Reducing the Harm Associated with Injection Drug Use in Canada

2. The Health And Social Issues

The public health and social impacts of injection drug use in Canada are extensive, complex and devastating. The enormous costs and other health, social, and economic consequences are growing daily. Although media reports have tended to focus on the situation in cities such as Vancouver, Toronto, and Montreal, injection drug use and its related harms can be seen and felt across the country, from coast to coast in both urban and rural settings. It affects the family and friends of those who inject drugs, and ultimately all Canadians.

Poverty, homelessness, lack of education, family dysfunction and parental substance misuse, mental health problems, and a history of child abuse are all social determinants that place people at higher risk of misusing drugs or of injecting drugs.

Individuals who develop alcohol and other drug addiction are still stigmatized in Canadian society. Canadians who inject drugs are even more stigmatized, as they are, by and large, rejected by society because of the illegal nature of their behaviour, their sometimes disorganized lives, and their vulnerability to diseases. They are often labeled as difficult to manage, disruptive and manipulative. A significant portion of society views them as lesser persons - criminals and derelicts. These attitudes and misconceptions have resulted in a variety of harms, including public apathy, undiagnosed mental illness and inaccessible treatment and rehabilitation programs.

It is estimated that up to 125,000 people in this country inject drugs. This includes an estimated 25,000 Canadians who inject steroids. In Canada, among the drugs injected, cocaine, heroin and steroids are the most common.⁵ However, some parts of the country are experiencing unique problems with the injection of other drugs such as Talwin and Ritalin.

Cocaine use by injection is of particular concern as people who inject cocaine typically do so as often as 20 times a day, increasing the problems associated with obtaining clean needles and sharing contaminated needles.⁶ Recent estimates of mortality indicate that the major causes of death attributable to illicit drug use are drug overdose, suicide and complications arising from HIV infection,^7,8 all of which are highly associated with injection drug use. Other health problems associated with or complicated by injection drug use include abscesses, infections, poor nutrition, endocarditis and adverse drug interactions.

The linkage between injection drug use and blood borne infections is a major concern. Use of injection drugs represents a major risk factor for becoming infected with HIV, hepatitis viruses and other communicable pathogens. Persons who use drugs by injection can transmit HIV to their sexual partners via sexual contact, to their children, via perinatal transmission, and to other injection drug users by sharing needles, syringes or other drug paraphernalia. As much as 40% of drug users are in a sexual relationship with a non-user.⁹ Many users or their sexual partners are women of childbearing age, and are therefore at risk of transmitting HIV to the fetus during pregnancy or to their child during delivery or through breastfeeding.

While injection drug use accounts for a substantial number of deaths and hospitalizations due to complications arising from HIV infections, it is alarming to note that injection drug use is a significant risk factor in new cases of HIV infection. The proportion of reported adult HIV positive cases directly attributed to injection drug use has increased from 8.9% prior to 1995 to 28.3% in 1999, with a high of 33.8% in 1997.¹⁰ Over one third of new HIV cases in 1999 were attributable to injection drug use¹¹.

There are even more dramatic trends regarding the role of injection drug use in the incidence of hepatitis B and C. It is estimated that between 210,000 - 275,000 Canadians have hepatitis C and that 70% of these individuals are current or former users of injection drugs.¹² Estimates also indicate that there may be 4,500 new hepatitis C infections occurring annually in Canada, of which at least 63% is related to injection drug use.¹³ It has been estimated that approximately one-third of new hepatitis B infections in Canada are associated with injection drug use.

Hepatitis C is transmitted more easily through blood than is HIV and is acquired earlier after the onset of sharing injection materials. Compared to HIV, hepatitis C is ten to fifteen times more infectious through contact with blood.¹⁴ The situation is further exacerbated by high prevalence rates of hepatitis C infection among populations that inject drugs, such that even occasional sharing of needles and other drug paraphernalia carries an extreme risk of infection. Hepatitis B and C are also of concern because of the length of time the virus can remain viable in discarded injection equipment. Accidental needle sticks are a known occupational hazard for health professionals, law enforcement officers, and correctional services personnel. Although there have not been any recorded incidents of infection of community members through accidental encounters with used needles, there is potential risk to others such as sanitation workers and children.

Injection drug use has an impact on all of society and is a key issue among the most vulnerable and marginalized individuals in society, such as those with a history of child abuse, those with mental illnesses, the homeless, street youth, sexually exploited children and inmates of correctional facilities. However, the population of Canadians who inject drugs is extremely diverse, due in part, to factors such as age, gender, culture, geographic location and polydrug use.

Women who inject drugs face unique challenges because they frequently have links to the sex trade and histories of child sexual abuse. They are also often hesitant to enter drug treatment programs, as they are afraid that their children will be taken away from them and often experience difficulties finding safe and suitable child care while in treatment.^15,16 People who inject drugs and engage in unsafe sexual practices represent a link by which HIV can spread from people who inject drugs to those who do not.

The use of drugs is high among street youth. Estimates of the number of the street youth population have ranged as high as 150,000.¹⁷ It is generally believed that a major pathway to this marginal lifestyle is the experience of physical, emotional and/or sexual abuse at home.¹⁸ Studies conducted between 1988 and 1992 show higher rates of illicit drug use and injection drug use by street youth than rates of drug use among youth living at home.^19,20,21,22 Needle sharing and unsafe sexual practices are common among street youth who inject drugs. Among street youth who inject drugs, the likelihood of HIV infection is related to lower age, being unemployed and being involved in prostitution.

Aboriginal Canadians are at a high risk of substance misuse and injection drug use as they experience many of the disadvantages associated with drug misuse such as poverty, low education, unstable family structure, physical abuse and poor social support networks.²³ The exact extent of injection drug use among Aboriginal peoples is not known, but Aboriginal peoples have expressed concern about the use of illicit drugs and adverse consequences from drug misuse. Alcohol and other drug misuse are major factors underlying the high rate of death among Aboriginal Canadians from accidents and suicide. Aboriginal peoples comprise a disproportionately high percentage of those using needle exchange programs and drug treatment facilities in several cities.²⁴ Although this signifies adoption of harm reduction practices, it may mean higher levels of injection drug use among Aboriginal than non-Aboriginal Canadians. Also, Aboriginal Canadians are over-represented among some prison populations in this country and may be more likely to have engaged in injection drug use than non-Aboriginal inmates and to do so at an earlier age.²⁵

The relationship between injection drug use and the prevalence of HIV, hepatitis viruses and other blood borne pathogens among incarcerated Canadians is significant and important to note. Incarcerated individuals are at particular risk because of engaging in high risk behaviours such as injection drug use and because of factors such as low education, dysfunctional family backgrounds, poor social support networks not necessarily because they are incarcerated. Drug use in Canadian correctional facilities is acknowledged to be wide spread and, although numerous measures are in place to address this issue, injection drug use is a leading contributing factor of the increasing prevalence of HIV and hepatitis C. In a study conducted with a focus group of inmates, one author has indicated that 25% of those people studied said they injected drugs for the first time while incarcerated.²⁶

Considerable concern arises, in the broader context of public health and safety, given that inmates are less likely to have access to clean injection equipment and are not aware of or concerned with the potential consequences of injection drug use.

It is reasonable to assume, therefore, that without considerable efforts to provide appropriate treatment and reduce the harms associated with injection drug use, the potential transmission of HIV, hepatitis viruses and other blood borne pathogens will extend beyond the perimeters of formal correctional facilities into Canadian communities and the population at large.

A detailed description of the health and social issues associated with injection drug use is presented in Appendix A.