is assessed to ensure they are eligible for the program. Clients are then given sterile injecting equipment or clean inhalation supplies  with instruction on safer drug use. A nurse supervises their consumption in a room dedicated for this purpose, and intervenes in the case of any medical emergencies. Once the clients have consumed their drugs, they are directed to a waiting area, and encouraged to stay for 15 minutes to be observed for any negative drug reactions. Clients also receive information and referrals about other health and social supports. This small-scale service has 2 consumption booths and is located in the Site program's existing location at 179 Clarence Street. The Site program and the supervised consumption service are open Monday to Friday from 9:00 am to 5:00 pm. The SCS is staffed by public health nurses trained in supervised consumption and overdose response, and by outreach/social workers and Peer Educators experienced and trained in harm reduction.

International and Canadian research shows that supervised consumption services have benefits both for individuals using the services and for the community, including:

• Reducing the number of drug overdoses and deaths;
• Reducing risk factors leading to infectious diseases such as HIV and hepatitis;
• Increasing the use of detox and drug treatment services;
• Connecting people with other health and social services;
• Reducing the amount of publicly discarded needles;
• Cost-effectiveness; and,
• Not contributing to crime or increased drug use in the local community.

Research has shown that harm reduction programs do not increase public disorder or threaten public safety. In fact, they tend to have the opposite effect. Supervised consumption services are located in neighbourhoods where there is a demonstrated need, usually where drug use is already having an impact on the community. Harm reduction programs have a positive impact on public health and safety by:

• Preventing blood-borne infections such as human immunodeficiency virus (HIV) and hepatitis C among people using drugs
• Ensuring that more needles and syringes are disposed of safely through programs, rather than discarded in the community
• Supporting agreements between police and harm reduction services that ensure drug trafficking laws are enforced. This creates an environment where open drug dealing is discouraged, and people who use drugs are encouraged to access needed services.

OPH conducted a public consultation in 2016 (see report for results of the consultation). Among the consultation's findings:

• 66% of respondents thought that having supervised injection services available would be beneficial.
• 60% of respondents thought that offering harm reduction services in more areas of the city would be beneficial.

Feedback, comments, questions from the public are always welcome using your choice of communications channel. Contact information here.

Evaluation of OPH's Interim Supervised Injection Service

To respond to an emergency situation in Ottawa, and to enhance harm reduction and help prevent overdoses in the community, Ottawa Public Heath (OPH) started offering supervised injection services (SIS) on an interim basis at its Clarence Street location. Between September 2017 and December 2017, OPH evaluated the implementation and operations of its interim SIS. The evaluation monitored how the services were used (i.e. client data, services provided) and the experiences of four distinct groups: clients, employees, neighbours (residents and businesses) and community partners. We gathered information through: a review of clinical forms; client comment cards; focus groups with partners and employees; surveys with clients and with neighbours (collected by going door-to-door); and, secondary data sources, such as police data and calls/contacts to 311 and OPH’s contact centre.

Here is what our stakeholders told us:

Clients
Overall, clients were satisfied with the various services received. Clients told us they:

• Felt safer when they use drugs at the SIS (93%)
• Injected in public less often (87%)
• Thought more about reducing or stopping using drugs (60%)
• Injected alone (by themselves) less often (77%)
• Felt that their drug use was more stable/less chaotic (77%)
• Reported a strong likelihood of recommending the service to other people who inject drugs (97%)
• Believed that staff provided good support (97%)
• Felt that staff had talked/helped them access other services (70%)

Selected quotes from clients:

• "I have overdosed at least 5 times in my life; since you opened I haven’t overdosed."
• "I feel I am supported and accepted even though I am a drug addict. I feel that I matter."
• "I have never felt like I can talk with health professionals so openly about my drug use. I am able to talk about others issues in my life. E.g. the other day they helped me by connecting me with mental health. All around they’ve been very helpful." 

Employees
Employees are passionate about helping SIS clients and they enjoy their therapeutic relationships with clients. Team collaboration is strong. Overall, they are satisfied with their additional roles and responsibilities at the SIS. 

Some recommendations from employees:

• Implement a workplace employee peer-support program
• Develop a formal training plan
• Develop a sustainable and more comprehensive model that includes best practices

Neighbours (residents, businesses)
Neighbours have diverse opinions regarding their support for SIS and about the impact that OPH’s interim SIS has had on them,

• 51% support SIS
• 37% not supportive
• 12% were undecided

Regarding the impact of OPH opening an interim SIS in the neighborhood,

• 44% indicated the impact has been “negative” or “very negative”
• 39% reported the impact has been “positive” or “very positive”
• 7% were “neutral”

Concerns expressed by residents include: threats to personal safety, damage to public and personal property, dissatisfaction with officials when responding to their issues and concerns, and an increase in disruptive/nuisance behaviors in the neighborhood.

Partners
The majority believed that OPH’s interim SIS has had no impact on their organization. Those who indicated that there was a negative impact perceive an increase presence of public drug use. While partners talked about public injecting, there were mixed perspectives on whether public injecting has increased or decreased as a result of the new SIS. Partners who were involved in advising OPH on its interim SIS were satisfied with their involvement. There are several factors external to OPH that may have influenced implementation and the experience of those involved with and impacted by the SIS. This included the opening and ending of operations of Overdose Prevention Ottawa’s ‘pop-up’ tent in Raphael Brunet Park and the opening of Shepherds of Good Hope’s SIS trailer; changes in drug use patterns among people who use drugs; and increasing number of overdoses in the community. There is agreement amongst community partners that there are many factors not related to OPH’s SIS that may have impacted the community. As such, it is difficult to attribute causality between OPH’s interim SIS and any impact on the community and partner agencies’ operations. 

For more information:
View the Harm Reduction and Overdose Prevention Follow-up Report received and approved by the Ottawa Board of Health on February 5, 2018.

References