Regional Overview 2.5 North America 127 2.5 NORTH AMERICA CANADA UNITED STATES 128 Global State of Harm Reduction 2020 TABLE 2.5.1: Epidemiology of HIV and viral hepatitis, and harm reduction responses in North America Country/ People who HIV Hepatitis C Hepatitis Harm reduction response territory inject drugs prevalence (anti-HCV) B (anti- with among prevalence HBsAg) reported people who among prevalence Peer injecting inject drugs people who among NSP1 OAT2 distribution DCRs3 drug use (%) inject drugs people of naloxone (%) who inject drugs (%) Canada 130,000[1] 14.6[2] 70.6[3] nk[3] 4 (M,B,BN,H,O) 40[4] United States 2,248,500[3] 8.7[3] 53.1[3] 4.8[3] >418[5] 5 6(M,B,TN) x nk = not known 1 All operational needle and syringe programme (NSP) sites, including fixed sites, vending machines and mobile NSPs operating from a vehicle or through outreach workers. 2 Opioid agonist therapy (OAT), including methadone (M), buprenorphine (B) and any other form (O) such as morphine and codeine. 3 Drug consumption rooms, also known as supervised injecting sites. 4 No estimate is available for the total number of NSPs in Canada. 5 This is the number of NSPs registered with the North American Syringe Exchange Network and is therefore a minimum figure for the number of NSPs operating in the United States. These services operate in 44 of the 50 states. 6 OAT is available in every state. Regional Overview 2.5 North America 129 MAP 2.5.1: Availability of harm reduction services CANADA UNITED STATES Both NSP and OAT available Neither available Peer-distribution of naloxone OAT only Not known NSP only DCR available 130 Global State of Harm Reduction 2020 2.5 Harm reduction in North America GLOBAL POPULATION OF PEOPLE OVERDOSE, OVERDOSE RESPONSE AND WHO INJECT DRUGS DRUG CONSUMPTION ROOMS (DCRS) FROM 1999 TO 2018, THERE WERE 769,935 NORTH AMERICA DRUG OVERDOSE DEATHS RECORDED IN THE UNITED STATES. IN 2018, THERE WERE 67,367 OVERDOSE DEATHS, 16% 70% OF WHICH INVOLVED AN OPIOID, MOST NORTH AMERICA IS HOME TO 16% OF THE GLOBAL COMMONLY ILLICITLY MANUFACTURED POPULATION OF PEOPLE WHO INJECT DRUGS. FENTANYL OR ITS ANALOGUES. DRUG CONSUMPTION ROOMS (DCRs) People of colour, 40 OUT OF 130 and most acutely DCRs IN THE Black people, are WORLD ARE IN discriminated CANADA against at every stage of the judicial process in the United States: policing, pre-trial, sentencing, parole and post- incarceration. Regional Overview 2.5 North America 131 1. Author: Sam Shirley-Beavan Overview Harm Reduction International North America is home to 16% of the global population In Canada, recent changes of people who inject drugs.[6] Canada is among the most progressive countries in the world with regard have led to the availability to the implementation of harm reduction, though there remain significant issues in accessibility and of heroin-assisted therapy service provision. The United States lags considerably behind Canada and other high-income countries in the (HAT) in the form of implementation of almost all harm reduction services. diacetylmorphine and Needle and syringe programmes (NSPs)7 and opioid hydromorphone in at least agonist therapy (OAT) programmes8 are in operation in both Canada and the United States. Since 2018, more three provinces. jurisdictions have enabled access to NSPs. Methadone and buprenorphine are the most widely used medications for OAT across North America, and are the only medications available in the United States. In Canada, recent changes have led to the availability of heroin-assisted therapy (HAT) in the form of diacetylmorphine and hydromorphone in at Drug checking is available in at least two provinces in least three provinces. Canada, and since 2019 has been available as an overdose prevention response often co-located with DCRs. In the North America continues to experience a crisis of overdose United States, federal and state restrictions on drug deaths. In 2018, almost 70,000 overdose deaths were checking are tighter and, as a result, access to drug checking recorded in the United States alone.[7] In Canada, the is more limited. number of federally regulated drug consumption rooms (DCRs) increased from 24 in 2018 to 40 in 2020. There In correctional settings, Canada is considerably more remain no officially licensed DCRs in the United States, advanced in harm reduction implementation than the but there is at least one unsanctioned programme in an United States, with OAT available in all federal prisons and undisclosed location.[8,9] While regulations on access to NSPs operational in 11 prisons. There is one operational naloxone have loosened in the United States since 2018, prison DCR in Canada. However, civil society actors naloxone is still designated a prescription-only medication, have expressed concern over its operation and the creating barriers to access. misconception among correctional staff that this may replace the need for an NSP. In the United States, no Despite the high prevalence of the use of stimulants in prison-based NSPs or DCRs are operational, and access to North America, the harm reduction response to stimulants OAT in prisons is severely limited. remains limited compared with the response to opioids. Harm reduction programmes in some cities in Canada and the United States report the distribution of safer smoking and inhalation equipment. 7 In the United States, these programmes are commonly called syringe service programmes (SSPs). 8 In the United States, these programmes are commonly called medications for opioid use disorder (MOUD). 132 Global State of Harm Reduction 2020 2. Developments in harm reduction implementation 2.1 NEEDLE AND SYRINGE PROGRAMMES (NSPs) Stigma remains a significant barrier to accessing NSPs in As reported in 2018, NSPs are operational in both Canada Canada and the United States, as evidenced in pharmacies. and the United States. In both countries, individual states, [20,21,23,24] Only one state (Delaware) expressly prevents provinces and territories are responsible for the legal status the sale of syringes in pharmacies, but many states allow of NSPs. The overall trend in the region is for an increase in for significant pharmacist discretion.[23] This frequently the availability of services. manifests in stigma and denial of service to people who inject drugs, as found in a 2019 study in Arizona.[23] NSPs are available in all Canadian provinces and territories except the Northwest Territories and Nunavut.[1] An Law enforcement also has a negative impact on the estimated 50 million syringes were distributed in 2016, accessibility of NSPs in North America. For example, state equivalent to 291 per person who injected drugs.[1] This is law in West Virginia permits the operation of NSPs but, in below the 300 syringes per person that the World Health some cases, city ordinances prohibit the possession of drug Organization (WHO) recommends to achieve hepatitis C paraphernalia including injecting equipment.[24] The result is elimination by 2030.[10] that people who inject drugs do not access NSPs for fear of arrest.[24] In 2018, such contradictory local policies forced a A United States government study found that 32.1% of West Virginia NSP to close as they could no longer operate people who inject drugs reported sharing syringes and in line with best practices.[25] 54.5% reported sharing any injecting equipment (including cookers and cotton wool).[11] Only 52.8% of people reported receiving syringes from NSPs, though this figure varied by city (from 93.1% in San Francisco to 0.9% in Houston).[11] Since 2018, in the United States, at least three states have taken steps to facilitate the establishment and operation of NSPs. New state legislation was passed in Idaho, Illinois and Florida to legalise or facilitate the establishment of NSPs.[12–15] At the federal level, in 2019 the Office of the Assistant Secretary of Health (OASH) launched an effort in collaboration with As of 2020, there are six regional health administrators, the Centers for Disease Control and Prevention (CDC) and other federal, state and states in which no legal NSPs local stakeholders to promote the implementation of NSPs. operate: Alabama, Kansas, [16] As of 2020, there are six states in which no legal NSPs operate: Alabama, Kansas, Mississippi, Nebraska, South Mississippi, Nebraska, South 9[5,12,17–19] Dakota and Wyoming. Dakota and Wyoming. Civil society organisations in Canada and the United States report that the primary barrier to accessing NSPs is the lack of availability in certain jurisdictions, most acutely in rural areas (refer to rural communities box).[20–22] A lack of funding, a hostile political environment and municipal bylaws can all obstruct the establishment of services in these areas.[20,22] Even where NSP implementation is extensive, there is a lack of tailored and targeted programmes for marginalised subpopulations, such as women, young people and Indigenous communities.[20,21] 9 In some of these states it may be possible to purchase syringes from pharmacies, but no programmes distribute injecting equipment for free to people who inject drugs. Regional Overview 2.5 North America 133 Rural communities 2.2 Almost 20% of people in Canada and the United OPIOID AGONIST THERAPY (OAT) States live in rural areas, as defined by their respective OAT is available in both Canada and the United States. In governments.[26] Rural communities have been affected Canada, provincial governments are responsible for OAT. by the ongoing crisis of overdose deaths. For example, the In the United States, the federal