This is straight from the public health agency ---and this harpocitter --does the exact opposite --it seem right across this country police, military and other law enforcement agencies are getting huge amounts of monies to "protect" them from the rest of the country ----
Prevention and harm reduction are the only areas where real results have been seen
I'm ashamed of my government at this point --there have been so many programs cut --we haven't even seen the vast majority --the Con government has sliced and diced taking millions away and replace it with pennies
we in Canada are left with either idiots or thieves at our helm --this is not the "new government" I want
http://www.phac-aspc.gc.ca/hepc/hepatitis_c/pdf/harm_reduction_e/canada.html
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Harm Reduction and Injection Drug Use:
an international comparative study of contextual factors influencing the development and implementation of relevant policies and programs
Harm reduction in Canada
The latest version of the Federal/Provincial/Territorial report (2001) provides an excellent summary of harm reduction and related initiatives concerning injection drug use in Canada. What follows is intentionally a brief overview that draws on the FPT and other reports and on information provided by key informants.
Overview
Canada has had needle exchange services since 1987, but the is a general consensus that more needs to be done to increase coverage especially in rural areas. Methadone maintenance treatment has increased significantly in the past few years, but the need still far exceeds the supply. Injection drug use is a major cause for concern in large cities across Canada such as Vancouver, Toronto, Ottawa and Montreal. The HIV/AIDS program of Health Canada reports a public health crisis concerning HIV/AIDS and other infections, such as hepatitis C, among injection drug users in Canada.
There is, however, a momentum to address injection drug use across Canada. The serious harms associated with injection drug use have been identified as a priority issue in Canada by various federal and provincial/territorial committees addressing related issues, including substance abuse, HIV/AIDS, infectious hepatitis, correctional services, Aboriginal issues, and enforcement and justice issues. It has been recognized as a key issue within Canada's Drug Strategy, the Canadian Strategy on HIV/AIDS and the Hepatitis C Prevention, Support and Research Program and by the Advisory Committee on Population Health. All three strategies highlight the need for enhanced harm reduction programming to address the concerns related to injection drug use. Proposals for a scientific trial of heroin prescription, supervised injection sites, and needle exchange in prisons are moving up the political agenda.
The policy context for harm reduction
Canada's Drug Strategy (CDS) has the stated aim of reducing the harm associated with alcohol and other drugs to individuals, families, and communities. The CDS endorses needle exchange, methadone maintenance, abstinence-oriented treatments such as therapeutic communities, and the enforcement of laws pertaing to the use of illegal drugs. Thus, harm reduction is used in a broad sense to refer to any policy or program that aims to reduce drug-related harm (Single, 2001). This contrasts with a more narrow use of the term "harm reduction" to refer to policies and programs that give priority to the reduction of high-risk drug use and related behaviours among current drug users.
The strategy reflects a balance between reducing the supply of drugs and reducing the demand for drugs. It involves a variety of partnerships among 14 federal departments, provincial and territorial governments, addictions agencies, non-governmental organizations, professional associations, law enforcement agencies, the private sector, and community groups.
The Office of Canada's Drug Strategy in Health Canada is the focal point within the federal government for harm reduction, prevention, and treatment and rehabilitation initiatives concerning alcohol and other drugs. The Office works collaboratively with other federal departments and provincial and territorial governments, and provides national leadership and coordination on substance abuse issues, conducts research into the risk factors and root causes of substance abuse, synthesizes and disseminates leading-edge information and best practices to key partners, and collaborates with multilateral organizations to address the global drug problem. Major partners in Health Canada for whom injection drug use is a significant health concern include the HIV/AIDS Policy, Coordination and Programs Division and the Hepatitis C Prevention, Support and Research Program.
There have been no funds for new programs under Canada's Drug Strategy since 1997. Cutbacks in other areas have severely limited new initiatives and have had negative effects on established programs. However, the federal government has announced plans for drug strategy that many hope that this will make more funds available and have clearer goals and priorities than the current strategy.
Recently, the Advisory Committee on Population Health (ACPH), and four federal, provincial and territorial (FPT) committees representing substance abuse, AIDS, corrections and justice, prepared a strategy document on reducing the harm associated with injection drug use. The role of the ACPH is to advise the Conference of Deputy Ministers of Health on national and inter-provincial strategies that are required to improve the health of Canadians and provide a more integrated approach to health. The report stresses
...(t)he 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 reducing the harms associated with injection drug use. (p. 8)
The proposed framework for action represents an extraordinary level of consensus among a broad range of stakeholders and calls for a number of priority actions in the areas of prevention and outreach treatment and rehabilitation research, surveillance and knowledge dissemination; and national leadership and coordination. Among the many recommendations, those most germane to the present report include:
Leadership and coordination to establish an inter-sectoral, multi-level dialogue regarding injection drug use.
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 for 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).
The involvement of drug users and drug user networks in reducing the harm associated with injection drug use.
Addressing barriers to effective substance misuse treatment and rehabilitation programs, including methadone maintenance treatment, and making these programs more available in all settings, including correctional facilities.
Support, in principle, for clinical trials to assess the treatment effectiveness of prescribing heroin, LAAM, buprenorphine, and other drugs in the treatment of people who inject drugs.
The establishment of a task group representing (at a minimum) law enforcement, correctional services, justice, health and social services, addiction and community perspectives to study the feasibility of establishing a scientific medical research project regarding a supervised injection site in Canada.
Improved 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.
A Task Group on the feasibility of a medical research project on supervised injection sites has recently been established.
British Columbia has taken a leading role in responding to injection drug use at the provincial level. A recently released discussion report, "A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver", contains an urgent appeal for the development and implementation of a coordinated, comprehensive framework for action to address the problem of substance misuse in the city of Vancouver. The framework seeks to balance public order and public health and calls for a strong, comprehensive drug strategy that incorporates four pillars: prevention, treatment, enforcement and harm reduction. It is a framework that ensures a continuum of care for those suffering from addiction to substances and support for the communities affected by their drug use.
The approach responds to those who need treatment for addiction, while clearly stressing that public disorder, including the open drug scene, must be stopped. "In short," says the report, "addiction needs treatment and criminal behaviour needs enforcement."
The framework, however, is not without opposition. There are those who fundamentally resist the expansion of harm reduction measures, including some members of the enforcement community and city council. Endorsement by all levels of enforcement, as well as the federal and provincial government, will be necessary for the framework to reach fruition. There is, however, a general feeling that support is strong.
Funding for harm reduction
Funds for new programs under Canada's Drug Strategy have been limited. Most alcohol and other drug treatment and rehabilitation programs and services are funded directly by provincial and territorial governments, and indirectly by the federal government through transfer payments. The federal government also provides direct funding for addiction treatment and rehabilitation services for some specific groups, including Aboriginal people living on reserves, members of the RCMP and the armed forces, and people in the federal corrections system. With the exception of Quebec, there are few specialized private programs that require clients to pay for treatment.
The current status of specific harm reduction initiatives
Needle and syringe distribution and exchange
Syringe exchanges were first established in Canada in 1987, with the first official exchange opening in Vancouver in March 1989. Services were initially provided through fixed sites and street outreach, and had limited representation at other agencies providing services to drug users in downtown areas. Over time, mobile vans have been added to services in several cities. Kits containing needles, bleach and condoms are distributed through these agencies. Between 1989 and 1993, the Federal government cost-shared pilot outreach programs in four provinces. At the present time, there are more than 200 syringe exchanges in rural and urban areas in Canada, with more under development. In addition, there are now numerous pharmacies that provide syringe exchange services.
The availability of needle exchange has not led to an increase in drug use. On the contrary, needle exchange programs have reduced rates of needle sharing among clients and have linked many drug users with health services. In Canada, needle exchange programs are an important strategy in a harm reduction approach to injection drug use, but various reports have indicated the need to increase and expand these programs to increase their availability. This is particularly the case in rural communities and in correctional facilities (Canadian HIV/AIDS Legal Network. Info sheet #8, 1999). Needle exchange programs are not available in any correctional facilities in Canada.
Drug substitution treatment
Methadone
The sale and manufacture of methadone is controlled by the Office of Controlled Substances within Health Canada. To prescribe methadone, physicians must receive an exemption under the Controlled Drugs and Substances Act. There are currently 699 physicians authorized to prescribe methadone. Stakeholders have indicated that this number is too low, especially in smaller communities and rural areas.
Methadone maintenance treatment is available in federal correctional facilities only for inmates who were enrolled in a methadone treatment program prior to incarceration. There are "exceptional circumstances" under which this rule may be set aside, but generally inmates cannot start methadone in correctional facilities. At the provincial level, British Columbia, Saskatchewan, Manitoba, Ontario, Quebec and Nova Scotia offer methadone maintenance treatment programs in prison as a continuation of participation in a community-based methadone maintenance program.
Waiting lists for methadone maintenance continue to be a problem in many communities. In response, the federal government has streamlined the authorization process for physicians. For example, the authorization does not place a limit on the number of patients, and physicians are not required to release information concerning patients to the government. The HIV/AIDS Policy, Coordination and Programs Division of Health Canada provides funding to a low-threshold methadone project in Montreal. Others have recommended further expansion of methadone maintenance treatment to correctional facilities and rural areas. However, attracting physicians to provide methadone prescriptions for opiate dependency is an ongoing challenge.
Other substitute drugs
Buprenorphine is not currently available on the Canadian market. However, physicians can access it through Health Canada's Special Access Program under the Food and Drug Regulations. A North American scientific consortium - the North American Opiate Medication Initiative (NAOMI) - is developing a proposal for a clinical heroin trial. Heroin substitution has been used in some countries with heroin users who are unable to benefit from substitution treatment such as methadone. There is no cocaine substitution treatment available in Canada.
Drug user education and outreach
Education and outreach programs, with a harm reduction focus aimed at users of injection drugs, are readily available throughout Canada, and Health Canada recently commissioned a report on ways of improving these programs (Wiebe, 2000). These programs are most often provided through needle exchange programs, and drug user groups and networks. Involving those who are former or current users of injection drugs in outreach efforts and the provision of services have proved to be effective in expanding the segment of the population reached. Formal groups exist in some major cities in Canada. For instance, the Vancouver Area Network of Drug Users (VANDU) is a group of active and former injection drug users who work to improve the lives of people who use illicit drugs.
User groups
VANDU is the most active of the support and advocacy groups of users and former users that are currently developing in several cities. VANDU holds bi-monthly member meetings with occasional guest speakers, and includes a methadone users group and a program to engage members as volunteers. Members also speak to other agencies in the community. Since its formation in 1998, membership has grown to over 500 and VANDU now is one of the largest organizations of its kind in the world
VANDU has collaborated with local health professionals and researchers to produce written material on drug use and proposals for new approaches based on harm reduction principles. A proposal for a supervised injection facility was recently presented to a federal task force on this issue (Kerr, 2000).
Harm reduction within the justice system
Injection drug use, needle sharing, and the transmission of HIV and hepatitis C are prevalent in correctional facilities. In 1994, the Expert Committee on AIDS and Prisons released a report that took a strong harm reduction approach to drug use in prisons. Among its numerous recommendations, the report called for the availability of household bleach, and access to methadone and sterile injection equipment in correctional facilities. The Correctional Service of Canada supported many of the recommendations, but access to methadone maintenance and sterile injecting equipment remains an unresolved issue. Some of the barriers affecting progress toward harm reduction initiatives within correctional facilities are resistance by prison administration and staff, safety concerns, perceptions that such strategies would be sending a contradictory message (that is, if the prison tolerates the use of drugs in prisons, then they are not taking the law seriously), and beliefs that injection drug use will increase.
Although they do not have clearly stated harm reduction objectives, drug treatment courts offer an alternative to incarceration for minor drug crimes. The first drug treatment court was established in Toronto on December 1, 1998, as a pilot project. The target group is non-violent offenders who are addicted to heroin or cocaine. Participation is voluntary. On completion of the program, participants receive a non-custodial sentence, or may have their charges withdrawn. The Toronto project has a comprehensive evaluation component attached. The results are still too preliminary to draw any conclusions about the effectiveness of the program.
Factors influencing harm reduction policies and practices
Trends in injection drug use
It is estimated that Canada has between 75,000 and 125,000 people who inject drugs such as heroin, cocaine or amphetamines (Single, 2000). In addition, 29.4% of young steroid users, or approximately 25,000 Canadians, report injection use (CCDFS, 1993).
Approximately 30,000 people who inject drugs reside in Toronto (Remis et al., 1997), and 15,000 in Vancouver (Millar, 1998). In Montreal, the number of people who inject cocaine is estimated between 6,000 and 25,000 and for heroin between 5,000 and 15,000 (Roy and Cloutier, 1994). Injection drug use has also been report in many other towns and cities and also in rural communities.
The proportion of injection drug users who report sharing needles varies considerably, but is exceedingly high in many communities: 76% in Montreal (Bruneau et al., 1997), 69% in Vancouver (Strathdee et al., 1997), 64% in a semi-rural Nova Scotia community (Stratton et al., 1997), 54% in Quebec City (Bélanger et al., 1996) and Calgary (Elnitsky and Abernathy, 1993), 46% in Toronto (Myers et al., 1995) and 37% in Hamilton-Wentworth (DeVillaer and Smyth, 1994).
Trends in the rates of HIV and other infections
The proportion of reported adult HIV-positive cases attributed to IDU has increased from 9.1% prior to 1995 to 29.9% in 1995, 34.3% in 1996, 33.6% in 1997 and 29.2% in 1998 (LCDC, 1999). In Canada, IDU is now the main route of HIV transmission and the proportion of new cases attributable to IDU is increasing. Surveillance data for 1999 indicate that almost half (46.8%) of all new HIV infections are among IDUs. In Vancouver, HIV prevalence among IDUs increased from 4% to 30% between 1992 and 1998, in Montreal from 5% before 1988 to 19.5% in 1997, and in Ottawa from 10.3% in 1992-93 to 21% in 1997.
In a recent draft report from the Canadian Strategy on HIV/AIDS Annual Direction-Setting Meeting, it was noted that since 1996, there have been fewer infections among injection drug users. The report cautions, however, that national aggregate information may be misleading, since it does not reflect local and regional trends; that is, although rates of HIV infection among injection drug users has been declining in large Canadian cities (Vancouver, Toronto, Montreal), there may not be a decline in small or mid-size Canadian cities.
It is estimated that 70% of new HCV infections in Canada each year are related to sharing needles, syringes, swabs, filters, spoons, tourniquets and water associated with injection drug use. Worldwide estimates of HCV infection range from 50% to 100% among drug-injecting populations. For this reason, people who inject drugs are a key group, and central to the persistence of HCV in Canada. HCV spreads quickly. Consistently, research shows high rates of HCV among short-term users of injection drugs who share needles, syringes, swabs, filters, spoons, tourniquets and water.
The most commonly injected drugs are cocaine and heroin. This is a cause for concern in itself, as cocaine use involves particular risk. People who inject cocaine may do so as often as 20 times a day, increasing the problems associated with sharing contaminated needles (McAmmond and Associates, 1997). Information obtained through detailed interviews with 610 individuals who inject drugs in Winnipeg, Manitoba (Elliot and Blanchard, 1998) found that cocaine was the predominant drug injected, and was associated with binge use and frequent injection. Talwin, Ritalin, amphetamines and steroids have also been used intravenously in some areas of Canada at various times (Single, 2000).
There are various injection practices that increase the risk of transmission of blood-borne diseases such as HIV or HCV. For example, in a practice called "front-loading or back-loading", the drug is mixed in one syringe, and then the mixture is divided by squirting some of the solution into one or more syringes. Although the needle is not shared, HCV can be transmitted if the syringe used for mixing has been previously contaminated. Limited research suggests that people with a history of intranasal or inhaled drug use may be at risk for HCV. Because users of cocaine often have nasal erosions and ulcers, sharing of cocaine straws can transmit HCV. Dehydrated and cracked lips, another common side effect of injection drug use, make pipe sharing a potential risk