Safer Crack Kits Ottawa’s Harm Reduction Program

1. 6 Dec 2007 Safer Crack KitsOttawa’s Harm Reduction Program

2. Why is this program needed? (1) To prevent transmission of infectious diseaseamong drug users and to prevent the spread to community-at-large

3. Why is the program needed? (2) To provide an outreach tool, connecting marginalized street drug users with health professionals • Outreach services – absence of primary care – co-morbidity • Life-saving strategy • A non-judgemental approach in keeping with practice of medicine

4. Why is this program needed? (3) To promote efficient use of taxpayer funds • Crack pipe distribution: $3,000 annually = 1 % of total Site program budget – no new money • Same cost as 3 nights in hospital • 1 prevented HIV case pays for entire Site budget • Fiscally responsible approach given health-care system pressures

5. Drug Users and Infectious Disease Public Health crisis - drug users and infectious diseases - HIV, Hep C Among drug users: • 21 % HIV-positive (2nd highest in Canada) • 76 % Hep C – positive (higher than Toronto, Montreal) Danger of other disease outbreaks – TB, meningitis

6. Prevalence HCV Infection by Years of Injection Drug Use

7. Ottawa’s Site Program • Fixed site, mobile service, partner agencies • Services offered Needle provision and disposal Safer injecting and disposal counselling Health education/promotion Condoms and lube First aid, including treatment of abscesses Anonymous HIV testing

8. Profile of crack smokers Crack-smoking injection drug users significantly more likely than non crack-smoking injection drug users to: • Be living on the street • To engage in the sex trade • To be infected with Hep C Many street drug users also mentally ill – ‘self-medication hypothesis’

9. How does disease spread? • Crack smokers – burned, cracked, bleeding lips and mouth sores • Sharing unsafe equipment - cut-off pop cans, copper tubing – contaminated blood • Unprotected sex Hep C 10-15 X more contagious than HIV Need to tailor interventions

12. Scope of problem • Ottawa has 3,000-5,000 injection drug users • Most (80 %) also smoke crack • Some (20 %) smoke crack only Ottawa Public Health now addressing the ‘missing’ risk factor (IDU’s who smoke crack) and missed segment of drug users (who smoke crack only). Providing needles only - a half-measure

13. Scientific Evidence: Reduction in infection rates University of Ottawa study – 56% reduction in HIV infection rate – long-term users of Site (2003) Seattle study – non-use of needle exchange among users – 6 x Hep B risk/7 x Hep C risk (1995) Montreal follow-up 1999 study – improved health outcomes with more needles, sites

14. Scientific Evidence: Equipment sharing • Crack smokers more likely to report oral sores & sores may facilitate HIV infection (Faruque et al, 1996) • Sharing non-injection equipment orally and intranasally risk factor for Hep C in NYC women (Tortu et al, 2004)

15. Winnipeg Findings • Reported frequency of pipe sharing before and after program implementation • Decreased from 79% to 40% • Majority (62 %) reported fewer problems with burned, cracked lips

16. EVALUATION FINDINGS/BENEFITS(Winnipeg Regional Health Authority)

17. Harm Reduction Does Not Promote Drug Use • “Our data did not support the hypothesis that a syringe exchange program would stimulate increased drug abuse in terms of frequency of injection or recruitment of new and/or younger users.” JAMA, 1994 • “Where offered, legal use of sterile injection equipment has been popular with IDU’s and has not led to any increases in illicit drug use.” Lancet, 1996 Crack pipe controversy similar to early days of needle exchange programs

18. Other Canadian Cities: Safer Crack Pipe Distribution • Winnipeg • Vancouver • Toronto • Montreal • Halifax • Kingston • Guelph • Yukon Ottawa is not a leader on this issue Practice becoming norm in Canada

19. It’s Legal (1) • Ontario’s Health Promotion and Protection Act requires MOH’s and Boards of Health to control and prevent the spread of disease. • Ontario Ministry of Health mandates needle exchange programs – these are minimum standards.

20. It’s Legal (2) • Criminal Code does not prohibit instruments for preventing disease – safer crack kits are not ‘drug paraphernalia.’ (intent of law vs. ‘head shops.’) • Within the authority of MOH acting as statutory officer

21. Consultation • Site Program Departmental Consultative Group – Council-appointed community advisory group including Police Services representative • Legal Services extensively involved • Fall 2004 report – HRSS approval • Extensive media coverage (Citizen, Sun, TheBody.com) • Ottawa Police Chief was not opposed

22. Program results to date • Since Apr. 1, more than 600 kits distributed – vast majority of clients received counselling & several rehab/housing referrals • Clinical health service with trained professionals, not a depot • Average age: 37 (only 10 clients under 21) • Average duration of drug use: more than 8 years

23. Ongoing Evaluation • Pre and post-evaluation • 300 in cohort studied before start of program • May, 2005 – 1st post-evaluation • Evaluated every 6 months afterward • Measures: HIV and Hep C incidence, sharing patterns of drug users National surveillance – I-Track

24. Support for Program includes: • 10 local Site partners i.e. Anglican Social Services and Centretown/Sandy Hill CHC’s • Mayor of Vancouver & BC Ministry of Health Services • Winnipeg MOH & Winnipeg Regional Health Authority • Canadian AIDS Society& Can. HIV-AIDS Legal Network

25. Postscript • After 2 years of successful program • No increase in drug use (but crack has become the predominant street drug in Ottawa) • Decrease in crack injection • Decrease in reported sharing behaviour • Hep C and HIV prevalence and incidence all “trending” down

26. Postscript 2 • Community engaged in a process to develop and Integrated Drug and Addictions Strategy (IDAS) • IDAS report resulted in 17 recommendations for Ottawa, one of which was an “independent study of the safer inhalation program” • PP invoked by one opponent that because we were unsure of all of the effects of the program and wanted to study it, it should be cancelled and it was

27. Conclusions • We have a disease epidemic • We have a means to combat it • More cost-effective to prevent disease than to treat it Context – Integrated Drug and Addictions Strategy for Ottawa