1. NEEDLE EXCHANGE
PROGRAM - UPDATE |
Committee Recommendations as amended
That Council:
1. Receive the information
respecting the City’s Needle Exchange Program that was requested at the 3 April
2008 meeting of the Community and Protective Services Committee;
2. Approve the enhancements
to the City’s Needle Pick-up Program including a $100,000 operating budget
pressure, and a one-time cost of up to $50,000 to complete a safe syringe
study, to be included in the 2009 budget, as detailed in this report; and
3. Direct the Medical Officer
of Health to report back in the fall of 2009 with a progress report on the
enhanced Needle Pick-up Program.
4. That the City of Ottawa’s “Needle Exchange
Program” be renamed in accordance with current international scientific
practice as the “Clean Needle Syringe Program.”
Recommandations modifiées du comité
Que le Conseil :
1. reçoive
l’information sur le Programme d’échange d’aiguilles de la Ville qui a été
demandée au cours de la réunion du 3 avril 2008 du Comité des services
communautaires et de protection;
2. approuve
les améliorations au Programme d’échange d’aiguilles de la Ville, y compris une
demande budgétaire de 100 000 $ et un coűt ponctuel d’un montant pouvant
atteindre 50 000 $ pour mener une étude sur les seringues
sécuritaires, qui devront ętre prises en compte dans le budget 2009 comme
l’indique le présent rapport;
3. demande
au médecin chef en santé publique de présenter ses conclusions ŕ
l’automne 2009 dans un rapport d’étape sur le Programme d’échange
d’aiguilles amélioré.
4. que
le Programme d’échange d’aiguilles de la Ville d’Ottawa soit renommé
conformémement ŕ la pratique scientifique internationale Programme de
seringues propres.
Documentation
1. Deputy City Manager's report (Community and
Protective Services) dated 12 June 2008
(ACS2008-CPS-OPH-0008).
2. Extract of Minute, 19 June 2008 may be issued
separately prior to Council meeting of 25 June 2008.
Report to/Rapport
au :
Community and Protective Services Committee
Comité des services communautaires et de protection
and Council/et au Conseil
12 June 2008 / le 12 juin 2008
Submitted by/Soumis par :
Steve Kanellakos, Deputy City Manager/Directeur municipal adjoint,
Community and Protective Services/Services communautaires et de
protection
Contact
Person/Personne ressource :
Dr. Isra
Levy, Acting Médical Officer of Health / médecin chef en santé publique
intérimaire
Ottawa
Public Heath / Santé publique Ottawa
(613)
580-2424 x 23681, isra.levy@ottawa.ca
SUBJECT:
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OBJET :
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That the Community and Protective Services Committee recommend that Council:
1. Receive the information respecting the City’s Needle Exchange Program that was requested at the 3 April 2008 meeting of the Community and Protective Services Committee;
2. Approve the enhancements to the City’s Needle Pick-up Program including a $100,000 operating budget pressure, and a one-time cost of up to $50,000 to complete a safe syringe study, to be included in the 2009 budget, as detailed in this report; and
3. Direct the Medical Officer of Health to report back in the fall of 2009 with a progress report on the enhanced Needle Pick-up Program.
Que le Comité des services communautaires et de
protection recommande que le Conseil :
1.
reçoive
l’information sur le Programme d’échange d’aiguilles de la Ville qui a été
demandée au cours de la réunion du 3 avril 2008 du Comité des services
communautaires et de protection;
2.
approuve
les améliorations au Programme d’échange d’aiguilles de la Ville, y compris une
demande budgétaire de 100 000 $ et un coűt ponctuel d’un montant
pouvant atteindre 50 000 $ pour mener une étude sur les seringues
sécuritaires, qui devront ętre prises en compte dans le budget 2009 comme
l’indique le présent rapport;
3.
demande
au médecin chef en santé publique de présenter ses conclusions ŕ
l’automne 2009 dans un rapport d’étape sur le Programme d’échange
d’aiguilles amélioré.
At its meeting of April 3, 2008, the Community and Protective Services Committee (CPSC) directed the then Medical Officer of Health to respond to the Committee’s six key questions with a comprehensive report that provided details on:
1) The history of the City’s Needle Exchange Program (NEP);
2) Medical evidence that current practices meet Ministry’s objectives;
3) Evidence that the current needs-based exchange policy is more effective than a one-for-one needle exchange;
4) Risks associated with a change to a one-for-one exchange model;
5) Comparisons with other large Canadian municipalities; and
6) A financial analysis of changing to a one-for-one exchange model.
The City
of Ottawa’s Needle Exchange Program (NEP) is a mandatory harm reduction program
that has been in place since 1991 to prevent the spread of communicable
diseases such as HIV, Hepatitis B and Hepatitis C.
Medical
studies, outlined in this report, have confirmed that HIV incidence has
declined in cities that have NEPs and increased in cities that have restricted
programs or none at all. HIV risk was
three times greater among those individuals that had limited coverage (access
to syringes) because of restrictive NEP than those who had adequate coverage. Based on modeled estimates, the City of Ottawa could expect
a 33% increase in new infections (i.e., 9 to 21 additional infections per year)
if the City were to revert to a one-for-one exchange policy.
Of the 36 Ontario public health jurisdictions currently delivering NEPs
none has restrictive one‑for-one exchange programs. HIV infections in Ottawa increased steadily from 145 infections in 1991 (at the inception
of the Site program) to 200 infections in 1994 and declined during the period
1996 to 2002 to 60 infections per year (as The Site Program moved away from a
restrictive exchange policy).
Individuals
with cocaine addictions can require 20-30 or more injections per day. One-for-one exchange policies would require
users to retain and carry needles to return them to the Site Program rather
than use the needle drop box program for safe disposal of needles or use them
less frequently. This would increase
the amount of time individuals carry around used needles and therefore the
amount of time the needles would be in the community. Thus, the net effect would be an increased health risk from
accidental needle stick injuries for residents and service providers including
police, paramedics and fire.
Given
the medical evidence respecting the efficacy of a non-restrictive needle
exchange program, as well as the adverse health consequences and the cost to
city and to the health care system overall ($150,000 to $600,000 for each new
HIV case), the Acting Medical Officer of Health does not recommend a change to
the City’s current needle exchange policy.
At
the same time, Ottawa Public Health (OPH) recognizes and acknowledges
legitimate community concerns respecting the increasing number of needles
discarded by injection drug users on downtown streets and residential
neighborhoods. Although OPH and its
partners have worked diligently within existing resources to respond to the
increasing number of needles on the street (i.e., the number of needles picked
up by the Needle Hunter program has increased nearly three-fold in the last
three years) it is clear that additional investments and focus on needle pick‑up
is required to respond to the safety and quality of life concerns raised by
residents in affected neighbourhoods.
Council,
at its meeting of May 14, 2008, acknowledged these community concerns by
approving a one-time $100,000 investment in Needle Pick-up program
enhancements. This report provides
details of the spending plan for the $100,000 and outlines additional
structural change that OPH proposes to implement the enhancements to the Needle
Pick-up program.
OPH proposes to return to Council in one year with a progress report on of the Needle Pick-up program.
Discarded needles are a safety hazard and have an impact on the quality of life for residents in affected areas of the city. The City of Ottawa must continue to address the issue with an enhanced, comprehensive response.
RÉSUMÉ
Au
cours de la réunion du 3 avril, le Comité des services communautaires et de
protection a prié le médecin chef en santé publique de répondre aux six
questions clés du Comité dans un rapport complet comprenant de l’information
détaillée sur :
1)
l'historique
du Programme d’échange d’aiguilles de la Ville d’Ottawa;
2)
les
preuves médicales indiquant que les pratiques actuelles sont conformes aux
objectifs du Ministčre;
3)
les
preuves qui démontrent que la politique d’échange axée sur les besoins est plus
efficace que l’échange d’une aiguille neuve contre une aiguille usagée;
4)
les
risques associés ŕ l’adoption d’un modčle d’échange « aiguille neuve
contre aiguille usagée »;
5)
les
comparaisons avec d’autres grandes municipalités canadiennes;
6)
une
analyse financičre de l’adoption d’un modčle d’échange « aiguille neuve
contre aiguille usagée ».
Le Programme
d’échange d’aiguilles de la Ville d’Ottawa est un programme obligatoire de
réduction des méfaits mis en śuvre en 1991 pour prévenir la propagation des
maladies transmissibles telles que le VIH, l’hépatite B et l’hépatite C.
Des études
médicales, décrites dans le présent rapport, ont confirmé que la prévalence du
VIH a diminué dans les villes qui disposent d’un programme d’échange
d’aiguilles, alors qu’elle a augmenté dans les villes qui ont mis en place un
programme restreint ou qui n’en offrent aucun.
Le risque
d’infection par le VIH était trois fois plus grand parmi les personnes qui
avaient accčs ŕ une couverture limitée (accčs aux seringues) en raison des
programmes d’échange d’aiguilles restrictifs que parmi celles qui avaient accčs
ŕ une couverture appropriée. Selon les estimations modélisées, la Ville
d’Ottawa pourrait s’attendre ŕ une augmentation de 33 % du nombre de
nouvelles infections (c.-ŕ-d. de 9 ŕ 21 nouvelles infections par année) si la
Ville retournait ŕ la politique d’échange « aiguille neuve contre aiguille
usagée
Sur les 36
autorités de santé publique de l’Ontario offrant actuellement des programmes
d’échange d’aiguilles, aucune ne dispose de programmes d’échange
« aiguille neuve contre aiguille usagée ». Les cas d’infection au VIH
ŕ Ottawa ont augmenté de façon constante, passant de 145 infections en 1991
(année de mise en śuvre du Programme SITE) ŕ 200 infections en 1994, pour
ensuite diminuer ŕ 60 infections par année entre 1996 et 2002 (ŕ mesure que le
Programme SITE abandonnait la politique de distribution restrictive).
Les
personnes ayant une dépendance ŕ la cocaďne peuvent avoir besoin de 20 ŕ 30
injections par jour. Les politiques d’échange « aiguille neuve contre
aiguille usagée » forceraient les utilisateurs de drogues par injection ŕ
conserver et ŕ transporter leurs aiguilles pour les retourner au Programme SITE
au lieu de les mettre au rebut de façon sécuritaire dans le cadre du programme
de boîte-dépôt pour aiguilles usagées, ou ŕ utiliser moins fréquemment ce
systčme. Cette politique aurait pour effet d’accroître le temps pendant lequel
des personnes transportent des aiguilles souillées et, par conséquent, le temps
pendant lequel les aiguilles restent dans la collectivité. Il y aurait donc un
risque accru de blessure par piqűre d’aiguille pour les résidents et les
fournisseurs de services comme les policiers, les paramédics et les
pompiers.
Compte tenu des preuves
médicales quant ŕ l’efficacité des programmes d’échange d’aiguilles sans
restriction ainsi que du coűt global pour la ville et le systčme de santé
(entre 150 000 $ et 600 000 $ pour chaque nouveau cas
d’infection au VIH), le médecin chef en santé publique intérimaire ne
recommande aucun changement ŕ la politique actuelle d’échange d’aiguilles de la
Ville.
Parallčlement,
Santé publique Ottawa (SPO)
tient compte des préoccupations légitimes soulevées dans la collectivité quant
au nombre croissant d’aiguilles jetées dans les rues du centre-ville et les
quartiers résidentiels par les utilisateurs de drogues par injection. Bien que
SPO et ses partenaires aient travaillé trčs fort avec les ressources actuelles
pour tenter de résoudre le problčme du nombre croissant d’aiguilles dans les
rues (le nombre d’aiguilles ramassées dans le cadre du Programme de ramassage
des aiguilles a presque triplé au cours des trois derničres années), il est
clair que, pour répondre aux préoccupations relatives ŕ la santé et ŕ la
qualité de vie des résidents dans les quartiers touchés, des investissements
supplémentaires sont nécessaires. Il faudra également mettre l’accent sur le
ramassage des aiguilles.
Au
cours de la réunion du 14 mai, le Conseil a répondu aux préoccupations de la
collectivité en approuvant un investissement de 100 000 $ visant ŕ
améliorer le Programme de ramassage des aiguilles. Le rapport fournit de
l’information détaillée sur le calendrier des dépenses de l’investissement de
100 000 $ ainsi que les autres changements structuraux que SPO propose
d’apporter en vue d’améliorer le Programme de ramassage des aiguilles.
SPO
propose de présenter ses conclusions dans un rapport d’étape sur le Programme
de ramassage des aiguilles.
Les
aiguilles jetées présentent un danger pour la sécurité et ont une incidence sur
la qualité de vie des résidents des quartiers touchés de la ville. La Ville
d’Ottawa doit poursuivre ses efforts pour régler ce problčme en proposant une
solution améliorée et complčte.
BACKGROUND
In February 2008, Council Member Inquiry 02-08 sought legal opinion as to the parameters under which the City of Ottawa, as the Board of Health, operates the NEP, including the degree of flexibility the Board has with respect to implementing this mandatory program. The City Solicitor advised the following:
“The City’s Board of Health’s role is full and complete responsibility for the operation, delivery and all aspects of the needle exchange program, including legal liability. However, before the Board of Health proposes changes or sets in place any requirements of a health program/health service that is provided by the City, it is recommended that the change be supported by evidence indicating that the change will enhance or improve the program or service. Failure to provide an “evidence-based” program may lead to a claim that the Board of Health failed to act in good faith in the execution of its duties, thereby exposing the Board of Health, and possibly its individual members, to claims for damages.”
At its meeting of April 3, 2008, Community and Protective Services Committee (CPSC) directed staff to report back on a number of questions pertaining to the City’s Needle Exchange Program (NEP) (full motion attached as Document 1). Staff was requested to provide:
1.
The history of the City’s Needle Exchange Program
(NEP);
2.
Medical evidence that current practices meet
Ministry’s objectives;
3.
Evidence that the
current needs-based exchange policy is more
effective than a one-for-one needle exchange;
4.
Risks associated with a change to a one-for-one
exchange model;
5.
Comparisons with other large Canadian
municipalities and
6.
A financial analysis of changing to a one-for-one
exchange model.
Council also directed staff to ensure statistics concerning the numbers of needles distributed and retrieved annually are made available on the City’s website by the fall of 2008. Council further directed staff to identify the costs expended to date this year on responding to requests on the NEP and preparing the current report.
This report provides information respecting the six information requests contained in the April 3 motion responds to the two additional directions cited above; and proposes enhancements to the City’s Needle Pick-up Program.
Recommendation 1 –
Requested Information Respecting Needle Exchange Programs
To answer these questions, OPH
undertook an extensive literature review of studies appearing in respected
scientific databases. One hundred and
thirty-seven (137) full studies were reviewed (the full bibliography
is attached as Document 2). (See Document
X for list of the studies reviewed) OPH
staff looked for a range of evidence to get as complete a picture as possible
of the benefits and risks of different NEP practices. Harm reduction was considered on two levels: to the individual injection drug user and to
the community at large.
The City of Ottawa’s needle exchange program is called The Site. This provincially mandated harm reduction program has been in operation in Ottawa since 1991. The availability of the NEP has been deemed a necessary public health measure to prevent the spread of communicable diseases, primarily HIV, Hepatitis B and Hepatitis C, and to minimize the risks associated with substance use in society. The Site Program provides access to sterile needles and other injection equipment for injection drug users, health education to promote safety and minimize risks associated with substance use, and referral to primary health services, addictions treatment services or social service agencies to individuals whom the professional staff assess are in need or have the readiness to access services if available.
The program originally utilized a one-for-one needle exchange policy. In 1998, the policy was changed to the current non-restrictive policy in response to high rates of HIV infection in injection drug users in Ottawa. This policy change was in keeping with the trends seen across Ontario, Canada and across the world to less restrictive NEPs.
The current City policy states that clients are not refused needles/syringes on the basis of having none to return. Based on the Ontario Needle Exchange Programs: Best Practices Recommendations, 2006, each client is asked: how many needles do you need to keep you safe?
Reporting
The Site Program provides reports annually on service utilisation statistics (e.g. the number of syringes provided) and key accomplishments of the program to the Ministry of Health and Long- Term Care. Reports have also been prepared and submitted to Committee and Council since the NEP was first proposed in 1989 (A History of Reports is attached as Document 3).
Evaluation
OPH implements
operates a cyclical program evaluation and
annual planning process, including a review and analysis of epidemiological
data; service utilization statistics; quality assurance surveys; and key
informant feedback, best practices literature and research. These activities assist in formulating
action plans for the following year.
The Site Program is actively
engaged in research initiatives for the purposes of program evaluations.
OPH benefits from a collaborative research partnership with the Canadian
Institute of Health Research, the Public Health Agency of Canada and the
University of Ottawa to implement the national I-Track Study, which examines
HIV prevalence and behaviours that increase HIV transmission among men and
women who inject drugs.
2. Medical Evidence that Demonstrates Current Best Practices Meet the
Ministry’s Objectives
In the late 1980’s, the Ontario Ministry of Health, under the Health Protection and Promotion Act[1], mandated that boards of health ensure access to sterile injection equipment due to the growing rate of HIV and Hepatitis B and C infection among injection drug users.
The Ministry’s goal was to prevent the transmission of HIV, Hepatitis B, C and other blood‑borne infections, as well as other associated diseases in communities where drug use was recognized as a problem.
The Ministry’s objective was to require boards of health to provide needle and syringe exchange programs. These programs were to also include counselling, education and referral to primary health services and addiction/treatment services.
Medical Evidence
In order to identify medical evidence, OPH conducted
searches in established research databases including CINHAL, Cochrane Database
of Systematic Reviews, CORK, EMBASE, Medline, and PsycINFO for articles
published from January 2000 – 2008.
Web Sites that were also searched for content related
to the this topic included:
·
Canadian Society for Addiction Medicine (CSAM)
·
Canadian HIV/AIDS Legal Network
·
Centres for Disease Control and Prevention (CDC)
·
European Monitoring Centre for Drugs and Drug
Addiction (AMCDDA)
·
Forward Thinking on Drugs
·
Health Canada
·
Public Health Agency of Canada (PHAC)
·
World Health Organization (WHO)
The searches generated numerous abstracts that were
subsequently scanned for relevancy as to include in a list of search
results. Six hundred and thirty-four
(634) articles were found during the database search. Abstracts were then reviewed for the purposes of determining
whether they were pertinent to address the questions specific to the report to
Council. One hundred and thirty seven
(137) studies were reviewed including several that were based on a
meta-analysis of existing literature and which specifically related to
Council’s questions on effectiveness, one-for-one exchange and community
safety.
A 2005 study by A. Wodak and A.
Cooney[2] presents one of the most
comprehensive reviews of studies on the effectiveness of NEPs. The authors reviewed one hundred and twenty
(120) studies from 1989 to 2002, examining HIV seroconversion, HIV
seroprevalence, HIV risk behaviours and NEP effectiveness. The study used the Bradford Hill criteria,
including strength of association; replication of findings; temporal sequence;
biological plausibility; coherence of evidence; and reasoning by analogy; to
assess the scientific credibility of studies for inclusion in the review.
For example, the authors referenced an article
published in Health Outcomes International (2002)[3]
that reported that in 103 cities in 24 different countries HIV prevalence
declined by a mean annual 18.6% for 36 cities with NEP, compared to an 8.1%
increase in 67 cities without NEP.
Another example cited by the authors is a 1997 study
by Hurley et al[4] which found
that, of 52 cities without NEP and 29 cities with NEP in Asia, Europe, North
America, South America and South Pacific, on average HIV seroprevalence
increased by 5.9% per year in the 52 cities without NEP and decreased by 5.8%
per year in the 29 cities with NEP.
In another
study Wodak and Cooney[5]
looked at 7 separate systematic reviews of NEPs conducted by or on
behalf of U.S. government agencies from 1991 – 2001. All 7 studies concluded that NEPs prevent HIV transmission.
Among Wodak and Cooney’s conclusions, based on this
comprehensive review, were the following:
1.
There is compelling
evidence that increasing the availability, accessibility, and both the
awareness of the imperative to avoid HIV and utilization of sterile injecting
equipment by injection drug users reduces HIV infection substantially;
2.
There
is evidence that sterile injecting equipment reduces other infections such as
hepatitis and several bacterial infections (of the heart valves for example);
3.
There
is no convincing evidence of any major unintended negative consequences;
and
4. Needle Exchange Programs are cost-effective.
Two early studies (Montreal[6]
and Vancouver[7]) are cited
by critics of NEPs as showing that implementation of a needle and syringe
exchange program caused an increase in new HIV infections in participants who
used them. Vlahov 1998[8] references a case-controlled study
in Montreal, which found of 974 HIV-negative subjects, followed for an average
of 22 months, 89 subjects seroconverted.
Consistent use of a needle exchange program
compared with non-use was associated with an odds ratio for HIV seroconversion
of 10.5However, this study has been criticized because the NEP
selected higher risk injection drug users, and this is argued to be the more
likely explanation for the findings.
Moreover, the senior author of the Vancouver study, Dr. Martin T. Schechter of the University of British Columbia, has since pointed out that more recently the incidence of HIV infections has decreased in Vancouver. He has further explained in detail, in public testimony before the Public Safety and Neighbourhood Services Committee of the San Diego City Council in September 2000, that in his view, the data from his studies had been misrepresented.
3. Evidence that the Current Need-Based Model
Is More Effective Than A One-For-One Exchange
Decline of
Disease
A 2005 study by Des Jarlais et al[9] indicates that adequate “coverage”
(level of syringe availability) matters when it comes to the effectiveness of
NEPs. The study shows that the period
of 1990-2001 included a very large expansion of syringe exchange in New York
City, from 250,000 to 3 million syringes exchanged. Over this same period, HIV prevalence declined from 54% to
13%. Hepatitis C virus prevalence
declined from 80% to 59% among individuals without HIV, and from 90% to 63%
overall.
Bluthenthal et al 2007[10], in a study of 24 needle exchange
programs and their injection drug using clients in California, found that NEPs
that provide less restrictive dispensation policies have more clients with
adequate syringe availability (needed quantities). Bluthenthal 2007[11], based on the findings from the
study of 24 NEPs and their injection drug using clients, also found that needed
quantities (availability of syringes) is associated with lower odds of HIV
risk.
As part of the Ontario I-Track
study referenced above, Dr. Robert Remis, a University of Toronto professor who
heads up the Ontario HIV Epidemiologic Monitoring Unit, modelled the incidence
of HIV among injection drug users locally from 1977-2004. HIV infections in Ottawa increased steadily from
145 infections in 1991 (at the inception of The Site Program) to 200 infections
in 1994 and declined during the period 1996 to 2002 to 60 infections per year
(as The Site Program moved away from a restrictive exchange policy). Dr. Robert Remis recently noted that in
Ottawa the rate of HIV infection is that one
of every 1
per 100
person years100 injection
drug users becomes
infected annually
in Ottawa, which, although declining in relative terms, is 4 to 4.5 times higher than anywhere else
in the provinces.[12]
An additional
positive outcome of NEP has been the increased access to addictions treatment
and health services by injection drug users. Wodak and Cooney,
based on the comprehensive review referenced above, concluded that there is
reasonable evidence that Needle Exchange Programs can increase recruitment into
drug user treatment.
Latkin 2006[13] studied 440 drug injectors with disadvantaged backgrounds
in Baltimore, Maryland who reported injecting in the prior 6 months but were
not currently in treatment. Follow-up
interviews were conducted. The study
found that entering treatment was associated with previous NEP utilization.
Latkin also cites Strathdee et al 1999[14] who found that utilizing NEP services was also associated
with entry into a detoxification program for HIV seropositive and HIV negative
drug users in Baltimore. She also cites
Shah and colleagues 2000[15] that found that, among HIV negative injection drug users,
utilizing the Baltimore NEP was associated with enrolling in a methadone
treatment program, compared to injectors who did not use NEPs.
In a 2000 study
by Hagan et al[16] among heroin
injectors in Seattle, compared to those who had never used a NEP, new NEP users
were five times more likely to enter methadone treatment and were 60% more
likely to remain in methadone treatment over the 1-year study period.
Ottawa Public
Health did not find any studies indicating that NEP users were less likely to
enter or remain in treatment programs.
In Ottawa, there are an estimated
3,000 injection drug users. In 2007,
The Site served an estimated 800-1000 individuals and undertook specific
counseling related to treatment readiness and discussion about service options
in Ottawa with 357 individuals.
Thirty-five (35) specific referrals were made to treatment programs.
Number of
Injection Drug Users
Wodak and Cooney2 looked at 7 separate
reviews of NEPs conducted by or on behalf of U.S. government agencies from 1991
– 2001. All 7 studies concluded that
NEPs are not associated with an increase in the number of injection drug users.
Perception
Among Youth
There has been little research done in this
area. However, the City of San Diego’s
Final Report of the Clean Syringe Exchange Program Task Force 2001[17]
cites a survey by John Hopkins University researchers of high school students
from four Baltimore City high schools conducted to determine what factors
influenced the students’ attitudes about illicit drug use. Among the 1,110 students who responded to
the survey, nearly half of the students (46%) viewed seeing drug users at clean
syringe exchange sites as a deterrent to drug use and almost as many (43%)
viewed seeing drug users at a clean syringe exchange site as having no
impact. The Task Force concludes that
these data refute the claimargue
against the intuitive perception that needle and syringe exchange
programs send the wrong message to youth.
Level of Discarded Needles
Fuller 2002[18]
evaluated the New York State Expanded Syringe Access Demonstration Program
(ESADP) including comparing the number of discarded needle and syringes on the
street pre- and post- ESADP.
Needle/syringe counts were conducted by trained survey teams of counters
and recorders on 27 systematically sampled city blocks in Harlem, New York. The study reports
that mean ratios of needles/syringes to background trash have not increased in
Harlem since ESADP began and concludes that no evidence of harmful
effects (discarded needles/syringes) resulting from ESADP was observed.
Vlahov 19988 states: “Another issue is whether or not needle
exchanges will result in more contaminated syringes found on the street. If a needle exchange is designed as
one-for-one the answer is no.” He
referenced a Baltimore systematic street survey that showed no increase in
discarded needles following the opening of the NEP with a one-for-one
policy. However, he did not
specifically address non-restrictive NEPs.
Contacted at John Hopkins University by an OPH researcher, Professor
Vlahov stated that he has since broadened his conclusions to include non‑restrictive
programs as not increasing the number of needles on the street based on the
work of Fuller (referenced above).
Bluthenthal 200710, referenced above, in
his study of 24 NEPs in California found that safety syringes (e.g. retractable
needles) disposal was associated with high syringe “coverage”
(level of availability). He concludes
that syringe availability is strongly associated with safer injection
behaviours without impacting syringe disposal among NEP clients.
4. Evidence of any Adverse Effects and Areas of Risk Associated with a
Change to a Strict One-For - One Exchange
Two studies provide evidence that one-for-one
programs are less effective than non-restrictive programs in reducing the
spread of communicable diseases.
Bluthenthal 200711, referenced above, found that HIV risk was three
times greater among those individuals that had limited coverage (access to
syringes) because of restrictive NEP than those who had adequate coverage.
Kral 2004[19]
classified 23 NEPs in California in 2001 according to whether the program
provided a strict one-for-one exchange program, gave a few extra syringes above
one-for-one or provided syringes based on need rather than on the number of
syringes turned in by clients. Kral
found that among people who accessed need-based NEP, 37% reported re-use of a
syringe versus 63% of those who accessed more restrictive programs. Re-using needles is a known risk factor for
the spread of communicable diseases.
An individual addicted to cocaine can require 20-30
or more injections per day. One-for-one
exchange policies would require users to retain and carry very large numbers of
needles to return them to The Site Program rather than use the black boxesneedle
drop boxes. As injection drug
users would need to save needles for exchange, the City’s black
boxesneedle drop boxes would be poorly
utilized. This will increase the time
that used needles are carried around and the amount of time the needle would be
in the community. Thus, the net effect
would be increased health risks from accidental needle stick injuries for
residents and service providers including police, paramedics and fire.
5. Comparisons of the Harm Reduction Practices of
other Large Canadian Municipalities
Thirty-six (36) out of 36
municipalities delivering NEPs in Ontario have need-based exchange policies
including the City of Ottawa. No
Ontario public health jurisdiction operates a one‑for‑one NEP. Most large Canadian cities operate
distributive programs under need-based policies, including Halifax, Winnipeg,
Montreal and Vancouver. However, it
should be noted that Regina operates a one-for-one program. Non-restrictive needle exchange programs are
accepted internationally and nationally as the best practice for NEPs by such
organizations as World Health Organization (WHO),
Canadian Medical Association, and the
Ontario Needle Exchange Network.
6. An Analysis of the Financial Implications of Changing to a
One-for-one Exchange Program
Cost for the program
The current budget for The Site Program is $380,000 cost shared 75/25 ($95,000 municipal dollars) with an additional allocation of $156,000 (100% provincial).
In order to implement a
one-for-one needle exchange policy, OPH will require additional staff and
infrastructure to accommodate service encounters beyond the current
27,000. This would require additional
dedicated vans and outreach personnel in Vanier, Lowertown, Centretown and
elsewhere in the city. The costs are
estimated as follows:
This
could increase the current budget by an additional $840,000; the cost share
arrangement for this additional funding with the province would need to be
determined.
Cost to the health care system
Cost to health care system has been calculated
by focusing on treatment costs for HIV.
It has been estimated that one case of HIV costs the system
approximately $150,000 to $600,000.
Based on Des Jarlais9 and Bluthenthal10 and
the Ottawa experience (factoring modelled incidence and case reports of HIV
infections to OPH) the city could expect an approximate 33% increase in new
infections each year (i.e., ranging from 9 to 21 additional people infected due
to a change to a one-for-one policy).
This would result in a conservative estimated increased cost ($150,000
per individual) to the health care system of $1.35 to $3.15 million should
treatment be sought and received.
Discarded needles are a safety hazard and have an impact on the quality of life for residents in affected areas of the city. The City of Ottawa must continue to address the issue with an enhanced, comprehensive response.
Reducing Community Risk
The City’s Needle Exchange Program operates on the principle of recovering all needles that are provided to clients. Needle drop boxes are available at 24 sites in the community for safe disposal of used syringes. A list of the location of needle drop boxes can be found at:
http://ottawa.ca/city_services/recycling_garbage/special_items/needles_en.html#drop,
and at:
http://ottawa.ca/city_services/recycling_garbage/special_items/needles_fr.html.
The exchange rate is obtained
calculated by direct counts of syringes
distributed along with estimates of syringes returned, including randomly
weighing black boxneedle
drop box containers. Black
boxes are made available in the community for safe disposal of used syringes.
Injection drug users obtain needles from a range of sources. In 1998, the City’s Needle Hunter Program was established to supplement the recovery policy and reduce harm to the community at large by picking up discarded needles. In 2001, an integrated approach across City departments was developed to harmonize the response to discarded needles found on public and private property.
The Changing Environment of Drug Use
Ottawa is facing the challenge of a changing environment of drug use. Clearly, there has been a marked increase in the number of needles on the street over the last two years. For example, in 2005, the Needle Hunter Program picked up 714 needles, in 2006, 1,523 needles were picked up, and in 2007, 2,029 needles were picked up.
The increase in needles on the street results in part from:
The presence of discarded needles
on the streets is a legitimate concern for residents in affected areas of the
city as it is both a quality of life issue and a safety issue for them. Residents in affected neighbourhoods are not
satisfied with the current situation and have
voiced concerns have
been vocal in bringing this issue to the attention of OPH, City
Councillors and the media. City
Councillors and staff agree the issue must be addressed and are responding to
fill the gap.
Discarded needles
OPH has, since the beginning of the needle
exchange in 1991, implemented measures to respond to public concerns of
discarded needles and public safety issues, including the installation of
needle drop boxes in areas experiencing significant numbers of discarded
needles; a by-law prohibiting the disposal of needles as household waste; the
initiation of a Needle Hunter Program (Causeway Work Centre) in 1998; creation
of a central data collection system to accurately track the number of discarded
needles reported; and, the distribution and web access of public education
materials on safe disposal procedures.
The above measures now form key
parts of the City’s integrated response system to discarded needles, which was
introduced in 2001. This system was
coordinated through the City’s Call Centre, now 311, to provide residents a
central point of access to address their concerns.
The following is a breakdown of the total number
of discarded needles reported to the City each year.
Year
|
2000 |
2001 |
2002 |
2003 |
2004 |
2005 |
2006 |
2007 |
Total
|
813 |
497 |
644 |
562 |
809 |
714 |
1,523 |
2,029 |
It would appear that OPH’s objective numbers are mirroring the community’s subjective experience. In addition to the changing environment of drug use, other possible explanations include: the extension of the Needle Hunter contract for an additional month in 2006 due to mild weather and large numbers of needles clustered in a “single find” reported. Increased community awareness and engagement together with the assistance of individual community members in locating and picking-up discarded needles led to increase needle recovery.
The Needle Hunter Program is responsible for 70-90% of the total number of discarded needles collected by the City’s response system. The remainder is collected by Surface Operations, By‑law officers, Public Health Inspectors and Site Program staff. In 2006, the Needle Hunter Program collected 1,381 of the 1,526 discarded needles reported. This represents less than 0.5% of the needles distributed by the needle exchange program. The vast bulk of needles collected are through the needle drop box program and the pharmacy based “Take it Back” program described below.
Of note, one of the best solutions for removing reducing
discarded needles from
in the community is the increased instalment
of needle drop boxes. They are
available around the clock 24/7 and if placed in the right locations will allow
for safely disposale
of used needles with minimum effort. It
has been observed that clients are increasingly using the needle
drop box program to dispose of their used needles.
A recent study conducted by the Site Program Departmental Consultative Group indicated that 110-150% of syringes distributed by the Needle Exchange program are recovered through the City’s integrated response system. Legitimate purchases from pharmacies and other sources represent a significant portion of the needles “on the street.” Thus, another initiative that has been created is the Take It Back Pharmacies’ program to provide additional means for safely disposing of used needles and syringes. Currently 78 local pharmacies are participating in this initiative across the City and a complete list can be found on the City of Ottawa’s website at
http://app01.ottawa.ca/takeitback/BusinessList.do?prod_id=35&lang=en or at
http://app01.ottawa.ca/takeitback/BusinessList.do?prod_id=35&lang=fr .
OPH is working with community members and Causeway Work Centrethe
Needle Hunter program contractor staff
to explore strategies to address the number of discarded needles
in Ward 12. These include: completing
site visits with community members; the doubling of the number of daily sweeps;
improving the City’s internal communication and responsiveness; and, community
education sessions on safe disposal of needles, delivered in partnership with
the AIDS Committee of Ottawa.
The
current annualUntil May 14, 2008, the budget available for
the Needle Hunter program is
was $50,000, which provides 1,470 hours of
‘needle hunter’ work. These funds cover
the cost of the crews and the ongoing support services that are provided by the
contractor. As requested by Council, a
Request For Proposal is currently being sought to find
an optimal contractorensure
the optimal service provider undertakes the next stage of this work.
Evaluation
ToolsMeasuring Progress
In order to allow for the program
to be evaluated monitored
and provide timely available information to the public, OPH has:
OPH’s measures for needle recovery and public safety were not designed to handle the current environment and volume of needles. A new approach will strengthen and enhance the City’s ability to respond to this challenge and eliminate needles from the streets.
OPH is implementing an enhanced and comprehensive
programmatic response, that includes five key components:
1)
Organizational
realignment;
2)
Reinvigorating
the integrated response;
3)
Program
enhancements;
4)
Partnerships;
and
5)
Liaising
with the community.
To ensure full and appropriate focus on respective mandates OPH is realigning its organizational structure by transferring responsibility for needle pick-up out of the Infectious Diseases program and into the Environmental Hazards program. The Infectious Disease Prevention and Control (IDPC) program’s mandate is the reduction of infectious disease risk in the community; the Environment and Health Protection mandate is to eliminate health hazards in the community.
OPH will take the lead role in reinvigorating a city-wide integrated approach involving Surface Operations, By-law, Police, Parks and Recreation, Public Health, and Corporate Communications. OPH will coordinate regular monthly meetings and quarterly reporting of progress to Senior Staff will be established. The goal of a reinvigorated integrated approach is to ensure a “rapid response” capability and an effective needle tracking system. This will be done through program enhancements, including items suggested in the request to the province for additional funding; community engagement and partnerships; and greater accountability through a report to Council in the fall of 2009.
Initiatives and deliverables identified to enhance the programmatic response include but are not limited to the following:
·
Implement
monthly meetings with Site Program Departmental Consultative Group (SPDGC) to
confer on emerging service delivery issues, program and policy development, and
emerging community concerns (Ongoing);
·
Review
and update the SPDCG priorities and work plan (30 September 2008);
·
Provide
quarterly operational progress reports to OPH senior management (Ongoing); and
·
Review
and update counselling strategies and policies with clients (December 2008).
·
Establish
Safety Syringes Study research advisory committee to design a second
feasibility study of the use of safety syringes for the program, involving
SPDCG members and other key stakeholders.
The study will also include a market search for safety syringes and a proposed timetable is as follows:
·
The
study design and RFP completed (December 2008);
·
Research
Ethics Board approval (January 2009);
·
Preliminary
product evaluation with NEP clients completed
(Phase 1: Spring 2009);
·
Feasibility
study (Phase 2 September 2009); and
·
Analysis
and Report to SPDCG and OPH management (December 2009).
·
Links
will be maintained with the University of Ottawa, Canadian Institute for Health
Research and the Public Health Agency of Canada for I-Track Study and Social
Networks Study (Ongoing); and
·
Web-based
public information on Harm Reduction updated (30 September 2008).
OPH is implementing a broad range of program enhancements in the immediate, medium and long term, including:
Immediate:
Medium Term:
By September 2008
By December 2008
·
Reviewing peer-based programs in place in other
jurisdictions and explore local feasibility with partners; and
By June 2009
·
Analysis
and fFeasibility
study of single-use, safety syringes report
to SPDCG and OPH management (December 2009).
· Student engaged immediately until August 31st, 2008: $6,500;
·
Additional black
boxesneedle drop boxes (16 x $1.8) to be placed by
September 31st, 2008: $28,800;
· Increased routes for needle hunters (2 x $15,000.00) by July 1st: $30,000;
Total cost until December 31st, 2008: $100,000
Given that the $100,000 approved by
Council on May 14 was one-time money, Ottawa Public Health proposes to include
a $100,000 pressure in the 2009 budget to sustain these programmatic
enhancements going forward.
Further
to the program enhancements to be undertaken by OPH, aAs
well, additional work will be done to enter into partnerships and enrich
community input. This will be
accomplished by:
Council directed staff to ensure statistics concerning the numbers of needles distributed and retrieved annually are made available on the City’s website by the fall of 2008. OPH will be proceeding with the required work to complete this request.
Council further directed staff to identify the costs expended to date this year on responding to requests on the NEP and preparing the current report.
In reviewing OPH files since December 1, 2007 to
May 30, 2008, OPH has received approximately eighteen (18) inquiries from
Councillors and the public related to needle exchange issues. As of December 2007, OPH received five (5)
inquiries from Councillor
Monetteone councillor.
In 2008, OPH received five (5) inquiries from a concerned resident and seven (7) inquiries were received from either a Councillor, constituent or staff from Surface Operations.
While these statistics include the inquiry for the recent needle stick, the data does not include direct contacts between Councillors or the public and OPH staff, which were not recorded and subsequently not reported to the Office of the Medical Officer of Health.
With respect to staff time, depending on the
complexity of the response, anywhere from two (2) to nine (9) staff were involved
in the research, drafting or editing of the response. It is estimated that approximately 10 to 15 hours of staff time
was spent in preparation of responding to one individual’s requests and in
excess of 20 hours of staff time was spent in preparation of the various
responses to Councillor
Monetteone councillor.
Given
the medical evidence respecting the efficacy of a non-restrictive needle
exchange program, as well as the adverse health consequences and the
cost to city and to the health care system overall ($150,000 to $600,000 for
each new HIV case), the Acting Medical Officer of Health does not recommend a
change to the City’s current needle exchange policy. Given
the medical and scientific evidence respecting the efficacy of a non-restrictive
needle exchange program, and taking into consideration the legal advice
previously received by Council, the Acting Medical Officer of Health does not
recommend a change to the City’s current needle exchange policy. Further,
the Acting Medical Officer of Health is recommending to Council a variety of
enhancements to needle recovery efforts and that a progress report be made by
the Fall of 2009.
CONSULTATION
OPH liaised with medical experts cited in this report to obtain additional materials and to seek clarification and additional information.
The Acting Medical Officer of Health sought information from and consulted with:
The Acting Medical Officer of Health provided a verbal update on the current Needle Exchange Program to the Health and Social Services Advisory Committee at its meeting of May 27, 2008.
Subject to Council approval, $100,000 will be
identified as part of the new operating needs and $50,000 will be identified as
a 1-time operating requirement in the 2009 draft budget that will be tabled to
Council November 5th.
Document 1 – Needle Exchange Program Motion from April 3 CPSC Meeting
Document 2 – Bibliography of 137 Studies reviewed in Preparation of this Report.
Document 3 – Reports on the NEP submitted to Committee and Council since Inception of the NEP in 1989.
Ottawa Public Health Branch of the Community and Protective Services Department will action any direction received as part of consideration of this report.
Document 1
Community and
Protective Services Committee
Disposition 24
Thursday,
3 April 2008
WHEREAS thousands of needles are picked-up every year on downtown streets and in residential areas within the City, not only by agencies but by local residents, in an effort to protect the community at large;
AND WHEREAS there was a noted increase in complaints of discarded needles since the introduction of the City’s Needle Exchange Program in 1999 and the incidents of needle-stick injuries appear to be on the rise due to an apparent increase in the amount of unsafely discarded needles;
AND WHEREAS Ottawa has the highest rate of HIV prevalence among injection drug users (IDU) in Ontario and second highest rate in Canada at 20%;
AND WHEREAS in accordance with the City’s Needle Exchange Program (“NEP”), the Public Health Unit distributes needles without requiring a used needle to be provided in exchange;
AND WHEREAS the Shepherd' s of Good Hope has implemented a “one-for-one” needle exchange program as of October 15th of 2007;
AND WHEREAS it is suggested that, in order to have an effective harm reduction strategy in a municipality, each needle exchange program should work in unison along the same parameters;
AND WHEREAS it is suggested that a direct one-for-one needle exchange encourages the safe disposal of used needles;
AND WHEREAS the city has a Needle Exchange Program which implies a direct one for one and not a distribution program.
AND WHEREAS the title of our current program implies a needle exchange not distribution methodology;
AND WHEREAS the recommended date in the 2002 report “Action Plan of the Site Program Review” that Site Program policies, program information annual reports and statistics will be available on the City’s Website has not been met;
AND WHEREAS the reporting measures attributed to the City’s NEP appear to have failed to prove the success of a broader, needle exchange program;
THEREFORE BE IT RESOLVED that the Medical Officer of Health be directed to prepare a comprehensive report on the Needle Exchange Program, to be presented to the Community and Protective Services Committee by July 2008, incorporating the following information:
1. The detailed history of all reports on the City’s NEP, including how the reporting of the NEP was accomplished, where it was published, how the program was evaluated, including by what measures the program was evaluated against;
2. Medical evidence that demonstrates that the current best practices successfully meet the Ministry’s objectives;
3. Evidence that the current needle distribution model is more effective than a direct, one-for-one needle exchange model and evidence of any adverse effects that could be associated with a proposed change in the current needle distribution practice to a direct, one-for-one needle exchange;
4. An outline of all the areas of risk associated with a potential change of policy from the current needle distribution practice to a direct, one-for-one exchange and detail how the risk was assessed;
5. Comparisons of other large Canadian municipalities and their current harm reduction practices;
6. An analysis of the financial implications of changing the current practice to a direct, one-for-one exchange;
BE IT FURTHER
RESOLVED THAT the Community and Protective Services Committee recommends that
Council, as the Board of Health, directs the Medical Officer of Health to
ensure that the statistics concerning the numbers of needles distributed and
retrieved annually are made available on the City of Ottawa’s website by the
fall of 2008; and,
BE IT FURTHER
RESOLVED that the costs expended to date this year on responding to questions
and information about the Needle Exchange Program and the costs to prepare the
current report, be included in the July report.
CARRIED
Document
2
List
of Studies Reviewed
NEP Articles
Reviewed – May/June 2008
Listed by Author
1. Anonymous (2005). Needle-Exchange
Program Dashed in Massachusetts. AIDS Patient Care & Stds,
19(9):619.
2. Aitken, C., Moore, D., Higgs, P.,
Kelsall, J. and Kerger, M. (2002). The Impact of a Police Crackdown on a Street
Drug Scene: Evidence from the Street. Int J Drug Policy, 13(3):189-198.
3. American Academy of Pediatrics
Committee on Pediatric,A.I.D.S. (2006). Reducing the Risk of HIV Infection
Associated with Illicit Drug use. Pediatrics, 117(2):566-571.
4. Amundsen, E.J. (2006). Measuring
Effectiveness of Needle and Syringe Exchange Programmes for Prevention of HIV
among Injecting Drug Users. Addiction, 101(7):911-912.
5. Anderson, R., Clancy, L., Flynn, N.,
Kral, A.H. and Bluthenthal, R.N. (2003). Delivering Syringe Exchange Services
through "Satellite Exchangers": The Sacramento Area Needle Exchange,
USA. International Journal of Drug Policy, 14(5/6):461-463.
6. Appel, P.W., Ellison, A.A., Jansky,
H.K. and Oldak, R. (2004). Barriers to Enrollment in Drug Abuse Treatment and
Suggestions for Reducing them: Opinions of Drug Injecting Street Outreach
Clients and Other System Stakeholders. American Journal of Drug &
Alcohol Abuse, 30(1):129-153.
7. Appel, P.W. and Oldak, R. (2007). A
Preliminary Comparison of Major Kinds of Obstacles to Enrolling in Substance
Abuse Treatment (AOD) Reported by Injecting Street Outreach Clients and Other
Stakeholders. Am J Drug Alcohol Abuse, 33(5):699-705.
8. Ashton, M. (2004). Needle Exchange: The
Vancouver Experience. Addiction Research & Theory, 12(5):445-460.
9. Bailey, S.L., Ouellet, L.J., Mackesy-Amiti, M.E., et al. (2007). Perceived
Risk, Peer Influences, and Injection Partner Type Predict Receptive Syringe
Sharing among Young Adult Injection Drug Users in Five U.S. Cities. Drug
& Alcohol Dependence, 91(Suppl 1):S18-29.
10. Beletsky, L., Davis, C.S., Anderson,
E. and Burris, S. (2008). The Law (and Politics) of Safe Injection Facilities
in the United States. Am J Public Health, 98(2):231-237.
11. Betteridge, G. (2004). British
Columbia: Studies show Positive Public Impacts of Harm-Reduction Measures for
Drug Users. HIV/AIDS Policy & Law Review / Canadian HIV/AIDS Legal
Network, 9(3):27.
12. Birkhead, G.S., Klein, S.J., Candelas,
A.R., et al. (2007). Integrating Multiple Programme and Policy Approaches to
Hepatitis C Prevention and Care for Injection Drug Users: A Comprehensive
Approach. International Journal of Drug Policy, 18(5):417-425.
13. Bloom, D.E., Mahal, A. and O'Flaherty,
B. (2005). Economic Perspectives on Injecting Drug use. Advances in Health
Economics & Health Services Research, 16:371-395.
14. Bluthenthal, R.N., Anderson, R.,
Flynn, N.M. and Kral, A.H. (2007). Higher Syringe Coverage is Associated with
Lower Odds of HIV Risk and does Not Increase Unsafe Syringe Disposal among
Syringe Exchange Program Clients. Drug & Alcohol Dependence,
89(2-3):214-222.
15. Bluthenthal, R.N., Ridgeway, G.,
Schell, T., Anderson, R., Flynn, N.M. and Kral, A.H. (2007). Examination of the
Association between Syringe Exchange Program (SEP) Dispensation Policy and SEP
Client-Level Syringe Coverage among Injection Drug Users. Addiction, 102(4):638-646.
16. Bluthenthal, R.N., Heinzerling, K.,
Martinez, A. and Kral, A.H. (2005). Police Crackdowns, Societal Cost, and the
Need for Alternative Approaches. Int J Drug Policy, 16(3):137-138.
17. Bluthenthal, R.N., Malik, M.R., Grau, L.E., et al. (2004). Sterile
Syringe Access Conditions and Variations in HIV Risk among Drug Injectors in
Three Cities. Addiction, 99(9):1136-1146.
18. Bluthenthal, R.N., Gogineni, A.,
Longshore, D. and Stein, M. (2001). Factors Associated with Readiness to Change
Drug use among Needle-Exchange Users. Drug & Alcohol Dependence,
62(3):225-230.
19. Bourgois, P. (1998). The Moral
Economies of Homeless Heroin Addicts: Confronting Ethnography, HIV Risk, and
Everyday Violence in San Francisco Shooting Encampments. Subst Use Misuse,
33(11):2323-2351.
20. Boutwell, A. and Rich, J.D. (2004).
Syringe Access for Injection Drug Users in Rhode Island. Medicine &
Health, Rhode Island, 87(1):15-16.
21. Braine, N., Des Jarlais, D.C., Ahmad,
S., Purchase, D. and Turner, C. (2004). Long-Term Effects of Syringe Exchange
on Risk Behavior and HIV Prevention. AIDS Education & Prevention,
16(3):264-275.
22. Bravo, M.J., Royuela, L., Barrio, G., de la Fuente, L., Suarez, M.
and Teresa Brugal, M. (2007). More Free Syringes, Fewer Drug Injectors in the
Case of Spain. Soc Sci Med, 65(8):1773-1778.
23. Brown, N.L., Luna, V., Ramirez, M.H.,
Vail, K.A. and Williams, C.A. (2005). Developing an Effective Intervention for
IDU Women: A Harm Reduction Approach to Collaboration. AIDS Education &
Prevention, 17(4):317-333.
24. Bruneau, J., Brogly, S.B., Tyndall,
M.W., Lamothe, F. and Franco, E.L. (2004). Intensity of Drug Injection as a
Determinant of Sustained Injection Cessation among Chronic Drug Users: The
Interface with Social Factors and Service Utilization. Addiction, 99(6):727-737.
25. Bruneau, J., Lamothe, F., Franco, E., et al. (1997). High
Rates of HIV Infection among Injection Drug Users Participating in Needle
Exchange Programs in Montreal: Results of a Cohort Study. Am J Epidemiol,
146(12):994-1002.
26. Burris, S., Strathdee, S.A. and
Vernick, J.S. (2003). Lethal Injections: The Law, Science, and Politics of
Syringe Access for Injection Drug Users. University of San Francisco Law
Review, 37(4):813-885.
27. Burrows, D. (2006). Rethinking
Coverage of Needle Exchange Programs. Subst Use Misuse,
41(6-7):1045-1048.
28. Burrows, D. (2006). Advocacy and
Coverage of Needle Exchange Programs: Results of a Comparative Study of Harm
Reduction Programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation,
and China. Cadernos de Saude
Publica, 22(4):871-879.
29. Caiaffa, W.T., Bastos, F.I. and
Proietti, F.A. (2003). Practices Surrounding Syringe Acquisition and Disposal:
Effects of Syringe Exchange Programmes from Different Brazilian Regions--the
AjUDE-Brasil II Project. International Journal of Drug Policy,
14(5/6):365-371.
30. Caiaffa, W.T. and Proietti, F.A.
(2003). Ecological Analyses and the Evaluation of Needle and Syringe
Programmes. International Journal of Drug Policy, 14(5/6):359-360.
31. Cao, W. and Treloar, C. (2006).
Comparison of Needle and Syringe Programme Attendees and Non-Attendees from a
High Drug-using Area in Sydney, New South Wales. Drug & Alcohol Review,
25(5):439-444.
32. Carrieri, M. and Spire, B. (2007).
'Forced Treatment Interruptions' and Risk of HIV Resistance in Countries
Adopting Law Enforcement Against Marginalized Populations. AIDS,
21(8):1062-1063.
33. Carruthers, S. (2007). The
Organization of a Community: Community-Based Prevention of Injecting Drug
use-Related Health Problems. Subst Use Misuse, 42(12-13):1971-1977.
34. Centers for Disease Control and
Prevention (CDC). (2007). Syringe Exchange Programs--United States, 2005. MMWR
- Morbidity & Mortality Weekly Report, 56(44):1164-1167.
35. Chemtob, D., Damelin, B., Bessudo-Manor, N., et al. (2006).
"Getting AIDS: Not in My Back Yard." Results from a National
Knowledge, Attitudes and Practices Survey. Isr Med Assoc J,
8(9):610-614.
36. Cleland, C.M., Deren, S., Fuller,
C.M., et al. (2007). Syringe Disposal among Injection Drug Users in Harlem and
the Bronx during the New York State Expanded Syringe Access Demonstration
Program. Health Education & Behavior, 34(2):390-403.
37. Coffin, P.O., Latka, M.H., Latkin, C., et al. (2007). Safe
Syringe Disposal is Related to Safe Syringe Access among HIV-Positive Injection
Drug Users. AIDS & Behavior, 11(5):652-662.
38. Coffin, P.O., Ahern, J., Dorris, S.,
Stevenson, L., Fuller, C. and Vlahov, D. (2002). More Pharmacists in High-Risk
Neighborhoods of New York City Support Selling Syringes to Injection Drug
Users. J Am Pharm Assoc (Wash), 42(6 Suppl 2):S62-7.
39. Coffin, P.O. (2000). Syringe
Availability as HIV Prevention: A Review of Modalities. Journal of Urban
Health, 77(3):306-330.
40. Cohen, J. and Csete, J. (2006). As
Strong as the Weakest Pillar: Harm Reduction, Law Enforcement and Human Rights.
International Journal of Drug Policy, 17(2):101-103.
41. Cooper, H.L.F., Wypij, D. and Krieger,
N. (2005). Police Drug Crackdowns and Hospitalisation Rates for Illicit-Injection-Related
Infections in New York City. International Journal of Drug Policy,
16(3):150-160.
42. Cruz, M.F., Patra, J., Fischer, B.,
Rehm, J. and Kalousek, K. (2007). Public Opinion Towards Supervised Injection
Facilities and Heroin-Assisted Treatment in Ontario, Canada. International
Journal of Drug Policy, 18(1):54-61.
43. Cusick, L. and Kimber, J. (2007).
Public Perceptions of Public Drug use in Four UK Urban Sites. Int J Drug
Policy, 18(1):10-17.
44. Davis, C.S., Burris, S., Kraut-Becher,
J., Lynch, K.G. and Metzger, D. (2005). Effects of an Intensive Street-Level
Police Intervention on Syringe Exchange Program use in Philadelphia, PA. Am
J Public Health, 95(2):233-236.
45. Day, C., Conroy, E., Lowe, J., Page,
J. and Dolan, K. (2006). Patterns of Drug use and Associated Harms among Rural
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Document 3
1989
Subject: Description of Special Services, Needle Exchange Program, Anonymous Testing, AIDS in the Workplace.
November 8, 1989 Regional Council approved the above-noted report from the Health Committee, which recommended “that Health Department staff be authorized to seek federal and provincial funding to implement a harm reduction program to prevent Human Immune Deficiency Virus in injection drug users which included an education program, provision of clean needles and referral to rehabilitation.
The report cited the dramatic spread of HIV through needle sharers and emphasized that the proposed program is not ‘just a needle exchange’ but a harm reduction program, an HIV prevention program, an educations program and also a program that offers testing and counselling to people taking drugs.
The proposed Ottawa needle exchange component of the program does state that “Needles will be provided free of charge, one for one, according to procedures developed for the program.”
Expected Outcomes of the program with respect to the needle exchange component were cited as:
· Increase in IDUs seeking help to rehabilitate;
· Decrease in the sharing of unclean needles
· Increase in the cleaning of needles/exchange of needles purchasing of new ones;
· Decrease in HIV infection over time;
1990
September 12, 1990 Regional Council received a brief information report update on the needle exchange program indicating that the Ministry of Health was responding favourably to the City’s proposal and the Health Department hoped to have funding in place for proposed program by the end of the year.
1991
July 11, 1991 the Medical Officer of Health advised Health Committee that the opening day of the Needle Exchange program (SITE) would be Friday, July 19, 1991.
Health Committee was provided the following information on the program: Program is being funded 100% by the Federal and Provincial governments and is being run in partnership with the Youth Services Bureau; Annual budget is $247,000; Location is 480A Somerset (also the location of the Region’s Birth Control Clinic) with a mobile van also in operation; Services to include the supply of new needles, syringes, bleach kits, confidential testing and assistance plus health information.
Information was forwarded to, and received by, Regional Council at its meeting of August 14, 1991.
1993
August 11, 1993 Regional Council approved recommendations from the July 8 meeting of the Health Committee respecting the Needle Exchange program as follows:
1. That Health Department staff contact the manufacturer immediately to request that RMOC needles have an identifying mark placed on them.
2. That the municipalities of Nepean, Gloucester and Vanier also develop procedures for the pick-up of needles in public areas and that the results of this be reported back to the December 1993
3. That a report come to the Health Committee in the fall providing a detailed update on the Needle Exchange Program including: methods of increasing HIV testing; methods of increasing access; and the inappropriateness of continuing with the numbers of needles given out.
The Health Committee had received copies of an Ottawa Citizen newspaper article (dated July 7, 1993), which had reported that approximately 6,000 needles provided through the region’s NEP had not been accounted for. The Health Department clarified that the 6,000 unaccounted for needles simply meant that the 6,000 needles had not come back to the clinic but had been disposed of in other ways.
As part of the discussion, some concern was expressed respecting “bulk” exchanges of needles. The AMOH confirmed that the “policy is one clean needle for every dirty needle and often one person carries all the needles in for their friends, which could result in a large exchange.” The AMOH indicated a maximum of 10 syringes are given to first time visitors to the program.
A motion to limit the needle exchange to a one-for-one exchange with a maximum of two clean needles provided to first time clients was lost.
Subject: Update on the Health Department’s HIV Prevention Programme for Injections Drug Users
The Health Committee received a report in September 1993, subsequently received by Regional Council at its meeting of January 12, 1994 that responded to the motions emanating from the July meeting of Health Committee.
The information report indicated that the marking of RMOC needles with an identifying mark would not be economically feasible. The municipalities of Nepean, Gloucester and Vanier were tasked to develop procedures for the pick-up of needles in public area
The report identified that approximately 21% of clientele requested HIV testing; 9.2% of clients were referred to drug rehabilitation programs (though it was noted that referral was hampered by the limited number of rehabilitation spots which numbered 12 for assessment and 20 for treatment at the time).
As of the fall of 1993 the Regional NEP provided for a one-to-one exchange with the provision of a maximum of 3 needles for first time users without exchange. The exchange rate for the program was 80%.
At the time of the writing of the report no agency provided statistics for needles found on the ground.
1998
The Regional Health Department revised its Needle Exchange policy from a strictly “one-for-one” exchange to a more flexible policy in 1998. The procedure provided that clients could receive 20 needles on a first visit. Return clients were encouraged to bring used needles back to get new ones however. No client will be refused needles on the basis that they do not have any used ones to exchange.
The needle exchange services operated on the principle of recovering all needles that are provided to clients and clients are advised of other locations can be retuned.
The reason for the change was the alarmingly high rates of HIV infection in IDU in Ottawa and the recognition that the use of cocaine as the drug of choice led to very high numbers of needles used.
1999
At its meeting of January 27, 1999 Regional Council approved a report attaching the above noted procedure as Regional policy.
The report also approved establishment of a Needle Exchange Network to increase community and agency involvement; safe zones around schools, parks and day care centres where needle/syringe may not be distributed; development of an incentive program (e.g., food vouchers or clothing) be to encourage the return of more needles; establishment of a needle clean-up program ($10,000 per year for April to November pick-up), and; enhancement of the education program re., safe needle disposal by the community.
2002
At its meeting of May 22, 2002 Ottawa City Council approved the SITE program action plan with the following highlights:
· Safety
o Public Health acknowledged concerns with respect to the risk of needle stick injuries and committed to coordinated approach to the pick-up o discarded needles as well as the continuation of other discarded needle programs (e.g., Needle Hunters, Needle Black Boxes, Take it Back pharmacies program).
o Committed to evaluate the feasibility of retractable needle
· Accountability and Communication:
o Recommended appointment of an advisory committee with community, client and partnership agency participation
o Continued proactive communication and education re., safe needle disposal, harm reduction, with the transparent posting of policies, annual reports and statistics on the City’s website.
At the same May 22, 2002 meeting Ottawa City Council also received a report respecting the Quick Response to Discarded Needles report (a joint Public Works / Public Health report)
[i] Start up costsOperating
cost for additional vans along
with operational costincluding fuel, insurance, etc.) are estimated to be $11,000 per year
per van for a total of $33,000 annually.
[i] As the materials collected in Needle Drop Boxes are hazardous waste weighing needles/syringes is considered the safest means safer of estimating numbers
[1] Health Protection and Promotion Act, R.S.O. 1990, c. H.7, Statutes and
Regulations, Province of Ontario.
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