Baseline Study of Substance Use,
Excluding Alcohol,
in Waterloo Region
June 20, 2008
Project funded and managed by
Region of Waterloo Public Health.
Research activities and report development completed by
the Centre for Community Based Research.
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Executive Summary
Illicit substance use is an important public health issue in Waterloo Region, but patterns of use
are not well researched. There is a general understanding that drug use occurs in each community
in the region; however, local information about the extent of illicit substance use and the
implications of this use is vague and often anecdotal.
The overall purposes of the Baseline Study of Drug Use, Excluding Alcohol, in Waterloo Region
are to develop a detailed description of drug use in Waterloo Region, to determine if existing
programs and services are meeting the needs of persons who use drugs, and to understand
challenges faced by service providers who work with this population.
This study conducted local analysis of existing data from hospitals, needle exchange programs,
addiction treatment programs and provincial research projects. The research team also conducted
face-to-face interviews with 32 persons who use drugs regularly and 33 local service providers.
Overall, drug use and trafficking were reported to occur throughout Waterloo Region. Crack,
cocaine, cannibis and prescription opioids appear to be the most prevalent illicit substances used.
Heroin, ecstasy and other hallucinogenic drugs were also said to be widely used. The use of
crystal methamphetamines is reportedly increasing.
Drug use was not limited to one demographic group or sub-group; however, patterns of drug
choice varied for individuals enrolled in senior elementary or high school. Hallucinogens,
cocaine, and crystal methamphetamine use seemed to be more prevalent among this population.
Patterns of drug use varied by geographic area. Participants described drug use in Cambridge and
Kitchener as more open and visible (e.g. used in shelters, parks, downtown core, on the streets)
than in Waterloo or the Townships where drug use (more frequently) occurred in private
dwellings. Drug use and trafficking was carried out by Waterloo Region and non-Waterloo
Region residents.
People who use non-injection drugs appear to be unaware of the health and safety risks associated
with sharing their equipment (e.g. crack pipes, sterile water, cookers) and reported that sharing
occurs at high rates.
Many of the individuals interviewed for the study had significant health issues, including poor
dental health, inadequate nutrition, and having a communicable disease (e.g. hepatitis C and
human immunodeficiency virus [HIV]). Despite the fact that participants were aware of available
services, many chose not to access care because of lack of access to health providers trained to
meet the needs of people who use drugs, fear of discrimination and/or the potential for criminal
repercussions. Over half of the participants reported that their social network would be unlikely
to seek medical help on their behalf in the event of an overdose.
People who use drugs have diverse and complex social needs, including appropriate housing, job
readiness training, and job related skill development. Isolation and insufficient social supports
are also major challenges for many people who use drugs. Those who desire support in
overcoming their addictions in Waterloo Region often face barriers including limited hours of
service availability, pre-requisites of pre-treatment sobriety and assessment tests, and the
presence of potential triggers in areas that surround services. For those who live in rural areas, a
Final Report - June 20, 2008 i
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
lack of transportation to city-based services is an additional challenge. Extensive waitlists for
services were an additional barrier to accessing services; over 80% of individuals seeking
residential treatment programs went outside of Waterloo Region to receive care.
Participants reported that there are an array of harm reduction services for those involved in
injection drug use in Waterloo Region, but similar supports for those who use non-injection drugs
may not be as readily available. Satisfaction with social supports and services seems to be high;
those who access support through social services described mainly positive experiences with their
service providers.
Waterloo Regional Police Service representatives highlighted the differing mandates between the
police and service providers, and how this sometimes hindered the growth of collaborative
relationships between these groups. Representatives from the police also expressed a desire to
assist persons that use drugs in terms of seeking treatment.
Interviewees previously approached by outreach workers reported the contact as helpful;
however, interviewees who had no previous experiences with outreach workers were reluctant to
consider this type of contact. Outreach by all participants was considered to be more effective if
it were guided by a community-wide unified approach, and if workers provided information about
services, how to overcome barriers to seeking services and treatment, and offered immediate
healthcare services and supplies. The ideal characteristics of an outreach worker were: people
with prior drug use experience, supportive, compassionate and non-judgmental. Gender balance
is also considered essential.
The methods and principles used in the Waterloo Region Baseline Study of Drug Use are based
on the World Health Organization’s Rapid Assessment Response guide. This approach builds on
accepted social science research methods, but has the advantage of assisting jurisdictions to
rapidly and economically compile data from multiple sources to quickly respond to health
problems or emergencies. While the approach is an effective way to assess current realities and
develop targeted interventions based on the key findings; however, it is not a substitute for longterm or in-depth studies.
In addition, the service providers and individuals using drugs who participated in this study were
volunteers, and although the research team took care to seek out a diverse set of participants, it
may be that their experiences do not fully reflect the range of experience or opinion in the region.
This is acceptable in the Rapid Assessment Response framework which recognizes that studies
using this approach rely on convenient or diverse samples that may not be fully representative of
the study population.
Final Report - June 20, 2008 ii
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Acknowledgements
Many parties collaborated in the initiation and carry-through of this research project and the
creation of this report.
Special acknowledgement is made to the Waterloo Region Harm Reduction Network for its
contributions throughout the process.
This research project was funded and managed by Region of Waterloo Public Health. Members
of the research team included: Karen Quigley-Hobbs, Karen Verhoeve, Daniela Seskar-Hencic,
Judy Maan Miedema, Marg McGee and Chris Harold. Special thanks to Chris Harold for his
significant contributions to the background research, methodology development and creation of
the final report.
The research activities and report were guided by an advisory group of stakeholders within
Waterloo Region. Members who served as a committee member at some point in the process
include:
• Pat Allan, Centre for Addiction and Mental Health
• Brice Balmer, Waterloo Region Harm Reduction Network
• Steve Beckett, Waterloo Regional Police Service
• Sandy Bell, Reaching Our Outdoor Friends (ROOF)
• Marion Best, The Bridges, Cambridge Shelter Corporation
• Susan Collison, Grand River Withdrawal Management Centre
• Rosemary Mackenzie, Ministry of Community Safety and Correctional Services
• Cathy Middleton, Waterloo Region Harm Reduction Network
• Coba Moolenburgh, St. Mary’s Counselling Service
• Frances Moriarty, Community Link Empowered Against Narcotics
• Rob Smith, Waterloo Region Harm Reduction Network
• Leesa Stephenson, Aids Committee of Cambridge, Kitchener, Waterloo and Area
• Brent Thomlison, Waterloo Regional Police Service
• Karen Verhoeve, Region of Waterloo Public Health
Special acknowledgment is also made to Dr. Margaret (Peggy) Millson, Associate Professor,
University of Toronto, for her contributions to the study’s research methodology and data
analysis.
The research activities, including the creation of this report was prepared by Centre for
Community Based Research. Team members were Andrew Taylor, Suzanne Field, Gabriela
Novotna, Brian Barlett, Don Johnson, and Leesa Stephenson.
The information learned through this report was made possible by those who participated in the
interviews, focus groups, and surveys. The research team wishes to offer a sincere thank you to
everyone who shared their stories, experiences, and opinions in this way.
For more information, please contact:
Andrew Taylor
Centre for Community Based Research
73 King St. W., Kitchener, Ontario
N2G 1A7
[email protected]
Final Report - June 20, 2008 iii
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Abbreviations
Abbreviation
AIDS
CAMH
DART
DATIS
HIV
ID
LSD
PCP
OERWR
OHRDP
OSAB
OSDUHS
PWUD
RAR
THC
WHO
Name
Acquired immunodeficiency syndrome
Centre for Addiction and Mental Health
Drug and Alcohol Registry of Treatment
Drug and Alcohol Treatment Information System
Human immunodeficiency virus
Injection drug
Lysergic acid diethylamide
Phencyclidine
Outcome Evaluation Report — Waterloo Region
Ontario Harm Reduction Distribution Program
Ontario Substance Abuse Bureau
Ontario Student Drug Use and Health Survey
Participant or person who uses drugs
Rapid Assessment Response
Tetrahydrocannabinol
World Health Organization
Final Report - June 20, 2008 iv
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Contents
EXECUTIVE SUMMARY ........................................................................................................................... I
ACKNOWLEDGEMENTS .......................................................................................................................III
ABBREVIATIONS .................................................................................................................................... IV
SECTION 1: INTRODUCTION................................................................................................................. 3
FRAMEWORK .............................................................................................................................................. 3
ETHICS ....................................................................................................................................................... 4
RESEARCH METHODS ................................................................................................................................. 5
Research Team...................................................................................................................................... 5
Data Gathering ..................................................................................................................................... 5
Interviews, focus group, and questionnaires: Participants who Use Drugs ......................................... 5
Focus Groups: Service/Healthcare Providers and Police Officers ..................................................... 7
Online survey for service providers ...................................................................................................... 8
Analysis of secondary data ................................................................................................................... 8
REFER TO APPENDIX N FOR A GLOSSARY OF TERMS. STUDY LIMITATIONS AND FUTURE RESEARCH
CONSIDERATIONS ....................................................................................................................................... 9
STUDY LIMITATIONS AND FUTURE RESEARCH CONSIDERATIONS ............................................................ 10
Study Limitations ................................................................................................................................ 10
Future Research Considerations ........................................................................................................ 10
SECTION TWO: DESCRIPTION OF DRUG USE IN WATERLOO REGION ............................... 11
TYPES OF DRUGS USED IN WATERLOO REGION: GENERAL POPULATION................................................. 12
TYPES OF DRUGS USED IN WATERLOO REGION: HIGH SCHOOL STUDENTS.............................................. 17
CHARACTERISTICS OF PEOPLE WHO USE DRUGS....................................................................................... 18
ACCESSING SUBSTANCES IN WATERLOO REGION..................................................................................... 21
Prescription pills................................................................................................................................. 21
Poly drug use ...................................................................................................................................... 21
Geographical regions ......................................................................................................................... 22
DRUG-RELATED TRAVEL TO THE REGION BY NON-REGION RESIDENTS .................................................. 23
PERCEPTIONS OF SAFETY: PURCHASING DRUGS ...................................................................................... 24
PERCEPTIONS OF SAFETY: USING DRUGS ................................................................................................ 25
Sharing drug instruments.................................................................................................................... 26
SAFETY CONCERNS RAISED BY SERVICE/HEALTHCARE PROVIDERS ......................................................... 26
SUMMARY ................................................................................................................................................ 27
SECTION THREE: HEALTH NEEDS AND COMMUNITY RESPONSE........................................ 28
HEALTH ISSUES FACING PEOPLE WHO USE DRUGS .................................................................................. 28
Hepatitis C and Human Immunodeficiency Virus (HIV)..................................................................... 28
Source: Ministry of Health and Long-Term Care and Region of Waterloo Public Health................. 29
Mental health ...................................................................................................................................... 29
Dental health....................................................................................................................................... 30
Nutritional intake ................................................................................................................................ 30
RESPONSE TO HEALTH PROBLEMS............................................................................................................ 31
Overdoses............................................................................................................................................ 31
Many persons who use drugs regularly find health care services accessible and respectful. ............ 32
Broader systemic issues sometimes act as obstacles to access for health care .................................. 33
Some individuals report experiences of discrimination when dealing with the health care system.... 34
Some health care providers are naming the need to improve their service to this population. .......... 34
SUMMARY ................................................................................................................................................ 35
SECTION FOUR: A HOLISTIC APPROACH TO SUPPORT FOR INDIVIDUALS WHO USE
DRUGS; SYSTEMIC ISSUES, SOCIAL NEEDS AND THE COMMUNITY RESPONSE............... 36
Final Report - June 20, 2008
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
SOCIAL DILEMMAS FACING PERSONS WHO USE DRUGS REGULARLY ....................................................... 36
Balancing a need for appropriate housing with a need to work towards treatment goals.................. 36
Overcoming shame in order to deal with isolation ............................................................................. 37
Managing a job or job-readiness training while dealing with the effects of drug dependence. ......... 38
The importance of hope ...................................................................................................................... 38
KNOWLEDGE OF HARM REDUCTION SERVICES AND PRACTICES............................................................... 38
DRUG USE AS A SOCIAL ISSUE: PRINCIPLES TO GUIDE AN APPROPRIATE RESPONSE ................................... 39
The importance of a comfortable, non-judgmental atmosphere ......................................................... 39
The importance of a timely response .................................................................................................. 40
The importance of making supports available in more than one geographic location ....................... 40
The importance of after-hours supports.............................................................................................. 41
The importance of a coordinated response capable of meeting individuals wherever they are “at.” 41
Importance of close collaboration between police services and social and healthcare organizations42
The importance of equipping service organizations with resources to effectively support persons who
use drugs ............................................................................................................................................. 43
SUMMARY ................................................................................................................................................ 43
SECTION FIVE: OUTREACH - LINKING PEOPLE WITH SERVICES ......................................... 44
EXPERIENCES WITH REFERRALS AND OUTREACH WORKERS.................................................................... 44
SUGGESTED APPROACH TO OUTREACH .................................................................................................... 46
Hard-to-Reach Populations ................................................................................................................ 47
Geographic Areas where outreach occurs.......................................................................................... 47
QUALITIES OF AN IDEAL OUTREACH WORKER ......................................................................................... 47
SUMMARY ................................................................................................................................................ 48
CONCLUSION........................................................................................................................................... 49
REFERENCES ........................................................................................................................................... 51
APPENDIX A - INVITATION TO PARTICIPATE IN AN INTERVIEW: PWUD ........................... 52
APPENDIX B - INVITATION TO PARTICIPATE IN A FOCUS GROUP: PWUD ......................... 53
APPENDIX C - INVITATION TO PARTICIPATE IN A FOCUS GROUP:
SERVICE/HEALTHCARE PROVIDERS .............................................................................................. 54
APPENDIX D - INVITATION TO PARTICIPATE IN A FOCUS GROUP: POLICE OFFICERS . 55
APPENDIX E - CONSENT FORM TO PARTICIPATE IN AN INTERVIEW: PWUD.................... 56
APPENDIX F - CONSENT FORM TO PARTICIPATE IN A FOCUS GROUP: PWUD.................. 59
APPENDIX H - DISCUSSION GUIDE FOR INTERVIEW WITH PWUD ........................................ 65
APPENDIX I - DISCUSSION GUIDE FOR FOCUS GROUP WITH PWUD..................................... 68
APPENDIX J - DISCUSSION GUIDE FOR FOCUS GROUP WITH HEALTH CARE PROVIDERS
...................................................................................................................................................................... 70
APPENDIX K - DISCUSSION GUIDE FOR FOCUS GROUP WITH SERVICE PROVIDERS ..... 72
APPENDIX L - DISCUSSION GUIDE FOR FOCUS GROUP WITH POLICE SERVICES............ 74
APPENDIX M - QUESTIONNAIRE........................................................................................................ 76
APPENDIX N - GLOSSARY .................................................................................................................... 81
APPENDIX O: ONLINE SERVICE PROVIDER SURVEY ................................................................. 86
Final Report - June 20, 2008
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Section 1: Introduction
Illicit substance use is associated with a number of adverse health effects. Unsafe substance use
practices such as sharing needles and other drug paraphernalia place people who use illicit
substances (herein referred to as drugs) at a higher risk for contracting and transmitting blood
borne pathogens such as human immunodeficiency virus (HIV)/acquired immunodeficiency
syndrome (AIDS), and hepatitis B and C viruses. Unsafe practices from impaired judgment
associated with substance use place people who use substances at a higher risk for contracting
sexually transmitted infections (STIs). There are also documented concerns about other health
care issues (e.g. dental care) and access to services in general.
In addition to the health effects associated with drug use, there are numerous social effects.
Often, there are stigmas associated with individuals who use these substances and many are from
already stigmatized populations. Additional social effects include, but are not limited to: issues
related to isolation, difficulty accessing services, and the lack of affordable housing.
Patterns or trends and the associated effects of illicit substance use (similar to those listed above)
in Waterloo Region are not well known or well researched. There is a general understanding that
drug use occurs in each community in the region; however, the extent of illicit substance use, and
the related issues or implications of this use, (specific to this region) is vague and often anecdotal.
This Baseline Study of Drug Use in Waterloo Region was conceived by the Waterloo Region
Harm Reduction Network in recognition of a need to better understand the scope and effects of
illicit substance use in Waterloo Region. The main purpose of the report is to provide local
information on illicit substance use that can be used to guide current and future program planning
initiatives and service development.
Five objectives were identified to guide the Waterloo Region Baseline Study of Drug Use:
1) To better understand illicit substance (drug) use in Waterloo Region;
2) To identify general areas where people who use illicit substances frequent in order to
develop effective outreach strategies to connect with these populations;
3) To document the service needs of the substance-using populations and assess whether
programs and services are meeting their needs;
4) To identify any existing barriers to accessing currently available services as perceived by
people who use illicit substances, service providers and existing documentation; and
5) To understand the challenges faced by service providers in Waterloo Region.
The study findings, related to these key objectives, are presented in this report.
Framework
The methods and principles used in the Waterloo Region Baseline Study of Drug Use are based
on the World Health Organization’s Rapid Assessment Response (RAR) guide. The approach or
framework “…is designed for those who wish to assess, within a city or region, the current
situation regarding drug injecting and who wish to use this information to develop interventions
to reduce the adverse health consequences of injecting” (WHO, 1998, 3). This approach builds
on accepted social science research methods, but has the advantage of assisting jurisdictions to
rapidly and economically compile data from multiple sources to quickly respond to health
Final Report - June 20, 2008 3
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
problems or emergencies. It is traditionally used when conventional social science and public
health methods are not suitable (Stimson et al., 2006).
The RAR guide and principles have evolved over time and have been used in studies conducted at
the national and local level. At the local level in North America, the approach was used to
complete both injection and non-injection drug-related studies in Victoria (Stajduhar et al., 2004),
Peel Region (Calzavara et al., 2003), and Buffalo (Erie County, 2003). Further, Dr. Margaret
(Peggy) Millson, who consulted on this study, was a consultant to the World Health Organization
in the development of the RAR methodology. This study’s approach is therefore consistent with
accepted practices in the research community that studies populations that use drugs.
Ethics
The research methods were designed to minimize potential harm to participants and the
community. The project received ethical approval to proceed from the Region of Waterloo
Public Health Ethics Committee on October 11, 2007 and from the University of Waterloo Office
of Research Ethics on January 22, 2008.
Participating in the project was voluntary and consent from each participant was obtained before
proceeding. Participants were free to choose the extent to which they wanted to participate. Each
participant/person who uses drugs (PWUD) received a $25 honorarium for participating, and was
informed at the onset of the interview/focus group that they would receive the money regardless
of their level of participation. Each participant received a copy of their consent form. Service
and healthcare providers and police officer participants did not receive remuneration. An
informed consent page was also included at the onset of the online survey. Please refer to
Appendices A to G for the invitation/information consent letters and forms to participate in an
interview or focus group for PWUD, service/health care providers and police officers.
To maintain and protect confidentiality, interview participants were not required to provide their
name or a pseudonym; all forms were coded numerically. When the participant provided
permission, the key informant interview was audio recorded. Audio-taped recordings were
transcribed and proofed for accuracy.
Focus group participants were asked to keep all information confidential; however, participants
were informed that the Centre for Community Based Research or Region of Waterloo Public
Health could not fully guarantee that other focus group participants would not disclose their
participation to others or the information discussed in the focus groups.
If appropriate, at the end of each interview and focus group, participants were provided
information on local services and programs.
Throughout the study, all data and notes were stored in a secure location at the Centre for
Community Based Research. Only members of the research team at the Centre had access to raw
data. The study coordinator and research team at Region of Waterloo Public Health had access to
summary notes. All recordings and notes will be destroyed within 60 days of study completion.
Final Report - June 20, 2008 4
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Research Methods
Research Team
The project was managed and funded by Region of Waterloo Public Health and carried out by a
research team from the Centre for Community Based Research. The research activities and report
were guided by an advisory committee of healthcare providers, service providers and a police
officer in Waterloo Region. The committee was involved in the planning, data gathering and
report finalizing stages.
In addition, three community researchers with awareness of local drug-related services and issues
were hired to conduct the interviews with PWUD. They also provided assistance and guidance in
the planning and creation of research activities.
Members of the Waterloo Region Harm Reduction Network were also involved in the data
gathering and report finalizing stages.
Data Gathering
Five methods were used to gather the data: individual interviews with PWUD, a questionnaire
for PWUD, a focus group with PWUD, focus groups with service providers and healthcare
providers and the Waterloo Regional Police Service, an online survey for service and healthcare
providers, and a review of secondary data sources. Refer to Appendices H to O for the research
tools used in the data collection process. Recruitment of participants varied, depending on the
method, and will be described below.
Interviews, focus group, and questionnaires: Participants who Use Drugs
A total of 26 key informant interviews were conducted with PWUD. One focus group, comprised
of 6 individuals, was also conducted. Interview and focus group questions focused on description
of drug use in the Waterloo Region, social and healthcare needs, social and healthcare service in
Waterloo Region, perceptions and practices of safety and harm reduction, perceptions of and
responses to outreach activities, and strategies and ideas for Waterloo Region.
Interviews were conducted by community researchers who were chosen in part on the basis of
their demonstrated ability to build rapport with the populations of interest.
Before each interview, participants completed a questionnaire that recorded their demographics,
types, methods, and frequency of drug use, and service knowledge and use.
Selection Criteria
Persons who participated in the interviews were individuals who:
• Self-identified to have used drugs illegally (including misuse of prescription drugs) on a
regular basis. ‘Regular basis’ was defined as using drugs at least six times in the past 12
months.1
• Are currently living, or lived within the past year, in Waterloo Region for at least three
months and has used drugs at least two times while living in the region.
1
Note: An analysis of the interview data reveals that most individuals interviewed used drugs on a daily or
weekly basis.
Final Report - June 20, 2008 5
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Recruitment
While no specific demographic criteria were used in the selection process, the recruitment process
was strategically developed to obtain a broad representation within the study population. The
demographics of participants were tracked and, as the recruitment process progressed,
recruitment activities were altered in an attempt to connect with groups that were not yet
represented. The following factors were considered when selecting individuals for the individual
interviews:
• Age
• Socio-economic status
• Ethno-cultural identity
• Geographical location
• Experience using services
• Type and method of illicit substances used
Recruitment activities included hanging posters in high traffic public areas, in service agency
washrooms, in primary care offices, pharmacies, community health centres and the University of
Waterloo; connecting with individuals through service providers; word of mouth through other
participants; and direct outreach through workers at service agencies.
Demographics
Self-identified Gender
Female
Male
Total
Frequency
8
24
32
%
25
75
100
Year of Birth
1960 to 1969
1970 to 1979
1980 to 1989
1990 to present
Did not disclose
Total
Frequency
9
11
7
1
4
32
%
28
34
22
3
13
100
Municipality
Cambridge
Kitchener
North Dumfries
Waterloo
Wilmot
Total
Frequency
16
13
1
1
1
32
%
50
41
3
3
3
100
Final Report - June 20, 2008 6
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Income Level
Under $15,000
$15,000 to $ 24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000+
Total
Frequency
22
3
5
1
1
32
%
69
9
16
3
3
100
There was limited representation from Waterloo and the surrounding townships, individuals with
higher incomes, students and seniors. Targeted recruitment strategies were followed in an
attempt to increase representation from these groups. Study findings indicate that persons
belonging to these groups are less visible and open with their drug use, suggesting a hesitation to
willingly identify as using drugs.
Focus Groups: Service/Healthcare Providers and Police Officers
Two focus groups were conducted with service providers — in Cambridge and in Kitchener —
one with healthcare providers, and one with the Waterloo Regional Police Service. A total of 33
individuals participated in the four focus groups.
Focus group questions differed slightly for the various groups, but overall focused on the same
areas as those for PWUD: description of drug use in the Waterloo Region, social and healthcare
needs, social and healthcare service in Waterloo Region, perceptions and practices of safety and
harm reduction, perceptions of and responses to outreach activities, and strategies and ideas for
Waterloo Region.
Selection Criteria
The following criteria were used when inviting community professionals to participate in the
above mentioned focus groups:
Service/Healthcare Providers:
• An employee that currently (or within the past year) provides a service to individuals that
use drugs. The study placed emphasis on providers of programs or services intended to
treat, help cope with, or reduce the harm of drug related issues to persons living in
Waterloo Region.
• An employee who has worked in this capacity in the Waterloo Region for at least 1 year.
Waterloo Regional Police Service:
• An individual who has experience, through the course of their work in policing,
interacting with persons who use drugs in Waterloo Region.
• An individual who has worked in this capacity in the Waterloo Region for at least 1 year.
Recruitment
Service Providers representing the following groups were invited to participate:
•
•
•
Rehabilitation Services
Counselling Services
Harm Reduction Workers
Final Report - June 20, 2008 7
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
•
•
•
•
•
Outreach workers
School Board (youth care workers)
Shelter Workers
Community Housing
Other Key Community Service Providers
Healthcare providers were invited from the following groups:
•
•
•
•
•
•
•
•
Urgent Care Clinics
Community Health Centers
Public Health
Hospital Emergency
Hospital In Patient
Mental Health Workers
General Practitioners
Pharmacists
Diversity in geographical area served was also considered in the recruitment process.
Police officers were recruited to represent diversity in the location of work within Waterloo
Region, involvement with illicit substances, and gender of the officer.
Online survey for service providers
At onset of the study, researchers at Centre for Community Based Research and Region of
Waterloo Public Health recognized that there may be a broad range of providers that service
PWUD even if the drug-related services do not fall under their organizational mandate. An
online survey was developed allowing for a wide range of data and opinions to be collected from
service providers. A general email was sent to over 200 providers inviting them to complete the
survey if they have clients that use illicit substances or if they provide services to the population
that uses these substances. Over 75 service providers responded to the survey. The data was
used to inform the focus group sessions with service providers and to triangulate the research
findings.
Analysis of secondary data
The research process included secondary analyses of existing data about drug use from a number
of sources.
The Centre for Addiction and Mental Health Monitor (CAMH Monitor)
The CAMH Monitor is an ongoing telephone survey of the adult population of Ontario, designed
to provide substance use and mental health indicators. Two hundred respondents are selected
randomly each month. For the purpose of this study, data was obtained on 345 residents of
Waterloo Region who completed the survey between 2002 and 2005.
Ontario Student Drug Use and Health Survey
The Ontario Student Drug Use and Health Survey (OSDUHS) is administered every two years to
4,000 students attending grades 7 through 13 in the public or Catholic education systems in
Final Report - June 20, 2008 8
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Ontario. The sampling frame excludes students enrolled in private schools or special education
classes, and those living in health or correctional institutions, on Native Reserves, Canadian
Forces Bases, and in the far northern regions of Ontario. For the purposes of this study, data was
made available form the 2005 and 2007 surveys. In 2005, 322 students from 6 Waterloo Region
schools participated. In 2007, 386 students from 6 schools participated.
Drug and Alcohol Treatment Information System (DATIS)
Treatment services funded by the Ontario Substance Abuse Bureau (OSAB) of the Ontario
Ministry of Health and Long-Term Care are required to participate in an ongoing client-based
information system, the Drug and Alcohol Treatment Information System (DATIS). This
information system monitors the number and types of clients seen and the services they have
received. Client demographics, substance use information and referral source are collected at the
initiation of a service episode.
In 2006-2007, 2925 individuals who were residents of Waterloo Region sought some form of
treatment for an issue related to drug or alcohol use, and were recorded in DATIS. This number
includes all cases that were open at some point during the year, including those that carried over
from the previous year.
HIV Diagnostic Testing Data
Information on HIV testing and diagnoses were provided by Waterloo Region Public Health.
These data describe the total number of HIV tests conducted in the region between 1992 and
June 2007. They also identify the reasons for the test and some information about the conditions
under which the test took place (i.e. whether a name was provided).
Needle Exchange Data
Statistics on the number of needles distributed in the region were provided by Region of Waterloo
Public Health.
Reportable Disease Data
Reportable disease information on the number of cases of HIV, hepatitis C and hepatitis B for
each year from 1995 to 2007 was provided by Region of Waterloo Public Health.
Emergency Room Visits
All three local hospitals (Cambridge Memorial, Grand River and St. Mary’s General) provided
detailed statistics on the number of emergency room visits that were coded as drug overdoses or
related to drug use. These data are broken down by year, month, age, and gender.
Refer to Appendix N for a glossary of terms.
Final Report - June 20, 2008 9
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Study Limitations and Future Research Considerations
Study Limitations
The Rapid Assessment Response framework used for this study is a cost-effective means of
collecting data on, and analyzing descriptions of, substance use in a defined geographic area. The
approach is an effective way to assess current realities and develop targeted interventions based
on the key findings; however, it is not a substitute for long-term or in-depth studies.
In addition, the service providers and individuals using drugs who participated in this study were
volunteers, and although the research team took care to seek out a diverse set of participants, it
may be that their experiences do not fully reflect the range of experience or opinion in the region.
This is acceptable in the Rapid Assessment Response framework which recognizes that studies
using this approach rely on convenient or diverse samples that may not be fully representative of
the study population.
It is also important to remember that secondary data sources, though very useful, are data
collected for other purposes. While they often address the key questions guiding this research
project, the linkages may be indirect and should be interpreted with caution.
Future Research Considerations
Future research on drug use in Waterloo Region should build on existing knowledge as
summarized in this report, secondary data sources and other related publications. Given the
difficulty in recruiting participants from certain segments of Waterloo Region’s population,
priority should be given to research projects that further explore drug use of:
• High school students
• College and university students
• Individuals with children
• Individuals with high incomes
• Individuals 60 years of age and older
• Individuals with concurrent disorders (mental health and addictions)
• Individuals with a disability
Throughout the research process, several topics were identified and explored on a cursory level,
but may warrant more focused research. These topic areas include:
• The extent and effects of the misuse of prescription drugs
• Treatment programs, particularly pre-treatment care and aftercare stabilization
• Overdoses
• The root of substance use (e.g. sexual or physical abuse, trauma, stress disorders)
• Evaluating Waterloo Region’s harm reduction services
Where possible, efforts should be made to collaborate with and avoid duplication with other
ongoing studies. Community research approaches, rooted in accepted social science
methodology and participatory in nature, should be adopted.
Final Report - June 20, 2008 10
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Section Two: Description of Drug Use in Waterloo
Region
Main Messages of this section: This section describes the extent, type and
patterns of drug use in Waterloo Region, drawing on data from multiple
sources. The findings from this section indicate that crack, cannabis, and
prescription opioids are the most prevalent drugs in Waterloo Region, with
indications that use of crystal methamphetamine is increasing and use of
heroin may be decreasing. Drug use and trafficking is widespread throughout
the region, often involving non-Waterloo Region residents, and is not limited
to any one demographic sub-group. Patterns of use within the surrounding
townships seem to be different from those in the cities. Safety concerns while
buying and using did not seem to be prominent for participants; however,
some common descriptions of drug use raised questions about the level of
awareness of potential safety risks.
Comprehensive data on drug use among adults in Waterloo Region is not available.
However, there are a number of local statistics that depict rates of use. Combining these
statistics with the observations and experiences described by the participants in this study
has created a reliable indication of substance use patterns and trends in this region. The
reader should, however, be cautioned that the findings do not fully describe the extent of
drug use, or its associated effects, within Waterloo Region.
Data from the CAMH Monitor2 tells us that about 16.7% of adults in Waterloo Region
surveyed between 2002 and 2005 reported use of cannabis within the last 12 months and
this rate is close to the provincial average.
An indication of the number of persons using injection drugs was provided by Region of
Waterloo Public Health. In 2008, Dr. Robert Remis of the University of Toronto used
data from Region of Waterloo Public Health to estimate that there were 1470 intravenous
drug users in Waterloo Region.3
Information about the extent of drug use by high school students is available through the
Ontario Student Drug Use and Health Survey (OSDUHS).4 Overall, about 26% of the
participating students reported some use of an illegal drug (including cannabis), and
2
The CAMH Monitor is a random, province-wide ongoing telephone survey about addiction and mental
health issues. For the purposes of this report, data gathered between 2002 and 2005 is used. During this
period, 9,169 individuals from across Ontario participated in the survey. Of this number, 345 were from
Waterloo Region.
3
Estimate based on modelling by Dr. Remis using a capture-recapture analysis from human
immunodeficiency (HIV) laboratory database data.
4
This study gathered data about drug use from 6,323 students in grades 7 to 12 across Ontario. In
Waterloo Region, 386 youth from 6 different schools participated.
Final Report - June 20, 2008 11
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
13.8% had used an illegal drug other than cannabis. If these figures are representative,
about 8811 students have used some form of illegal drug in last year.5
These rates were close to the provincial averages, and similar to those reported in 2005.
In 2007, about 9% of students between grades 7 and 12 in Waterloo Region reported
having been drunk or high at school, and 16% reported that they had been offered, given
or sold a drug at school. Both of these rates appear to have dropped in the last two years
locally. In 2005, about 16.2 % reported having been drunk or high at school, and 27.7 %
reported that they had offered, given or sold a drug at school.
Types of Drugs Used in Waterloo Region: General population
All of the methods used in this study (interviews with various stakeholders, surveys, and
analysis of secondary data) pointed to similar conclusions — crack, cocaine, cannabis
and prescription opioids appear to be the most prevalent illegal drugs in Waterloo
Region. Heroin, ecstasy and other hallucinogenic drugs were also said to be widely used.
The secondary data source which comes closest to telling us something about the relative
prevalence of different drugs in the region as a whole is DATIS. It provides information
about the presenting problems of individuals seeking treatment for an addiction. DATIS
statistics from 2006-2007 suggest that excluding alcohol, cannabis, crack, cocaine and
prescription opioids are the substances most likely to be mentioned as problems by
residents of Waterloo Region when seeking treatment.
Our interviews with persons who use drugs (PWUD)6 supported the conclusion that
cannabis use is common. Many PWUD described a disregard for the illegality of
cannabis. Thus, many described using in open public spaces, for example, while walking
down the street. A common reported use of cannabis is to help ‘come down’ off of a
high from a stimulant such as cocaine.
Another study that suggests which drugs are used most frequently wave one of the
Ontario Harm Reduction Distribution Program’s 2007 Outcome Evaluation Report for
Waterloo Region (OERWR). The OERWR looked at drug use patterns of persons who
use injection drugs. It lists cannabis, crack and cocaine as the most commonly noninjected drugs used by persons who also use injection drugs. Seventy-nine percent of
persons in this group used cannabis at some point in the past six months, with 22.9%
describing it as their most commonly used non-injection substance. In the CAMH
Monitor survey of 2002 to 2005, 16.7% of Waterloo Region adults reported using
cannabis at some point in the last 12 months, which was close to the provincial average.
Seventy-five percent of participants in the OERWR reported using crack in the past six
months, with 37% listing it as their most common non-injection drug used. In addition,
5
According to the 2006 census, there are 33,890 youth aged 15-19 in Waterloo Region.
6
Throughout this report, we have used this term to refer to the individuals interviewed for this study who
used illegal drugs regularly.
Final Report - June 20, 2008 12
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
the percentage of participants who reported using cocaine in the past year (75%) equaled
those who used crack; however, far less participants (11%) reported cocaine to be their
most common non-injection drug.
The rates of persons who inject drugs who reported also using OxyContin, Dilaudid or
Percocet in the past six months were 56%, 49% and 44% respectively. Thirty percent of
persons who inject drugs reported smoking crystal methamphetamine in the six months
prior to their interview. Twenty percent had injected heroin in the six months prior to
their interview and 18% reported using heroin at some point during the same time frame
without injecting. Ecstasy use by this group was reported at a rate of 35%.
Our interviews with people who use drugs and service providers generally suggested
similar conclusions about types of drugs used and offered additional insights into the
trends and patterns of local drug use. Crack was described to be one of the most
accessible drugs believed by many to be “available anywhere, anytime” (person who uses
drugs). Frequent use of crack does not seem to be limited to any one demographic group.
Crack is the biggest substance I see on a daily basis. But I am seeing more people
using crack who are not street involved: husband and wives, grandmothers… They
are getting involved with it basically to cope with some stressful event (service
provider).
While the numbers are low compared with other demographic groups, one service
provider observed an increase in the number of senior people who are dependent on
crack-cocaine. A second service provider described crack cocaine and crystal
methamphetamine as being the two most prevalent drugs used with youth who are
homeless or who are at risk of becoming homeless.
Some service providers described prescription drugs as having replaced heroin as the
primary reason people seek assistance from local methadone clinics. Frequency rates for
drugs used by people seeking treatment in methadone clinics were not available to
support or dispute this perception. The most commonly ‘misused’ kinds of prescription
pills in Waterloo Region, as described by service providers and PWUD, were opiates
such as Percocet, OxyContin, and Dilaudid and barbituates. Misuse of prescription pills
is said to be particularly prevalent amongst seniors. One service provider noted high
rates of benzodiazepines (e.g. psychoactive drugs used to treat anxiety and insomnia) and
opiate analgesics (e.g. pain killers) among this population. Reportedly, misuse of
prescription pills is often overlooked by the people who use them and other community
members because they are not recognized commonly recognized as addictive drugs.
Additionally, the greater public and service providers are described as having low
awareness of drug use by seniors.
Many of those interviewed who are dependent on prescription opioids reported using
their pills to quickly ‘come down’ off of a crack-cocaine high or to reduce physical pain.
Several PWUD and service providers spoke of a pattern in prescription pill dependence
where the individual was first prescribed the pills by their doctor for a medical condition.
Final Report - June 20, 2008 13
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
A dependence on the pills developed, and upon noticing the dependence, their doctor
discontinued the prescription. Without a prescription, the interviewees then turned to the
streets for their pills.
I know one woman who had a Tylenol 3 prescription for years for a back injury.
One day, she got a new doctor who told her ‘I don’t prescribe narcotics’. This
woman is significantly disabled with a back injury. So where does she go for
medical help? She goes down to the corner there and gets Percocet or OxyContin.
(service provider)
Consistent with the secondary data findings, interviewees told us that crystal
methamphetamine was less prevalent than crack, other forms of cocaine, prescription
opioids or heroin. However, some service providers and PWUD reported its use to be
growing, particularly among youth. Its cheaper cost compared to crack may be one
contributing factor to this growth.
Crystal meth is really starting to take its place as the front runner. I have seen more
people over the years from being in the shelters and whatever who were addicted to
crack and are now are addicted to crystal meth. (Person who uses drugs).
Several PWUD and service providers described a decreasing trend in the amount of
heroin use that they see as compared to their observations of the drug in previous years.
Despite this common observation, police officers described seeing an increase in heroin
seizure reports. Reasons for this discrepancy are only speculative. Participants in this
study also reported seeing greater amounts of heroin use in Cambridge versus Kitchener
or Waterloo.
A legal intoxicant herb called salvia divinorum was described by service providers as
becoming more common among youth. The perennial herb, said to be derived from the
mint plant family, offers short-lived intense hallucinogenic experiences, reportedly often
lasting only 20-25 minutes. This drug is sold legally, for example in local convenience
stores.
Service providers who participated in the online survey had somewhat different
perceptions about the frequency with which various types of drugs were used, depending
on where they worked (Refer to Figure 1). Kitchener-based service providers saw the use
of prescription opioids and steroids as more common, while those based in Cambridge
rated cocaine, crack, and ecstasy as more common than did their counterparts in other
cities. Participant response from rural areas was not sufficient enough to produce reliable
results.
Final Report - June 20, 2008 14
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Figure 1: How Common Is Use of Specific Drug Types?: Perceptions of
Service Providers Based in Different Cities
Methamphetamines
Ketamine
Waterloo (n=6)
Heroin
Kitchener
(n=18)
Ecstacy
Dilaudid, Oxys, and pain
relief pills
Cambridge
(n=14)
Cocaine & Crack
Cannabis
Anabolic Steroids
0
Not at All
1
2
3
4
Very Common
Respondents whose primary focus was working with PWUD saw most types of drug use
as more common than did service providers whose work was not primarily in addictions.
In particular, experienced providers expressed more concern about some of the lesserknown drugs like ketamine and some types of prescription pills (Refer to Figure 2).
Final Report - June 20, 2008 15
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Figure 2: How Common Is Use of Specific Drug Types?: Perceptions of Service
Providers Who Work With Users vs. Those Who Work with Various Populations
Methamphetamines
Ketamine
all of our
clients use
regularly (n=6)
Heroin
Ecstacy
more than half
of our clients
use regularly
(7)
Dilaudid, Oxys, and pain
relief pills
about half of
our clients use
regularly
(n=16)
Cocaine & Crack
Cannabis
Anabolic Steroids
0
Not at All
1
2
3
4
Very Common
More experienced service and healthcare providers tended to see crystal
methamphetamine and cannabis as less common problems than their less experienced
colleagues. They tended to see stimulant use as more common than their less
experienced counterparts (Refer to Figure 3).
Final Report - June 20, 2008 16
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Figure 3: How Common Is Use of Specific Drug Types?: Comparing
Perceptions of Service Providers with Varying Levels of Experience
Methamphetamines
Ketamine
10 years or more
(n=20)
Heroin
4 to 9 years (n=10)
Ecstacy
Dilaudid, Oxys, and pain
relief pills
1 to 3 years (n=5)
Cocaine & Crack
Cannabis
Anabolic Steroids
0
Not at All
1
2
3
4
Very Common
Types of Drugs Used in Waterloo Region: High School Students
The OSDUHS results from 2007 suggest that the patterns of drug use are somewhat
different among youth who are enrolled in school than the general population. Although
the absolute percentages from DATIS and OSDUHS cannot be compared directly,
differences in the rankings of specific drugs across the two sources may be instructive.
Overall, they suggest that cocaine use is a more serious problem among the general
population than it is among students, and that hallucinogen use is more prevalent among
students than it is among adults. There is some suggestion of a downward trend in
cocaine use among students both in Waterloo Region and elsewhere in Ontario over the
last two years.
The OSDUHS report provided indications of types of drug use among high school
students, suggesting cannabis and opiates as the most common drugs used. In the
OSDUHS study, 21.8% of local students surveyed in 2007 reported using cannabis at
some point in the last 12 months. Provincially, the rate was 25.6%. At 18.3% of
respondents, students were more likely to have tried opiates for non-medical purposes
than they were to have smoked cigarettes (11.4%). Non-medical use of pain relievers in
2007 was slightly lower in Waterloo Region than the average provincial rate of 20.6%.
In 2007, 3.9% of the local students surveyed reported use of cocaine, as did 3.4% of
youth from across Ontario. Provincially, 1% of respondents reported using crack.
OSDUHS analysts were not able to make a reliable estimate of local crack usage rates.
Final Report - June 20, 2008 17
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
About 3.4% of local youth reported use of ecstasy in 2007, which was close to the
provincial average (3.5%) and similar to the local rate reported in 2005 (4.4%).
Other common types of drug use among grade 7 to 12 students in 2007 were
hallucinogens other than LSD or PCP (7.8%), over the counter sleeping medication
(6.7%), solvents (6.6%), glue (5.4%), and other stimulants (5.1%). Grade 7 to 12
students in Waterloo Region appear to have higher than provincial average usage rates
for sleeping medications, glue, and hallucinogens (Refer to Figure 4). Although there is
some suggestion in OSDUHS that OxyContin use among students is rising at a provincial
level (from 1% in 2005 to 1.8% in 2007), the OSDUHS was not able to produce reliable
local estimates of the rates of OxyContin use.
Figure 4: Rates of Use Reported by Students
(Source: OSDUS 2007)
Any Illicit Drug, including cannabis
Cannabis
Opioid Pain Relievers (non-medical use)
Any Illicit Drug, excluding cannabis
Cigarette Smoking
Other Hallucinogens
OTC Sleeping Medication (other purpose…
Solvents
Glue
Stimulants (non-medical use)
Cocaine
Ice (Crystal Methamphetamine)
Ecstasy (MDMA)
LSD
Students in Ontario (n=6323)
Students in Waterloo Region (n=386)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
% of students reporting use at least once during past
It should be noted that the Ontario Student Drug Use and Health Survey gathers data on
drug use among students in publicly funded high schools. These figures should not be
taken as representative of the drug use among youth who live on the streets.
Characteristics of People who use Drugs
Information from the DATIS database tells us that approximately 2925 local residents
sought some form of case management or community treatment for drug or gambling
addictions in 2006/07, and that the vast majority found these services locally.7
Residential withdrawal management services were used by 1067 individuals from
7
In addition, 191 family members of persons who used drugs sought treatment during the same period.
Therefore, the total of all individuals seeking treatment is 3116.
Final Report - June 20, 2008 18
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Waterloo Region during the same time period. Of the 251 residents of Waterloo Region
who made use of residential treatment services in 2006-2007, 82.4% left Waterloo
Region to access these programs in other parts of Ontario.
The most common presenting problems among people seeking treatment for addictions in
Waterloo Region in 2006-2007 (excluding alcohol), were cannabis, crack and cocaine
(Refer to Figure 5).
Figure 5: Presenting Problem Substances Among People
Seeking Treatment for Addictions in Waterloo Region (source:
DATIS 2006-2007 n=3116)
Cannabis
Crack
Cocaine
Prescription opioids
Tobacco
Ecstasy
Benzodiazepines
Methamphetamines (crystal meth.)
Amphet. & other stimulants exc. methamphetamines
Over-the-counter codeine preparations
Hallucinogens
Heroin/Opium
Other psychoactive drugs
Glue & other inhalants
Barbiturates
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
People seeking treatment for addictions in 2006-2007 varied in their life situations. As
Figure 6 and Figure 7 demonstrate, people at differing levels of income and education
struggle with drug addictions and dependence. A typical client seeking treatment for
drug/alcohol and/or gambling addictions, according to these data, has some or all of their
high school education and no contact with the legal system. Employment status varied.
Final Report - June 20, 2008 19
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Figure 6: Presenting Problem Substances Among People Seeking
Treatment for Addictions in Waterloo Region
(source: DATIS 2006-2007 n=3116)
Cannabis
Crack
Cocaine
Prescription opioids
Tobacco
Ecstasy
Benzodiazepines
Methamphetamines (crystal meth.)
Amphet. & other stimulants exc.…
Over-the-counter codeine preparations
Hallucinogens
Heroin/Opium
Other psychoactive drugs
Glue & other inhalants
Barbiturates
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Figure 7: Sources of Referral Among People Seeking Treatment for
Addictions in Waterloo Region (source: DATIS 2006-2007 n=3116)
Self
Addiction Agencies
Legal System
Family/Friends
Medical Services Private/Hospital
Social Service Agency - Adult
and Child
Physician/Private Practitioner
Psychiatric Services/Hospital
Women's/Men's Shelters
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Note: These charts include people seeking treatment for themselves (N=2925) as well as
those seeking treatment as family members (N=191).
Final Report - June 20, 2008 20
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Accessing Substances in Waterloo Region
Interviewees reported that drugs are sold throughout the region, by a range of people in
many different types of locations. Reportedly, drugs are not as accessible in the
surrounding townships as in the cities. Many who live in rural areas travel to Kitchener
or Cambridge to buy their drugs.
Many dealers reportedly sell more than one type of drug, increasing the ease with which a
buyer can try a new drug. This pattern was described by some people who use drugs as
one of the ways that people become involved with more than one drug.
You can find just about anything anywhere now. That is the problem. The coke
dealer has pills too (Person who uses drugs).
Reportedly, many people who are involved with drugs both use and sell:
It could really surprise you how many people are actually dealing at some level.
They will split [their drugs to sell] and then they will get [a cut]. It surprises me
when I ask ‘how do you get money to do this’ and how many say ‘well I have to
deal a little bit’. They are not heavy into it and it really surprises me, especially in
the youth how many are involved. I think the numbers [of dealers] are not just 2 or
3 big players, there are a lot of levels that I can’t even begin to comprehend.
(Service provider)
Prescription pills
Acquiring and selling prescription pills involves a unique set of practices. PWUD
explained that dealers often have doctors’ scripts for their pills. Instead of filling the
prescriptions for themselves, these individuals sell them on the street for a profit.
The practice of visiting different doctors to receive similar prescriptions was described by
some service providers. There was disagreement about the extent of this practice. Those
who saw this as a relatively uncommon practice pointed to an overall scarcity of
physicians in the region, and to recent efforts by hospitals to reduce ‘double doctoring’.
Poly drug use
Poly drug use is the practice of using more than one drug together. In this study, PWUD
described poly drug use to be occurring, but not frequently. In the mixing of drugs, there
is often a ‘primary drug’ or ‘drug of choice’ with an additional drug included to balance
out or counteract the effects of the primary drug. Prescription drugs, cannabis, heroin,
and alcohol were all described as substances used to balance out the effects of
crack/cocaine. In addition, drugs are sometimes combined to create an effect that differs
from what one would experience if using only one drug. For example, the mixing of
stimulants (e.g. ecstasy and cocaine) was described by service providers to be common
among youth in a party scene.
Final Report - June 20, 2008 21
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Geographical regions
Service providers who completed the survey had differing perceptions about where drug
use was most likely to occur depending on the city in which they worked.
Kitchener-based providers were more likely to report drug use in shelters, suburbs, and at
work, while those from Cambridge tended to report more frequent use in parks, on the
streets, or in the downtown core. Waterloo-based providers tended to rate drug use as
less common overall than their counterparts in Kitchener and Cambridge (Refer to Figure
8). Reliable data on the actual frequency of drug use by city or township is not currently
available, thus, these perceptions cannot yet be verified nor contradicted.
Figure 8: How Common is Drug Use in Specific Locations?: Perceptions of Service
Providers Based in Different Cities
bars/ dance
clubs
work
fitness clubs
Waterloo (n=6)
shelter
Kitchener
(n=18)
public streets
park
Cambridge
(n=14)
home
rural areas
suburbs
downtown
0
Not at All
1
2
3
4
Very Common
Although there were difficulties in this study recruiting interviewees who use drugs and
live in the surrounding townships, two interviewees and several service providers and
police officers were able to provide a general perspective of the patterns in Waterloo
Region’s rural communities. Within the surrounding townships, comparatively few
organized recreational opportunities exist and limited transportation is available to meet
up with peers or to travel to the city. Some service providers reported that drug use fills
this gap. In the small communities “everyone knows everyone else’s business and word
travels fast” (Person who uses drugs). This is said to affect how and where people use
their drugs. Reportedly, homes are where most people in surrounding townships use,
because homes provides privacy from other community members and security from
police. Parks, corn fields, community centres, and parking lots in cars were also
mentioned as places for quick, short term use.
Final Report - June 20, 2008 22
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Cities
Persons who use drugs, some service providers and some police officers described drug
use in Kitchener and Cambridge as more open and visible than use in Waterloo or in the
surrounding townships. Some participants in this study noted the concentration of people
in this area who do not have a fixed address and thus, do not have the option of private
places in which to use their drugs:
We’ve seen people using crack in their own place and in washrooms. Or just
somebody walking down the street with their stem and you wouldn’t even know it.
You’d think it was a cigarette. And they are walking [downtown] lighting it.
(Person who uses drugs).
Interviewees saw Waterloo and/or suburban areas in the cities as having a more affluent
demographic than either downtown Kitchener or downtown Cambridge, which affects the
location and visibility of drug use. A service provider explains this:
There are different demographics in the different cities. For the people in
downtown Kitchener, if you don’t have a place to live and you don’t have a car and
don’t have any money, you haven’t got a whole lot of choices about where you do
your drugs. Whereas if you are a university student and you can do it in your
residence or if you live in a big house you can probably do it in the room in the
basement with just a TV because everybody else is in some other room of the
house. Nobody even knows that you are down there using. (Service provider)
Drug-Related Travel to the Region by Non-Region Residents
Interviewees disagreed about the frequency with which people travel into Waterloo
Region for reasons related to drug use. About half of the participants reported that it was
common practice for people to travel to the region to buy and sell drugs. Dealers and
buyers were said to be greater in numbers and more visible in the region at the end of the
month, often staying and selling in hotels. Dealers from Waterloo Region also travel out
of the region to sell.
Some interviewees reported that people from cities and townships outside of Waterloo
Region sometimes traveled into Waterloo Region to buy and use drugs. The limited
availability of drugs in their own town was specified as the most common cause. People
also reportedly come to the region from outside areas to party.
When asked about the reasons for this travel, interviewees offered a wide variety of
examples and opinions. Some people felt that Waterloo Region had a reputation as an
area where drugs (and, in particular, crack) were easily accessible in comparison with
other cities in Southern Ontario.
Final Report - June 20, 2008 23
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
People come here because everything is so readily available and dealers come here
because all the usual dealers are in jail right now and they can make a killing.
(Person who uses drugs)
In addition, Kitchener was seen by some as a community with a reputation for good drug
treatment services. These services were described as attracting PWUD from other
regions. Reportedly, many of the people who arrive in Kitchener intending to access
services and address their drug dependency become discouraged and instead settle here
and join the local drug scenes. An insufficient number of services, contributing to a long
wait list, is credited by service providers as a source of this discouragement.
Other reasons for drug-related travel to this region included the practice of former
Waterloo Region residents returning to this area to purchase their drugs from their
previous dealers, and the practice of men, described mostly as professional, married, and
with families, travelling to Waterloo Region to anonymously buy and use drugs while
engaging in the sex trade.
The people who come from out of town [to use the sex trade], do not want to mix
business with pleasure. They do not want people to know in their home town that
they are drug users. Some just come in to Cambridge because they know crack is
available, some are from small towns. People who come into Cambridge from out
of town, find the drugs by going to the girls. (Person who uses drugs)
Perceptions of Safety: Purchasing Drugs
While some safety risks were noted, most PWUD described little to no safety concerns
when purchasing their drugs. The large majority of interviewees explained that they feel
safe when purchasing their drugs because they know their dealer(s) and they are familiar
with the place where the drugs are sold. Some described the dealers as friends. This
familiarity also serves to reassure people about the quality of the drugs they are buying.
People who use drugs were also aware of the competition between dealers, noting the
need for them to create ‘repeat customers’ and thus, ensure that a safe transaction occurs.
There are so many people that sell in these cities that you don’t have to worry about
getting ripped off so much from them because they would rather get you as a
clientele than rip you off a quick $60 or $40. Why wouldn’t they just keep you as a
client and make 10 times that off you? (PWUD)
While very few PWUD worried about purchasing their drugs if they knew their dealer,
some risks were shared. The situation that caused the greatest worry was the potential
for police to become involved and the criminal consequences that may follow. Personal
theft was also a concern for some.
Final Report - June 20, 2008 24
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Purchasing drugs impromptu from unknown dealers on the street is believed to be a risky
activity, potentially resulting in physical harm, theft, or criminal charges. Most PWUD
in this study avoided unfamiliar street transactions when purchasing their drugs.
If you deal on the street in an alley way or something, you are open to robbery and
assault and stuff like that. And rip offs. People don’t want to spend their money on
drugs and get ripped off. (Person who uses drugs)
Perceptions of Safety: Using Drugs
Most PWUD also reported feeling relatively safe when using their drugs. Many risks
were identified, but the majority of the participants reported that they had developed
ways to limit these risks. Some interviewees described examples of life-threatening
situations, but had strong beliefs that they would be able to defend themselves in these
situations; thus they believed themselves to be safe. This finding raises the question of
how participants are assessing the safety of certain situations and whether dangerous
situations have become normalized through repeated exposure. With this possible
phenomenon in mind, there may be other safety risks that people using drugs are exposed
to that were not mentioned in the interviews.
The risk most commonly noted was the potential of getting caught by police or family
members and facing criminal charges. Secondly, people who are high on drugs (most
pointedly crack) were described by PWUD and by some police officers as having
unpredictable behaviours and as sometimes experiencing suicidal ideation. For these
reasons, some people were concerned about what they might do or what others might do
to them while high. Thus, a common practice was to use only around others whom they
trusted and in places with which they were familiar.
I’m concerned for my own safety. I might end up in a gutter. I’m not afraid of
someone trying to hurt me, but maybe to steal from me. When I’m high and
working on the streets, I’m afraid but always try to be aware of my surroundings
and where I’m being taken. I watch out for idiots in the car and always have a plan
to get out. (Person who uses drugs)
Those who spoke of engaging in sexual activities while high noted the easy availability
of condoms and other contraceptives and believed themselves to be following safe
practices.
Drinking and driving was seen as a foolish and dangerous activity by youth PWUD who
were interviewed for this study. However, driving while under the influence of
marijuana was described as a common, socially acceptable practice among some cannibis
users. Data from the CAMH Monitor survey of adults8 supported this perception. About
2.6% of the local Monitor sample, and 15.6% of those who reported cannabis use in the
8
The CAMH Monitor is an ongoing random digit telephone survey. Figures quoted here are based on local
responses collected between 2002 and 2005.
Final Report - June 20, 2008 25
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
last 12 months, reported to have driven while under the influence of marijuana. These
rates were close to provincial averages.
Sharing drug instruments
Although the sharing of IV needles was commonly regarded by PWUD as a dangerous
practice, the sharing of crack pipes and other equipment seems to occur frequently.
Comments made in interviews suggested a low level of awareness or worry of the safety
risks involved. Service providers noted that crack pipes create a high possibly of cut lips,
broken skin, and burns. Thus, the sharing of equipment carries a high risk of blood
transmission and a potential contraction of communicable diseases (e.g. human
immunodeficiency virus [HIV] or hepatitis C). Some participants did not limit the
sharing of these instruments, while others only shared with people they knew and trusted.
When I use, of course I share pipes. Cigarettes and joints too. I guess [we
share pipes] because it is more comfortable. With accessibility wise, it is more
of a social activity. More of a group activity. And sometimes it is you don’t
have [your pipe], your friend has it. And since you are friends, you kind of
trust each other. (Person who uses drugs)
I’m aware of safe drug use. I share pipes, but never cookers, needles or water.
(Person who uses drugs)
A recent study conducted for the Ontario Harm Reduction Distribution Program by the
University of Ottawa that looked at the behaviours of injection drug users in Waterloo
Region quantified this contrast in harm reduction practices. About 11% of those
interviewed reported that they had given, lent or sold used needles in the last 6 months
and while 26% reported that they had taken a used needle from someone else, most
reported that they made use of used needles rarely. However, 85% of this same
population had shared their non-injection equipment (for example, crack smoking pipes)
with someone in the last six months, with 71% reporting this as a frequent practice.
Safety Concerns raised by Service/Healthcare Providers
Two potential safety risks were raised by some service and healthcare providers.
Some participants held the strong perception that marijuana is being laced with traces of
cocaine, causing an unbeknownst cocaine addiction for someone who has purchased and
used marijuana. There was disagreement between participants in this study as to whether
this practice was a myth or was actually occurring. Several of those who believe it to be
true, believe that some dealers are engaging in this practice to ‘hook’ buyers on the more
expensive drug, cocaine. Some service providers also believed this practice to be
occurring.
You can’t even prove that [lacing is] what [has happened], but when somebody has
a reaction that is totally not typical, totally differently than what they normally have
and you have two or three [patients] at the same time with this, you will somewhat
Final Report - June 20, 2008 26
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
assume at that point in time that something has happened there. But there is
nothing to trace. (Healthcare provider)
After seizures, Waterloo Regional Police Service routinely sends drugs for laboratory
testing. Police officers involved in this study noted that test results did not reveal any
cases where marijuana had been laced with other drugs.
Other participants described a perception that cocaine and crack are also frequently laced
with unknown substances. Secondly, some service and health providers described a
possible increase in THC in local marijuana products.
Although local data on the strength of drugs is not available, a 2004 report completed on
drug use in Toronto tracked the strength of various street drugs using data from Health
Canada tests carried out on seized substances9. This report tracked THC levels between
1987 and 2000, and found that the average THC level in marijuana had grown steadily
over that period of time from a purity rating of 2.5 to 7.5. During the same period, the
strength of crack appears to have decreased somewhat (from ratings in the 90s in the
early 1990’s to ratings in the 60s in 1999 and 200010). Although the study also tracked
the strength or purity of cocaine, heroin, and LSD, no clear trends over time emerged.
Summary
This study indicated that the most commonly bought and used substances (excluding
alcohol) in Waterloo Region are cannabis, crack, cocaine and prescription pills.
Following these four substances, hallucinogenic drugs and heroin were described as the
next most prevalent substances. Patterns of local drug use seem to be changing: use of
crystal methamphetamine was said to be increasing while heroin use seems to be
decreasing. Drug patterns among grade 7 to 12 students were found to differ somewhat
from those of the general population. Hallucinogens and cocaine use seemed to be more
prevalent among this student population as compared to its use by members of the
general population. Drug trafficking is carried out by both local and non-local residents
throughout the region, with greater numbers of transactions reportedly occurring in the
tri-cities than in the surrounding townships. People who use drugs seem to perceive little
to no safety concerns when buying or using their drugs. People using non-injection drugs
seem to be unaware of the health and safety risks directly associated with sharing their
equipment and reported that sharing occurs at high rates.
9
10
Berstein, Adlaf & Paglia-Boak (2004). Drug Use in Toronto. Toronto: Research Group on Drug Use.
At time of writing, no information was available about the metrics used to rate purity in this study.
Final Report - June 20, 2008 27
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Section Three: Health Needs and Community Response
Main messages of this section: This section discusses the health issues
and needs of persons who use drugs regularly, their response to these
health needs, their experiences with local healthcare and the challenges
of accessing and providing appropriate healthcare services. Overall,
most PWUD described access to healthcare and many accessed this care
with great satisfaction. However, a significant number of PWUD chose
to avoid these services for fear of judgment or criminal repercussions.
The perception of a stigma towards persons who use drugs was said to
deter people from accessing the necessary healthcare.
Health Issues Facing People who Use Drugs
While some persons who use drugs (PWUD) described themselves to be in “surprisingly
good health”, most participants noted several health complications and challenges, often
directly contributing their problems to their drug use. Lung difficulties (e.g. pneumonia,
water in the lungs) and immune deficiencies (e.g. recurring and long-lasting colds) were
most commonly discussed. One healthcare provider linked pneumonia and digestive
problems with excessive crack use. A second healthcare provider noted the wide-spread
need for asthma inhalers among those who use drugs. Other health problems commonly
mentioned included abscesses, rapid and excessive weight loss, chest and heart pains,
sleeping disorders, mental health illness and hepatitis C. Two healthcare providers also
mentioned the connection between thyroid problems and women who use crack.
Hepatitis C and Human Immunodeficiency Virus (HIV)
In the OERWR study of injection drug users, 90% of participants in that study had
received HIV tests in the past year and none had tested positive for HIV. However, of
the 87% who had received tests for hepatitis C in the past year, 50% had received a
positive result.
As of 2005, 960 people in Waterloo Region had sought out HIV tests and indicated that
they were at risk as a result of injection drug (ID) use11. To place this figure in context,
proportionally fewer local residents seek HIV tests for this reason than the provincial
average of 0.31%. Waterloo Region has similar rates of ID-drug related HIV tests as the
health units in Wellington, Niagara, Hamilton, Windsor and Northwestern Ontario, and
ranks 26th out of 36 Ontario health units in terms of the proportion of the population
seeking tests for this reason.
11
These figures are collected by the Ministry of Health and Long-Term Care and Region of Waterloo
Public Health. They represent all individuals tested since 1992. Other data from the health unit indicates
that a total of 1307 negative and 5 positive HIV tests were performed during this same period for
individuals who presented with IV drug use as a risk factor.
Final Report - June 20, 2008 28
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
The number of local injection drug-related HIV tests per year reached a high of 172 in
2002, and has since leveled off at about 145 per year. As Figure 9 shows, local injection
drug users have become more likely over time to use a name when seeking an HIV test,
although anonymous tests have become somewhat more common in the last three years.
Figure 9: HIV Negative Tests among IDU's By Type of Identifier
100.00%
90.00%
80.00%
70.00%
60.00%
Nominal
Coded
Anonymous
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Source: Ministry of Health and Long-Term Care and Region of Waterloo Public Health
Mental health
Mental illness and serious emotional difficulties affect many PWUD. Individuals
described struggling with depression, anxiety, panic attacks, manic episodes, suicidal
ideation, and general emotional stress.
I would be up and down a lot. You get really emotional some days thinking about
how your life is going and your friends. You want to stop doing it, but it’s a
struggle. You can’t, cause you’re addicted. It’s tough emotionally. (Person who
uses drugs)
Several of these individuals had been prescribed medications (e.g. anti-depressants or
tranquilizers), but often considered these prescriptions to be ineffective. Instead, these
individuals described a reliance on their drug of choice to escape their illness or current
situation.
Reportedly, the experience of drug use varies, depending on the mental health status
at the time of use. One participant explained that someone will experience a very
different effect if they are using it to manage their illness than if they are using
Final Report - June 20, 2008 29
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
simply to “have a good time”. The associated risk factors were described to increase
when escape became the motivation.
People with significant mental health conditions were described as particularly vulnerable
to entering into a drug use cycle:
People with mental health issues coming into a city can be very vulnerable to drug
dealers. I think the lack of support probably pushes that too and also the need to
make some more money. I hear that a lot too. They get involved for these reasons
when they probably wouldn’t have otherwise. (Healthcare provider)
Dental health
Dental problems among people who are regularly using drugs are widespread, most
commonly including cavities and tooth decay. Healthcare providers explained that any
drugs that have an effect of ‘speeding you up’ will rot your teeth. The acidic ingredients
in some drugs (for example methamphetamine) also contribute to poor dental health. In
addition, to deal with an excessively dry mouth (a symptom of crystal methamphetamine
use), people using crystal methamphetamine are said to frequently suck on candy. This is
also a contributing factor to poor dental health. The high cost of receiving the necessary
dental care seems to be to greatest contributing factor to poor dental health amongst this
population.
Nutritional intake
There seems to be ready access within Waterloo Region to healthy meals, most notably at
local shelters and food banks for those without a fixed address or an ability to shop and
cook for those living in a residence. Discrepancies were shared as to whether or not
people using drugs access the healthy foods available to them. While most PWUD
described themselves as maintaining a healthy diet, healthcare providers had a different
perspective on nutrition among those using drugs. Some expressed concern about their
clients looking malnourished and ill. Other PWUD described a tendency to not eat
during periods of crack use, followed by a day of binge eating.
When we smoke, we don’t eat. We don’t care. It makes you not want to eat.
Then a day later, I eat like a horse. (Person who uses drugs)
I used to eat a lot and be active. But once I started getting into drugs, I’d miss
meals. I went from eating healthy meals to eating a burger here and there.
My nutrition wasn’t very good. (Person who uses drugs)
Final Report - June 20, 2008 30
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Response to Health Problems
Overdoses
People who use drugs have complex needs and require a holistic approach to social
supports. This complexity was illustrated through one of the questions asked during the
interviews with people who use drugs. PWUD were asked during the interview about
what they thought would happen if they were facing a medical emergency like an
overdose. About half of PWUD had experienced overdoses, seizures, or other bad
reactions. One participant believed he had overdosed at least 30 times in his life. A
second participant described overdosing 5 times in one week, receiving professional help
each time.
About half told us that other people using drugs in their social network would be unlikely
to seek medical help on their behalf. They believed that their friends would either try to
help them themselves or would simply flee the scene. The remaining half of the PWUD
felt confident that members of their social network would contact health providers. In
some situations, friends would then stay with them until the medical response arrived,
while others would flee the scene once a call to emergency had been made.
I think it would depend on who was there. Most people I would say are pretty
well fending for themselves. I have seen situations where people have gone under
and overdosed and people have helped and I have also seen situations where
people walk away. (Person who uses drugs)
All three local hospitals provided statistics about emergency room visits that offer some
insights into the use of health care services by PWUD. There were more than 500 visits
to these three emergency rooms for drug overdoses or exposure to drugs between April of
2007 and March of 2008.
Final Report - June 20, 2008 31
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Table 1: Number of emergency room visits to Cambridge Memorial, Grand River and St.
Mary’s General Hospitals coded as self poisonings (overdoes) between April 2007 and
March 2008.
Self-poisoning by and exposure to
nonopioid analgesics, antipyretics
and antirheumatics
Self-poisoning by and exposure to
antiepileptic, sedative-hypnotic,
antiparkinsonism and psychotropic
drugs, not elsewhere classified
Self-poisoning by and exposure to
narcotics and psychodysleptics
[hallucinogens], not elsewhere
classified
Self-poisoning by and exposure to
other drugs acting on the autonomic
nervous system
Self-poisoning by and exposure to
other and unspecified drugs,
medicaments and biological
substances
Totals
# of emergency room
visits by people aged
20 or younger
(40.1% of
all visits
for this
53
reason)
# of emergency
room visits by
people aged 60 or
older
Total emergency
room visits coded
as self-poisoning
2
(1.5%)
132
40
(17%)
13
(5.5%)
235
11
(16.6%)
2
(3%)
66
3
(33.3%)
0
(0.0%)
9
15
(23.4%)
5
(7.8%)
64
122
22
NOTE: Data from St. Mary’s General Hospital does not include cases from March of
2008.
This table shows that there were 122 occasions last year on which individuals under the
age of 20 came to the emergency room for treatment of some type of overdose. Over
40% of those treated for analgesics (i.e. pain killers such as codeine and oxycodone),
antipyretics (i.e. pain relievers such as aspirin and acetaminophen) and antirheumatics
(i.e. disease modifying drugs) were youth.
Relatively few seniors came to local emergency rooms last year due to overdoes. Those
older adults who were treated tended to have overdosed on antiepileptic,
sedative-hypnotic (i.e. depressants), antiparkinsonism and psychotropic (i.e.
antidepressants and mood stabilizers) drugs.
Many persons who use drugs regularly find health care services
accessible and respectful.
Accessing health care didn’t seem to be an issue for most city-located PWUD. Many
mentioned physicians, family doctors, walk-in-clinics, hospitals, community health
nurses, jail-based healthcare, and shelter or community-based nurses as being available to
Final Report - June 20, 2008 32
506
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
them. Participants from the surrounding townships described having long-term family
doctors for ongoing care, but a lack of local services for quick health attention. One
participant described driving into Waterloo to access the walk-in clinics if he needed to
see someone more urgently.
Most PWUD described positive interactions with healthcare professionals, using words
like “convenient”, “very helpful”, “understanding of addictions”, and “extremely
supportive”.
Broader systemic issues sometimes act as obstacles to access for
health care
Sometimes, the factors that limit access to healthcare for people who are using drugs
regularly are broader systemic problems rather than characteristics of health care
providers or organizations specifically. For example, one individual explained that not
having a health card made him ineligible for non-emergency health services. Many
people who use drugs and live on the streets are said to have had their health cards lost,
stolen, or sold. Obtaining a new health card is a lengthy process. Healthcare services are
available without a health card, but patients are required to pay for treatment. This is
often not a feasible option for those who are dependent on substances.12
Despite having access to healthcare providers, about half of PWUD revealed that they do
not willingly seek healthcare in a timely manner. Instead, these individuals described
waiting until “the last second possible” to have someone treat a lingering illness or
complication. The criminal lens through which drug use is commonly viewed and the
subsequent stigma of people who use drugs and fear of criminal repercussions seemed to
contribute to the unwillingness to seek necessary healthcare. Several PWUD described
avoiding healthcare because of a fear of criminal repercussions for violating their no-drug
parole conditions.
[They should create a place where] they can check you over and make sure
you are okay without getting [you] in trouble. Because there are some people
who are on bail and if you go in and part of their conditions are not to ingest
or inject any illegal substances, they are screwed. (Person who uses drugs)
I am going this evening, but only because I can’t stand it anymore. It is just
getting worse. Yesterday I wouldn’t have gone but this morning when I woke
up I can’t move my thumb so I thought it is time to go before I lose my arm.
But I will take it right to the end. Always have, and more so now depending
on what it is and how visible the marks are. (Person who uses drugs)
People who are dealing with mental health issues and addictions sometimes have trouble
getting the services they need. Limited collaboration between the two sectors, and a
12
Some local health care providers are willing to provide service to people without health cards. The
Kitchener Downtown Community Health Centre also offers an ID clinic to help people acquire the ID they
need to access services.
Final Report - June 20, 2008 33
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
shortage of psychiatrists was said to lead to gaps in care for people with concurrent
disorders.
In some of the hospital crisis clinics, if there is any mention of drugs [by someone
seeking help], then their condition is not considered a mental health issue, but a
drug issue. That’s the opinion and I can understand why they see it that way
because they are dealing with someone who happens to be high on drugs right now
but also has mental health issues. (Healthcare provider).
There has been a shortage of psychiatrists in this area for a long time. When they
are dealing with so many and they come through the door, they want to service the
ones they can help. And if there is someone acting out they would rather have the
police come and take them away. (Healthcare provider).
Some individuals report experiences of discrimination when dealing
with the health care system.
Although the majority of people interviewed spoke about health providers in positive
terms, the sense of feeling judged and rejected when seeking healthcare seems to affect
some people who use drugs:
They [certain health care providers] see the track marks and they are very
judgmental. They should be taught as nurses to be non-judgmental and not form
opinions and they definitely do there. I ended up going to a [different location to
receive care] because the [first location] called the police and said I was only
there for pain pills. They treat you like you are just there for drugs even though
you have a legitimate reason to be there. I have told them before I am not looking
for pain medication. I am looking to have the problem fixed. I was there 5 times
in one week. (Person who uses drugs)
Several examples were shared of persons who use drugs being turned away or ridiculed
by health care providers. Some interviewees reported that they either chose not to seek
healthcare when needed or did not disclose their drug use to their practitioner because of
their concern about discrimination. Consequently, they risked not receiving the
appropriate care.
Some health care providers are naming the need to improve their
service to this population.
Some healthcare providers interviewed for this study discussed a need to reflect upon
their own values and judgments to ensure that they are not negatively influencing their
ability to support and offer service to persons using drugs.
Professionals have to look at themselves and where they are at with what they are
doing. You have to be very non judgmental and there to help your client
regardless. You have to look at yourself. Can I do this? I think that might impede
some of the programs if that professional hasn’t got there and not to say they are
Final Report - June 20, 2008 34
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
not doing their job, but it might not be the right job for them. (Healthcare
provider)
Some healthcare providers raised the need for an increased dissemination of information
on drug use and addictions. In addition to allowing healthcare providers to offer more
complete services, this may also address some of the existing judgment discussed above.
There certainly is a reluctance to access medical care, […], because of the attitude
that they are likely to get. Some will say ‘I would have to be half dead’. Last week
I saw someone who had [a serious injury]. And there was no way he was going to
the hospital. No way. (Healthcare provider)
Summary
Many of the individuals who were interviewed for this study had significant health issues.
Despite the fact that most were aware of healthcare services and knew how to access
them, it was clear that interviewees were not, on average, getting adequate healthcare.
Lack of understanding among users about the importance of care, fear of discrimination
or arrest, and lack of access to health care providers trained to meet the needs of people
who use drugs were some of the reasons why.
When people who use drugs can not or do not access health care, the reasons are often
complex. Sometimes the reason is a preoccupation with obtaining and using substances
that takes priority over seeking out and following through on medical appointments.
However, if people who use drugs don’t get the health care they need, it is also frequently
a result of the ways in which the health care system interacts with the criminal system or
with the mental health system. Lack of proper identification, lack of adequate housing,
and isolation can also play a role.
Final Report - June 20, 2008 35
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Section Four: A Holistic Approach to Support for
Individuals who Use Drugs; Systemic Issues, Social
Needs and the Community Response
Main Messages of this Section: This section describes social issues facing people
who use drugs regularly, their knowledge of available services and harm reduction
programs, experiences with services, and barriers to accessing and providing
services and harm reduction programs. The findings identify some of the key
factors that seem to distinguish effective support services, as well as some of the
barriers that can prevent those who decide to seek help from receiving appropriate
treatment.
Social Dilemmas facing Persons who Use Drugs Regularly
Over the course of this study, we heard a great deal about the ways in which systemic,
structural issues are obstacles to people who are attempting to seek help or make healthier
choices. For example, almost all respondents to the online survey of service providers
felt that unemployment, inadequate housing, lack of social supports and isolation were
issues that affected persons using drugs.
Many of the people who use drugs we spoke to felt that they were caught in dilemmas.
In order to overcome their drug dependence, they believed they would have to sever
important social ties with people who influenced their drug use. In order to help their
friends in an emergency situation, they would have to risk being arrested. In order to
present themselves as stable enough to hold a job, they would have to take steps that
risked further destabilization. These paradoxes are one of the indications that the system
is not serving people who use drugs as well as it could.
Balancing a need for appropriate housing with a need to work
towards treatment goals.
An inability to acquire affordable housing was described by some interviewees (both
service providers and persons using drugs) as the most pressing social issue facing
persons who have made a choice to reduce their use or stop altogether. Limited options
for housing were described as particularly debilitating during the transition periods from
treatment or correctional facilities back into the community. PWUD or former PWUD
are sometimes faced with the dilemma of returning to a neighbourhood or community
where they feel there is a high risk of relapse, in order to meet basic needs like food or
shelter.
I go [to the shelter] once every couple of weeks, but in my opinion it is a scary
place. There is drug selling and everything. And all you hear about is drugs when
you walk through that door. Want to buy some, want some? It’s like oh my god, I
Final Report - June 20, 2008 36
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
need to get in and out of here. [They] planted the seed [of thinking about drugs].
All they had to do was say it and then what am I doing that night? I’ll buy some
with this extra money I’ve got. I can’t blame anybody else but myself, but it makes
you want it. (Person who uses drugs)
Two service providers explained the impact of this situation:
There are a few options [for people who need subsidized housing and want to
address their drug addiction]. If you are on a fixed income or you have no income,
what are your choices? You don’t have many. Trying to move away from the
friends that are involved with drugs to isolate yourself and hang out with healthier
people is really hard to do. So, if you have to go a shelter or you need to find
subsidized housing, they can’t even say it’s safe and affordable. And you’re going
to be around folks who do a lot of drugs. So they’re really caught in a pickle
(Service provider).
Simply starting treatment on the addictions and underlying issues – because it will
continue to be an ongoing battle for probably the rest of the person’s life – isn't
enough. We send them back to their environments and triggers and expect them to
survive. It's key to their recovery that we give them the skills and abilities to stay
clean once they're out. (Service provider)
Overcoming shame in order to deal with isolation
A pattern of drug use often leads to a deterioration of relationships and friendships,
paranoia and shame about their addiction, a rejection of previously enjoyed activities,
isolation, and a lack of social supports. These factors often led people we interviewed to
express intense feelings of loneliness.
We don’t have much family for advice and can’t go to our parents and say look we
have a drug problem. My parents don’t believe in drugs. That’s a no-no in my
household and a no-no in his household so who can you go to? I can’t go to
anybody except him. We have each other and that’s all we have, and we both do it.
So you see our problem? Who are we supposed to turn to? (Person who uses
drugs)
This loneliness often leads those who are trying to alter or stop their drug use, back to
people from their former drug scene and subsequently back to their former drug patterns.
I know it is not just crack that is hurting me, it is my own stupidity. But at the same
time, it is the only thing that is helping me. I don’t really have someone to talk to
and the only kind of friend, like a bartender, that I have is the crack. The one thing
that is killing me is the one thing that is helping me. At the same time.” (Person
who uses drugs).
Final Report - June 20, 2008 37
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Managing a job or job-readiness training while dealing with the
effects of drug dependence.
A lack of job-readiness, in terms of emotional stability and job obtainment skills, was
said to commonly affect unemployed persons with drug dependence. Even for people
who use drugs who do have jobs, limited job productivity and job instability are common.
The requirement of criminal record checks also poses a significant barrier to acquiring
employment for those who have been charged with drug possession and/or trafficking.
High rates of crime, both as a perpetrator and as a victim, were also described as
significant issues facing people with drug dependence. This issue arose most commonly
in association with use of crack and cocaine.
The importance of hope
These dilemmas are only examples, and do not by any means reflect the diversity of
experiences and challenges faced by people who use drugs regularly in Waterloo Region.
These dilemmas do, however, provide some sense of the challenges involved in seeking
help and helping oneself in the face of an addiction.
Perhaps for these reasons, limited hope for recovery was evident throughout the
interviews and focus groups. A doubt in their ability to overcome their addiction seems
to be created through repeated unsuccessful attempts to receive treatment. One
participant explained:
I really deep down don’t want to do it anymore it’s just I think this is the
hardest thing I have ever had to face in my entire life and I have come
across a lot of hard crap. This is the hardest thing I have ever had to fight.
That’s the honest truth. I have quit alcohol, I have quit cigarettes and this is
honestly the hardest thing I have ever dealt with. (Person who uses drugs)
Knowledge of Harm Reduction Services and Practices
When asked about harm reduction, most PWUD and service providers focused on
practices and services related to safer use of drug instruments, communicable disease
testing, and the substitution of one drug for another with ‘less severe’ symptoms (for
example, smoking marijuana to curb cravings for crack or using methadone instead of
heroin or prescription pills). Some service providers also spoke about educational
sessions and workshops on drug related topics for the general public. The low diversity
of answers to this question suggests a limited awareness by some persons who use drugs
and some service providers within Waterloo Region of the full spectrum of practices and
services that fall within the umbrella of harm reduction.
However, within the described areas of harm reduction, knowledge and perceived value
of supports and practices for safe injection drug use was high for PWUD. Most PWUD
were aware of needle exchange services, condom distribution, polysporin distribution,
and HIV and hepatitis C tests. In contrast, knowledge and perceived value of harm
reduction supports and practices was quite low for non-injection drug use. The sharing of
Final Report - June 20, 2008 38
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
non-injection drug instruments was found to be a common practice, with the majority of
PWUD seemingly not understanding the subsequent risks.
Overall, information about harm reduction practices is described to be less readily
available for high school students than for other populations. There is also an indication
that those in the surrounding townships may have less understanding of the harm
reduction practices and services, due to the more hidden and less frequently discussed
nature of drug use.
Drug use as a social issue: principles to guide an appropriate
response
Interviews conducted for this study suggested that meeting the social needs of persons
who use drugs requires an approach that is non-judgmental, context and person-specific,
and timely.
The importance of a comfortable, non-judgmental atmosphere
The majority of the people interviewed who had used one or more of the services
available to them reported positive experiences. Most people commented on the friendly
staff and welcoming, non-judgmental nature of the agency or location. Places that
offered services, but “didn’t push them on you” were held in high regard.
[At this organization], you don’t have to be embarrassed and go into a drug store to
get [your supplies]. They have couches and everything else if you want to sit down.
There are computers you can use or a phone. It’s a good resource place. You don’t
have to be afraid to go in and talk to them. These people are the same as you and
me. They have been there before and they know exactly what you’re going
through. They will answer any questions you have. There is enough [staff] there
that if one of them can’t answer your question, you will get pointed to someone
who can. (Person who uses drugs).
The description of this setting is in sharp contract to the one below, in which a person
who uses drugs describes a service agency that s/he did not perceive to be comfortable
and welcoming;
[It was] too scary. The desk and office and receptionist and everything, it is just too
freaky. I just don’t like it. Going there it is more like walking into a clinic. I think
if a younger person had to go, it would freak them out. For the younger crowd, it
has got to be more welcoming. You can’t be walking into a place like that. They
are going to be afraid of whether there is a cop there. Or if somebody is watching
them. (Person who uses drugs)
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
The importance of a timely response
Extensive wait times were described as a significant barrier to receiving services and
support in a timely way. For people who use drugs, the window of opportunity within
which they are willing and able to reach out for support may be small.
If they have made a decision to come to a place where they are like ya, I do need to
make some changes, they are going to take 6 weeks to get them in. They will be
back with the peer group doing exactly the same thing and will become all caught
up in it again. Then you’ve have lost the momentum. I think remembering when
the appointment is [also a struggle]. (Service provider)
The windows of opportunity to appeal to someone who uses drugs and who has
come to terms with his or her “problem” is small. Making these resources available
at the right moment is difficult and is rarely obvious. You have to seek out and
serve the individuals who are ready for help at the right time. Making these
resources more readily accessible is imperative to addressing these issues and
helping this population. (Service provider)
Contributing to the extensive waitlists is an insufficient number of residential options.
Participants spoke of options in other cities, but few local facilities.
It is woefully inadequate in this community in terms of out patient treatment; there
is only one out patient organization. People wait weeks if not months to get the
appointment and it is far too late. And that’s sometimes just for the intake
appointment (Service provider).
The importance of making supports available in more than one
geographic location
The location of services was seen as deterring some people from seeking support. Many
services are available in areas with large concentrations of people. Some individuals
interviewed for this study, who are trying to refrain from drug use, choose to avoid the
downtown areas where services are located in order to avoid the triggers of seeing people
from their former drug scene and of smelling drug smoke. Additionally, the courts will
sometimes order individuals charged with drug-related offenses to avoid a geographical
area – often the downtown Kitchener core. This becomes an additional barrier to
accessing services.
There seems to be limited services available in the surrounding townships and a lack of
easy transportation to the services available in the cities. Additional challenges exist for
rural youth who use drugs who do not drive or have access to a vehicle, and do not wish
to disclose their use in order to access a ride.
Final Report - June 20, 2008 40
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
The importance of after-hours supports
The hours of operation for needle exchange and other services are seen as barrier. Some
of these services are limited to a 9 a.m. to 5 p.m. window, whereas drug use occurs
throughout the day and night. One participant explained that if she needs support or
needles at 3am, the only person she knows to be available to her is her drug dealer. A
mobile unit offering supports such as needle exchange was suggested by several service
providers as a possible solution to this challenge.
The importance of a coordinated response capable of meeting
individuals wherever they are “at.”
All of the principles listed above take for granted a simple but important truth. Providing
support to people who use drugs requires a multi-faceted approach. People who use
drugs vary greatly with respect to their socio-economic situation, the underlying reasons
for their drug use, and their degree of readiness for change. An appropriate system of
supports needs to have multiple entry points, multiple treatment modalities, and the
capacity to adapt constantly.
Many treatment centres are designed to meet the needs of clients who are at a particular
stage in the recovery process, and they have a requirement that people be sober for a
number of days prior to entering treatment. Those with limited social supports have
difficulty refraining from drug use.
I had a woman that had long time ketamine use and she said she wanted to go into
treatment. So I called up a place and she has to be clean for seven days before she
can come. Seven days? I am lucky if I can keep her away from this drug for seven
hours. So, they get there and they say they haven’t used and they do a urine test
and they send you home. It was outside of Waterloo Region, in Toronto. That is
fairly usual. I called a number of treatment places and they have to have a period of
sobriety before they can get in. (Service provider)
Secondly, many treatment facilities required that those wishing to access services have a
provincially regulated assessment tool completed before they can enter the intake
process. There are restrictions as to where these tools can be completed and this can lead
to an additional wait for treatment.
It used to be that somebody would present and say I want treatment and you could
get out the old DART registry and call around and say “they have a bed, here is a
bus ticket. Off you go.” Now, this policy has been implemented requiring an
assessment. It could be weeks before they get an assessment, so that is a huge
barrier because the person says the heck with it and they give up. Whereas you
could have sent them off that day in the old days. (Service Provider)
Some participants told us that there are disagreements within the local service community
about how best to respond to the needs of people who use drugs regularly. Opinions
Final Report - June 20, 2008 41
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
about harm reduction practices such as needle exchange and dissemination of crack kits,
for example, appear to differ greatly in this region.
Harm reduction is a bit of a touchy subject because there are certain groups of
people who believe abstinence is the only way – and that is fine. So sometimes it is
a political hot potato for agencies to even come out and admit they are doing harm
reduction type stuff because it is seen as enabling and encouraging. (Service
provider).
I think the challenge comes from other agencies that mandate services. There is a
time frame and the person is often going for drug testing. They might smoke pot
once over a 6 month period twice or have a drink and it is often viewed as a big
issue. (Service provider)
Some police officers described how their mandate to encourage accordance with the law
makes it difficult to respond to certain harm reduction initiatives when collaborating with
service providers in Waterloo Region.
Several service provider interviewees talked about the importance of taking a
differentiated, context-sensitive approach to support people who use drugs. Police
officers, for example, described a strong desire to not simply arrest someone for
possessing drugs, but to serve as a bridge for those using drugs to gain help for their
situation.
It’s ineffective to arrest these people. They’re out the next day and they’re still
addicted. They would all prefer not to use drugs. They tell us the cost of the drugs.
There is that level of humanity you can touch on. It doesn’t help anybody to get
into the rotating door of arrests. We are not there to throw a kid in jail because he
has a joint in his pocket. There’s lots of misunderstanding [about our role]. (Police
officer)
Importance of close collaboration between police services and social
and healthcare organizations
Given their regular interactions with people who use drugs, some police officers
emphasized the importance of their involvement in community planning initiatives.
Additionally, the anticipation of a criminal response to drug use has created a barrier to
persons who use drugs receiving appropriate health care and social supports. Thus,
police involvement in planning initiatives is important when developing strategies to
reduce these barriers.
Collaborations between police officers and service providers/support persons do currently
exist, but a desired for further development in this area was expressed by police
participants. Police officers described active relationships with local schools and
teachers, local parents affected by drug use, and diverse types of health and social service
providers.
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Some police officers perceived a lack of trust towards them by some social agencies.
This perception was said to serve as a barrier in the development of relationships and
collaborative groups. Conversely, none of the service provider participants indicated low
trust toward police services. Some service and healthcare providers noted that police
officers were changing and becoming more collaborative in their response, but added that
a continued focus on strengthening relationships between support agencies and police
officers is needed. In addition, the perception of differing mandates between the police
force and harm reduction agencies and a lack of full understanding of the working
context of the other party may also hinder the growth of a collaborative relationship.
The importance of equipping service organizations with resources to
effectively support persons who use drugs
When asked about the challenges of providing supports to persons who use drugs, most
service providers pointed to “insufficient funding” for drug-related services.
Summary
Participants in this study described how drug use touched vast areas of their life. The
findings revealed diverse and complex social needs, including housing, job readiness
skills, and support to overcome isolation and insufficient social supports. Those who
desire support in overcoming these challenges often face barriers including limited hours
of availability for services, extensive waitlists, pre-requisites of pre-treatment sobriety
and assessment tests, and the presence of potential triggers in areas that surround
services. For those who live in rural areas, a lack of transportation to the city-based
services adds an additional challenge. Overall, satisfaction with social supports seems to
be high: those who access support through social services described mainly positive
experiences with their service providers.
Final Report - June 20, 2008 43
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Section Five: Outreach - Linking People with Services
Main Messages of this Section: Section five describes the
experiences and perspectives of outreach and referral activities, as held
by PWUD. The section also summarizes suggested approaches to
future outreach initiatives, and offers indications of qualities of an
ideal outreach worker. Those who had prior experience with outreach
or referrals shared positive response, while those with no prior
experience did not welcome the practice. The suggestions for future
outreach activities provided a rich and detailed description of how
efforts to reach out to this population should look.
Experiences with Referrals and Outreach Workers
Information from DATIS tells us that more than 60% of people who sought treatment for
addictions last year were self-referrals. Other common referral sources were other
addictions agencies, the legal system, family and friends, and health care providers (Refer
to Figure 10).
Figure 10: Sources of Referral Among People Seeking
Treatment for Addictions in Waterloo Region (source: DATIS
2006-2007 n=3116)
Self
Addiction Agencies
Legal System
Family/Friends
Medical Services Private/Hospital
Social Service Agency - Adult
and Child
Physician/Private Practitioner
Psychiatric Services/Hospital
Women's/Men's Shelters
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
Final Report - June 20, 2008 44
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Of the PWUD interviewed for this study, about three-quarters had reportedly never been
approached by an outreach worker or referred to a service or community support. Those
with experience of outreach or referral described a wide range of contacts - street
outreach workers, pharmacists, lawyers, probation officers, judges, and staff from social
services they already accessed.
At the drugstore was how I found out about [the outreach worker]. That is when I
started using them. [The pharmacist] said ‘why are you paying for it when you
can get it for nothing’. Alcohol swabs and stuff like that. So I went in, and sat
down with a staff member and told her what I do and she basically set me up with
what I needed. (Person who uses drugs)
Everyone who had been approached by a type of outreach worker described a positive
experience and outcome.
It made me think about how you hear about all these people getting HIV and AIDS
and stuff because they used an old needle and stuff and it is preventable totally. It
would be terrible to get it that way when you could have prevented it. (Person who
uses drugs)
They were very helpful and approachable as well as willing to discuss anything that
I was willing to talk about with them. It was usually about services and how to get
certain things done. (Person who uses drugs)
My probation officer and lawyer have both tried to help me with this. It is because
of their efforts that I am going for the assessment in January. They discussed with
me the necessity of getting clean and that I needed treatment to do that as well as
the legal consequences if I didn’t follow through: breach and a 2 year jail term.
(Person who uses drugs)
The outreach program assisted me with the clean needle exchange and options [to
get clean], food, and support. The people helping me have been life savers.
(Person who uses drugs)
Of those participants who had not been approached by a type of outreach worker, nearly
all believed they would not welcome someone trying to connect with them. Reasons for
this rejection included a lack of trust of an unknown person, an unwillingness to listen to
a “clean” (non-drug using) person, and a disbelief in the effectiveness of services.
I wouldn’t want an Outreach Worker to approach me on the street but I
might pick up a flyer or brochure from a bus station. I use the bus station a
lot. It’s a good place to pick up information. I know where to get help
when I want it. (Person who uses drugs)
Final Report - June 20, 2008 45
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Suggested Approach to Outreach
Many social service and healthcare providers identified that the creation of a unified,
regional outreach plan, involving key service and healthcare players, would be an
initiative that would increase the degree to which people are connected with the most
appropriate and comprehensive care. It’s believed that this approach would also ensure
that agencies and organizations cooperate and make them aware of the information
publicly shared about their services.
According to most PWUD and service and healthcare providers, outreach workers should
maintain an open mind without a pre-determined idea of what will be best for the people
they approach and be equipped with in-depth information about available services and
supports and about safer drug practices. Of specific importance was how to avoid
waitlists and receive help quickly.
If someone were to offer information, it would need to be quick and to the point.
Say what you have to say quickly and to the point, if you have a sandwich for me or
something to offer, do it with little questions, tell me where to get a pap test or a
pregnancy test, don't tell me what to do, tell me I can get help if I want it. (Person
who uses drugs).
Hosting or attending seminars or workshops on safer drug use were suggested to be a
beneficial way to connect with people who use drugs. As indicated above the desire to
understand and follow safer drug practices is strong for people who use drugs in this
region.
It was also suggested that outreach workers should carry healthcare items or clean drug
instruments. These resources will help provide needed health services for those choosing
not to access healthcare centres, and will also help to build trust and rapport with people
who are using drugs. Specifically suggested were condoms, clean needles and IV
equipment, stems, pipes, screens, abscess kits, saline water, gauze, tape, and a sharps
container for collecting disposals.
[Outreach workers need to] go out there and build that rapport and that trust. Not
just try to pull them in initially. [They should be asking] ‘what do you need and
how can we help you just today’? It may be a pair of mitts. Build that rapport to
bring them in so that they can see the plethora of help they could get if they wanted
it. Being proactive is very successful. It is the whole notion of “you are coming to
me” that builds connections with people. That means I am an important person
even though I am not feeling it. You are coming to me. There are the skeptics still
who think you are being paid to come out here and if you pull me in you get more
money and so on. But again it is that protective shell that people put around
themselves. (Service provider)
Final Report - June 20, 2008 46
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Hard-to-Reach Populations
Current outreach efforts were seen to be more effective at reaching some demographic
groups than others. Two strategies were raised to reach those who may be harder to
connect with. First, a broad community-wide social marketing campaign about what
drug use is, how it affects people, and options for support for those affected was
suggested. This strategy could educate those who do not consider their use to be drugrelated (e.g. misuse of prescription pills, use of party drugs, etc.) and could address the
general stigma that surrounds people affecting by drug use by eliciting a compassionate
regard.
Secondly, populations deemed hard to reach could be identified and targeted with a
specialized plan. Youth and seniors were noted by service providers to be two
populations that currently don’t receive effective outreach. Some service providers
suggested that seniors were particularly hard to reach because their drug use often
involves misuse of prescription pills, and as such, they reportedly don’t view themselves
as someone affected by drug dependency. Thus, they often don’t relate or respond to
information and literature that discusses topics related to “drug” or “substance” use.
Geographic Areas where outreach occurs
When asked about places to connect with people using drugs, most participants reiterated
that drug use is not confined to any specific area; that people who are in need of services
are everywhere throughout the region. The Kitchener downtown core, parks, alleys, bus
terminals, soup kitchens, and Cambridge convenience stores were identified as places
where drug use and transactions frequently occur.
Qualities of an Ideal Outreach Worker
Foremost, based on the comments shared by interviewees who use drugs, outreach
workers with prior personal experiences with drugs will be better received by people with
personal drug dependency than those without. This commonality of experiences seems to
be held in high regard amongst people who are currently using drugs. Experience was
often perceived to be the only way that people would genuinely understand the issues and
day-to-day struggles with drugs.
Someone who has never used drugs or alcohol or been through what I have
been through can’t sit there and tell me that they can relate to me or
understand what I am going through because they don’t have a clue.
(Person who uses drugs)
Reportedly, outreach approaches used in the cities would not necessarily work as well in
more rural areas, where drug use is said to be more hidden. Thus, it was described as
important for outreach workers within the surrounding townships to have a strong
understanding of the unique dynamics of drug use in rural areas.
Final Report - June 20, 2008 47
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
In addition, outreach workers need to be supportive, compassionate, and non-judgmental.
They need to be someone with whom people feel safe sharing their needs.
I think there is a personality for outreach. There has to be a love of the human
spirit. Unequivocal. If you are out there to change, transform, forget it. You have
to just be able to really enjoy that person for who they are. Otherwise it can be
debilitating and you have to be able to collaborate. We have run into problems with
people who are not able to collaborate despite them being really good people. You
can’t be out there basing it on your own ego, or that this is a job that is going to
define me. [The heroic] kind of stuff… it doesn’t work. We are all broken so I am
not talking about brokenness in many ways, but you need the support, the
collaboration and support and non-ego kind of stuff. There is a personality. And
you have to not be afraid either. (Service provider)
Finally, many PWUD also specified that both males and females should become outreach
workers, allowing for a connection with both genders.
Summary
People who had previously been approached by outreach workers generally reported that
they found the contact helpful. However, interviewees who had no previous experience
with outreach were often reluctant to consider this type of contact. Outreach was seen as
most likely to be effective if it were guided by a community-wide unified approach,
provided information about services and how to overcome accessibility barriers, provided
immediate healthcare and supplies, and followed specified approaches for youth and
seniors. Those who were perceived to receive the most positive response from people
who use drugs were people with prior drug use experiences and people who were
supportive, compassionate, and non-judgmental. A balance of males and females was
also considered important.
Final Report - June 20, 2008 48
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Conclusion
The overall purpose of this research project was to develop a detailed description of drug
use in Waterloo Region. Overall, cannabis, crack, cocaine, and prescription opioids
appear to be the most prevalent substances used (excluding alcohol) in Waterloo Region.
Heroin, ecstasy and other hallucinogenic drugs were also said to be widely used.
Patterns of local drug use seem to be changing: use of crystal methamphetamines
appears to be increasing while heroin use seems to be falling. Hallucinogen and cocaine
use seemed more prevalent among youth populations than among adults; however
cocaine use among youth appears to have decreased slightly in recent years. Drug
trafficking occurs throughout the region in a wide range of locales, and is most common
in urban areas. People who use drugs, in general, see their own buying and using
behaviours as relatively safe. However, people using drugs seem to be unaware of the
health and safety risks associated with sharing their non-injection drug use equipment and
reported that sharing of this equipment occurs at high rates.
People who use drugs regularly have diverse and complex social needs, including
appropriate housing, job readiness training, and job related skill development. Isolation
and insufficient social supports are also major challenges for many people who use drugs.
Those who desire support in overcoming their addictions often face barriers including
limited hours of availability for services, extensive waitlists, pre-requisites of pretreatment sobriety and assessment tests, and the presence of potential triggers in areas
that surround services. For those who live in rural areas, a lack of transportation to citybased services adds an additional challenge. A good array of harm reduction services for
those involved in injection drug use seems to be a strength within Waterloo Region, but
similar supports for those who use other types of drugs may not be as readily available.
Satisfaction with social supports and services seems to be high: those who access support
through social services described mainly positive experiences with their service
providers.
Many of the individuals who were interviewed for this study had significant health issues.
Despite the fact that most were aware of healthcare services and knew how to access
them, it was clear that interviewees were not, on average, getting adequate healthcare.
Lack of understanding among users about the importance of care, fear of discrimination
or arrest, and lack of access to health care providers trained to meet the needs of people
who use drugs were some of the reasons.
People who had previously been approached by outreach workers generally reported that
they found the contact helpful. However, interviewees who had no previous experience
with outreach were often reluctant to consider this type of contact. Outreach was viewed
by service providers to be most effective if it followed a community-wide collaborative
approach, provided information about services and how to overcome accessibility
barriers, provided immediate healthcare and supplies, and followed specified approaches
for youth and seniors. Those who were perceived to receive the most positive response
Final Report - June 20, 2008 49
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
from people with drug addictions were people with prior drug use experiences and people
who were supportive, compassionate, and non-judgmental. A balance of males and
females was also considered important.
These messages emerged clearly from this research process. However, it is important to
remember that the service providers and PWUD who were interviewed for this study
were volunteers. There may be other important issues in the region not yet identified.
Final Report - June 20, 2008 50
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
References
Adlaf & Paglia-Boak (2005). Drug Use Among Ontario Students: Detailed Findings of
Ontario Student Drug Use and Health Survey. Toronto: Centre for Addiction and Mental
Health
Berstein, Adlaf & Paglia-Boak (2004). Drug Use in Toronto. Toronto: Research Group
on Drug Use.
Calzavara, Strike, Millson, Major, Myers, Fischer, Remis & Ramuscak (2003). Rapid
Assessment of Injecting Drug Use in Peel Region. Toronto: HIV Social, Behavioural &
Epidemiological Studies Unit, University of Toronto.
Erie County (2003). Rapid Assessment, Response and Evaluation Final Report and
Recommendations.
Stajduhar, K.I., L. Poffenroth, E. Wong, C.P. Archibald, D. Sutherland, M. Rekart
(2004). “Missed opportunities: injection drug use and HIV/AIDS in Victoria, Canada.”
International Journal of Drug Policy 15(3): 171-181.
Stimson, G.V., C. Fitch, D Des Jarlais, V. Poznyak, T. Perlis, E. Oppenheimer (2006).
“Rapid Assessment and Response Studies of Injection Drug Use: Knowledge Gain,
Capacity Building, and Intervention Development in a Multisite Study.” American
Journal of Public Health 96(2): 288-295.
Stimson, Donoghoe, Fitch & Rhodes (2003). Rapid Assessment and Response Technical
Guide. Geneva: World Health Organization Department of Child and Adolescent Health
and Development, and Department of HIV/AIDS, Geneva
University of Ottawa HIV Prevention Research Team & Leanord (2007). Ontario Harm
Reduction Distribution Program. Outcome Evaluation Wave One: Baseline. Waterloo
Region Public Health.
World Health Organization (1998). The Rapid Assessment and Response Guide on
Injecting Drug Use.
Final Report - June 20, 2008 51
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix A - Invitation to participate in an interview:
PWUDRegion of Waterloo Public Health
Baseline Drug Use Study
Information Consent Letter for Individuals Who Regularly Use Drugs
Dear Potential Participant,
Region of Waterloo Public Health is working with other organizations in the
community to gain information about local drug use (e.g. which drugs are being used,
the types of places where people are using, and safety risks while using and buying).
They will also look at the various services and programs available to people with drug
use to understand which needs are and are not currently being met.
At the end of the study, we’ll create a report on the themes that we learn. This report
will be available to interested persons and groups in the community (e.g. people who
provide services, police officers, healthcare providers, etc…). This report will help these
people know how to develop programs and services that best meet the needs of
people who use drugs in our region.
We’re interested in hearing your stories and experiences and are inviting you to
participate in a 60 to 90 minute interview. Information from interviews with up to
30 individuals will help to inform our report.
If you agree to participate in this study, your name and identity will remain private.
The person interviewing you won’t ask your name and won’t share anything that will
suggest who you are. The following form will give you more information about the
project. It’s a good idea to carefully review this consent form before you decide about
whether or not to be interviewed. If you’d like, this form can be read to you.
You should share only what you feel comfortable sharing. Your opinions, ideas and
experiences are important and could help Public Health and others in the community
understand the needs of people who use drugs in this region. There will not be a penalty
if you stop the interview early or if you don’t answer all of the questions. Therefore, you
can stop participating at any time and the services you receive will not be affected.
As a thank you for your participation, you’ll receive compensation for your time.
If you agree to someone contacting you, one of the Research Team members will follow
up with you within a week to answer any questions and to hear your participation
decision. If you have any questions in the meantime, or if you would like to be
interviewed, please contact Suzanne at 519-741-1318, ext. 234.
Sincerely,
Centre for Community-Based Research (formerly, Centre for Research & Education in Human Services)
In partnership with Region of Waterloo Public Health
Final Report - June 20, 2008 52
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix B - Invitation to participate in a focus group:
PWUD
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Letter (Group Interview -Focus Group)
Individuals with Regular Drug Use
Dear Potential Participant,
Region of Waterloo Public Health is working with other organizations in the
community to gain information about local drug use (e.g. which drugs are being used,
the types of places where people are using, and safety risks while using and buying).
They will also look at the various services and programs available to people with drug
use to understand which needs are and are not currently being met.
At the end of the study, we’ll create a report on the themes that we learn. This report
will be available to interested persons and groups in the community (e.g. people who
provide services, police officers, healthcare providers, etc…). This report will help these
people know how to develop programs and services that best meet the needs of
people who use drugs in our region.
We’re interested in hearing your stories and experiences and are inviting you to
participate in a group interview (with 6 to 8 people in total).
The group interview will be 1.5 to 2 hours.
If you agree to participate in this study, your name and identity will remain private.
The person interviewing you won’t ask your name and won’t share anything that will
suggest who you are. The following form will give you more information about the
project. It’s a good idea to carefully review this consent form before you decide about
whether or not to be interviewed. If you’d like, this form can be read to you.
You should share only what you feel comfortable sharing. Your opinions, ideas and
experiences are important and could help Public Health and others in the community
understand the needs of people who use drugs in this region. There will not be a penalty
if you stop the interview early or if you don’t answer all of the questions. Therefore, you
can stop participating at any time and the services you receive will not be affected.
As a thank you for your participation, you’ll receive remuneration for your time.
If you agree to someone contacting you, one of the Research Team members will follow
up with you within a week to answer any questions and to hear your participation
decision. If you have any questions in the meantime, or if you would like to be
interviewed, please contact Suzanne at 519-741-1318, ext. 234.
Sincerely,
Centre for Community-Based Research (formerly, Centre for Research & Education in Human Services)
In partnership with Region of Waterloo Public Health
Final Report - June 20, 2008 53
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix C - Invitation to participate in a focus group:
Service/Healthcare Providers
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Letter (Group Interview - Focus Group)
Service Providers
Dear Potential Participant,
Region of Waterloo Public Health is working with other organizations in the community
to gain information about local drug use (e.g. which drugs are being used, the types of
places where people are using, and safety risks while using and buying). They will also
look at the various services and programs available to people with drug use to understand
which needs are and are not currently being met.
We are inviting you to participate in a project designed to understand these areas.
As someone with firsthand experience and knowledge about drug related services
and programs, we are interested in hearing your experiences and insights in a group
interview (focus group) for service providers. The group will be comprised of up to
12 people and should be 1.5-2 hours in length.
If you agree to participate in this study, we will not include your name in our findings and
will not share anything that will suggest who you are. The consent form explains more
about how we will keep your information private. This form also explains the project,
the type of questions we will be asking, and what it will mean to participate in the
interview. We suggest that you carefully read this form so that you have a good
understanding of these areas before you decide about whether or not to participate.
Your participation will help Region of Waterloo Public Health and other community
organizations better understand the needs of people who use drugs in Waterloo Region.
In this way, you’ll help more people who want support become connected with helpful
services and programs. We value your time and will greatly appreciate your
contributions in this important study. We thank you for considering our request.
One of the research team members will follow up with you within a week to answer any
questions and to hear your participation decision. If you have any questions in the
meantime, please feel free to contact Andrew at 519-741-1318, ext. 224 or Suzanne at
ext. 234.
Sincerely,
The Research Team
Centre for Community-Based Research
(formerly, Centre for Research & Education in Human Services)
In partnership with Region of Waterloo Public Health
Final Report - June 20, 2008 54
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix D - Invitation to participate in a focus group:
Police Officers
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Letter (Group Interview - Focus Group)
Police Officers
Dear Potential Participant,
Region of Waterloo Public Health is working with other organizations in the community
to gain information about local drug use (e.g. which drugs are being used, the types of
places where people are using, and safety risks while using and buying). They will also
look at the various services and programs available to people with drug use to understand
which needs are and are not currently being met.
We are inviting you to participate in a project designed to understand these areas.
As someone with firsthand experience and knowledge about drug related services
and programs, we are interested in hearing your experiences and insights in a group
interview (focus group) for service providers. The group will be comprised of up to
12 people and should be 1.5-2 hours in length.
If you agree to participate in this study, we will not include your name in our findings and
will not share anything that will suggest who you are. The consent form explains more
about how we will keep your information private. This form also explains the project,
the type of questions we will be asking, and what it will mean to participate in the
interview. We suggest that you carefully read this form so that you have a good
understanding of these areas before you decide about whether or not to participate.
Your participation will help Region of Waterloo Public Health and other community
organizations better understand the needs of people who use drugs in Waterloo Region.
In this way, you’ll help more people who want support become connected with helpful
services and programs. We value your time and will greatly appreciate your
contributions in this important study. We thank you for considering our request.
One of the research team members will follow up with you within a week to answer any
questions and to hear your participation decision. If you have any questions in the
meantime, please feel free to contact Andrew at 519-741-1318, ext. 224 or Suzanne at
ext. 234.
Sincerely,
The Research Team
Centre for Community-Based Research (formerly, Centre for Research & Education in Human
Services)
In partnership with the Region of Waterloo Public Health
Final Report - June 20, 2008 55
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix E - Consent Form to participate in an
interview: PWUD
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Form (Individual Interview)
Individuals with Regular Drug Use
This form describes the Baseline Drug Use Study, the types of questions we will be
asking and what it will mean to participate in the interview. Feel free to ask any
additional questions.
What is this project about?
•
This project is meant to gain a stronger understanding about drug use in the
Waterloo Region (example, which drugs are being used, the types of places
where people are using, and safety risks while using and buying). It will also look
at the current services and programs available to people who use drugs and at
what can be done to improve these services and programs.
•
The project is funded by Region of Waterloo Public Health. Your interviewer and
the other researchers are from a research agency in Kitchener called the Centre for
Community-Based Research (CCBR - formerly The Centre for Research and
Education in Human Services). Public Health and the research centre are working
together on this project.
How will the information be gathered and used?
•
The research agency will be asking questions through interviews (30 in total will
be conducted), focus groups and surveys. We’ll be speaking with people who use
or have used drugs regularly, with staff members from organizations who offer
services and programs to this population, and to police officers who work with
drug use.
•
You’re being asked to participate in an individual interview. In the interview,
you’ll be asked questions about your experiences related to:
o drug use in Waterloo Region;
o local services, programs, or the health care system; and,
o your opinions about how service providers could better meet your needs.
•
The interview will be no more than one to one and a half hours.
•
We won’t include your name anywhere in the findings and won’t include any
details that might suggest who you are. At the end of the study, we’ll compile the
themes collected during the interviews and focus groups and highlight them in a
report. This report will be made available to Region of Waterloo Public Health,
Region of Waterloo Council and organizations who provide drug-related services
Final Report - June 20, 2008 56
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
and programs. This report may also be available to other people upon request
(see ‘potential risks’ below).
•
If you agree, the interview will be audio taped. This will help the researcher
later on in the process when they are completing their data analysis. If you don’t
want the interview to be audio taped, your interviewer will write down notes.
You can ask to see these notes at any time during the interview. The tapes will
only be listened to by the research team. The notes will only be read by the
research team. Staff from Public Health may also review these notes, but no
copies will be made of the notes. They will be stored at CCBR on a secure server.
Staff from Public Health won’t listen to any recorded audio tapes. All audio tapes
and notes will be locked away when not in use, and the tapes and notes will be
destroyed within 60 days of the final report being submitted to Public Health.
Do I have to participate?
•
You don’t have to participate. If you do, you can choose to skip some of the
questions without answering, change your mind about previous answers, or stop
the interview at any time if you wish. There WON’T be a penalty if you stop the
interview early or if you don’t answer all of the questions. Therefore, you can
stop participating at any time and the services you receive WON’T be affected.
Are there any risks if I participate?
•
Although you can choose what you want to share, you may become
uncomfortable thinking about your drug-related experiences and may experience
emotional distress after the interview is over. Your interviewer will give you a
list of contacts of where you can receive support to deal with these issues.
Please let your researcher know if you feel that you need any assistance.
•
The final report may be read by members of the public. People interested in
reading the report may include the police, addiction treatment services, health
care providers, and organizations that reach out to people who use illicit drugs.
Reminder: this report will share general information and will not identity people.
What are the benefits if I participate?
•
You’ll help Region of Waterloo Public Health and other community organizations
better understand the needs of people who use drugs in Waterloo Region.
Therefore, you’ll help more people who want support be connected with helpful
services and programs. Information received from the group may also lead to
improved services and programs for individuals who use drugs.
Do I receive anything for participating?
•
You’ll receive $25 for agreeing to participate as a thank you for your time and
contributions.
Final Report - June 20, 2008 57
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
What if I have any questions, comments or concerns?
You can call:
• Andrew Taylor, the lead researcher, at 519-741-1318, ext. 224
• Chris Harold, Public Health Planner, Region of Waterloo Public Health, at
519-883 -006, ext. 5560
Ethics Approval
This study has been reviewed by, and received ethics clearance through, the Region of
Waterloo Public Health Ethics Committee and the Office of Research Ethics at the
University of Waterloo. Participants with concerns or questions may contact the:
• Region of Waterloo Public Health Ethics Committee Chair at 519-883-2004.
• Director of the University of Waterloo Office of Research Ethics at 519-888-4567
ext. 36005.
I have read or had read to me the information that is included on the previous 2
pages?
Yes
No
Is it okay if we interview you for this study?
Yes
No
Is it okay if we tape your interview?
Yes
No
Researcher’s signature: ______________________________
Date: ________________________
Final Report - June 20, 2008 58
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix F - Consent Form to participate in a focus
group: PWUD
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Form (Group Interview – Focus Group)
Individuals with Regular Drug Use
This form describes the Baseline Drug Use Study, the types of questions we will be
asking and what it will mean to participate in the interview. Feel free to ask any
additional questions.
What is this project about?
• This project is meant to gain a stronger understanding about drug use in
Waterloo Region (example, which drugs are being used, the types of places
where people are using, and safety risks while using and buying). It will also look
at the current services and programs available to people who use drugs and at
what can be done to improve these services and programs.
•
The project is funded by Region of Waterloo Public Health. Your interviewer and
the other researchers are from a research agency in Kitchener called the Centre for
Community-Based Research (CCBR - formerly The Centre for Research and
Education in Human Services). Public Health and the research centre are working
together on this project.
How will we gather and use the information that you and others tell us?
• The research team will be asking questions through interviews, focus groups
(groups of 6 to 8 people), and surveys. We’ll be speaking with people who use or
have used drugs regularly, with people who offer services and programs to this
group, and to police officers who have worked with this group. Note: Your focus
group will only include other people who use drugs. No service providers or
police officers will be present.
•
You’re being asked to participate in a focus group. In the group, you’ll be asked
questions about your thoughts and ideas about:
o drug use in Waterloo Region;
o local services, programs, or the health care system; and,
o your opinions about how service providers could better meet the needs of
those who use drugs.
You can share your own experiences if you wish or you can talk more generally
about local drug use and services.
•
The group discussion will be no more than 1 to 1 ½ hours.
•
Your name and identity will be kept private. The interviewer won’t ask your
name and details that might suggest who you are will not be included anywhere in
Final Report - June 20, 2008 59
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
the findings. At the end of the study, we’ll compile the themes collected during
the interviews and focus groups and highlight them in a report. This report will
be made available to Region of Waterloo Public Health, Region of Waterloo
Council and organizations who provide drug-related services and programs. This
report may also be available to other people upon request (see ‘potential risks’
below).
•
If everyone agrees, the group interview will be audio taped. This will help the
researcher later on in the process when they are completing their data analysis. If
you don’t want the interview to be audio taped, your interviewer will write down
notes. You can ask to see these notes at any time during the interview. The tapes
will only be listened to by the research team. The notes will only be read by the
research team. Staff from Public Health may also review these notes, but no
copies will be made of the notes. They will be stored at CCBR on a secure server.
Staff from Public Health won’t listen to any recorded audio tapes. All audio tapes
and notes will be locked away when not in use, and the tapes and notes will be
destroyed within 60 days of the final report being submitted to Public Health.
Do I have to participate?
• You don’t have to participate. If you do, you can choose to skip some of the
questions without answering, change your mind about previous answers, or stop
the interview at any time if you wish. There WON’T be a penalty if you stop the
interview early or if you don’t answer all of the questions. Therefore, you can
stop participating at any time and the services you receive WON’T be affected.
Are there any risks if I participate?
• Although you can choose what you want to share, you may become
uncomfortable thinking about your drug-related experiences and may experience
emotional distress after the interview is over. Your interviewer will give you a
list of contacts of where you can receive support to deal with these issues.
Please let your researcher know if you need assistance.
•
While everyone who participates in the group will agree to keep the information
private by signing a confidentiality note, we cannot control if group members
share with others any of the information discussed after they have left the
group.
•
The final report may be read by members of the public. People interested in
reading the report may include the police, addiction treatment services, health
care providers, and organizations that reach out to people who use illicit drugs.
Reminder: this report will share general information and will not identity people.
What are the benefits if I participate?
• You’ll help the Region of Waterloo and other community organizations better
understand the needs of people who use drugs in Waterloo Region.
Therefore, you’ll help more people who want support be connected with helpful
Final Report - June 20, 2008 60
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
services and programs. Information received from the group may also lead to
improved services and programs for individuals who use drugs.
Do I receive anything for participating?
• You’ll receive $25 for agreeing to participate as a thank you for your time and
contributions.
What if I have any questions, comments or concerns?
You can call:
• Andrew Taylor, the lead researcher, at (519) 741 1318, ext. 224
• Chris Harold, Public Health Planner, Region of Waterloo Public Health, at
(519) 883 2006, ext. 5560
Ethics Approval
This study has been reviewed by, and received ethics clearance through, the Region of
Waterloo Public Health Ethics Committee and the Office of Research Ethics at the
University of Waterloo. Participants with concerns or questions may contact the:
• Region of Waterloo Public Health Ethics Committee Chair at 519-883-2004.
• Director of the University of Waterloo Office of Research Ethics at 519-888-4567
ext. 36005.
I have read or had read to me the information that is included on the previous 2 pages
Yes
No
Do you agree to keep all information shared in this group session private
(that is, to NOT share what others in the group say with people outside of the group)?
Yes
No
Is it okay if we tape the focus group ?
Yes
No
Would you like to participate in this focus group?
Yes
No
Researcher’s signature______________________________
Date_______________
Final Report - June 20, 2008 61
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix G - Consent Form to participate in a focus
group: Service/Healthcare providers and Police Officers
Region of Waterloo Public Health
Baseline Drug Use Study
Information Consent Form (Group Interview – Focus Group)
Service Providers and Police Officers
This form describes the Baseline Drug Use Study, the types of questions we will be
asking and what it will mean to participate in the interview. Feel free to ask any
additional questions.
What is this project about?
• This project is meant to gain a stronger understanding about drug use in the
Waterloo Region (example, which drugs are being used, the types of places
where people are using, and safety risks while using and buying). It will also look
at the current services and programs available to people who use drugs and at
what can be done to improve these services and programs.
•
The project is funded by Region of Waterloo Public Health. Your interviewer and
the other researchers are from a research agency in Kitchener called the Centre for
Community-Based Research (CCBR - formerly The Centre for Research and
Education in Human Services). Public Health and the research centre are working
together on this project.
How will we gather and use the information that you and others tell us?
• The research agency will be asking questions through interviews, focus groups
(up to 12 people in total), and surveys. We’ll be speaking with people who use or
have used drugs regularly, with staff members from organizations who offer
services and programs to this population, and to police officers who work with
drug use.
•
You’ll be asked questions about:
o drug use in Waterloo Region,
o the responses to drug related issues,
o the region’s services and programs, and
o your opinions about how better meet the needs of people who use
drugs.
•
The group discussion will be between 1 to 1 ½ hours.
•
We won’t include your name anywhere in the findings and won’t include any
details that might suggest who you are. At the end of the study, we’ll compile the
themes collected during the interviews and focus groups and highlight them in a
report. This report will be made available to the Region of Waterloo Public
Health, Region of Waterloo Council and organizations who provide drug-related
Final Report - June 20, 2008 62
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
services and programs. This report may also be available to other people upon
request (see ‘potential risks’ below).
•
If everyone agrees, the group interview will be audio taped. This will help the
researcher later on in the process when they are completing their data analysis. If
you don’t want the interview to be audio taped, your interviewer will write down
notes. You can ask to see these notes at any time during the interview. The tapes
will only be listened to by the research team. The notes will only be read by the
research team. Staff from Public Health may also review these notes, but no
copies will be made of the notes. They will be stored at CCBR on a secure server.
Staff from Public Health won’t listen to any recorded audio tapes. All audio tapes
and notes will be locked away when not in use, and the tapes and notes will be
destroyed within 60 days of the final report being submitted to Public Health.
Do I have to participate?
You don’t have to participate. You can also choose to skip some of the questions
without answering, change your mind about previous answers, or leave the group at
any time if you wish. There will not be a penalty if you decide to leave the group
early.
Are there any risks if I participate?
• The questions are about drug-related issues in Waterloo Region. Although you
can choose what you want to share, you may become uncomfortable thinking
about these issues.
•
While everyone who participates in the group will agree to keep the information
private by signing a confidentiality note, we cannot control if group members
share with others any of the information discussed after they have left the
group.
•
The final report may be read by members of the public. People interested in
reading the report may include the police, addiction treatment services, health
care providers, and organizations that reach out to people who use illicit drugs.
Reminder: this report will share general information and will not identity people.
What are the benefits if I participate?
• You’ll help the Region of Waterloo and other community organizations better
understand the needs of people who use illicit drugs in Waterloo Region. In
this way, you’ll help more people who want support become connected with
helpful services and programs. Information received from the group may also
lead to improved services and programs for individuals who use drugs.
What if I have any questions, comments or concerns?
You can call:
• Andrew Taylor, the lead researcher, at 519-741-1318, ext. 224
• Chris Harold, Public Health Planner, Region of Waterloo Public Health, at
519-883-2006, ext. 5560
Final Report - June 20, 2008 63
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Ethics Approval
This study has been reviewed by, and received ethics clearance through, the Region of
Waterloo Public Health Ethics Committee and the Office of Research Ethics at the
University of Waterloo. Participants with concerns or questions may contact the:
• Region of Waterloo Public Health Ethics Committee Chair at 519-883-2004.
• Director of the University of Waterloo Office of Research Ethics at 519-888-4567
ext. 36005.
I have read or had read to me the information that is included on the previous 2 pages?
Yes
No
Do you agree to keep all information shared in this group session private
(that is, to NOT share what others in the group say with people outside of the group)?
Yes
No
Is it okay if we tape the focus group?
Yes
No
Would you like to participate in this focus group?
Yes
No
Researcher’s signature______________________________
Date_______________
Final Report - June 20, 2008 64
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix H - Discussion Guide for interview with PWUD
WATERLOO REGION BASELINE USER STUDY
DISCUSSION GUIDE:
INTERVIEW WITH PARTICIPANTS WHO USE DRUGS
Please Note: Question 1 is intended to be used as an ice-breaker. As the interviewer,
please use your own judgment as to whether or not you feel an ice-breaker is required
(i.e. whether or not the person already seems comfortable). If you choose to skip this
question, please begin the interview with q. #2.
The italics below the questions indicate additional areas/questions of interest for this
study. If the person does not discuss these areas in their answers to the main questions,
please ask them to expand/discuss in these areas.
1. How long have you lived in Waterloo Region?
b) What has it been like for you living in this Region?
2. Have you found that certain drugs are more commonly used than others? If so,
which drugs?
3. Are there people using drugs in Waterloo Region who are from out of town?
• If yes, where do they come from? Why do they travel to this region?
• How common do you think it is for people from out of town to come to
Waterloo Region to use drugs?
4. Can you think for a minute about how you get your drugs? How safe do you feel
when you are getting your drugs? Can you explain?
b) When you use your drugs, do you do anything to help you use them more
safely? Can you explain?
• Do you reuse or share your drug instruments (e.g. needles, syringes,
cookers, pipes, or other drug supplies [water, etc.])? What are the
reasons that you share?
• Are there people around you who would respond if you or someone
with you had a drug overdose or a bad reaction? What do you think
they would do to help you or someone else in this situation?
Final Report - June 20, 2008 65
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
c) Are you concerned for your own safety when you are on your drugs? What
are some of the situations that concern you?
d) Is there anything that you could do to make any of your drug use safer (ex:
getting your drugs, using them, or the things you do during or after)? Can
you explain?
e) Do you know of services or programs in the community that make drug use
safer? Can you describe them?
• Which services exist?
• What do these services provide?
• Are these services you use? What are the reasons for using or not
using these services?
5. Have you ever accessed detox, treatment (methadone or other), or counselling
services in Waterloo Region for your substance use?
If yes:
• Which services were received?
• Can you describe what the experience was like for you? What did you find
helpful? What would you change?
• What was your impression of the person providing the service?
6. What kinds of things could a program or service offer that would be helpful to
you?
7. a) How would you describe your health in the past 2 years?
• Can you describe any problems (health - disease, dental, emotional,
mental, social) experienced in the past few years?
• How would you describe the amount of nutritious food you are able to
eat?
b)
What do you typically do if you experience health problems in Waterloo
Region?
(if specific problems were listed, refer to these situations)
• If seeing a healthcare or other professional is not included in this list, ask
to explain the reasons for not seeking help in this way.
• Are you able to get the healthcare you need? Can you explain?
8. Has someone ever tried to connect you or someone you were with safer drug
practices or with services or programs to help you with your drug use? If yes:
• What is this person’s role?
• What did the person discuss with you?
• Was this person helpful?
• Where did you meet this person?
If no:
Final Report - June 20, 2008 66
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
•
How do you think you would respond if an outreach worker offered you
help?
b) An outreach worker is someone who tries to connect people with services.
What can an outreach worker do to meet with and help people who use drugs?
ƒ Who should they meet with?
ƒ Where and when should they go? What info should they have?
ƒ Are there types of areas in Waterloo Region (for example, parks, private
homes, street corners, alleys, etc.) where people who use drugs hang out?
ƒ Are there different areas for different types of drugs?
ƒ What type of person should be hired? What types of things should they say or
do?
Final Report - June 20, 2008 67
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Appendix I - Discussion Guide for focus group with
PWUD
1. What is it like to be someone who uses drugs living in Waterloo Region?
2. a) Are certain drugs more commonly used than others? If so, which drugs?
b) Do you think different types of drugs are more common in different areas?
Can you explain?
3. Are there types of areas in Waterloo Region (for example, parks, private homes,
street corners, alleys, etc…) where people who use drugs hang out?
• Are there different areas for different types of drugs?
4. What are some of the health problems and social problems that have affected
either you or other people you know who use drugs?
• AIDS/HIV, Hep C, Hep B, lung problems, mental health problems, lack of
necessary food, dental problems, unplanned pregnancy, stigmatization,
housing problems, relationship problems, unstable income
5. a) Who or where do people turn to for help when they experience these problems?
• Family?
• Friends?
• Others who are using drugs?
• Do people generally turn to professionals for help? If no, what prevents
people from receiving healthcare?
b) Are people who use drugs usually able to receive the healthcare they need?
Can you explain?
6. When using drugs, are there certain things that people do to help them use their
drugs more safely?
• How common is it for people to reuse or share things like needles,
syringes, pipes and other supplies (e.g. water)? What are the reasons for
reusing or sharing?
• Are there places (for example, services, individuals, organizations, etc) in
Waterloo Region that help make the activities safer?
• Do people use these services? Why or why not?
7. a) How safe do you think people generally are when they are high on their drugs?
Can you explain why they are safe or unsafe?
• Are there people around you who would respond if you or someone with
you had a drug overdose or a bad reaction? What do you think they
would do to help you or someone else in this situation?
Final Report - June 20, 2008 68
Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
•
Do people generally act in safe or unsafe ways when they are high? Can
you explain?
b) What would people need to make their drug-use safer?
• Knowledge of prevention practices?
• Clean drug instruments?
• Awareness of safer sexual practices?
8. Think about the needle exchange programs and the detox, drug treatment, and
counselling services in the Waterloo Region. What do people who use drugs
generally think of these programs and services?
• Are they believed to meet the needs of those using drugs?
• Which services are believed to be most helpful?
• Which services are believed to be least helpful?
• Is it generally easy or difficult to receive these services? What makes it
so?
9. What about the services and programs in this region could be changed or
developed to best help people who use drugs?
• What kinds of things could current programs or services offer that would
be helpful to people who use drugs?
• Is there anything else that isn’t currently offered or available that would be
helpful to people who use drugs?
10. Outreach workers often try to meet with people who use drugs to let them know
about how they can reduce the harm of their drug use and how to receive services.
What would be helpful for someone to know or do if they were trying to reach out
to persons who use drugs in Waterloo/ Kitchener/ Cambridge/Townships?
• Who should they meet with?
• Where and when should they go? What information should they have?
• What type of person should be an outreach worker? What types of things
should they say or do?
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Appendix J - Discussion Guide for focus group with
Health Care Providers
1. a) Can you describe the types of drug ‘scenes’ that exist in Waterloo Region?
• drugs used
• method of drug use (smoke, snort, swallow, inject, insert)
• availability
• demographics (age, gender, ethnicity)
• differences by geographical location (Kitchener, Waterloo, Cambridge,
Townships)
• physical location (home, park, gym, street, cars, elsewhere, etc.)
• types of activities that occur
b) Are there other people who use drugs in Waterloo Region who aren’t included
in these drug scenes?
2. In your interactions with people who use drugs, what are some of the health issues
you have found affect people who use drugs?
• AIDS/HIV, Hep C, Hep B, lung problems, mental health problems,
nutritional deficiency, dental problems, unplanned pregnancy,
stigmatization, housing problems, relationship problems, income
instability, employment
3. How well do you believe people who use drugs understand these health issues?
• Do they understand what they are and how they develop/transmit?
• Do they understand what they can do to prevent them?
4. What are some of the safety risks that currently exist for someone using drugs?
Regarding:
• Obtaining their drugs
• Using their drugs
• Activities they engage in when they are high on their drugs
5. a) What types of harm reduction services are currently available in Waterloo
Region and how well do you think they are working?
Heroin prescription programs, drug treatment based on harm reduction
model, safe injection rooms, other?
b) What other types of harm reduction do people using drugs in the Waterloo
Region need?
6. a) Which aspects of the programs or services available for people who use drugs
do your clients seem to find helpful?
• Which services or programs seem to be meeting the needs of users?
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7. a) Are there aspects of the programs or services that do not seem to be meeting
the needs of people using drugs? If so, please explain.
• Ethno-cultural considerations?
b) What can be done to improve these services and programs?
• What can be done to improve access to these programs?
8. What service model(s) would best fit the needs of drug users in Waterloo Region?
For example, home visits, street based services, using drug users to provide
services, mosaic approach, ‘one-stop shop’ approach, etc…
• Home visits, mobile van, more locations for needle exchange, expand
programs for other drugs (e.g. crack), using drug users to provide
services, other?
9. As a healthcare provider, is there anything that limits your ability to meet the
needs of your clients?
• What general challenges do you face as healthcare providers?
• Are there related areas that you feel are ‘off limits’ or out of your control
to help with?
• Are there organizational or local conditions that hinder your ability to
work in an effective way?
10. a) What, if any, are the challenges of recruiting and/or connecting people with
drug-related services?
• Are some populations easier/harder to reach than others? Please explain.
b) What could be done to improve this process?
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Appendix K - Discussion Guide for focus group with
Service Providers
5. a) Can you describe the types of drug use that exist in Waterloo Region? Are
there different ‘drug scenes’? That is, does the drug use and practices vary for
different ‘groups’, geographical areas, or types of drugs?
• drugs used
• method of drug use (smoke, snort, swallow, inject, insert)
• availability
• demographics (age, gender, ethnicity, income levels)
• geographical location (Kitchener, Waterloo, Cambridge, Townships)
• physical location (home, park, gym, street, cars, elsewhere, etc.)
• types of activities that occur
b) Are there other people who use drugs in Waterloo Region who aren’t included
in these drug scenes? That is, are there people who are considered to have
‘hidden and less known’ use?.
6. In your interactions with people who use drugs, what are some of health and
social issues you have found affect people who use drugs?
• AIDS/HIV, Hep C, Hep B, lung problems, mental health problems,
nutritional deficiency, dental problems, unplanned pregnancy,
stigmatization, housing problems, relationship problems, income
instability, employment
7. How well do you believe people who use drugs understand these issues?
• Do they understand what they are and how/why they
develop/transmit/exist?
• Do they understand what they can do to prevent them?
8. What are some of the safety risks that currently exist for someone using drugs?
Regarding:
• Obtaining their drugs
• Using their drugs
• Activities they engage in when they are high on their drugs
10. a) What types of harm reduction services are currently available in Waterloo
Region and how well do you think they are working?
• Methadone prescription programs, drug treatment based on harm
reduction model, needle exchange, education and awareness, safe
injection rooms, other?
b) What other types of harm reduction services do drug users in Waterloo Region
need?
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11. a) Which aspects of the programs or services available for people who use drugs
do your clients seem to find helpful? What is it that makes them helpful?
• Which services or programs seem to be meeting the needs of users?
12. a) Are there aspects of the programs or services that do not seem to be meeting
the needs of people using drugs? If so, please explain.
• Ethno-cultural considerations?
b) What can be done to improve these services and programs?
• What can be done to improve access to these programs?
13. What service model(s) would best fit the needs of drug users in Waterloo Region?
For example, home visits, street-based services, using drug users to provide
services…
• Home visits, mobile van, more locations for needle exchange, expand
programs for other drugs (e.g. crack), using drug users to provide
services, one-stop shops, mosaic approach, other?
14. As a service provider, is there anything that limits your ability to meet the needs
of your clients?
• What general challenges do you face as service providers?
• Are there related areas that you feel are ‘off limits’ or out of your control
to help with?
• Are there organizational or local conditions that hinder your ability to
work in an effective way?
11. a) What, if any, are the challenges of recruiting and/or connecting people with
drug-related services?
• Are some populations easier/harder to reach than others? Please explain.
b) What could be done to improve this process?
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Appendix L - Discussion Guide for focus group with
Police Services
1. Can you describe the types of ‘drug scenes’ that exist in Waterloo Region?
• drugs used
• method of drug use (smoke, snort, swallow, inject, insert)
• availability of drugs
• demographics (age, gender, ethnicity)
• geographical location (Kitchener, Waterloo, Cambridge, Townships)
• physical location (home, park, gym, street, cars, elsewhere, etc.)
• types of activities that occur
• Can you estimate the number of users?
2. In your line of work, have you found certain drugs to be more commonly used
than others? If so, which drugs? Does this vary by location? Types of users
(demographics, etc.)?
3. What are all of the ways in which police officers might be involved with persons
who regularly use drugs? How often does each of these interactions occur?
• Detox?
• Other referrals (e.g. to shelters, needle exchange programs, other
services)?
• In what ways do police officers interact with persons who use drugs when
they are not engaged in illegal activities? (e.g. informally on the street?)
• Are police officers involved when a drug-related 911 call is placed for a
health concern (i.e. overdose)?
• Where do you get called to commonly deal with drug problems?
4. Have you found the people who use drugs in Waterloo Region to be long-term
residents, shorter-term, or from out of town?
• If from out of town, where do they come from? Why?
• When in town, where do out-of-town individuals use drugs?
6. What are some of the safety risks that currently exist for someone using drugs?
Regarding:
• how they get their drugs
• methods of taking their drugs
• the things they do when they are high
b) What do you think could be done to improve the safety of these drug
activities?
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7. How would you describe the working relationship between the police and the
local drug-related service providers (e.g. detox, needle exchange, outreach,
treatment, counselling, etc.)?
• To what degree do you work together? Do you share information?
• Do you understand each other’s role?
• Do you respect each other?
• Benefits? Challenges?
b) With respect to drug use, how do officers decide what is a policing issue
versus an issue for other service providers? (i.e. level of individual discretion)
8. From your perspective, what do you think should be done (in terms of providing
services or other) to manage drug use in the Waterloo Region?
• Incarceration?
• Enhanced services (harm reduction strategies)
• Ignore certain situations? Please explain in which situations (specifically,
what types of drugs and/or users) and circumstances.
9. Do police officers use different strategies or approaches when interacting
(formally or informally) with this population as opposed to other populations?
Please explain.
• Are there things that police officers do to build trust when interacting
informally with persons who use drugs?
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Appendix M - Questionnaire
TO BE COMPLETED AT THE BEGINNING OR END OF THE INTERVIEW
BY THE INTERVIEWEE, WITH ASSISTANCE IF NEEDED
Note:
- This information is being collected so we can learn more about who is using drugs in
Waterloo Region.
- This information will remain private (kept confidential).
- You can refuse to answer any question.
Note for interviewer: Please use the more common drug names where appropriate
1. Which gender do you see yourself as (circle one):
male
female
trans-gendered (M-F)
2. What is your month and year of birth:
trans-gendered (F-M)
Month: _____ Year: _____
3. Where do you live? (circle one)
Cambridge
Kitchener
North Dumfries
Wellesley
Wilmot
Waterloo
Woolwich
4. Which ethnic cultural group do you see yourself to be a part of?
_________________________
5. What is the language you prefer to use? ________________________________
6. What is your personal income? (circle one)
• Under $15,000
• $15,000 - $24,999
• $25,000 - $49,999
• $50,000 - $74,999
• $75,000 - $99,999
• $100,000+
7. In the past 2 years, how often have you used the following drugs? (Only check the
drugs you used)
Drug
At least At least
More
Less
About
once a
once a
than
than
Irregular
once a
week,
month,
once a
once a
Binge Use
Day
but not
but not
Day
month
daily
weekly
Anabolic Stereoids
Barbiturates
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
“downers” (e.g.
Seconal, Nembutal,
Amytal, Tuinal,
Imovane)
Cocaine (powder)
Crack cocaine
Other Stimulants
(e.g. diet pills, Ritalin,
Dexedrine )
Crystal Meth (“ice”)
Dilaudid
DMT
Ecstasy (MDMA)
GHB
Glue
Hallucinogen - LSD
Hallucinogen – PCP
(“angel dust”)
Other hallucinogens
(e.g. Mescaline and
Psilocybin, “magic
mushrooms”)
Hash
Heroin
Ketamine
Marijuana
Methadone
Methamphetamine
(speed)
Morphine
Oxycontine
Pain Relief Pills (e.g.
Vicodin, Percocet,
Percodine, Tylenol #3,
Demerol, codeine)
Rohypnol - “Roofies”
(for personal use, not
on another individual)
Sedative-Tranquilizers
(e.g. Valium, Xanax,
Halcion, Serax,
Ativan)
Solvents
Poly-Drugs (using
more than one drug
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
simultaneously)
Other (please specify)
If you combine drugs (poly drug use), which drugs do you typically combine?
8. When was the last time you used the following drugs? (Only check the drugs you
used)
Drug
In the
past 6
months
6-11
months
ago
1 to 2
years ago
More
than 2
years
Anabolic Stereoids
Barbiturates “downers” (e.g.
Seconal, Nembutal, Amytal, Tuinal,
Imovane)
Cocaine (powder)
Crack cocaine
Crystal Meth (ice)
Dilaudid
DMT
Ecstasy (MDMA)
GHB
Glue
Hallucinogen - LSD
Hallucinogen – PCP (“angel dust”)
Other hallucinogens (e.g. Mescaline
and Psilocybin, “magic
mushrooms”)
Hash
Heroin
Ketamine
Marijuana
Methadone
Methamphetamine (speed)
Morphine
Oxycontine
Pain Relief Pills (e.g. Vicodin,
Percocet, Percodine, Tylenol #3,
Demerol, codeine)
Rohypnol
Sedative-Tranquilizers
(e.g. Valium, Xanax, Halcion,
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
Serax, Ativan)
Solvents
Stimulants
(e.g. diet pills, Ritalin, Dexedrine )
Poly-Drugs (using more than one
drug simultaneously)
Other (please specify)
9. How do you normally take your drugs (circle all that apply):
Inject
Insert
Smoke
Snort
(Suppository)
Swallow
10. a) When do you normally use drugs? (circle one)
When you’re by yourself
When you’re with others
b) If you’re with others, how large is the group?
3 or less people
4-10 people
11-20 people
21 or more people
The number of people varies
11. Please list the services and programs that you know are available in Waterloo
Region. Indicate if you have used the service or program for a drug-related
reason. Services and programs include: health care services (physicians, hospital,
dental, mental health), addiction-related services, support services, or services to
reduce the harm of your drug-related activities.
Service or Program
Check if you used the
service
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Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region
12. Is there any additional information you would like to share?
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Appendix N - Glossary
Abscess
An abscess is a collection of pus, somewhere in the body. It is the result of the body's
defensive reaction to foreign material. Injection drug use is associated with a number of
health issues, including abscesses (sources: Health Canada and Canadian Centre on
Substance Abuse).
Addiction
Used to describe anything from a desire to have or do something that gives pleasure, to a
medical issue, and/ or to an uncontrollable compulsion. Addiction is a primary, chronic,
neurobiologic disease with genetic, psychosocial and environmental factors that influence
its development and manifestations. It is characterized by behaviours that include one or
more of the following: loss of control over drug use, continued use despite harm, and/or
compulsive use and craving (source: CAMH).
Barbiturates
Sedative/hypnotic drugs (powerful depressants) that slow down the central nervous
system. They can be prescribed by a doctor under such trade names as Seconal®,
Amytal®, Nembutal®, and Tuinal®. Fiorinal® for migraine headaches. Doctors don't
often prescribe them now because there are safer drugs available. Barbiturates are among
the most dangerous of drugs when they are used illegally. On the street they are called
downers, barbs, blue heavens, yellow jackets, red devils (source: CAMH).
Benzodiazepines
Benzodiazepines are a family of prescription drugs that are used mainly to relieve anxiety
and to help people sleep. These are sedative drugs, which reduce activity in certain parts
of your brain, resulting in a calming effect. In Canada and the United States,
benzodiazepines are available legally only by prescription. On the street they are called
benzos, tranks, and downers (source: CAMH).
Cannabis
Cannabis sativa, also known as the hemp plant, has been cultivated for centuries for
industrial and medical use, and for its "psychoactive," or mind-altering, effects.
Marijuana, hashish and hashish oil all derive from the cannabis plant. More than sixtyone chemicals, called cannabinoids, have been identified as specific to the cannabis plant.
THC (delta-9-tetrahydrocannabinol) is the main psychoactive cannabinoid, and is most
responsible for the "high" associated with marijuana smoke. On the street cannabis is
called grass, weed, pot, dope, ganja and others (source: CAMH).
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Cocaine
Cocaine is a stimulant drug. Stimulants make people feel more alert and energetic.
Cocaine can also make people feel euphoric, or "high." Cocaine hydrochloride is a white
crystalline powder, and is the form in which cocaine is snorted or injected. It is
sometimes "cut," or mixed, with things that look like it, such as cornstarch or talcum
powder, or with other drugs, such as local anesthetics or amphetamines. On the street it is
called blow, C, coke, crack, flake, freebase, rock, snow (source: CAMH).
Concurrent Disorder (Canadian definition)
Concurrent Disorders (CD for short) describe the situation in which a person has both a
mental health disorder and a substance use disorder. There are many different kinds of
problems that are covered by these various terms (psychiatric disorder etc); as a result,
CD presents itself in many different forms (source: CAMH).
Crack Cocaine
Powder cocaine can be chemically changed to create forms of cocaine that can be
smoked. Smoking the drug sends it to the brain very quickly, and gives more of a “rush”
than snorting it. The high from crack lasts about five to 10 minutes. These forms, known
as "freebase" and "crack," look like crystals or rocks. Smoking cocaine can damage the
lungs and cause "crack lung” which can be fatal. Smoking crack, with its rapid, intense
and short-lived effects, is the most addictive form of cocaine. However, any method of
taking cocaine can lead to addiction. Crack cocaine is also called ‘crack’ (source:
CAMH).
Crystal Methamphetamine
Methamphetamine belongs to a family of drugs called amphetamines which are powerful
stimulants that speed up the central nervous system. The drug can be made easily in
clandestine laboratories with relatively inexpensive over-the-counter ingredients. On the
street it is known as crystal meth, speed, meth, or chalk. In its smoked form it can be
referred to as ice, crystal, crank, and glass (source: CAMH).
Dilaudid (an opioid)
Dilaudid, called juice on the street, is also called Hydromorphone. It is an opioid and is
used therapeutically for the treatment of pain and recreationally for its psychogenic
qualities and for its ability to produce a mellow, relaxed "high" (source: CAMH).
Drug Dependence
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 to a substance, withdrawal symptoms, unsuccessful
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efforts to control substance use, a great deal of time is spent in activities necessary to
obtain the substance, use the substance, or recover from its effects. Other indicators of
drug dependence include reducing social, occupation, or recreation activities, and
continuing substance use despite knowledge of persistent physical or psychological
problems that is likely to have been caused or exacerbated by the substance (source:
CAMH).
Ecstasy
The chemical name for ecstasy is 3,4-methylenedioxymethamphetamine, or MDMA. The
chemical structure and the effects of MDMA are similar to amphetamine (a stimulant)
and to mescaline (a hallucinogen). What is sold as ecstasy often contains drugs other than
MDMA, which may or may not be similar in effect to MDMA. Some of the other drugs
include caffeine, ephedrine, amphetamine, dextromethorphan, ketamine or LSD. Ecstasy
sometimes contains highly toxic drugs, such as PMA (paramethoxyamphetamine), which
can be lethal even in low doses. MDMA affects the chemistry of the brain, in particular
by releasing a high level of serotonin. Serotonin is a chemical in the brain that plays an
important role in the regulation of mood, energy level and appetite, among other things
(source: CAMH).
Hallucinogens
The term hallucinogen refers to many different drugs, which are often called
“psychedelic” drugs. While the effects of these drugs vary widely, they all change the
way people see, hear, taste, smell or feel, and affect mood and thought. At large doses, all
may cause a person to hallucinate, or see, hear or feel things that aren’t really there
(source: CAMH).
Harm Reduction
Harm Reduction refers to policies and practices that aim to reduce the adverse health,
social and economic consequences of substance use without requiring abstinence. (based
on definition created by United Nations. Source: WRHRN).
Hepatitis C
Hepatitis C is a chronic liver disease caused by the hepatitis C virus (HCV). HCV causes
inflammation of the liver, which can progress to cirrhosis (extensive scarring that can
affect the normal function of the liver). HCV is spread through contact with infected
blood. In the past, many people became infected through blood and blood products. Now,
between 70-80% of HCV transmission in Canada is due to injection drug use. This
includes the sharing of contaminated needles and other drug-using equipment, such as
straws, pipes, spoons and cookers (source: Health Canada)
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Heroin
Heroin is a dangerous and illegal drug with a high addictive potential. It is also an
effective painkiller. It belongs to the opioid family of drugs. Heroin is a "semi-synthetic"
opioid; it is made from morphine that has been chemically processed, giving it a stronger
and more immediate effect. Heroin is converted back into morphine in the brain (source:
CAMH).
Inhalants
Refers to chemical vapours or gases that produce a "high" when they are breathed in.
Most of the substances used as inhalants, such as glue, gasoline, cleaning solvents and
aerosols, have legitimate everyday uses, but they were never meant for human
consumption. Inhalants are cheap, legal and easy to get. They have a high potential for
abuse - especially by children and young adults (source: CAMH).
Ketamine
Ketamine is a fast-acting anaesthetic and painkiller used primarily in veterinary surgery.
It is also used to a lesser extent in human medicine. Ketamine can produce vivid dreams
or hallucinations, and make the user feel as though the mind is separated from the body.
This effect is called "dissociation." When ketamine is given to humans for medical
reasons, it is often given in combination with another drug that prevents hallucinations.
On the street it is called special K, K, ket, vitamin K, or cat tranquilizers (source:
CAMH).
LSD
LSD (lysergic acid diethylamide) is a potent hallucinogen. The term "hallucinogen"
describes a drug that can alter a person's perception of reality and vividly distort the
senses. LSD was originally derived from "ergot," a fungus that grows on rye and other
grains (source: CAMH).
Mental Health Illness
When there are changes in a person’s thinking, mood and behaviour that cause a lot of
distress and make it difficult to do daily tasks, that person may have a mental illness, for
example, depression or schizophrenia (source: CAMH).
Opiates
Opiates include heroin, codeine and morphine. They may be prescribed by a doctor for
severe pain, but excess amounts can cause intoxication, giving them a high addictive
potential. Opiate use is a problem when the person who is using them either has no
medical reason to use them, or is using the drug in larger amounts than needed to manage
pain. People who are dependent become extremely tolerant to the drug (they need to
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increase the amount to get the same level of intoxication) and will undergo withdrawal if
they stop using abruptly (source: CAMH).
OxyContin
OxyContin is a time-released pain medication. It contains oxycodone, which is an opioid
drug, like morphine, codeine, heroin and methadone. Oxycodone is the same opioid that’s
in other drugs such as Percocet, Oxycocet and Endocet. On the street it is called Oxy or
OC (source: CAMH).
Poly Drug Use
Poly drug use or polysubstance abuse is the concurrent abuse of more than one
psychotropic medication and/or illegal substance (source: CAMH).
PWUD
Person (or people) who use(s) drugs. A term to refer to the individuals interviewed for
this study who used illegal drugs regularly, in order to avoid terms like “users,” “abusers”
or “addicts.”
Salvia divinorum
Salvia divinorum is a plant that is categorized as form of hallucinogen under the name of
diterpene salvinorin. It is usually called ‘salvia’ and causes intense, short-lived
hallucinogenic effects, making it different from other hallucinogens (source: CAMH).
THC (re: Marijuana)
THC (delta-9-tetrahydrocannabinol) is the main psychoactive cannabinoid, and is most
responsible for the "high" associated with marijuana smoke. Hemp grown for industrial
use has very low levels of THC. The effects of the psychoactive ingredient as a result of
smoking occur within minutes. Peak plasma concentrations and effects on the brain occur
within 15-30 minutes and last for about 3-4 hours (source: CAMH).
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Appendix O: Online Service Provider Survey
Final Report - June 20, 2008 86
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
1. Introduction and Consent
You are invited to participate in an important Waterloo Region Public Health survey.
This survey is designed to understand the social services and healthcare available to persons who use illicit substances
and/or misuse presecription pills. As someone with experience and knowledge about social services and/or healthcare in the
Waterloo Region, your input will be valuable to this project. Because we are interested in learning about which services are
and are not accessed by persons who use drugs, we'd like you to participate regardless of whether or not you currently serve
this population.
The survey will take you an average of 20 minutes to complete. You will be asked questions about all or some of the
following areas:
a) demographics of your organization
b) your perceptions of drug use in Waterloo Region
c) the types of services offered by your organization
d) possible barriers to receiving services
e) outreach activities and strategies
THE RESEARCH PROJECT:
This survey is part of a Baseline Drug Use Study managed by Region of Waterloo Public Health, in collaboration with the
Centre for Community Based Research, in Kitchener.
This purpose of this project is to gain information about local drug use (e.g. which drugs are being used, the types of places
where people are using, and safety risks while using and buying), learn about the various services and programs available to
people with drug use, and assess if the current services collectively are meeting the identified needs.
The findings will be used to guide and inform future planning initiatives.
DEFINITION:
For the purpose of this project, an individual who regularly uses illicit substances includes anyone who has used a substance
(excluding alcohol, including misuse of prescription pills) at least 6 times in the past year and at least 3 times in the
Waterloo region.
QUESTIONS OR CONCERNS? Please contact:
Suzanne Field at 519 741-1318, ext. 234
Andrew Taylor at 519 741-1318, ext. 224 or
Chris Harold at 519 883-2006, ext. 5560
* 1. Please understand that completing this survey is voluntary. Your responses
will be kept confidential and you and your organization will not be linked to any
information you provide.
nI
j
k
l
m
have read and understand the above information and agree to participate in this survey.
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Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
2. Thank you for agreeing to participate
Thank you! Your insights will be greatly appreciated and helpful. The bar at the top of the page will indicate how much of the
survey you have already completed.
Please remember, in this survey, an individual who "regularly uses illicit substances" includes anyone who has used a
substance (excluding alcohol, including misuse of prescription pills) at least 6 times in the past year and at least 3 times in
the Waterloo region.
Please click NEXT to begin.
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Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
3. Organizational Details
1. Which city/township is your organization located in?
n Cambridge
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n Kitchener
j
k
l
m
j North
k
l
m
n
Dumphries
n Waterloo
j
k
l
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n Wellesley
j
k
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n Wilmot
j
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j Woolwich
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2. How would you describe the setting surrounding your organization?
j Downtown
k
l
m
n
n Rural
j
k
l
m
n Suburban
j
k
l
m
3. Which of the following BEST defines your organization?
g Primary
c
d
e
f
Health Care (e.g. family physicians, urgent care, community health centres)
g Specialized
c
d
e
f
g Addictions
c
d
e
f
c Harm
d
e
f
g
Treatment and Rehabilitation (e.g. detox, residential treatment)
Reduction Service Agency (e.g. needle exchange, safe injection sites, maintenance programs)
g Counselling
c
d
e
f
g Family
c
d
e
f
c Agency
d
e
f
g
Service Agency
Services (e.g. Family and Children's Services, Parenting programs)
g Outreach
c
d
e
f
organization
providing basic needs (e.g. shelter, food bank, clothing depot)
c Corrections
d
e
f
g
g Other
c
d
e
f
Health Care (e.g. mental health agencies, HIV treatment centres)
Services
(please specify)
Page 3
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
4. Which of the following types of services are offered by your organization?
(please check all that apply and specify the services in the comment box
below)
c Primary
d
e
f
g
healthcare (e.g. generalized healthcare, urgent care, community health)
g Specialized
c
d
e
f
g Addictions
c
d
e
f
g Harm
c
d
e
f
healthcare (e.g. mental health services, HIV treatment)
treatment and rehabilitation (e.g. detox, residential treatment)
reduction services (e.g. needle exchange, safe injection, maintenance services)
c Counselling
d
e
f
g
g family
c
d
e
f
services
services (e.g. parenting classes, supervised visits)
g Outreach
c
d
e
f
services
g Provision
c
d
e
f
of basic needs (e.g. food, shelter, clothes)
Other (please specify services)
5. Approximately how long have you worked in your current position?
j Less
k
l
m
n
than 1 year
j1
k
l
m
n
to 3 years
n4
j
k
l
m
to 9 years
n 10
j
k
l
m
years or more
6. How long have you worked in Waterloo Region with persons who use illicit
substances?
n Less
j
k
l
m
than 1 year
j1
k
l
m
n
to 3 years
n4
j
k
l
m
to 9 years
n 10
j
k
l
m
years or more
* 7. To the best of your knowledge, approximately how many of the
clients/patients served by your organization are persons who use illicit
substances regularly?
j None
k
l
m
n
j Less
k
l
m
n
than half
n About
j
k
l
m
n More
j
k
l
m
half
than half
n All
j
k
l
m
j Not
k
l
m
n
Sure
Page 4
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
4. Perceptions of illicit substance use and related services
1. Based on your interactions with your clients/patients, please indicate how
commonly used you think the following substances are in the Waterloo Region.
1 being 'not at all common' and 5 being "very common"
1
2
3
4
5
Not sure
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Anabolic Steroids
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Barbiturates “downers” (e.g. Seconal, Nembutal,
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Cannibis (e.g. marijuana, hashish, hash oil)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Other Hallucinogens (e.g. LSD, PCP "angel dust",
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Cocaine (e.g. powder, crack cocaine)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Other Stimulants (e.g. diet pills, Ritalin,
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Dilaudid
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
DMT
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Ecstasy (MDMA)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
GHB (e.g. liquid ecstasy)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Heroin
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Inhalents (e.g. glue, gas, VCR cleaner)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Ketamine
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Methadone
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Morphine
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Oxycontine
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Pain Relief Pills (e.g. Vicodin, Percocet,
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Solvents
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Poly-Drugs (using more than one drug
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Amphetamines (e.g. speed, crystal meth, pep
pills, uppers)
Amytal, Tuinal, Imovane)
"magic mushrooms", Mescaline, Psilocybin)
Dexedrine)
Percodine, Tylenol #3, Demerol, codeine)
Rohypnol – “Roofies” (for personal use, not on
another individual)
Sedative-Tranquilizers (e.g. Valium, Xanax,
Halcion, Serax, Ativan)
simultaneously)
Other(s) (please specify)
Page 5
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
2. In your city or township, how common do you think it is for illicit substances
to be used in the following places?
1 being "not at all common" and 5 being "very common"
1
2
3
4
5
Not sure
Downtown
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Suburban
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Rural
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
3. In your city or township, how common do you think it is for illicit substances
to be used in the following types of places?
1 being "not at all common" and 5 being "very common"
1
2
3
4
5
Not sure
Home
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Park
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Public Streets
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Shelter
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Fitness Club
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Workplace
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Dance club/bar
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Adult exotic dance club
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Retirement/Nursing
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Home
Other(s) (please specify)
Page 6
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
5. Perceived Needs and Harm Reduction
1. To what extent do you think the following social issues affect persons in
Waterloo Region who use illicit substances regularly?
Almost
Not at all
Infrequently
Sometimes
Frequently
Negative Stigma
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty gaining and/or maintaining
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Insufficient/unstable income
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Insufficient clothing
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining hygiene
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty finding employment
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining employment
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Isolation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Lack of social supports
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining personal
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Fear for personal safety
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Suicidal ideation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Crime (perpetrator)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Crime (victim)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Involvement in sex trade
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
housing
relationships
always
Not sure
Other(s) (please specify)
Page 7
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
2. To what extent do you think the following healthcare issues and conditions
affect persons who regularly use illicit substances in the Waterloo Region?
Almost
Not at all
Infrequently
Sometimes
Frequently
HIV positive / AIDS
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Hepatitis B
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Hepatitis C
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Other Sexually Transmitted Diseases
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Mental Health complications
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Unplanned pregnancies
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Inadequate nutrition
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Dental problems
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
(please specify below)
always
Not sure
Other(s) (please specify)
3. To what extent do you believe harm reduction measures are used by your
clients/patients/participants in the following activities?
Injection drug use (e.g. uses needle
exchange services)
Sexual activities while under the
influence (e.g. uses contraceptive)
Transportation while under the
influence (e.g. uses a designated
Almost
Not at all
Infrequently
Sometimes
Frequently
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
always
Not sure
driver or public transportation)
Purchase of drugs (e.g. understanding
ingredients of particular purchase)
Other(s) (please specify)
Page 8
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
6. Adequacy of available services
1. In general, please indicate how adequate you think services are in your city
or township for the following substances.
1 being "not at all adequate" and 5 being "very adequate"
1
2
3
4
5
Not sure
Cannibis (e.g. marijuana, hashish, hash oil)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Depressants (e.g. Opiates: heroin, morphine, pethidine,
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Inhalents (glue, household products, gas)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Poly-Drugs (using more than one drug simultaneously)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Stimulants (e.g. Speed, Ecstasy, Anabolic steroids, Amyl nitrite,
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
methadone, codeine, dilaudid. Benzodiazopines: tranquillizers
such as Valium, Temazepam)
Hallucinogens (e.g. LSD, Ecstasy, Magic mushrooms, high
potency cannabis such as 'skunk')
Cocaine, Crack cocaine)
Other(s) (please specify)
2. In general, in your city or township, how adequate do you think services are
for individuals in the following age categories who regularly use illicit
substances?
Not at all adequate
Somewhat adequate
Very adequate
Not sure
youth (aged 25 and under)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
adults (aged 26 to 59)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
older adults (aged 60 and above)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
3. In general, in your city or township, how adequate do you think services are
for individuals in the following socio-economic situations who regularly use illicit
substances?
Not at all adequate
Somewhat adequate
Very adequate
Not sure
No fixed address
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Low income with residence
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Middle income with residence
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Upper income with residence
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Other (please specify situation and perception of available services)
Page 9
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
4. Please include any comments or explanations about your answers to
questions 2 and/or 3.
5. To the best of your knowledge, what percentage of persons who regularly
use illicit substances have received services from your organization/agency on
more than one occasion (thus, are repeat or regular clients/patients)?
j all
k
l
m
n
or almost all
n more
j
k
l
m
n about
j
k
l
m
than half
half
n less
j
k
l
m
than half
j very
k
l
m
n
few or none
n not
j
k
l
m
sure
* 6. In order to determine the appropriate next page, please indicate the type of
support offered by your organization.
n My
j
k
l
m
organization offers support through social services only.
n My
j
k
l
m
organization offers support through healthcare only.
n My
j
k
l
m
organization offers support through both social services and healthcare.
Page 10
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
7. Appropriateness of social services
1. As a service provider, to what extent do you feel able to meet the overall
needs of your clients/participants who regularly use illicit substances?
j Not
k
l
m
n
at all
j Somewhat
k
l
m
n
n Sufficiently
j
k
l
m
n Exceptionally
j
k
l
m
n Not
j
k
l
m
Applicable - I don't personally offer social services
2. In which areas, if any, do you feel you require additional training or
education to successfully support and serve individuals with illicit substance
use?
3. How well do you believe your agency addresses the following social
situations for individuals who regularly use illicit substances?
Not at all
Somewhat, but
not sufficently
Sufficiently
Expectionally
Not sure
Negative stigma from general public
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty gaining and/or maintaining
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Insufficient/unstable income
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Insufficient clothing
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining hygiene
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty finding employment
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining employment
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Isolation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Lack of social supports
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Difficulty maintaining personal
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Suicidal ideation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Fear for personal safety
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Crime (as perpetrator)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Crime (as victim)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Involvement in sex trade
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
housing
relationships
Other(s) (please specify)
Page 11
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
4. Please provide any additional comments or explanations about your answers
in question 3.
5. Please list any services and/or programs that are not currently available
that you believe would be helpful for persons who regularly use illicit
substances?
* 6. Please indicate below to determine the next appropriate page.
n My
j
k
l
m
organization offers support through social services only.
n My
j
k
l
m
organization offers support through both social services and healthcare.
Page 12
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
8. Appropriateness of healthcare services
1. As a healthcare provider, to what extent do you feel able to meet the overall
needs of your patients who regularly use illicit substances?
j Not
k
l
m
n
at all
j Somewhat
k
l
m
n
n Sufficiently
j
k
l
m
n Exceptionally
j
k
l
m
n Not
j
k
l
m
Applicable - I don't personally offer healthcare
2. In which areas, if any, do you feel you require additional training or
education to successfully support and serve individuals with illicit substance
use?
3. How well do you believe your organization addresses the following
healthcare needs of individuals who regularly use illicit substances?
Not at all
Somewhat, but
not sufficiently
Sufficiently
Exceptionally
Not sure
HIV positive / AIDS
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Hepatitis B
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Hepatitis C
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Other Sexually Transmitted
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Suicidal ideation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Mental Health complications (please
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Unplanned pregnancies
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Inadequate nutrition
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Dental problems
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Overdoses
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Diseases (please specify below)
specify below)
Other(s) (please specify)
Page 13
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
4. Please provide any additional comments or explanations about your answers
in question 3.
5. Please list any healthcare services and/or programs that are not currently
available that you believe would be helpful for persons who regularly use illicit
substances?
Page 14
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
9. Barriers to Accessing Services or Healthcare
1. Based on your understanding of the living conditions of those who reguarly
use illicit substances in Waterloo Region, to what extent do you think the
following limits the ability of someone from this population to access services
from your organization?
Not at all
Infrequently
Somewhat
Frequently
Not sure
Location (considering transportation)
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Cost of service
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Stigma surrounding service
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Awareness of services
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Trust of agency/centre and/or
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Lack of personal motivation
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Language and/or communication
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Cultural needs
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Limited relevancy or appropriateness
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
service providers
barriers
of services
Other(s) (please specify)
2. Please provide any additional comments or explanations about your answers
in question 1.
3. Is there anything that prevents or limits you from providing the most
adequate support/healthcare for individuals with regular drug use? Please
explain.
Page 15
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
10. Outreach Activities
1. How are people who use your services typically connected with your
organization? (please check all that apply)
c Outreach
d
e
f
g
c Learned
d
e
f
g
workers
about service/program through posters, advertisements, etc...
g Suggested
c
d
e
f
g Referral
c
d
e
f
by friend or family member
from other service or healthcare providers
g Mandated
c
d
e
f
c Other(s)
d
e
f
g
through the legal system
(please specify)
2. In the past year, has your organization attempted to outreach to persons
who regularly use illicit substances?
n yes
j
k
l
m
n no
j
k
l
m
n not
j
k
l
m
sure
3. If your organization has attempted to outreach to persons who regularly
use illicit substances, what was the result?
j We
k
l
m
n
met with and successfully linked persons with our services
n We
j
k
l
m
met with, but could not link persons with our services
n We
j
k
l
m
were not able to meet with persons in this group
Please include any additional explanations or comments about your agencies experiences with outreach
4. What, if anything, might prevent your organization from engaging in
outreach activities for persons who regularly use illicit substances? (please
check all that apply)
g Limited
c
d
e
f
time
g Insufficient
c
d
e
f
funding
g Limited
c
d
e
f
knowledge (of where to go, who to speak with, etc...)
c Feeling
d
e
f
g
uncomfortable with approaching people in this group
g Organizational
c
d
e
f
g Other(s)
c
d
e
f
policies that limit outreach (directly or indirectly)
(please specify)
Page 16
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
5. Please provide any additional comments about your organization's
experiences and/or challenges with outreach activities.
Page 17
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
11. Additional Comments
1. Do you have any additional comments or explanations that you believe will
be helpful in understanding illicit substance use, healthcare, and social services
in the Waterloo Region? If so, please provide them below.
Page 18
Waterloo Region Public Health: Baseline Drug Use Study - Healthcare and Social
12. Finished!
Thank you for participating in this important survey! We appreciate your contributions.
If you have any questions or further comments, please contact:
Andrew Taylor: 519.741.1318 ext. 224
Suzanne Field: 519.741.1318 ext. 234 or
Chris Harold: 519.883.2006, ext. 5560
If you are ready to submit your answers, please click DONE. If you'd like to change any answers, please click PREV to return
to the previous pages.
Page 19