Last year nearly 2 million people in Ontario filled opioid prescriptions, representing approximately 14% of the overall population, or one out of every seven people (Health Quality Ontario, 2017).  These high volumes of opioid being made available in communities across the province have led to higher rates of misuse, abuse and overdose.  This is a concern not only for patients who are prescribed opioids but also their family members, and those who obtain these substances on the illicit market. Federal and provincial governments have recently released strategies to address some of these issues however additional action is needed at the local and regional levels. 

In December of 2016, the Windsor-Essex Community Opioid Strategy Leadership Committee (WECOS-LC) was formed, bringing together leadership and key stakeholders across many sectors to collectively address rising rates of opioid use in Windsor and Essex County. Consisting of stakeholders from public health, emergency services, law enforcement agencies, the Erie St. Clair Local Health Integration Network, the City of Windsor, County of Essex, Windsor-Essex hospitals, addiction and mental health service providers, school boards, pharmacies, and community peer representatives, the WECOS-LC committed to the ongoing development and implementation of the Windsor-Essex Community Opioid Strategy.

The strategy was developed by the WECOS-LC in consultation with residents of the community, beginning with an environmental scan of existing community resources and best practices from other regions at the provincial, national, and international levels. This set of strategies was then further refined through a community consultation process involving two community forums and an online community feedback survey. The development process resulted in the following set of recommendations categorized under the Pillars: Prevention/Education, Harm Reduction, Treatment/Recovery, and Enforcement/Justice. Under each recommendation there are a set of short and long-term actions to be implemented by pillar-based working groups to build upon existing community resources, programs and services. The actions are as follows:

• Support peer engagement and meaningful involvement of people with lived experience, as a critical feature for building local capacity.

Prevention and Education

• Support all healthcare providers to lay a key role, through appropriate prescribing practices, patient education about opioids and overdose prevention and other pain management options. 
• Provide early education and prevention about opioids and other substance use.
• Develop a local overdose monitoring and response system. 

Harm Reduction

• Increase access to a variety of harm reduction options for people who use opioids and those affected by people who use opioids. 
• Address stigma associated with problematic substance use through the development of supportive polices and education of healthcare professionals, community organizations and the public. 

Treatment and Recovery

• Work with provincial partners to advocate for increased funding to expand the capacity of the local substance use treatment system. 

Enforcement and Justice

• Redefine the role for enforcement agencies and other first responders to build “public safety-public health” partnerships for a safer and healthier community.

Four working groups will be established to focus on actions related to each pillar (Prevention/Education, Harm Reduction, Treatment/Recovery, and Enforcement/Justice). These groups will create work plans based on the above suggested actions and will begin the process of implementing the strategy.

The words we use can impact the way we think and it is for this reason that the Windsor Essex Community Opioid Strategy -Leadership Committee offers the following explanations. 

Opioid substitution therapies (OST) (e.g., methadone or suboxone): These are medications to treat opioid use disorder symptoms and cravings.  

Non-abstinence treatment programs: Abstinence is defined as the complete cessation or quitting of drug or alcohol use.  Non-abstinence programs are a harm reduction approach, and can include the use of opioid substitution therapies. 

People with lived experience: People who have experience, either personally or through a friend or family member, with substance use problems and with accessing or trying to access the treatment system. The meaningful participation of people with lived experience in planning and being involved in decisions that impact the services to which they have access, is important. 

Peer (leader):   A peer is a person who is of equal standing with another and who belongs to a specific group, and shares distinct characteristics with this group.  Peers can provide valuable guidance and connection in a community. A peer leader can use their personal experiences to be a leader to others in their community. 

Good Samaritan Law: The Good Samaritan Drug Overdose Act applies to anyone who seeks emergency support during an overdose, including the person experiencing an overdose. The act also protects anyone else who is at the scene when emergency services arrive. 

Increasing rates of opioid overdose across Canada have prompted action at all levels of government.  In addition to the broad increases in opioid-related emergency department (ED) visits, hospitalizations, and deaths noted at the provincial level (Ontario Agency for Health Protection and Promotion (Public Health Ontario), 2017), a recent report identified Windsor-Essex having an increased burden of opioid-related harms  (Windsor-Essex County Health Unit, 2017) relative to other regions in Ontario.  With increased funding for local public health units to address this issue, an opportunity exists to address opioid overdose in Windsor-Essex with strategies driven by community need and a community focused approach to overdose prevention and harm reduction. 

The Windsor-Essex Community Opioid Strategy (WECOS) seeks to address the increases in opioid related harms through a set of best practice strategies tailored through community feedback to address the unique needs of Windsor-Essex residents.  Recognizing that no single agency or single activity or action can adequately address an issue as complex as substance abuse, a four pillar approach utilizing Prevention/Education, Harm Reduction, Treatment, and Enforcement has been implemented in similar sized Ontario municipalities and as such will serve as the model on which the WECOS is based.   

An initial set of eight interventions plus one foundational step were developed utilizing national and provincial best practices such as those implemented by the City of Toronto (Toronto Public Health, 2017) and the Region of Waterloo (Waterloo Region Crime Prevention Council, 2011), as well as a local environmental scan to determine areas of need specific to Windsor-Essex.  These interventions were further refined through community consultations.  

Windsor-Essex County is the southernmost county in Canada and consists of one metropolitan area (The City of Windsor) and the seven municipalities of Amherstburg, Essex, Kingsville, Tecumseh, Lakeshore, LaSalle, and Leamington.  The majority of the population is located in the City of Windsor. Local data related to overdose-related ED visits, hospitalizations and death pinpoint the downtown core of Windsor with  the highest rates of opioid overdose.  In addition to the downtown of Windsor, the Leamington downtown is also identified with high rates of opioid related harms. Given that the impact of opioid related harms is concentrated in these two downtown areas they present  the greatest opportunity to reduce the overall opioid overdose burden in Windsor-Essex. 

The rate of opioid users in Windsor-Essex is the 7th highest in the province.  In addition, a recent report (Health Quality Ontario, 2017) describes the Erie-St. Clair LHIN region (in which Windsor-Essex County resides) as having the highest rate of opioid prescriptions in the province.  Opioid-related emergency department visits have increased by 3.6 times since 2003. Opioid related deaths in the City of Windsor are significantly greater than the rest of the county, with 19 out of 24 deaths county-wide occurring in the City in 2015.  Based on the morbidity and mortality data in this region, the burden of illness for opioid misuse is disproportionately greater among the working-age (20-64 years-old) population (primarily males) in the City of Windsor (Windsor-Essex County Health Unit, 2017). 

A foundational process necessary to ensure implementation across multiple sectors and address all four pillars of the WECOS, was to mobilize a small group of community leaders representing community organizations from each pillar of Prevention/Education, Harm Reduction, Treatment, and Enforcement.  This leadership is tasked with ensuring the feasibility of suggested interventions as well as assisting in the implementation of effective, local and sustainable solutions for opioid use and overdose prevention.  Effort was made to include people with lived experience to ensure they have direct input into the high-level planning of the strategy. 

The Windsor-Essex Community Opioid Strategy Leadership Committee (WECOS-LC) is a collaboration of stakeholders from public health, emergency services, law enforcement agencies (federal drug prosecution, Windsor, LaSalle and Amherstburg Police Services, OPP), the Local Health Integration Network, the City of Windsor, County of Essex, Windsor-Essex hospitals, addiction and mental health service providers/harm reduction agencies, education sector, pharmacy(s), and the community through peer representation.   

The WECOS-LC has committed to the ongoing development and implementation of a community based opioid strategy that will reduce the burden of opioid related social and health issues in our community.  Members of WECOS-LC are interested in mobilizing individual and shared efforts to encourage collective impact on the health and social issues of problematic opioid use (Canadian Centre on Substance Use and Addiction, 2017). 

Strategy development process at a glance… 

The first phase of action for the WECOS-LC was to conduct a scan of other community drug strategies (CDS), including both poly-substance and opioid-specific strategies.  Common approaches that were considered and incorporated into the WECOS include: 

• Four pillar approach: 1) Prevention, (2) Treatment, (3) Enforcement, and (4) Harm reduction.
• Coordinated and comprehensive response: A response that balances public health with public safety.
• Leadership structure: To provide sustainability, coordination, evaluation, and oversight of projects.
• Front line workers and those with lived experience: By including these groups in the development process we will learn about and from groups which are at high risk of addiction and overdose.
• Collective impact framework: Collective impact theory is based on the idea that complex social issues are best addressed when different sectors of a community work together.
• Communication: Consistent communication is needed with the broader community about opioid use and overdose prevention, and among working groups.
• Evidence-based activities: Many ideas may come from activities that are part of developing a strategy (e.g., community consultations), but they must be backed by an evidence base to be part of the final strategy.
• Support of the municipality: Municipal or regional council endorsement of a CDS can be helpful to moving activities forward and championing the strategy at several levels.

An asset and gap analysis of existing services in our community was conducted to identify specific needs of Windsor and Essex County (WEC).  The Windsor-Essex Community Substance Use Programs and Services Survey (Appendix A) was developed and administered to gain a better understanding about demands, gaps, and barriers to accessing these services, as well as to gather information on how the current system could be improved.   

A four pillar approach was utilized to collect and organize responses related to the types of programs offered, whether organizations felt they were able to meet the overall needs of their clients, and challenges or barriers faced by organizations as they related to the opioid use and overdose prevention.  It should be noted that the responses were organized in the pillar in which they were provided by the respondent organization, in this sense some comments may apply to more than one pillar. 

The survey was disseminated to 53 organizations with a reasonable response rate of 51% (27 organizations) with representation from across each of the four pillars.  Organizations which responded to the survey were also asked if they would be interested in collaborating to support the work of developing and implementing a community opioid strategy.  The majority (91%) indicated that this was something they would support.  

Responding organizations were asked to identify priority strategies to better address the issues that relate to substance use in Windsor-Essex County.  A list of options was provided or respondents could express additional ideas.  The top areas identified to be included in a community opioid strategy and ranked in order of importance can be found below:  

1. Increasing access to treatment services.
2. Increasing public awareness of opioid misuse, diversion, and overdose prevention.
3. Increasing access to Naloxone/overdose prevention, education, and training.
4. Increasing provider and patient education on managing pain and the risks associated with opioids.

In addition to these priorities responding organizations provided an overview of programs and services, as well as challenges/barriers, and opportunities to address gaps in the opioid/overdose prevention system.  A summary of the findings are as follows: 

Prevention and Education  
Twenty-one of the 27 organizations that responded indicated that they undertook some type of prevention and education activities or services.  The most frequent type of program or services offered under this pillar was educational programming (e.g., presentations to schools and community groups) (70%) as well as community events.  More than half of the organizations said that funding and resources, such as staffing (52 %) were key challenges they faced in implementing these types of programs.  Organizations reported that there are several gaps or needs in Windsor-Essex for prevention and education resources or programming, including lack of early intervention programs, and lack of public awareness of the issues surrounding substance use. 

Harm Reduction 
Nineteen organizations indicated that they offered programs or services under this pillar.  Education about harm reduction approaches was identified as a key programming activity under the harm reduction pillar (47%), as well as programs for methadone and naloxone.  Lack of access to harm reduction services (35%, n=6), supplies (e.g., clean needles), and wait times for services (e.g., for residential treatment programs that accept clients on methadone, or other opioid substitution therapies) were some of the main challenges identified with implementing harm reduction programs and services.  

Responding organizations also reported that there are several gaps or needs in Windsor-Essex for harm reduction resources or programming.  Two of the main gaps related to the need for improved access to these types of services (58%) and increased awareness of what harm reduction is and the need to reduce the stigma related to this treatment approach (58%).  Another key area of concern was access to harm reduction supplies, especially for those living in the county. 

Treatment and Recovery  
Seventeen organizations reported offering treatment and recovery services and programs.  These types of programs or services offered locally aligned with three general categories - counselling services (65%, n=11), life skills education (29%, n=5), and referrals to other community resources (e.g., dental care or primary health care providers, 12 step meetings, or housing supports).  Responding organizations reported that there were several significant challenges with implementing these types of services, including an overall lack of treatment and recovery options (69%, n=10), low staffing and capacity due to funding (62%, n=8). 

Service gaps identified in Windsor-Essex for treatment and recovery resources included:  lack of non-abstinence based programs (46%), the length of wait times to access services, and insufficient support for clients and their families (e.g., lack of outpatient services). 

Enforcement and Justice  
Nine organizations indicated they provide some form of programming, support, or enforcement activities.  Programs and services under this pillar include education programs and outreach (44%), system navigation and referral to other services, such as court-ordered treatment programs (56%), and criminal investigations.  One of the main challenges for these organizations outlined, is simply the need to increase awareness of substance use services and programs in this region (50%).  Responding organizations reported that they lacked knowledge about what services are available, especially which services are offered outside of the City of Windsor. 

Input from local service providers gathered from the Windsor-Essex Community Substance Use Programs and Services Survey and best practices from other community drug strategies were incorporated to develop the Proposed Action Plan: Windsor-Essex Community Opioid Strategy.  The proposed action plan consisted of a set of strategies under each of the four pillars and was anchored by one core strategy related to public health surveillance and monitoring.  These strategies were proposed to complement existing services and fill gaps in programming across all four pillars.  

The Proposed Action Plan: Windsor-Essex Community Opioid Strategy (see Appendix B) included the following:  

1. Enhance monitoring activities and use of overdose data across sectors.
2. Increase public awareness about opioid misuse, diversion, and overdose prevention through public awareness campaigns.
3. Increase provider and patient education on opioid use and managing chronic pain.
4. Improve overdose prevention education, training, and services.
5. Increase access to naloxone through changes in practice and policy.
6. Develop a local evidence-based harm reduction framework, including increased access to harm reduction services and supplies.
7. Increase treatment options and ensure people can access appropriate services when they need them.
8. Collaborate across law enforcement agencies to develop a consistent approach to address overdose scenes and diversion activities.

In order to capture the diverse perspectives of those most directly impacted, community consultation(s) were used to further refine the proposed action plan.  Locations for community consultations were based on the areas in Windsor-Essex identified with the highest opioid use.  As such, one consultation was held in downtown Windsor (YMCA) and one in Leamington (Kinsmen Recreation Centre). The proposed action plan (see Appendix B) was presented and feedback was collected to be incorporated into the final plan for Windsor-Essex.  

A media event was hosted by the WECOS-LC at the Windsor-Essex County Health Unit to mark the release of the consultation document and the upcoming community consultation strategy.  At the event the co-chairs of the WECOS-LC and other community leaders highlighted the need for a collective community response to the opioid issue in Windsor-Essex and welcomed the community to provide their input on the proposed action that was outlined in the consultation document. 

Community Forum Events  

Both community conversations were held in the evening in late October 2017.  The WECOS-LC members, along with senior municipal officials supported these events and were an opportunity for members of the community, including families and individuals with lived experience, to learn more about the proposed strategy and provide input into potential actions and needs for Windsor-Essex. 

Both evening events included an overview of the local opioid picture, a summary of the proposed strategy, and a presentation from the keynote speaker, Michael Parkinson, Community Engagement Coordinator, Waterloo Region Crime Prevention Council. 

Following presentations, attendees participated in facilitated table discussions with members of the WECOS-LC.  Attendees had the opportunity to provide input on any or all of the four pillars by responding to two questions:

• Based on what you heard today, what stands out for you the most as it relates to the [PILLAR NAME] pillar? 
• Are there any points that you thought were missing from the strategy, under the [PILLAR NAME] pillar?

Community Feedback Survey  

The Windsor-Essex Community Opioid Strategy Feedback Survey (see Appendix C) was also disseminated for those who were not able to attend the forums or who did not feel comfortable providing feedback related to lived experience in a public setting.  The survey was primarily disseminated online through WECOS-LC partners’ social media accounts, but paper copies of the survey were also available at key organizations which serve people who use drugs throughout Windsor and Essex County.  A mixed methods approach was embedded in the survey design.  Respondents were asked to indicate the perceived benefit of specific strategies under each pillar and offered the opportunity to provide general feedback in the form of open-ended questions.  

The consultation process generated 89 completed surveys, and approximately 150 attendees offering feedback at the community forum events.  The results from the community consultation process are summarized below.  A synthesis of the three sources of data by pillar can be found in Appendix D (i.e., Community Forum Feedback, Survey Quantitative Results, and Survey Qualitative Results). 

Key recommendations under each pillar are identified below, as well as recommendations related to leadership and implementation moving forward. One recommendation that emerged that was relevant across all four pillars was the importance of meaningful involvement of people with lived experience. This theme seems to align with the recommendations initially proposed in the action plan and as a result, the following recommendation should be considered across all pillars. 

1)    Support peer engagement and meaningful involvement of people with lived experience as a critical feature for building local capacity.

• Short-term action: Identify and establish peer leaders and ensure meaningful involvement in development and implementation of the Windsor-Essex County Opioid Strategy.

PILLAR ONE: PREVENTION AND EDUCATION 

Prevention and Education refers to interventions that seek to prevent or delay substance use, and which address root causes of addiction (Waterloo Region Crime Prevention Council, 2011).  These interventions may include approaches such as:  promoting healthy families, mentoring programs, school and community education, to enhance the knowledge and skills of the community related to substance use.

WHAT WAS PROPOSED TO THE COMMUNITY:

STRATEGY ONE: Enhance surveillance activities and use of overdose data across sectors.  Collecting and analyzing health-related data is essential in planning, implementing, and evaluating public health programs and interventions.  Until recently there has been a lack of accurate data about how many people have overdosed due to opioids in Ontario, and difficulty in the tracking the number of deaths caused by opioid use.  The lack of this type of data at the local level has impacted the ability for a timely and comprehensive response.  

STRATEGY TWO: Increase public awareness about opioid misuse, diversion, and overdose prevention through public awareness campaigns.  Among the best approaches to addressing opioid use is to intervene before it occurs (Hahn, 2011).  Education and prevention activities should be implemented to increase awareness of opioid use, associated dangers, and the importance of proper use, storage, and disposal of prescription opioids, as well as the risks associated with possibly contaminated illicit opioids (e.g., bootleg fentanyl). 

STRATEGY THREE: Increase provider and patient education on opioid use and managing chronic pain. A multipronged approach to address problems related to opioid use and overdose through education and prevention must also include educating patients and health care providers about opioid use and chronic pain management.  Increased education for health care providers about safe prescribing practices has been identified as a key strategy in Ontario’s Strategy to Prevent Opioid Addiction and Overdose (Ministry of Health and Long-Term Care, 2017).  

WHAT WE HEARD FROM THE COMMUNITY: 

In reviewing the data collected through our community consultation, there was agreement across all sources that there needs to be more education on pain management and appropriate prescribing practices for doctors and others who prescribe opioids.  Over 80% of survey respondents saw this as a large or very large benefit, and over 15% of comments from the forum and open-ended survey questions supported this.  

“I am concerned about the frequency and reasons local doctors are prescribing opioids and narcotics.  My daughter was offered opioids after getting her wisdom teeth out”  
–Survey respondent

“Doctor’s giving huge prescriptions (70 pills) should give 7-day dose and see them again” 
-Community forum participant 

The importance of targeting high risk populations, children/youth, parents, and other caregivers with a clear education campaign was also highlighted.  Over 90% of survey respondents saw a moderate or greater benefit in a campaign which provides clear information about opioid use and how to help opioid users, along with 37% of survey respondents and several comments from the community forum.  

“School-based education for youth as well as teachers and parents is strongly needed.  People need to know what to do when a friend or parent thinks a loved one is taking opioids and how to help them.  People need to know where to get information” 
-Survey respondent

“There is a general lack of knowledge across all demographics.  If we could have better educational materials for a wide variety of people, it will increase general community awareness” 
-Community forum participant

There was also evidence of support for a real-time overdose surveillance system and additional information for patients receiving opioid prescription, including associated risks and access to harm reduction options.  

SUMMARY AND RECOMMENDATIONS 

There was clear support across all respondents for: 1) supporting improvement of healthcare professionals’ practices and knowledge of opioids and other options for pain management; 2) more education on opioid use and how to help opioid users; 3) implementing an overdose monitoring system; and 4) ensuring patients get clear information about opioids, the risks associated with opioids.  These themes seem to align with the recommendations initially proposed in the action plan and as a result, the following recommendations should be considered under the Prevention & Education pillar: 

1. Support healthcare providers to play a key role, through appropriate prescribing practices, patient education about opioidsand overdose prevention, and other pain management options.
   • Short-term action: Develop or adapt existing education resources and partner with local healthcare professionals (e.g., primary healthcare providers and pharmacists) to support dissemination of these resources with patients and clients.
2. Provide early education and prevention about opioids and other substance use.
   • Short-term action: Collaborate across all four pillars to develop and disseminate education and prevention about opioids and other substance use.
   • Short-term action: Promote substance use education and prevention programming that incorporates multiple perspectives, including those of peers, police services, health care workers, etc.
   • Short-term action: Develop and evaluate a public awareness campaign on opioids, including the root causes to inform the community’s understanding of addiction.
   • Short-term action: Work with schools, families and youth to support drug and addiction literacy in young people.
   • Short-term action: Develop a “shared agenda” between service agencies for prevention and education to maximize resources and minimize duplication. This includes identifying roles and awareness within community providers.
   • Short-term action: Work with post-secondary institutions, both colleges and university, to support drug and addiction
     literacy in young people.
   • Short-term action: Develop a primer document about opioids, other substance use and harm reduction approaches, for journalists and collaborate with local media.
3. Develop a local overdose monitoring and response system.
   • Short-term action: Establish data sharing agreements between public health, emergency health services, and other community stakeholders to support the development of a local on-line monitoring and response system dashboard.
   • Short-term action: Develop a communication and emergency response system between public health, emergency health services, and other community stakeholders to be able to use local data to plan and respond promptly.
   • Short-term action: Analyze and use local data to identify priority populations for rapid intervention and response.
   • Long-term action: Investigate real-time mapping tools that can be used by first responders, to enhance the quality of the surveillance data that is used to develop response plans and early warning systems.

PILLAR TWO: HARM REDUCTION 

Harm Reduction refers to interventions that seek to reduce the harms associated with substance use (Waterloo Region Crime Prevention Council, 2011).  These interventions aim to reduce the spread of communicable diseases, prevent overdose deaths, increase contact with healthcare providers, and reduce consumption of illicit substances in unsafe settings. 

WHAT WAS PROPOSED TO THE COMMUNITY: 

STRATEGY FOUR: Increase access to naloxone through changes in practice and policy. 

Naloxone, or Narcan®, is an antidote to opioid overdose.  It reverses the effects of opioids by displacing opioids from their receptors, temporarily preventing the opioids from having an effect (Webber, 2016).  Naloxone distribution programs have recently been extended to a variety of clinical settings, first responders, and other agencies in some communities (Orkin, 2015). 

STRATEGY FIVE: Improve overdose prevention education, training, and services. 

Best practice guidelines for harm reduction approaches include training people who use opioids (and their friends and families) on how to avoid overdosing and how to act if they see another person overdosing.  Education involves knowing the signs of an overdose, when to call 911, and how to administer naloxone.  Existing evidence shows that overdose education and the distribution of naloxone improves people’s willingness to intervene in an overdose, reduces mortality and is cost-effective (Strike, et al., 2013). 

STRATEGY SIX: Develop a local evidence-based harm reduction framework, including increased access to harm reduction services and supplies. 

The pillar of harm reduction has been restored to the Canadian Drugs and Substances Strategy (Health Canada, 2016), which allows problematic drug use to be primarily recognized as a health issue rather than criminal matter.  Yet, there remains work to be done to inform the public and society as whole of the key issues and benefits related to harm reduction approaches and to increase access to harm reduction options and supplies.  

WHAT WE HEARD FROM THE COMMUNITY: 
In reviewing the data collected through our community consultation there was agreement across sources that there needs to be greater access to harm reduction options for people who use opioids and those most affected by the use of opioids by others.  In the survey, 81% of respondents indicated that “take-home naloxone” program sites in acute care, community health centres, and treatment facilities would be a large or very large benefit toward improving harm reduction.  Increased access to naloxone for medical/non-medical staff and for first responders was also seen as a large to very large benefit (77.4%).  The need and benefit of naloxone was also reflected in the comments (31%) from the community forum indicated under this pillar.  

A second area highlighted was the need for needle syringe programs to ensure safe opioid use and safe disposal of needles.  Over three-quarters (76.8%) of survey respondents saw large or very large benefit in investigating the expansion of the Needle Syringe Program.  Furthermore, 22% of community forum comments mentioned a need for more needle boxes, better communication on accessing and using needle boxes, implementing safe injection sites, and increased access harm reduction supplies. 

“Make a place for supervised use of drugs like opioids and meth then doctors can treat overdoses before it is too late”  
– Survey respondent

“Windsor and Essex County needs to increase awareness of where people can dispose of used drugs and used needles”  
– Survey respondent

“Since a needle box was put at Street Health, I see way more needles around.  The problem might be there was no education about the boxes”  
– Community forum participant

“I think that needle boxes would help a lot to clean up the city” 
– Community forum participant

“People need street outreach at night and on weekends to get access to naloxone, get tested for HIV/AIDS, and get abscess care
– Survey respondent

Addressing the stigma associated with opioid use through education and the cultivation of more respectful attitudes toward opioid users was also identified.  Over 71% of survey respondents saw a large to very large benefit in this approach.  Furthermore, survey comments called for more respectful language which will encourage treatment, and this was further reflected in the community forum feedback. 

“Reduction in shame felt by addicts will encourage them to seek help and follow through with treatment.”  
–Survey respondent

“Overall feel there is a stigma.  When you seek help or go to the hospital they treat you differently if you are an addict”  
-Community forum participant

“[Lack of] housing, trauma, mental illness, dependency, sex trade workers (are all barriers to harm reduction)”
– Community forum participant 

SUMMARY AND RECOMMENDATIONS 

There was clear support across the community consultation feedback for: 1) enhanced access to harm reduction options (including, but not limited to naloxone); 2) growth of needle syringe programs to ensure safe opioid use and disposal of needles; and 3) reducing the stigma associated with opioid use by educating service providers (e.g., healthcare professionals) and the community in general, on respectful communication and attitudes toward those who use opioids and other substances.  These themes align with, and build upon the recommendations initially proposed in the action plan and as a result, the following recommendations should be considered under the Harm Reduction pillar: 

1. Increase access to a variety of harm reduction options, such as non- abstinence based programs that accept clients using opioid substitution therapies, safer drug use equipment, and mobile outreach activities, for people who use opioids and those affected by people who use opioids.
   • Short-term action: Expand the Needle Syringe Program to other areas in Windsor and Essex County.
   • Short-term action: Reduce the divide in the system between abstinence versus non-abstinence based services (e.g., expanding the Needle Syringe Program to include referrals to treatment, not just offering harm reduction supplies).
   • Short-term action: Develop better signage and education for existing needle drop boxes and investigate the need and possible locations for additional needle drop boxes.
   • Long-term action: Continued investigation by Windsor-Essex County Health Unit into the feasibility of Safe Injection Sites in Windsor and Essex County.
2. Address stigma associated with problematic substance use through the development of supportive polices and education of healthcare professionals, community organizations and the public.
   • Short-term action: Promote respectful language and dialogue on substance use and harm reduction approaches in our community.
   • Short-term action: Host educational workshops/events for healthcare professionals and other service providers to increase awareness on substance use disorders, as a health condition, and harm reduction approaches.
   • Short-term action: Continue to expand the distribution of naloxone and promote points of access.
   • Short-term action: Encourage and provide support to organizations looking to develop organizational policies to support harm reduction approaches (e.g., support to develop policies around naloxone use).
   • Long-term action: Advocate for more affordable housing, as a social determinant of health that can impact opioid use and risk of overdose.

PILLAR THREE: TREATMENT AND RECOVERY 

Treatment and Recovery refers to interventions that seek to improve the physical and emotional well-being of people who use or have used substances (Waterloo Region Crime Prevention Council, 2011).  These interventions may include, counselling, residential programs, and community-based withdrawal programs.

WHAT WAS PROPOSED TO THE COMMUNITY: 

STRATEGY SEVEN: Increase treatment options and ensure people can access appropriate services when they need them.

Opioid substitution treatments (OST) are prescribed long-acting opioid medications that have been shown to be the most effective treatment available for opioid dependency.  Access to OST (e.g., methadone and buprenorphine) should be made widely available, as it can reduce the risk of overdose deaths, the transmission of HIV, and Hepatitis B.  Treatment for opioid use disorder should be provided in the community and where primary care is also available (Centre for Addiction and Mental Health, 2016).  A medical model for opioid treatment must also be combined with a community based social services model to be effective in meeting the needs of those experiencing opioid dependence issues (e.g., support with finding housing and other social services). 

WHAT WAS PROPOSED TO THE COMMUNITY: 

Feedback from our community consultation showed there was agreement across all sources that greater integration of mental health services with addiction services is needed.  In the survey, 83% of respondents indicated that improving the integration of substance abuse treatment services with primary care and mental health services would provide a large or very large benefit to meeting the goals of treatment and recovery.  

“The vast majority of people that I work with that have addictions issues also have trauma in their life that has never been addressed….” 
–Survey respondent

There was consensus across all sources that more readily available or effective treatment options, especially for those who do not have the insurance or financial resources, are needed.  Over half of survey comments mentioned the need for more access to treatment resources for people who use opioids and their families.  Community forum participants mentioned a lack of expedient access to treatment for financial/insurance reasons, the absence of needed programs, or absence of qualified professionals.  In the quantitative survey results, there was moderate support for increasing funding to expand the capacity of the local treatment system to include non-abstinence based programs (e.g., residential treatment programs that allow clients to continue with opioid substitution therapies, like methadone or Suboxone).  

“There are “cash beds -if you have money you can get treatment quicker”
-Community forum participant

“Getting into treatment is impossible (3-6 months) unless you have money to pay. Impossible to get clean waiting to get into treatment….” 
– Community forum participant

“OHIP only covers 5 days of detox then you go home and wait for a call from rehab”  
– Community forum participant

“There needs to be more beds available for detox and residential treatment so that clients can access the treatment system in a timely fashion as the window of opportunity is often small and if someone has to wait even 24 hours they can change their mind and fall through the cracks”  
–Survey respondent

“Can we not have supports before residential treatment? What can be done pre-treatment to keep clients safe (given other stressors, neighborhood, co-morbidities)?” 
– Community forum participant

SUMMARY AND RECOMMENDATIONS 

There was clear support across the community consultation feedback that: 1) integration of mental health services with addiction services is needed due to the frequent co-occurrence of these conditions; 

2)    treatment resources need to be more readily available and equally accessible to all people who use opioids regardless of insurance coverage or financial ability; and 3) increased funding for non-abstinence based programs.  These themes align with, and build upon the recommendations initially proposed in the action plan and as a result, the following recommendations should be considered under the Treatment and Recovery pillar:

1. Work with provincial partners to advocate for increased funding to expand the capacity of the local substance use treatment system.
   • Short-term action: Collaborate to develop and promote well-defined pathways for persons and loved ones looking to access substance use services.
   • Short-term action: Collaborate to promote and better inform other professionals of the treatment and referral process to access substance use services in the community.
   • Short-term action: Work across community agencies to better coordinate services and ensure that there is no wait between detox and treatment and recovery services.
   • Long-term action: Work with provincial partners on improving the integration of substance use treatment services with primary and mental health services.
   • Long-term action: Work with provincial partners to provide more training for professionals about concurrent issues (both mental health and addictions) and increase staffing to levels that support safety and flexibility to meet client’s needs.
   • Long-term action: Advocate for a greater number and more equitable access to treatment and recovery programs and services, including a more balanced set of before and aftercare supports, specialized services for youth, day treatment options, and increased access to OST with supports to taper off these treatments.

PILLAR FOUR: ENFORCEMENT AND JUSTICE 

Enforcement and Justice refers to interventions that seek to strengthen community safety by responding to crime and community disorder caused by substance use (Waterloo Region Crime Prevention Council, 2011).  Given that police interact frequently with people who use drugs, these interventions aim to increase coordination between law enforcement and health services. 

WHAT WAS PROPOSED TO THE COMMUNITY

STRATEGY EIGHT: Collaborate across law enforcement and first responder agencies to develop a consistent approach to address overdose scenes and diversion activities. 

Law enforcement agencies and other first responders are key stakeholder groups that need to be engaged and informed when developing a community response to the opioid and overdose issues in a community.  There has been a shift in recent years in how law enforcement agencies are addressing opioid and other substance abuse in their communities.  Traditionally, law enforcement efforts have focused on using enforcement actions like arrests and jail to target drug use and distribution.  

WHAT WE HEARD FROM THE COMMUNITY: 

In reviewing the data collected through our community consultation, there was agreement across all sources that law enforcement needs to not only be visible and accessible in the community, but they also need to consistently interact with people who use opioids in a respectful way that de-escalates tensions and encourages harm-reduction treatment.  The majority of survey respondents saw a moderate or greater benefit (89%) in law enforcement establishing a consistent approach in how they respond to overdose scenes.  Open-ended responses on the survey added to this, with 29% of comments advocating that law enforcement and other emergency personnel receive training in effective communication strategies that promote safety and the likelihood of effective treatment.  Although community forum participants did not focus on effective communication, 26% of comments suggested that law enforcement be more visible and accessible in the community. 

“Law enforcement agents need better training on how to de-escalate situations with individuals who may be experiencing substance-related outbursts that other residents are fearful of.  Building a rapport and better communication is paramount.” 
– Survey respondent

Greater security at pharmacies and in other places where opioids are distributed was also highlighted.  In the survey, 77% of respondents thought that training pharmacists on how to respond to diversion activities and providing better security inspections at pharmacies would provide a large or very large benefit.  Community forum participants supported this perspective and recommended that law enforcement address the importance of enhancing safety in areas in which opioid use is disproportionately high. 

There was also evidence to support harm-reduction and rehabilitative options as preferable to incarceration, for people who use opioids and other substances.  The use of naloxone, education, and a drug treatment court that mandates treatment were suggested as options. 

SUMMARY AND RECOMMENDATIONS 

There was clear support across the community consultation feedback that: 1) law enforcement should build rapport with those that use opioids with the goal of reducing further harm and finding appropriate treatment; 2) places where opioids are distributed (e.g., pharmacies, neighborhoods with higher rates of crime) should be kept safe by increasing security in these respective environments; and 3) system changes that include less harsh penalties for people who are addicted to opioids and those who “traffic” opioids in favour of harm-reduction and rehabilitative options.  These themes align with, and build upon the recommendations initially proposed in the action plan and as a result, the following recommendations should be considered under the Enforcement and Justice pillar: 

1. Redefine the role for enforcement agencies and other first responders to build “public safety-public health” partnerships for a safer and healthier community.
   • Short-term action: Strengthen community safety through a formalized partnership and a coordinated approach between police, municipalities and municipal leaders, peer leaders and other community stakeholders, to address opioid-related crime and other substance use issues.
   • Short-term action: Develop a community safety plan to protect those that are not using drugs but that are still directly impacted, including improved communication channels between neighborhood groups (e.g., Downtown Windsor Community Collaborative) and law enforcement.
   • Short-term action: Raise the profile of enforcement agencies as a “community resource” by:
     • Promoting the “Good Samaritan” law to reduce barriers to accessing emergency services>
     • Increasing public awareness of the community outreach role of law enforcement using social media and face to face presentations.
     • Promoting the COAST program (City of Windsor) and Mental Health Response Units (county) as responders/crisis workers that can help those struggling with addiction.
   • Short-term action: Increase programs that divert people from the justice system to appropriate health supports, by further incorporating drug related cases into diversion programs.

It is clear that changes are required at all levels to tackle the complex issues contributing to the opioid crisis in Windsor and Essex County.  Individual agencies will need to work in effective partnerships to develop comprehensive solutions and community-level initiatives to reduce the harms associated with opioid use and enhance the quality and range of services and supports for substance use issues, in this region.  

In recent years, successful work has been done to address complex public health issues by forming community partnerships.  These projects have shown that there are guidelines and principles that can help begin and maintain effective partnerships, such as trust, good communication and commitment (Morrel-Samuels, 2016).  In order to build these relationships across sectors, among a variety of service providers, and between people with lived experience and families, proper preparation, time and supportive structures, such as funding and strong leadership are required for successful outcomes (Addiction and Mental Health Collaborative Project Steering Committee, 2015).  

To action the above-mentioned recommendations, four pillar-based working groups will be formed to support change and project implementation in Windsor and Essex County.  Working groups will consist of community stakeholders with complementary skills committed to a common purpose and set of activities.  In areas where there are good working relationships already in place, activities may progress more quickly, however the collective effort of all groups will be critical in reducing the harms related to opioid use in this region.  In all cases, people with lived experience (addicts, family/friends of addicts) should be represented at working group tables. 

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Canadian Centre on Substance Use and Addiction. (2017). What we heard: Refreshing the national framework for action to reduce the harms associated with alcohol and other drugs and substance in Canada. Ottawa, ON: Canadian Centre on Substance Use and Addiction. 

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This report was prepared by the Windsor-Essex County Health Unit, in partnership with the Windsor-Essex Community Opioid Strategy – Leadership Committee.

For further information please contact the Windsor-Essex County Health Unit at 519-258-2146 ext. 3100

2018 Windsor-Essex Community Opioid Strategy-Leadership Committee