Ottawa Public Health Protecting you. Promoting a healthy city. Safer Crack Kits Ottawa’s Harm Reduction Program 6 Dec 2007

2 Ottawa Public Health Protecting you. Promoting a healthy city. Why is this program needed? (1) To prevent transmission of infectious disease among drug users and to prevent the spread to community-at- large

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

Prevalence HCV Infection by Years of Injection Drug Use

HIV and HCV Infection: Women IDUs

HIV and HCV Infection: Men IDUs

9 Ottawa Public Health Protecting you. Promoting a healthy city. 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

10 Ottawa Public Health Protecting you. Promoting a healthy city. 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’

11 Ottawa Public Health Protecting you. Promoting a healthy city. 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 X more contagious than HIV Need to tailor interventions

14 Ottawa Public Health Protecting you. Promoting a healthy city. 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

15 Ottawa Public Health Protecting you. Promoting a healthy city. 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

16 Ottawa Public Health Protecting you. Promoting a healthy city. 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)

17 Ottawa Public Health Protecting you. Promoting a healthy city. 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

EVALUATION FINDINGS/BENEFITS (Winnipeg Regional Health Authority)

19 Ottawa Public Health Protecting you. Promoting a healthy city. 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

20 Ottawa Public Health Protecting you. Promoting a healthy city. 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

21 Ottawa Public Health Protecting you. Promoting a healthy city. 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.

22 Ottawa Public Health Protecting you. Promoting a healthy city. 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

23 Ottawa Public Health Protecting you. Promoting a healthy city. 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

24 Ottawa Public Health Protecting you. Promoting a healthy city. 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

25 Ottawa Public Health Protecting you. Promoting a healthy city. Ongoing Evaluation Pre and post-evaluation 300 in cohort studied before start of program May, 2005 – 1 st post-evaluation Evaluated every 6 months afterward Measures: HIV and Hep C incidence, sharing patterns of drug users National surveillance – I-Track

26 Ottawa Public Health Protecting you. Promoting a healthy city. 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

27 Ottawa Public Health Protecting you. Promoting a healthy city. 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

28 Ottawa Public Health Protecting you. Promoting a healthy city. 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

29 Ottawa Public Health Protecting you. Promoting a healthy city. 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

31 Ottawa Public Health Protecting you. Promoting a healthy city.