Reducing the Harm Associated with Injection Drug Use in Canada

Executive Summary

This report is the federal/provincial/territorial response to a significant number of recent, well-researched papers^b and consultations recommending action to reduce the harm associated with injection drug use in Canada. It is intended to provide a framework for multi-level strategies and action plans to reduce the harm associated with injection drug use in Canada and to promote a new level of coordinated action and collaboration among various sectors and jurisdictions in adopting policies and practices to address injection drug use and the associated harms.

In February 2001, the Federal/Provincial/Territorial Deputy Ministers of Health approved the release of a draft of this report, as a working paper, to allow for broad consultation within and outside of government. The intensive consultation included representatives of health, social services, addictions, HIV/AIDS, hepatitis C, police, corrections, justice, Aboriginal peoples, community agencies, and people who inject drugs. The purpose of the consultation was to gain further support and to obtain feedback in order to refine the report. This revised document reflects the results of the consultation. As a result, the report represents an extraordinary level of consensus among a broad range of governmental and non-governmental stakeholders and has garnered the support of senior officials. As such, there is now an opportunity to use the overall framework, as appropriate, to develop individually-tailored, multijurisdictional action plans.

Injection drug use is a serious health and social issue for many countries, including Canada. The economic costs associated with injection drug use are substantial and rising due to the escalation of HIV and hepatitis C infections. In 1992, before the dramatic increase in HIV and hepatitis C infections associated with injection drug use, the costs related to illicit drug use were conservatively estimated at $1.4 billion per year. The majority of these costs were attributable to injection drug use and included lost productivity due to morbidity and premature death, health care costs and law enforcement. A study estimated that the direct and indirect costs of HIV/AIDS attributed to injection drug use would be $8.7 billion over a six-year period if trends continued. The medical costs to treat people with hepatitis C are expected to exceed those for HIV/AIDS.

In combining their efforts at this time, the federal/provincial/territorial committees involved in this process agree that the problems associated with injection drug use have reached critical proportions. In addition, the committees agree that Canada will not be able to turn the situation around without a bold new level of coordinated action and enhanced multisectoral and interjurisdictional collaboration on several fronts as described in this paper. Immediate action is called for in the areas of prevention; outreach; treatment and rehabilitation; research, surveillance and knowledge dissemination; and national leadership and coordination. A detailed discussion of the regulatory framework regarding access to and use of psychotropic substances is not included in the scope of this paper. All of the recommendations cited are possible within the existing legal framework.

While new dollars may be required in the medium term, the focus in the short term should be on intensive, high level, cross-governmental and multi-stakeholder consultation to further communicate and build consensus around the priorities presented in the report. This, in turn, will allow finetuning of more specific plans to be accommodated in future budget plans.

Injection drug use is an issue for all Canadians, but particularly among the vulnerable and marginalized. The relative risk of harms from drug use is highest for Canadians with a history of victimization, poverty, family dysfunction, including alcohol and other drug problems among family members, low educational attainment and unemployment, and those who lack accessibility to appropriate and effective services. However, the population of Canadians who inject drugs is extremely diverse. It is crucial that programs, policies, and strategies are designed and adapted to take into account factors such as age, gender, culture, geographic location and polydrug use.

It is estimated that up to125,000 Canadians inject drugs, most commonly cocaine, heroin and steroids. Injection drug use is associated with death from drug overdose, complications arising from HIV, hepatitis C, and other communicable pathogens, and suicide. A variety of other health problems are also associated with injection drug use and include abscesses, infections, poor nutrition, endocarditis and adverse drug interactions due to polydrug use.

The linkage between injection drug use and blood borne diseases is a major concern and reason for urgent action. Over one third of new HIV cases in 1999 were attributable to injection drug use. Additional HIV cases occur in the sexual partners and newborn children of individuals using drugs by injection. Also, it is estimated that between 210,000 and 275,000 Canadians are infected with the hepatitis C virus. Estimates also indicate that of the thousands of new cases of hepatitis C every year, 63% are related to injection drug use.

Injection drug use does not arise in isolation, but is part of the broader context of drug misuse^c. Comprehensive, coordinated, and multi-sectoral action should be taken both in the short term and in the longer term to reduce drug misuse as well as to reduce drug use by injection and the immediate harms associated with injection drug use, such as HIV/AIDS, hepatitis C, and overdose. In this way, federal/provincial/territorial officials agree that actions which are successful at preventing or reducing drug use in the first place can be viewed as contributing in the long term to a reduction in the overall harm associated with injection drug use. The reality of the situation in Canada requires a national response that also addresses the immediate risk factors for people who are injecting drugs as part of a continuum of addiction interventions. Given the urgency of the situation in Canada, this report deliberately focuses on actions which should be undertaken in the short term. These actions need to reflect both the broader context of a population health perspective aimed at addressing the determinants of health associated with drug use as well as the immediate risks associated with the use of drugs by injection. Canada's Drug Strategy, the Canadian Strategy on HIV/AIDS, and the Hepatitis C Prevention, Support, and Research Program, are, therefore, essential foundations to addressing injection drug use within the overall context of drug misuse and addiction.

The foundation provided by a population health perspective, Canada's Drug Strategy, the Canadian Strategy on HIV/AIDS and coordinated long-term action supports a comprehensive approach to reducing the harm associated with injection drug use with the goals of:

• increasing efforts to address the determinants of health and the underlying factors associated with drug misuse.
  
• reducing injection drug-related mortality and morbidity.
  
• reducing the incidence and prevalence of injection drug use.
  
• reducing the health, social and economic costs and consequences of drug use.

The goals will be supported by adopting the following principles:

• Injection drug use should be regarded first and foremost as a health and social issue.
  
• People who inject drugs should be treated with dignity and have their rights respected.
  
• Services should be accessible and appropriate and should involve people who inject drugs in all aspects of planning and decision making.
  
• Programs and policies should take into account diversity among the injection drug using population such as gender, culture, age, geographic location, and polydrug use.
  
• The community and stakeholders should be involved in the responses.

Given the serious nature of the situation in Canada, there are a number of priority actions within this comprehensive framework that should be undertaken in the short term to reduce the harm associated with injection drug use:

Prevention

• Develop and enhance initiatives that address the underlying factors and conditions that put people at risk of misusing drugs, particularly by injection.
  
• Develop and enhance initiatives that address the underlying factors and conditions that put people at risk of engaging in unsafe injection practices.
  
• Develop and enhance initiatives that focus on high risk youth and the prevention of injection drug use.

Outreach

• Work with law enforcement, justice, all levels of government, community groups and others to enhance the implementation, accessibility and effectiveness of needle exchange programs and reduce the barriers in all settings in Canada, including the consideration of pilot projects in correctional facilities.
  
• Support outreach and networking initiatives at all levels to foster and increase harm reduction initiatives, increase access to effective health, social and treatment and rehabilitation services, and enhance social integration and reintegration (e.g. prisoners returning to their communities upon release from a correctional facility).
  Foster the involvement of people who use drugs by injection and drug user networks in reducing the harm associated with injection drug use.

Treatment and Rehabilitation

• Increase the availability of and address barriers to effective substance misuse treatment and rehabilitation programs, including methadone maintenance treatment, in all settings, including correctional facilities.
  
• Support, in principle, clinical trials to assess the treatment effectiveness of the prescription of heroin, LAAM, buprenorphine, and other drugs in the treatment of people who inject drugs.^d

Research, Surveillance, and Knowledge Dissemination

• Monitor innovative approaches used in other countries to address injection drug use and assess their applicability to the Canadian context.
  
• Develop a framework for reporting regularly using agreed-upon indicators on injection drug use and its consequences, develop the tools necessary to collect and disseminate the relevant data and information, and monitor progress made to address this critical issue.
  
• Establish a task group consisting of (at a minimum) law enforcement, justice, health and social services, addiction and community perspectives to conduct a feasibility study of establishing a scientific, medical research project regarding a supervised injection site^e in Canada.
  
• Improve surveillance of the injection drug use situation and its consequences in Canada through data collection, targeted studies, and research to assess causes, co-factors, and effectiveness of interventions.
• Enhance knowledge dissemination and education regarding injection drug use, its determinants and its health and social effects for health and social service professionals, enforcement and justice officials, persons who inject drugs, inmates in correctional facilities and the community at large.
  
• Conduct research on Canadians' attitudes regarding harm reduction principles and specific harm reduction strategies.

National Leadership and Coordination

• Provide leadership and coordination to establish an intersectoral, multi-level dialogue regarding injection drug use.
  
• Provide leadership and collaborate with colleagues from other ministries/departments/jurisdictions to promote the adoption of policies and practices that reduce the harm associated with injection drug use.
  
• Foster intersectoral action through mechanisms such as the Health and Enforcement in Partnership (HEP) initiative to achieve the objectives of this framework for action.

The misuse of injection drugs is a health and social issue that has and will continue to have significant consequences for individuals, families and communities in Canada. Failure to act now will result in escalating health, social and economic impacts. It is time for all jurisdictions and stakeholders to work together to renew their commitment to comprehensive action to reduce the harms associated with injection drug use.

In taking the next steps to address injection drug use, governments and other stakeholders should:

• Recognize the importance of injection drug use as an urgent health and social issue requiring both short and long-term action;
  
• Adopt the goals and principles as outlined in this report;
  
• Endorse the continued collaborative work of federal/provincial/territorial colleagues and other stakeholders in reducing the harms associated with injection drug use;
  
• Support the priority actions identified to reduce the harms associated with injection drug use and demonstrate leadership within respective jurisdictions; and
  
• Use the framework, as appropriate, to develop comprehensive, strategic action plans to reduce the harms associated with injection drug use in Canada.

^c Drug misuse is defined as use that is associated with physical, psychological, economic or social problems or which constitutes a risk to the health, security or well-being of individuals, families and communities. Whether or not any particular use is defined as misuse depends on the user, the substance, and the context in which it is used. (Ministère de la Santé et des Services sociaux du Québec. Pour une approche pragmatique de prévention en toxicomanie. Orientations et stratégie. Document de consultation, 1998.)

^d Proposals for clinical trials would have to be reviewed and approved by peers and regulators before they could be undertaken.

^e In some countries, these sites are referred to as supervised consumption sites, since the drugs may be consumed in ways other than by injection.