The harms associated with the injection of substances have recently been brought into focus with deaths involving fentanyl across Canada. Considered the most potent and addictive painkiller on the market, between 2009 and 2014, some 655 deaths in Canada have been linked to fentanyl, including one involving injection. The crisis continues, as in 2016 an estimated 2,458 Canadians died from an opioid-related overdose.
Injection overdoses from substances such as morphine, heroin, cocaine, amphetamine, and methamphetamine are a public health issue that disproportionally affects marginalized populations, including people experiencing homelessness. Those with a history of abuse, addiction, poverty, incarceration, mental health, low educational attainment, un/underemployment and who lack access to housing and/or appropriate healthcare services are at an increased risk of harm from substance use. It is estimated that over 89,000 people inject substances in Canada, and the issue remains a significant risk factor for premature mortality, suicide, mental health conditions and HIV or hepatitis C infection. In the year 2015 it was estimated that 16.3% of Injection Drug Users (IDU) were exposed to HIV.
Homelessness has consistently been associated with injection drug use and found to be a coping mechanism in dealing with the dangerous and harsh realities of homelessness.
Available health services across Canada tend to focus on prevention, withdrawal management and treatment programs. However, there are also pragmatic treatments and rehabilitation approaches that neither condone nor condemn substance use, but rather focus on harm reduction. Such measures include needle exchange programs, methadone maintenance treatments and supervised injection facilities (SIF). Outreach and education programs, as well as cooperation between health and law enforcement officials, can help those who use substances to access health and social services. Harm reduction models are relatively new to Canada with the first SIF in North America, Insite, opening in 2003 in Vancouver’s Downtown Eastside.Harm reduction initiatives have been shown to reduce:
- The sharing of needles and other drug paraphernalia
- The transmission of infections
- Overdose deaths and injuries
- Crime rates
- Costs for health, social, legal and incarceration associated with injection drug use
Insite provides a safe health-focused centre where people can inject substances under the supervision of nurses. Since opening its doors, fatal overdoses in Vancouver’s Downtown Eastside have decreased by 35% and no deaths have occurred onsite. In the year 2016, there were 75,092 registrants at Insite, with 3,636,512 visits. There were also 48,798 clinical treatment visits, 6,440 overdose interventions, and no deaths.
Because half of Insite’s clients are homeless and/or have mental health conditions, it offers counselling, detox treatment, primary care to treat disease and infection and connects users with other health care services, housing and community agencies. The influence of Insite goes beyond changing behaviour, reducing overdose fatalities and enhancing public safety. Clients create meaningful, trusting and dignified relationships with staff that fosters personal empowerment while raising self-awareness. In turn, substance users become safety and educational ambassadors within their own circles and strengthen their community bond.
The body of scientific evidence emerging out of Insite’s success has been instrumental in making the case to expand supervised injection services to other communities affected by injection drug use. While Montreal is preparing to establish its first SIF, Toronto city council has recently approved three SIFs to open at existing downtown health-care facilities. There has been overwhelming support from city officials, neighbourhood residents and business improvement associations where the sites are being planned to open next year. The three agencies that will provide supervised injection services include: Toronto Public Health (The Works), Queen West-Central Toronto Community Health Centre and the South Riverdale Community Health Centre.
A major concern for the city of Toronto is the 41% jump in overdose deaths from 2004 to 2013 as well as the increase in use of opioids, such as heroin and fentanyl.
To address these issues, Toronto SIFs will provide sterile injecting equipment and instructions on safe practices. Users will also receive information and referrals to other health and social support services in the community. However, before establishing the sites, the municipality needs to seek provincial approval and a federal exemption from Section 56 of the Controlled Substances and Substances Act. By following Vancouver’s SIF model, Toronto and Montreal are making critical steps forward in providing a wider range of programs and strategies to protect its residents, families and communities. As of June 2017, three safe injection sites have opened in Montreal, Canada— Cactus, Dopamine and Spectre de Rue.
While SIFs and harm reduction programs are essential components in addressing injection drug use, more supports are required to further reduce substance use-related harm using the best available evidence. Thus far, the evidence is clear-cut; SIFs, including Insite, save lives.