OIDAS Issues Table
Part B: Addressing Health Issues & the Epidemic of HIV/HCV
Team Membership (organizations represented):
ü Alfred
Cormier, CAMH (Co-Chair)
ü Niki
Economo, United Way (Co-Chair)
ü
Public
Health
ü
Ottawa
Police
ü
Rideau-Vanier
BIA
ü
Dalhousie
Safety Committee
ü
Sandy
Hill CHC- OASIS
ü
Salvation
Army
ü
CMHA
ü
Maison
Fraternité
ü
Crime
Prevention Ottawa
ü
Youth
Services Bureau
ü
Consumers
(youth & adult)
ü
Robert
Smart
ü
Carleton
University School of Journalism & Mass Communication
a)
Identifying
gaps in providing a comprehensive, evidenced-based continuum of interventions.
b)
Recommending
evidenced-based interventions and practices that are guided by a “stages of
change” framework in order to promote suitable linkages with the addictions
service continuum.
Ottawa has an HIV and HCV
epidemic. The HIV and HCV rates among
injection drug users are the highest in the province and the HIV rate is the
second highest in the country after Vancouver (Injection Drug Use, HIV and HCV
Infection in Ontario: The Evidence 1992
to 2004, Faculty of Medicine, University of Toronto, 2004: 16, 38). Among the 3000-5000 people in Ottawa who
inject drugs (Remis in Ibid), approximately 70% also report smoking crack
cocaine (The situation among women and men in Ottawa who inject drugs, Lynne
Leonard and Christine Navarro, May 2004, p.14).
Sharing drug equipment, whether it is a needle or a crack pipe, can lead
to HIV and/or HCV. Although harm
reduction programs, including needle exchange and glass stem distribution, have
made a significant contribution to reducing the transmission of HIV and HCV,
the number of new infections each year is still cause for concern.
More needs to be done to support
people who use drugs to reduce their sharing of drug equipment and to access
treatment. In order to do this,
however, it is necessary to address the determinants of health that may
otherwise prevent them from addressing their substance use problems,
including: social stigma and
marginalization; inability to access appropriate health and social services;
inadequate housing and/or homelessness; inadequate income; inadequate social
supports; physical and mental health problems; safety issues; food security;
etc.
One of the
most successful treatment models in the addictions field is called “Stages of
Change.” The model acknowledges that people are at different stages in their
journey to recovery. Each stage of
change requires a different treatment intervention (Components of integrated
treatment from: Mueser, K. T., Noodsy, D.L., Drake, R.E., & Fox, L.,
(2003). Integrated Treatment for Dual Disorders: A Guide to Effective
Practice. New York: Guilford Press).
Some people have not even considered
treatment and are in the “Precontemplation Stage.” At this stage, the primary goal of the outreach worker becomes
“engagement” to develop a working relationship with the person using
substances. This may involve helping
the person to secure housing, social assistance, medical services or food and
may also involve the distribution of harm reduction supplies, such as clean
needles or safe inhalation equipment, in order to reduce the risk of HIV and
HCV while they are continuing to use substances.
Once a working relationship is
developed, the person using substances may be more open to discussing the risks
associated with their substance use, as well as the various treatment
options. It is at this stage that the
outreach worker uses “motivational interviewing” or “persuasion” techniques to
help the person to recognize how the risks may outweigh the benefits and to
believe that change is possible. A
significant part of this process is to help the person to articulate their life
goals and to help them to see how their substance use may be preventing them
from achieving these goals. It may take several such discussions over a period
of time before the person is ready to enter into treatment.
Once a person is open to change, the
outreach worker can “prepare” the person to choose the treatment option that
best fits their goals and circumstances and make the appropriate
arrangements. Options may include an
addiction program and/or support group to help them to reduce their use or stop
using altogether, or it may involve addressing their cravings through a
prescribed medication, such as methadone.
It may involve an outpatient program, residential program, detox and/or
peer support group. Although the explicit goal of any treatment program is to
reduce substance use, treatment also includes helping the person to address
some of the other psychiatric, psychological and social factors that may be
contributing to substance use.
Unfortunately, a treatment program
is not necessarily the end of the journey.
The majority of people who receive treatment will relapse along the
journey to recovery. Part of a good
treatment program is to provide the person with a “relapse prevention plan” that
helps the person to understand the particular circumstances that lead to their
substance use and what steps to take to either avoid these circumstances or
intervene early before things get out of control.
There are several recommendations
that come out of the above discussion.
Recommendations:
The first, and perhaps most
critical, is to increase treatment capacity and options for people using
substances. One of the most poignant
comments came from Perry Rowe, Executive Director of the Salvation Army shelter
who claimed that he could not get one of the clients in the shelter into his
own addiction program, the Anchorage.
There were numerous other stories of how outreach workers were finally
able to motivate their clients to consider treatment, only to find out that
there was a long waiting list. Although
the committee recognizes that the Treatment workgroup is addressing this issue,
it would like to support their recommendation concerning an increase in
treatment capacity and make a specific recommendation that treatment options,
such as methadone, be available. Any additional services, however, must address
community concerns regarding location and proximity of new services to existing
services.
6.
We recommend an increase in
treatment capacity and the further development of the continuum of services in
Ottawa to include options for people using substances eg. substitution therapy
for crack and cocaine addiction. Any increase in services will address
community concerns regarding location and proximity of new services to existing
services.
Another recommendation is to
establish peer-driven interventions, which would expand the capacity
and effectiveness of professional outreach services and provide an on-going
voice to influence the implementation of the integrated drug strategy (see
Injection Drug Use, p. 68).
7.
We recommend the establishment of a
sustainable peer-driven intervention plan for people who use substances.
Unlike the other three pillars
(prevention, treatment and enforcement), harm reduction is often misunderstood
and criticized. For this reason, the
Site Development Consultative Group was established to improve communications
across sectors.
8. We
recommend that the Site Development Consultative Group be expanded and be used
as a vehicle to bring various stakeholders together including Public Health,
Police, Crime Prevention Ottawa, BIAs, community representatives, Services
Providers and Service Users to provide on-going guidance to harm reduction
programming in the City.
In addition to the on-going work of the Site
Development Consultative Group, members of the committee felt that it would be
helpful to conduct an independent review of the harm reduction program and its
effectiveness.
9. We recommend an independent operational review of
the safer inhalation program (i.e. policies, procedures and practices) its
effectiveness and impact on the community. Public Health would have the
responsibility to oversee this independent operational review and would
also require access to appropriate funding to do this review.
There is extensive literature to demonstrate that a person requires a supportive environment and stable income in order to reduce their substance use or to remain abstinent. Many people who use substances also have a co-occurring mental health problem, which is exacerbated by the stress of an unstable environment. Tragically, many people who leave a treatment program go right back into a chaotic environment surrounded by drug use and drug dealers.
A national report on Hepatitis C
emphasizes the importance of addressing these environmental factors:
To avoid HCV infection, people must
be aware of HCV and its routes of transmission; however, their ability to
translate that knowledge into practice is strongly related to environmental and
social factors… these include effective access to medical care, freedom from
addiction, functional literacy, adequate income, secure housing, safe domestic
environments, respectful and abuse-free relationships, robust self-esteem and
the sense of belonging to a broader community.
When these critical determinants of health are in place, and given
adequate information, people can make healthful choices. Without these basics, such choices become
difficult, if not impossible (Responding to the Epidemic: Recommendations for a Canadian Hepatitis C
Strategy, Canadian Hepatitis C Information Centre, 2005: 4, www.hepc.cpha.ca).
There are already promising examples
that can be used as templates eg. CMHA’s Housing First model and the Rideau BIA
youth employment initiative in partnership with Operation Go Home.
10. We recommend that the availability of safe, affordable, supervised
and/or supportive housing, as well as adequate income levels and/or employment
opportunities for people with substance use and/or mental health problems be
increased in the city. There are
already promising examples that can be used as templates eg. CMHA’s Housing
First model; YSB Hepatitis C Youth Advisory Committee youth employment program;
and the Rideau BIA youth employment initiative in partnership with Operation Go
Home. It is important that these services be available for both Francophones
and Anglophones.
People using substances often face
barriers to primary care and other support services, including housing, and are
treated as second class citizens. In
addition to their needs not being met, an opportunity is lost to engage with a
person and motivate them to consider treatment. Although these services go beyond the City’s jurisdiction, the
committee urges the City of Ottawa to advocate other levels of government,
including the Champlain LHIN, to increase these services.
11. We recommend that the
City advocate other levels of government for an increase in primary care and
support services for people using substances; including housing; and liaising
with the Champlain Local Health Integration Network (LHIN) and other health and
social service funders.
Communication
There is a need for clear, balanced
and consistent messaging that includes the impact of drug use on the individual
who is using, as well as the affected neighbourhood. For this to happen, the key stakeholders need to create
opportunities to learn from each other, share information and develop a
strong internal communications strategy. This communications strategy
will help to shape media messages, as well as inform public information
materials and awareness sessions. Awareness sessions need to provide adequate
and accurate information stressing the detrimental long-term effects of
substance abuse.
12. We recommend that the IDAS task force
continue to establish and develop their relationship and partnerships with
those involved in the Steering Committee and the Working Group such as the
Ottawa Police Service, Crime Prevention Ottawa, the Centre for Addiction and
Mental Health (CAMH), Ottawa Public Health, BIA and, community representatives
within affected communities in order to share information and develop a strong
internal communications strategy.
13. We recommend that there be joint education and training sessions with
key stakeholders from enforcement, treatment, harm reduction and prevention in
order to create an integrated approach.
14. We recommend that there be public information materials and sessions
with all concerned stakeholders, to dialogue with affected communities about
addictions, harm reduction policies, practices and procedures and their
immediate and long-term impact on the individual and neighborhood.
Moving Forward: A Funding Strategy
i)
Cost
of recommendations
Some of the above recommendations
could be implemented “in kind” by the various partner organizations. Other
recommendations, however, would require additional funding, which will be
addressed by OIDAS in phase three.
Conclusion: Pay Now or Pay Later
Besides the tremendous emotional
cost to seeing a loved one suffer from HIV, HCV and related illnesses, the
financial cost for medications, liver transplants, healthcare and lost
productivity is enormous. For example,
the cost of a liver transplant can cost up to $250,000 and the lifetime cost to
treat a person with HCV from diagnosis to death, including medical costs and
the economic loss, is $1 million.
Altogether, HCV alone costs the Canadian healthcare system about $500
million annually, which is expected to double to $1 billion by 2010 (Responding
to the Epidemic: Recommendations for a
Canadian Hepatitis C Strategy, Canadian Hepatitis C Information Centre, 2005:
7-8, www.hepc.cpha.ca).
References
Injection Drug Use, HIV and HCV
Infection in Ontario: The Evidence 1992
to 2004, Faculty of Medicine, University of Toronto, 2004.
The situation
among women and men in Ottawa who inject drugs, Lynne Leonard and Christine
Navarro, May 2004.
Components of integrated treatment
from: Mueser, K. T., Noodsy, D.L., Drake, R.E., & Fox, L., (2003). Integrated
Treatment for Dual Disorders: A Guide to Effective Practice.
New York: Guilford Press.
Responding to the Epidemic: Recommendations for a Canadian Hepatitis C
Strategy, Canadian Hepatitis C Information Centre, 2005.
Forward Thinking on Drugs: A review of the evidence-base for harm
reduction approaches to drug use, Neil Hunt, www.forward-thinking-on-drugs.org/review2-print.html.
City of Ottawa Public Health Safer
Crack Use Initiative Evaluation Report, October 2006.
Issues Planning Communications
Strategy: Effective Communication
Effective Policy, School of Journalism and Mass Communication, Carleton University,
March 2007, Commissioned by the Issues Table of OIDAS.