APPENDIX 1
London CAReS
London’s Community Addictions
Response Strategy Phase One:
-
Plan to Improve the Health Outcomes of our
Addicted and Homeless Population and Make
the Downtown Safer
A
The combination of grinding poverty, mental illness and addiction
is taking a serious toll on our most vulnerable citizens.
A caring society cannot remain passive while lives are being wasted!
1
OCTOBER, 2007
A Call To Action:
This report is a call to action. According to a
recent study by Health Canada, addiction is
costing our community $243M per year in terms
of social, medical and law enforcement costs, as
well as lost productivity. The continued problem
of addiction to alcohol and illegal drugs is being
compounded by an alarming increase in
addictionsto opioid based prescriptionpainkillers.
We are not alone, as this is a national problem
and nothing short of a national strategy is
needed.
They say we have free will
and free choice, but not in
the face of addiction.
Addiction is habitual; a
dependence of the mind
and body. It's hard to
ignore the compulsion to
use if you can? close the
door to the world and you're
still leff in the same
environment
Anonymous Substance
User, London, Ontario
The London Community Addictions Responses Strategy, or London CAReS can, in time,
be a platform for discussion about a city-wide, made in London initiative, however,
Phase One is focused on our most vulnerable population- our homeless who have
fallen into addiction.
The increasing presence of the homeless, the increasing level of addiction and the
criminal elements that fuel prostitutionand the drug trade have collectively raised the
level of anger, concern and fear of local business owners, residents of our downtown
neighbourhoods and visitors to an unprecedentedlevel.
Some of this anger has coalesced around the view that the so-called concentration of
health and social service agencies in the downtown is the problem and that it is these
agencies that are bringing the homeless to our downtown. The reality is the only place
the homeless can feel at some degree of comfort is within the anonymity of the
downtown, as call be seen in all major urban centres. Perhaps the issue is that we are
not doing enough as a society to prevent homelessnessand not enough to assist the
homeless in getting off the streets. There is no doubt that there needs to be a greater
degree of dialogue and engagement between social service agencies, residents and
businesses - to build bridges to understandingand to coordinate efforts to the
betterment of all.
Social agencies have grown increasingly concerned about the number of at-risk youth,
women and the chronically homeless who have become substance involved. It is
estimated that 18 homeless individuals have died this year in London as a result of drug
overdose, ten of whom were women fleeing a life of violence and abuse. The London
Police Service At Risk Persons Task Force is in regular contact with over 100 young
women who because of addiction are engaged in survival sex trade. Most of these
women have and are fleeing lives of abuse and violence.
Over the past sixteen months, we have undertaken a literature review and visited other
urban areas already dealing with the problem of substance abuse among the homeless.
We have met with addictions experts, front line workers and a group of addicts to hear
2
their stories. We attended community meetings throughout the downtown where we
heard several key messages:
Get help for the ill
Arrest the criminals
Make the downtown safer
The greatest deal of concem was for the young women who have become involved in
prostitution; teens on the streets; and the chronic homeless dealing with both addiction
and mental illness.
Cities around the world that are making progress on this issue are doing so by planning
within the context of the Four Pillars model. The literature describes each of the pillars:
Prevention initiatives attempt to prevent substance use altogether or delay the onset of
substance use.
Harm Reduction accepts that abstinence-basedtreatments may not be a realistic goal
for some drug users, particularly, in the short term and acknowledgesthat an
achievable, pragmatic approach to supporting users may lead to a healthier outcome in
the mid to long term.
Treatment is about encouraging and supporting people with addiction problems to make
healthier decisions about their lives. Decreasingpreventable deaths, illnesses and
injuries and increasing social interactions are key outcomes.
Enforcement recognizes the need for safety and public order in our community, and
acknowledges that to be effective, enforcement must be integrated with actions
emanating from other pillars.
London's strategy is built around these Pillars, balancing public health and public order
initiatives. We are recommendingan action plan that will build a continuum of care for
those suffering from addiction, as well as increase the capacity of London Police
Services to address criminal activity in our downtown area defned by Queens Ave.; the
Western Fair and the Thames River. The goal of the strategy is better health outcomes
for the addicted and homeless and a safer and more vibrant downtown.
Implementationof the strategy will be contingent on the senior levels of government
providing funding for key elements of the strategy that are within their legislative
mandates, as well as a significant investment from the City of London. Nor will this be a
strategy with a quick return. Our addicted and homeless population have complex
barriers to good health and the ability to contribute to the life of our community. A multiyear investment will be required.
The Strategy is the outcome of a process of consultation and research. To that end, we
have attended and/or organized a series of community meetings over the past twelve
months including:
Attending a meeting at the London Coffee House to listen to a community discussion
about the impacts of substance use on the Dundas and William Street neighbourhood;
3
Organizing and facilitating a community meeting at Bishop Cronyn Memorial Church;
Attending follow-up meetings at Bishop Cronyn Memorial Church;
Attending several meetings with the Old East Village Business ImprovementArea and
Old East Village Residents Association
Attending a meeting of the Executive of the Downtown Business Improvement
Association
Facilitating a community meeting of residents in the South of Horton (SOHO)
neighbourhood
Organizing a meeting of senior addiction and mental health administrators including
the Medical Officer of Health and Chief of Police and well as other member of London
Police Services;
Attending a meeting of women’s social service providers;
Organizing a meeting of executive directors and senior managers in addictions and
related services;
Organizing a meeting of front line workers in addictions and related services;
Organizing a meeting of youth workers at WAYS; and
0 Organizing a meeting of substance users.
Conducting a survey of the clients of the London Coffee House
Met with Senior managers of London’s emergency shelters
0 Met with officials from the College of Physiciansand Surgeons
Visited major cities where best practices have been identified: San Francisco,
Vancouver, Ottawa and Toronto
This work is documented in the Background Paper that is attached to this report.
Substance abuse is affecting London’s health and well-being
The C i of London is committedto improvingthe health and well-being of all its citizens
and “growing a strong and caring community”. To achieve this goal, we must address
the growing problem of substance abuse.
How serious is the problem? Most people in Canada use substances, such as alcohol or
drugs. For example, in the past year, about 1 out of every 7 Londoners exceeded lowrisk drinking guidelines, 1 in 8 used cannabis, and 1 in 33 used an illicit dtug, such as
cocaine, ecstasy or methamphetamine.And these figures probably underestimateactual
substance use. Not everyone who drinks alcohol or tries an illegal drug develops a
substance abuse problem, but some do, including individuals from all groups within
society.
Substance abuse is not a “downtown” problem, nor is it limited to the poor and
homeless. It is, however, becoming an increasingly critical issue among London’s poor
and homeless populations. Health and social service agencies in London report
relatively high rates of substance abuse among their clients. For example:
Ontario Works estimates that substance abuse is a barrier to employment for
between 820 and 984 of its clients (IO to 12% of the caseload).
The city‘s shelter operators estimate that 40 to 60% of residents - or 350 to 525
people - have substance use or abuse issues.
About 40% of visits to the London IntercommunityHealth Centre are substance
related.
4
My Sister's Place provides services to 50 to 70 women a day with addictions andlor
mental health problems.
Between January and June 2000,London Counter Point Needle Exchange Program
served 730 clients and distributed over 230,000needles.
Addiction Services of Thames Valley serves between 1500 and 1700 clients each
year.
Clinic 528 which operates a methadone maintenance program sees 900 clients per
month
London's homeless population is growing. In addition to local residents who descend to
a life on the streets, we are a regional centre for mental health, justice and social
services. Issues associated with release from provincial mental health facilities to "no
fixed address"; criminal discharges to local emergency shelters; and the lack of
appropriate social service and emergency shelter services in many southwestern
Ontario communities result in an inward migrationof the homelessto London.
Complicating this situation is the deteriorating health of the homeless. A growing number
are presenting with multiple health challenges as a result of poverty, mental health and
addiction, particularlyto alcohol and prescription painkillers. Local social service
agencies are struggling to cope with this changing population. Faith based agencies are
being forced to reconsider its core values about abstinence, in order to meet their
mission of serving the most vulnerable in society.
Not surprisingly, drug trafficking to these vulnerable populations is a key contributor to
the declining health of these individuals. In turn, those with addictions are forced to enter
into illegal activities to support their habits. Prostitution, as well as, break and enter
crimes are on the increase and London PolicB Chief, Murray Faulkner, attributes these
increasesto the drug trade.
Substance abuse hurts individuals
The problem is not just the number of people abusing substances, nor the substances
being produced and sold. It is the effect that substance abuse has on the health and well
being of users. Substance abuse threatens people's health, their social life, their
relationships, their ability to work and their financial health. For example, alcohol, drug or
solvent use is a factor in between 22 and 33% of cases of child abuse and neglect in
Ontario.
Jane Fitzgerald, Executive Director of the Children's Aid Society of London-Middlesex
reported that research conducted in 2003,showed that adult substance abuse is one of
the key factors that has contributed to the increase in the number of children being
admitted to the care of the Children's Aid Society of London and Middlesex. Most
recently, the Society has admitted an increasing number of infants who an? suffering
from the affects of exposure to drugs. Substance abuse not only threatens people's
health but it has significant negative impact on the well being of children of the addicted
adults.
In 2002,almost 3% of all deaths in Canada were attributed to alcohol and drugs.
Substance abuse is associated with high rates of suicide and infectionswith lifethreatening illnesses such as HIV and hepatitis C. Too many lives are ruined or lost
because of substance use. It is estimated that 18 homeless individuals have died from
injection drug overdose in London so far in 2007, according to two street level workers.
5
The combination of grinding poverty, mental illness and addiction is taking a serious toll
on our most vulnerable citizens. A caring society cannot remain passive while lives are
being wasted.
Why do people become addicted?
In our conversationswith addictions professionalsand with addicts themselves, several
key themes emerged as to why individuals become addicted to substances, most
frequently alcohol, marijuana, cocaine and with increasingfrequency, prescription
painkillers. Fleeing violent or abusive family situations, poverty, physical pain and bad
choices were all reasons cited. Past efforts to address substance abuse have failed
because they have not addressed the many complex, inter-related factors that make
people susceptible to substance abuse or to becoming dependent on substances.
The chart below outlines the various factors that contribute to addiction.
Biolouical Factors
Psychosocial
Factors
Predisposition
Genes affect
metabolism and
reaction to
alcohol and
other drugs, and
make some people
more sensitive
families where there is
abuse (physical, sexual,
etc.),conflict, poverty
and substance use are
more likely to use abuse
substances than those in
families with positive
coping skills
neurologically
vulnerable
A fetus's central or
nervous system can
be damaged in utero,
making the child
more vulnerable to
alcohol or drug use.
Physiologic81
Differences
Sickness, accidents,
physical trauma,
improper diet and
exposure to alcohol
and drugs (e.g.,
painkillers) can make
people more vulnerable
to substance abuse.
schools where there is
poverty, high crime rates,,
discrimination, and
conflict are more likely to
abuse substances than those
in communities/schools with
positive leadership,
problem solving skills and
resources.
Peer Attitudes, Values and
Stresses
People who are under pressure
from friends and don't have
other support or opportunities
are more likely to abuse
substances that those who have
social support, and conflict
resolution and communication
skills.
Who is at risk?
Certain populations are particularly vulnerable to addictions, and have higher rates of
substance use and different usage patterns. For example:
Out-of the-Mainstream Youth -including street involved youth, youth who are
homeless, absent from home or frequently truant from school, youth involved in
the sex trade, and youth in the community services and/or justice system tend
to use more cannabis, alcohol, cocaine and prescription pills, and use them more
frequently than mainstream youth. Street youth typically become drug-involved
within six weeks of arriving on the streets.
People who are Homeless have a high rate of substance use, which is often
linked to poverty, mental illness, incarceration,unemployment or the absence of
family or peer support. In some cases, substance use prevents people from
finding and keeping stable housing and leads to homelessness.
0
Aboriginal Peoples over age 15 are three times more likely than nonAboriginals to have used cannabis, hashish, LSD, speed, crack or heroin, and 11
times more likely to have used solvents or aerosols. These high rates of
substance use are linked to poverty, family breakdown, unemployment, lack of
social support, discrimination,the effects of residential schools, and barriers to
accessing health services (e.g., language, lack of culturally sensitive services).
Sex Trade Workers have high rates of substance use. London Police Service's
outreach project to female prostitutes (Le., Persons at Risk Project) estimates
that 100% of the women involved in the project use substances.
People with Mental Health Problems are at high risk of also having a
concurrent substance abuse disorder. About 30% of people with a mental health
disorder will also have a substance use disorder at some time in their lives, and
53% of people with a substance abuse disorder other than alcohol will have a
mental health disorder. People with concurrent disorders often have difficulty
accessing treatment for either disorder.
Older peopldpople with workplace injuries are at high risk of becoming
addicted to prescription pain killers.
-
Life Tralectories of the Addicted. Mentallv 111 Homeless
While we do not have an accurate count of the homeless, most local experts agree that
on a given day we may have up to 1,500 individualswithout stable accommodation. Up
to 360 can be accommodated in the City's emergency shelters. About 40% present with
addiction and mental health issues. As noted in the preceding section the homeless are
not a homogeneous group, however, some central themes about life trajectory are
obvious.
Due to the combination of poverty, addiction and mental illness, many of these citizens
are on a road to premature death. For some, death will come soon. For others it may
take awhile. Some will continue in the fog of illness and addiction, while others will make
a decision to change and seek out help to do so. Some will engage in illegal activities to
gamer sufficient funds to purchase drugs or alcohol to feed their addiction. Some will
steal, some will prostitute themselves. One in three will be physically beaten, one in five
women will be raped, All will see their health decline, as noted in a recent study of the
homeless in Toronto.
7
Cities across Canada are facing the same
substance-related challenges as London:
increasing rates of substance abuse and the
associated health, social and economic problems.
London has a higher rate of drug offences than
Ottawa or Toronto, but lower than Vancouver or
Thunder Bay.
Canadian municipal leaders have identifieddrug
abuse as a strategic concern for communities
across the country. Major integrated strategies
and projects are underway in Vancouver, Toronto
and Ottawa. The Federationof Canadian
Municipalitieshas struck a task force to
investigate responses to the issue.
~
Rptecl of
Drug Offenses In Canadlan
Munlclpalities
OffenseRate
(per 100,OOOpersons)
Thunder Bay
Vancower
st Catharines Niagara
London
Hamilton
Montreal
Windsor
Kitchener
571
468
316
269
245
215
21 1
188
186
151
NationalAveraaa
29s
-
Ottawa
Past strateaies to solve the problem have fallen short
Substance abuse has traditionally been seen as a IegaVcriminaljustice/public order
issue. Past efforts to stop or reduce substance abuse have relied primarily on policing
and enforcement to reduce both the supply of and demand for drugs and the
inappropriate sale or use of alcohol, and put relatively little emphasis on addressing the
health issues or the underlying causes of substance abuse. In 2001, the Auditor General
for Canada estimated that for every $95 spent on substance-related enforcement
federally; only $5.00 is spent on treatment or prevention. The treatment that is available
is offen limited to abstinence models, which are not effective for many people with
addictions.
Despite a massive investment in enforcement, communities have not seen long-term
reductions in either the supply or demand for illegal drugs. In fact, the strong emphasis
on enforcement strategies and abstinence treatment models has resulted in unintended
consequences such as: high rates of incarceration, an increase in crime, and an
increase in HIV and hepatitis C infections.
What are the emeraina trends in substance abuse?
Abuse of alcohol, marijuana and cocaine (and its derivatives) remain the three biggest
areas of concern, however, one of the challenges in developing a substance abuse
strategy is that the substances of choice and the problems can shift and change. For
example, over the past few years, we have seen a significant increase in
methamphetamine use, addictions to the opioid-based prescription pain killer
oxycodone, and concerns related to methadone maintenance treatment.
Methamphetamine
The production and use of methamphetamine has been moving east across Canada,
and Perth County is now Ontario's 'meth capital". Supplies of the drug seized on the
street in London are 86% to 100% pure, which indicatesthat the production facilities are
nearby. Methamphetamine is a particularly addictive substance, and the addiction is
highly destructive and hard to treat. The trend in Canada, where methamphetamineuse
is less of a threat than it is in the US,has been to produce the drug in commercial size
labs; however, new Health Canada regulations are making it more difficult to purchase
the ingredients in bulk and may lead to more small home-based labs that pose
environmental and safety risks to their neighbourhoods.
Prescription Painkillers
Over the past number of years there has been a dramatic increase in the prescribingby
doctors of opioid based (oxycodone) painkillers, best known by commercial names like
OxyContin and Percocet. While this drug produces dramatic relief from pain for those
with serious illnesses, including cancer, its highly addictive properties has led to a
significant increase in misuse of the drug. A recent national study has concluded that the
majority of opioid injection needle users in Canada are now injecting prescription
painkillers rather than heroin.
The diversion and abuse of oxycodone is, also, a serious issue in London. Much of the
drug has been obtained through physician prescriptions; however, the demand for
oxycodone has been linked to a series of armed robberies at pharmacies in the city. We
have heard that diversion of oxycodone for sale on the streets is being undertakenby
organized crime groups.
9
More people are entering methadone maintenance programs for treatment for
oxycodone addiction, and some clinicians believe this will be the biggest drug problem
across North America in the future.
Methadone maintenance treatment programs (MMT)
Not surprisingly the rapid growth in addiction to prescriptionpainkillers has resulted in
increased demand for and provision of MMT programs. MMT can provide effective
treatment for people who are addicted to opioids- particularly when supported by
counseling and case management services. While it does not cure dependency it is a
medical treatment that can help people manage their addiction and stabilize their lives. It
is both a treatment and a harm reduction strategy
Recently, the Ontario Minister of Health and Long Term Care commissioneda study of
methadone practices. The March 2007 ReDort of the Methadone Maintenance
Treatment Practices Task Force has prepared twenty-six (26) recommendations that
represent best practices for MMT programs. A full summary of the Study findings is
included in the Background Report but the following two recommendationsare notable:
The Ministry develop a provincialsfrategy and policies to ensure that Ontarians
have equitable access to a comprehensive range of integratedMMT services
that include information and advice on all treatment options, medical care,
counseling and support, case management, healthpromotion, disease
prevention and education, and methadone dispensing.
The Ministry address the critical issue of the abuse and diversion of oxycodone in
the province. This should build on the work being done in Ontario, Canada and
other countries and serve as the fitst step towards the development of a
comprehensivelong-term drug strategy for the province.
We have reviewed and support the recommendations of the Task Force. It is important
that the provincial government implement and fund these important recommendations.
A comprehensive strategy can reduce harm to individuals and our community
W e cannot ignore [substance abuse]. We cannot incarcerate our way out of it and we
cannot liberalize our way out of it. Rather, all levels of governmentmust play their part in
managingit. What we need is a balance of public health and public order.
Fonner Vancouver Mayor, Phillip Owen
"Addiction needs treatment and criminal behaviour needs enforcement"
A Framework for Action, City of Vancouver, 2001
Experience in other jurisdictions indicates that when municipalities approach substance
use as both a public health issue and a public order issue, they can successfully address
the problem. In the early 199Os, Switzerland and Germany adopted a comprehensive
drug strategy. In 2001, the City of Vancouver adopted what is now known as the Four
Pillars Model. Since then, the model has been used as the basis for substance abuse
10
strategies in Toronto, Regina, Ottawa, the Central Okanagan Region, and the Sunrise
Health Region in BC. The chart below summarizes how this strategy can work
Publia health strategies
work to:
reduce harm to
individuals and
neighbourhoods
e increase public
awareness of addiction
as a health issue
e reduce the number of
people who misuse drugs
e reduce HIV and
hepatitis C infections
provide a range of
services for
populations at risk
Public order strategies
work to:
increase public safety
by implementing crime
prevention programs
reduce the negative
impact of drugs on our
community
reduce the presence of
"open drug scenes" in
the community
reduce the impact of
crime on neighbourhoods
and individuals
give neighbourhoods,
organizations and
individuals mechanisms
to address concerns
The Four Pillars Model
Experience in other jurisdictions indicates that when municipalities approach substance
use as both a public health issue and a public order issue, they can successfully address
the problem. In the early IQQO's,Switzerland and Germany adopted a comprehensive
drug strategy. In 2001, the City of Vancouver adopted what is now known as the Four
Pillars Model. Since then, the model has been used as the basis for substance abuse
strategies in Toronto, Regina, Ottawa, the Central Okanagan Region, and the Sunrise
Health Region in BC.
The Four Pillar Model is based on using a mix of prevention, treatment, harm reduction
and enforcement strategies to address problematic substance use.
Preventlon programs and strategies give people the information and skills to
prevent or avoid harmful substance use. Prevention includes efforts to prevent
or delay substance use (Le., abstinence), to reach people in the early stages of
substance use before they develop problems, and to give people who choose
to experiment with substances the informationthey need to do so safely.
Ttuatment programs encourage people with addiction problems to make
healthier decisions about their lives. Treatments, such as withdrawal
management, counseling, l i e skills and methadone maintenance programs,
help people manage their addiction.
Harm Reduction programs acknowledge that abstinence-basedtreatments
may not be a realistic goal for some drug usen, and provide supports such as
11
emergency shelters, food banks, supportive housing that improve health, reduce harm,
and provide a gateway to treatment services.
Enforcement programs, such as efforts to target organized crime and to link
substance users to treatment services, recognize the need for safety and pubic
order in our community. To be effective, enforcement must be integrated with
prevention, treatment and harm reduction.
Critical Success Factors
Successful implementationof the four pillar model depends on:
1. An integratedfoundation: the policy, legislation, funding and action to support the
four-pillar approach.
2. Shared ownership by different levels of government, the community, and service
sectors, including health, mental health, social services, education and policing.
3. A single group or e n t i accountablefor coordinating implementationof the strategy
and monitoring the process.
4. A comprehensive, coordinated plan.
5. Community engagement: effective ways to involve the public - including people with
substance abuse problems - in planning, delivering and supporting comprehensive
integrated services.
Where we are now?
In London, we have some prevention, treatment, harm reduction and enforcement
programs in place, but there are many gaps. For example:
Our prevention programs are targeted mainly at school children, and do not
reach all the individuals and populations at risk of substance abuse. They do not
address the underlying causes of substance abuse, such as poverty, unstable
housing and lack of recreation and employment opportunities.
Our addictions treatment agencies are achieving success, but it takes too long
for individualsto gain access to addiction treatment. It can take up to eight
months to find a residentialtreatment bed.
There are two youth addictions treatment facilities in Ontario, in Thunder Bay and
in Ottawa and youth have to find their way there on their own or with agency
supp0rt.
There is insufficient integration of mental health and addiction treatment services
We do not offer a full range of treatment options in our community, services are
hard to access, and we lack services for youth, women with children, and
individualswho are hard to serve, such as the homeless and people with
concurrent disorders.
We have some harm reduction services, such as the Counterpoint needle
exchange program and methadone maintenance programs, but we must do more
to help drug users use safely, get off the street and access programs and
services. We need to also increase our return rate of used needles.
12
We are achieving success in the transition of individuals and families from
emergency shelters to stable housing via the Hostels to Homes Pilot project.
We are achieving success in serving OW clients with addictions
TOWARDS A PLAN FOR LONDON:
During our public consultationswe heard that our downtown community wants and
expects that the criminals be dealt with. We also heard that they want and expect a
caring response for the homeless. We all want safe and vibrant downtown
neighbourhoods.
Importantly, what emerged from these discussions was a vision for a “continuum of care”
for the homeless one that provides ongoing street level contact, outreach and delivery
of services, including nursing; places to refer the homeless to get off the streets, even if
for a short time; a pathway to a home, with appropriatewrap around services, including
addictions counseling and access to Ontario Woks.
-
It was evident a separate and concentratedapproach will be required to support survival
sex trade workers, one which closely coordinates enforcement activities with outreach
and diversions strategies to ensure young women wishing to leave the streets have a
sensitive and trusted pathway to safety. This pathway would flow from outreach worker
to day safe haven space, to a place to live with appropriate supports including access to
Ontario Woks and addiction treatment. This pathway would be replicatedfor others on
the streets including our aboriginal homeless population.
There was a surprisingly strong consensus that this continuum of care, combined with a
stronger police pressure to deal with criminal activity might achieve measurable progress
for the homeless as well as for the community. This is also the case if we were to
choose a small area of concentration. For this reason it is evident that a neighbourhood
specific approach will not work. The entire downtown area must be seen as one service
area in order for this strategy to be successful. For the purposes of the Strategy, we are
considering the area bounded by Queens Ave. on the north, the Western Fair to the east
and the Thames River on the south and west. The vision of a continuum of care working
together with law enforcement seems to be a correct balance.
This complex and challenging issue is not the City’s alone to tackle. Integratednational
and provincial legislation, programs and funding are required. A national Four Pillar
oriented drug strategy, a national homeless strategy and a provincial mental health and
addictions strategy are important pieces of an effective response. These strategies need
to be accompanied by appropriate and sustainablefunding.
Our Strateay
London will take a comprehensive approach to substance abuse, integrating and
coordinating services, based on the four pillar model of prevention, harm reduction,
treatment and enforcement initiatives, in partnershipwith the Governments of Canada
and Ontario, community partners, local businessesand residents.
We are recommendinga five year funding commitment to the Strategy and its programs.
A multi-year commitment will be required to make progress. The programs will be
13
I
evaluated annually and there will be opportunitiesto adjust the programs and funding as
dictated by the evaluation process.
key to the success of this straGgy.
Investments: strategic and sustainable over time -five year plan
Results: Value for money and outcome evaluation processes be included in the strategy
I.
Insist the senior levels of novernment fulfill their
resRonsibilities bv advocating for:
a) A national homeless strategy that provides stable, long term funding for the
creation of affordable housing and for streets to homes initiatives
b) A national drug strategy built on the Four Pillars foundation which includes stable
long term funding.
c) A provincial strategy to ensure adequate funding and direction to ensure the
availability of integrated addiction, mental health treatment and public health
services including
a. expansion and integration of addiction and mental health services
b. establishment of wait time standards for admission to addiction treatment,
with funding necessary to meet and sustain these standards
c. greater mix of harm reduction and community-based treatment options
d. implementationof the recommendations from the Report of the
Methadone Maintenance Treatment Practices Task Force
d) Greater flexibility for ConsolidatedMunicipal Service Managers to utilize social
service funding to best support the needs of individuals, as evidenced by the
early success of the Hostels to Homes and the Ontario Works Addictions
Services Initiative.
14
e) Substantial increases to penaltiesfor soliciting prostitutes and dealing of illegal
substances
f) Partnershipwith the City in financing London CAReS
2.
Build a Continuum of Care:
A Service continuum meets the needs of clients as they exist at the moment in time,
keeping people alive while identifying a pathway to better health. The following actions
will assist in building a continuum of care:
a) Implement a comprehensive and coordinatedstreet outreach initiative across the
downtown that includes:
a. Regular contact with those on the street -prevention and harm reduction
messages
b. Presence of street nurses and addictionsworkers working as a team with
agency outreach workers
c. Informationand referral but not case management
d. Interventionand mediation of street level issues (non-police contact point
for residents and businesses)
e. 24/7/365 emergency social services response in coordinationwith police
and land ambulance to provide a third option for placement of individuals
in difficulty on the streets
b) Expand the capacity of existing safe haven dmp-in programs (Mission Services,
Centre of Hope, My Sisters Place and APLohsa so that full day and evening service
provision is available:
a. Safe refuge every day and evening
b. Necessities -food, clothing, and comfort
c. Health services
d. Information and counseling
e. Referral services
f Rapid access to streets/hostels to homes and Ontario Works
addiction services initiative
c) Provide a streets to homes service building on the success of the Ontario Works
Hostels to Homes and Addictions Services pilots
a. Community support workers will assist individuals in transitioning to
housing.
b. Rapid access to the Addiction Services Initiative and Ontario Works
c. Availability of a community support worker for a period of up to 18 months
d) Increase our capacity to plck up and dispose of used needles be placing deposit
bins at strategic locations in the downtown and invite the Aids Committee of London
to increase its street outreach, distribution of clean needles and pick up of used
needles capacity through the development of a peer outreach program.
.
e) Increase the dep/oyneni strength of the London Police Service to focus on
illegal actiiies related to prostitutionand drug dealing, as well as work in liaison with
the community and social agencies to advance the overall strategy within the whole
downtown area. (Queen’s Ave -Western Fair - Thames River)
f) Where requested establish neighbourhoodliaison committees for the downtown
composed of residents, local business, agency representatives, including police,
15
public health and city staff resource support. The purpose would be to provide a
forum for discussion of issues, mediation and joint planning.
g) Continue to investigate the feasibility of opening a low thresholdshehran&or a
managed alcohol shelter
h) Continue to work with community partners to develop “ u ~ m ” p m v e n t a t i v e
strategies including public education programs; poverty reduction; and strong
neighbourhoods
i) Monitor the implementationof the recommendations of the Task Force on
Methadone MaintenanceTreatment Practices by the new Minister of Health and
Long Term Care
3.
Consider Long Term Initiatives:
a) Development of a Phase Two strategy that focuses on the issue of addiction
across the broader community.
b) Monitor current debate about the efficacy of safer injection sites
c) Analyze the need to develop a business licensing program to regulate the
operation of methadone clinics, incorporating the recommendationsof the
provincial Report of the Methadone Maintenance Treatment Practices Task
Force.
d) Consider an examination of any possible link between the concentration and
location of social service agencies in neighbourhoodsand social disruption within
those neighbourhoods against the primacy and needs these agencies serve.
SUMMARY OF FINANCIAL INVESTMENTS
The Civic Administration has been discussing the annual cost of delivering the programs
identified in the strategy on an informal basis with several community stakeholders. The
following chart summarizes the annualized cost for all programs. It also includes a
summary of potential funding sources from the respective levels of government,
recognizing respective mandates and announced or planned programs which align with
the Strategy.
16
I INVESTMENT:
AMOUNT
Street outreach initiative
Safe haven drop-in programs
Streets to Homes
Pick up/ dispose of used needles
Municipal deposit bins (IO@ $1800)
Counter Point Peer program
Expand OW London Addiction Services Capacity -200 more clients
OW London - Addictions team
OW London Complex Issues Team
Addiction Services of Thames Valley counselors
Deployment strength of the London Police Service (5 officers)
Total Cost:
$770,000
877,000
165,000
18,000
45,000
599,400
318,232
214,200
750,000
$3,756,832
FUNDING SOURCES
Government of Canada
Policing
Treatment - nursing and addictions team 50% share
Homeless Partnering Strategy - outreachktreetsto homes
Sub-Total:
-
Government of Ontario
OW Addictions Team - 80% cost share
OW Complex Issues Team - 100% share
ADSTV addictions counselors
Treatment - nurses and addictions team - 50% share
Peer Outreach and needle pick up
SUb-tOtal:
1
City of London
CVP Reserve
Service Growth Package
Sub-total:
Total fundina reauired:
$ 750,000
200,000
208,000
$1,158,oOO
699,200
318,232
214,200
200,000
45,000
$1,476,632
500,000
622,200
$1’122,200
$3.756.832
INVESTMENT.
AMOUNT
Street outreach initiative
$770,000
17
FINANCIAL RISK AND PRIORITY SETTING:
Full implementation of the Strategy is dependent upon receipt of about 66% of the
funding from senior levels of government, decisions that are out of the control of City
Council.
Council could choose to fund the entire strategy or it could implement a portion of the
program that can be financed by local funds. Should that be the case we would
recommendthe following investments:
Street Outreach component at reduced level
Safe Haven drop-in programs at reduced level
Streets to Homes program at reduced level
PERFORMANCE MEASURES:
Given the complexity of the issues a significant expenditure of public funding is being
recommended. Public accountability requires that the intended objectives are achieved
and that efforts are directed to achieve the goals for which the strategy was developed.
The chart below identifies a series of performance measures and targets, assuming full
roll out of the strategy.
MEASURE
TARGET
Number of survival sex trade workers
identied by London Police Service
years
50% reduction in three
Return rate of used needles
99% in three years
Number of homeless entering
OW/Addictions Program
Number of overdose deaths among
Homeless
Numbers of homelesstransitioning from
Streets to homes
Retention of housing at 6 ms
Retention of housing at 12 ms.
200 -five year annual
average
0
90%
75%
Reduction in number of police calls relating
to homeless in downtown
25% reductionin year one
Reduction in transfer of homeless to hospital
Emergency wards per month
25% reduction in year one
Average daily usage of Safe Haven spaces
75% of capacity in year
one
CONCLUSION:
This report presents London's Community Addictions Response Strategy (London
CAReS) which is attached hereto as Appendix 1.
The Strategy document is in two parts. The first outlines the strategy and the second
part contains a detailed Background Report that documents research and consultation
work that led to the development of the strategy.
The report calls for an annual investment of about $3.8M a year for the next five years in
order to make substantive progress in reducing the incidence of addiction amongst
London's homeless population and its impact on the quality of life in London's downtown
neighbourhood.
The Governments of Canada and Ontario are being asked to match the investment of
the City of London, to be its funding partners in dealing with this important and serious
public health and public order issue in our community.
The Strategy recommends advocacy from the City on the need for national and
provincial strategies for affordable housing, homelessness and substance abuse, in the
context of the Four Pillars Model.
It also calls for investment in several key program areas:
0
0
0
0
Street level policing focussed on illegal activities associated with prostitution and
drug dealing
Development of neighbourhoodliaison committees
Street outreach to the homeless in London's downtown - information and
referral, public mediation and harm reduction services including expanded needle
distribution and used needle pick up via peer group processes
Emergency and crisis response service
Expanded day "safe haven" spaces, including nursing services
Expansion of Ontario Works London's Addiction Services initiative
Development of a "streets to homes" program, modelled on the successful
Hostels to Homes pilot project
We recognize that a significant amount of the funding will have to come from senior
levels of governmeni and that these decisions may take time. The Strategy outlines how
incremental implementation can roll out.
We are recommending approval, in principle, by City Council and that the Community
and Protective Services Committee receive delegations on the Strategy with final
approval of the strategy contingent on Council's approval of its 2008 budget.
19
ACKNOWLEDGEMENTS:
Police Chief Murray Faulkner and Medical Officer of Health Dr. Graham Pollen have
provided invaluable advice to the development of this strategy.
Randy MacTaggart served as the lead investigator and writer for the research and data
gathering phase of this project, supervised by Mo Jeng, Manager of Social Research
and Planning. They along with a team of Community Services Department staff provided
strategic and tactical advice and facilitated community meetings, Thanks are extended to
Lynne Livingstone, Cindy Howard, Cheryl Smith, Steve Giustizia and Glennalee
Berman-Hatch. Deputy Police Chief Ian Peer has also been a major contributor to the
development of this Strategy
Many individuals in the commun'w have taken keen interest in this project and have
provided sound advice and criticism along the way. We thank them.
As well, we are appreciative of the comments and advice provided by senior executives
and front line workers engaged in the provision of services to the homeless, to the
mentally ill and the addicted.
Finally, we spoke to many Londoners who live in a state of homelessness, managing
addiction and mental illness on a day to day basis as well as many residents and
business people who live and work in areas of the City where the illegal activity that
addiction draw.
We hope this Strategy, when implemented, will make the lives of these individuals
better.
Ross L. Fair
General Manager
Community Services Department
20
London Substance
Abuse Strategy
Background Paper
Table of Contents
1. Introduction
1
2. Background Information
2.1. Overview
2.2. Community Consultation and Research
2.3. Substance Abuse
2.4. Vulnerable/High Risk Groups
2.5. Profile of London, Ontario
2.6. Why do people Use Substances?
2.7. Substance Use, Dependence and Abuse
2.8. Why do people abusehecome dependent on Substances?
2.9. Summary and Trends
2.10.
Emerging Issues
2.11.
Economic Effects of Substance Abuse
2.12.
Health and Social Impacts of Substance Abuse
2.13.
Criminal Impacts of Substance Abuse
2.14.
Substance Abuse and its Impact on London's Downtown
Neighbourhoods
2
2
2
3
6
8
15
15
16
17
18
21
22
25
3. The Framework
3.1. Supply and Demand Reduction
3.2. Public Health and Public Order
3.3. Four Pillars Model
3.3.1. Prevention
3.3.2. Harm Reduction
3.3.3. Treatment
3.3.4. Enforcement
3.3.5. Integration
3.4. Policy Context
3.4.1. Governmental Responsibilities in Canada
3.4.2. Canadian Drug Policy and Legislation
3.4.3. Federationof Canadian Municipalities
3.4.4. Municipalities in Ontario
31
31
32
33
33
34
35
35
35
35
35
38
41
42
4. Programs, -mien, and Gaps
4.1. Existing Substance use programs and interventions in London
4.2. BarrierdGaps
45
45
49
5. Strategic Interventions
5.1. Community and Neighbourhood
5.2. Recommendations
51
51
55
Glossary of Terms
58
Appendix A: The Social Costs of Alcohol and Illegal Drugs in Canada 2002
60
Appendix B: Inventory of Addiction Programs and Services
61
Notes
66
28
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London Substance Abuse Strategy Background Paper
October 2007
~
1. INTRODUCTION
Problematic substance abuse is a complex issue that reaches into all aspects of life in a
community and, in doing so, affects each and every member of that community. It has
no single cause, presents no single profile and cannot be successfully addressed by any
single approach. Its root causes are numerous, and there are as many different paths to
substance abuse as there are people who travel them.
Although there is no universally accepted definition, substance abuse is simply
understoodas the harmful and excessive use of alcohol or a drug for mood altering
purposes. As indicated in Medline's medical encyclopedia, this includes "the use of illicit
drugs or the abuse of prescription over-the-counter drugs for purposes other than those
for which they are indicated or in a manner or in quantities other than directed."
For most people, becoming a substance abuser was not a conscious choice. An
individual who elects to try a substancefor the first time is not consciously choosing to
become either dependent or addicted. Substance abuse is usually the unfortunate and
unanticipatedend result of a series of decisions, oflen combined with personal trauma
such as mental illness, family breakdown, unemployment, poverty and childhood
physical or sexual abuse. For many, substances become a means of surviving personal
tragedy, of coping with the reality of a life that is, to them, often unbearable. As long as
the conditions that give rise to substance abuse persist, it will not be possible to
completely eliminate the phenomenon from any community.
Much can be done by working together as a community, and responding to issues
relatedto problematic substance use in a balanced and coordinated manner. In this way
a community can work towards improving public health and begin to mitigate the impact
of substances on resident's' social and economic quality of life. At the same time public
wder is restored making the community a safer and more invitingfor all residents.
This Background Paper contains the results of the many months of research and
consultationthat lead to the preparation of London's Substance Abuse Strategy.
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London Substance Abuse Strategy - Background Paper
October 2007
2. BACKGROUND INFORMATION
2.1. Overview
In the summer of 2006, London City Council asked the civic administration, in
consultationwith the Chief of Police. the Medical Officer of Health and other
stakeholders, to report back with a strategy and preliminary work plan to address the
issue of and consequences of substance abuse in London’s downtown areas.
Direction was provided by Council that the strategy should consider, but not be limited to
the following areas of concern: programs of treatment: prevention; harm reduction; and
enforcement as well as the investments required to advance the strategy.
In August, 2006 an initial report was made to the Community and Protective Services
Committee (CPSC) of Council on the Substance Abuse Strategy and the Committee
formally endorsed that the Four Pillars model be supported as the framework to be used
in the development of a Substance Abuse Strategy for the Ciy of London. In
September, Council further directed that the civic administration report back on funding
criteria and opportunities to obtain matching funding from senior levels of government.
2.2. Community Consultatlon and Research
Community Consultation:
The development of the London Substance Abuse Strategy is the outcome of a process
of community consultation and research. To that end, management and staff from the
Community Services Department have attended andlor organized a series of community
meetings over the preceding months including:
0
Attending a meeting at the London Coffee House to listen to a community discussion
about the impacts of substance use on the Dundas and William Street neighbourhood:
Organizing and facilitating a community meeting at Bishop Cronyn Memorial Church;
Attending follow-up meetings at Bishop Cronyn Memorial Church;
Attending several meetings with the Old East Village Business ImprovementArea and
Old East Village Residents Association;
Attending a meeting of the Executive of the Downtown Business Improvement
Association:
Organizinga meeting of senior administrators including the Medical Officer of Health
and Chief of Police as well as other members of London Police Services;
Attending a meeting of women’s social service providers;
Organizing a meeting of executive directors and senior managers in addictions and
related services;
Organizing a meeting of front line workers in addictions and related services;
Organizing a meeting of youth workers at WAYS;
Organizing a meeting of substance users;
Organizing a meeting with senior managers of London’s emergency shelters;
Attending a community meeting of residents in the South of Horton (SOHO)
neighbourhood; and
Meeting with officials from the College of Physicians and Surgeons
These community meetings resulted in a wide ranging discussion of issues, patterns,
trends, gaps and barriers related to substance abuse in London. From a research
2
London Substance Abuse Strategy - Background Paper
October 2007
perspective a common thread was maintainedthrough the posing of three basic
questions as the foundation for each meeting:
What is the extent of the substance abuse issue in London?
What services are currently available?
What are the key gaps in service?
Research:
To supplement the material derived from the community consultation process
management and staff from the Community Services Department has:
0
Conducted general research into substance abuse and related issues;
Conducted research into similar substance abuse strategies of other major Canadian
cities including Vancouver, Ottawa and Toronto;
Designed and conducted a community member survey on social service usage and
behaviourl attiiudeslperceptionsof individualsabout drug use in London;
Conducted a study tour of Ottawa’s program and service delivery models on
substance abuse, harm reduction, homelessness, housing, mental health, community
outreach and community health care;
Observed program and service delivery models on substance abuse, harm reduction,
homelessness. housing, mental health, community outreach and community health
care in San Francisco and Vancouver;
Reviewed preliminary findings of a 2007 Study conducted by the Centre for Addictions
and Mental Health (CAMH) for the Aids Committee of London concerning Drug
Treatment Readiness among clients of the Counterpoint Needle Exchange Program;
and
Reviewed the March 2007 Report of the Methadone MaintenanceTreatment Practices
Task Force prepared for the Ministry of Health and Long Term Care.
2.3. Substance Abuse
Information on rates of substance abuse comes mainly from general population surveys.
While this is the best data available, it is importantto note the limitations.’ Specifically:
Rates of use tend to be under reported as some people chose not to reveal their use,
particularly of illegal substances;
Distinctions between such measures as rates of use, rates of proMematic uselabuse
and rates of addiction can be problematic;
Population surveys with interviews conducted through telephone calls do not tend to
reflect the experience of vulnerable or high risk groups such as the homeless: and
Population surveys rarely provide data at a sub municipal level and do not reflect the
unique circumstances associated with substance abuse within individual
neighbourhoods?
While data from general population surveys can be supplementedwith agency based
data this too has its limitations. Specifically:
0
Data is derived from only that portion of the population that comes into contact with
the agency; and
Data tends to be collected for agency specific purposes and not for general research.
3
I
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London Substance Abuse Strategy Backpound Paper
I
1
October 2007
Based on the preceding acknowledged limitations of the available data a profile of
substance use in London Ontario can be constructed by examining the data from
national, provincial and municipal surveys and the available data from local service
providers.
In the absence of a comprehensive community survey on substance abuse this is the
best profile possible.
Substance Use:
Since 1989 Heath Canada has funded three major national surveys on substance use:
the National Alcohol and other Drugs Survey (1989); the Canadian Alcohol and other
Drugs Survey (1994) and the Canadian Addiction Survey (2204).
According to the Canadian Addiction Survey, a national survey on Canadians use of
alcohol and other drugs, frequency of usage for individuals aged 15 years or older can
be summarized as follows:'
Alcohol Use:
Overall, 79.3% of Canadians report consuming alcohol in the 12 months before the
survey;
Canadians who reported consuming alcohol in the past 12 months can be divided into
4 categories based on the amount and frequency of alcohol consumption: light
infrequent (38.7%); heavy infrequent (5.6%); light frequent (27.7%) and heavy
frequent (7.1%);5
22.6% of past year drinkers exceeded low risk drinking guidelines?
s Males 18-24 were the most likely to exceed low risk drinking guidelines; and
Among past year drinkers 17.0% or 13.6% of all Canadians would be considered high
risk drinkers.
Cannabis Use:
Overall 40.4% of Canadians report using cannabis at least once in their lifetime and
12.4% in the 12 months before the survey;
s Of past year users 18.1% report daily usage and 20.3% report weekly usage;
Males are more likely than females to have used Cannabis in their lifetime (50.1% vs.
39.2%) and in the 12 months before the survey (18.2% vs. 10.2%);
Younger people are more likely to have ever used cannabis in their lietime with
almost 70.0% having used X once and are also more likely to be past year users with
15-17 year olds at almost 30.0% and 18 to 19 year olds exceeding 47.0%;
s Incidenceof l i e time cannabis use increases with both level of income and level of
education;
About 1 in 20 Canadians report a cannabis related concern with the most common
concern being failure to control use (4.8%) followed by a strong desire to use (4.5%)
and wncern by friends about usage (2.2%); and
Amongst past year cannabis users the frequency of reported concerns rises
dramatically with 34.1% reporting failure to control their usage, 32.0% reporting a
strong desire to use and 16.0% reporting concerns expressed by friends or relatives
about their usage.
4
London Substance Abuse Strategy - Background Paper
October 2007
Othw Illicit Drug Use:
The use of illicit drugs is generally restricted to the use of cannabis only with 63.4 % of
lifetime users and 79.1% of past year users reporting using only cannabis.
Excluding cannabis the most common illicit drugs used during one's lifetime are reported
to be hallucinogens (11.4%) followed by cocaine (10.6%) speed (6.4%) and ecstasy
(4.1%).
Life time use of IV drugs is about 1.0% of the population.
While lifetime use of illicit drugs other than cannabis is 16.5% past year use is
significantly lower at 3.0%,these frequencies change with respect to sub groups such as
men (21.1% and 4.3% respectively), 16 to 19 year olds (30.6 and 17.6) and 20 to 24
year olds (28.1% and 11.5%).
Students:
The Ontario Student Drug Use Survey is the longest systematic study of alcohol and
drug use among a youthful population in Canada and as such provides a significant
contribution to an understanding of current and changing patterns of alcohol and other
drug use, the problems stemming from use, and the associated social and demographic
factors.'
According to the 2005 survey of students in grades 7 to 12:
Overall 65.5 % of students report having consumed alcohol in their lifetime and 62.0%
in the past 12 months;
Overall 31.I% of students report having used cannabis in their life time and 26.5% in
the past year;
Including cannabis 26.7% report using at least one illicit drug in the past year and
when cannabis is excluded this frequency drop to 12.1%; and
Excluding cannabis the most common illicit drugs used by students in the past year
are; hallucinogens (6.7%); solvents (5.3%); stimulants (4.8%); ecstasy (4.5%); cocaine
(4.4%); Ritalin (2.4%); glue (2.3%); methamphetamine(2.2%); Crack (2.0%); and LSD
(1.7%).
Some Trends:
On the positive side:
More students reported being drug free (including alcohol and tobacco) during 2005
as compared to 2003 (36% versus 32%);
Among all students, the use of any illicit drug excluding cannabis is currently lower
(12.1%) compared to surveys since Ig99; and
Despite recent media attention regarding the use of methamphetamineand oxyContin
there is no evidence that either drug has diffused into the students population with
past year usage at 2.2% and 1.0% respectively.
On the negative side:
Daily cannabis use among cannabis users has increased significantly over the long
term. About 12% of users or about 3% of students report daily cannabis use;
5
London Substance Abuse Strategy - Background Paper
October 2007
Cocaine use has been increasing steadily among all students since 1993 and is
currently at 4.4% for past year use;
Of the students who are licensed drivers 14.0% report drinking and driving and 20.0%
report using cannabis and then driving;
29.0% of students report being a passenger with a driver who had been drinking and
22% report being a passengerwith a driver who had been using drugs;
33% of students report that someone tried to sell them drugs over the past 12 months
and 23% report being offered, sold or given a drug at school; and
17% of students report getting ‘high” or “drunK’ at school.
The 2005 survey included a screening tool in order to identify students who may have a
drug use problem and responses indicated that:
16.0% of students are identified as potentially having a drug use problem;
There is a significant variation amongst grade levels ranging from 7th grade (2.0%) to
12* grade (28.0%); and
There was no significant difference based on gender with respect to a potential drug
use problem: 17% of males and 16.0% of females.
In 2005, 0.7% of Students indicated that they had received either alcohol andlor drug
treatment in the preceding 12 months.
2.4. VulnerabldHlgh Risk Groups
While the precedingfrequencies hold true across the general population a range of
vulnerable or high risk groups exhibit both significantly higher substance use/abuse
frequencies and different usage characteristics:’
Out of the Main Stream Youth:
Out of the main stream youth include overlapping groups such as street involved youth,
youth who are homeless or who are largely absent from home, youth involved in the sex
trade, youth in the care of community services or known to the justice system, and youth
who are frequently truant from school?
Their substance use patterns are very different from those of mainstream youth still in
school.
Out-of-the-mainstreamyouth are at high risk of a substance use trajectory that may
include extensive alcohol and cannabis use, the use of cocaine and opiates, and
injection drug use.
A recent Toronto study of street youth found high levels of overall substance usage
including:
Cannabis:
Alcohol:
Crack cocaine:
Prescription pills:
84%
83%
60%
41%
This study also found these street youth tend to use substances more frequently with
72% using daily and usually more than one substance at a time.”
6
London Substance Abuse Strategy - Background Paper
October 2007
Research also suggests that typically street youth become drug-involved within six
weeks of their arrival “as a means of survival””
Substance use trends for out of the main stream youth underscore the importance of
preventionlharmreduction programs for this group to prevent episodic
homelessnesdsubstanceabuse from producing long term health consequences such as
HIWAIDS, Hepatitis C and/or death by overdose.
Homeless Persons
Individuals who are homeless tend to use substances at significantly higher rate than
those who are not and indeed there is a strong correlation between substance abuse
and homelessness.
A number of factors that increase the risk of substance abuse such as poverty, mental
illness, incarceration, unemployment, or the absence of strong family or peer support
networks also increase the risk of homelessness.
Substance abuse and addiction themselves can also lead to homelessness, and act as a
bamer to housing stability, while individuals who are having difficulty finding stable, or
indeed any housing, may turn to substance use as a way of coping with these negative
experiences. A Toronto study focusing on the health of homeless persons found that
44% of the respondents had used illicit drugs in the previous moMh.’*
Emergency shelter providers in London estimate that between 40% and 60% of
individuals using the shelters may have substance use/abuse issues.
Another Toronto study underscoredthe endemic nature of substance use amongst many
homeless persons with 85% of users reporting that they had been using their drug of
choice for at least five years and 65% using it for 10 years or more.13
Aboriginal Persons
Aboriginal persons are at a higher risk level for substance uselabuse. Issues of poverty,
familial breakdown, unemployment and poor social support networks are in many cases
further aggravated by discrimination, the effects of residential schools, and barriers to
health care such as language and the lack of culturally sensitive services.
One study found that Aboriginal people over the age of fifteen were almost three times
more likely than non-abonginalsto have used cannabis or hashish in the part year, three
and a half times more likely to have used LSD, speed, crack or heroin and 11times
more likely to have used solvents or aerosols.”
Drug and alcohol treatment centre use in Ontario by aboriginal ersons is six times that
expected for this sub group as a percentage of the population.1P
Sex Trade Workers
Research shows that incidence of substance use/abuse amongst sex trade workers
vanes widely.
Studies in the United States have found the prevalenceof substance use and addiction
ranging from near 0% to 84%, depending on the population being studied, with
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London Substance Abuse Strategy - Background Paper
October 2007
substance addiction relatively common among street prostitutes (generally in excess of
50%), but much lower reported levels among women who work off the street."
A study conducted at Maggies, which houses the Toronto Prostitute's Community
Service Project,found that of the street prostitutes surveyed 78% were drug users and
of these 76% Indicatedthat their drug use was related to their work.''
Of the individuals involvedwith the 'Persons at Risk" project, an outreach project
through London Police Services to assist female prostitutes exit the lifestyle it is
estimatedthat the incidence of substance use/abuse approaches 100%.
Mental HealthlConcurrentDisorders:
A concurrent disorder is a combined or concurrent substance use and mental health
problem. For example a person could have an anxiety disorder and a drinking problem
or schizophrenia and cannabis dependence.
One study found that:"
30% of people diagnosed with a mental health disorder will also have a substance
abuse disorder at some point in their lives;
37% of people diagnosed with an alcohol disorder will have a mental health disorder
at some point in their lives; and
53% of people diagnosed with a substance abuse disorder other than alcohol will have
a mental health disorder at some point in their lives.
This relationshiphave been further exacerbated by the trend towards the
deinstitutionalizationof the mentally ill without adequate housing, medical and support
structures which has produced high level of homelessnessand hopelessness.
A London study found that in 2002 at least 194 people had been discharged from
psychiatricwards to either shelters or the streets."
Individualsoften have difficulty accessing treatment for either substance abuse or
mental health issues as the presence of one disorder serves as a barrier to accessing
the programs and services that are generally designed to address one but not both
disorders.
2.6. Profile of London, Ontario
Based on a 2006 population estimate of 292,600 persons (15 years of age or older) for
the City of London frequencies from general populationsurveys on substance use would
suggest that:"
52,439 Londoners have in the past year exceeded Low-Risk Drinking Guidelines of
weekly alcohol intake not exceeding 14 standard drinks for males and 9 standard
drinks for females, and daily consumption not exceeding two drinks;
36,240 Londoners have used cannabis at least once in the past year;
6,559 Londoners use cannabis on a weekly basis; and
7,320 Londoners use cannabis on a daily basis.
8,748 Londoners have used an illicit drug other than cannabis at least once in the past
year;
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London Substance Abuse Strategy - Background Paper
October 2007
5,530 Londoners have used cocaine at least once in the past year;
3,189 Londoners have used ecstasy at least once in the past year;
2,311 Londoners have used speed (methamphetamine) at least once in the past year;
2,048 Londoners have used hallucinogens at least once in the past year; and
2,926 Londoners have used injection as a method of illicit drug delivery at least once
in their lifetime?'
Extent of Substance Abuse in London
But what is the extent of substance abuse in London? What is the evidence? The
following section attempts to answer these questions.
Survey of Londoners:
In order to obtain additional local information about substance use by the City of London
Substance Abuse Strategy's target population, a survey of 40 individualswas conducted
in the summer of 2006 at locations in the downtown core that are frequented by
individualswith addictions and also at some emergency hostels.
13% classified themselves as heavy drinkers and 60% classified themselves as
abstainers;
98% reported using streeffnon-prescriptiondrugs;
68% are taking prescriptiondrugs. Of these, almost all were also using streeffnonprescriptiondrugs;
50% of drug users are taking medication prescribedfor mental health issues; and
83% believe they have a problem with alcohol or drugs.
The drugs used most commonly by survey respondents are pictured in Figure 1:
Fiaure 1: Druas Used bv Suwev Reswndents
9
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London Substance Abuse Strategy Background Paper
October 2007
The top five life challenges are pictured in Figure 2:
Fiure 2: TODFive Life Challenqes ReDorted bv Survev Rewondents
CAMWCOUNTER POINT STUDY:
In the Fall of 2006, the Centre for Addiction and Mental Health (CAMH) conducted a
study into the Drug Treatment Readiness of clients of the Aids Committee of London's
Counter Point Needle Exchange Program.
Research shows that the types of drugs people use can influence their risk of acquiring
Human ImmunodeficiencyVirus (HIV) Hepatitis C (HCV)or other blood borne
pathogens, their risk of death from overdose and also the types of services they require.
For example, people who use opiates are at heightened risk of overdose and people
who use crack tend to be at higher risk of acquiring HIV and HCV.
Kev General Findinas:
0
-
Many Counterpoint clients reported illicit use of prescription drugs, in particular
opiates (82.6%) and Ritalin (65.3%);
Crack (67.4%) and cocaine (65.3%) use were also common;
Most clients injected an opiate (81.3%); and
About half of clients (48.3%) reported injecting heroin and other opiates one or more
times per day.
Approximately one-fifth of clients injected cocaine, crack or another stimulant one or
more times per day, however, many injectedthese drugs on a weekly basis.
Acauirina and diwosina of needles:
A new, sterile needle for every injection is a best method for preventing the risk of
transmitting blood-borne infections such as HIV and Hepatitis B and C
10
London Substance Abuse Strategy - Background Paper
October 2007
Key Findings:
Almost 10% of clients typically used a needle three or more times - slightly higher for
men (11.8%) than for women (7.7%);
72% of clients said they typically used a needle once;
The six most commonly reported sources of sterile needles were: the needle
exchange program (NEP; 91.5%), other drug users (70.2%), pharmacistlchemist
(48.2%), a drug dealer (30.5%), a sex partner (28.8%) and needles bought on the
street (29%);
Almost onequarter of clients reported that when they ran out of sterile needles they
shared a needle with someone else and 16% reported that they borrowed a needle
that someone else had used: and
When clients were asked how they had disposed of used needles in the past 6
months, the most common response was that they took them to the NEP (69.5%).
However, 46.1% said they had thrown used needles in the garbage, almost onequarter reported that they had lost used needles, and 22.5% reported that they had
lost track of used needles when they were high.
lniection risk behaviour in the Dast 6 months:
Previous research has linked specific types of injection practices with elevated risks of
acquiring HN, HCV andlor other blood borne pathogens. In the sections to follow, we
examine the prevalence of these behaviours among Counterpoint clients
Key findings:
Almost half of clients injected more than 10 times per day. This frequency of
injection has important implicationsfor service delivery most clients require large
quantities of needles and other equipment to ensure that every injeHion is completed
with clean works;
Most Counterpoint clients injected in their homes suggesting that outreach to homes
may be particularly beneficial;
The majority of women needed help to inject and this may place them at elevated
risk for a number of injection related problems:
Over half of men and women reported injecting alone in the 6 months prior to the
study. This finding is concerning because there may be no-one to help if an overdose
occurs;
Just under half of study participants (42.3%) stated that in the past 6 months they
had injected with people they did not know;
Approximately one-fifth of clients said they had injected with a needle that was
previously used by someone else, in the past 6 months;
While cleaning of used equipment is not recommended as a risk reduction method, a
small proportion of clients (11.9%) continued to do so: and
Many clients reported re-using someone else’s injection equipment: tourniquets
(43.0%); cookerkpoon (37.3%);water (19.0%); and filters (18.3%).
-
HIV and HCV infection status:
Injection practices such as needle, equipment and drug sharing put IDUs at risk of
acquiring HIV and HCV. HIV and HCV have the same transmission route (Le., through
London Substance Abuse Strategy - Background Paper
October 2007
blood contact) however HCV is four to five times more easily transmitted through a
contaminated needle.
Key findings:
0
The HIV infection rate (self-reported) among Counterpointclients was 3%. The selfreported HCV rate was 53%;
The majority of clients reported that they had been tested for HIV (91%) and HCV
(87.1%) during the past 2 years. However, 9% had not been tested for HIV and
approximately 13% had not been tested for HCV in the past two years;
Among HIV negative clients, (73.2%) felt they were less likely than other drug users
to acquire HIV. 10.1% felt they were more likely than other drug userS to acquire
HIV; and
Among HCV negative clients, almost 72% felt they were less likely than other drug
users to acquire HCV. While 11.1% felt they were more likely to acquire HCV slightly higherfor men than women (13.7% vs. 5.3%).
Finally, a series of ‘snapshots” of those individualsin the City of London who may have
substance dependencelabuseissues can be derived from client informationfrom various
social service agencies:
Ontario Works
OW London estimates that 10%-12% of the total Ontario Works caseload or 820 to 984
individualsexperience substance abuse as a barrier to employment.
OW London is participating in a provincial pilot project aimed at participantswith
addictions called the Ontario Works Addiction Services Initiative. For the first year, a
target of 300 individuals was set to be serviced by this program.
Emergency Shelters
There are currently 380 fixed emergency shelter beds in the City of London available
through Mission Services; the Salvation Army and the Unity Project.
Based on the current average length of client stay of 12.5 days emergency shelter
system capacity is approximately 876 persons per month.
Local emergency shelters have been consistently operating at or near capacity on a
regular basis with little prospect of diminished demand in the immediate future.
Local shelter operators estimate that between 40% and 60% of residents have
substance uselabuse issues which would translate into between 350 and 525
individuals.
The trend has been towards an increasing number of shelter users with substance
use/abuse issues as well as an increase in the level of active substance consumption
within the shelter system
My Slstefs Place
My Sister‘s Place is a drop in centre for homeless (or at risk of being homeless) women
which also provides a range of services including: meals, day beds, support
12
London Substance Abuse Strategy - BackgroundPaper
October 2007
- -
programming
and referrals to other services. Tvoicallv MYSister's dace DrOVideS
.
services to between 50 and 70 women a day, many with addictions'and/dr mental health
problems.22
London Counter Polnt Needle Exchange program
Offers needle exchange services to injection drug users through a number of community
locations as well as other harm reduction, education and counselling services,
In 2005 Counterpoint staff interactedwith 1,367clients and distributed over 350,000
needles?' From January, 2006 to June, 2006 Counterpoint staff interactedwith 730
clients and distributed over 230,000needlesz4 In the period of July 2006 to May 2007
there were 2,535clients and over 545,000 needles were distributed.
London Intercommunity Health
Provided health care services including outreach programs, groups, dropin
programs, clinical and counseling services to 6,146clients in 2005-2006.
Staff estimate that of the client's served approximately 1,000 have substance use/abuse
issues and that 40 % of the visits to LlCH are substance related.
-
Salvation Army Withdrawal Management Services (Detox)
Withdrawal management services at the Centre of Hope provides non-medical
supervised withdrawal from alcohol and drugs and is currently the only detox facility in
the City of London.
The facility opened in October 2005 and in its first 3 months of operation conducted 31 5
intakes of which 85 were re-intakes.
Addiction Services of Thames Valley (ADSTV)
Addiction Services of Thames Valley provides a range of community based addictions
programs and services including assessment, development of treatment plans,
education, etc.
Currently the agency is averaging 1,500 to1,700 client referrals per year.
The most prevalent drugs clients report having problems with are alcohol, marijuana and
cocaindcrack.
Of note is the fact that there is a lag between drug use trends and when those trends
show up in the statistics of addiction services. The evolution of substance use to
substance abuse and addiction can take months to years depending on the substance
involved. On that basis there has been a significant reported increase in the use of
Oxycodone, a powerful prescriptionpainkiller and opiate, where as the same trend has
not yet emerged for crystal meth use.
Heartspace is a prevention and early identification, education, and treatment program for
women pregnant, parenting and substance-involvedand their children (prenatalto 6
years of age) run through ADSTV. Since 2002 Heartspace has engaged more than 200
13
London Substance Abuse Strategy - BackgroundPaper
October 2007
families through onsite services. Many women face multiple challenges and 51% have
identified a problem with more than one substance.
From June, 2006 to December, 2006 65 Ontario Works participants were referred
through Addiction Services to the Fresh Start program at ADSTV. The chart below
outlines the frequency of drug use among these dients. Also included is a summary of
mental health diagnoses by a qualified individual.
A. The freauencv of substance use for these cliente was as follows:"
Crack
Alcohol
Cannabis
Cocaine
PrescriptionOpiates
Ecstasy
Tobacco
HeroinlOpium
Methyphetamines
None
Some other characteristicsof this group include:
Injection Drug Use
Never Injected:
Injected in the past 12 months:
Injectedprior to I year ago:
Unknown/not specified
Current Legal Status
No problem:
Probation:
Parole:
Awaiting TriaUSentencing:
Other:
60%
50%
20%
20%
20%
9%
7%
5%
2%
47%
34%
13%
6%
74%
19%
2%
2%
3%
B. Mental Health Dlaanoslsbv a auallfied Plofeselonal:"
Major Depressive Disorder:
Bipolar Affective Disorder.
Antisocial Personality Disorder:
Obsessive Compulsive Disorder:
Anxiety Disorder:
Schizophrenia
ADDIADHDIDisruptweDisorder
BorderlinePersonality Disorder:
30%
9%
7%
5%
2%
2%
2%
2%
Clinic 528
Clinic 528 is a privately owned and operated medical facility located at 528 Dundas
Street. As a methadone clinic, it is both a treatment and a harm reduction facility. Clinic
528 provides methadone maintenancetreatment to opiate addicted individuals in the
London and area community. Treatment interventions are available for those wishing to
reduca or discontinue their opiate use. As well, harm redudion strategies are available
14
London Substance Abuse Strategy - Background Paper
October 2007
allowing individualsto retain employment while still addicted, and to prevent the need for
criminal activity by those addicted and looking for means of supporting their "habit."
The facility at 528 Dundas Street includes individual treatment spaces, a group meeting
space, testing lab and full service pharmacy. It is a seven day a week operation.
The Clinic screens clients for addictions using the Diagnostic and Statistical Manual, ed.
4 (DSM4). Client intake is growing at a reduced rate -new clients almost equal to those
leaving program.
The clinic opened at its current location in 2002 with 120 active clients and a waiting list
of 80. Currently the Clinic has over 800 clients half of which access the Clinic on a daily
basis.
Only about 10% of the clients are recovering heroin addicts with the pain killer
Oxycodone. an opiate based prescriptionmedication, presenting as the primary
substance to which clients have an addiction.
Weatover Treatment Centre
It is a residential treatment centre located in Thamesville Ontario that offers a variety of
programmingfor drug and/or alcohol addiction.
The Centre averages 350 clients a year and generally one half are from the LondonMiddlesex area.
Canadlan Mental Health Assoclatlon -London- Middlesex
Of the total clients it is estimated that between 30 and 40% have a concurrent disorder.
2.6. Why Do People Use Substances?
- A
The reasons for illicit drug use are many and varied and can be associated with poverty;
substandard housing; homelessness; unemployment; physical injury; mental or
emotional illness; familial breakdown; and penonal tragedy. Confronted with one or
more of these factors, some people turn to drugs as a form of refuge, where the user
sees "the harm that they inflict upon themselves as the lesser of two - or perhaps
several -evils." Some use drugs for pleasure, some to relieve physical or emotional
pain, others still because they believe drugs enable them to function at a higher
intellectual or physical level.
2.7. Substance Use, Depemdence and Abuse
Based on available data from general population surveys the reality is that most people
in Canadian society have used and/or do use substances to varying degrees.
It is important therefore to draw a distinction between substance use, substance
dependence and substance abuse.
15
London Substance Abuse Strategy - Background Paper
October 2007
Most illegal drug users in Canada will never be regular users. It
bears repeatingthat drug use are still, for the most part, a sporadic,
recreational, exploratory activity. Mostpeople are able to manage their drug
use without any dflculty. Very few will become regular users, and even fewer
will develop a drug addiction.
Illegal Drug Use in Canada & Crime, Senate Special Committee on Illegal
Drugs, October 2001
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines
substance dependence as "a maladaptive pattern of substance use, leading to clinically
significant impairment or distress" as manifested by three (or more) of the following,
occurring at any time in the same 12-month period:
Tolerance (Le., need for markedly increased amounts to achieve intoxication or
desired effect, and markedly diminished effect with continued use of the same amount
of a substance);
Withdrawal (Le., characteristic of withdrawal syndrome for the substance, and taking
the same subsiance or one closely related to relieve or avoid withdrawal symptoms);
Consuming larger amounts or over a longer period than was intended;
Persistent desire or unsuccessful efforts to cut down or control substance use;
Spending a great deal of time in activities to obtain the substance, to use the
substance or to recover from its effects;
Giving up or reducing important social, occupational or recreational activities because
of substance use; and
Continued use despite awareness of having a persistent or recurrent physical or
psychological problem that is to have been caused or exacerbated by the substance.
The Diagnostic and Statistical Manual of Mental Disorders associates substance abuse
with situations of:
Failure to fulfill major role obligations at work, school, home:
Recurrent substance use in which it is physically hazardous (e.g., driving or operating
machinery);
Recurrent substance-relatedlegal problems; and
Continued substance use desple having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of the substance.
2.8. Why Do People AbuselBecome Dependent on Substances?
Most researchers agree that there is no single cause of substance abuseldependence,
but rather many complex and interrelatedfactors that make people more susceptible to
abuse substances andlor to become dependent substances.
16
London Substance Abuse Strategy - Background Paper
.October2007
They say we have free will and free choice, but not in the face of addiction.
Addiction is habitual a dependence of the mind and body. It‘s hard to ignore the
compulsion to use if you can’t close the door to the world and you’re still left in the
same environment
Anonymous Substance User, London, Ontario
There are as many possible contributing factors as there are theories of substance
abuseanddependence:
0
Moral (e.g., lack of self-control);
Biologicallphysiological(e.g., genetic predisposition, chemical imbalance, central
nervous system damage);
Psychological (e.g., emotional and/or behavioral problems, mental illness); and
Sociological (e.g., adaptive response to social stressors, peer pressure).
The stories told by substance users serve to underscore some of these factors.
For example:
“I was out jogging and broke a leg. / had opiates prescribedandjust loved
them, have been hooked ever since. ... Ithink more blame should be
placed on doctors who prescribe loosely.”
Anonymous Substance User, London, Ontario
~
“I’m having problems bettering my life because I’ve been doing drugs for so
many years. Puttinga needle in my ann is what I’ve been good at. I’m
afraid of change and being a different person. Someone I’ve had hidden for
so long. Knowing there’s a good person inside me keeps me going.*
Anonymous Substance User, London, Ontario
2.9. Summary and Trends
Since 1989, Health Canada has funded three major national surveys on substance use the National Alcohol and Other Drugs Survey (NADs, 1989), the Canadian Alcohol and
Other Drugs Survey (CADS, 1994) and the Canadian Addiction Survey (CAS, 2004).
Comparing these surveys it is evident that drug use in Canada has risen sharply over
the past 10 years; cocaine use has more than doubled, while the use of amphetamines,
LSD and Heroin has nearly tripled.
London Substance Abuse Strategy - Background Paper
October 2007
According to the Canadian Addiction Survey (2004) self reported trends of illicit drug use
are increasing in Canada. The proportion of Canadians reporting any illicit drug use in
their lifetime rose from 28.5% in 1994to 45.0% in 2004, and in the past 12 months from
7.6% to 14.4%.
The lifetime use of cannabis increased from 23.2% in 1989, to 28.2% in 1994, and to
44.5% in 2004.
For cocaine, use rose from 3.5% in 1989, to 3.8% in 1994, and to 10.6% in 2004.
For LSDlspeedlheroin,the rate rose from 4.1% in 1989 to 5.9% in 1994 and to 13.2% in
2004.
The past-year use of cannabis rose from 6.5% in 1989 to 7.4% in 1994 and to 14.1% in
2004.
For cocaine and crack, rates declined from 1.4% in 1989 to 0.7% in 1994,
and rose again to 1.9% in 2004.
2.10.
Emerging Issues
According to the World Health Organizationmethamphetamine is the second only to
cannabis as the world's most widely used illicit drug.
In July 2005 a number of arrests were made affer a joint investigation by the RCMP
London Drug Section, the Ontario Provincial Police Drug Enforcement Section and the
London Police Service Drug Unit focusing on crystal methamphetaminedistribution
networks operating within the County of Huron. of particular note was the fact that the
seized drugs were in the 86% to 100% purity range. As an RCMP officer noted
"Seizures of 100% purity are unusual at the street level and are a good indicator that the
drug has come directly from the lab to the street.""
At a meeting of the Counter Point Needle Exchange Program Community Advisory
Committee held in September, 2007 several front line workers pointed out they are
observing a rapid increase in the prevalence of individualsusing and addicted to crystal
methamphetamine and expressed serious concerns at the consequencesof this usage
spike - increased incidents of psychotic behaviour and serious health issues. No
reasons were identied for this increased use.
One of the 40 individualssurveyed report using methamphetamine.
Survey of Londoners
Home Grow Operations
The prevalence of marijuana home grow operations has been on the increase
throughout Ontario and police estimate that there are as many as 15,000 illegal home
grow operations in the province."
18
London Substance Abuse Strategy - Background Paper
October 2007
Since 2000 London Police Services have dismantled462 home grow ops. It is
estimated that there is a home grow operations within a 10 minute walk from every
urban home in London."
Oxycodone
Oxycodone is a potent and potentially addictive opioid analgesic medication that is an
important medicationfor treatment of pain in cancer patients. It is commonly obtained
legally through prescriptions as well as illegally on the ~treet.~'
It is sold under a number
of company or trade names including Oxycontin and Percocet.
Possessionfor purpose of trafficking is guilty of an indictable offence and liable to
imprisonment for lie.
Emergency shelter providers in London are seeing more clients with Oxycodone
dependencelabuse issues as is Addiction Services of Thames Valley.
30% of individuals surveyed report using oxycodone
Survey of Londoners
A majority of the patients at London's Clinic 528 are involved with a methadone
maintenance pmgram for Oxycodone addiction. In fact Dr. John Craven from the clinic
believes that prescriptiondrug abuse, notably of Oxycodone, will be the biggest drug
problem across North America in the decades to come.'*
In early 2006 there was a series of armed robberies at pharmacies in London where the
target was Oxycodone as opposed to money which, according to London Police
Services, is indicative of the demand for the drug by both addicts and dealers.
Also in 2006 one of the largest illegal prescription seizures (including 300 Oxycontin)
was made in London at a business located near the Richmond St and Dundas St
intersections?'
A recent provincial task force in Newfoundland and Labrador reached a number of
findings that are consistent with anecdotal information available locally in London:J4
Oxycodone users come from a variety of environments. Police intelligence suggests
that the bulk of Oxycodone on the streets originates with prescriptions generated in
the province;
Information collected by the Task Force suggests a growing number of users among
the adolescent population;
19
-
-
London Substance Abuse Strategy Background Paper
October 2007
There are significant changes in the number of prescriptions, the number of tablets,
and the increasing strength of Oxycodone available. These changes cause significant
concern among professionals dealing with the misuselabuse of Oxycodone;
Diversion of Oxycodone for criminal purposes is widespread and the increased
access to Oxycodone supports drug seeking behavior such as double dodoring; and
There are a small number of physicianswho are prescribing controlled substances in
an excessive manner.
Methadone Malntenance Treatment Plograms
Over the last decade, methadone maintenance as a treatment option for opiate addiction
has increased significantly in Ontario.
Methadone maintenanceprograms are either operated by community agencies usually
overseen by the Ministry of Health and Long Term Care or operated by physicians in
private practice governed by the College of Physician and Surgeons.
The trend in the last fwe years has been the opening of large scale clinics operated by a
physician’s group with client bases in excess of 200 to 300 people combined with the
closures of smaller community tun clinic3 generally due to lack of funding.
A number of concerns have emerged regarding the large scale clinics:36
Lack of case management for larger caseloads of over 200 clients;
Lack of treatment for concurrent disorders:
Very high doses of methadone dispensed (280 mg in some cases);
Low levels of monitoring for methadone diversion;
Methadone prescribedfor those without prior opiate addiction;
Methadone dispensed to those under the influence of alcohol and other substances;
Drug dealing on the premises; and
Lack of linkage or physician follow up when clients are admitted to withdrawal
management or other programs.
One-third of survey respondentsreported being in a methadone treatment
program. Some of these individuals also reported using 9V street
methadone”. Only about one in fwe, however, reportedusingprescribed
methadone.
Survey of Londoners
Methadone MaintenanceTreatment Task Force
In April 2006 the Government of Ontario established an external task force to provide
advice to the government on how to improve methadone treatment in the province.
The Task Force viewed methadone maintenance treatment as a valuable but small
piece of the large area of addictions and that the issues surrounding drug addiction are
20
London Substance Abuse Strategy - Background Paper
October 2007
complex and need to be addressed using a 'four pillars approach" as the foundation for
a long term provincial drug strategy.
Key recommendationscontained in the Task Force report include that?
0
The Ministry of Health and Long Term Care (MOHLTC) develop a provincial strategy
and policies that ensure that Ontarians have equitable access to a comprehensive
range of methadone maintenance treatment (MMT) services:
The MOHLTC build on its Primary Care Reform priorities by strongly encouraging
and supporting Family Health Teams to provide comprehensive methadone
maintenancetreatment where access to care close to home is an issue:
The Ontario Pharmacy Council develop and submit to MOHLTC a plan to enhance
the role of pharmacists in methadone maintenance treatment;
The MOHLTC support amendments to provincial regulations that would enable
primary health care nurse practioners to prescribe and administer methadonefor
opioid dependence in communities and situations where access to methadone
maintenancetreatment is limited;
Local Health Integration Networks strongly encourage and support public acute care
hospitals that have pharmacies to dispense methadone to meet the needs of local
communities where access to methadone maintenance treatment is limited;
The MOHLTC work in collaboration with the Ministry of Community Safety and
CorrectionalServices to ensure that standard provincial admission and discharge
policies and procedures are followed for persons receiving MMT who are serving in
correctionalfacilities;
The Ontario Pharmacy Council determine and advise the MOHLTC on the most
appropriatefunding model to encourage pharmaciststo dispense MMT;
The MOHLTC bring stakeholders together to develop a public education campaign
that addresses the stigma associated with addiction and MMT;
The MOHLTC support the College of Physiciansand Surgeons to develop and
implement a plan a assess physician group practices that provide MMT:
The MOHLTC provide appropriate funds to expand and support comprehensive MMT
services in Ontario:
The MOHLTC develop a computerizedweb based information system to track
prescribingand dispensing activity for all prescriptions in Ontario with the goal of
improving public safety;
The MOHLTC address the critical issue of the abuse and diversion of Oxycodone in
the province: and
The MOHLTC identify a single point of authority and accountability for MMT within the
Ministry.
2.1 1.
Economic Effect8 of Substance Abuse
In 1996 the Canadian Centre on Substance Abuse released the first-ever report on the
costs of substance abuse in Canada, a study that estimated the costs of alcohol,
tobacco and illicit drugs abuse in Canada?'
In 2003 Health Canada funded the Canadian Centre on Substance Abuse to conduct an
update of the earlier study and The Costs of Substance Abuse in Canada 2002 was
released in 2006.
21
billion or 1.9% of the province's GDP
The Costs of Substance Abuse in Canada (2002)
The overall economic impact of substance abuse is a conservative estimate based on
the fact that a number of costs were not or could not be factored in. Examples include:
0
Costs to individuals in purchasing their substance;
Social assistance payments to individuals disabled by substance abuse;
Individual pain and sufferiw;
Cost associated with the abusehisuse of pharmaceuticals; and
Lost productivity due to incarcerationfor a substance related wme
The costs attributable to alcohol abuse are $441 a year for every person in London or
almost $157 million to the community ~ollectively.~~
The costs attributable to illegal drug abuse are $242 a year for every person in London
or over $86 million to the community collecti~ely.~~
2.12.
Health and Soclal Impacts of Substance Abuse
According to the report The Costs of SubstanceAbuse in Canada in 2002, a total of
4,258 deaths were attributed to alcohol, accounting for 1.9% of all deaths in that year.
Cirrhosis was the leading cause of death (1,246 deaths) followed by motor vehicle
collisions (909) and alcohol-attributed suicides (603).
Alcohol-attributed deaths resulted in 191,136 potential years of life lost.
Alcohol-attributed illness accounted for 1,567,054days of acute care in hospital
22
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London Substance Abuse Strategy Background Paper
October 2007
Just over half of survey respondentssay they have been to a hospital
emergency department for an accidentaldrug overdose or other drug use
related condition.
Survey of Londoners
According to the report The Costs of Substance Abuse in Canada in 2002 a total of
1,695 Canadians died as a result of illegal drug use, accounting for 0.8% of all deaths.
The leading causes of death linked to illegal drug use were overdose (958), drugattributable suicide (295), drug-attributable hepatitis C infection (165), and HIV infection
(87).
Deaths linked to illegal drugs resulted in 62,110 potential years of l i e lost.
Illegal drug-attributed illness accounted for 352,121 days of acute care
in hospital.
Imight have AIDS, Ihave Hep C from needle use. I’ve been doing drugs for so
many years.
I’ve been on drugs 26 years. Ihave Hep C possibly from injecting heroin.
Anonymous Substance Users
London. Ontario
Although fewer Canadian die of causes related to illegal drug use than alcohol or
tobacco, the deaths tend to involve younger people and therefore represent a more
significant impact in terms of life years lost.
Aggregate mortality, acute care days and potential years of life lost can present a rather
sterile picture of the social impact of substance abuse.
The Canadian Addiction Survey (2004) illustrates some of the harms respondents
reported from there own and other substance abuse.
According to the Canadian Addiction Survey for past year drinkers the percentage of
respondents reporting harm from one’s own alcohol use across various aspects of life is
as follows:
0
Friends and Social Lie:
Physical Health:
Home Life or Marriage:
Work, studies or
Employment Opportunities:
Financial Position:
Legal Problems:
Housing: (sample too small)
Learning:
More than Iof the preceding:
3.0%
5.0%
1.8%
1.7%
2.7%
0.7%
0.5%
0.8%
23
London Substance Abuse Strategy - Background Paper
October 2007
Furthermore, according to the same survey 32.7% of Canadians 18+ reported being
harmed at least once in the past 12 months by someone else's drinking:
0
22.1% were insulted or humiliated;
15.8% were verbally abused;
15.5 % experienced serious arguments or quarrels:
10.8% were pushed or shoved;
10.5 % experienced family or marriage problems; and
3.2% were hit or physically assaulted
According to the Canadian Addiction Survey (2004) for past year drug users (including
cannabis) the percentage of respondents reporting harm from one's own drug use
across various aspects of l i e is as follows:
Friends and Social Life:
Physical Health:
Home Life or Marriage:
Work, studies or
Employment Opportunities:
Financia\Position:
Legal Problems:
Housing: (sample to small)
Learning:
More than 1 of the preceding:
6.0%
10.1%
5.1%
5.1%
6.5%
1.3%
3.5%
17.5%
My mom told me to kill myselt Ihad my two boys, once Ilost them to their dad, that was it
Now I'm in self-destnrctmode. When asked doctor for help to calm down he didn'thelp.
Someone came by and had sex with bunch of hookers at my place and now there's blood
all over my bed. Hot water heater exploded. Got evicted because Icouldn't be nice. Dr.
won't help because I'm too angry. Where do you go for help when you're too angry? I
don't ask for help any more. Doesn't matter if anyone else hurts me, Ican hurt myself
better than anyone else. Been attackedtwice in my building had stitches. Idon't have
nothing and Idon't have nothing to work towards.
Anonymous Substance User
London, Ontario
A higher percentage of respondentswho are past year drug users excluding cannabis
report harm from one's own drug use across the same indicators
Friends and Social Life:
Physical Health:
Home Life or Marriage:
Work, studies or
Employment Opportunities:
Financial Position:
Legal Problems:
Housing:
Learning:
More than 1 of the preceding
16.4%
23.9%
18.9%
18.9%
19.6%
10.0%
4.4%
12.0%
45.7%
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London Substance Abuse Strategy - Background Paper
October 2007
According to a study of the incidence of reported child abuse and neglect in Ontario it
was found that 22% to 33% of the substantiated maltreatment investigations, caregiver
functioning was impacted by alcohol, drug and/or solvent abuse"
Chasing the dragon, looking for my fix daily. Wdhout drugs or being dope-sick, you
can't hold ajob. Itake needles to work every dayjust to keep working. Imiscarried
because Iwas doing drugs so could not afford to buy food. My family, especially my
son who's in care, keeps me going - knowing Ineed to keep working so Ican someday
have him back.
Anonymous Substance User
London, Ontario
2.13.
Criminal impacts of Substance Abuse
The relationship between substance usddependencdabuseand crime is a complex
one?'
The police reported drug related crime rate has risen an estimated 42% since the early
1990s and now stands at a 20 year high.
The national average is 295 drug related offenses for every 100,000 persons. Within
the national average there is a wide variability based on both age and location. Young
adults 18 -24 had the highest rate (860 offenses per 100,000 persons) followed by youth
12 -17 (645 offenses per 100,000 persons)42
Rates of drug offenses reported by police amongst census metropolitanareas also vary
CMA
Offense Rate
(per 100,000 persons)
Natlonal Average
29s
Thunder Bay
Vancouver
St Catherines - Niagara
London
Hamilton
Montreal
Toronto
Ottawa
Windsor
Kitchener
571
468
316
269
245
215
21 1
188
186
151
Drug related crime statistics are generally considered merely the tip of the iceberg based
on the fact that while drug possession is considered a drug-related crime; crimes that
may be committed to support a drug habit (theft, fraud, prostitutionetc) are not.
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It must be recognized that not all people that have a substance problem are criminals
and conversely much crime is committed by those who do not have a drug or alcohol
dependency.
The research shows that a number of social, psychological and cultural factors can be
used to identify people who are at risk of becoming criminals and/or drug users. Factors
that may explain both drug use and criminal activity include poverty, lack of social
values, personality disorders, association with drug users and/or delinquents, and loss of
contact with agents of socialization.”
It is certain a range of criminal activity is undertaken by some individuals with substance
problems. For example:
0
Possession of substances from marijuana to heroin is illegal (Police in Canada laid
93,000 drug charges in 2002 of which 2/3 were for po~session)~~:
Many addicts sell drugs to finance their own drug use;
Property crimes: fraud, break and enter, theft etc“. and
prostitution4’.
In general crimes are most often committed by individuals who have developed an
intense dependency on a drug and who do not have the financial and social means to
obtain that drug.
~~
Itraded eight Ritalin for a bike, that’s how desperate people are. People will sell
wedding rings, anythingfor their drugs
Anonymous Substance User
London, Ontario
Excluding “affluent addicts” on whom little research has been conducted researchers
agree that drug addicts have three main sources of income: social assistance4,
acquisitive crime“, and the illegal drug market”.
Aside from the preceding sources of inwme research has also indicated that addicted
users may seek to increase their usual money-gameringactivities while reducing their
overall spending. They may engage in term labour, bonow money from friends or family
members, pan handle etc. while at the same time utilize meal programs and homeless
shelters in order to reduce the amount they spend on their own meals and
accommodation and thus free up money for drugs.
According to Statistics Canada the overall crime rate in Canada has generally been
declining since 1991 and Ontario has recently posted some of the lowest overall rates in
the country.
The City of London experienced an 8.0% increase in the overall crime rate in 2006 as
compared to 2005 with at least some of this increase being attributable to addaional
police resources being available to check for people breachingtheir probation, violating
bail conditions and failing to attend court.
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Of concern however has been the increase (2006 versus 2005) in a number of
'acquisitive crimes" such a d '
Robberies - 25% increase;
Break ins - 10% increase: and
Auto Theft - - 18% increase
According to London Police Services these problems are tied together by the common
denominator of drugs.
~~
1
I'm taking too many risks to get money for drugs. I'm stealing, fighting and
hurting people for money. Hurting myself to get money
Anonymous Substance User
London, Ontario
Aside from drug related crimes (possession, trafficking etc) and crimes committed to
support a drug habit (theft, prostitutionetc) some individuals may commit crimes after
using substances which may serve to undermine judgment and self-control, generate
paranoid ideas andlor distort inhibitions and perceptions.
One of the difficulties in testing a psychopharmacologicallinkage between substance
use and crime is that offenders when arrested are not tested for substance use (except
in the case of impaired driving). As a result official cn'me statistics do not contain
information on whether alcohol or drug use was a factor in the commission of a crime.
However, a Canadian study involving individuals newly incarcerated in federal
penitentiariesfound that:
0
rn
Slightly more than half (50.6%) of the inmates had used drugs andlor alcohol on the
day they committed the offence for which they were incarcerated;
Among this group, approximately 16% had used illegal drugs only and 13% had used
a combination of the two;
Significant differences in the types of crimes committed by type of substance used
(While homicides and, more pronouncedly, assaults and wounding were
predominantly alcohol-related, acquisitory crimes such as thefIs and break and enter
showed a higher prevalence of drug use on the day of the crime;
28% of the inmates said that they had committed all or at least most of their crimes
under the influence of an illegal drug:
Nearly 44% of inmates who reported that they had previously used illegal drugs
believed that their drug usage had increasedtheir illegal activity, 51% thought it had
no effect on their criminal activity and 5% thought it had contributed to a decline in
their criminal activity; and
Nearly 80% of inmates who used illegal drugs on the day they committed the crime for
which they were incarcerated (16% of inmates in the study) stated that their drug use
had facilitated their acting out. Of those, 83.1% reported that their drug use had
altered their judgment, 33.6% that it had made them more inclined to tight, and
37% that it had made them more aggressive and violent?'
Finally, violence is an integral component of the illegal substance distribution market
where by definition there is no recourse to the justice system or other legitimate
21
London Substance Abuse Strategy - Background Paper
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enforcement mechanisms. The potential for high profits produces rivalries amongst
dealers at all levels over territory/customersas well as disputes between dealers and
buyers (who may be dealers andlor users) over price, quality, quantity and debts owed
A Canadian study of drug dealers on probation noted that 56% of the individuals
interviewed admitted to using violence in their activitie~.~~
Overview
The relationship between substance use/abuse and crime is a complex one.
The Senate Special Committee on Illegal Drugs (2001) noted that Drug use is only one
factor among a group of variables that may account for criminal behaviour; other
variables include physiological, psychologicaland behaviourai,family, cultural, social,
economic and situational.
Furthermore, the implications of this observation for drug intervention and policy
development are considerable. An approach that would fail to treat all factors
contributing to drug use and crime or that would attribute a causal role exclusively to
drug use would inevitably result in the implementationof ineffective policies.
The need for the development of broad based social policies to address the issue of
substance and crime often runs counterintuitive to the life experience of many members
of the community who would advocate for increased enforcement measures as the
solution.
Although the overall crime rate in Canada has been generally declining since 1991 this
fact gives little solace to residents and business operators in areas of London where
crime and public disorder seem to be a daily occurrence.
Community members in these neighbourhoods live with the negative impacts of
substance abuse and criminal activity and are anxious for something to be done.
2.14.
Substance Abuse and Its impact on London’s Downtown Neighbourhoods
Three neighbourhoodswere identified as key “hot spots” in the initial report to City
Council by the civic administration. These were:
The Dundas-WilliamStreet area, which includes a mix of business and residential
areas and is the location of several social service agencies, London Police Services
as well as the privately operated Clinic 528;
The Dundas-RichmondStreet area -the central downtown business district for the
City, an area that also contains several social service agencies including the City’s
Community Services Department: and
The Wellington-Hotton street area, or the SOH0 neighbourhoodwhich is a mix of
business and residential areas and has two major emergency shelters proximate and
is directly between the downtown and the valley of the south branch of the Thames
River, a popular area for the homeless.
During the course of the consultation several meetings were held in London with
residents, business owners and representativesfrom the Downtown Business
Association, Old East Village CommunityAssociation and Old East Village Business
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London Substance Abuse Strategy Background Paper
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ImprovementArea to discuss issues with respect to homelessnessand illegal injection
drug use.
Dundas-WilliamStreet Neighbourhood
A number of issues and concerns were raised including:
0
The opening and rapid expansion of Clinic 528 became a flashpoint for residents of
the neighbouringWoodfield community and that friction remains today;
Prime concem is foot and vehicle traffic generated by clients of Clinic 528, a medical
clinic that provides Methadone Maintenance Treatment to addicts;
Business plan for Clinic suggested 200 clients a month; current practice is about 900,
with about 400 making daily visits;
This volume of traffic has attracted drug dealers looking to obtain and sell drugs;
Many dirty needles being found;
Levels of violence escalating;
Drug injection being done in the open;
Escalation in drug dealing and related violence has increased concerns about the
safety of staff and clients of the Coffee House- a drop-in recreation program for
homeless and mentally ill adults operated by WOTCH; and
Many in community prepared to work with City to address the issues.
Old East Vlllage
Members of the civic administration met on several occasions with members of the Old
East Village NeighbourhoodAssociation and the Old East Village Business Improvement
Area to hear concerns about the impact of the homeless, drug dealers and survival sex
trade workers on the quality of business and community life.
A number of issues and concerns were raised including:
0
Recognitionthat people should feel safe and secure in the neighbourhoodin which
they live and conduct business;
A recognition that addicted individuals are not a homogenous group and that most of
the problems are created by those addicted individuals who engage in criminal activity
in the area;
A concern that a disproportionate number of social services agencies are located in
the area whether or not the community needs them. There is a need to provide
services to people in the neighbourhoods in which they live and not concentrate all
the services in one area;
Strategies need to be developed to address the problems created by individual
loitering and congregating outside social service agencies which is perceived to have
a negative impact on adjacent businesses;
Washrooms in business establishment are being used as injection sites;
The presence of visible street level prostitution activities;
A need for increasedlongoing street level enforcement; and
Recognition of the need for housing options for homeless individuals.
Dundas-Richmond Area
The civic administration met with the executive of the Downtown Business Association.
The following issues and concerns were expressed:
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London Substance Abuse Strategy - Background Paper
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The presence and visibility of the homeless is increasing and having a negative impact
on the downtown.
People sleeping in back alleys and in doorways
Homeless begging for money becoming more aggressive
Drug dealing visible at Dundas and Richmond
Shoppers uncomfortable, less likely to return
The homeless should be treated humanely with services to assist them. Roaming the
downtown is not healthy for the homeless -vulnerable to drug dealers, etc.;
For downtown to prosper, the climate and perception of safety must be improved; and
Downtown BIA supports efforts to provide caring responses to those homeless who
are ill but want more effective law enforcement to deal with illegal activity.
SOH0 (South of Horton) Nelghbourhood
A number of issues and concerns were raised including:
0
Neighbourhoodis changing for the better with more people buying and improving
homes and local businesses;
This improvement in a downtown neighbourhoodis being hurt by increasing presence
of prostitutes, drug dealers and the homeless:
Dirty used needles being found at increasing rates;
People sleeping the parks along the river;
Prostitutes propositioning business owners and customers;
Salvation Army Centre of Hope - people don't feel safe walking past the front of the
Centre on Wellington Street where many homeless people "hang out." and
Daytime space for the homeless to go is needed.
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London Substance.Abuse Strategy - Background Paper
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3. THE FRAMEWORK
A spectrum of public policy approaches exists for the control of substances and their
use. The regulatory regime in Canada has placed most of these individual substances in
either legal (e.g. alcohol and tobacco), prescription (e.g. morphine, benzodiazepines and
Ritalin) or illegal (e.g. marijuana, cocaine and heroin) drug status. It is important to
recognize that this taxonomy is not based in pharmacology, economic analysis or riskbenefit analysis, but is derived from historical precedent and cultural preference.
3.1. Supply and Demand Reduction
As traditionally conceptualized in Canada and most western nations the two prongs
of illegal drug control policy are supply reduction and demand reduction under the
rubric of "The War on Drugs."
Supply reduction is usually understoodto be synonymous with the enforcement in
the context of legislation and application of drug law prohibitions (possession,
trafficking and/or importation, cultivation, manufacturing), interdiction of drugs at the
border@)and where applicable the eradication of the substances themselves and/or
the capacity to produce them.
Demand reduction has focused on:
Enforcement of drug laws to reduce demand through apprehending and punishing
users for possessing drugs and as a mode of general deterrence;
Prevention strategies traditionally aimed at youth (e.g. media campaigns and
school based education program) with a historical emphasis on the "Just say no to
Drugs" approach; and
Treatment from a clinical perspective generally based on an abstinence model for
those who use/depend/abuse substances.
The predominant response, based on fiscal allocation, to illegal drugs in Canada is
through enforcement mechanisms in the context of the criminal justice system.
In a 1996 research report The Canadian Centre on Substance Abuse concluded that
Canadians spend approximately $4.00 on enforcement for every $1.OO spent on
treatment.%
In 2001 the federal Auditor General estimated that for every $95.00 spent on
enforcement at the federal level only $5.00 is spent on treatment.%
Enforcement alone is insufficient for achieving long-term reductions in either the supply
or demand for illegal drugs. Some studies have observed thailaw enforcement does not
affect the price, purity or perceived availability of illegal drugs.
In Canada, the United Stated and most western European countries drug use seems to
have peaked in the 197Os, declined through the 1980s and has been on the rise since.
Trends in illegal drug use over the past 40 years appear to operate independently of the
emphasis placed on enforcement strategies5'
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London Substance Abuse Strategy - Background Paper
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Furthermore, not only has the current policy mechanism not achieved its stated
objectives of supply and demand reduction; the "war on drugs" through the enforcement
of criminal sanctions has also accrued significant, if unintended harms, such as:
Increased transmission of HIV and the societal burden of AIDS;
Increased transmission of Hepatitis C and consequent liver disease and cancer;
Corruption in civil and government sectors;
Crime - personal, property, financial;
Violence due to both related-criminal activity and enforcement;
Destabilizationof governments;
Funding for terrorism;
Destabilizationof world markets;
Criminalization of youth, and otherwise non-criminal groups;
Family breakdown -divorce, seizure of children;
Disrespect for the law and judiciary;
High rates of incarceration, racial profiling, and other prejudicial actions; and
Lost opportunity costs from money spent on ineffective measures."
In summary a public policy response to substances that is built on the twin outcomes of
supply reduction and demand reduction through enforcement treatment and prevention
strategies with a disproportionateresource allocation towards enforcement has proven
to be ineffectual.
A move towards a rebalancing of these strategies is required along with the addition of
new strategies to address the problematic impacts of substance abuse,
3.2. Public Health and Public Older
Problematic drug use is not restricted to any one population group, and an effective drug
strategy must recognize and address the varied needs of the entire community. This
includes: non-users, non-addicted casual users, problematicor addicted users (including
those not yet ready or able to seek treatment), their family and friends, and those druginvolved individualswho constitute a real or potential threat to public safety.
By viewing substance abuse as a public health issue the goal is to work towards
addressing the drug-related health crisis by:
Reducing harm to neighbourhoods and individuals;
Increasing public awareness of addiction as a health issue;
Reducing the number of individuals who misuse drugs;
Reducing HIWhepatitis C infection rates; and
Providing a range of services to groups at risk including: youth, women, Aboriginal
persons, and the mentally ill.
By viewing substance abuse as a public order issue the goal is to work towards
addressing issues related to public order by:
Implementingcrime preventiontechniques to increase public safety;
Reducing the negative impact of drugs on our community;
Reducing the presence of "open drug scenes" in the community;
Reducing the impact of crime on neighbourhoodsand individuals; and
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London Substance Abuse Strategy - Background Paper
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Providing neighbourhoods,organizations and individuals with mechanismsto address
their concerns related to safety, criminal activity, drug misuse, and related problems.
We cannot ignore this issue (substance abuse). We cannot incarcerate our way
out of it and we cannot liberalize our way out of it. Rather, all levels of government
must play their part in managingit What we need is a balance of public health
and public ofder.
(Former Vancouver Mayor Phill/p Owen)
3.3. Four Pillars Model
The Four Pillars model was first implementedin early 1990s in Switzerland and
Germany to address escalating drug problems in a number of urban centres in those
countries. In 2001, the City of Vancouver adopted the Four Pillars drug strategy as a
policy to respond to that City's increasing drug problem and open-air drug scene. More
recently the model has served as a basis for the development of substance abuse
strategies in the cities of Toronto, Regina and Ottawa, the Central Okanagan Region
and the Sunrise Health Region''.
I
In short, addiction needs treatment and criminal behaviour needs enforcement.
A Frameworkfor Action
City of Vancouver, 2001
I
The Four Pillars approach holds that the most effective means of addressing problematic
substance use is through a balance of prevention, treatment, enforcement and harm
reduction initiatives contained within a coordinated strategy. To succeed, such a strategy
requires the support and participationof all levels of government, service providers and
members of the public and must reflect the community's specific needs.
This model has been widely used to develop municipal substance abuse strategies
because it is broad based and integrative and because it fundamentally sees substance
abuse as both a public health issue and a public order issue.
It is not always easy to determine which activities fall under which Pillar; depending on
the needs and circumstances of the individual using the service, one person's harm
reduction might be another's treatment. This concern is less significant if the pillars are
cohesively integrated. In general, the pillars and related strategiedresponses can be
described as follows:
3.3.1.
Prevention
Prevention includes strategies that help harmful substance abuse. Within the prevention
continuum there is an acknowledgment of both abstinence based programs and those
programs that provide individuals, who choose to experiment with drugs, access to
33
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London Substance Abuse Strategy - Background Paper
I
October 2007
information to do so safely. Prevention of problematicsubstance use contributes to the
public good by reducing costs and harm to both individuals and society.
Prevention strategies can be grouped in 3 broad categories based on where individuals
are on the substance use continuum:
1. Primary Prevention: attempt to prevent substance use altogether or delay the
onset of substance use;
2. Secondary Prevention: target individuals in the early stages of substance use,
before serious problems have developed; and
3. Tertiary Prevention: focuses on preventingserious harm to individuals who have
become addicted to drugs.
Strategic interventionsinclude:
0
Messages that are tailored to specific populations;
Early interventionprograms;
Public education initiatives through multiple channeldmediums;
Initiatives that are evidence based;
Initiatives with input from target groups e.g. substance users; and
Peer based as opposed to informatiin only programs.
Strategies under prevention may also include ones which seek to address the causal
factors underlying substance use such as poverty, unemployment, homelessness and
substandard housing, mental health issues etc.
3.3.2.
Harm Reduction
Harm reduction accepts that abstinence-based treatments may not be a realistic goal for
some drug users, particularly, in the short term and acknowledges that an achievable,
pragmatic approach to supporting users may lead to a healthier outcome in the mid to
long term.
Strategic interventions include:
Drop-in centres;
Public health outreach;
Emergency shelters;
Soup kitchens, food banks;
Supportive housing;
Employment services,
Needle exchanges;
Overdose preventioncampaigns;
Needle drop boxes;
Prescription narcotics; and
Supervised drug consumptionfacilities.
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London Substance Abuse Strategy - Background Paper
3.3.3.
October 2007
Treatment
Treatment is about encouragingand supporting people with addiction problems to make
healthier decisions about their lives. Decreasing preventable deaths, illnesses and
injuries and increasing social interactionsare key outcomes.
Strategic interventions include:
0
Detoxificationprograms;
Methadone programs;
Outpatienttreatment and counselling;
Residentialtreatment;
Dual diagnosis programs; and
Life skills programming
3.3.4.
Enforcement
Enforcement recognizesthe need for safety and pubic order in our community, and
acknowledges that to be effective, enforcement must be integrated with actions
emanating from other pillars.
Strategic interventions include:
Redeployment of committed manpower and additional resources;
Efforts to target organized crime, drug houses and drug dealers;
Changes or alternatives to existing sentencing guidelines;
Improved court system support for enforcement activities;
Amended Federal, Provincial or Municipal legislation;
Improved co-ordination between enforcement agencies and service providers;
Directing active users to available treatment programs; and
Increasing public awareness and participation.
3.3.5. Integration
The successful implementationof any "Four Pillars" based strategy rests on a balanced
implementation of each of the four pillars which suggests the pivotal role to be played by
a Sh pillar that of"integration." Best practices throughout Canada and elsewhere
highlight the importance of a single accountable entity to integrate the implementation of
a substance abuse strategy and to monitor the process.
3.4.
Policy Context
3.4.1. Governmental Responslbilities In Canada
In Canada, no one level of government bears sole, or even primary, responsibility for
reducing the effects of substance abuse. Jurisdiction is broadly distributed on an issueby-issue basis, with the three levels of government often effectively sharing
responsibility.The goals and actions that will necessarilyflow from a Four Pillars
approach will need the actiie co-operation of all levels of government if they are to
succeed.
35
,
.
.
, .
.
~.
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London Substance Abuse Strategy Background Paper
I
October 2007
Federal Government
The federal government is responsiblefor federal offenses under the Criminal Code and
the Controlled Drugs and Substances Act within the criminal justice system as well as
immigration,justice, health promotion and research and so forth. For example:
Prevention:
Health Promotion (Health Canada);
Substance use research and education (Canadian Centre on Substance Abuse,
Social Science and Humanities Research Council);
Homelessness(National Homelessness Initiative);
Urban Renewal and Economic Development (Industry Canada); and
Employment and Training (Human Resources Skills DevelopmentCanada, Youth
Employment Strategy).
Treatment:
Drug treatment trials, clinical research and evaluation (Canadian Institute for Health,
Canada's Drug Strategy);
Treatment Facilities for Aboriginal People (National Native Drug Abuse and Treatment
Program); and
Housing and shelter with services for drug users (Human Resources Skills
Development Canada, Supporting Community Partnership Initiative).
Enforcement:
Domestic and International Drug Enforcement (RCMP, Canada's Drug Strategy);
Interdiction of cross border drug traffic (Canadian Border Service Agency);
Drug Treatment Courts, Diversion Programs, Community Courts (Department of
Justice Canada); and
Offender Rehabilitation (Corrections Services Canada).
Harm Reduction:
Developmentof Innovation Pilot Projects (Health Canada);
Low Threshold Support Program Pilots(Health Canada); and
Housing and shelter with services for substance users (Human Resources
Development Canada Supporting Community Partnership Initiative).
-
Provincial Government
The provincial government is responsiblefor funding health and education services as
well as provincial courts and provincial offenseswithin the criminaljustice system. For
example:
Prevention:
Education (Ministry of Education, Ministry of Health Promotion);
Affordable Housing (Ministry of Municipal Affairs and Housing);
Emergency Shelters (Ministry of Community and Social Services);
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London Substance Abuse Strategy - Background Paper
October 2007
Employment and Training (Ministry of Training, Colleges and Universitiesand Ministry
of Community and Social Services);
Income Supports- OW ODSP (Ministry of Community and Social Services); and
Violence against Women (Ministry of Community and Social Services).
Treatment:
Treatment programs and facilities (Ministry of Health and Long Term Care, Ministry of
Children and Youth Services);
Drug Treatment (Ministry of Community Safety and CorrectionalServices); and
Drug treatment Trial, Research and Evaluation (Ministry of Health and Long Term
Care).
Enforcement:
Policing Services (Ministry of Community Safety and Correctional Services):
Courts (Ministry of the Attorney General);
Organized Crime (Ministry of the Attorney General);
Offender Rehabilitation (Ministry of Community Safety and Correctional Services); and
Youth Justice Services (Ministry of Children and Youth Services).
Harm Reduction:
Health and substance abuse referral services (Ministry of Children and Youth
Services, Ministry of Health and Long Term Care);
Needle Exchange (Ministry of Heath and Long Term Care); and
Shelter and Housing Options for drug users (Ministry of MunicipalAffairs and
Housing).
Municipal Government
The City of London is responsiblefor bylaw enforcement, zoning, and a range of
community services relatedto where people work and live in the city. For example:
Prevention:
Community Information and forums including a community process to address
substance abuse;
Grants; and
Parks and Recreation.
Treatment:
Grants; and
Support for service providers.
Enforcement:
Police services; and
Bylaw enforcement.
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London Substance Abuse Strategy - Background Paper
October 2007
Harm Reduction:
Community information and forums:
Grants; and
Support for service providers
It is clear that multiple jurisdictions must be involved in dealing with the City of London's
substance abuse issues.
The City of London, the provincial and federal governments, police and health authorities
have specific responsibilitiesfor health and enforcement issues, but many challenges
exist in clarifying roles, responsibilities and funding.
3.4.2.
Canadian drug policy and legislation
The production, distribution and consumption of substances, whether legal or illegal are
complex global issues extending far beyond the borders of London. However, they are
global issues with a profound local impact. Understandingthe impact and interplay of
international, national and provincial policies and legislation provides a useful context for
the formulation of a municipal drug strategy.
international Conventlons
Canada is a signatory to three key internationaltreaties related to illicit drugs:
Single Conventionon Narcotic Drugs (1961);
Convention on PsychotropicSubstances (1971); and
Convention against Illicit Traffic in Narcotic Drugs and PsychotropicSubstances
(1988)
Collectively, these treaties form the basis for the international prohibition of the
production, trafficking and possession of illicit drugs. It is up to each country to create the
necessary legislative and regulatory measures to establish the controls within their own
jurisdiction to meet the commitments of treaties.
Canadian Drug Policy and Legislation
Historically Canadian drug policy focused on legal suppression as typified by the
establishment of the Narcotic Control Act (1961) which emphasized prohibition as the
primary response to drug control.
However, in 1987 the federal government released the Canada Drug Strategy a
redirectionof its drug policy efforts by shifting more toward the principles of "harm
reduction" and "balance of demand" and supply reduction" measures which includes:
Education about the dangers of substance abuse and information on how to adopt
healthy behaviours;
Enforcement measures to halt the unlawful import, export, production, distribution and
possession of controlled substances;
Treatment activities directed at those who have developed an unhealthy dependency
on licit and illicit substances; and
38
London Substance Abuse Strategy - Background Paper
October 2007
Harm reduction measures to limit the secondary effects of substance abuse, such as
the spread of HIWAIDS or Hepatitis C.
The latest renewal of the Canada Drug Strategy occurred in 2003 with a focus "to have
Canadians living in a society increasingly free of the harms associated with substance
abuse." Federal funding of $245 million has been committed over five years as follows:
Health Canada: $12lmillion;
Department of Justice: $47 million;
Solicitor General: $62 million; and
Foreign Affairs and International Trade: $3 million.
The Government of Canada's commitment to a comprehensive,renewed strategy will
involve reporting to Parliament and Canadians every two years on the Strategy's
direction and progress, particularlywith respect to the following key objectives:
Decrease the prevalence of harmful drug use;
Decrease the number of young Canadianswho experiment with drugs;
Decrease the incidence of communicable diseases related to substance abuse;
Increase the use of alternative justice measures like drug treatment courts;
Decrease the illicit drug supply and address new and emerging drug trends; and
Decrease avoidable health, social, and economic costs.
In response to demands issued by Canadians, their Governments and nongovernmental organizations for a more coordinated approach to meeting the challenges
posed by the harms associated with alcohol and other drugs and substances the federal
government, through Health Canada and the Canadian Centre on Substance Abuse
(CCSA), held a number of cross Canada consultationswhich resulted in the National
Framework For Action on SubstanceAbuse Initiative.
At the First National Framework Forum (June 2005) representativesfrom the federal
government, provincial and territorial departments and agencies, municipalities,nongovernmental organization,Aboriginal organizations, communities of interest and the
private sector reached consensus on a number of priority areas for action including:
0
0
Increasing awareness and understandingof problematic substance use;
Reducing alcohol related harms;
Addressing fetal alcohol spectrum disorder (FASD);
Preventing the problematic use of pharmaceuticals;
Addressing enforcement issues;
Sustaining workforce development;
Implementinga national research agenda and facilitating knowledge transfer;
Improvingthe quality, accessibility and range of options available to treat substance
abuse including substance use disorders;
Modernizing legislative, regulatory and policy frameworks;
Focusing on children and youth;
Reaching out to Canada's north;
Supporting first nations, Inuit and MMs people in addressing their needs; and
Responding to offender related issues.
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London Substance Abuse Strategy - Background Paper
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Health Canada, CCSA and other framework partners are currently seeking formal
endorsement of the Framework by their ministers, boards and governing bodies while a
long term governance model is scheduledfor discussion at the Second National
Framework Forum (February, 2007).80
Province of Ontarlo
Currently the Province of Ontario does not have a coordinated strategy or policy on
substance abuse. In 1993 the NDP government introduced Partners in Action: Ontario's
Substance Abuse Strategy, but this was not implementedby the subsequent
conservative government
In 1996-97, as part of a larger health system restructuring exercise, the Ontario
Substance Abuse Bureau commissioned restructuring studies in each of Ontario's six
health planning regions. This review looked at how to make the best use of addiction
treatment resources (as opposed to prevention) and how to structure services to best
meet the needs of the clients. The 1999 report of this review, Setting the Course: A
Framework for IntegratingAddiction Treatment Services in Ontario, recommended
actions to:
Improve the quality of addiction services;
Increase the capacity of the system;
Coordinate services; and
Make better use of existing resources"
Strategies were directed to government, district health councils, addiction services and
others, toward creating a more "client-centered"approach to care. The framework
promotes a "stepped" approach that provides people with more choice and easier
access to the services they need.
In March 2000, flowing from directions proposed in Setting the Course, a province-wide
Residential Working Group released a report recommending actions to strengthen the
sector including harm reduction approaches, flexible lengths of stay, and the types of
resources and geographical considerations needed relative to particular target
populations. Other parts of the sector, such as Withdrawal Management Services
(detox), also went through a process of reviewing and redesigningthe way they deiiver
services.B2
Under the Local Health System IntegrationAct (2006)the management of local health
services was devolved to Local Integrated Health Networks (LHINs). LHlNs are
responsible for local health system planning and community engagement, funding a
wide range of service providers and local health system integration. Local service
providers such as hospitals, community care access centres, community support
services, mental health agencies, addictions agencies, community health centres and
long term care homes are components of LIHNs. As individual LlHNs establish their
integration priorities there is the potential for a significant impact on how substance
dependemdabuse is addressed in a c0mmunity.6~
Public health is another important source of strategic action regarding substance use.
The Health Protection & PromotionAct directs local public health units to undertake
health promotion and diseasefinjury prevention. In this program area the Ministry of
Health sets out mandatory service guidelines with a goal to "reduce disability, morbidity
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London Substance Abuse Strategy - Background Paper
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and mortality caused by motorizedvehicles, bicycle crashes, alcohol and other
substances, falls in the elderly and to prevent drowning in specific recreational water
facilities."w
Ministry of Health targets for the year 2010 include:
Reducing the rate of alcohol and other substance related injuries or deaths by 20%;
Reducing the percentage of adults who drink more than two drinks a day by 20%; and
Reducing the rate of illegal substance use and non-medical use of drugs and other
psychoactive substances by 20%.
The provincial AIDS Bureau funds organizations and initiatives across the provinces that
operate HIV/AIDS education and suppotVpracticalassistance programs for a diverse
range of comm~nities!~They also fund anonymous and prenatal HIV testing and
various research initiatives.
In addition, the HlVllDU Outreach Program funds outreach workers to provide
prevention education to injection drug users at risk for HIV infection and support to
people living with HIV.
The HIV/AIDS Strategy for Ontario to 2008 proposes a comprehensiveapproach to
fighting HIV, which takes into account factors that put people at risk of infection and
disease, the increasing complexity of client needs, existing services and the need for
new leadership. Recommendedstrategies include extending the availability and range of
harm reduction and treatment options for people at risk, including injection drug users.
3.4.3.
Federation of Canadian Municipalities
Canadian municipal leaders have identied drug abuse as a central and strategic
concern for communities across the country. In response, the Federation of Canadian
Municipalitiesbegan the Municipal Drug Strategy project to complement national efforts
under Canada's Drug Strategy. The resulting municipal drug strategy model is built on
three complimentary elements that comprise a comprehensive response to substance
abuse: prevention, including public awareness and education; rehabilitationwithin a
continuum of services including harm reduction, housing, employment etc.; and law
enforcement.
The key recommended elements of a Municipal Drug Strategy are:
0
0
Municipal leadership;
A municipal drug policy;
A strategy tailored to meet local needs; and
Organization, coordination and leadership.
The Municipal Drug Strategy was piloted in nine Canadian communities and a
subsequent evaluation revealed a number of key accomplishments, challenges as well
as lessons learned from these communities.
Key accomplishments included:
0
Raising awareness about drug problems in the community;
Securing endorsementfrom municipal officials;
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London Substance Abuse Strategy - Background Paper
October 2007
Coordinatingaction plans;
Executing needs assessments and resource inventories; and
Establishing community partnerships.
Challenges that impeded the success of local drug strategies included:
Engagingthe community, especially specific groups, such as senior citizens,
Aboriginal people and business leaders;
Maintaining focus among a range of stakeholders;
Obtaining accurate information on substance abuse in the community; and
Securing adequate resources to accomplish goals and sustain the drug strategy over
the long term
Lessons learned by participant communities included:
The importance of involving local organizations,governments and other institutional
players to create strong community partnerships or build on existing relationships;
Involving the community at large is critical to success;
Goals and objectives are easier to obtain when clearly defined;
The process should be simple building on incremental but visible successes
The importance of a solid information base to inform the community and guide
decision making; and
Scarce resources are a significant challenge when establishing and maintaining a
local drug strategy.
3.A.4.
Municipalities in Ontario
City of Toronto
The City of Toronto's Drug Strategy Initiative released its report in October 2005 and it
was approved by City Council in December 2005.88
The report takes a strong harm reduction approach to substance usdabuse while
recognizing the need to balance public health and public order.
The report's 66 recommendationswere designed to prevent drug abuse, improve
treatment for addicts, enforce the law, and reduce the harm that addicts do to
themselves and others.
Key recommendationsincluded:
Urging the provincial government to set up more treatment centres and programs
especially for youth and individuals with mental illness;
Supporting that addiction no longer be excluded as an eligible disability under ODSP:
Supporting the decriminalizationof possession of small amounts of cannabis:
Expand harm reduction strategies to include the distribution of "crackpipe kits." and
To further study the issuefieasibility of safe injection sites being established in
Toronto
The Toronto drug strategy initiative process and subsequent report illustrates some key
lessons learned that can be considered by other communities:
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The importance of municipal leadershi while at the same time ensuring that the
process is broadly community based;
The importance of intergovernmentalrepresentationat the discussion table (City of
Toronto including members of Council, Toronto Police Services, Toronto Public
Health, Shelter, Support and Housing Administration; Ministry of Health and Long
Term Care; Departmentof Justice and Health Canada.)
Endorsement of the report and recommendations by Council;
The need to establish an implementationcommittee and working groups or other
mechanisms to move the recommendations and actions contained in the strategy
forward;
Establishing priorities for more immediate action amongst the recommendations (17 of
the 66 were designated as such)
The importance of being able to incorporate ad manage potentially controversial
issues such as safe injection sites and crack pipe kits within the process;
Setting the discussion and subsequent report, strategy and recommendations in a
public health context; and
The importance of recognizingthe need to foster intersectoral cc-ordination and cooperation in order to move forward.
,P
City of Ottawa
Ottawa's Community Network for the Integrated Drugs and Addiction Strategy Phase 1
report was submitted to City Council in June, 2006.
The goal of the Integrated Drug and Addiction Strategy initiative is to support a balanced
ongoing strategy to respond to drug and addiction issues in Ottawa by:
Making Ottawa a safer and healthier place for all residents by ensuring that Ottawa
residents live in a community free of the hams associated with problematic substance
abuse; and
Ensuring an integrated and coordinated approach across the four pillars of prevention,
treatment, h a m reduction and enforcement
Phase 1 actions included the endorsement of treatment and prevention/publiceducation
as priority areas with the specAc recommendations including:
0
The development of an action plan to increase the capacity of treatment in Ottawa
along a continuum of service that addresses identified gaps including outpatient and
residentialtreatment for youth, increased services for diverse groups including
withdrawal management, timely access to treatment, management of concurrent
disorders and transitional housing; and
The development of a comprehensive PreventionPublic Education plan that
addresses identified gaps by supporting families, improving access to information for
local addictions services; alignment of strategies with Drovincial and federal initiatives:
and supports for family functioning.
Other issues such as: the need for co-ordination between City services, other service
providers and key community stakeholders enabling neighbourhoodsto deal with drugrelated problems; and balancing the need to address the HIV and Hepatiis C rate
among the drug using population in Ottawa while addressing the concerns of the
community and the safety of front line workers were recommendedto be addressed
through the development of community planning tables.
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As with the Toronto drug strategy initiative the City of Ottawa's integrated Drugs and
Addiction Strategy process also illustrates the importance of broad community
representation, prioritization of recommendations,development of an ongoing
implementation strategy etc. The Ottawa case study also illustrates a number of other
considerations such as:
0
The importance of early media positioning to maximum coverage of the issues and to
build and support;
The importance of a united community approach to provincial lobbying - e.g. a
treatment centre for youth under 16;
The "role of politics" in the process of developing and implementing a strategy was
evidenced (1) by a change in the mayor and some members of council producing a
shift in support for components of the strategy and (2) a gulf forming between the
Chief of Police and The Chief Medical Officer of Health over harm reduction
strategies; in particular the distribution of crack pipe kits?'
Clty of London
In 1993, the City of London Mayor's Task Force on Drugs addressed community
concams regarding teen alcohol abuse, impaired driving, increased drug use, poor
sexual choices, vandalism, and violence at celebrations throughout the year, especially
at prom and graduation.
As a result, an annual program called Safegrad Celebration Program was developed in
order to bring student leaders and planners together to address these issue^?^
The goal of Safegrad is to reduce injuries due to drug andlor alcohol use for both the
students and those who may be affected by their choices. Presently there are two
components to the Safegrad Celebration Program: Safegrad workshop and the website
"safegrad.com".
The City of London does not currently have a comprehensive municipal drug policy or
strategy, hence the need for the current London Substance Abuse Strategy initiative. As
indicated earlier, this strategy is in response to addressingthe problematic drug abuse in
the city's downtown area and to follow the strategic footsteps of Toronto, Ottawa and
Vancouver in handling municipal drug problems. Apart from being the custodian of the
Substance Abuse Strategy, the City would also monitor the implementationprocess to
make London a much safer and healthier community to live in.
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4. PROGRAMS, BARRIERS AND GAPS
4.1. Existing Substance use programs and interventions In London
There are a range of addictions programs and services offered by multiple providers to
individuals and families in the City of London.
(Refer to Appendix B: Inventory of Services)
Although 8 out of I O individualssurveyed believe they have a problem with
drugs or alcohol, only 55% report having used at least one addiction treatment
sewice.
Survey of Londoners
Strategic responsesto the underlying causes of addiction are being developed through
City of London Social Policy Framework and policy papers on income security, housing
and food security. These policy papers are being developed in partnership with the
community and will make recommendationsto the three levels of governmentto
advocate for policy, legislative and funding changes.
Within the City of London's Ontario Works service delivery model there are a number of
specialized initiatives such as Addiction Services and Hostels to Homes that M within the
continuum of programs and services of an integrated substance abuse strategy.
Addiction Services
Addiction Services is a voluntary Ontario Works (OW) program for individuals for whom
addiction is a barrier to employment
Participantswill generally enter Addiction Services through self-identificationof potential
addiction issues to their regular caseworker?'
Internal screening and assessment is conducted internally by OW job developers who
provide existing supports to case management teams.
The addictions services caseworker provides income and employment assistance and
addiction supports through intensive case management.
Formal assessment and the development of a treatment plan are conducted through
Addiction Services of Thames Valley or another existing assessment service provider.
The participants' treatment plan may include participationin services such as withdrawal
management,community treatment programs (individual or group), residential programs,
harm reduction, peer support programs, after care and relapse prevention.
Followingfrom service delivery principles established between Ontario Works and
community partners support to participants are made available in a way that responds to
the unique needs of the individual in order to successfully complete hidher treatment
plan.
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Employment Related Expenses (ERE) can be used to support child care and
transportation costs, as well as the costs of “diversion activities” to build new positive
behaviours and activities that replace substance abusing patterns. Diversion activities
can include memberships to the YMCA subsidized recreational programs, books etc.
Local flexibility is also being exercised in the use of the Full Time Employment Benefit
(FTEB) and the Community Start Up and Maintenance Beneffi (CSUMB) as a part of
supports to participants.
Between July, 2006 and December, 2006 131 participants have been on the Addiction
Services caseload. Of these participants 65 have been being referred to the Fresh Start
program at Addiction Services of Thames Valley (ADSTV) and 46 have become Fresh
Start clients.
Treatment goals at ADSTV for Fresh Start participants include:
65%
Abstinence goals:
Harm reduction goals:
23%
Harm reduction and abstinence: 12%’’
Although the Addiction Services component of Ontario Works is too recent to evaluate
outcomes there has been a number of remarkable successes as evidenced in the stories
of program participants. For example:
Initial situation:
Addiction to both crack and marijuana;
Engagedto illegaldrug dealing;
History of incarceration;
Suffered a serious stab wound from a drug related incident;
No contact with familyho friends;
Low motivation and self esteem;
Not employed (nor was employment a realistic goal at this point) and no hobbies or
interests; and
Had not previously accessed formal treatment and rejectedAA/NA programs
RecenVcumnt situation:
Maintained weekly appts with ADSTV and Team A;
Startedusing h a m reduction;
Ceased drug dealing activities;
Startedattending a gym;
Ultimately decided to access and graduated from a residentialtreatment program;
Currently attends NA meetings;
Reconnectedwith family and is developing a set of friends who are not substance
users; and
Activelyjob searching (now a realistic goal)
0W Addiction Setvices Participant
London, Ontario
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London Substance Abuse Strategy BackgroundPaper
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Hostels to Homes (H2H)
The Hostels to Homes Emergency Pilot Initiative is an 18 month project supported by the
Ministry of Community and Social Services being piloted in 6 Ontario communities?
The Ministry’s objectives for this initiative are to:
Stabilize the use of emergency hostel services and return its service delivery to its
original purpose of short term and infrequent housing; and
Provide municipalitieswith the flexibility to use/reallocateexisting cost shared
emergency per diem funding to create innovative cross-sectoral supports and
strategies to adequately and appropriatelyhouse and support person who are
homeless.
The H2H pilot in the City of Londonfocuses on three populations of emergency shelter
users who have been identified as being most in need:
Hard to house individuals (who have multiple and/or long term shelters stays and
often have addiction and /or mental health issues;
Families; and
Youth
Supports are provided by 2 designated Ontario Works caseworkers and 5 community
support workers (one housed at each of the community partner agencies”) and although
they are client centered typically supports might include:
Assisting familiedindividuals access housing options (e.g. register for London
Housing, utilize the Housing Access Centre etc.);
Assistance in applying for Ontario Works assistance;
Targeted life skills programming; and
Assistance accessing community programskervices.
Participantswith substance abuse issues may choose to access programs and/or
services to address their substance use however, the decision not to did not exclude
individualsfrom participating in the H2H program or limit their housing 0ptions.7~
Intake for the program ended February, 2007 with a final total of 190 individuals
participating as follows:
Adult Participants:
Single:
Couple:
Sole Support:
Couple with
Dependent children:
Total Number of Children of
Adult Participants:
143
107
10
16
10
47
Adopting a housing first approach the H2H initiative seeks to transition
individualdfamiliesfrom the emergency shelter system to housing and provide the
41
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necessary supports to assist in the maintenance of that housing. By September, 2007
the initial results were as follows:
Housed:
Private:
London Housing:
Rent Supplement:
143
60
69
14
In Transitional Housing:75
5
In Emergency Shelter:
5
Missingllncarcerated:
16
No Fixed Address:
5
While the H2H pilot initiative is not an addiction program as per se it clearly falls with the
substance abuse strategy continuum.
It is widely recognizedthat housing and support can play a key role in helping people to
tackle their substance issues, and that a lack of housing and support can at best render
treatment ineffective and at worst unusable or inaccessible.
Survey findings related to housing:
4 out of I O individualslisted only unstable housing (crash beds, street, couch
surfing and emergencyshelters) as their housing
7 out of 10 say they use shelters or housing services regulady
Half say that homelessnessis one of their top five life challenges
Survey of Londoners
In the report Homeless, Housing, and Harm Reduction: Stable Housing for Homeless
People with Substance Abuse Issues, an evaluation of 13 initiatives in Canada, the
United States and the United Kingdom that provided housing and services to eople who
are homeless or at risk of homelessness and who use substances found that:
A harm reduction approach combined with supportive housing can be an effective way
to address the needs of homeless people who are dealing with substance use issues;
Effective treatment for homeless persons with substance use issues requires
comprehensive, integrated, and client centered services as well as stable housing.
Housing is essential both during and following treatment. The literature review also
found growing evidence that supported housing is essential regardless of treatment.
In the programs profiled in the report safe and secure housing was identified as a key
factor that makes it possible for residents/programparticipants to address their
substance use issues and to become abstinent, reduce their substance use or reduce
the negative impacts of their use; and
The programs profiled in the report found that the participants had undergone a
number of positive changes. One of the most frequent changes noted was a stable
housing tenure. Using a harm reduction approach which provided for flexibility and
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focused on the individual needs of each client was identified as a key factor for
success.
4.2.
BarriedGaps
This section enumerates some of the barriers to accessing addiction programs and
services in London as well as some of the gaps in the setvice system.
The information was primarily collected through as series of community consultations
with various stakeholder groups and the survey of Londoners and has been augmented
by material from available research and literature.
The material has been organized either under a 'general" category or one of the 4
pillars: prevention, treatment harm reduction and enforcement. In so doing it should be
recognized that some of the material may be suitable for inclusion under more than one
category.
General
There is a need for the community to recognize that individuals should not be defined
by their addiction and that it is only one facet of an individual at a particular point in his
or her lie;
There is a need to create a continuum of programs and services as the central tenet of
an integrated substance abuse strategy;
There is a need for the system to be able to respond in a timely and appropriate
manner particularly for urgent cases;
There is a need for programs and services where people live most programs and
services are based in the downtown core;
There are insufficient family doctors in London. This creates barriers for many
individuals to basic health care; referral to specialists; prescription renewal; completion
of ODSP applicationsetc. and
Walk in clinics and hospital emergency rooms often label individuals as having "drug
seeking behaviour"which can prevent legitimate condtions/injuries from being
adequately addressed.
-
Lack of a bus pass or transportation was identifiedas a service bamer by
survey respondents.
Survey of Respondents
Prevention
Current public education and prevention programs need to be more comprehensive
and that must address the needs of individuals over their life span;"
Public education and prevention program and available resources for all ages and
culture must be easily accessible;
To have a comprehensive public education plan including support and education to
individuals, families and communities;
To increase support and awareness education for parents and families affected by
addictions;
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The 'just say no" message does not work. Preventationstrategies should be tied into
harm reduction strategies so if individuals decide to use a particular substance they
will know not only the risks but also how to minimize them;
Development of effective mentoring and peer counselling programs: and
There is a lack of case management and effective exit strategiesfor many individuals
taking legally prescribed drugs which are potentially highly addictive.
Treatment
Long waiting lists and intake procedures mean that treatment options are not available
when a person needs and wants them;
Waiting times of 4 to 6 weeks for space in a residential treatment program:
Inability to cover transportation costs is a barrier to accessing out of town treatment
services;
Some intakeheferral procedures require access to a telephone in order to both leave a
message and receive the subsequent appointment information:
The lack of detox (withdrawal management) programs available for women7', seniors,
youth and other special interest groups:
Lack of options for women with children combined with a fear that child welfare
authorities will remove the children from the home if the woman seeks treatment
options;
Lack of treatment options for the 'hard to service" homelesdstreet addict;
Need to separate out detox for alcohol and detox for other substances. Multi
substance use and/or certain addictions may not be suitable for existing detox
facilities;
Need for other detox models to be available such as daytox and home detox with the
appropriate medical and other supports based on an individuals needs and
preferences:
The lack of residential substance abuse treatment for youth under 16 in South
Western Ontario:"
It is difficult for individualswith concurrent disorders (mental health and addictions) to
access programs and services that are designed to address one but not both needs;"
Many programs and services are abstinence based which is not suitable or desirable
for all individuals:
Individuals on Methadone maintenance may be excluded from other treatment options
as they would be still viewed as "actively using"
Individuals on methadone maintenance may ba required to pay a dispensing fee of
$5.00. For individualsutilizing daily Methadone maintenance this can serve as a
barrier:
The weak link or lack of connection betweentreatment programs and aftercare or
ongoing support;
The lack of affordable housing options for individualswith substance abuse issues
including 2"6stage post treatment or transitional housing. This lack of housing options
frequently results in individuals residing in rooming houses and emergency shelters
which are often high risk environments that serve to maintain the treatment, relapse,
treatment, relapse cycle:
The need to increase in post treatment support options such as transitional housing,
employment, counselling, reintegration to school etc.;
A need for a range of homeless shelter options -dry, damp and wet;
There is a lack of long term treatment programs (6 months to 2 years) for those who
require them or request this option.
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Harm Reduction
The absence of a managed alcohol program in London;
Absence of 24 hour street outreach that can provide food, blankets, harm reduction
informationlsuppliesand referral to service providers. The Police are effectively the
only 24/7 "feet on the street;"
Absence of 24 basic needs services;
Access is not always available to harm reduction equipment such as needles and
crack pipes;
There is a lack of safe locations for many addicts to consume their drug of choice. In
reality emergency shelters, public washrooms etc can become de facto "safe" (or not
so safe) injectionlconsumptionsites;
Need for low threshold day centres that "get people off the street" and can serve as a
gateway to other types of programming: and
There is no mechanism for the timely sharing of information related to potential drug
alerts with respect to contaminationof unusual purity/potency.
Enforcement
A range of barrierslgaps relating to enforcement were presented during the collection
of material for this report. These were on occasion contradictory in nature depending
on the source of the information: police, community or substance user;
A need for more diversion programming within the legal system for people struggling
with addictions - alternative sentencing options andlor specialized drug courts;
Decriminalization of possession of small amounts of a range of substances decriminalization of addiction; and
Police services are increasingly forced to deal with addiction and mental health issues,
particularly late at night and weekends, which places a burden on existing resources.
Integration
A lack of effective co-ordination between City services, other service providers and
key community stakeholders enabling neighbourhoods and the community as a whole
to deal with substance abuse-related problems;
A lack of effective coordination between the municipality and the senior levels of
government enabling the community as a whole to deal with substance abuse
problems; and
A fragmented system means that many addicts must juggle a range of programs and
services to meet basic needs (income. food, clothing, shelter) without even beginning
to address their addiction issues."
5. STRATEGIC INTERVENTIONS
5.1.
Community and Neighburhoods
City Council asked the civic administration to address the issue of and consequences of
substance abuse in London's downtown areas.
Specifically three locations in the downtown have been identied as particularly
problematic due to the presence of an 'open drug scene" which has generated
complaints from local residents and businesses.
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London Substance Abuse Strategy - Background Paper
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These are:
Richmond St.and Dundaa St area
Some characteristics:
.
Core of London's traditional downtown area:
Mixture of retail, commercial restaurantibar, govemmentlsocial service and some
residential (almost exclusively rental);
Location of the Ontario Works office;
One of the main London Transit Commission service transfer points;
Concerns regarding open drug dealing -particularly from business owners;
Most people (dealers and users) frequenting the area are unlikely to reside in the
immediate area; and
Younger age range of individuals frequenting and remaining in the immediate area on
a regular basis
"When I think about a chronic problem of drug trafficking, I think of Dundas and
Richmond."
London Police Det. Waight
London Free Press May 20,2006
I
Dundas St and William St area
Some characteristics:
0
Locatedjust east of London's traditional downtown area:
Mixture of retail, commercial restaurantlbar, sccial service agencies and residential
(owner occupied and rental)**
Numerous social service agencies including:
o London Coffee House
o SOLE Project
o My Sister's Place
o Unity Project
o Mission services
o London intercommunity Health
o Ark Aid Street Mission
Also of note is the presence of:
o Clinic 528 (methadone clinic)
o London Police service Headquarters
o Beal High School
o Catholic Central High School
Concerns regarding open drug dealingldrug use from business owners and residents;
Concerns regarding the negative impact of the presence of social service agencies on
the neighbourhood; and
It is unclear the extent to which individuals utilizing addiction and other support
services reside in the neighbourhood. Some residents and business owners suggest
that the presence of social services agencies has attracted a clientele from outside of
52
London Substance Abuse Strategy - Background Paper
October 2007
the neighbourhoodwith the effect of magnifying substance uselabuse problems in the
neighbourhood. Individuals working in the various social service agencies suggest
that the high number of agencies located in the area is a response to a relatively high
level of neighbourhoodneedE3
Wellington Road and Horton St. area
Some characteristics:
Located just south of London's traditional Downtown area;
Mixture of retail, commercial, restaurantmar,social service agencies and residential
(owner occupied and rental);
Location of both the Salvation Amy Centre of Hope (shelter, withdrawal management
etc.) and Street Connection;
Concerns regarding open drug dealing in the area; and
Concerns regarding loitering in the area"
Public policy generally emphasizes that substance abuse harms US all and that a
community response is required.
In practice responses are often more pragmatic in nature focusing on the visible
manifestations of substance uselabuse (open drug dealinglusing) in a particular
geographic area such as a neighbourhoodor group of high-rise buildings.
It targeting several "problem" areas within the City of London namely RichmondlDundas
St; WilliamlDundas St and WellingtonlHorton St research suggests that although a short
term impact on substance uselabuse in those areas is possible and even desirable a
much broader approach will be required in order to achieve long term success.
A neighbourhood or geographic approach to substance abuse can produce short term
"quick wins" to allow for the development and implementationof longer term community
strategies.
The limitations of a neighbourhoodapproach to substance use can be illustrated in the
context of both enforcement initiatives and broader preventionleducation initiatives.
Enforcement:
Research demonstrates that illegal drug markets are spatially concentrated in certain
parts of metropolitan areasa5
As to why this occurs there are two major schools of thought: socio-economic and
geographic
The socio-economic position suggests that the lower the social and economic status of
the neighborhood, the more likely it is to be socially disorganized -the lower the level of
social capital. This produces an environment where levels of substance use may be
elevated and also importantly the ability of neighbourhood residents' to prevent the
incursion of illegal drug dealers is reduced.
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The geographic position suggests that the number and location of potential customers in
a neighbowhood andlor the accessibility of external customers to that drug market are
critical.
Enforcement initiativestargeting a particular neighbourhoodmay generate a quick term
win of reducing visible drug useldealing in that neighbourhoodas well as reducing the
incidence of a range of criminal activity often linked to substance abuse (prostitution,
theft etc.)
However, enforcement initiatives tend to produce some unwanted outcomes such as:
An increase of enforcement initiatives in one neighbourhoodcan cause a shift of
illegal activities to adjacent neighbourhoods;" and
An increase in enforcement initiatives can actually diminish the public perception of
neighbourhood safety. Increasedenforcement will generally result in more arrests
and potentially more media coverage leaving some neighbourhoodresidents to
interpret this as evidence of an increasing problem.
Ultimately, it can be argued that the displacement of illegal drug dealers from a preferred
neighbourhood is much like stretching a rubber band anchored at a best location to sell
illegal drugs. Once you release the rubber band, it snaps back to its previous anchored
location. Likewise, as soon as the increasedenforcement activity ceases, illegal drug
dealers will attempt to snap back to the best-advantagedlocations from which they were
removed.''
In the absence of limitless police resources to maintain increased enforcement initiatives
in a particular geographic area a "weed" and 'seed" approach may yield results for that
neighbourhood. This approach ultimately shffs the emphasis from police activity to
resident activity. Enforcement initiatives are employed to 'weed" the neighbourhood of
drug dealerddrug dealing and community empowerment ("seed') is developed to resist
their return.
While the weed and seed approach may yield results in particular neighburhoods it
does address the issue of the displacement of illegal activity into adjacent
neighbourhoods and it is not well suited for many core urban areas with relativity few
residents.
Prevention and Education
Research also questions the assumption that broader prevention and education
initiatives need to target
most visibility affected by drug
- the neighbourhoods
- sales and
crime.
-
There is an assumption that neighbourhoodswith the most visible substance problems
are those with the highest rates of substance use.
A research evaluation of community based demand reduction programs conducted in
the United States examining the differences between the visibility of drugs and drug use
found that:
Drug usage is slighter higher in disadvantaged neighbourhoods;
Drug dependency is also slightly higher in disadvantaged neighbourhoods; and
54
London Substance Abuse Strategy - Background Paper
October 2007
Generally a much higher level of visible drug use and sales in disadvantaged
neighbourhoods!*
These neighbourhoodsact as hubs for the distribution of drugs among both those inside
and outside the neighbourhood.
The visibility of drug transactions creates the actuality as well as the perception of
greater drug related individual and social problems.
These neighbourhoodsare in effect victims not only of their own drug use, but also of as
market that serves a much broader community.
The study concluded that “community coalitions and mobilizations targeted only at users
are likely to have minimal effects in disadvantaged neighbourhoods. Only with sustained
effort to rebuild the social capital of such neighbourhoods can residents acquire the
wherewithal; to eliminate drug markets. Effective programs must reach all of this
market‘s far-flung consumers.Bg
5.2. Recommendations
Based on the information collected through as series of community consultations with
various stakeholder groups supplemented by material from available research and
literature a series of recommendations are proposed as follows:
1. Implementationof the London SubstanceAbuse Strategy be coordinated with
related municipal initiatives such as Ontario Works Addiction Services and
Hostels to Homes.
2. The City of London pursue opportunitieswith the federal and provincial
governments to facilitate intergovernmentalcooperation and action to reduce the
harms associated with substance use in London.
3. The City of Londonto fonnally endorse the National Framework for Action on
Substance Abuse Initiative.
4. The City of London urge the Province of Ontario to formalize its commitment to
collaborate with the Health, Education and Enforcement in Partnership (HEP)
and other key partners to develop a comprehensive drug strategy for Ontario.
5. The City of London urge the provincial government to increase funding for familybased support services to address issues of substance use within the family.
6. The City of London work with community-based agencies to expand
comprehensive prevention programming for families.
7. The City of London, in partnership with child welfare agencies and other
community service providers develop a range of child custody options to support
parents who want treatment.
8. The City of London urge the provincial government to increase funding to expand
the range and number of treatment options for youth.
55
London Substance Abuse Strategy - Background Paper
October 2007
9. The City of London urge the provincial government to allocate increasedfunding
for residentialtreatment services for youth.
I O . The City of London urge the provincial government to increase social assistance
rates to more realistically reflect actual costs of living.
11. The City of London urge the provincial government to reinstate addiction as an
eligible disability under the Ontario Disability Program.
12. The City of London will urge the federal government to reinstate SClPl funding.
13. The City of London urge the provincial government to strengthen regulatory
legislation and policy regarding access to alcohol.
14. The City of London urge the provincial government to implementstronger
enforcement of the Liquor LicenseAct to reduce the illegal distribution of alcohol
and to prevent underage drinking and service to people who are intoxicated.
15. The City of London review limiting the number of licensed establishments within
any given area of the city to reduce the harms of alcohol for individualsand
neighbourhoods.
16. The City of London explore the feasibility of using bylaws to regulate the location
of social services agencies within areas of the cfty/neighbourhoods.
17. The City of London urge Health Canada, the Ontario College of Pharmacists, the
Ontario College of Physicians and Surgeons, the Ontario Association of
Pharmacists,the Ontario MedicalAssociation and the Ontario College of Family
Physicians to reduce the misuse of prescription drugs and the diversion of
prescriptiondrugs into the illegal drug market.
18. The City of London expand its innovative harm reduction outreach strategies
including the provision of equipment to support safer use of substances, as
outlined in this report, to reach marginalizeddrug users, in particular people who
use crack cocaine.
19. The City of Londonwork with the Ministry of Community & Social Services, the
Ministry of Health & Long-Term Care and other relevant ministries, institutions
and community groups to determine what additional harm reduction services may
be needed within the shelter system and to determine appropriate service
models and sources of funding to better respond to the needs of homeless
people with substance use issues.
20. The City of London urge the Ministry of Health & Long-Term Care to increase
funding for community-based case management services to provide
comprehensive support for people with substance use andor mental health
issues.
21. The City of London urge the provincialgovernment to commit new funding and
resources to expand the capacity and range of all treatment services in Toronto
that reflects the broad diversity of need.
56
London Substance Abuse Strategy - Background Paper
October 2007
22. The London Drug Strategy ImplementationCommitteework with the Local Health
Integration Network (LHIN) to ensure the planning and funding of mental health
and addiction services in London is addressed as a priority area.
23.The City of London lobby federal and provincial governments to fund flexible,
supportive and affordable housing initiatives that include the opportunity to
develop both on site and off site supports to help people with alcohol or other
drug use issues to maintain their housing.
24. The City of London support the London Police Service to increase enforcement
efforts through partnershipswith local, regional and national law enforcement
agencies targeting high-level drug traffickers, importers and producers of illegal
substances.
25. The City of London, including the London Police Setvice, work with public and
private sector landlords, including the London and Middlesex Housing
Corporation, to develop strategies to address drug-related crime and disorder in
rental housing.
26. Develop strategies to promote opportunities for peer workers to work in and
deliver programs.
27. Increase funding for supervision, training and skills development for peer
workers.
28. The City of London support the development of a drug users group to provide
input in addictions programs and services.
29. The City of Londonfacilitate an evaluation of the implementationand
effectiveness of the London Substance Abuse Strategy.
London Substance Abuse Strategy - Background Paper
October 2007
GLOSSARYOFTERMS
Concurrent Disorder: a combined or concurrent substance use and mental health
problem.
Daytox: is a withdrawal management program that treats clients in an outpatient setting
and is designed for individuals who do not experience severe withdrawal symptoms,
have a relatively stable environment and supportive social network. The program might
offer counselling on substance abuse, education on relapse prevention, emotional
management, nutrition education etc as well as referralto other drug and alcohol
treatment programs.
Detox: a form of substance rehabilitation used to treat alcohol or other drug addiction.
The process involves abstinenceto clear the drug from the body, accompanied by social
and environmental support during the associated physiological and psychological
changes.
Enforcement: is a set of strategies primarily concerned with the maintenance and
enhancement of public order and safety for all members of the community.
H a m Reduction: a holistic philosophy and set of practical strategies that seek to
reduce the harms associatedwith substances.
Housing First the direct provision of permanent, independent housing to people who
are homeless. Central to this concept is that clients receive whatever individual services
and assistance they need and want to obtaidmaintaintheir housing choice. The
housing is viewed primarily as a place to live, not to receive treatment.
Prevention: includes a range of strategies that help harmful substance abuse. Within
the prevention continuum there is an acknowledgment of both abstinence based
programs and those pmgrams that provide individuals, who choose to experiment with
drugs, access to information to do so safely
Social Capital: consists of the stock of active connections among people: the trust,
mutual understanding, and shared values and behaviorsthat bind the members of
human networks and communities and make cooperative action possible. The concept
of social capital contends that building or rebuilding community and trust requires faceto-face encounters. The term social capital is now being used by the World Bank with
regard to economic and societal development and by management experts as a way of
thinking about organizational development.
58
London Substance Abuse Strategy - Background Paper
October 2007
Treatment: is about encouraging and supporting people with addiction problemsto
make healthier decisions about their lives. Decreasing preventable deaths, illnesses
and injuries and inmasing social interactions are key outcomes
59
London Substance Abuse Strategy - Background Paper
October 2007
Appendix A
The Social Costs of Alcohol and Illegal Drugs in Canada 2002 (In millions)
Dimct health cam costs: total
1 .Imorbidity - acute care hospitalization
- psychiatric hospitalization
1.2 inpatient specialized treatment
1.3 outpatient specialized treatment
1.4ambulatory care: physicianfees
1.5family physician visit
1.6prescriptiondrugs
1 Direct law enforcement costs
2.1 police
2.2courts
2.3 corrections (including probation)
1 Direct costs for prevention and research
3.1 research
3.2prevention programs
3.3salaries and operating funds
0 Other direct costs
4.1fire damage
4.2traffic accident damage
4.3losses associated with the workplace
4.3.1 EAP & health promotion programs
4.3.2drug testing in the workplace
4.4administrative costs for transfer payments
4.4.1social welfare & other programs
4.4.2worker's compensation
6 Indirect c o r k rxoductivitv losses
5.1 due to long ierm disabiliy
5.2due to short t e n disability (days in bed)
5.3due to short term disability (reduced activity)
5.4due to premature mortality
Total
Total per capita (in 5)
Total as % of all substance related costs
i
Ucohol
3,306.2
1.458.6
19.6
754.9
52.4
80.2
172.8
767.6
llegal Drugs
1,134.6
rotai
4,440.8
426.4 1,885.0
11.5
31.1
352.1 1,108.7
108.7
56.3
102.8
22.6
21.6
48.8
984.4
216.8
3,072.2
2,335.5
1,898.8
513.1
660.4
1,432.0 3,330.8
843.7
330.6
573.0 1,233.4
53.0
17.3
33.9
1.8
996.1
156.5
756.9
17.0
17.0
--
65.8
4.3
61.5
5,407.7
16.5
69.6
8.6
7.9
25.9
41.0
1 .e
79.1
-
67.0
6.6
4.2
2.4
5.4
-
5.4
1,075.2
156.:
823.5
23.E
21.2
2.4
71.2
4.:
66.9
7,126.4
4,678.6
6,163.9
15.9
23.E
923.C
4,408.4 10,572.:
21 .a
37.i
-0.1
23.f
248.5 1171.:
14,SX.O
463
36.8
12,003.t
8,244.3 22,798.;
262
52t
20.1
57.:
60
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NOTES
The section of The Report of the Auditor General in 2001 on the "Illicit Substances The Federal Government's Role" concluded that "informationon the extent of the drug
yoblem is sparse, outdated, not available or located in a myriad of diverse sites."
This is a factor apparent with most national Canadian surveys on substance use such
as: the National Alcohol and other Drugs Survey (1989); the Canadian Alcohol and
other Drugs Survey (1994) and the Canadian Addiction Survey (2204) which utilize
telephone calls to contact potential survey respondents
In the Canadian context : the National Alcohol and other Drugs Survey (1989); the
Canadian Alcohol and other Drugs Survey (1994) and the Canadian Addiction Survey
(2204) do not provide data at a sub provincial level. The Ontario Student Drug Use
Survey does not provide data at a sub regional level.
Adlaf, E.M., Begin, P., 8 Sawka, E., eds. Canadian Addiction Survey (CAS):
A National Survev of Canadians Use of Alcohol and Other Druas: Prevalence of Use and
Related Harms: Detailed Report. Ottawa: Canadian Centre on Substance Abuse, 2005.
Light infrequent drinker (fewer than 5 drinks less than once a week) light frequent
drinker (fewer than 5 drinks more than once a week) heavy infrequent more than 5
drinks less than once a week) and heavy frequent (more than 5 drinks more than once a
week)
According to established Low-Risk Drinking Guidelines, weekly alcohol intake should
not exceed 14 standard drinks for males and nine standard drinks for females, and daily
consumption should not exceed two drinks.
Since 1977 the study has surveyed about 4,000 students every two years and has to
date interviewedover 65,000 students
The section of The Report of the Auditor General in 2001 on the "Illicit SubstancesThe Federal Government's Role" noted that "Knowledge of particular high-risk groups is
also limited. One of the most significant gaps is in information on illicit drug use on
Native reserves; there is virtually no such information. ... Similarly, little is known about
the nature, extent, and consequences of new drugs such as ecstasy or about some
farticular groups, such as homeless Canadians."
Caputo, T., Weiler, R., Anderson J. The Street Life Stvle Study, Office of Alcohol Drugs
and Dependency Issues Health Canada, f997.
Goodman, D., HeDatiis C SUDDOI?
Prwram Final ReDOrt, Youthlink Inner City, 2004
I' Out from the Shadows, "Final Report Out from the Shadows International Summit of
Sexually Exploited Youth", May 1998.
"Ambrosia, E.,a. The Street Health Report: A Studv of Health Status and Barriers
to Health Care of Homeless Women and Men in the Citv of Toronto, Toronto: Street
Health, 1992.
l3City of Toronto, "Substance Use in Toronto: Issues, Impacts and Interventions", March
2005.
-
'
a.,
w.
l4
'5
" Priscilla Alexander, "Prostitution: A
Difficult Issue For Feminists", in Frederique
Delacoste and Priscilla Alexander, Sex Work: Writinas bv Women in the Sex Industry,
San Francisco: Cleis Press, 1987. p. 188.
66
London Substance Abuse Strategy - Background Paper
October 2007
"Survey conducted at Maggies -The Toronto Prostitute'sCommunity Services Project
p o date)
Reiger, D.A., Farmer, M.E. &Rae, D.S., "Co-morbidity of mental disorders with alcohol
and other drug abuse, Results from the EpidemiologicalCatchment Area (ECA) study,"
Journal of the American Medical Association, 264, 1990.
le
Forchuk, C., et.,
"From PsychiatricWard to the Streets and Shelters", Journal of
Psvchiatric and Mental Health Nursinq, 13 (2006).
lo Clayton Research Associates, 'Employment, Population, Housing and NonResidential Construction Projects, City of London Ontario," November, 2003.
London frequency estimates are based on aggregate percentagesextracted from the
Canadian Addiction Survey (2004) which provides frequency data on the use of alcohol
and drugs for individuals 15 years and over and applies them to 2006 population
estimates for the City of London (The category 10-19 years of age for the City of London
has been divided by 2 to provide an approximationto match the CAS data set.
The executive director of My Sister's Place, Susan Mcphail estimates that up to 85%
of the women who access the facility have mental health issues.
23 In 2005 Counterpoint's used syringe recovery rate was 75% (2004 provincial average
across 30 needle exchanges was 72%). In 2005 each Counterpoint client received an
average of 256 syringes during the service year (provincial average was 253).
" London Counterpoint Needle Exchange, Annual Report, 2006.
25 Some clients identified more than one problem substance.
Clients who were prescribed methadone.
More than one diagnosis may apply to a single individual.
"100% Purity Crystal Meth Taken off the Streets," 8 July, 2005 RCMP New Release.
29 "Massive Marijuana Busty Symptom of Epidemic," London Free Press, 13 January,
2004
30 London Police Services web site.
31 The issue of individuals actively seeking out persons with legal Oxycontin
prescriptionsin some seniors and public housing buildings in London was raised at
community consultations meetings in preparationfor this document.
32 "London - Ugly Problem of Addiction," London Free Press
33 "One of the Largest Prescription Pill Busts. Authorities Say," London Free Press, 12
May, 2006
~4 Ibid.
35 Ontario Federation of Community Mental Health and Addiction Programs, "Methadone
Maintenance Treatment Concerns in Ontario." 2005.
JB Refer to The ReDoft of the Methadone Maintenance Task Force, W. Anton Hart, Chair,
Ontario March 2007 for the complete set of recommendations.
"The Canadian Centre on Substance Abuse defines substance abuse in an economic
context -abuse occurs when substance use imposes costs on society that exceed the
costs to the user of obtainina the substance.
38 Canadian Centre on Substance Abuse, The Costs of Substance Abuse in Canada
2002, Health Canada, 2006.
Ibid.
40 Fallon, Barbara, e
t..
Ontario
, Incidence Studv of ReDorted Child Abuse and Nealect,
The Centre of Excellence for Child Welfare (2003). In 2006 the London Middlesex
Children's Aid Society provided protectiveservices to 1,700 families; results from the
Fallon study would suggest the between 374 and 561 of these families caregiver
functioning was impacted by alcohol, drug and/or solvent abuse.
''
''
''
-
61
-
London Substance Abuse Strategy Background Paper
October 2007
Refer to: The Senate Special Committee on Illegal Drugs, llleaal Drua Use and Crime,
October, 2001.
42 Statistics Canada, "Trends in Drug Offenses and the Role of Alcohol and Drugs in
Crime, 2002," The Daily, 23 February, 2004. Research has also clearly shown that a
large percentage of crime is never reported to or investigated by police. This is all the
more likely to occur with crimes related to illegal drug use. Individuals involved in these
types of activities are usually consenting; as a result, they are generally not inclined to
report the incidents to police.
43 Ibid.
%ever, it is important to assert that human behaviour cannot be reduced to a set of
risk factors. The mere presence of such risk factors does not necessarily put a person
on a path toward drug use andlor crime. It is important to give the individual his or her
rightful place in the drug-crime equation and to recognize the significance the individual
ascribes to the actions that shape his or her lie.
45
Research has also clearly shown that a large percentage of crime is never
reported to or investigated by police. This is all the more likely to occur with crimes
related to illegal drug use. Individuals involved in these types of activties are usually
consenting; as a result, they are generally not inclined to report the incidents to police.
48Areport by the Ontario Association of Chiefs of Police stated that most crimes against
property (such as theft, break and enter, and fraud), as well as prostitution, are
committed by drug users in order to feed their habit. Refer to Ontario Association of
Chiefs of Police, Canadian Drua PersDective, 1995.
"Women tend to engage in prostitution to a greater degree than do men. The
difference may be attributable in particular to "the fact that it is difficult for women to gain
access to other types of crime (e.g., trafficking) and the fact that they are economically
dependent" as well as by the traditional role of women as perceived by men.
48 Social assistance is also the main source of income, apart from illegal activities, for
opiate users in Toronto.
49 Acquisitive crime accounts for 24% of the total income.
50 A Canadian study of drug dealers on probation provided an updated view of the
frequent use of violence in the context of the drug trade. According to the study's
findings, slightly more than half of the drug dealers interviewed (56%) admitted they had
used violence in their activities Nor will it be surprising that most major drug users get
involved in reselling illegal drugs in exchange for either money or drugs
""Chief to Target Gangs Next," London Free Press, 13 February, 2007
52 S. Brochu, L.G. Cournoyer, L. Motiuk and K. Pernaen, "Drugs, Alcohol and Crime:
Patterns among Canadian Federal Inmates," Bulletin on Narcotics, Vol. LI, No. 1 and 2,
1999, pp. 57-73.
41
m.
53
,L:A
IUIU.
%Single, E., et. al., The Costs of Substance Abuse in Canada - Hiahliahtsof A Maior
Studv of the Health Canada. Social and Economic Costs Associated with the Use of
Alcohol. Tobacco and Illicit Druas, Canadian Centre on Substance Abuse, 1996.
55 The Audtor General of Canada, Illicit Druas: The Federal Government's Role, 2001.
The British Columbia Centre for Excellence in HIV/AIDS that 73% or $271 million of the
$368 million spent by Ottawa in 2004/05 went towards enforcement measures such as
border control, RCMP investigations, and federal prosecution expenses. Of the
remaining $97 million, $51 million went to treatment, $26 millionwas spent on
"coordination and research," $10 million went to prevention programs, and $10 million
was devoted to harm reduction. "Tough on Drugs Plans Don't Work but get Funds:
Study," Vancouver Sun 15 January, 2007.
68
London Substance Abuse Strategy - Background Paper
October 2007
"Analyses conducted through the United Nations Office for Drug Control and Crime
Prevention suggest that a maximum of 5% of the global illegal drug flow is seized by law
enforcement agencies. ODCCP Studies on Drugs and Crime, Global Illicit Drua Trends
2001, United Nations Office for Drug Control and Crime Prevention, 2001. Also refer to
Wood, E., &.
"Displacementof Canada's Largest Private Illicit Drug Market in
Response to a Police Crackdown," Canadian MedicalAssociation Journal, 170 (2004).
and Wood, E., et. d.,
'Impact of Supply Side Policies for Control of Illicit Drugs in the
Face of AODS and overdose Epidemics: Investigationof a Massive Heroin Seizure,"
Canadian MedicalAssociation Journal, 168 ( 2003).
Health Officers Council of British Columbia, 'A Public Health Approach to Drug Control
in Canada," DiscussionPaper, 2005. MacCoun, R. and Reuter, P.. Drua War Heresies:
Learning from Other Vices, Times and Places, Cambridge: Cambridge University Press,
2001.
58 Refer to: Health Officers Council of British Columbia, 'A Public Health Approach to
Drug Control in Canada," Discussion Paper, 2005.
The Sunrise Health Region is located in South East Saskatchewan.
Bo A number of organizations have already endorsed the framework including Canadian
Centre on Substance Abuse (CCSA), the Alberta Alcohol and Drug Abuse Commission
(AADAC), the Canadian Executive Council on Addictions (CECA), MADD Canada, the
Correctional Investigatorof Canada, the City of Fredericton and the Canadian
Association of Principals.
" When the report was published in 1999 provincial funding of addiction treatment
services in Ontario had not increased in ten years,
Residential Working Group, "ResidentialWorking Group Phase II Report: A Strategy
for Residential Addiction Treatment in Ontario," March 2000.
63 The South West LIHN, which encompasses the City of London, includes the following
local service providersthat impact on the delivery of addiction/mental health and related
services: Addiction Services of Thames Valley: Drug and Alcohol Registry of Treatment;
Mission Services of London - QuintonWarner House; Slavation Army -Withdrawal
Management Centre: Turning Point; London IntercommunityHealth Centre; London
Health Sciences; St Joseph's Health Care; Can Voice; Canadian Mental Health
Association London- Middlesex Branch: Women's Mental Health Resources of London;
and London Mental Health Crisis Services.
a.,
''
''
The South West LIHN has identified addiction and mental health services as a priority
area for action under the general priority of patient care/services integration. Refer to
South West Local Integration Network (LIHN #2) Integration Priority Assessment Final
Report February 11,2005
B4Ministryof Health, "Mandatory Health Programs and Service Guidelines Requirements:
Injury Prevention and Substance Use Preventation," Ontario: Ministry of Health (1997)
65 For example gay men, hemophiliacs, aboriginal communities, street youth, women,
children, deaf people, culturally and linguistically diverse groups and people who use
iniection drugs.
"-Refer to The Toronto Drua Strateav. A ComDrehensive ADDroach to Alcohol and other
Druas. Toronto Drua Strateav Advisow Committee October, 2005
The committee w i s chaigd by a member of council and 4 other council members sat
on the committee. A total of 27 community agencies were also represented on the
committee
" The issue of "crack pipe kits" has been particularly divisive in the City of Ottawa. In
2004 the City of Ottawa augmented its needle distribution program with a safer
''
69
London Substance Abuse Strategy - BackgroundPaper
October 2007
inhalation initiative to distribute clean pipe kits to crack cocaine users based on a report
submitted by the medical officer of health Dr Robert Cushman. The program was
opposed by Ottawa's Chief of Police, amongst others, who argued the program may be
illegal and that it could encourage the drugs (crack) use. The program has effectively
produced a rift batween public heath and police services and resulted in a poliiicization
of the harm reduction components of the City of Ottawa's Drugs and Addiction Strategy.
A study conducted by the University of Ottawa in 2006 found that while the crack pipe
program has radically reduced the sharing of drug paraphernalia,which is the main
cause of disease, it has also increasedthe amount of crack smoking. While the increase
in crack smoking initially appeared as a negative outcome it is offset by a decrease in
injection drug use which is more risky in terms of potential health impact than smoking
"Crack Program Cut Disease: Study: But Free Paraphernaliaalso Increased Drug Use,
AIDS Conference Told," Ottawa Sun 18 August, 2006.
The program is coordinated each year by the Middlesex-London Health Unit, Elgin St.
Thomas Health Unit and Oxford County Public Health and Emergency Services and a
dedicated committee of community partners. Safegrad committee membershipincludes
the Centre for Addiction & Mental Health, London Police Department,Thames
Emergency Medical Services, Sexual Assault Center London, Thames Valley District
School Board, MADD London Chapter, London Health Sciences Centre (IMPACT),
London District Catholic School Board. the Ministry of Transportation and Bud Gowan
Formal Wear.
70 Ontario Works clients may choose to remain with their regular caseworker and access
addiction supports or may choose to transfer to the specialized addictions team (Team
A) with intensive case management (lower participant to caseworker ratios; desk side
interview, more frequent meetingswith caseworker etc.)
7' While seemingly contradictory this group of participants has chosen a goal of
abstinence with respect to certain substances and a goal of harm reduction was respect
to others.
72 These communities are: London, Hamilton, Kingston, Windsor and Toronto
73 These partner agencies include: Youth Opportunities Unlimited; the Centre of Hope;
The Men's Mission; Rotholme and The Unity Project.
74 Based on emergency shelter providers estimates of 40% - 60% of the shelter users
potentially having substance abuse issues it is plausible that 55 to 85 of the adult H2H
participants may have substance abuse issues. This number is subject to adjustment
based on the results from an analysis of more detailed H2H intake data and community
support workerkaseworker feedback.
75 Transitional housing in located at 3 of the emergency shelters: Unity Project, Centre of
Hope and Men's Mission.
76 Social Planning Council for British Columbia, Homelessness. Housina. and Harm
Reduction: Stable Housina for Homeless People with Substance Use Issues, Canada
Mortgage and Housing Corporation, July 2005.
771n1998 substance use educationwas mandatedfor Ontario Students in grades 1 to 8
as part of the new Health and Physical Education curriculum. In 1999, Ontario
introduced a new curriculum for high school students stipulating that at least one Health
and Physical Education credit is needed in order to graduate. Most students fulfill this
requirement in the gthor IO* grade. Substance use education is a course component in
both grades 9 and I O .
78 In order that treatment programs are effective for women they should: be gender
specific incorporatinga women-centered approach; provide a variety of interventions
including harm reduction; address all aspects of a women's life including spousal and
70
London Substance Abuse Strategy - Backsound Paper
October 2007
child considerations; support empowerment for women and be client driven and based
on client strengths.
The nearest available residentialtreatment facility for youth under 16 is located in
Thunder Bay Ontario and it has a waiting list of approximately 12 weeks.
An example of an unique initiative in this area is the Community-UniversityResearch
Alliance (CURA) came together as an initiative from community organizations in London,
to build the capacity of the community to create, support, and evaluate housing for
psychiatric consumerdsurvivors.The CURA focus on building capacity uses a
participatory research approach to evaluate existing models of supported housing, to
enable information sharing between community and academic partners, to give voice to
the consumers (residents) of supported housing, and to develop working relationships as
fartners in the community.
For example refer to the City of London's Social Policy Framework.
From a household perspectivethe area has a substantially higher proportion of one
person households than London as a whole (42% versus 30%) which may be indicative
of the housing stock being suitable for smaller households and affordable for smaller
households. According to Putman changes in family structure Le. more people living
alone is a factor in the decline of social capital as conventional avenues to civic
involvement are not well designedfor single and childless people.
Refer to Robert
. .
Putman. Bowlina Alone: TheCollaDse a i d Revival of American Community. New York.
2000. Data also indicates that residents of may be more likely to move than other
Londoners,with only 40% residing in the same place as 5 years ago, compared to
approximately 52% of Londoners as a whole that still lived at the same address as five
years ago. When residents were surveyed as to what they liked least about the
neighbourhoodthe responses in descending frequency were: neglected
propertiedabsentee landlords; image; undesirables; garbage; roads/parking conditions
and crime/drug/sex trade. Refer to Old East Heritage Conservation District Study 2004
The Community Member Survey of individuals accessing selected social service
agencies in the DundasMlilliam Street areas found that 50% of the respondents did not
reside in the area.
83 These contrasting positions were expressed at community meetings at both the
London Coffee House and Bishop Cronyn Memorial Church
84 While the assumption is that resident of the Centre of Hope are the individuals loitering
in the immediate vicinity of the shelter this fact is not clear. Associates of residents, drug
dealers etc also frequent the area. In an effort to address loitering concerns the Centre
of Hope has adopted policies directed at reducing loitering in the immediate area by
residents-"red zone." The Salvation Army has also recently purchasedan adjacent
property and building that had been previously allegedly been associated with drug
dealing/consumption.
85 For example refer to Robinson, Jennifer B. and Rengert, George F. "Illegal drug
markets: The geographic perspective and crime propensity." Western Cfiminoloay
m
w 7(1): 20-32 (2006),Rengert, George F., Sanjoy Chakravorty, Tom Bole and
Kristin Henderson. "A GemraDhic Analysis of Illegal Drug Markets." In Mangai
Natarajan and Mike HoughTeds.) IlleaaiDrva Markets: FFom Research to Pkvention
Policv. Monsev. New York: Criminal Justice Press, 2000 and Weisburd. David D. and
Loraine Greei.'1995. "Policina Drua Hot Soots: The Jersev Citv Market Analvsis
Experiment." Justice Quarterli 12:?11-736
The analogy can be drawn to water in a sealed bag: squeezing the comer of the bag
only displaces the water it does not reduce the overall amount
''
'
~.
71
London Substance Abuse Strategy - Background Paper
October 2007
Robinson, Jennifer B. and Rengert, George F. "Illegal drug markets: The geographic
prspective and crime propensity." Westem CriminologyReview 7(1): 20-32 (2006)
Leonard Saxe et.al., The Visibility of Illicit Drugs: Implicationsfor Community Based
Drug Control Strategies, American Public Health Association December 1994. The
study examined the differences between the visibility of drugs and drug use in more than
2,100 neighbourhoods in 41 communities collecting informationfrom 42,000
respondents.
ag
m.
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