CBC News: Toronto Public Health strategy calls for culturally safe care, Indigenous-led consumption sites

‘When I’m around my people, I feel safe’: City aims to combat Indigenous overdoses amid opioid crisis

Harm reduction work ‘needs to be driven by our own community,’ says Les Harper, who is one of only a handful of Indigenous people working in the supervised consumption sphere in Toronto, despite huge rates of drug use among Indigenous residents. (Jon Castell/CBC News)

Catching up in the bustling lobby of an east-end Toronto clinic and supervised consumption site, Les Harper and Lawrence Boyer have lots to talk about — and lots in common.

Both men understand the complicated nature of drug use, from the pleasures to the potentially-deadly pains. Both have also lost loved ones to overdoses — roughly 30 friends for Boyer, and three brothers, one sister, and various cousins, aunts, and uncles for Harper.

And, like so many of those affected by addiction, both men are Indigenous.

But while Boyer is a client and two-time overdose survivor, Harper is on the other side.

Tall and soft-spoken, he is one of only a handful of Indigenous people working in Toronto’s harm reduction community, even though he estimates Indigenous community members make up at least half of all those seeking services, despite making up less than three per cent of the city’s population.

It’s a lopsided arrangement both men agree needs to change.

Harm reduction work “needs to be driven by our own community,” said Harper, a staff member at the supervised consumption site at South Riverdale Community Health Centre who is from the Saddle Lake Cree Nation northeast of Edmonton.

“I don’t know one Indigenous person it doesn’t affect,” he added. “That hasn’t had somebody pass away from an overdose.”

The city, it seems, is listening. Released this month, a new Indigenous overdose strategy, developed by an independent Indigenous contractor with input from the community and support from Toronto Public Health, stresses the need for Indigenous-led consumption and treatment spaces as a way to combat the stigma and isolation experienced by Indigenous people who use drugs.

NEW YORK, NY – OCTOBER 07: A heroin user prepares to shoot up on the street in a South Bronx neighborhood which has the highest rate of heroin-involved overdose deaths in the city on October 7, 2017 in New York City. (Spencer Platt/Getty Images)

The recommendations tie into the city’s broader overdose action plan to combat the opioid crisis, which has led to the deaths of at least 16 people in Toronto so far in 2019 and roughly 450 people over the previous two years.

The “desperately needed” strategy is also the first of its kind in Canada, according to city councillor and board of health chair Joe Cressy. He said it was more than a year in the making, and in that time, the city learned it can’t use “just a one-size-fits-all approach.”

Thanks to recommendations from Indigenous drug users, the strategy calls for Toronto Public Health to request federal and provincial funding support for Indigenous agencies, drop-in spaces, and safe consumption and treatment sites.

It also stresses the importance of weaving Indigenous elders, healing circles, and traditional medicines and teachings into the city’s health care system.

“Currently, the perception is that service workers are generally not knowledgeable about Indigenous culture and history and colonialism, including the assimilation and repression of residential schools, the 60s scoop, and Indian hospitals,” the report reads.

“This results in spaces in which [Indigenous people who use drugs] feel judged and like misfits.”

The ‘desperately needed’ strategy is the first of its kind in Canada, according to city councillor and board of health chair Joe Cressy. (Paul Borkwood/CBC)

That’s a feeling Boyer, an Ojibway father of four, knows well.

The 51-year-old began using drugs — mainly crack cocaine — roughly two decades ago. Now a regular at the Queen Street E. centre where Harper works, Boyer grew up in a home with alcoholic parents and an abusive father. Not everyone understands that experience, he explained.

“When I’m around my people, I feel safe and at ease,” he said. “When I’m not, I’m on edge, and have my guard up.”

‘We know mainstream approaches don’t work’

Research shows “mainstream” approaches don’t work well for Indigenous families, noted Jeffrey Schiffer, executive director at Indigenous non-profit Native Child and Family Services of Toronto.

While he said the city is behind the times when it comes to co-developing strategies with the Indigenous community, Schiffer also praised Toronto Public Health for the new “proactive” direction.

“We’re also at a point where we’re recognizing that Indigenous approaches and tools are beneficial to all people,” he said.

Lawrence Boyer, left, is an Ojibway father and two-time overdose survivor. Les Harper, right, is one of only a handful of Indigenous people working in Toronto’s harm reduction community. (Jon Castell/CBC News)

The strategy report, heading to the board of health for approval later this month, stresses the legacy of trauma facing Indigenous residents today — from child protective services interventions to the ongoing crisis of missing and murdered Indigenous women.

Fringe programming in care settings is not enough, the report continues, because healing can only come when non-Indigenous people are allies “rather than accomplices in continued cultural degradation.”

To implement the strategy, Toronto Public Health has pledged to dedicate an Indigenous staff resource to work with the city in collaboration with Indigenous service providers and community members, wrote de Villa in a note introducing the report to the board of health for its Feb. 25 meeting.

But with many of the recommendations hinging on funding from higher levels of government, some question what can be accomplished.

“How is it going to be implemented? What are the resources behind it?” Schiffer asked.

In particular, it’s unclear how receptive the province would be to the calls for funding and support.

Research shows ‘mainstream’ approaches don’t work well for Indigenous families, says Jeffrey Schiffer, executive director at Indigenous non-profit Native Child and Family Services of Toronto.

While federal Health Minister Ginette Petitpas Taylor has previously said overdose prevention sites “save lives,” Premier Doug Ford claimed the sites offer little long-term help for people with addictions while on the campaign trail last year.

Once elected, his government announced a freeze on the expansion of overdose prevention sites, despite calls from harm reduction workers and Mayor John Tory for a scaling-up of efforts instead.

It was only in late October that the Ford government announced it will keep funding supervised drug consumption sites, but their focus will change to help users receive treatment and get rehabilitated. And as recently as late last month, some sites were unsure if the province would accept their funding applications.

Against that backdrop, Harper also wonders about the strategy’s future.

Standing outside the jam-packed health centre where he works, he said one thing is clear: Drug use is affecting Toronto’s Indigenous communities at a far higher rate than non-Indigenous groups, meaning the city’s approach needs to shift before the crisis gets worse.

“Every Indigenous person I know who works in social work will have a relative come into their space,” Harper said. “A non-Indigenous person will work their whole life — and never have a family member walk in their door.”

https://www.cbc.ca/news/canada/toronto/when-i-m-around-my-people-i-feel-safe-city-aims-to-combat-indigenous-overdoses-amid-opioid-crisis-1.5025560

CATIE: Programming Connection Case Study on keepSIX Supervised Consumption Service

CATIE: Programming Connection. Shared Experience, Stronger Programs.

CATIE includes a case study of SRCHC’s keepSIX Supervised Consumption Service in Programming Connection.

The Programming Connection is an online toolkit that highlights promising approaches to frontline programs in HIV and hepatitis C prevention, testing, treatment, care and support efforts in Canadian communities.

Canadian AIDS Treatment Information Exchange (CATIE) strengthens Canada’s response to HIV and hepatitis C by bridging research and practice. CATIE connects healthcare and community-based service providers with the latest science, and promote good practices for prevention and treatment programs.

https://www.catie.ca/en/pc/program/keepsix

Consumption Treatment Services at SRCHC: Frequently Asked Questions

What is a Consumption and Treatment Services (CTS)? How is it different than an Overdose Prevention Site (OPS) or Supervised Consumption/Injection Site (SIS/SCS)? 

Overall, these services are all quite similar. The main differences between CTS, OPS, and SIS/SCS are the expected duration of the sites, the different services they are each able to offer and which level of government (federal or provincial) approves the site to operate.

From January to June 2018, Ontario had an Overdose Prevention Site (OPS) program.  This program was established to allow the rapid establishment of servicesto help address the overdose crisis.  Agencies wishing to open an OPS only had to apply to the Ministry of Health and Long-Term Care for both exemption approval and funding. Exhaustive community consultation was not a requirement, nor were renovations. Supervised Injection/Consumption Services are more permanent and require a more onerous application to the federal government for an exemption under the Controlled Drugs and Substances Act (CDSA)[1], in addition to applying to the province for funding.

In terms of service delivery, only OPS allow peer-to-peer assisted injection for people who use drugs but who cannot self-inject.  OPS are also lower barrier because they had fewer reporting requirements which meant fewer intake questions for service users. Both OPS & SIS/SCS provide people with a safe and hygienic place to inject or consume pre-obtained drugs in the presence of trained staff who provide sterile equipment and safe disposal, overdose intervention and/or reversal, and safer drug use education. On-site primary care, mental health supports and referrals to health and social services (including treatment) have been part of both models in Toronto.  Toronto currently has 5 OPS and 4 Supervised Injection/Consumption Services.  South Riverdale CHC operates both a SIS/SCS (“keepSIX”) and OPS (Moss Park).

Consumption and Treatment Services (CTS) are the new terminology/model developed by the provincial government in November 2018. The CTS model encompasses and combines both OPS and SCS/SIS. The CTS model includes all of the services of an OPS/SCS/SIS with the exception of peer-to-peer assisted injection (which is not currently –permitted by sites with federal exemptions). The CTS model requires that each agency go through the federal exemption process, for each service site. All existing OPS and SIS/SCS must reapply under the new model and there will be a cap of 21 sites across the province. The CTS model has an emphasis on treatment (substance use counselling, referrals to methadone/suboxone providers, detox, and residential treatment programs); however, these services and/or pathways to treatment have always been available to SCS and OPS service users and are part of the harm reduction continuum of care. With CTS, more rigorous data collection and compliance measures are required, including more comprehensive enforcement and audit protocols.  In addition, CTS have restrictions about how close these services can be located from one-another (not less than 600m) and require letters of support from nearby schools and child care centres.

 

What is the Moss Park Overdose Prevention Site (OPS)?

In August 2017, in response to a dramatic spike in overdose deaths in the area, a group of harm reduction volunteers set up a tent in Moss Park to support and care for people who use drugs.  The volunteer OPS received an outpouring of public support from people who congregate in the park, local social service agencies and the general public.  When the Overdose Prevention Site program was formally established by the Ministry of Health & Long-Term Care in January 2018, the Moss Park group transitioned to this new model.  The Moss Park OPS now operates indoors near Queen & Sherbourne as a satellite service of South Riverdale Community Health Centre. The Moss Park OPS has a harm reduction supply distribution area, an intake/waiting area, six injection tables and a post-injection observation space. The service has operated 6 days per week since July 3/18 from 12 to 6 pm and has been staffed by nurses, overdose prevention workers (people with lived expertise of drug use) and community health workers.  The Moss Park site has a daily average of 60 visits for consumption and 48 additional visits for supplies, support and referrals. 56 overdoses were reversed in its first 5 months of operation.

 

What is keepSIX Supervised Consumption Service?

keepSIX opened on November 27/17 at SRCHC’s Queen St East location after a very long consultation and program planning process. keepSIX is open at the same time as the rest of the Health Centre from Monday to Friday.  keepSIX is a small-scale service with a daily average of 14 visits.  In nearly one year of operation it saw over 400 unique visitors, supervised over 2,800 drug consumptions and reversed 8 overdoses. keepSIX is also staffed by nurses, health promoters and harm reduction workers (who have lived expertise).  keepSIX means “got your back” and is an homage to Raffi Balian, founder of SRCHC’s COUNTERfit harm reduction program (established 20 years ago) and lifelong advocate for people who use drugs.

Will SRCHC apply to have Moss Park OPS and keepSIX SCS be established as CTS?

Yes. Applications were submitted for both sites to the Ministry of Health and Long-Term Care in December 2018.  There will be no change to the number of service users that each site can accommodate at any one time but there may be an expansion of hours (if funding is approved). A federal exemption request was submitted for Moss Park OPS to the federal government in August and is still pending.  The federal exemption for keepSIX was recently renewed for a period of 3-years.

 

Why do we need these services?

Unfortunately, the overdose crisis continues to get worse and we need services like these more than ever.  Recently released data estimates that 11 to 12 people die per day from overdose across Canada.  In 2017, 308 people died from overdose in Toronto (the most recent time period for which we have data). This represents a 66% increase in deaths compared to 2016 and a 125% increase in deaths compared to 2015. The Moss Park neighbourhood has been described as the epicentre of the overdose crisis in Toronto by Toronto’s Medical Officer of Health.  The proposed CTS at our Queen St location is the only service of this kind east of the Don Valley.

 

Is there ongoing opportunity for community input?

Engaging with the local community and providing opportunities to raise any issues or concerns has always been important to South Riverdale CHC. If you would like more information or have questions, please contact us.  The contact person for Moss Park site is Jen Ko who can be reached at 416.303.4453 or jko@srchc.com. For information about the keepSIX supervised consumption site, please contact Julia Barnett at 416-461-1925 x 356 or jbarnett@srchc.com.  keepSIX has a monthly open house from 8:30 to 9:30 am on the first Wednesday of each month.  Moss Park also has bi-monthly Open House events, with the next one scheduled for January 23, 2019 from 9 am-11 am. Contact us for more information.

[1]This exemption allows for the legal consumption of pre-obtained drugs within the service space.

 Consumption and Treatment Services at SRCHC: FAQ’s