Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012 APRIL 11, 2012 Report of the Toronto and Ottawa Supervised Consumption Assessment Study | 1 Ahmed M. Bayoumi and Carol Strike Margaret Brandeau Naushaba Degani Benedikt Fischer Richard Glazier Shaun Hopkins Lynne Leonard Janine Luce Peggy Millson Patricia O’Campo Susan Shepherd Christopher Smith Gregory S. Zaric Bayoumi AM and Strike C (co-principal investigators), Jairam J, Watson T, Enns E, Kolla G, Lee A, Shepherd S, Hopkins S, Millson M, Leonard L, Zaric G, Luce J, Degani N, Fischer B, Glazier R, O’Campo P, Smith C, Penn R, Brandeau M. Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012. Toronto, Ontario: St. Michael’s Hospital and the Dalla Lana School of Public Health, University of Toronto. 2 Acknowledgements We thank all of our study participants for their willingness to share their opinions and data. TOSCA was generously funded by the Ontario HIV Treatment Network and the Canadian Institutes of Health Research. TOSCA was also supported by the Centre for Research on Inner City Health at St. Michael¹s Hospital, Dalla Lana School of Public Health at the University of Toronto, the Institute for Clinical Evaluative Sciences, and the Centre for Addiction and Mental Health. The Centre for Research on Inner City Health is part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael¹s Hospital. The Center for Research on Inner City Health is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care. The Institute for Clinical Evaluative Sciences and the Centre for Addiction and Mental Health are funded by an annual grants from the Ontario Ministry of Health and Long-Term Care. The views expressed in this report are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care, the funding agencies, or supporting organizations. No endorsement by St. Michael¹s Hospital, the University of Toronto, the Institute for Clinical Evaluative Sciences or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred. Report of the Toronto and Ottawa Supervised Consumption Assessment Study | 3 Table of Contents 5 Executive Summary 14 Recommendations 17 Chapter 1. Introduction 23 Chapter 2. Drug Use in Toronto and Ottawa 71 Chapter 3. Do Ontario Residents Agree or Disagree with Making Supervised Consumption Facilities Available? 103 Chapter 4. Supervised Consumption Facility Services, Models, and Rules 152 Chapter 5. Potential Use of Supervised Consumption Facilities 182 Chapter 6. Deciding Where to Establish Supervised Consumption Facilities 217 Chapter 7. Potential Health Benefits and Costs of Supervised Consumption Facilities in Toronto and O ttawa 263 Chapter 8. Potential Implementation and Liability Issues Involved in Establishing Supervised Consumption Facilities 274 Appendix 1. Glossary 280 Appendix 2. TOSCA Team Members 282 Appendix 3. Articles Included in the Systematic Review 287 Appendix 4. Methods 4 Executive Summary Do Toronto and Ottawa need prevention, harm reduction, treatment, supervised consumption facilities? and enforcement. Supervised consumption facilities are an example of a harm reduction Is the implementation of supervised program and are a component of some drug consumption facilities in Toronto or strategies. These facilities were designed Ottawa feasible? To answer these to address the health and social problems questions, we conducted the Toronto not addressed by existing drug policies and Ottawa Supervised Consumption and programs. Across the world, including Canada, other harm reduction programs Assessment (TOSCA) a scientific such as needle and syringe programs and study involving the collection and opioid substitution programs have been analysis of data from a variety of implemented. sources. In Canada, there is one supervised injection facility and another organization that offers a supervised injecting service, but no What is a supervised consumption supervised smoking facilities. In September facility? 2003, Canada’s first supervised consumption A supervised consumption facility is a legally facility opened in the Downtown Eastside sanctioned public health facility that offers of Vancouver, an area with a high rate of a hygienic environment where people can poverty, open drug use, HIV infection rate and inject illicit drugs under the supervision of overdose deaths. Dr. Peter AIDS Foundation trained staff. Some facilities also allow people in Vancouver offers a supervised injecting to smoke illicit drugs. The primary goals of service that is open only to clients of the supervised consumption facilities include: agency. Several other Canadian cities have reducing drug-related risks including the considered the establishment of supervised transmission of Human Immunodeficiency consumption facilities, including Victoria Virus (HIV), Hepatitis B and C and other and Montreal. A 2008 report explored the blood-borne infections; decreasing the feasibility of a supervised injection facility number of overdoses; minimizing public order for Ottawa. In 2005, Toronto City Council problems (including public drug use); and adopted the Toronto Drug Strategy, which improving access to health and social services. included a recommendation for a needs assessment and feasibility study for supervised To address drug-related problems, consumption site(s) taking into account the communities across the world have responded decentralized nature of drug use in Toronto. with policies and programs designed to reduce demand for illicit drugs, reduce the supply of illicit drugs, and reduce drug-related The TOSCA Study harm. Communities across Canada use a comprehensive approach, which includes TOSCA focuses on the cities of Toronto and Report of the Toronto and Ottawa Supervised Consumption Assessment Study | 5 Ottawa since they account for approximately • Survey data were used to characterize the half of all people who inject drugs in Ontario. epidemiology of drug use and the health Toronto has the province’s largest number of of people who use drugs, the likelihood people who use drugs but, unlike Vancouver, that people who use drugs would visit drug use is not as heavily concentrated in a supervised consumption facility, one area. Toronto also has relatively low HIV and Ontarians’ public opinions about prevalence rates among people who inject supervised consumption facilities. drugs. In contrast, Ottawa has the highest new rate of HIV infections amongst people • We used geographic analysis to map the who inject drugs in Ontario. distribution of drug use in Toronto and Ottawa. We identified key factors to help decision makers when considering the establishment of • To understand the potential effectiveness a supervised consumption facility. We address and cost-effectiveness of supervised each of these in the chapters that follow: consumption facilities in Toronto and Ottawa, we used mathematical • What is the distribution of drug use, modeling. We used cost-effectiveness risk behaviours and drug-related health analysis to compare the costs of an problems? intervention with its potential benefits. • Are supervised consumption facilities The TOSCA team includes researchers likely to be used by people who use drugs? with diverse expertise ranging from public health science, epidemiology, health services • What is the epidemiology of blood-borne research, operations research, and health infections and associated risk factors? economics. TOSCA also has four advisory • Where are people who use drugs located groups, with representatives from diverse in Toronto and Ottawa? health and social service providers, as well as people with past/current experience of • What is the social and political drug use. TOSCA was funded by the Ontario environment relating to supervised HIV Treatment Network and the Canadian consumption facilities? Institutes of Health Research. The views of • Are supervised consumption facilities a this report are not necessarily the views of the good use of money? funding agencies. To address these questions, we used multiple Detailed information about the research research methods and data sources as follows: methods used in TOSCA and other materials are available on our study website, www. • Qualitative research methods were used toscastudy.ca to explore attitudes towards supervised consumption facilities from residents, business owners, police, social service employees, public health officials, healthcare providers, emergency medical services, and people who use drugs. 6 Drug Use in Toronto and Ottawa Sharing used smoking equipment was common: 73% of people who use drugs in In Toronto, the large majority of people who Toronto, 71% of people who use drugs in inject drugs injected both cocaine (including Ottawa, 76% of street-involved youth who crack cocaine) and opiates in the 6 months smoke crack cocaine in Toronto, and 81% prior to being interviewed. In Ottawa, 79% of street-involved youth who smoke crystal of people who inject drugs reported injecting methamphetamine in Toronto reported cocaine and 64% reported injecting opiates, smoking with used pipes at least once in in the 6 months prior to being interviewed. the 6 months prior to being interviewed. The proportion of people injecting cocaine In Toronto, 78% of people who smoke most frequently was similar to the proportion crack cocaine had lent or sold a pipe they injecting opiates most frequently. The already used in the