Reducing the Harm Associated with Injection Drug Use in Canada

6. Framework For Action

It is imperative that immediate action be initiated within a framework of: prevention; outreach; research, surveillance and knowledge dissemination; treatment and rehabilitation; and national leadership and coordination. This framework supports the development and enhancement of multi-level strategies and actions to reduce the harm associated with injection drug use in Canada. It is important that it be adapted to meet the needs of various communities, jurisdictions, and diverse populations of people who inject drugs. Immediate actions are presented below and a comprehensive approach with actions for both the immediate and longer-term is presented in Appendix C.

Prevention

Prevention is an essential part of any comprehensive approach to substance misuse. Prevention can reduce the incidence of substance misuse and injection drug use in the long term. Prevention strategies (including public awareness, education, skill development, social marketing, community action, and policy development) work together over time to shift attitudes, knowledge, behaviours, and social conditions in ways that reduce the chances that someone will begin misusing drugs in the first place, particularly for youth, or begin using them in more harmful ways, such as by injection.

Recommended Actions

Develop and enhance initiatives that address the underlying factors and conditions that put people at risk of misusing drugs, particularly by injection.
Develop and enhance initiatives that address the underlying factors and conditions that put people at risk of engaging in unsafe injection practices.
Develop and enhance initiatives that focus on at high risk youth and the prevention of injection drug use.

Outreach

An integral part of reducing the harm associated with injection drug use is outreach work. Peers are most effective in reaching people with drug problems, and are often seen as the most credible and trustworthy people to provide them with information to reduce the risk associated with drug use and link them with health, social, and addiction services. Peers are also in the best position to provide referrals to drug user groups and networks.

It is necessary to reduce particularly high-risk behaviours associated with injection drug use such as those leading to HIV and hepatitis B and C (needle sharing), and overdose. Needle exchange programs are a classic example of outreach. Needle exchange programs in Canada exchange millions of needles and syringes annually. A fundamental rationale for their establishment is that people who inject drugs share needles, syringes and other injection materials, a frequent mode of transmission of HIV, hepatitis B and C viruses and other blood borne pathogens. Needle exchange programs convey educational messages about the health risks of injecting and provide bleach kits, counseling, referral and support and other services. The availability of needle exchange has not led to an increase in drug use. Needle exchange programs have, however, reduced rates of needle sharing among clients, linked many drug users with health, addictions, and social support systems, reduced rates of occupational exposure for correctional services personnel and taken used needles out of circulation.

In Canada, community-based needle exchange programs are one of the important strategies in a harm reduction approach to injection drug use, but it is necessary to improve them, expand them, particularly in rural communities, and consider pilot projects in correctional facilities. Despite concerns expressed by clients and staff of needle exchange programs regarding enforcement, for the most part, health and enforcement services work well together. It is necessary, however, to be aware of the concerns and to ensure that health and enforcement sectors are working toward complementary goals.

Despite the availability of needle exchange programs in Canada, the actual injection of drugs may take place in an unsafe or unhygienic environment, increasing the risk of overdose and infection. In some countries, supervised injection sites^j are provided to decrease these risks. Supervised injection sites are legally accepted and medically supervised facilities designed to provide people who use drugs by injection with a safer and more hygienic site where they can inject drugs. They are provided in order to reduce the hazards of unsafe injection practices and also to counteract the public order problems associated with illegal injection drug use and are considered to be a low threshold service usually embedded within a harm reduction strategy. There are some positive evaluation data from countries that have tested and implemented supervised injection sites. Some results show decreased rates of overdose, fewer needles found in the environment, fewer people injecting in public, and reduced criminality. There is much discussion regarding the effectiveness, feasibility, and applicability to the Canadian context.

Recommended Actions

• Work with law enforcement, justice, all levels of government, community groups and others to enhance the implementation, accessibility and effectiveness of needle exchange programs and reduce the barriers in all settings in Canada, including the consideration of pilot projects in correctional facilities.
  
• Support outreach and networking initiatives at all levels to foster and increase harm reduction initiatives, increase access to effective health, social and treatment and rehabilitation services, and enhance social integration and reintegration (e.g. prisoners returning to their communities upon release from a correctional facility).
  
• Foster the involvement of people who use drugs by injection and drug user networks in reducing the harm associated with injection drug use.

Treatment and Rehabilitation

The broad economic and social policies in Canada should recognize and deal with addiction and drug use as a barrier to growth, social cohesion and population health. For each citizen to have the opportunity to participate in society and the economy, it is important to provide immediate and compassionate care to those individuals experiencing substance misuse and injection drug use problems.

The availability of and accessibility to a range of addiction treatment options is an essential component of a comprehensive response to injection drug use. The options offered should be based on evidence of efficacy while recognizing the importance of including a range of services and treatment philosophies (e.g. professional counseling, peer counseling, detoxification, residential, referral and community service coordination and housing).

Methadone maintenance treatment, which includes a range of ancillary supports, is an effective means of reducing injection drug use, needle sharing and the harm associated with the injection of opiates and criminal activity. Since the rates of illicit drug use, mortality, and transmission of pathogens such as HIV and the hepatitis C virus have risen to serious proportions, it is imperative to increase the availability of and accessibility to effective methadone maintenance treatment, including in correctional facilities and rural areas. It is also necessary to ensure that methadone maintenance treatment is closely linked to complementary health, social, and addictions services. These services often include counseling, job training, and help in returning to school.

Some countries with highly developed systems for methadone maintenance treatment have found that a substantial proportion of heroin users remain resistant or refractory to this mode of treatment. These individuals tend to be long-term heroin users, have experienced several failures with methadone maintenance treatment, and are often currently diagnosed with psychiatric illnesses. It is important to note that, even in countries that are testing and using heroin as a treatment option for a select population, methadone maintenance treatment continues to be the best option and gold standard course of treatment for the majority of clients.

Recommended Actions

• Increase the availability of and address barriers to effective substance misuse treatment and rehabilitation programs, including methadone maintenance treatment, in all settings, including correctional facilities.
  
• Support, in principle, clinical trials to assess the treatment effectiveness of the prescription of heroin, LAAM, buprenorphine, and other drugs in the treatment of people who inject drugs.^k

Research, Surveillance, and Knowledge Dissemination

Addiction research and research directed at injection drug use in particular are critical to maintain a sound base of evidence that reflects current knowledge about drug use prevalence and trends, best practices and program outcomes. It is particularly important to remain abreast of the innovative and alternative approaches that are being piloted, evaluated and adopted in various countries. In this way, it is possible to learn more about options for program and service expansion and alternate methods of delivering existing programs, including varying thresholds for eligibility.

Recommended Actions

• Monitor innovative approaches used in other countries to address injection drug use and assess their applicability to the Canadian context.
  
• Develop a framework for reporting regularly using agreed-upon indicators on injection drug use and its consequences, develop the tools necessary to collect and disseminate the relevant data and information, and monitor progress made to address this critical issue.
  
• Establish a task group consisting of, at a minimum, law enforcement, justice, health and social services, addiction and community perspectives to conduct a feasibility study of establishing a scientific, medical research project regarding a supervised injection site in Canada.
  
• Improve surveillance of the injection drug use situation and its consequences in Canada through data collection, targeted studies, and research to assess causes, co-factors, and effectiveness of interventions.
  
• Enhance knowledge dissemination and education regarding injection drug use, its determinants, and its health and social effects for health and social service professionals, enforcement and justice officials, persons who inject drugs, inmates in correctional facilities and the community at large.
  
• Conduct research on Canadians' attitudes regarding harm reduction principles and specific harm reduction strategies.

National Leadership and Coordination

There is currently significant national collaboration and coordination with respect to substance misuse, HIV/AIDS, hepatitis C, and other issues linked to injection drug use through interdepartmental working groups, federal/provincial/territorial committees, etc. However, it is necessary to enhance the links among these existing mechanisms to ensure focused collaboration and dialogue on the cross issue of injection drug use.

For example, a focus on reducing the harm associated with injection drug use requires strong partnerships between health and enforcement sectors. Collaboration is necessary to reduce tensions, build synergies, and ensure that both sectors are working together to achieve complementary goals. The efforts of one sector should not impede the work of the other. On the contrary, collaboration between health and enforcement at national, provincial/territorial, and local levels is vital to reduce the harm associated with injection drug use.

A national Health and Enforcement in Partnership (HEP) initiative, involving both government and non-governmental organizations representing health and enforcement sectors, facilitates cooperation between health and enforcement at the national, provincial/territorial, and local levels.

Recommended Actions

• Provide leadership and coordination to establish an intersectoral, multi-level dialogue regarding injection drug use.
  
• Provide leadership and collaborate with colleagues from other ministries/departments/jurisdictions to promote the adoption of policies and practices that reduce the harm associated with injection drug use.
  
• Foster intersectoral action through mechanisms such as the Health and Enforcement in Partnership (HEP) initiative to achieve the objectives of this framework for action.
  
• Given the magnitude of the problem in Canada, it is clear that investment in addressing the harms associated with injection drug use will result in savings in health and social costs. It is time to examine and commit or realign resources to this important health and social issue.

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^j In some countries, these sites are referred to as supervised consumption sites, since the drugs may be consumed in ways other than by injection.

k Proposals for clinical trials would have to be reviewed and approved by peers and regulators before they could be undertaken.