Here’s what the Ford government doesn’t get about addiction
Vincent Lam, The Toronto Star
August 26, 2024
hile well-intentioned, the Ontario government plan to close 10 supervised consumption sites and create 19 new homeless and addiction recovery hubs fails to recognize the complexity of addiction.
As an addiction doctor, I often hear a patient’s “first day resolutions” when they initially seek help. Many swear they will never use illicit drugs again, and they will build a new life from this day forward.
I prescribe treatment and offer counselling, but I also ask: Do they have a naloxone kit? Can they access clean drug use supplies to reduce the risk of hepatitis and HIV? Do they use a supervised consumption site?
Alongside my deep conviction that with treatment and support people can recover from addiction, I also know that people’s choices are impacted by the physiological changes of addiction, mental-health issues, challenging circumstances, and habits. It is common to want a linear path, but often things move sideways before going forward. I respect and applaud my patients’ commitment to recovery — and I encourage them to access harm reduction as needed.
The Ontario Government has announced that it will close 10 supervised consumption sites that are within 200 metres of schools and child-care centres. It will create 19 new Homelessness and Addiction Recovery Hubs (HART) which will not offer supervised drug consumption, needle exchange or the public supply of addictive drugs (aka: “safe supply”). It will fund 500 addiction recovery beds and 375 supportive housing units.
While I applaud these investments, when paired with indiscriminate cuts to harm reduction, the announcement has the spirit of “first day resolutions” plans — well-intentioned, linear, but failing to recognize the complexity of addiction, and the need for a multi-faceted, co-ordinated approach to the opioid crisis.
Ontario Health Minister Sylvia Jones said in her remarks at the Association of Municipalities of Ontario on Aug. 20 that, “the cycle of addiction is not being broken by using drug consumption sites.”
That same day, the government announced it is mandating new requirements for safety and security plans at the supervised consumption sites that will remain open, as well as policies that will “discourage loitering and promote conflict de-escalation.”
Rather than closing consumption sites, I suggest we implement these safety measures and look at how we can use the sites to break the cycle of addiction, and more actively engage people in treatment and recovery.
A specific suggestion: saving a life should be followed by immediately offering treatment.
Between March 2020 and January 2024 supervised consumption sites across Canada reversed 16,180 overdoses with the antidote naloxone. Naloxone results in agonizing opioid withdrawal and people often immediately seek more drugs and may overdose again. This can be remedied by immediately offering the patient a dose of buprenorphine, which relieves this withdrawal and is the first dose of a long-term treatment with an excellent safety profile.
Offering buprenorphine should be standard practice in every naloxone resuscitation, but we will lose thousands of these opportunities – as well as lives – by simply closing supervised consumption sites.
Broadly, we should recognize that many people who use drugs are deeply mistrustful of health-care providers and institutions because they have experienced stigma and discrimination. Where they have built relationships of trust with harm reduction workers, these are valuable and should be respected as pathways to engagement in treatment.
With the new government plan, many consumption sites will convert to HARTs. That means that many of the existing clients will attend the new programs at the old locations but without any indoor, safe, private place to use drugs. With HARTs prohibited from exchanging needles and having to apply for permission to receive needles for disposal, we may see an increase in public drug use and increased needle litter in the surrounding neighbourhoods.
The specifics matter.
The government move is a broad-brush approach that shuts down anything under the umbrella of harm reduction. It would be better to examine individual harm reduction strategies. For example, the concerns around the public supply of addictive drugs (aka — “safe supply”), a practice in which people are dispensed tablets of hydromorphone to take with them, are real and twofold. First, it is not clear that it provides any benefit superior to that of accepted treatments like methadone and buprenorphine. Second, it creates a public health risk by increasing the supply of abuse-prone opioids in the community. Moving to limit this risk is wise. The practice should be replaced with Injectable Opioid Agonist Treatment (iOAT). With this treatment, people are given hydromorphone or other opioids to be used on-site, which minimizes the risk of public harm.
However, I find it shocking that needle exchange will be limited. Providing clean needles is well-established as a measure that limits HIV and Hepatitis transmission, which benefits all members of the public. It is quite different from the public supply of addictive drugs, because it doesn’t increase the supply of drugs.
Rather than prohibiting the creation of new supervised consumption sites, which the government has said it will do, it should establish supervised consumption sites in hospitals. This should be accompanied by an expectation of addiction medicine services being provided in hospitals, and part of an integration of addiction services into mainstream health care. Locations should be guided by the current distribution of overdoses, so that supervised consumption sites are available in communities that most urgently need them.
I welcome the investment in treatment and recovery but urge the Ontario government to reconsider its broad cuts to harm reduction services. The premise of this plan — that a choice needs to be made between harm reduction and treatment, is wrong.
We need both, and we should use harm reduction as a pathway to treatment.
The Toronto Star