Emma Woolley - Canadian Observatory on Homelessness/Homeless Hub: York University
This question came from Ari F. via our latest website survey.
Harm reduction is quickly becoming more and more accepted in policy and practice in Canada. As it is an effective public health and engagement initiative with plenty of evidence behind most practices (Ball, 2007; Hunt et al., 2003; Wodak & McLeod, 2008), this isn’t surprising. Research has shown that as long as harm reduction interventions are effectively implemented and exist as part of a system of services, they are successful in their intended goals. Practices include distribution programs (of clean supplies), overdose prevention and education, social service referrals, advocacy and social action. Harm reduction values and principles speak to agency and respect, and are an important part of advocating for the rights of people who use drugs. Given the fact that people who use drugs also tend to experience social isolation and stigma, this element of harm reduction is very important.
Consumption sites — like managed alcohol programs and supervised injection sites — are still considered a “promising practice” and exist in far fewer numbers than needle exchanges and other programs. One issue is the lack of shelters and supportive housing that allow substance use and embrace harm reduction practices: Where can people go after visiting a site if they can’t go “home”?
Another challenge is based in community perception. Consumption sites bring drug use even more in focus, to the point that people often accuse them of “encouraging” drug use. Such arguments are based in morality. As Dr. Stephen Gaetz wrote in a blog post about government harm reduction policy:
The criticisms of harm reduction are often driven once again by moral arguments that people use substances are somehow bad, or, you know, deviant people. The views are often that harm reduction is about giving people drugs and keeping them dependent. In fact, it’s a much more complex and supportive approach than that.
Even so, there are a number of new initiatives, based on the harm reduction model, happening across the country.
Managed alcohol programs
After tobacco, alcohol is the second-most costly (in physical, social and economic measures) substance to Canadians. A now famous 2010 European study determined that alcohol was overall the most damaging drug in existence. These conclusions barely touch on the drinking of non-beverage alcohol (like mouthwash or rubbing alcohol), which has a much greater potential for physical harm. Non-beverage alcohol (sometimes called illicit alcohol) is cheap and extremely effective — making it an attractive option for some people living in poverty and/or homelessness, While “illicit drinkers” are a small minority of alcohol users, they are vastly underserved despite having high service and health needs.
There are very few alcohol programs created within a harm reduction framework. Seaton House in Toronto was the first to begin, opening a managed alcohol program called The Annex Program in 1996 after a number of community members died from a combination of alcohol-related harms and freezing temperatures. A group in London, Ontario has been trying for several years to get a program started, but many of the primary people who most needed the service have since died. There are currently managed alcohol programs in Toronto, Ottawa, Hamilton, Thunder Bay and Vancouver.
In managed alcohol programs, members are given beer, wine, sherry or other types of drinkable alcohol at pre-determined times during the day. The goals are to reduce symptoms of withdrawal, injuries, illness, and conflict with the criminal justice system.
The Portland Hotel Society (PHS), a non-profit agency in Vancouver, was recently discussed in a Vice story about managed alcohol programs. In it, director of programming Coco Culbertson describes the condition that many program participants arrive in:
Due to lifelong use, many PHS clients are in stages of liver failure, have diabetes, pancreatitis, brain injuries (falls can be very extremely dangerous when highly intoxicated), and suffer from severe withdrawal symptoms without access to booze, causing seizures, Culbertson told VICE. At its worst, alcohol withdrawal can be fatal.
So while managed alcohol programs don’t always stop people from drinking, they do provide people with housing and supports when they need them. Existing pilot studies — from sites in Vancouver, Ottawa and Thunder Bay — show that managed alcohols are effective in reducing alcohol-related harms and the frequency that members drink non-beverage alcohol. According to a report by a London working group, participants in the Annex Program reported fewer emergency room visits and time spent incarcerated. Another study found that managed alcohol programs can be “enabling sites” of recovery, where people can improve their mental health and social support systems.
Given these early positive findings, it’s likely that we will see more managed alcohol programs across Canada. A study currently underway by researchers at the University of Victoria aims to evaluate at least six managed alcohol programs across Canada. Two members of their research team, Pauly and Stockwell, wrote a bit about their work for the Homeless Hub this past Wednesday, where they shared the following:
In our recent CARBC evaluation, our research team found that providing regulated doses of alcohol in a supportive housing environment can improve the lives of people with severe and reoccurring alcohol problems and homelessness while reducing social, police and health service costs. Compared to those with severe and reoccurring alcohol problems not in a MAP, MAP residents had 43% fewer police contacts, 70% fewer detox admissions, 47% fewer hospital admissions, and spent 33% less time in custody over the study period. Importantly, they also reported less frequent use of non-beverage alcohol, fewer alcohol-related harms (such as withdrawal seizures) and had improved scores on liver function tests.
Compared to life on the streets, participants described the MAP as a safe place characterized by respect, trust and a non-judgemental approach. They reported a sense of belonging and of having a secure home, a base from which they could also reconnect with family members and access other health and social services.
Furthermore, the programs were deemed to be very cost effective solutions to homelessness for people with severe alcohol dependance. Hopefully, their work will continue to draw attention to these much-needed programs.
Supervised injection sites
With opiod overdoses on the rise throughout the country — now the third leading cause of accidental death in Ontario alone — the need for supervised injection sites is especially visible. And organizations are responding: back in March, the Toronto Board of Health announced that three agencies intend to develop supervised injection sites: The Works (Toronto Public Health), South Riverdale Community Health Centre and Queen West Community Health Centre.
Insite, located in Vancouver’s east side, opened 13 years ago following years of activism and awareness raising by community organizations. It is the only supervised injection site in North America — there are many in the Netherlands, Germany and Switzerland. Since its opening, workers have seen a number of positive results, including a lower number of fatal overdoses. Despite the fact that supervised injection sites have demonstrated that their existence saves lives, creating and maintaining them in Canada has been difficult.
Interested organizations must apply for an exemption from the federal health minister under the Controlled Drugs and Substances Act. In The Globe and Mail, Andrea Woo chronicled the evidence that grew in support of Insite’s services between its inception and 2006:
… new HIV/AIDS cases dropped. A report in the Canadian Medical Association Journal projected the facility could avert 1,191 cases of HIV and 54 cases of hepatitis C in a decade, saving $14-million health care dollars. A 2008 study by the B.C. Centre for Excellence in HIV/AIDS found that the facility prevented up to a dozen overdose deaths a year. Police reported less street disorder and public drug use in the area. Evidence seemed to back the fledgling harm-reduction initiative.
In 2006, Insite’s application was blocked, which led to a 2011 Supreme Court case that ended in the program’s favour. This year, the federal government voluntarily granted Insite a four-year exception — a hopeful sign for the three organizations seeking their own exceptions this fall.