What You Need to Know about Safer Inhalation. Ontario Harm Reduction Conference FEBRUARY 2013

Transcription

1 What You Need to Know about Safer Inhalation Ontario Harm Reduction Conference FEBRUARY

2 Indicators of urgent necessity to implement safer inhalation initiatives Evidence of prevalence of engagement in smoking crack Evidence of HIV and HCV transmission risk associated with smoking crack Evidence of safer inhalation program success Evidence of need for provincial mandate 2

3 Street name for cocaine dissolved and cooked in mixture of water and baking soda to form rocks Crack from crackling noise when rock of crack is heated Extremely addictive associated with compulsive behaviors, restlessness, exhaustion, tension and paranoia Popularity: non-invasive intense high 5 10 minutes low cost $10 wide availability

4 Baseline evaluation of the Ontario Harm Reduction Distribution Program May 2007 March ,643 active IDUs from 26 Public Health Units in Ontario 62% smoked crack in 6 months prior to interview 64% at least once a week 19% three or more times a week 24% daily Average number of times per day smoked crack 24 times (Range ) 4

5 I-Track - Enhanced Surveillance of Risk Behaviors among Injecting Drug Users in Canada ,031 women and men who inject drugs 63% reported smoking crack in the 6 months prior to interview Higher rates of engagement documented for Toronto 89% Edmonton 84% Winnipeg 75%

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11 Devices EVER Used to Smoke Crack Recommended 83% Glass stems NON Recommended 79% Metal pipe 74% Pop can 69% Inhalers 21% Car antenna 13% Light bulb 11

12 Two conditions must be met to facilitate transmission and acquisition of HIV and HCV HCV RNA or HIV RNA must be present in biological fluids; and Trauma to a mucous membrane presenting as opportunistic site for virus entry. Chronic cuts, burns, blisters and open sores inside mouth and on lips are a consequence of sustained contact with: Hot smoke and hot metal from makeshift devices. Splintered and hot glass from unprotected stems no mouthpiece. These injuries act as opportunistic blood sharing sites allowing direct virus-to-blood interaction when smoking devices contaminated with infected blood are shared.

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14 Epidemiological role of non-injection drug use in HIV infection examined in a number of studies Smoking crack an independent risk factor for HIV seroconversion among daily users of crack. (DeBeck et al., 2009) Non-injection drug use independently associated with HIV prevalence among Chinese female sex workers. (Wang et al., 2009)

15 Epidemiological role of non-injection drug use in HCV infection examined in a number of studies Sharing crack pipes when blood present associated with higher prevalence of HCV among 722 crack smokers with no history of IDU (OR 12.78, CI 1.12,145.29). (Howe et al., 2005) Sharing crack inhalation equipment independently associated with HCV prevalence among 182 Spanish non-idus, elevating risk three fold (AOR=3.6; CI 1.3, 9.8). (Macias, 2008)

16 Multiperson Use of Devices to Smoke Crack Smoking with previously-used drug-smoking equipment 78% 54% Every time/frequently Passing on previously-used devices to others to use 78% 49% Every time/frequently 16

17 street-recruited active crack smokers in Ottawa Laboratory results of saliva testing HIV prevalence among 89 dual users (smoking crack and injecting other drugs) 20.2% (95%CI: 12.4, 30.0) HIV prevalence among 160 JUST crack smokers 10.6% (95%CI: 6.3, 16.5)

18 street-recruited active crack smokers Laboratory results of saliva testing HCV prevalence among 89 dual users (smoking crack and injecting other drugs) 87% (95%CI: 77.6, 92.8) HCV prevalence among 160 JUST crack smokers 36% (95%CI: 28.2, 43.6)

19 April 2005 Ottawa Public Health (OPH) expanded its existing Clean Needle and Syringe Program services to include the provision of safer inhalation equipment glass stems, mouthpieces, brass screens and push sticks. 10 community agencies, partner agencies of OPH, also distributed safer inhalation equipment in addition to safer injection and drug preparation equipment. Results of evaluation: Program Uptake - immediate, high and sustained Risk Behaviors - decline in sharing crack-smoking equipment Drug Use - significant decrease in injecting drugs Access to Harm Reduction Services over 4,000 visits made by people who only smoke crack July 2007 Program cancelled

20 August the Ontario Minister of Health s Advisory Committee on HIV/AIDS (OACHA) and the Minister s Advisory Committee on Hepatitis C (The Hepatitis C Task Force) sent a letter to the Health Minister expressing serious concerns about the cancellation of the Safer Crack Use Initiative at Ottawa Public Health and making recommendations to mitigate the impact of that decision November the Ontario Minister of Health met with former CEO Dr Robert Cushman of the Champlain LHIN, Jack McCarthy of the Somerset West Community Health Centre and other community partners to discuss the urgent need created in Ottawa as a result of the Ottawa City Council decision to cancel the Safer Crack Use Initiative December 2007 the Minister agreed to fund an alternative Safe Inhalation Program in Ottawa at the Somerset West Community Health Centre July 2008 Safe Inhalation Program operational

21 Services Available Safer inhalation supplies Supportive information, counseling and health teaching related to risk reduction and disease prevention Testing for HIV, Hepatitis and sexually transmitted infections Safer disposal of used equipment Referrals to health and social services Community clean ups

22 Three rounds of interviews (n 250 each) August June 2009 provided data for four time points. Time Point PRE-implementation Effect Baseline 2 months POST-implementation Immediate effect 6 months POST-implementation Middle-range effect 11 months POST-implementation Long-range effect To assess the impact of the SIP, we compared data from PRE and POST time points.

23 PRE vs. POST 11 Months Reports of UNAVAILABLE SUPPLIES significantly decreased 47 to 11% p Reports of INSUFFICIENT AMOUNTS of supplies significantly decreased 31 to 8% p 0.001

24 PRE vs. POST 11 Months Smoking with RECOMMENDED glass stem increased 89 to 93%

25 PRE vs. POST 11 Months Smoking with NON-RECOMMENDED makeshift devices significantly decreased Metal pipes 40 to 11% p Car antennae 7 to 1% p Pop cans 42 to 15% p Inhalers 44 to 17% p 0.001

26 PRE vs. POST 11 Months Reports of SMOKING WITH PREVIOUSLY-USED DEVICES significantly decreased 65 to 53% p 0.01

27 PRE vs. POST 11 Months Reports of PASSING ON PREVIOUSLY-USED DEVICES to others to use significantly decreased 64 to 49% p 0.001

28 POST 2 Months vs. POST 11 Months Mean NUMBER OF TIMES STEM RE-USED BEFORE DISPOSAL significantly decreased 288 to 40 times p 0.001

29 Ottawa s Safe Inhalation Program had an initial positive impact Increased community accessibility to safer inhalation devices in Ottawa Engagement in smoking with safer smoking devices increased Engagement in HIV- and HCV-related risk behaviors declined but remain high

30 Politics Killed Crack-Pipe Program Ottawa Citizen July 14, 2007 The City s chief MOH repeatedly told Council that the program was working, saving lives, saved millions in future medical expenses and was good for public health in the city before it was cancelled. He added that scientific evidence backed up these claims and an internationally recognized study of the program concluded that it was working. His message fell on deaf ears as council struck down the program. 30

31 Politics Killed Crack-Pipe Program Ottawa Citizen July 14, 2007 there was clear evidence the program was working to help stem the spread of HIV and hepatitis C amongst the city's drug users, but that it was so unpopular with the general public, many city councilors and the Mayor voted to kill it instead of risking turning off voters. 31

32 The decision to kill the program was politically motivated, and it shows Council is not living up to its role as a Board of Health. Obviously we are not up to the task. When people are ignoring the clear advice of our chief medical officer of health, there s a huge problem. Councillor Peggy Feltmate, Ottawa Citizen, 14 July

33 The police chief himself has written to me about the fact that he has had his officers confiscating pipes from people. That is, in my mind, interfering with my program. Dr David Salisbury, Medical Officer of Health, Ottawa CBC News, January

34 SWCHC SIP Evaluation POST-2-Months vs. POST-11- Months Level of comfort carrying around NEW/UNUSED safer crack-smoking supplies An increasing and substantial proportion reported they DID NOT feel comfortable Reasons for discomfort Fear of police (range: 58-68%) 41 to 44% Conditions of bail/probation (range: 11-17%) Judgment by others (range: 3-12%) 34

35 OHRDP Evaluation Police taken clean glass stems in six months prior to interview? Ottawa 24% 1 50 times Toronto 41% 1 50 times Kingston 17% 1 2 times Guelph 16% 1 6 times 35

36 Reasons for Non-distribution of Safer Inhalation Supplies Among 20 Public Health Units not distributing 55% Distribution not approved by MOH or Regional Board of Health 23% No financing available to purchase 22% Supplies not available for distribution 10% Not yet sought approval from PHU 36

37 ON THE BASIS OF THE EVIDENCE Of the documented successful impacts of safer inhalation programs in Ontario in modifying the risk environment for women and men who smoke crack. Of the documented ability of Boards of Health, law enforcement personnel and Medical Officers of Health (MOHs) to negatively impact successful harm reduction programs. IT IS RECOMMENDED THAT The distribution of safer inhalation resources, including educational materials, be distributed thorough the Ontario Harm Reduction Distribution Program and that each Regional MOH be directed by the Provincial MOH to comply with the distribution. 37

38 Improving Services for People in Ottawa who Smoke Crack Dr Lynne Leonard x 8286