Limitations It’s a really a small part of the larger puzzle, and, so, it really does feel like a crisis response to a crisis situation and not a comprehensive response to a really big problem which, is ultimately drug policy, both federally and globally. [Harm Reduction Staff]
Possible lessons learned • National and international example of an alternative to sanctioning processes for SCSs. • Alternative to sanctioning demands that limit responsiveness, adaptation and innovation. • Centering PWUD in service design, implementation and delivery • Innovative and inclusionary practices were possible within state-sanctioned OPSs • Rules discounting drug-user culture limit access and effectiveness
Conclusions • End restrictive policies and expand services. • OPS as integrated services within harm reduction, housing, and health and social services. • Explore the expansion of needle distribution services to include safer spaces to use. • Prioritize experiential and peer staffing and peer- operated sites with suitable, equitable salary and supports.
OPS expansion
Drug checking within an overdose crisis Bruce Wallace & Bernie Pauly May 2019
Drug checking definition • Drug checking is a harm reduction approach which allows people to identify the contents of a substance and receive drug information from a peer and/or harm reduction worker. • A history in nightlife and festival settings, and now increasingly explored as a potential response to the illicit overdose crisis which occurs throughout all communities.
Drug checking in the overdose crisis “Given the alarming influx of high potency and adulterated drugs in the market in British Columbia in recent years, and the corresponding increase in overdose deaths, real-time, consumer-derived, street level generated data regarding trends in the illegal drug supply may be instrumental in appropriately allocating federal, provincial, and regional harm- reduction resources, and in providing potentially life-saving information to people who use illegal drugs” [4] (Pg:26).
Questions & cautions A recent BMC article on drug checking as a response to opioid overdose ends with the caution: “[I] mplementation in the absence of rigorous evaluation could result in the wasting of precious resources, and more importantly, more lost lives to fatal overdose” (2018:2).
Victoria drug checking project A three year project to pilot and evaluate drug checking in community settings to assess the limitations and benefits of the instruments as a response to the current overdose emergency and will assess how the services could potentially be scaled-up as harm reduction responses.
Drug-checking technologies: Chemical tests Marquis reagent Strip tests Chemical-based, formaldehyde + Antibody based sulfuric acid Colour indicates class of compound http://testkitplus.com/wp-content/uploads/mdma-test-kit.jpg http://www.careshop.co.uk/7844-thickbox_default/fentanyl-test-strip-1x50.jpg
Drug-checking technologies: Instrumental tests https://www.atago.net/ https://www.agilent.com/ http://www.nanalysis.com/ http://www.perkinelmer.com/
Immunoassay Test Strips Fentanyl Testing Strips, produced by BTNX
Infrared (IR) Absorption Spectroscopy 4500a FTIR produced by Agilent
Gas Chromatography-Mass Spectrometry (GC-MS) Torion T-9 Portable GC-MS produced by Perkin Elmer
Raman Spectroscopy Resolve Handheld Raman produced by Cobalt (now Agilent) with Surface Enhanced Raman Scattering (SERS)
Drug Checking in Context • The contexts of the current illicit drug overdose emergency. • Politicized harm reduction and drug checking. • Evaluation framework - harm reduction, health equity and social justice principles. • Drug checking vs. safe supply – false binary.
More information website: https://substance.uvic.ca team email: substance@uvic.ca
Comprehensive Equity Oriented Responses Bernie Pauly RN, Ph.D Bruce Wallace, RSW, Ph.D UVIC Schools of Nursing and Social Work Canadian Institute for Substance Use Research (CISUR) @UVIC_CISUR
How Effective are the responses? Time Period : April 2016 (when emergency declared) to Dec 31st 2017 (21month) in BC # Overdose Deaths : 2,177 overdose deaths Death events averted all interventions : Estimated 3,030 (2,900 – 3,240). By Intervention : Take Home Naloxone : 1,580 deaths (1 480 – 1 740) Overdose Prevention Services : 230 (160 – 350) 13 months OAT : 590 (510 – 720) Reference : Irvine et al., 2019, Addiction
Is there a Social Gradient in Overdose Epidemics? Insufficient SDOH, Colonization, Increasing Criminalization, Overdose Stigma and Discrimination Deaths and Harms Insufficient Treatment Systems Changes in Opioid Prescribing Unsafe Drug Supply Pauly, 2018 Photo credit: Public Health Watch
Health Equity Responses Contexts of harm (Historical-Social- Economic- Social Harms Political) • Poverty Injury, Harms • Homelessness Violence Overdose • Colonization: Racism Stigma HIV/HCV, • Gender Norms: Sexism Social Addiction • Heteronormativity Exclusion Medicalized • Criminalization Responses • Age restrictions_Ageism • Trauma and Brown & Pauly, 2017 Intergenerational trauma
Toward an Equity Oriented Framework to Inform Responses to Opioid Overdoses: A Scoping Review For more information, please contact: Bernie Pauly at bpauly@uvic.ca 1
What is an Equity Oriented Response to Overdose? Health System Functions Health Promotion Health Protection Prevention Surveillance Treatment
Shifting Values: People Not Pathologies SEE People STOP Pathologizing People as Capable Moralizing Knowledgeable Medicalizing Deserving Undeserving Strong Victimizing
Social Networks Organizations by and for People who use Drugs, Peer to Peer Networks of PWUDs, Families, & Communities Specific attention to Women, LGBTQ, racialized groups
Harm Reduction Art by” Xan Beauchamp
Drug User Activism: Overdose Prevention Sites December, 2016 October, 2016 Novel, Nimble, Establised by a August, 2016: Pop Up Overdose Tent Responsive (Wallace, Ministerial Order Site in Surrey Established by Pagan & Pauly, under under Emergency Volunteers review) Services and HA Act File Photo: Georgia Straight and Canadian Press
❑ Peer Engagement in Research, Policy, Education ✓ Peer Involvement in visioning, development of policies ✓ Peer informed design and implementation of services ✓ Peer Educator Roles ✓ Peer Research Roles ❑ Peer 2 Peer Interventions ✓ Peer Counsellors (shared experience) ✓ Peer Navigation and Accompaniment ✓ Peer 2 Peer Education ✓ Peer Outreach
Enhancing Peer Engagement (www.bccdc.ca) Lan guage m at t ers… \ 4 guid elin es t o usin g n on -st igm at izin g lan guage 1 c Use People-first language vs. Person who uses opioids Opioid user OR Addict 2 c Use language that re flects the m edic al nature of substance use disorders Person experiencing problems vs. Abuser OR Junkie with substance use c 3 Use language that promotes recovery Person experiencing barriers to vs. Unmotivated OR accessing services Non-compliant 4 c Avoid slang and idioms Positive test results OR vs. Dirty test results OR Negative test results Clean test results VISIT t ow ard t h eh eart .com FOR M ORE IN FORM ATION CREATED BY BCCDC HARM REDUCTION TEAM Adapted from Broyles et al. Confronting Inadvertent Stigma and Pejorative Language in Addiction Scholarship: A Recognition and Response. Substance Abuse 2014 Last Updated: December 6th 2017
Organizational Recommendations: Peers Tokenism: Organization Peer Led and Partnership Recipient of Informing, Initiated: Initiated: Building a Shared Power Services: Peer Workforce/ Advisory, Lone Peer Reps and Decision Client Organization Making Consultation Peer Workers Strength and Resilience Arnstein, 1969 Hart, 1992;1997
Benefits of Peer Work For Programs and Services ➢ Increase Reach, Effectiveness and Relevance of initiatives due to community connections ➢ Peer workers preferred by clients for support, greater safety ➢ More able to connect and communicate due to shared life experiences For Peer Workers: ➢ feelings of dignity, pride, accomplishment, confidence, ➢ sense of purpose, empowerment ➢ Build morale, skills andemployment record 76
Background Peer engagement (PE) in BC • PE has been increasingly recognized as a ‘best practice’ in BC • Largely due to advocacy of peer- based orgs like VANDU, Solid Outreach etc. • Support for peer engagement and workplace standards remain an issue
Labor Market Discrimination • Criminal Record Checks • Drug Testing • Reinforce notions of abstinence • Need for Low Barrier Employment Options 78
Organizational Issues (Greer et al, 2019) • Lack of Knowledge or awareness of role and value of peers • Vague and unclear role expectations and responsibilities (note peers will always go above and beyond!!!!!) • Lack of knowledge of peers life circumstances and supports. • Workplace Stigma and discrimination by non peer staff • Volunteerism, low wages (exploitation) • Precarious work, Job Insecurity (daily, temporary, lack of stability, multiple jobs) • Work stress, trauma and loss • Lack of understanding of peer diversity of lived experience (e.g. sex trade, Indigenous, HIV, type of drug use, housing and homelessness experiences, gender, age). Experiential knowledge should relate to their job. 79
PEEP (Peer Engagement and Empowerment Project (2015-2017) (www.bccdc.ca) February 2018 V1 VERSION 2 DECEMBER 2017 PAYING PEERS IN COMMUNITY BASED WORK AN OVERVIEW OF CONSIDERATIONS FOR EQUITABLE COMPENSATION In partnership with the Paying Peers Working Group Sincerest thanks to the late Larry Howett for his review of this document. PEER ENGAGEMENT PRINCIPLES AND BEST PRACTICES A GUIDE FOR BC HEALTH AUTHORITIES AND OTHER PROVIDERS Written in partnership with peers and providers This guide was developed by the Peer Engagement and Evaluation Project Team through a research project funded by Peter Wall Institute for Advanced Studies
Peer Payment Standards For Short Term Engagements (www.bccdc.ca) 1. Be Upfront about February 2018 V1 Payment (amount, PEER PAYMENT STANDARDS FOR SHORT- TERM ENGAGEMENTS timing) Created in collaboration with peers and providers BC Centre for Disease Control 2. Provide Options 3. Pay Cash 4. Pay other costs (transportation, meals) 5. Discuss implications for social assistance/welfare 81
Past Versus Current Use POLICY: Employees and peers may not come to work showing signs of inebriation. All staff — including outreach workers — are expected to perform their professional duties in a coherent, competent, and respectful manner. POLICY: Management may not conduct witch hunts or drug testing to determine drug use by employees. 82
Who are the First Responders?
Definitions • Compassion fatigue: profound emotional and physical erosion when unable to refuel and regenerate “cost of caring” for others in emotional pain • Vicarious trauma: beliefs in the world shift in helping professionals when they work with individuals who have experienced trauma and they are repeatedly exposed to traumatic material • Burnout: physical and emotional exhaustion that workers experience when they have low job satisfaction and feel powerless and overwhelmed at work • Moral distress: when you know the right thing to do but can’t do it because of system constraints
Peer2Peer Project aims • Identify peer support interventions for people who are working in BC OD response environments, determined as needed by Peers themselves • Health Canada Funded • Co-led by Pauly, Buxton, SOLID and RainCity
Project setting • SOLID Outreach: Victoria, BC – Provide overdose prevention services across settings • RainCity: Vancouver, BC – Housing-first organization that provides housing and social supports
P2P Project Methods Mixed-methods, multiple phase participatory community-action research design Step 3: What do Step 1: Identify Step 2: Develop peers think? what matters a model Evaluate the most to peers model Step 4: Step 5: Improve/expand Implement the the model model
Developing a peer wellness model • What constitutes peer support in overdose work? • Developed model first • Rooted in social determinants of health • Model accounts for Step 3: What do Step 1: Identify Step 2: Develop peers think? what matters 1) material determinants a model Evaluate the most to peers model. 2) non-material determinants Step 4: Step 5: Improve/expand Implement the the model model
P2P: Peer Wellness Model Creative Art and Music Goal : Health and wellbeing Therapy Assistance with Equitable Living Conditions (e.g. Peer workers & Housing income and other resources) worker solidarity Peer to = Work Place Peer Supports Counselling Essential Skill development and Training Valuing Work: Equitable Pay and Foundation : Working Conditions
Focus Groups with Peers – Refine the model – Develop interventions to best implement the model – Baseline interviews (without model) Step 3: What do Step 1: Identify Step 2: Develop peers think? what matters a model Evaluate the most to peers model. Step 4: Step 5: Improve/expand Implement the the model model
P2P Findings First Aid and CPR Conflict Resolution Communication Skills Mental Health Skill-Building Self Defence Job Title, Job Description, P2P Living Wage, Clarity re Breaks, Sick Time, Fair and Equitable Pay, Initiative Meet and Greet with Housing Coach other professionals Recognition Organization Ability to Refer to Resources of Peer Work al Support Day in the Life, Awards, Peer Debriefing/Support
Next steps • Expand, improve & implement the model • Interviews @ midpoint and endpoint • Peer Support Manual for Overdose Prevention Step 3: What do Step 1: Identify Step 2: Develop peers think? what matters a model Evaluate the most to peers model. Step 4: Step 5: Improve/expand Implement the the model model
Creating Cultural Shifts: Organizational Recommendations • Harm Reduction Policies • Education re harms and impacts of stigma • Knowledge of benefits and effectiveness of harm reduction interventions • Structural Competency: Recognize role of racism/stigma • Cultural Safety Training at all levels in the organization • Involve peers in education • Training in socio ecological understanding of inequities • Training informed by social justice frameworks
There is still a need for public policy changes……From current drug policy to healthy public policy
Healthy Public Policy….Harm Reduction “The new strategy ‘restores harm reduction as a core pillar of Canada’s drug policy.’ That new strategy would also put drug policy back under the health ministry and away from Justice Department” (Dec 12, 2016)
Passed May, 2017 but Knowledge and Implementation varies
BC Provincial Health Officer (April, 2019) ”Immediate provincial action is warranted, and I recommend that the Province of BC urgently move to decriminalize people who possess controlled substances for personal use.” 97
Compassion Clubs - Cooperatives • Similar to cannabis compassion clubs from people living with HIV/AIDS movements. • A cooperative approach with heroin restricted to to members and legally obtained from a pharmaceutical manufacturer and securely stored – similar to heroin prescription programs. • Could undermine the illegal market • Could be initiated at little to no operating cost to the public. • Could be peer based – those with most experience in securing heroin – operated by NGOs.
Canadian Association of People Who Use Drugs (CAPUD) • Safe supply refers to a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market. • Substitution treatments, such as methadone and suboxone, do not meet the criteria as safe supply because they do not contain the mind/body altering properties that people seek in recreational drugs. • Safe supply is a drug policy category that ought to fit alongside other “pillars” of drug policy such as treatment, harm reduction, education, and prevention.
BC Community Network of SU Observatories (Funded by Health Canada for Five Years) • Peer Led Community Network • Monitoring structural conditions that produce drug related harms • Refinement of Equity Oriented Indicator Framework (public policy, community, social networks, organizational indicators) • Focus on responses to substance use and level of services. • Community of Practice 100
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