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Bridge over Grand River in Brantford

​​​Moving from stories to action: A qualitative research approach to assess the needs of people engaging in high risk drug use in Brant​

Lead author 

Tin Vo

Project team 

Brant County Health Unit: Karen Boughner, Sarah Edwards, Jo Ann Tober

Brantford Clinic: Brittany Chontos

St. Leonard’s Community Services: Andrew Bak, Marion Bristo, Sue Lefler, Lindsay Serbu, Julie Smith, Lorna Sowa, Tegan Ward

Executive Summary

Introduction

  • Brant County Health Unit’s (BCHU) Needle Exchange is currently run by two community agencies (St. Leonard’s Community Services and Brantford Clinic), offering harm reduction equipment and resources so that people who used intravenous drugs have increased opportunities to reduce sharing of needles and other drug paraphernalia. 
  • At present, limited information is known about the intravenous drug use (IDU) population in Brantford and Brant County (‘Brant’), particularly around the needs and the impact the Needle Exchange has had on this population. 
  • BCHU conducted a needs assessment to determine experiences of people who engage in high risk drug use as well as attitudes and existing challenges of service providers. 

Methods

  • The needs assessment involved: (1) document analysis from 2010-2013; (2) Needle Exchange site observations; (3) semi-structured interviews with 26 service providers, 27 current and 11 former IDUs. The 26 service providers worked in the following sectors: human and social services (42.3%); healthcare (30.8%); and justice and law enforcement (26.9%). 
  • The semi-structure interviews with IDUs and service providers represent a convenience sample and may not be representative of the overall clientele for the Needle Exchange Program. The IDUs interviewed were only those who visited the Needle Exchange at the drop-in time for interviews. The service providers interviewed were only those who were available during the recruitment period and those who felt comfortable speaking about their experience working with IDUs. 

Results

Use of the Needle Exchange

  • There was a gradual increase in the number of visits to the Needle Exchange between 2009 and 2012 (from 2604 visits to 5611 visits), and decreased by 47.1% (from 5611 to 2970) between 2012 and 2013. The proportion of males visiting the Needle Exchange remained higher than females between 2009 and 2013 (67.8%, 5-year average). The majority of visitors to the Needle Exchange were regulars; however, the number of visits per person is unknown and difficult to track. 
  • Based on the program statistics, the total number of needles given out steadily increased between 2009 and 2012, but decreased by 18.6% in 2013. The 5-year average was 73.7% for the rate of needles returned based on the total needles given out over 2009-2013. The proportion of visits with zero needles returned had a 5-year average of 73.4%.
  • The majority of IDUs interviewed visited the Needle Exchange 1-2 times per week (55.6%) and more often than not picked up harm reduction supplies for themselves and others (55.6%). 
  • Many IDUs spoke about their positive experiences with the Needle Exchange, including the non-judgemental attitude of the Needle Exchange staff and the flexible nature of the Needle Exchange. Some IDUs voiced structural and individual level challenges to getting access to the Needle Exchange, such as hours of operations and location of the Needle Exchange, paranoia, and laziness.
  • The majority of the IDUs used drugs every day (75.7%), and quite often it was more than 10 times per day (41.7%). 
  • A small group of IDUs noted that they had shared needles within the past month (7.1%), while a larger group shared other equipment in the past month (48.1%).

Community services used by drug using participants

  • The IDUs spoke about the realities of drug use and addictions. Specifically, many of the IDUs spoke about their life amidst the drug use, while others spoke to their sense of remorse and shame due to their use of drugs in general. The interviews explicitly and implicitly highlighted the widespread stigma in the Brant community and how that stigma has been internalized by many IDUs.
  • Many IDUs spoke highly about their experience using certain agencies and criticized others. Much of their concern stemmed from the stigma that existed within the general community and some service providers. Because of the internalization of the societal stigma associated with drug use and the ‘addict’ label applied on them, the IDUs seemed to have developed a social hierarchy of drug users, from the ‘junkie’ to the ‘responsible user’. This concept is comprised of two components: (1) naming identities in the hierarchy; and (2) distancing self from more degrading identities.

Service provider experience with drug using clients

  • The service providers spoke about many of their positive experiences and learning moments with IDUs, while noting the realities of working with IDUs. Many service providers offered guidance for working with IDUs: (1) see the person and build them up; (2) develop a relationship with them; and (3) remain supportive despite their setbacks. 
  • For the experienced service providers, challenges to their work often existed at the organizational and community/societal levels, particularly focused around stigma and lack of coordination or understanding of drug use and addictions beyond the control of the service providers themselves. The interviews demonstrated the challenges in offering services to people who engage in high risk drug use and the widespread stigma and misunderstanding of drug use at the community level. 
  • Organizational level challenges faced by service providers included: policies related to safety of staff and clients; service provider capacity to better assist IDUs; and systemic constraints that hinder service delivery (e.g., availability of services, waitlists, and making appointments). Some identified training topics included: incorporating harm reduction approaches; communicating with difficult clients; and overdose treatment.

Discussion and Conclusion

  • The needs assessment surfaced many limitations to working with IDUs and openly discussing drug use in the Brant community, including the need for privacy. The lived experience of IDUs in Brant illustrates a diversity of realities of someone who engages in high risk drug use or has addictions.
  • The project results offered a glimpse into the reality of drug use in Brant and data relating to drug use, access and use of the Needle Exchange, and documented evidence to support advocacy efforts locally. The needs assessment was the first step toward bringing the intravenous drug use and addictions to the forefront to help inform the development of a more comprehensive approach to addressing the needs of people who engage in high risk drug use. This work is also expected to facilitate a more frank, inclusive, and respectful conversation among local agencies of the realities of high risk drug users and ways to address their needs.

​​Table of Contents

1. Introduction

1.1. Context

1.2. Background

1.3. Purpose

2. Methods

2.1. Data collection and data analysis

2.2. Ethical considerations

2.2.1. Consent and confidentiality

2.2.2. Risks and benefits to participation

3. Results

3.1. Interview participant demographics 

3.1.1. Intravenous drug using participants 

3.1.2. Service provider participants 

3.2. IDU interview participant engagement in drug use 

3.2.1. Frequency of drug use and type of drugs used 

3.2.2. Sharing and testing 

3.2.3. Experience as someone who uses or has used drugs 

3.3. Use of the Needle Exchange 

3.3.1. Use of the Needle Exchange based on program use statistics 

3.3.2. Use of the Needle Exchange as reported by IDU participants 

3.3.3. IDU participant experience with the Needle Exchange 

3.4. Community services used by IDU participants 

3.4.1. Positive experiences with agencies 

3.4.2. Negative experiences 

3.5. Service provider experience with drug using clients 

3.5.1. Challenges to service provision 

3.5.2. Service provider attitudes 

3.5.3. Service provider approach with drug using clients 

4. Discussion 

4.1. Discussion 

4.1.1. Access to the Needle Exchange 

4.1.2. Pervasive stigma 

4.1.3. Meeting the needs of IDUs 

4.1.4. Comparison to the OHRDP evaluation 

4.2. Limitations 

4.3. Recommendations for Next Steps 

5. Conclusion 

6. References 

Appendix I: Overview of Methods of Data Collection and Data Analysis 

Appendix II: Recommendations for the Next Steps 


Moving from stories to action: A qualitative research approach to assess the needs of people engaging in high risk drug use in Brant

1. Introduction

1.1. Context

Brant County Health Unit (BCHU) has the following community partners who administer the Needle Exchange in the City of Brantford: St. Leonard’s Community Services and Brantford Clinic. In total there are currently two Needle Exchange sites run by St. Leonard’s Community Services and one site by Brantford Clinic. The Needle Exchange is centralized in the City of Brantford, but is available for County of Brant residents. Upon request, these Needle Exchange sites provide individuals items such as: needles, syringes, tourniquets, cookers/spoons, acidifiers (Vitamin C), filters, alcohol swabs, condoms, and educational resources. Clients are encouraged to return used needles, but are not required to do so to pick up new equipment, specifically needles, to ensure greater coverage and availability of new equipment. Providing the Needle Exchange at multiple sites offers people who use intravenous drugs (IDUs) in the City of Brantford increased opportunities to reduce sharing of needles and other intravenous drug paraphernalia. The Needle Exchange is a point of contact where public health and other service providers can reach out to these individuals, in order to ensure that they are receiving the health attention they need, and have the appropriate skills, knowledge, and tools to protect their health.

The Needle Exchange Program in Brant has been in place for at least 10 years. This report provides the findings of a needs assessment at St. Leonard’s Community Services and Brantford Clinic. The needs assessment was conducted to determine how well the program is meeting the needs of the clients and to review the process for service delivery. The needs assessment also serves to prepare the Needle Exchange Program for future evaluation activities. An initial Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was conducted with the staff at St. Leonard’s Community Services as a preliminary status update of the Needle Exchange.

​1.2. Background

Harm reduction approaches work to reduce negative health, social, and economic impacts of drug use without requiring the individual to abstain from drug use. Harm reduction includes (quoted directly from Ontario NEP Best Practice Report):

  • A primary goal of reducing drug-related harm rather than a primary goal of reducing drug use;
  • Pragmatic strategies and interventions for people who continue to use drugs;
  • A net reduction in drug-related harm;
  • Ensuring drug users are treated with dignity and as full members of society. This includes a non-judgemental and non-punitive stance towards the consumption of alcohol and drugs; and 
  • A focus on realistic and achievable goals.

Needle and syringe distribution through Needle Exchanges is a key strategy to prevent human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) by ensuring that sterile needles are used for each injection. Needle Exchanges are one component of harm reduction approaches. Needle Exchanges offer direct protection from infection by providing condoms, HIV counselling and testing, immunization from HBV and other vaccine-preventable diseases, and referral to drug treatment (e.g., methadone treatment). Needle Exchanges can also offer indirect protection on the Needle Exchange attender’s social network, including prevention of transmission to the individual’s sexual partner(s), offspring, and receptive needle sharing partner(s), as well as among IDUs who do not attend Needle Exchanges or share injection equipment with those who do attend. IDUs who exclusively obtain their syringes from a Needle Exchange are less likely to report syringe sharing (Hyshka et al., 2012). Black market sources are replaced when Needle Exchanges are readily accessible (Delgado, 2004), and may even reduce the need to purchase or lease drug paraphernalia, thereby freeing funds to purchase drugs and reducing the likelihood that individuals share needles (Delgado, 2004). 

Needle Exchanges are effective if they reduce the likelihood that uninfected IDUs come in contact with contaminated needles/syringes in their social networks (Bastos & Strathdee, 2000). This likelihood is dependent on the rate that contaminated needles/syringes are removed from the community; the prevalence and incidence of blood-borne infections; the duration of infection; and the nature of subsequent arrangements among formal and informal syringe distribution circuits (Bastos & Strathdee, 2000). Achieving adequate coverage of new needles/syringes in the IDU community may be difficult because of the underground nature of injection drug use that deter IDUs from accessing Needle Exchanges and associated services (Bastos & Strathdee, 2000). 

Evaluation of the Ontario Harm Reduction Distribution Program after six months follow-up interviews demonstrated that significantly smaller proportions of participants, compared to the baseline participants from six months prior, reported instances of sharing injecting drug equipment that were offered by the Ontario Harm Reduction Distribution Program through Ontario Needle Exchanges (Leonard & Germain, 2009). More participants reported that they exclusively used the recommended equipment for injecting drugs offered by Needle Exchanges, as opposed to non-recommended equipment, such as tap or urinal water to dissolve drugs and to rinse needles, and cigarette filters or tampons to filter drugs, among others (Leonard & Germain, 2009). In addition, the evaluation identified that there was an increase from the baseline participants in accessing Needle Exchanges for injecting drug equipment, which may increase exposure to other harm reduction and health promotion resources and information, particularly around safer injection and sexual practices.

Making clean injection equipment available reduces sharing of needles and associated infections, but does not impact drug use (Hyshka, Strathdee, Wood, Kerr, 2012; Watters et al., 1994). That is, drug use does not increase nor do youth start injecting drugs in the presence of Needle Exchanges (Hyshka et al., 2012). The presence of Needle Exchanges has been shown to promote entry into addiction treatment, while decreasing the numbers of publicly discarded syringes and high risk social networks (Hyshka et al., 2012). 

1.3. Purpose

The purpose of the needs assessment was to obtain local contextual data relating to drug use, injection practices, access to harm reduction / injection equipment, access and use of Needle Exchanges, self-reported HCV and HIV status, and documented evidence to support advocacy efforts locally. The results of the needs assessment will be used to bolster the Needle Exchange sites in Brant, as well as provide direction for the development of a comprehensive harm reduction strategy. The intended users of the needs assessment results are agencies that provide services in Brant to IDUs, including BCHU, St. Leonard’s Community Services, and Brantford Clinic.

The objectives of the needs assessment were to:

1. Determine the needs and issues faced by people who inject drugs in Brant.

2. Identify gaps in services in Brant for IDUs.

3. Describe the IDU population using the NEP sites.

4. Describe the impact of the distribution of harm reduction supplies on the HCV- and HIV-related risk practice of sharing drug injection equipment.

5. Document the capacity of Brantford NEP sites to deliver harm reduction resources including equipment and education to IDUs in Brant.

6. Describe the attitudes of service providers in Brant regarding IDUs, high risk drug use, and harm reduction in general.

7. Explore what community agencies are doing to meet the needs of IDUs.

8. Identify ways to assist with coordinating the system for service users who are IDUs.

​2. Methods

2.1. Data collection and data analysis

The needs assessment employed a mixed methods approach. Details on the data collection and data analysis can be found in Appendix I. The mixed methods approach is summarized as follows:

1. Program-specific document analyses. Program use statistics over 2009-2013 were reviewed.

2. Semi-structured interviews with:

a. Current and former people who use intravenous drugs and people who engaged in high risk drug use (IDUs) in Brant. IDUs were recruited on-site at the three Needle Exchange sites (Brantford Clinic, and both locations of St. Leonard’s Community Services). They were asked to participate in the short interview and were also asked to speak with their peers (i.e., snowball recruitment) as a way to reach a broader group of IDUs, including those who may not be using services in general. The IDUs interviewed represented a convenience sample of the IDU population who visited each of the Needle Exchange sites for the Needle Exchange and/or other services.

b. Service providers in Brant who may interact with intravenous drug users. Service providers came from three sectors: Social and human services, healthcare services, and law enforcement and justice. An initial list of agencies and contacts were identified by frontline staff at BCHU and the staff at the Needle Exchange sites. Additional agencies and contacts were identified by service providers who were interviewed. Twenty agencies were contacted for interviews, but only 15 agencies were reached. Multiple staff and different teams were reached at certain agencies. The service providers interviewed represented a purposeful sample and convenience sample.

Observations of Needle Exchange sites were carried out to build rapport with IDU clients, which later assisted with the interview process and providing context for the data analysis. Observations were recorded, relating to the interactions between Needle Exchange site staff and IDU clients. Differences in procedures were also noted. 

All data were compared to results obtained from the evaluation of Needle Exchanges in Ontario completed by the Ontario Harm Reduction Distribution Program (OHRDP; Leonard & Germain, 2009). The current needs assessment and the OHRDP evaluation were similar in methods in that similar questions were asked of IDUs; however, variations were made to the methods to align with the Brant context. Therefore, variations in methods might have impacted the data collection and subsequent data analysis. 

​2.2. Ethical considerations

Full ethics review was completed internally by the BCHU ethics committee.

2.2.1. Consent and confidentiality

Interview participants (both IDUs and service providers) were asked to sign a consent form or to provide verbal consent prior to the interviews. Data collected was kept confidential. IDUs were able to maintain anonymity because they were not asked to offer a true identity if they wished. Service providers were assigned an interview number; efforts were made to not refer to their respective agencies. Both IDU participants and service providers were given the option to withdraw their comments following the interview if they no longer wished to have their comments included in the results.

2.2.2. Risks and benefits to participation

It was anticipated that issues might be uncovered during the interviews that could not be satisfactorily addressed or resolved by BCHU or in collaboration with any one community agency. Parameters and limitations of what could and could not be done were put forth initially and made clear so that expectations were appropriately managed among IDUs and service providers interviewed. 

One major risk included stumbling upon triggers for the IDU participant that may be unbeknownst to the interviewer, which could have resulted in mental or physical harm to the IDU participant. IDU participants were asked if they were comfortable speaking with the interviewer about negative or traumatic experiences (e.g., poor treatment by service providers or general public). The staff members at St Leonard’s Community Services and Brantford Clinic were asked to be available if the IDU participant needed to speak with someone who was trained in mental health first response following the interviews. The IDU participants were given an opportunity to debrief with the interviewer at the end of the interview. Debrief questions included: 

  • How do you feel about the interview? 
  • Do you feel satisfied or comfortable to leave this room knowing what you have spoken about? 
  • Would you like any additional supports, services, or information before you go?

IDU participants directly benefitted from participation in the interviews through having their voice heard by individuals who have responsibility over service planning. Service providers benefitted from participation through increased awareness of programs and services that other agencies offer, and developed a better understanding of the needs of IDU clients in Brant. By joining the conversation about needs of IDUs, the service providers were able to identify potential areas of improvement in their own programs and services. 

No direct risks from participation were identified for service providers. No indirect risks or benefits from participation were identified for IDU participants and service providers. 

3. Results

3.1. Interview participant demographics

3.1.1. Intravenous drug using participants

3.1.1.1. Sex, age, and location of interview

A total of 38 current and former IDUs were interviewed. Twenty-one (55.3%) were male and 17 (44.7%) were female. Interview participants ranged in age from 20 to 60 years with 10 between 20 and 29 years, 10 between 30 and 39 years, 7 between 40 and 49 years, and 11 were 50 years or older. This group represents a convenience sample and may not be representative of the overall clientele for the Needle Exchange Program.

IDUs were interviewed at three locations: 21 (53.8%) from Brantford Clinic; 15 (41.0%) from St. Leonard’s Community Services – Elgin Street; and 2 (5.1%) from St. Leonard’s Community Services – Fairview Drive. 

3.1.1.2. Status of drug use

Twenty-seven (71.1%) individuals interviewed currently used some type of drug (intravenous or otherwise). Of the 27 current drug users, 7 had been using drugs for up to 10 years, 5 had been using drugs between 11 and 20 years, and 7 had been using drugs for more than 20 years (data not shown) . The shortest period that an individual reported using drugs was one year, while the longest period of drug use was 48 years. One individual said that they had injected once in their life.

Eleven individuals interviewed (28.9%) considered themselves to be ‘off’ drugs (i.e., former drug users). Of the 11 former drug users, 6 had quit within the past year with the most recent being about one month from the date of the interview and the longest was 3 years from the date of the interview.

3.1.1.3. Living situation

Of the 38 IDU interview participants, 33 (86.8%) currently rent or live with others (e.g., parents). Two (5.3%) said that they own their house. Three (7.9%) said that they either lived on the street, in a shelter, or are couch surfing. A majority of interview participants (81.6%) considered their living situation to be stable. The one person who said that they were living in a shelter considered his living situation to be relatively stable, comparing it to living on the streets. Another couple who were renting said that their living situation was not stable because they had a ‘slum landlord’. 

3.1.2. Service provider participants

Twenty-six service providers were interviewed about their experience providing services to people who use intravenous drugs or people who engage in high risk drug use. Eleven (42.3%), 8 (30.8%), and 7 (26.9%) service providers represented the human and social services sector, healthcare sector, and justice and law enforcement sector, respectively. There was an even spread across the three categories for the number of years of service in Brant: 8 service providers have worked in Brant for 1 to 5 years; 10 for 6 to 10 years; and 8 for more than 10 years.

3.2. IDU interview participant engagement in drug use

3.2.1. Frequency of drug use and type of drugs used

Of the 37 IDU participants interviewed who reported their frequency of drug use, 28 said that they currently or had previously  used drugs every day (Figure 1). Two (5.4%) IDU participants interviewed reported they used drugs 3 or more times per week but not every day.

Figure 1 - Self-reported frequency of drug use per month (n=37)

Bar graph showing self-reported frequency of drug use per month (n=37)

Thirty-six IDU participants interviewed reported their frequency of drug use in a day (Figure 2). The most common number of times individuals used drugs in a day was more than 10 times with 15 (41.7%) IDU participants (Figure 2). The least common frequency was 7-10 times a day with 4 (11.1%) IDU participants interviewed (Figure 2). 

Figure 2 - Self-reported frequency of drug use per day (n=36)

Bar graph showing self-reported frequency of drug use per day (n=36)

All interview participants were asked about their preferred drug. Some interview participants listed several type of drugs used; a majority of participants (n=31) noted injecting pain-relieving medications (e.g., opiates, hydromorphine, dilaudids, oxycodone, heroin). Other drugs noted included: speed, cocaine, crack, valium, crystal methamphetamine, and fentanyl patches. 

3.2.2. Sharing and testing

Twenty-eight IDU interview participants reported their behaviour around sharing needles. Two (7.1%) interview participants reported having shared needles in the past month. Three (11.1%) reported having used a needle without knowing if it was previously used by someone else (Table 1). Conversely, 13 (48.1%) reported that, in the past month, they had shared injecting equipment (other than needles) that they or someone else had already used (Table 1). Some interview participants said that they shared new or unused injecting equipment (other than needles) if they had extra equipment available. 

From the comments, many individuals understood the importance of not sharing needles, including reducing the spread of communicable diseases. Some individuals expressed disgust for people who shared needles through the use of a more condescending tone and language. Some individuals picked up new needles for their friends so that they would not share or reuse old needles. Several individuals had a sense of remorse around sharing, partly because they were desperate to use their drugs. One person was vocal and adamant about not sharing needles; he seemed offended that he was even asked that question. Essentially, people who use drugs generally know that they should not share needles, but in more urgent situations (e.g., when the need to use drugs was powerful), safer injection practices are not adhered to.

​​​​“There was a 2 month period when I was living with someone and we shared. I was not in the best place so I didn’t care, but now I’m more stable and have since stopped sharing.”

All 38 IDU participants interviewed shared their history of STI testing. Thirty-six (94.7%) IDUs reported that they have been tested previously for HIV, Hepatitis B Virus, and Hepatitis C Virus (Table 1). Many individuals noted that they have only gotten tested once many years ago. Some individuals only got tested because it was a requirement for services (e.g., access to methadone and upon entry to jail). One individual noted that he did not need to get tested because, as he puts it: “I know I’m clean.” Testing seemed to be low priority for many of the interview participants, mostly because they did not see themselves at risk of disease transmission. As several individuals put it, they felt fine, so they did not need to get tested regularly (or another time).

Table 1 - Interview questions about sharing equipment and testing

Table showing interview questions about sharing equipment and testing

3.2.3. Experience as someone who uses or has used drugs

3.2.3.1. The realities of drug use and addictions 

Theme: Life amidst drug use

The interviews highlighted the fact that drug use has its many positive and negative realities, which many individuals accepted as the way things were and moved on with their lives. One individual developed a pain in his abdomen during the interview. The interview was paused, but he wanted to complete the interview, he stated: “This is normal, and is just going to be the way it is for the rest of my life.” 

The discussion between the older and the younger generation of drug users were seemingly different. One IDU participant reflected on the fact that the older generation of drug users tended to try and maintain their image, kept to themselves, and looked after their own health. Comparatively, the younger generation seemed to not care so much about their image, their health, or who they associated with during their drug use. Another individual noted that the younger generation of drug users seemed to get their start from being “at the wrong place at the wrong time.” These differences were seen in the way IDU participants from across the age spectrum spoke about their experiences. On the one hand, the older IDU participants (40 years and older) had a more reflective nature around discussing their drug use and a sense of care for others and their own decorum. On the other hand, the younger IDU participants (40 years and younger) focused on their immediate need and the people around them.

From the other side of addictions, several IDU participants who considered themselves former drug users reflected on their life before and after the drug use. It seemed as though the definition of ‘healthy’ was different whether one was under the influence of drugs or had quit using drugs. This was demonstrated by one individual who defined ‘healthy’ when under addictions as being able and having the means to get high. 

​“When you’re straight (no longer using drugs), you look after your own health. Before that, you look after your addiction; healthy meant to get high, and you let the rest go.”

Many individuals identified concern for their health, and made the realization that their health was important to them, thereby supporting their movement away from their addiction. This was illustrated by one individual who spoke about his friend who went on life support following a bout of drug use, which made him realize that it was time to quit his drug use. Another individual recounted his own experience of going into the depths of drug use, “going from one drug to the next.” This resulted in the loss of his family and the people he cared about, which prompted him to “wake up” from the drug use.

One person spoke of her experience as a drug user, where her addiction was driven by the needle. This was one of the realities that she struggled with in her life.

​“I sometimes slip up on methadone. I’ve been doing pills for 17 years. I go after speed and inject. When you’re in with the buzz, it’s always on your mind. It’s what the needle does to you, the instant high. You’re addicted to the needle, what the needle does to you, not the drug. When you inject, it’s like boom-bang and you’re off running. I’m not proud, I wish I didn’t say ‘yes’.”

Theme: A sense of remorse and shame of drug use

As a part of the reality of drug use, there were things that people did to get by in their life, which were detrimental to their social life. Several IDU participants spoke about their addiction and how it drove their life and their actions. One interview participant said that, “When you’re a drug addict, you do whatever to get your drugs, like steal or shoplift, because pills are expensive.” The same individual followed up with: “There are things I’ve done in my life because of addictions…. I’ve got friends who know who I am, not as a user. I just hang out with the wrong people sometimes, and it gets tough.” This individual felt remorse for his actions through the drug use. Similarly, one individual reflected on hers and others’ experience with drug use.

​“I’ve talked to other people who use like me; they’re not proud. I get so depressed every time I use. I look at the hole in my arm, and it’s a letdown.”

Theme: Widespread stigma and its internalization

Stigma was discussed by the IDU participants, albeit not the use of the term, more in how they had been treated by the general public and various service providers. Many individuals spoke about the sense of judgement and condescending treatment by people who do not use drugs, including service providers. The terms ‘waste’ and ‘junkie’ do not support individuals’ self-esteem. Two individuals said that they would get those labels, but would shrug off the labels and hope that the people throwing around those labels would inform themselves to learn what it is like to live with addictions. 

​“You always get that one person who will say something. I try not to hold onto stuff like that.”

Several IDU participants noted how they were refused services outright when the service provider found out about their drug use. This refusal of service did not make it easier for individuals to seek help when they need it.

From the constant discrimination, many individuals began to internalize the stigma. Much of this internalization was linked to simply accepting their life for what it is, and taking on the label of the ‘drug addict’. One individual kept referring to herself as a ‘junkie’; this prompted her peer who was also in the interview to respond with: “You can’t describe yourself as a junkie! A junkie is someone who sticks anything and everything in themselves, and you don’t do that.” Instances like this, where the stigma had been internalized, demonstrated that the drug users interviewed saw different classes of drug users.

​“When you get a label, you live up to it, you become that label. You must fit the label.”

This theme is reflected in the terms used by many individuals to refer to the drug users who did not visit the Needle Exchange: dirty and lazy. These individuals seemed to look down upon other drug users who shared or reused old needles, linking the ‘dirtiness’ to diseases, such as HIV and Hepatitis C. One IDU participant commented that, “people jonesing for that hit, they don’t care [about diseases].” ‘Jonesing’ in this context meant that the drug user was anxious to take their drug. Similarly, some individuals spoke about safer inhalation kits as enabling or condoning drug use, which seemed to imply that smoking crack was different or worse than injecting drugs.

3.3. Use of the Needle Exchange 

3.3.1. Use of the Needle Exchange based on program use statistics

Data related to program use were tracked by staff at each Needle Exchange site. Some questions were self-reported (e.g., name, age, number of needles returned upon visit), which compromised the reliability of the statistics tracked related to program use. 

There was a gradual increase in the number of visits to the Needle Exchange between 2009 and 2012. There was a drastic decrease in visits by 47.1% between 2012 and 2013 (Table 2). This could also explain the increase by 41.8% in visits to the Needle Exchange at St. Leonard’s Community Services, Elgin Street location. The proportion of males visiting the Needle Exchange remained higher than females between 2009 and 2013 with a steady increase over the same period (Table 2). The proportion of individuals visiting the Needle Exchange for the first time remained below 6% over 2009-2013 (Table 2), meaning that the majority of visitors to the Needle Exchange were regulars; however, the number of visits per person is unknown and difficult to track.

The total number of needles returned to the Needle Exchange increased between 2009 and 2011 with a decrease by 10.7% between 2011 and 2013 (Table 2). The total number of needles given out steadily increased between 2009 and 2012, but decreased by 18.6% in 2013 (Table 2). The 5-year average was 73.7% for the rate of needles returned based on the total needles given out over 2009-2013. Although IDU individuals visiting the Needle Exchange were asked to return used needles, the 5-year average showed that 73.4% of visits with zero needles returned. The proportion of visits with zero needles returned increased between 2009 and 2012 from 60.8% to 81.7%, but later decreased in 2013 to 77.6% (Table 2). 

Table 2 - Needle Exchange use statistics, 2009-2013

Table showing needle Exchange use statistics, 2009-2013

3.3.2. Use of the Needle Exchange as reported by IDU participants

Of 38 IDU participants interviewed, 36 (94.7%)  have used the Needle Exchange in Brant before. Of the 27 current drug users, 15 (55.6%) visited the Needle Exchange 1-2 times per week (Figure 3). Ten (37.0%) current drug users visited the Needle Exchange a few times a month (Figure 3). Only 2 (7.4%) current drug users visited 3-6 times per week (Figure 3).

Figure 3 - Current drug users using the Needle Exchange (n=27)

Bar graph showing current drug users using the Needle Exchange (n=27)

Of the 27 current drug users interviewed who visited the Needle Exchange, 15 (55.6%) picked up needles and other equipment for themselves and other people, while 11 picked up just for themselves (Figure 4). Only one person said that they picked up for just other people and not for herself .

Figure 4 - For whom individuals pick up equipment at the Needle Exchange (n=27)

Bar graph showing for whom individuals pick up equipment at the Needle Exchange (n=27)Sharing of crack smoking equipment might put individuals at risk for disease transmission, such as Hepatitis C. Twenty-three (71.9%) of the 32 individuals who responded said that it would be beneficial to offer safer inhalation kits at the Needle Exchange. Some individuals saw the importance of having safer inhalation kits similar to having new needles, while others had never thought about the potential for disease transmission. Several individuals declared that giving out this type of equipment is condoning and encouraging crack smoking. 

Thirty-five IDU participants said that they got their new needles from the Needle Exchange . Twenty-seven IDU participants noted that they also got new needles from a pharmacy (e.g., Shoppers Drug Mart), usually when they have money and are desperate for needles (when the Needle Exchange sites were closed) or require a specific needle size that they cannot get from the Needle Exchange. Three IDU participants said that they also got new needles from friends and family. 

When discarding used needles, 23 IDU participants said that they would often put their used needles into a container (e.g., biohazard box, pop bottle, water bottle, coffee tin, or ziplock bag) and discard them at the Needle Exchange (i.e., drop box) or the pharmacy. Nine IDU participants said that they would put their used needles into a container (e.g., pop bottle, water bottle, coffee tin, or ziplock bag) and throw in a garbage bin. Only one IDU participant reported loosely discarding his used needles in the garbage, alley, or street – he said that he would often break the needle point prior to loosely discarding his needles.

Regarding used equipment (other than used needles), 28 IDU participants reported loosely discarding the equipment into the garbage. Seven IDU participants often put the used equipment into a container or garbage bag and then throw it out. One IDU participant said that she sometimes gave her used equipment to others to discard on her behalf for fear of her family finding out about her drug use. None of the IDU participants discarded their used equipment (other than used needles) in the drop boxes available, as recommended.

3.3.3. IDU participant experience with the Needle Exchange

3.3.3.1. Positive experience with the Needle Exchange

Theme: Non-judgemental experiences

Many IDU participants who have visited the Needle Exchange have had positive experiences with the staff. They thought that the staff members were friendly and non-judgemental. The positive experiences come down to how the individuals were treated: with dignity and respect. The clients visiting the Needle Exchange felt as though they were treated like anyone else and were not looked down upon by the staff. This experience was contrasted by one individual who described his experience visiting a pharmacy to pick up new needles, where he was treated differently by the staff at the pharmacy. The positive experience at the Needle Exchange went beyond the friendliness, as one IDU participant noted that the staff at one Needle Exchange site seemed to offer support when it was needed, but did not force help and resources when it was unwanted.

​“I’m not looked down on at the Needle Exchange, or categorized as a user. I get a different type of service at the pharmacy. I’m treated differently than other customers.”

Theme: Flexible nature of the Needle Exchange

Many clients enjoyed the fact that each Needle Exchange site offered the flexibility of picking up harm reduction supplies for others and even several days’ worth of supplies. The first option to pick up supplies for other people increased the likelihood that more people would have access to new injecting equipment. The latter option to pick up enough supplies for a short period reduced the need to visit the Needle Exchange multiple times a week, which reduced the stress on individuals who might have difficulty with transportation to and from the Needle Exchange. 

The confidential aspect of the Needle Exchange made it a more comfortable for IDUs to visit. Clients were not required to provide their true identity, which helps to maintain confidentiality. One individual noted that the person who drove him to the Needle Exchange did not even know why he visited that agency.

Theme: Other positive aspects

Other positive aspects of the Needle Exchange included:

  • Saving money and not having to purchase new needles every time;
  • Reduced risk of disease transmission from reduced instances of sharing or reusing used needles; and
  • Increased safety from reduced number of used needles lying around in public spaces.

3.3.3.2. Challenges to getting access to the Needle Exchange

Theme: Structural challenges

The most common challenge to getting access to new needles and other injecting equipment was the hours of operation for the Needle Exchange. Twelve of the IDU participants noted that they would require the Needle Exchange on weekends and late at night when the Needle Exchange was closed. The timing was challenging for one participant who reported that having no money made it difficult to get new needles, especially when the Needle Exchange was closed. Several participants noted the location was a barrier to getting access to new needles because some locations were not conveniently located or they did not have access to reliable transportation to get to any of the Needle Exchange sites. When asked what they did when they had trouble getting new needles, 5 IDU participants said that they would use old needles, especially when the Needle Exchange was closed.

​“They’d just get them elsewhere. Some people just use dirty needles lying around.”

Contrastingly, many individuals would get their new needles from the pharmacy instead of the Needle Exchange when that option was not available. One IDU participant said that they would just wait until the Needle Exchange was open again to get their new needles. Some people had different ways to manage their drug use when they could not get to the Needle Exchange, which depended on their financial situation and how powerful the addiction was.

Theme: Individual level challenges

Almost all IDU participants interviewed noted that other IDUs in their social network did not visit the Needle Exchange because they feel embarrassed. The IDU interview participants said that those individuals were often afraid of who they will see at the agency, whether it was a staff member or a peer, partly because the individual did not want the staff member or their peers to know that they used intravenous drugs, or even that they visited an agency for help. Some individuals stated that they often provided a false identity when they visited the Needle Exchange, so that they could not be traced.

​“When up for several days, I would develop paranoia, making it difficult to leave the house. I would often use the same needle dozens of times just so I wouldn’t have to leave the house. You find tricks to get around that fear, such as sharpening the needle with a match.”

Seven of the 38 IDU participants interviewed identified paranoia as a reason for not visiting the Needle Exchange. The paranoia often prevented those individuals from leaving the house and often led them to reusing old needles, as one individual described. One participant reasoned that perhaps certain individuals felt anti-social and felt as though they did not belong in mainstream society. Another individual said that some people might be afraid to have their name tracked so they did not visit the Needle Exchange.

​“Some people may not access the [Needle Exchange] out of fear of knowing someone who works there.”

Theme: Other challenges

Other challenges experienced by interview participants when accessing the Needle Exchange included:

  • Not knowing where to go (e.g., new to the community, new to drug use);
  • Laziness;
  • Illness; and
  • Shyness.

​“The people who don’t go [to the Needle Exchange] are lazy and have no self-respect. They should be looking out for themselves and their health. Living with addictions is awful, but you should still look after yourself.”

3.4. Community services used by IDU participants 

3.4.1. Positive experiences with agencies

Six IDU participants spoke about their positive experiences with certain agencies. These individuals said that the service providers at various agencies seemed to be attentive to their concerns. One individual noted that one community agency was often fairly lenient and understanding, especially when it came to missing appointments. Another individual noted that the assistance that they received from one agency helped them keep off other drugs. 

​They help [at the agency], don’t show any judgements. Everybody works together. Support groups are amazing. [The staff have] done wonders for us. They look after you rather than someone looking down their nose. We have been to other clinics elsewhere and that’s not the case.”

Five IDU participants discussed positive experiences with certain services. Several individuals pointed out their supportive service provider provided them with the space to speak openly about their concerns, while other service providers offered tools and strategies to cope with and manage their addictions. 

​“My [service provider at the agency] listens, and tries to help out. I think about life and getting off methadone. I’m still thinking about my drive to live life.”

Seven IDU participants said that all of the agencies that they have visited seemed to help in whatever way they could, as demonstrated by one IDU participant who spoke appreciatively about his positive experiences with many service providers. 

​“Most [service providers] are pretty non-judgemental, help you understand the best that they can. They try to make you feel as comfortable, like you’re not an idiot for reaching out. From reaching out, I’m getting community support. They will help with what they can. I appreciate whatever services I can get linked to at this point.”

​3.4.2. Negative experiences

Eighteen IDU participants identified the numerous negative experiences with certain services. The common sentiment focused on the drug use identity. The interview participants said that they would be treated differently, poorly, by staff at certain agencies when the staff found out that the interview participants have used intravenous drugs before. 

​“[The agency] is a terrible place! They need new staff, or they should just tear it down. They treat me like an addict, like I am and will always be an addict. They treat me like I am using no matter what.”

Several IDU participants have felt looked down upon by the staff at certain agencies because of their drug use. One individual said that they felt embarrassed to even visit one agency because of the way the staff at the agency would treat the individual.

​“At [agency], everybody who finds out you’re a drug user, they think you’re a loser and they judge you. They think, ‘Go die in a corner because we’re not going to help you. We don’t care.’ That’s all [service] providers, including at [agency]. Every one of them looks down on you.”

From the IDU perspective, they felt their treatment by certain agencies had been unjust because these agencies’ policies did not consider life circumstances, particularly when it came to missed appointments. One individual commented that they have not had any good experiences at any agency other than at the Needle Exchange. With a number of participants, it was difficult to get them to speak openly about their general experiences using services in the community – a lot of probing was needed. Two IDU participants stated that they did not want to talk about their negative experiences for personal reasons.

3.5. Service provider experience with drug using clients

3.5.1. Challenges to service provision

3.5.1.1. Challenges at the individual level

The service providers discussed many challenges at the individual level which were associated with the struggles of addiction. Several service providers described their frustration as their clients were losing the fight with their addictions and allowing it to overcome their lives. This type of control by the addiction affected the person’s actions and tolerance for stress, making it difficult to provide the necessary counselling and services. One service provider described the way an individual would easily get agitated and aggressive, which made it difficult to offer the support he needed. The service provider emphasized patience as a quality to employ, noting that, “It’s hard to get them to concentrate on following policies, especially when the problem is constantly immediate.” Similarly, another service provider empathized with the daily struggles of the IDUs and their understanding of the impact that the drug had on their health and life in general. Rather than focusing on the negative impacts of drug use, this service provider suggested that the focus should shift toward the supportive role and remain patient as the IDU individual struggles through their addiction. 

​“Does the patient have to hear that the drug is dangerous, that it has a negative impact on their life? They already live that reality.”

One service provider noted that the addiction can be quite gripping to the point where the individual might not even see their own need, or what the drug use was doing to their body. Another service provider found it difficult to get through to one of her clients that the client had a lot of people who cared about her. The service providers emphasized that feelings of acceptance and understanding one’s own needs were difficult to achieve when so much stigma exist in the community, which often made it challenging for individuals to seek out help.

Societal discrimination of people who use intravenous drugs did not make it easy for an individual to disclose their status or confront their drug use. One service provider noted that the non-disclosure can become problematic for someone who was trying to help an IDU client with their concerns. Similarly, another service provider noted that, “If you’re immersed in that lifestyle, it’s tough to get out when everywhere you go you’re reminded of it.”

Another area of concern was the lack of or limited amount of supports that IDUs had around them. One service provider described that meeting the needs of IDUs was challenging because the people who cared about them before the drug use might be gone. The IDUs might have burned those bridges through their struggles and pushed away the people who cared about them. 

3.5.3.2. Challenges at the organizational level

Theme: Safety

Many service providers described the concern around safety as a possible barrier at their respective agencies. Some agencies did not offer services to individuals who were currently under the influence of drugs, or were still using drugs in general (i.e., not abstinent). These service providers noted that their organizational policies were designed to ensure safety of the staff and other clients. Two service providers said that they would try to reschedule the individual at a time that better met their needs (i.e., when they were not under the influence of drugs). Five service providers noted that part of their work entails ensuring safety of their clients, which had an impact on how welcoming their agency might be.

​"We may ask them to come back when they’re not under the influence. It may be difficult because you need to make sure they are safe. Sometimes they can’t talk because they’re jonesing; sometimes they’re withdrawing (e.g., vomiting, shaking) in the office."

Theme: Service provider capacity

Seven service providers described capacity as a challenge to better assist IDUs. As part of capacity development, they cited training around: how to incorporate harm reduction approaches in their work; knowledge of new drugs, how to use them and their associated equipment, and the drug’s impact on the body; communicating with difficult clients; responding to clients in crisis/withdrawal; and knowledge of managing addictions and working with people who have addictions. One issue that has been brought up by several frontline service providers and managers is the need for overdose treatment (e.g., naloxone). The technical training topics, such as knowing about types of drugs and how to use them, were identified by service providers from all sectors. Service providers from the healthcare sector were more likely to identify interpersonal and communication topics for further training. Service providers from the law enforcement and justice sector were less likely to identify a need for additional training.

Training and capacity building is vital because, as one service provider put it, “It’s hard to advocate for needs if we don’t know much about the population we are working with.” One service provider emphasized that, “To do better, we need to learn, share, and talk about what works.” In other words, it was important to come together and share lived experiences related to working with IDUs.

Theme: Systemic constraints

Constraints existed at the organization level, which might impact how services were delivered for people who engage in high risk drug use. Five service providers noted that it was difficult when an IDU individual needed treatment immediately, but there was a waitlist to get them help. One service provider noted that it would be important to recognize that once an individual has a “glimmer of insight” then help should be offered as soon as possible, otherwise if they were put on a waiting list, for example, “you’ve missed that chance. It might help if we could respond in a timely fashion to meet their needs.”

​“They will continue to use until they can get the help. [Being waitlisted] almost forces them to continue using.”

Another challenge was related to the hours of operations: Drug users have their own schedule, and they sought services in their own time. One challenge associated with hours of operations was with the Needle Exchange and getting needles when they needed it, which could be late at night when the Needle Exchange was closed. Alternatively, rescheduling counselling services because an individual was under the influence could be difficult because they might not plan when they used drugs, especially when their addiction was strong. 

One service provider described the challenge of working in an agency that offered a host of services to the general public in addition to individuals who were at risk. The resulting space was one that might not be as inviting for the individuals at risk and more for “people who fit into neat boxes.” In other words, the lack of an inviting space made it difficult for individuals to feel comfortable and to identify with the issues at hand (e.g., having relevant posters in the waiting room), which often deterred them from visiting the agency. Another service provider noted that, because they have such a diverse population that visit their agency, the presence of a Needle Exchange would put off some of the other clients visiting the agency. 

​3.5.1.3. Challenges at the community and societal level

Theme: Negative impacts of stigma

All the service providers discussed how stigma toward people who engaged in high risk drug use was pervasive in the community and at the societal level. This was demonstrated by one service provider who said: “The community sees [drug addiction] as a shameful disease. Some [individuals] don’t feel they can talk about it because of how the community treats drug users.” Many of the service providers sympathized that the stigma made it difficult for individuals to open up about their drug use or be truthful about their addictions when they are seeking help. One service provider empathized with the IDUs: “The general public thinks they’re just junkies, and who cares about them. But they need to be treated as humans, too.” Similarly, another service provider noted that the ‘junkie’ label attached to these individuals could be destructive because it is an extremely difficult label to remove. This stigma stays with the individual even when they try to leave their addiction behind and quit, as one service provider observed: “We are getting good citizens back [from the addiction], but in a small town, [the public and some service providers] still treat them as addicts. They discriminate, so [these individuals] often have to leave town.”

​“Some people think, ‘once a junkie, always a junkie.’ The reality is not true. It’s a label that we put on people, and it’s a hard label to get off. They are human.”

One service provider noted the formation of opinions based on a lack of understanding of addictions and drug use: “Some people talk about methadone clinics and are against without understanding what it is, thinking it promotes drug use, and are not aware of the benefits.” This lack of understanding encouraged further discrimination of people with addictions and limited the availability of services for those who wanted to seek help for their addiction.

​“There’s a huge stigma associated with it. People don’t want it in their neighbourhood. It’s better for them to come [to the needle exchange] to get rid of the needles than in the park.”

Most of the service providers spoke to the importance of the Needle Exchange and the societal benefits. Beyond that, several service providers discussed the societal cost of drug addictions, which included: costs to the healthcare system; the drain on the economy; the rise in theft and petty crime. One service provider noted that, “We spend so much time and money dealing with individuals in courts and going through the legal process” because we have criminalized drug use and, with that, addictions.

​“How long do we try to change societal values?”

Many service providers talked about how prejudice and discrimination of IDUs and addictions have resulted in poor treatment of IDUs and pushed the issue underground. By negatively treating IDUs, the community has forced the IDUs into hiding. As one service provider described, for example, discrimination by healthcare providers made them less likely to seek medical attention when issues arose. Another service provider noted that, “Some [IDUs] don’t visit the needle exchange or professional health because of bad experience with professionals. They assume all professionals have negative attitudes and stigma toward IDUs.” It was clear that poor treatment of IDUs reduced the likelihood that IDUs would even consider finding help when they were ready. 

Theme: Lack of coordinated services 

Six service providers spoke to the need to work together to coordinate services, rather than working separately. One service provider emphasized that working in silos hindered efficacy of efforts. Another service provider suggested that there were various sectors that should be integrated into the larger system. She suggested that they work together with community partners to take a multi-faceted approach in order to improve the reach of services. 

Regarding social services, one service provider suggested that counselling and treatment should be available when they wanted it and when they were ready. She suggested that “partnering together with a circle of care idea, and community partners communicating with each other along the way, so that they don’t fall through the cracks.” Another service provider spoke about the involvement of the justice system to identify barriers that IDUs faced within the justice system (e.g., probation, in jail) and the needs that arose in the justice system. 

Eight service providers emphasized the importance of having a local detox centre so that they could easily refer clients to, rather than forcing them to travel a long distance to get that service. Six service providers spoke about the need for services and support for individuals who have managed to quit the drug use because without that support and follow-up, these individuals might fall back into the drug use again. One service provider observed that the IDU have social ties to “other people who are doing the same thing they were doing… so when they do get clean for some time and they return to these relationships, they eventually fall back into that life. They need to get rid of those temptations.” One service provider added that the follow-up services should be done “in conjunction with other services to help improve the issue, such as community outreach programs.” The service providers emphasized that efforts in these sectors and integration of other sectors helped to ensure that IDUs did not fall through the cracks and become further marginalized.

​“They may finish up detox, but they don’t have intensive follow-up afterward. It’s the nature of detox. You don’t just spend 21 days dry and then all is well in your world. They need that support. It’s very hard for them to make those good choices. If they had that ongoing support, then it would be awesome.”

One area related to service coordination was knowledge of and referral to the Needle Exchange. Twenty-five of the 26 service providers interviewed knew that the Needle Exchange existed in Brant. Five service providers did not know exactly where the Needle Exchange was located; they tended to be service providers in the healthcare sector and those who did not provide frontline service (e.g., managers). Thirteen service providers interviewed have shared information with their clients about where to find the Needle Exchange, while 12 service providers had never done so. The main reason why some of these services providers had not referred clients to the Needle Exchange was because they did not have the frontline interaction to do so. Eight service providers knew that their clients were using the Needle Exchange, while 17 service providers did not know whether or not their clients were visiting the Needle Exchange because they have not seen those clients since the service provider referred them to the Needle Exchange, or their clients did not disclose that information.

3.5.2. Service provider attitudes

3.5.2.1. Attitudes toward harm reduction equipment

Fourteen (53.8%) service providers either disagreed or strongly disagreed that harm reduction equipment supported drug use (Figure 5). Of note were the 4 service providers who felt neutral and the 3 service providers who had no answer to the question (26.9%) because they had a conflicting sense of the issue (Figure 5). Most service providers interviewed saw both sides to the question, as some spoke about the moral and practical aspects of the question. Many service providers understood the importance of providing new needles: new needles reduced the harm associated with sharing and/or using old needles (e.g., disease transmission). There was a sense of care among many service providers, as one service provider put it: “Just because they use drugs doesn’t mean that they need to have diseases.” A number of service providers saw that there was an underlying reason for the drug use, and that underlying issues needed to be dealt with over time, but that the provision of harm reduction supplies helped those individuals get by in the meantime.

Figure 5 - Service provider attitudes about whether or not harm reduction equipment supports drug use

Bar graph showing service provider attitudes about whether or not harm reduction equipment supports drug use

​“They’re going to find a way to do it anyway. There is evidence that people are dying from transmitted diseases. But there are no testimonies of individuals saying that they’ve quit drugs because they couldn’t find needles.”

The main argument in support of providing harm reduction supplies was that individuals would find a way to inject their drugs so offering them the tools to reduce potential harms would be beneficial in the long run. One service provider saw this support as meeting the IDUs where they were at in their lives. However, one service provider warned that: “Even if they know the consequences of sharing, that goes out the window when they need to get high.” Another service provider emphasized that the IDU “will use unless they break the cycle of addiction. New needles benefit society by helping to keep the IDU as healthy as possible and stop the spread of disease.” To summarize what many service providers have said, IDUs will find a way to use drugs anyway, why not let them choose to do it in a safer manner?

​“Ultimately, the goal is to get people to abstain from drug use, but before they get there, how do we make it safe – where, when, and how to do it. Our clients are required to abstain, but they’re never going to abstain, so let’s just meet them where they’re at.”

Contrasting to those supportive arguments, some service providers saw the provision of harm reduction equipment as a bandage solution, whereby providing new needles did not help the individual end the drug use. Differences in opinions were similar across all three sectors. One service provider noted that giving individuals harm reduction equipment was giving them the tools and the option to continue their drug use, which in a way was encouraging the use of drugs. Inherent in many of the arguments with a negative or conflicting nature was the fact that providing new needles supported drug use. The fact that this argument even arose was of concern because it demonstrated a misunderstanding of what organizations offering harm reduction equipment represented: hope for individuals engaging in high risk drug use. This sense of hope was reflected in the many supportive arguments. In other words, offering harm reduction equipment illustrated to IDUs that someone cared and their life mattered; that help was there when they were ready.

​“Giving them new needles will let me see them one more time to encourage change. If they don’t get needles from me, then they will get it from somewhere else. Drug users will use drugs; they will do and get whatever they can to do their drugs. If they come to me, then I can also slip in that reminder to get them thinking about change.”

​3.5.2.2. Attitudes toward helping drug using clients manage/overcome their drug use

Fifteen (57.7%) service providers either agreed or strongly agreed that drug users should get help to manage/overcome their drug use (Figure 6). Much like the question about harm reduction equipment, many service providers wrestled with their response before landing on one. Similar to the previous question, 5 service providers felt neutral and 4 service providers gave no answer (34.6%), as they saw both sides to the argument and could not give a firm response (Figure 6). 

Figure 6 - Service provider attitudes about whether or not drug users should get help to manage/overcome their drug use

Bar graph showing service provider attitudes about whether or not drug users should get help to manage/overcome their drug use

​“It’s not my place to tell somebody what they need to do. I encourage them to look at the negative influence the drug use has on their life. If they’re not ready to confront the pain, then they’re not ready. It has to come from within for the person that’s using the drugs. It’s not about being superior and making them change.”

A majority of service providers believed that drug users should get help for their drug use. However, several of these service providers provided a caveat: Drug users should only get help when they are ready and they should not be forced to get help. 

​“It is not a consideration for them whether I want them to get help. I would like to see them help themselves, but I cannot force them to get help.”

Added to the discussion was the need to inform the drug user about the availability of resources, tools, and support should they want it. Five service providers spoke about the fact that they tried to plant the seeds over time as the IDU individual visited them for services. They told the drug users that help is there when they want it. One service provider suggested that perhaps they want the help, “but don’t know how to or don’t have the means to” get that help. Similarly, one service provider noted that, “if the [IDU] is willing to seek help to end [their] addiction, they should be fully supported by the community.” That is, the support should be there when it is needed.

One service provider asked if there was any other way of answering the question, that the individual should get help for their drug use. This service provider suggested offering help instead of handing individuals harm reduction supplies because it was further encouraging their drug use. This statement demonstrated the service provider’s lack of understanding regarding harm reduction.

​3.5.3. Service provider approach with drug using clients

3.5.3.1. See the person and build them up

Underlying the comments by many service providers was the concept that anyone helping someone with their drug use must look beyond the drug use and see the person. Many individuals spoke to the root cause for the drug use, and the need to work with the individual to resolve the underlying reasons why the individual began, and why they continued, to use drugs. One service provider suggested that not addressing the root cause was simply putting a bandage over the issue. Another service provider reminded that, “Quite often with drug use, there are traumatic events these people are trying to block out. Drugs are a way to escape or numb the pain.” Poignantly, one service provider discussed the reality of drug use from the Aboriginal perspective. 

​“Aboriginal drug users aren’t looking to tell their Aboriginal story over again. When the individual decides to access that support, they need that support immediately. They don’t need to retell their story to someone who doesn’t understand their story to figure out how to heal them…. Many indigenous people in this country have experienced something unique that no other Canadian would have experienced. Whoever is providing the support needs to understand the Aboriginal experience.”

Many service providers found that they must bear in mind the need to withhold judgements and avoid imposing their own values on the person they were trying to help. Seeing the person behind the drug use was vital because, as one service provider put it simply, “It could easily be you.” This service provider noted that every person had a different norm, or consideration of what was normal. In other words, it was important to consider that everyone had their own reality, and life amidst the drug use was the reality that drug users lived with, and that service providers needed to work within that reality. 

​“People need to recognize that people just can’t stop, it’s a process. The drug addiction didn’t start overnight, so you can’t just stop drug use overnight.”

Eight service providers described the first part of seeing the person was by understanding where they were in their lives: “What is their context?” From that perspective, one would begin to see the person and understand their reality. As one service provider said: “You have to talk to them at their level…. It’s getting the client’s perspective. I believe it in my heart that deep down, there is an underlying issue and if we can clear that issue, then they may get better.”

Closely linked to seeing the person beyond the drug use was the act of building up the person. Three service providers spoke about the fact that drug users have lives beyond the drug use, that anyone could be using drugs, and that those people have others who care about them. This was demonstrated by one service provider who learned that a lot of drug users have jobs. She reflected on the fact that, “We seem to romanticize that they’re [IDUs] down and out, sleeping under the bridge or prostituting.” Similarly, another service provider observed that addictions does not “fit within a certain strata and can be found across the board.” In other words, these individuals came from all walks of life and were not different than anyone else. One service provider spoke about their program that looked at the individual at the core of the addiction, framed the situation based on the supports that surround them (including friends and family), and relied on those supports to help the individual at the core of the addiction to move forward.

​“It is important to realize that individuals with substance abuse are no different than anybody else. They work; they have families. Some are doing well, some not so much. They can go in and out, up and down. It’s important to understand that certain clients don’t have a stable lifestyle/position. You have to be flexible with them. If they don’t know where they’re sleeping every night, then you can’t expect them to call and tell you where they are. They might not have a phone to call and set up another appointment.”

Many service providers discussed the need to maintain the focus on the drug user and allow them the freedom to choose and drive how they are helped (i.e., client-centred and client-driven). One service provider reminded that, “The purpose [for the Needle Exchange] isn’t to give needles or to give counselling, but to get the drug users to a good place.” Getting the IDU individual to that good place might just “focus on meeting them where they are,” as noted by another service provider. 

3.5.3.2. Build a relationship

Closely linked to seeing the person and building them up, many service providers advised that it was important to build a relationship with the drug users, as a way to move forward with them. They spoke about the fact that the lack of relationship deterred the individual from returning and/or trusting the service. Several service providers noted that building relationships encouraged the individual to come back for more help, knowing that someone out there cared about them as a human being. Part of relationship building was to give the individual reason to trust the service provider. As an example, one service provider said that they have to “build rapport with kids [who use drugs] so they are more apt to opening up.” That is, the trusting relationship got the drug users to confide in the service providers.

​“We need to make it okay for them to come in to break the cycle of drug use.”

Several service providers have built that relationship with their drug using clients. They spoke about their concern for their clients, and only hope for the best for them. They hoped that the individual return to them alive, and even get past the addiction. 

3.5.3.3. Remain supportive

Several service providers spoke directly or indirectly about the need to remain supportive through the process of helping the individual with their drug use because an addiction can be difficult to overcome. One service provider reminded that, “the individual doesn’t control the addiction, the addiction controls them. So you need to be empathetic that they may relapse.” Many service providers noted that a lot of pain was associated with the process of fighting addictions, which might result in relapse back into drug use. One service provider described that, “Quitting is easy, but the challenge is dealing with the [mess] that [the IDUs] created in drug use.” Another service provider learned that the struggle with addictions could be powerful; “how immediate [the addiction] is; the powerful hold that it has on the person; that the needle is most important to them.”

​“You know the addiction is going to hurt them. All their hopes and dreams are going to be affected by drug use. Getting them to understand that is the hard part. Standing by as a counsellor is hard to do because we have to accept what they want.”

One service provider advised that, “We should keep openness in our service delivery and respect for autonomy, self-determination, and personal choice…. We should keep that openness in repeating that if they don’t want something now, that that door could be opened later.” This type of openness was important to maintain to ensure that the IDUs felt welcomed and the realities of their drug use were recognized. Many of the service providers saw the importance of remaining supportive because there would come a time when the individual would need their help.

​“Do I want to see people live healthy, fulfilling lives? Yeah, absolutely. Drug use comes with a lot of destructive behaviours. I would like to be there when they’re ready.”

Four service providers who offered counselling to individuals struggling with addictions discussed their frustration with individuals relapsing with their drug use, despite the service providers’ efforts to put strategies in place to prevent the relapse from occurring. One service provider learned that, “You always need to expect the unexpected even though you might have a plan.” However, these struggles have surfaced the need for the service providers to maintain patience as their clients go through the gruelling process of the addiction. 

Several service providers emphasized the fact that one cannot push the drug user into recovery and change their behaviour. As one service provider said, doing so “will cause them to run and fall into the cracks where there are more pressures and labels, making it harder to get back up.” Many service providers highlighted that they needed to remain supportive and offer a helping hand and tools to guide the individual once they are ready. The unfortunate alternative, as some service providers mentioned, would be to push the IDU back into the margins and risk losing them, which would result in a more profound impact on human capacity, the healthcare system, and societal costs, such as crime and economic vitality (or lack thereof).

​“Sometimes, we need to forget about curing or treating the individual, and focus on meeting them where they are. It’s better than isolating them. There has to be someone in society who doesn’t give up on them.”

4. Discussion

4.1. Discussion

The needs assessment offered a glimpse into the reality of drug use in Brant and data relating to drug use, access and use of the Needle Exchange and other community services. Two issues remain at the forefront of the IDU experience: access to the Needle Exchange and pervasive stigma. The service providers offered some guidance on how to better provide services to IDUs. A comparison of the current needs assessment and the OHRDP evaluation was completed (OHRDP, 2009).

4.1.1. Access to the Needle Exchange

Many IDUs discussed their challenges with getting access to the Needle Exchange and reasons why certain people may not visit the Needle Exchange, including hours of operations, transportation/distance to the Needle Exchange, lack of privacy, embarrassment, paranoia, and laziness. These challenges and reasons are similar to those identified by the European Centre for Disease Prevention and Control (ECDC; 2011). The ECDC (2011) suggested that the fear of being searched by police for drug paraphernalia might be another barrier to getting access to a Needle Exchange service, which was not a barrier that was identified in the interviews with IDUs. This fear of being arrested and charged by police may account for the high percentage of IDUs who visit the Needle Exchange and do not return any used needles. When individuals have difficulty getting access to the Needle Exchange, they are more likely to share needles or reuse old needles, as illustrated by some IDUs interviewed in this needs assessment and by Strike et al. (2013). Strike et al. (2013) recommend that a Needle Exchange should be available when and where people need needles, including having extended hours, mobile exchange sites, peer exchangers, pharmacies, delivery service, and vending machines. Having these other options may address the barriers to getting access to harm reduction supplies.

The impact of the closure of one Needle Exchange site in Brant that had a high volume of visits remains to be determined, as it is still too soon to know what happened to those visitors. At this time, the closure of this Needle Exchange site shows a decrease in the number of visits to the Needle Exchange in general, similar to what others have found following closures of Needle Exchange services (MacNeil & Pauly, 2010). The decrease in visitors impacts the number of needles that are returned and given out to IDUs, which in turn results in increased high risk behaviours, such as sharing and reusing needles (MacNeil & Pauly, 2010). Beyond the physical access to new needles, IDUs in Brant have lost access to a place where they can visit and connect with a service provider, whether it is for health or social services. This has a profound impact because the Needle Exchange symbolizes hope for IDUs. Organizations offering harm reduction equipment provide more than just new needles; they provide an opportunity to reach out to drug users and bring them back into mainstream society, rather than letting them fall through the cracks due to their drug use (MacNeil & Pauly, 2011; MacNeil & Pauly, 2010; Strike et al., 2013; Weiker, Edgington, Kipke, 1999). The impact the Needle Exchange has on the lives of IDUs makes it tantamount to ensure that knowledge of the Needle Exchange (e.g., its purpose, hours of operations, locations) is openly known and accessible for IDUs and their service providers. 

4.1.2. Pervasive stigma

4.1.2.1. Prevalence and impact of stigma

The interviews demonstrated the challenges that exist in offering services to people who engage in high risk drug use and the widespread stigma and misunderstanding of drug use at the community level. This overwhelming stigma is not unique to Brant (Bernstein & Bennett, 2013; MacNeil & Pauly, 2011; Parker, Jackson, Dykeman, Gahagan, Karabanow, 2012; Strike et al., 2013), but is a reality that IDUs must face every day. The prevalence of negative experiences with access to services among IDUs interviewed was unacceptably high, particularly in certain agencies. Interestingly, only a few of the service providers interviewed spoke about their negative experiences with IDUs. Consequently, the needs assessment surfaced many limitations to working with IDUs and openly discussing drug use in the Brant community. Several IDUs interviewed refused to speak openly about their experiences as IDUs and their access to services, potentially as a way to safeguard themselves and maintain privacy. This was also illustrated by the number of IDUs who visited the Needle Exchange and refused to participate in the interview (data not shown).

4.1.2.2. Social hierarchy of drug use

Stigma in Brant seems pervasive to the point where it is experienced by IDUs in many directions and settings, which understandably has resulted in the internalization of stigma. The internalization of stigma is demonstrated through the use of terms, such as ‘junkie’, ‘user’, and ‘addict’, to identify themselves and others despite their disparaging connotation. However, interviews with the IDUs surfaced a concept around identity and hierarchy similar to that in the population of people who are homeless (Boydell, Goering, Morrell-Bellai, 2000; Frederick, 2012; Snow & Anderson, 1987), whereby individuals of a marginalized population develop strategies to cope with their marginalized identity via the development of a social hierarchy of what it means to be someone who engages in high risk drug use. This concept is comprised of two components: (1) naming identities in the hierarchy; and (2) distancing self from more degrading identities.

The first component of the social hierarchy of drug use is naming identities in the hierarchy, such as ‘junkie’ for those at the bottom of the hierarchy and ‘responsible user’ for those at the top. Attachment of identities to the individual and others seems to be associated with the way one uses drugs and whether or not one uses community services. Individuals who shared or reused needles, or had a disregard for safety or cleanliness of drug use, were identified as ‘lazy’ and ‘dirty’ – or ‘junkie’, someone who used anything and everything. Individuals who did not access services, such as the Needle Exchange, counselling, medical attention, were considered irresponsible. This component is similar to those identified for people who are homeless (Boydell et al., 2000; Frederick, 2012; Snow & Anderson, 1987), where individuals of varying levels of ‘homeless’ are identified by their peers. These different levels of the homeless identity include care for personal hygiene (e.g., body odour, facial hair), types of clothes worn, and use of services. 

The second component of the social hierarchy of drug use, closely linked to the first component, is distancing self from more degrading identities, whereby IDUs described themselves as different or separate from others because they themselves were above them. This could be seen in various instances: one IDU felt offended that he was even asked about his needle sharing practices; one IDU described who junkies were; many IDUs deemed themselves different or better than people who did not visit the Needle Exchange because they were being responsible. The practice of distancing self from others to put themselves above them is similar to strategies identified by the homeless identity research (Boydell, Goering, Morrell-Bellai, 2000; Frederick, 2012; Snow & Anderson, 1987). The different aspect from this needs assessment and that of research by Boydell et al. (2000) and Snow & Anderson (1987) is that some people who were homeless spoke about others who attended certain services, such as shelters, as people who had a lower status than they did using us/them terms.

4.1.3. Meeting the needs of IDUs

The service providers spoke about many of their positive experiences and learning moments with IDUs, while noting the realities of working with IDUs through the various challenges that they faced at the individual, organizational, and societal levels. Many service providers offered guiding practices for working with IDUs: (1) see the person and build them up; (2) develop a relationship with them; and (3) remain supportive despite their setbacks. These guiding practices are similar to those of building human capacity and empowerment (Burris, 2004; Pauly, 2008; White, 2009). Essentially, these guiding practices centre on giving IDUs figurative power, as a way to build self-esteem, dignity, and autonomy. These practices allow service providers to create a supportive and welcoming environment that would help to continue the relationship with IDUs so that they do not fall through the cracks (Pauly, 2008; Weiker et al., 1999). 

The guiding practices are linked to the underlying principles of harm reduction. Harm reduction inherently advocates that everyone deserves care, which is in essence working toward health equity (Pauly, 2008). Achieving health equity is not a simple feat and requires coordinated efforts to meet the needs of such a marginalized population. 

The needs assessment was the first step toward bringing the issues of intravenous drug use and addictions to the forefront, as a way to formulate a more comprehensive approach to addressing the needs of people who engage in high risk drug use. This work is expected to facilitate a more frank, inclusive, and respectful conversation of the realities of drug use and the needs of people who engage in high risk drug use.

​4.1.4. Comparison to the OHRDP evaluation

Compared to the Ontario Harm Reduction Distribution Program (OHRDP) evaluation (Leonard & Germain, 2009) , a higher proportion of IDUs interviewed in this project (75.7%) used drugs daily, as compared to the OHRDP sample (36.1%) who disclosed injecting daily. Fewer IDUs interviewed in the current project injected three or more times per week but not every day (5.4%) when compared to the OHRDP sample at 20.0% (Leonard & Germain, 2009). The drugs identified by the IDUs interviewed were similar to those identified in the OHRDP evaluation (Leonard & Germain, 2009). Locations of where the IDUs collected their new needles from were similar to the OHRDP evaluation, which found that the most common locations where individuals collected new needles were the Needle Exchange (58.2%) and pharmacy (18.6%) (Leonard & Germain, 2009).

4.2. Limitations

Intravenous drug use, and even illicit drug use in general, is a relatively sensitive topic that can be polarizing because it touches on individual beliefs, morals, and values. As such, social desirability bias might have influenced the truthfulness of responses. Some IDUs interviewed might have offered responses that they thought the interviewer would want to hear, particularly around sensitive topics such as frequency of drug use, sharing and reusing needles, and STI testing. This might be associated with their fear of being judged and possibly the lack of trust with service providers and people in authoritative positions. It is possible that the lack of rapport with the IDUs might have reduced the likelihood that they would speak openly or truthfully about their experience as IDUs. The limited number of negative experiences described by the service providers interviewed might not be due to the lack of negative experiences, but perhaps more to hide those experiences because they were involved in those situations and felt embarrassed about how those situations occurred.  

The truthfulness of responses by IDUs (i.e., reliability) could also be seen in the analysis of the program use statistics. The program use statistics rely on self-reported data, such as name, age, and number of needles returned. The reliability of these data might be low because of the sensitivity of the topic and the fact that many IDUs do not want to be tracked. This issue of reliability is demonstrated in the way the program use statistics are tracked. Real names are not required, so IDU clients might be inclined provide a false identity, which they could use to visit multiple Needle Exchange sites in one day to pick up more than the maximum amount of harm reduction supplies. Therefore, it is difficult to determine the number of unique visitors to the Needle Exchange using the current method of program use statistics. 

Particular to the IDUs, only individuals visiting the Needle Exchange were interviewed. As such, IDUs not visiting the Needle Exchange were not represented in the sample of IDUs interviewed. The individuals who agreed to participate in the needs assessment might be different than those who do not; for example, the IDUs who agreed to be interviewed might be more likely to use the Needle Exchange and other services and are more considerate of their health and safety. The recruitment process via a drop-in basis only captured IDUs who visited the Needle Exchange at the time the main interviewer (T. Vo) was available; however, this issue was partly resolved by having the Needle Exchange staff interview IDUs in place of the main interviewer and having the main interviewer visit at varying times during the day and days of the week. However, the results from the interviews with IDUs might not be generalizable to all IDUs in Brant.

Service providers interviewed already had some knowledge and understanding of how to work with IDUs and most had positive experiences to speak of. It is clear that the service providers interviewed are different from the general group of service providers in Brant because of the limited discussion of negative experiences. The service providers interviewed were only those who were available during the recruitment period and those who felt comfortable speaking about their experience working with IDUs. Service providers encapsulate such a broad spectrum of sectors, which makes it difficult to generalize results from the interviews with service providers to all service providers in Brant. 

Attitudes regarding IDUs gleaned from all the interviews cannot be assumed to be the major opinion of the general public.

4.3. Recommendations for Next Steps

Recommendations for the next steps are described in Appendix II. The next steps are intended to be accomplished by the Needle Exchange community partners, St. Leonard’s Community Services and Brantford Clinic, with support from Brant County Health Unit. Other community partners should be brought into conversation to ensure harm reduction philosophy is understood and applied within the Brant context, where appropriate.

​5. Conclusion

The lived experience of IDUs in Brant illustrates a diversity of realities of someone who engages in high risk drug use or has addictions. The three Needle Exchange sites in Brant have been doing what they can to meet the needs of the IDU population, altering their approach based on what those needs are at the time. The needs assessment offered a glimpse into the reality of drug use in Brant, access to and use of the Needle Exchange, and the experience of service providers. The needs assessment also provided evidence to support advocacy efforts locally, while demonstrating the need for continued efforts to address the challenges of drug use in Brant, to tackle the widespread and systemic stigma, and to explore more comprehensive and coordinated efforts within the community. The needs assessment was the first step toward bringing the intravenous drug use and addictions to the forefront to help inform the development of a more comprehensive approach to addressing the needs of people who engage in high risk drug use. This work is also expected to facilitate a more frank, inclusive, and respectful conversation among local agencies of the realities of high risk drug users and ways to address their needs. 

​6. References

Bastos, F.I., Strathdee, S.A. (2000). Evaluating effectiveness of syringe exchange programmes: Current issues and future prospects. Social Science & Medicine, 51, 1771-1782.

Bernstein, S.E., Bennett, D. (2013). Zoned out: “NIMBYism”, addiction services and municipal governance in British Columbia. International Journal of Drug Policy, 24(6), e61-e65

Boydell, K.M., Goering, P., Morrell-Bellai, T.L. (2000). Narratives of identity: Re-presentation of self in people who are homeless. Qualitative Health Research, 10(1), 26-38.

Buris, S. (2004). Harm reduction’s first principle: “The opposite of hatred”. International Journal of Drug Policy, 15, 243-244.

Delgado, C. (2004). Evaluation of needle exchange programs. Public Health Nursing, 21 (2), 171-178.

European Centre for Disease Prevention and Control. (2011). Evidence for the effectiveness of interventions to prevent infections among people who inject drugs. Part 1: Needle and syringe programmes and other interventions for preventing hepatitis C, HIV and injecting risk behaviour. Stockholm, Sweden: ECDC.

Frederick, T.J. (2012). Deciding how to get by: Subsistence choices among homeless youth in Toronto. Retrieved from T-Space, University of Toronto Research Repository. (http://hdl.handle.net/1807/34007). 

Hyshka, E., Strathdee, S., Wood, E., Kerr, T. (2012). Needle exchange and the HIV epidemic in Vancouver: Lessons learned from 15 years of research. International Journal of Drug Policy, 23, 261-270.

Leonard, L., Germain, A. (2009). Ontario Harm Reduction Distribution Program: Final outcome evaluation. Kingston, Ontario: OHRDP.

MacNeil, J., Pauly, B. (2011). Needle exchange as a safe haven in an unsafe world. Drug and Alcohol Review, 30, 26-32.

MacNeil, J., Pauly, B. (2010). Impact: A case study examining the closure of a large urban fixed site needle exchange in Canada. Harm Reduction Journal, 7, 11-18. 

Needle, R.H., Burrows, D., Friedman, S., Dorabjee, J., Touze, G., Badrieva, L., Grund, J.P.C., Suresh Kumar, M., Nigro, L., Manning, G., Latkin, C. (2004). Evidence for action: Effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users. Geneva, Switzerland: World Health Organization.

Parker, J., Jackson, L., Dykeman, M., Gahagan, J., Karabanow, J. (2012). Access to harm reduction services in Atlantic Canada: Implications for non-urban residents who inject drugs. Health & Place, 18, 152-162.

Pauly, B. (2008). Harm reduction through a social justice lens. International Journal of Drug Policy, 19, 4-10.

Porter, J., Metzger, D., Scotti, R. (2002). Bridge to services: Drug injectors’ awareness and utilization of drug user treatment and social service referrals, medical care, and HIV testing provided by needle exchange programs. Substance Use & Misuse, 37 (11), 1305-1330.

Strike, C., Hopkins, S., Watson, T.M., Gohil, H., Leece, P., Young, S., Buxton, J., Challacombe, L., Demel, G., Heywood, D., Lampkin, H., Leonard, L., Lebounga Vouma, J., Lockie, L., Millson, P., Morissette, C., Nielson, D., Petersen, D., Tzemis, D., Zurba, N. (2013). Best practice recommendations for Canadian harm reduction programs that provide service to people who use drugs and are at risk for HIV, HCV, and other harms: Part 1. Toronto, Ontario: Working Group on Best Practice for Harm Reduction Programs in Canada. 

Snow, D.A., Anderson, L. (1987). Identity work among the homeless: The verbal construction and avowal of personal identities. American Journal of Sociology, 92(6), 1336-1371.

Strike, C., Leonard, L., Millson, M., Anstice, S., Berkeley, N., Medd, E. (2006). Ontario needle exchange programs: Best practice recommendations. Toronto, Ontario: Ontario Needle Exchange Coordinating Committee.

Weiker, R.L., Edgington, R., Kipke, M.D. (1999). A collaborative evaluation of a needle exchange program for youth. Health Education & Behaviour, 26(2), 213-224.

White, C.L. (2001). Beyond professional harm reduction: The empowerment of multiply-marginalized illicit drug users to engage in a politics of solidarity towards ending the war on illicit drug users. Drug and Alcohol Review, 20, 449-458.

Appendix I: Overview of Methods of Data Collection and Data Analysis

Table 1. Methods overview


Data Analysis

Qualitative data from semi-structured interviews were analyzed for themes using QSR NVivo (version 10) software. Documents were analyzed and described in terms of proportions based on various demographics collected by St. Leonard’s Community Services and Brantford Clinic. Quantitative data from the interviews and the document analysis were analyzed using Microsoft Excel 2010 software to calculate proportions and create any graphic representations of the results. All data were compared to results obtained from the evaluation of Needle Exchanges in Ontario completed by the Ontario Harm Reduction Distribution Program (2009).

Appendix II: Recommendations for Next Steps

Short-term Recommendations

​Recommendation 1
Disseminate results and create a forum to openly discuss the results at the community level
​Rationale
The intended approach to disseminate the results for the needs assessment include: (1) a final report; (2) a summary factsheet available online; and (3) a roundtable with community agencies. A summary of the report should be offered to the stakeholders identified in the needs assessment (i.e., agencies that were approached as participants for the needs assessment). The summary should be posted on BCHU’s website and made available through BCHU’s existing communication channels (e.g., Twitter, relevant working groups, etc.). Dissemination methods should be discussed in collaboration with St. Leonard’s Community Services to ensure relevance of products and greater reach.
The community forum could take the form of a roundtable comprised of a presentation and an open discussion regarding the results. The roundtable could bring together the key players in Brant who will likely use the needs assessment results for their planning. The community agencies (identified as possible participants) and others not involved in the needs assessment could be brought together to discuss the results and next steps and develop a community-led action plan. Each stakeholder agency may gain information with regard to IDUs that would be useful to incorporate into current practice at their respective agency. The community forum should occur around other relevant events to bring together key players in the community.
​Actions
• Develop summary factsheet and disseminate electronically.
Explore next steps with community stakeholder agencies via a community-led forum, such as a roundtable discussion.
​Recommendation 2
Develop a policy for opioid overdose response and training
​Rationale
The request for overdose response training and implementation (i.e., use of naloxone to respond to overdoses) has been explored. Naloxone is an opioid reversal drug that is often used in the hospital and pre-hospital settings, and is recommended for individuals who have had a known or suspected overdose. Naloxone could potentially decrease the mortality and morbidity associated with overdose.
A policy is required to ensure clarity in roles, responsibilities, and procedures. This policy could be developed based on what other Needle Exchanges in Ontario currently have in place. The policies should consider the Best Practice Policies outlined in Best Practice Recommendations for Canadian Harm Reduction Programs: Part 1 (Strike et al., 2013). Training for overdose response may include topics such as: preventing overdoses; recognizing overdose emergencies; recommended bystander first response techniques; and administering naloxone (Strike et al., 2013).
​Actions
• Review policies of other Needle Exchanges in Ontario and the recommended best practice policies.
• Develop policy for overdose response and the use of naloxone by BCHU and Needle Exchange partner agencies.
Train appropriate staff for opioid overdose response.
​Recommendation 3
Identify resources and opportunities for staff training regarding harm reduction practices
​Rationale
Numerous service providers have noted their limited knowledge regarding the use of injection drug paraphernalia. Information is available in Best Practice Recommendations for Canadian Harm Reduction Programs: Part 1 (Strike et al., 2013). These recommendations could be consolidated and referenced to provide these service providers with easy access on how to use those specific drug paraphernalia. In addition, other training opportunities related to harm reduction should be made available to service providers, particularly those who work at each of the Needle Exchange sites and at Brant County Health Unit.
​Actions
• Develop a repository of current resources and training opportunities around use of equipment, etc.
• Share resources and training opportunities between partner agencies.
​Recommendation 4
Implement marketing approaches to increase awareness of Needle Exchange locations and services
​Rationale
Many IDUs interviewed pointed out that there were still some people who did not know where and when the Needle Exchange was open. Some service providers also did not know this either. As such, locations where the Needle Exchange could be advertised should be identified, particularly in locations where more IDUs may frequent, such as the agencies that the IDUs identified in the interview where they have visited for services, the bus station downtown Brantford, etc.
Marketing approaches should be evaluated for their effectiveness to ensure the intended population is being reached.
​Actions
• Develop advertising materials to publicize the Needle Exchange in various locations across Brant.
Evaluate effectiveness of marketing approaches.
​Recommendation 5
Provide safer inhalation kits for crack smoking
Rationale
There appears to be support from the IDU level and service providers at the Needle Exchange partner agencies to offer safer inhalation kits to smoke crack. Many Needle Exchanges in Ontario are already providing safer inhalation kits, while the Ontario Harm Reduction Distribution Program is currently providing equipment for the kits to Needle Exchanges free of charge. Therefore, safer inhalation kits should be provided. However, training needs for staff and procedure for disposal of used equipment should be explored.
​Actions
• Explore at the Central West Regional Needle Exchange Network their procedures and staff training regarding safer inhalation kits.
Train staff on providing safer inhalation kits.
​Recommendation 6
Explore locations to place needle disposal boxes in public spaces in Brant
​Rationale
Many IDUs and service providers interviewed mentioned some of the trouble spots where used needles were found in Brant (not discussed in the results). It would be ideal to determine and document exactly where the most common public spaces where used needles are found. This could be done by speaking with law enforcement, public works, and Brant County Health Unit staff as to where they often receive calls for used needle pick-up.
Once the common public spaces are known, some exploration is required to determine the feasibility of putting in additional disposal boxes in those locations. Part of this exploration is to connect with other Needle Exchanges in Ontario to see what they do with their disposal boxes in public spaces (i.e., who monitors the disposal boxes, who empties them, how they are marketed). Placement of these disposal boxes in public spaces should be done in collaboration with community partners, including the City of Brantford.
​Actions
• Determine common public spaces where used needles are found.
• Explore what other Needle Exchanges are doing with their disposal boxes in public spaces.
• Determine the feasibility of placing additional disposal boxes in public spaces in Brant.
Partner with community agencies and groups to offer needle disposal boxes in and around their respective locations.
​Recommendation 7
Determine the available resources for people who engage in high risk drug use to be used by service providers for referral purposes
​Rationale
The interviews surfaced the issue that some IDUs did not know where to go and some service providers did not know who else they could refer clients to for assistance with mental health and addictions – other than St. Leonard’s Community Services. A list should be created and maintained to outline services of where IDUs can go to for help (e.g., quick reference sheet for services).
​Actions
Develop and maintain a repository of services for IDUs and make it available to community agencies serving people with addictions and people who engage in high risk drug use.
​Recommendation 8
Explore a place for offering basic health services (including STI testing and immunizations) and outreach to people who engage in high risk drug use
​Rationale
The interviews surfaced the importance of having a safe space for IDUs to visit for health concerns and social support. The service providers recommended coordinating efforts to meet the needs of IDUs. This level of coordination could be the creation of a place with a variety of services in an accessible location where there exists a higher concentration of IDUs, such as downtown Brantford. Numerous community agencies service diverse populations, making it challenging for them to create a welcoming and safe space for IDUs. Services offered at this safe space may include: STI testing, outreach, counselling, and referral to other relevant services. Efforts to creating such a space should be done in collaboration with community partners, including St. Leonard’s Community Services.
​Actions
• Explore the feasibility of creating a safe space for testing, outreach, and counselling for IDUs.
• Determine appropriate partners and the available spaces for such a space.
Long-term Recommendations
​Recommendation 9
Develop and implement a community-led comprehensive harm reduction action plan in Brant
​Rationale
A community-led comprehensive harm reduction action plan should be developed among community agencies to address drug use and addictions in Brant. This action plan could be accomplished by the community agencies through coordinated efforts and tangible next steps. The roundtable discussions could be one venue to begin discussions to formulate the action plan. The results of the needs assessment provides evidence for how to move forward, but the discussions in a roundtable format offer details to the steps to be taken. Part of the action plan should be to determine how to embed values of, and strategies for, harm reduction in all services in Brant.
The following characteristics of effective harm reduction programs (Strike et al., 2006) should be considered as part of the action plan:
• Provide a comprehensive range of well-coordinated and flexible services;
• Involve the community in planning and implementation;
• Continually assess and understand local community needs;
• Make services available in multiple locations with varied hours of operation;
• Provide community-based outreach to drug users where they live and use or buy drugs;
• Communicate respect for IDUs and their families to ensure all are treated with dignity and with sensitivity to cultural, racial, ethnic, and gender-based characteristics; and
• Provide a supportive political environment.
Development and implementation of the action plan would be dependent on the resources and political climate that currently exists. There currently exist various planning tables at the community level that address the health, wellbeing, and prosperity of the community. These tables could be places to start to determine how necessary a new working group would be. However, it would be vital to ensure the vision of the harm reduction action plan is not lost when working alongside other planning tables. In addition, the working group should endeavour to include the individuals who are current and former drug users.
The site observations demonstrated a need for clarity in procedures and processes for the Needle Exchange, in order to ensure consistency across all three sites. Public health units in Ontario were offered a list of start-up tasks to successfully implement the Needle Exchange in their respective jurisdictions. It would be beneficial to review the list of start-up tasks to ensure that all the tasks have been completed. If there are any outstanding tasks, they can be followed up on and be included in steps to bolster the Needle Exchange in Brant.
The start-up tasks include (Strike et al., 2006):
• Develop an advisory committee;
• Identify mentors at other Needle Exchanges;
• Conduct advocacy and community development with IDUs;
• Conduct advocacy for the Needle Exchange in the community;
• Collect information about the IDU community;
• Select a program model(s), site(s), and hours of operation;
• Develop a program plan, policies, and procedures; and
• Hire and train staff.
Details of these tasks could be found in the Ontario Needle Exchange Programs Best Practices Report (Strike et al., 2006).
Many service providers spoke about their lack of knowledge around harm reduction and how to appropriately apply harm reduction approaches in their work. An assessment should be conducted to determine how many agencies and service providers require training around harm reduction and other related topics. Some topics include: how to incorporate harm reduction approaches in their work; knowledge of new drugs, how to use them and their associated equipment, and the drug’s impact on the body; communicating with difficult clients; responding to clients in crisis/withdrawal; and knowledge of managing addictions and working with people who have addictions. One important topic that underpins the challenges faced by many service providers interviewed is how to properly and effectively work with people from marginalized populations. This training may be able to address and challenge service provider assumptions, values, and attitudes related to people who engage in high risk drug use, as noted by the IDUs regarding their negative experiences getting access to services at certain community agencies.
Strike et al. (2006) identify topics that should be included in training programs for the Needle Exchange:
• Target populations;
• Risk behaviours for transmission of HIV and other blood-borne infections;
• Safer sex, injection, and drug use practices; and
• Interpersonal boundaries.
The interviews revealed the positive working relationships between law enforcement and various community agencies, including St. Leonard’s Community Services. One area of concern is the enforcement of public order, specifically charging individuals carrying drug paraphernalia. Charging individuals carrying drug paraphernalia, a concern in Brant, is not recommended because it reduces the likelihood that they would visit the Needle Exchange and/or return used needles and other supplies (Hyshka et al., 2012; Strike et al., 2013). Therefore, it would be important to strengthen the relationship with law enforcement in Brant to explore other ways to both maintain public order in the community and encourage access to harm reduction services by IDUs.
​Actions
• Identify and develop the most appropriate vehicle to implement a comprehensive harm reduction action plan (i.e., via a working group of some sort).
• Begin discussions of the comprehensive harm reduction action plan at the community forum.
• Develop and implement a community-led Comprehensive Harm Reduction Action Plan for Brant.
• Review recommended start-up tasks and implement as appropriate.
• Conduct an assessment of training needs for service providers around harm reduction.
• Explore the appropriate learning methods for the required training.
• Compile relevant training resources and facilitate training sessions for frontline staff.
• Determine the type of relationship that currently exists between the Needle Exchange partners and law enforcement and where that relationship could be strengthened to address drug use in the community.
​Recommendation 10
Explore the feasibility of and approaches for mobile outreach
​Rationale
The closure of one Needle Exchange site in Brant has had in impact on the number of visits to the Needle Exchange in Brant. Over the past year, the number of visits has been steadily rising, but it is still too soon to make an assessment of the change in use of the Needle Exchange sites. Evidence from both the program use statistics and the interviews reinforce the fact that IDUs are a difficult to reach population. Needle et al. (2004) advocate that outreach workers may be one approach to reaching more IDUs. Outreach workers help to build the relationship with IDUs in the community to encourage reducing risk of disease transmission, use of harm reduction supplies, and referrals to services (Needle et al., 2004). For the Needle Exchange in Brant, the outreach worker would be able to determine where IDUs live, buy and use drugs, and hang out, which, in effect, helps to determine how to best reach the IDUs. Other activities the outreach worker could do include: hand out harm reduction supplies and information in specific, safe locations; provide one-to-one education of harm reduction, use of harm reduction supplies, and how to recognize the need for medical attention; and make referrals as necessary. The outreach worker would be another point of contact for IDUs and could potentially build positive relationships with IDUs in Brant, which may increase the likelihood that IDUs will seek out services, particularly those who might not otherwise reach out for help.
Hiring and training of the outreach worker should be done in collaboration with community partners, including St. Leonard’s Community Services. The feasibility of having an outreach worker should first be determined before proceeding, including how the outreach worker would work, where they would be housed, their roles and responsibilities, training needs, safety concerns, etc.
The IDUs interviewed expressed the need for a form of mobile needle exchange and additional needle exchange sites. They also identified their desire for extended hours and weekend hours of operations for the Needle Exchange. These issues need to be considered appropriately and their feasibility should be noted based on available resources.
​Actions
•    Determine the feasibility of hiring and training an outreach worker in collaboration with community partners.
Determine the vital aspects of having an outreach worker, including their roles and responsibilities, training needs, safety concerns, etc.
​Recommendation 11
Conduct evaluation of process (every 2 years) and outcome (every 5 years)
​Rationale
The needs assessment had a lack of the youth voice. The needs of youth who engage in high risk drug use should be explored so as to help the younger IDUs before they become overwhelmed by the addiction.
A more in-depth and ongoing evaluation of the Needle Exchange needs to be incorporated into the service to determine the impact of access, reach, and the ability of the Needle Exchange to influence communicable diseases, particularly HIV and HCV. As surfaced in the analysis of the program use statistics, the questions asked (essentially, the measures of program use) may not provide the most useful information. Therefore, more appropriate measures should be used and explored with frontline staff for the Needle Exchange. Additional questions asked of clients could be staged (e.g., several questions asked rotated every 2 months).
Ongoing evaluation of the Needle Exchange will help to understand the context of drug use in Brant to better meet the needs of IDUs (Hyshka et al., 2012; Strike et al., 2006). Specifically, evaluation can identify factors that hinder or facilitate access to the Needle Exchange/sterile needles; identify appropriate approaches to reaching IDUs, especially those who do not often seek services; determine how to better work with community partners on addressing drug use in Brant.
​Actions
•    Conduct an assessment of drug use among young IDUs in Brant.
•    Identify appropriate measures for program use in exploration with frontline staff for the Needle Exchange for future process evaluations.
•    Develop an evaluation plan to be embedded into the routine functions of the Needle Exchange.

Tin Vo
Health Planner

519-753-4937 ext. 214
tin.vo@bchu.org