Report on Findings from January Supervised Injection Services (SIS) Fact-Finding Mission to Montreal, Canada

Ministère de la Santé et des Services sociaux Harm Reduction Services in Québec Access to injection and inhalation equipment and supervised injection services Prevention and response to opioid overdoses Presentation to Marc C. McGovern Mayor of Cambridge Richard Cloutier, M. Nurs. Public Health General Direction Direction générale de santé publique

Québec’s National Public Health Program 2015-2025 HIV, HCV and overdose prevention: a public health priority for Québec

3 Harm reduction approach • Rather than aiming solely at reducing drug use itself, it seeks to reduce the harmful consequences associated with drug use • Pragmatism and humanism 3

4 ASSOCIATION GENEVOISE DE REDUCTION DES RISQUES LIÉS AUX DROGUES http://www.grea.ch/sites/default/files/brochure_rdr1.pdf 4 pillars policy

Ministère de la Santé et des Services sociaux Ministère de la Santé et des Services sociaux Access to injection and inhalation equipment and supervised injection services Direction générale de santé publique

Number of injection material centers in Québec (2014) Région CLSC Hospitals Private clinics Rehab centers Pharmacies Community group Total Bas-Saint-Laurent 16 8 1 9 55 1 90 Saguenay–Lac-Saint-Jean 8 6 27 8 49 Capitale-Nationale 27 7 8 113 6 161 Mauricie et Centre-du- Québec 19 10 5 12 46 Estrie 12 8 3 1 47 3 74 Montréal 19 231 24 274 Outaouais 17 6 1 26 2 52 Abitibi-Témiscamingue 14 6 3 12 5 40 Côte-Nord 22 7 16 1 46 Nord-du-Québec 2 5 4 11 Gaspésie–Îles-de-la- Madeleine 18 2 20 40 Chaudière-Appalaches 16 5 30 51 Laval 5 1 49 5 60 Lanaudière 7 2 50 4 63 Laurentides 12 5 1 1 23 7 49 Montérégie 35 9 5 84 6 139 Total 249 86 20 14 792 84 1245 6

7 Injection material distributed 7

Information and education on safer injection

9 Finding free injection material in Québec 9

Injection equipment distributed in Québec in 2014 • 2.7 million syringes • 1.5 million Stéricups • 1.7 million water vials 10

Use of syringes and other equipment already used by others in the last 6 months (March 31, 2012) 11 11 Leclerc, P., INSPQ 2015 0 10 20 30 40 50 Proportion de participants (%) Emprunt de seringues Emprunt d'autres matériels p<0,001 17,5% 43,4% 14,4% 29,8% 33,0% 25,3%

HIV and HCV infection among IDUs HIV infection: • Prevalence 2003-2014: 14% (19% in Montréal) • Incidence 1995-2014: 2.2 per 100 persons/year Antibodies to HCV: • Prevalence 2011: 63% (67% in Montréal) • Incidence 1997-2014: 22 per 100 persons/year HIV and HCV (antibodies) co-infection: 12% 35% are not HIV or HCV infected PY: person-years Data on March 31, 2014 12 Leclerc, P., INSPQ 2016 12

Incidence of HIV (1995-2015) 5,0 5,1 3,9 3,4 2,8 2,8 2,0 1,9 2,3 2,1 1,8 1,9 1,3 0,9 0,7 0,9 0,6 0,5 0,5 0,2 0,1 0 4 8 12 16 199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Taux d’incidence par 100 pa p<0,001

• Help reach the most vulnerable IDUs; • Reduce the sharing of injection equipment; • Foster safer injection techniques; • Decrease overdoses and their consequences; • Reduce the use of ambulance and emergency services; • Encourage enrolment in treatment programs; • Have a beneficial effect on public order (decrease of injections in public, decrease in the number of syringes lying around); • Do not increase drug use; • Do not lead to higher crime rates. Supervised injection services (SIS): SOURCES : Noël et al., 2009. Institut national de santé publique du Québec

• access to sterile injection equipment • HIV and HCV screening by public health nurses • basic health services, counselling and medical referral • social services, addiction treatment • training and job placement services. Organizations offering SIS are already providing:

SOURCE : GOUVERNEMENT DU QUÉBEC, 2014: 23 Effectiveness of harm reduction Comparative effects associated with the addition of harm reduction measures to injection equipment access programs (Cloutier 2013)

Guidelines produced with support from the Ministry of Public Security and the Ministry of Justice of Québec. 17 MOHSS’ frame of reference for SIS (2013) SOURCE: MOHSS, 2013. Inspired by the BRITISH COLUMBIA MINISTRY OF HEALTH, Guidance Document: Supervised Injection Services,

1. Local characteristics determine needs 2. Description of the organization providing SIS 3. Demonstrating the fact that SIS are consistent with the national principles of drug use harm reduction 4. Link with the community 5. Public security 6. Monitoring and information tools for clients 7. Regulatory structure and human resource structure 8. Supply of care and services 9. Measures implemented for adequate disposal of biomedical waste 10. Governance and sustainability 11. Surveillance and monitoring MOHSS’ frame of reference for SIS

MSSS (2008), BALISES ÉLABORÉES PAR LE MINISTÈRE DE LA SANTÉ ET DES SERVICES SOCIAUX APPLICABLES AUX SERVICES DE SANTÉ EN MILIEU CARCÉRAL QC, AVRIL 2008 19 • Great collaboration from the Québec’s Ministry of Public Security on SIS issue. MPS has asked police chiefs to collaborate with regional health authorities in implementing SIS • Collaboration from Québec Association of Chiefs of Police Coherence: Harm Reduction Services and the police:

20 Coherence: Harm Reduction Services and the police: To view the English versions, click on Version with English subtitles. Training video for police and harm reduction groups http://aidq.org/outils/outils-intervention/sante-securite-publique

Ministère de la Santé et des Services sociaux Ministère de la Santé et des Services sociaux Prevention and response to opioid overdoses Direction générale de santé publique

Death related to opioid overdoses in Canada 22 Québec has the lowest death rate in Canada (12th on the 13 provinces) with a death rate of 2,2 for 100 000 inhabitants. In comparaison, that rate is an average of 10 in Canada and 29 in British Columbia (PHAC 2018)

Hospitalisations related to opioid intoxication 23 Rate of hospitalization due to opioid poisoning is 15,5 pour 100 000 in habitants in Canada. much less in Québec : 9,4.

Opioid prescription 24 • Canada : 6 110 • Québec : 3 601 Lowest rate in Canada

1. Monitoring and epidemiology surveillance 2. Interventions in regards to overdose prevention and response to overdose and harm reduction 3. Information and sensibilisation activities 4. Optimisation of medical and pharmaceutical interventions in regards to opioid and pain management 5. Acces to integrated and adapted services for persons with a opioid use trouble requiring a medication. 6. Training 7. Research and evaluation Québec’s National Strategy in prevention of opioid overdoses (2018)

Brendan S. A. Public Health Strategy for the Opioid Crisis. Public Health Reports 2018, Vol. 133 (Supplement 1) 24S-34S

Communications by government of Québec

Free access to naloxone kits for opioid overdose prevention in pharmacies and community groups

29 Finding free naloxone in Québec 29

What to do in case of opioid overdose 30 http://publications. msss.gouv.qc.ca/ms ss/fichiers/2018/18- 233-02A.pdf Training programs for : • health workers • community workers • police and correctional officers

The MOHSS supports the Québec Association for the promotion of health among drug users 31

SOURCE : Carter et Macpherson (2013) : 101 http://drugpolicy.ca/report/CDPC2013_fr.pdf Reflection at MOHSS on coherent drug policies