Opioids

Few opioid overdose patients prescribed drugs to manage disorder: Study

Christopher.Sorensen — Wed, 03 Jan 2024 20:01:20 +0000

Few opioid overdose patients prescribed drugs to manage disorder: Study

Christopher.Sorensen Wed, 01/03/2024 - 15:01

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(photo by Tetra Images/Getty Images)

Gabrielle Giroday

Topic

Breaking Research

Temerty Faculty of Medicine

Opioids

Research & Innovation

Subheadline

Researchers say low prescription rates in Ontario for drugs such as methadone or suboxone, which help people manage opioid use, are a missed opportunity for harm reduction

Only one in 18 people who go to the emergency department or end up in hospital after an opioid overdose in Ontario are prescribed drugs like methadone or suboxone to help manage their substance use disorder, University of Toronto researchers have found.

The study – published recently in the Canadian Medical Association Journal – looked at more than 47,000 emergency room visits or hospital admissions from January 2013 to March 2020.

The ICES data reflected the health care experiences of approximately 14,000 patients who sought hospital treatment for opioid toxicity – including those that received opioid agonist therapy (OAT), which is the clinical practice of prescribing drugs like methadone or suboxone to help people with an opioid use disorder minimize their cravings and lower their physical withdrawal symptoms.

Researchers concluded from their analysis that “despite slight increases over time, [opioid agonist therapy] initiation rates after an emergency department visit or hospital admission for opioid toxicity in Ontario were low, with only one in 18 events leading to filling an [opioid agonist therapy] prescription within a week of discharge.”

Researchers add that low prescription rate of drugs like methadone or suboxone to help people manage their opioid use disorder is a missed opportunity for harm reduction.

“We now know that only about four per cent of hospital encounters for opioid overdose led to OAT initiation. These low rates show that we need to improve care and access to treatment,” says Tina Hu, an assistant professor in the Temerty Faculty of Medicine’s department of family and community medicine who was involved in the study.

Researchers also found that although the initiation rate of OAT increased over time in the study population, reaching more than five per cent of all patients seen in hospital by 2020, the process of starting OAT remained low overall.

“Our research shows that there were substantial disparities in OAT initiation rates, with potential barriers to prescribing for older patients, those with mental health diagnoses and those in the lowest neighbourhood income quintile,” the study stated.

The missed opportunity to start OAT was especially striking given that the study noted that in about 22 per cent of cases, people who were part of the study population had an outpatient visit within seven days of their hospital visit.

“These results highlight critical missed opportunities to prevent future mortality and morbidity related to opioid use, despite connection to health care for many patients in the days after a toxicity event,” the study said.

The study also noted that a 2018 call by the Canadian Research Initiative in Substance Misuse to use “buprenorphine/naloxone as the preferred first-line treatment for [opioid use disorder] when possible” did not appear to lead to an increase in initiation rates.

“The release of a national guideline advocating for buprenorphine–naloxone as first-line therapy did not appear to substantially influence OAT initiation rates, suggesting that additional efforts are needed to improve initiation of OAT in acute care settings,” said the researchers.

The research was supported by the Canadian Institutes for Health Research.

Researchers develop tool to help hospitals reduce loss and theft of medications

Christopher.Sorensen — Tue, 13 Jun 2023 15:34:56 +0000

Researchers develop tool to help hospitals reduce loss and theft of medications

Christopher.Sorensen Tue, 06/13/2023 - 11:34

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(photo by BackyardProduction/Getty Images)

Alisa Kim

Topic

Breaking Research

Opioids

Institute of Health Policy Management and Evaluation

Dalla Lana School of Public Health

Hospital

Research & Innovation

University Health Network

Drug diversion in health-care facilities, when prescription medications are obtained or used illegally, is on the rise in Canada – and most Canadian hospitals do not have sufficient safeguards in place to detect and deal with the problem.

That's why Patricia Trbovich and her team at the University of Toronto, in partnership with the Institute for Safe Medication Practices Canada, have developed a free, online tool that helps hospitals identify the risk of drugs being lost or stolen within their organization, and offers guidance on how to address those risks.

In developing the tool, the team pinpointed areas that make a hospital vulnerable to diversion as opposed to targeting individuals who lose or steal drugs.

“We saw this as an opportunity to look at it from a system perspective, seeing what is it in terms of the way we’ve configured our technologies, workflow processes and environments that is allowing for diversion to occur?” says Trbovich, an associate professor at the Institute of Health Policy, Management and Evaluation in the Dalla Lana School of Public Health.

The diversion risk assessment tool addresses a huge and complex problem. Nationally, reports of the loss of opioids and other controlled drugs have doubled annually since 2015. When drugs are lost or stolen within hospitals, everyone suffers. Drug diversion compromises the safety of patients and staff, increases health-care costs and contributes to substance abuse in the population.

The most commonly diverted drugs are opioids, which are prescribed to relieve pain. Trbovich and Mark Fan, manager of Trbovich’s research group HumanEra, published a study in CMAJ Open that looked at opioid losses from Canadian health-care facilities from 2012 through 2017. Using Health Canada data, they found there were about 65,000 reports of loss during this period, equating to about 112 kilograms of opioids with a street value of about $136 million.

“What makes this topic challenging is that we think losses and thefts are underdetected, and then potentially underreported. We don’t know the relative contributions of those two things,” says Fan, noting that any medication is at risk of going missing.

Moreover, hospitals don’t seem to know when or how medications are being lost or stolen.

“When we started talking to hospitals about it, they were saying, ‘We know it happens, but we don’t have a good way to track how often it happens,’” says Trbovich, who holds the Badeau Family Research Chair in Patient Safety and Quality Improvement at North York General Hospital. “Opioids might go missing for example, but they don’t necessarily know what led to it going missing. They are mandated to report to Health Canada when opioids go missing; often they report it back as ‘unexplained loss.’”

Organizations can use the tool at no cost, but they must first register. The risk assessment examines how controlled drugs are managed throughout a hospital. Users are asked, for example, how discrepancies in inventory records are detected, how staff access controlled areas and how processes around ordering, storage, transfer and disposal of medications are conducted.

The tool produces a risk score based on the information provided. Users can compare their score against other hospitals. There is also a reference guide that has recommendations to address areas of weakness, which was developed in collaboration with the Institute for Safe Medication Practices Canada and the Ontario Branch of the Canadian Society of Hospital Pharmacists.

Hospitals can re-do the assessment after implementing recommended safeguards, notes Trbovich. “Once they’ve addressed [vulnerabilities], they could then on a regular basis benchmark themselves against others or themselves if they want to see how they’re improving,” she says.

To date, dozens of hospitals have signed up to do the risk assessment. The research team will analyze the aggregated results to provide an overview of the diversion risks in Canadian hospitals. The analysis will highlight differences in risk based on region, hospital size and technologies used, so that organizations can learn from each other, says Fan.

“Having this national ‘snapshot’ is going to help policymakers assess where we need to raise the floor on our safety practices across Canada, and to transfer the learnings,” he says. “If we see some people are doing really well, it’s something to celebrate and bring to other hospitals.”

The project received support from the Canadian Institutes of Health Research.

U of T's Discovery Pharmacy launches naloxone program for university community

Christopher.Sorensen — Thu, 03 Feb 2022 18:16:49 +0000

U of T's Discovery Pharmacy launches naloxone program for university community

Christopher.Sorensen Thu, 02/03/2022 - 13:16

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A fast-acting and potentially life-saving medication, naloxone can be used to counter the effects of an opioid overdose (photo by Steve Russell/Toronto Star/Getty Images)

Topic

Centre for Addiction and Mental Health

Lawrence S. Bloomberg Faculty of Nursing

Leslie Dan Faculty of Pharmacy

The Discovery Pharmacy at the University of Toronto’s Leslie Dan Faculty of Pharmacy is now piloting naloxone training for select offices and programs at the university.

A fast-acting and potentially life-saving medication, naloxone can be used to counter the effects of an opioid overdose the moment it is occurring. Much like an EpiPen is used to treat anaphylaxis, naloxone can be used by anyone with access to a kit and proper training.

“Providing naloxone kits and training is one way to help support the safety of our community and to help combat the effects of the ongoing opioid crisis,” said Jonathan Nhan, interim pharmacist lead at the Discovery Pharmacy.

In 2016, in response to the growing opioid crisis, naloxone kits became available without the need for a prescription nationally and free of charge in Ontario through the Ontario Naloxone Program and the Ontario Naloxone Program for Pharmacists. Since then, pharmacists have played a key role in dispensing take-home naloxone kits, a service that is coupled with one-on-one training and harm reduction counselling.

Maria Zhang, clinician educator at the Leslie Dan Faculty of Pharmacy and the Centre for Addiction and Mental Health (CAMH), has been working alongside Nhan to develop the Discovery Pharmacy naloxone program. The team of pharmacists and pharmacy students will be using resources originally developed by CAMH to deliver training at both the individual and group levels.

“We want to reduce the harms associated with drug use,” said Zhang, pointing out that many people can be exposed to opioids through different means. “Opioid poisoning can result from prescription opioid use as well as from taking recreational drugs that contain opioids – known or unknown – to the person taking them.”

Both Zhang and Nhan emphasize that maintaining individual privacy and reducing stigma associated with drug use are key to improving access to life-saving interventions. “Even if someone is interested in just learning more about the take-home kits, they can reach us at Discovery Pharmacy to ask questions,” said Nhan.

Stigma surrounding drug use can be a barrier to people accessing tools like naloxone – an issue the group training sessions aim to address.

The onset of the COVID-19 pandemic has exacerbated the opioid crisis. A September 2021 report from Ontario’s COVID-19 science advisory table outlined opioid overdose deaths increased by 60 per cent since the pandemic started in March 2020. Several subpopulations including men and individuals aged 20 to 49 are disproportionally impacted.

“We know that drug use can happen … and in isolation now more than ever. We want to contribute to the solutions addressing the opioid crisis with this service,” said Zhang.

In addition to the direct care delivery of providing naloxone kits and training, the Discovery Pharmacy program layers in the interprofessional education of health-care students, research and quality improvement.

“As an accredited pharmacy embedded in the U of T ecosystem, we aim to advance pharmacy practice and offer interprofessional care to our community,” said Zhang. “We also plan to interlay research and education and collaborate with other disciplines to see how we can better deliver our naloxone training, reach more people and destigmatize substance use so that those who require help don’t hesitate in getting it.”

Students and faculty from the Lawrence S. Bloomberg Faculty of Nursing will also play an active role in naloxone training and education through the Discovery Pharmacy. This provides a tangible opportunity for students to develop skills in interprofessional practice.

“For the most part, students across our health faculties learn within their respective fields. We talk about interprofessional practice in theory but often the first time a nursing student is exposed to it is when they are in hospital on clinical rotation,” said Sarah Ibrahim, assistant professor, teaching stream at the Lawrence S. Bloomberg Faculty of Nursing. “The more our students have the opportunity to gain interprofessional experience, the better equipped they will be once they are ready to enter practice.”

Nursing students will take initial training alongside pharmacy students and then will be paired up to provide peer-to-peer training. “This is a great way for students to come together to build that interprofessional partnership and rapport and carry this over as health-care providers,” said Ibrahim, who points out the need for health-care students to learn about harm reduction and the negative impact of stigma. “Stigma of drug use is a barrier for people accessing care and if, as a health-care provider, you don’t have the skills to provide care in this context, that’s also a barrier.”

Virtual 'spotting' could help keep drug users safe during COVID-19, U of T researchers say

Christopher.Sorensen — Mon, 26 Apr 2021 13:29:09 +0000

Virtual 'spotting' could help keep drug users safe during COVID-19, U of T researchers say

Christopher.Sorensen Mon, 04/26/2021 - 09:29

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Carol Strike, a professor at U of T's Dalla Lana School of Public Health, and Natalie Kaminski, a research assistant, are studying a remote supervised-consumption model known as "spotting."

Topic

Dalla Lana School of Public Health

Drugs

Research & Innovation

A group of researchers at the University of Toronto and the Canadian Association of People Who Use Drugs are studying a remote supervised-consumption model known as “spotting” to understand its benefits among people who use drugs during the pandemic.

The research team coined the term because the model involves a “spottee” consuming drugs in a safe location such as their home while a friend, family member or an acquaintance – the spotter –monitors them virtually.

“Before someone consumes a drug, they call their spotter on the phone who will be there on the call with them as they use,” says project lead Carol Strike, a professor at the Dalla Lana School of Public Health. “The spotter stays on the line with the spottee for another five to 15 minutes to ensure they are safe or call for help if needed.”

So far, Strike says the researchers have found that spotters and spottees view the model as a way to be safe during the pandemic.

“If the spottee overdoses, the spotter will call a neighbour, friend or an ambulance to come and help,” says Natalie Kaminski, a research assistant on the project.

The plan for overdose response is created by both parties before the spottee consumes a substance.

While people who use drugs have spotted each other in person for a long time, the study is exploring how it is being used amid COVID-19, Kaminski says.

Research team members with lived experience of drug use recruited 30 participants from their personal networks in Nova Scotia and Ontario to take part in the study. The participants reported an increase in their safety and said they appreciated the privacy and stigma-free environment that spotting offered. Spotters, meantime, reported an improved connection with their community and a sense of accomplishment when working with spottees.

“Also, given COVID, they can consume at home instead of coming to the safe injection site,” says Strike.

The researchers say such tactics are needed amid reports of a growing number of fatal opioid overdoses in Canada during the pandemic.

However, the spotting model isn’t foolproof. For one thing, some spotters fear help may not arrive in time to revive spottees.

“There are also concerns about police intervention if 911 is called, especially among people who use drugs who are racialized,” says Strike, pointing to recent headlines about over-policing and criminalizing of racialized people.

The research team has produced recommendations to improve spotting programs – notably the development of guidelines for spotters and spottees, awareness programs for spotting services in the community and trauma support for spotters.

They are also presenting results to conferences and will submit their findings to an open-access journal. Strike and her team are poised to receive additional funding to create educational materials such as animated videos and tip sheets. The team hopes to do more research about app-based supervised consumption and the recently-launched National Overdose Prevention Service – a service funded to provide spotting 24 hours a day, seven days a week.

“The primary goal of this project is to improve options for overdose prevention,” says Kaminski. “We’re hoping to make spotting safe for more people – in particular, those who don’t have access to supervised consumption sites.”

The study was made possible through funding from the Dalla Lana School of Public Health.

U of T researchers identify four types of opioid stigma contributing to the current crisis

Christopher.Sorensen — Mon, 02 Dec 2019 16:37:25 +0000

U of T researchers identify four types of opioid stigma contributing to the current crisis

Christopher.Sorensen Mon, 12/02/2019 - 11:37

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Methadone and other types of opioid agonist therapy can be an effective way to treat an opioid use disorder, but researchers found patients face stigma because of methadone's association with heroin use (photo by Hailshadow via Getty Images)

Nicole Bodnar

Topic

Our Community

Opioids

Dalla Lana School of Public Health

Graduate Students

Joint Centre for Bioethics

Research & Innovation

Researchers from the University of Toronto have identified four types of opioid-related stigma that depend on a variety of factors, including the context of opioid use, the social identity and networks of the person who is consuming the opioid, and what type of opioid is being consumed, including prescribed opioids.

Each type requires targeted strategies to address the unique stigmas and reduce health inequities, the researchers say. The study was published in the December 2019 edition of the International Journal of Drug Policy.

“We know that stigma is both a driver and consequence of the current overdose crisis, but opioid-related stigma is poorly understood,” said Daniel Buchman, an assistant professor at the Dalla Lana School of Public Health and a senior author of the paper.

North America is in the grips of an opioid-related overdose crisis and stigma, discrimination and prejudice are major contributors. Substance use in general is highly stigmatized, but stigma is a complex concept. Researchers say that there’s a lack of good evidence on the specific sources of opioid stigma, how it manifests in various contexts and its impact on affected groups.

Buchman worked with a research team to conduct a review of publications on opioid-related stigma. The team identified more than 8,500 papers of which 51 were analyzed. Four main themes emerged: interpersonal and structural stigma toward people accessing opioid agonist therapy, which involves taking long-acting opioid medications like methadone and buprenorphine to prevent withdrawal symptoms; stigma related to opioids for the treatment of chronic pain; stigma in health-care settings; and self-stigma.

“Labels like ‘addict,’ ‘drug-seeker’ and ‘junkie’ are barriers to accessing treatment and many people who use opioids internalize these labels and report feelings of self-blame, loathing, despair, shame and moral weakness,” said Melissa McCradden, first-author on the paper and a master of health science student at the U of T Joint Centre for Bioethics.

Opioid agonist therapy is the gold standard of treatment for opioid use disorders, but researchers found that individuals receiving this treatment face stigma from multiple angles.

For example, methadone’s association with heroin use stigmatizes the medication and the people who use it. The literature suggests that some physicians refuse to prescribe opioid agonist therapy out of fear of being stigmatized by their colleagues. Some patients who are prescribed opioids for cancer pain feel compelled to disclose their identity as a ‘cancer patient’ at the pharmacy in order to differentiate themselves from people on methadone and avoid barriers in accessing their medications.

Stigma in health-care settings was another theme identified by the research team, both in the perception of physicians, nurses and pharmacists toward people who use opioids, as well as within health care’s bureaucratic systems. For example, excessive regulation, paperwork and requirements specific to prescribing opioids may intensify the stigma experienced by people who use opioids.

“The literature suggests that some health-care professionals will make a distinction between patients with legitimate pain who have ‘legitimate’ reasons for accessing opioids, and patients with ‘illegitimate’ pain who do not have legitimate reasons for accessing opioids,” said McCradden.

“This makes a harsh moral distinction between so-called ‘deserving’ and ‘undeserving’ patients. It entrenches stigma.”

Ultimately, researchers say that a paradigm shift is needed to address the structural forms of stigma – including social and economic determinants, laws and public attitudes – in order to have an impact at the individual level.

“Stigma is considered a fundamental cause of population health inequalities and an independent social determinant of health,” said Buchman, who is also a bioethicist at the University Health Network.

The social determinants of health are the conditions in which people live that are shaped by the distribution of money, power and resources. Social disadvantages – such as poverty, housing instability and discrimination – often occur simultaneously and can intensify stigma toward those who use opioids. This further marginalizes individuals, exacerbates health inequities and perpetuates stigma.

Buchman and McCradden say that evidence-based strategies to address stigma and its long-term impact on population health are critical to curb the overdose crisis.

“The more familiar you are with a person, the less likely you are to stigmatize them, so there’s tremendous value in including and amplifying the voices of people who use opioids in health policy-making,” said Buchman.

“Humanizing people who use drugs and moving towards decriminalization of all drugs are key to a cultural shift in re-thinking substance use and redressing opioid-related stigma.”

'The scale of grief and loss is terrible': Meet the U of T student fighting to prevent opioid overdose deaths

noreen.rasbach — Thu, 18 Jul 2019 14:45:17 +0000

'The scale of grief and loss is terrible': Meet the U of T student fighting to prevent opioid overdose deaths

noreen.rasbach Thu, 07/18/2019 - 10:45

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Gillian Kolla, a PhD candidate at the Dalla Lana School of Public Health, has helped save scores of lives with oxygen tanks and naloxone kits at Moss Park (photo by Nick Iwanyshyn)

Topic

Dalla Lana School of Public Health

Graduate Students

Public Health

Subheadline

A young woman with blonde hair and a nose ring peers curiously at the camera. A middle-aged man with grey hair leans against a tree. A young man grins.

These photographs are scattered on the memorial wall of the Moss Park Overdose Prevention Site. They represent only a fraction of the overdose deaths the Moss Park community has suffered so far this year. The overdose crisis has taken the lives of more than 10,300 people in Canada in the past three years, but right now Toronto’s illegal opioid supply is more lethal than ever.

In 2016, heroin began to give way to the far more potent fentanyl, and overdose deaths soared. Then, starting in January of this year, lab tests showed carfentanil, an even more powerful opioid not meant for humans, had entered the supply.

“The scale of grief and loss is terrible,” said Gillian Kolla, a PhD candidate at the Dalla Lana School of Public Health who has helped save scores of lives with oxygen tanks and naloxone kits. “We don’t think of people who are homeless and use drugs as having strong communities, but they do. And these communities have been devastated.”

A naloxone kit at the Moss Park Overdose Prevention Site (photo by Nick Iwanyshyn)

Starting in the summer of 2017, Kolla worked alongside other volunteers from the Toronto Overdose Prevention Society to open Ontario’s first supervised consumption site. For 11 months, they operated unsanctioned in tents, and later a trailer, in Toronto’s Moss Park, stocked with naloxone kits, oxygen tanks and sterile injection equipment. Over 150 volunteers – many of them people with lived or current experience of drug use – supervised more than 9,000 injections, and saved the lives of 251 people.

They also served on the province’s Opioid Emergency Task Force, helping the provincial government develop its model for overdose prevention sites. The following summer, by the time the Moss Park operation moved to an officially approved and funded space across from the park, eight legal supervised injection and overdose prevention sites were already operating in the city.

Kolla, a 41-year-old mother of two young children, is a fierce advocate for street-involved drug users. Her current research examines the delivery of harm-reduction services to people who use drugs by meeting them where they live and use drugs, aiming to improve their health in the process.

“Gillian is unique in how she has blended her skills as a service provider, academic researcher and advocate,” said her PhD thesis supervisor, Professor Carol Strike. “She’s amongst the talented few with the skills and credibility to truly partner with people who use drugs to address issues like overdose, criminalization of drug use and housing that impact their lives.”

Kolla has been working with people who use drugs for over a decade, starting in Montreal with homeless and street-involved youth. She moved to Toronto to work on her master’s degree in public health at Dalla Lana in 2007, and began her PhD a few years later. When the overdose crisis hit, Kolla was doing field research on a novel harm-reduction program that delivered education and equipment directly in the spaces where people gather to use drugs. She saw first-hand the increased overdoses caused by the contamination of heroin with more potent opioids like fentanyl.

For Cuz, a 45-year-old man originally from Nova Scotia, the sense of community in the tents felt healing (photo by Nick Iwanyshyn)

In the fall of 2016, when overdose-related deaths started climbing across Canada, Vancouver activists opened the first guerilla overdose prevention site by erecting a tent in an alley. The following summer, after years of frustration trying to open supervised injection sites in Ontario, Toronto activists decided they didn’t need anyone’s permission to save lives, either. They formed the Toronto Overdose Protection Society (TOPS), bought a few tents and set up in Moss Park.

“We didn’t know it at the time, but Toronto Public Health released data months later showing we opened the tents at the epicentre of the city’s overdose crisis,” said Kolla, who is a member of the co-ordinating committee for TOPS and was responsible for compiling usage data. “In our very first month in the park we reversed 15 overdoses, in only 18 days. And it just continued from there.”

Community members who spent time in the park helped with tent setup and takedown every day. Cuz, a 45-year-old man originally from Nova Scotia, pitched in regularly.

At the time, Cuz was overdosing and ending up in the hospital frequently. Once he was in a coma for a week. With fentanyl, he said, there’s no way to know what you’re getting. It scared him to think of the girl he watched overdose after injecting just $2 worth of it. Cuz began hanging out at the site, and started to use in the tent. He spent time learning about safe injection practices, but also enjoying the feeling of safety – knowing he was not going to die or be arrested in that moment.

For Cuz, the sense of community in the tents felt healing.

“It’s the love, the caring, and all the little things,” he recalled. “There was nothing those guys wouldn’t do for me. It was the tent – I didn’t know it at the time, but I knew I was excited. They say it takes a village. When the first tent opened up out here, that was the first time it felt like a village. There wasn’t a sense of community for me until then.”

Said Kolla: “There was something so special about being in the park. People were bringing food, hanging out and chatting in front of the tents. It was really powerful and it fostered a sense of community that has continued to this day.”

Today, Cuz still uses fentanyl, but he’s careful to follow safe injection protocols, and to take care of himself by eating and most importantly getting enough sleep. He fears death a lot less.

He volunteers at a downtown supervised consumption site, enjoys his son and new baby granddaughter, and is thinking about starting a roofing company that could employ drug users able to do strenuous work.

“When you feel like you’re making a difference you don’t want to stop that,” he said. “You’re creating happiness, safety and nurturing. I took myself out of a certain crowd and saw that each time I helped out, things got better for me.”

Supplies in the Moss Park Overdose Prevention Site (photo by Nick Iwanyshyn)

Overdose prevention sites are about saving lives first and foremost. And yet during her Saturday-night shifts in the Moss Park tents, Kolla found herself constantly on the phone, trying to find people spots in shelters, helping them get into detox or connected to other social services.

“Research shows that people who use supervised injection sites are more likely to access treatment than those who don’t use these services,” she said. “But it’s important that treatment is not seen as the goal. When people are forced into treatment it’s much less effective than when they choose to go on their own.”

She believes the tents sent a powerful message that the community “cared whether people who use drugs lived or died. And there was much more community support than we anticipated. If we tweeted that it was hot out and we needed more water, cars would pull up with bottles of water. Union members helped us get a trailer in the park and then wire it for electricity so we could stay warm through the winter. Neighbours donated food and we raised a lot of money on GoFundMe.”

Even law enforcement has been largely supportive, Kolla recalled. “Police see the deaths. They’ve even tweeted out drug warnings and advised people to use supervised consumption sites,” she said. “There has been a sea change in the way they relate to harm reduction. It’s amazing how far they’ve come.”

Jen Ko, the nurse who co-coordinates the Moss Park Overdose Prevention Site, got her start as a volunteer in the park. “My experience was really transformative,” she said. “In health care, there’s a lot of lip service to being patient-centred. This was radical health care. It felt like such a privilege to be in this space.”

The needle disposal box in the downtown Toronto neighbourhood of Moss Park (photo by Nick Iwanyshyn)

Today, there are nine supervised consumption sites in Toronto, but people are still dying when they inject at home, at night, or in places like Scarborough and Etobicoke that are far away from the downtown core, where most of the services are located.

The next frontier in harm reduction, Kolla said, is advocacy for the decriminalization of drug use, and the establishment of safer supply programs.

“Criminalization is negatively impacting how quickly we are responding to the overdose crisis,” she said. “Right now, the drug supply is very dangerous, and there’s no way to get around this unless we get a safer supply to people at risk. And this isn’t something that can happen in a small pilot project: We are seeing catastrophic death rates. We need to roll out safer supply in big cities and small towns – and we need to roll this out yesterday.”

This article is part of the Dalla Lana School of Public Health’s 2018/19 Annual Report. For more highlights, check out the full report.