Harm Reduction and Overdose in Hamilton Kathy Guffroy Public Health Nurse Harm Reduction Program City of Hamilton Public Health Services Kathy.guffroy@hamilton.ca

Overview: Harm Reduction The Opioid Crisis Hamilton’s approach Opioid overdose – symptoms and response Fentanyl and Carfentanil Questions

Harm reduction is a respectful nonjudgmental approach to reducing harms of substance use that meets people “where they are at” What harm reduction isn’t- a new thing, or way to try and get someone to stop using drugs. Image source: harmreductioncafe.com

Four Pillars Drug Strategy ENFORCEMENT PREVENTION HARM REDUCTION TREATMENT The City of Hamilton engages in all 4 pillars. Public Health specifically in 3 Prevention – comprehensive Mental Health Strategy Harm Reduction – that’s us Treatment – Alcohol, Drug and Gambling Services Four Pillars Drug Strategy

Harm Reduction are the strategies we put in place to keep folks safe Mount Recovery Ideal!!! Harm Reduction are the strategies we put in place to keep folks safe Reality Substance use is cyclical – not a smooth road to ‘mount recovery’ but with relapse and with different areas of need. Help folks stay as healthy as possible – for example avoid contracting HCV, which can be silent for a very long period of time. Although people who inject drugs account for only 0.2–0.5% of the world’s population, they make up approximately 5–10% of all people living with HIV. However, globally, less than 1% of people who use drugs have access to HIV treatment. (UNAIDS, March 2014)

Harm Reduction in Hamilton Public Health began to offer needle exchange services in 1992 (on the street outreach with backpacks!) The VAN as a mobile outreach and in clinics and other sites where people get unused injection supplies and can return used supplies

Harm Reduction – the VAN Operates Monday to Saturday, 8 pm to 12 am Will meet with people anywhere in Hamilton Accepts text messages Confidential, focused on developing relationships and trust New injection equipment, safer sex supplies, information, connection with community supports Disposal of used supplies Naloxone Connection with the Cold Alert Response in winter, cold supplies Expansion hopes: testing and wound care

Harm Reduction – Needle Syringe Program Sites The Wesley Centre, 195 Ferguson Ave N The AIDS Network, 140 King St E, Lower Level Hamilton Urban Core Community Health Centre, 71 Rebecca St Sexual Health Clinics

Harm Reduction - IDU Outreach Worker 1:1 Practical Assistance – reducing barriers to housing, food, access to health care Harm Reduction Approach Peer Engagement

Safer Inhalation Kits Image source: Ontario Harm Reduction Program

Safer Injection The Kit: Needles Ties Spoons/cookers Alcohol swabs Filters Matches Vitamin C Water Condoms

Popcorn, Fentanyl, Carfentanil and Overdose

Popcorn Heroin + Fentanyl Inconsistent dosing of both substances People who are used to heroin OD’ing with smaller amount

Fentanyl Previously mostly available by patch or in hospital settings by IV Used patches cut up, melted and injected or smoked Inconsistent dosing and availability

Fentanyl Change from OxyContin to OxyNeo 2012 OxyNeo made harder to dissolve and inject Bootleg fentanyl developed – chemical make-up continually changed slightly to avoid detection Overseas suppliers

Carfentanil Analog of Fentanyl 10 000 more potent than morphine, 100 x stronger than fentanyl General anesthetic for large animals, such as elephants No safe amount for human consumption Naloxone may be ineffective Occupational exposure concerns

The Opioid Crisis Locally Between January 10, 2017 and Sept 24, 2017, Hamilton Paramedics responded to 296 calls related to opioid overdoses. 52 deaths in Hamilton were caused by opioids or a combination of opioids and alcohol in 2016. Hamilton’s death rate was 48% higher than Ontario’s provincial average. There have been more opioid-related deaths in the Hamilton LHIN over a five-year period than anywhere else in the province In well over half of overdoses in which Naloxone was used from the HOPE program, 911 was not called. Rates of death not accurate due to only coroner cases

Hamilton’s Response so far…. HOPE Naloxone Program 2014 Opioid Summit January 2017 – EMS, Hospitals, Methadone Clinics, Public Health, Police Opioid Surveillance and Monitoring Community Consultation re: Supervised Injection Services

Hamilton’s surveillance and monitoring system: https://www.hamilton.ca/public-health/reporting/hamilton-opioid-information-system

What does an overdose look like? Opioid Overdose Stimulant Overdose Slow or no breathing Blue lips and/or fingertips Pinpoint pupils Not able to wake up Snoring or gurgling sounds Cold and clammy skin Unconscious Rapid breathing Chest pain and/or racing heart Shaking or seizures Confusion, anxiety and/or psychosis Sweating

Overdose: How to reduce the risk Who will overdose? Anyone can, there is no magic formula. How you take the drug (Route of administration) Avoid mixing- or use less of each substance Change in tolerance – start low and go slow Inconsistent drug quality/strength – do testers Using alone – Fix with a friend or let someone know Stronger drugs (examples: Fentanyl, carfentanil)

How to respond to an overdose Know what an overdose looks like (Signs and symptoms) Know what to do (911! Naloxone! First aid care!) Know what to avoid

Naloxone (aka Narcan) Naloxone reverses an overdose. Works for 30-90 minutes. When it wears off, the overdose could return. ~2000 kits dispensed* Around 550 overdoses have been reversed by the Naloxone in the kits* * From May 2014-Sept 2017

How does Naloxone work? Kicks Opioid off Brain Keeps Opioids off for 45-90 mins When Naloxone wears off, leftover opioid can take effect again

What don’t you need to get a Naloxone kit? ID An appointment Lots of time What do you need to get a Naloxone kit? 1. To currently be using opioids, or a history of opioid use OR 2. To be a friend or family member of someone who uses opioids 3. To not have an allergy to Naloxone. 4. To be willing to participate in a training session on Naloxone.

Where can you get Naloxone kits? Contact numbers for more information: Wesley Street Health Centre The AIDS Network Notre Dame House Urban Core Community Health Centre City of Hamilton’s Sexual Health Clinics Home visits and group training available Various pharmacies throughout the City The VAN Contact numbers for more information: Public Health Program: 905-546-4276 (injectable & nasal) Pharmacy Program: 1-800-565-8603 (injectable only currently)

Public Health Response Improve reporting systems for OD’s and deaths in the city www.hamilton.ca/opioidmonitoring Improve communication with stakeholders i.e. weekly report Recently received approval for funding for more staff and Van hours for naloxone response Planning started for input regarding supervised injection sites

Lived experience suggestions: “be real, don’t be phoney” “don’t judge if someone asks for help” “make someone feel at ease” “work with me” “meet me halfway”