Last summer, while visiting Toronto, Four Pillars News editor Jennifer Gray-Grant spoke with three people running harm reduction programs in that city. One was responsible for the distribution of 24,000 crack kits each month through Toronto Public Health, another offered a peer-based overdose-prevention project and another heads up the wet shelter at Seaton House, where residents are given maintenance amounts of alcohol throughout each day.

Safer crack use kits

Before the official Toronto Drug Strategy even existed, Toronto Public Health knew it had to get into the distribution of safer crack use kits. It was aware of the need because while a local Safer Crack Use Coalition had started distributing some kits, their efforts didn’t come close to meeting the need. “They had line-ups before 10 am,” Toronto Public Health’s Leah Boelhouwer said, adding fights sometimes broke out among those waiting.

Boelhouwer, who is responsible for Toronto Public Health’s kit distribution program explained that, for a variety of reasons, crack has become “the drug of choice” in Toronto. But she could only get approval to start distributing the kits once the Toronto Drug Strategy was passed by council in 2005; it included a recommendation calling for the distribution of safer crack kits.

Boelhouwer said Public Health started getting everything in place in 2005, as soon as Toronto adopted the strategy. Its partners were already providing needle exchange so they simply re-wrote their contracts to offer safer crack use kits as well. The biggest challenge was anticipating the demand. “Initially we really had no idea what the needs would be, the volume.”

Leah Boelhouwer

In May, 2006, when Toronto council passed the recommendation calling for Public Health to distribute safer crack kits, they were able to start the distribution immediately.

They started with 12,000 kits a month, but that doubled to 24,000 within a couple of years.

“It’s not without controversy,” Boelhouwer said, but the medical officer of health is fully supportive and “we had a totally supportive mayor and some councillors who are supportive and understand harm reduction.” Some councillors have spoken out against it and the Chief of Police has said he’s not as supportive either.

The kits, which contain glass stems, plastic tubing, screens and a push stick cost about $1 each and are assembled by peers. They don’t usually place limits on the number of kits people can collect; sometimes people explain they’re picking up kits for themselves and friends at a crack house so they let them take as many as they need, sometimes up to 30.

Boelhouwer said one of the benefits of handing out the kits is that they’re attracting huge numbers of people who would not typically access Public Health’s other healthcare services. “Our kits connect us with people we would never see,” she said, adding that since they started offering crack kits, the total volume of people accessing healthcare services through their offices has tripled.

For more information, listen to the Drug Policy Program’s Crack kits podcast, August 7, 2008.

Overdose prevention for peers

When she considered the services offered through Toronto Public Health, counsellor Ruth Yeoman thought she could offer something new: an overdose prevention program for peers. “It’s a natural progression because we’re working with opiate users.”

Yeoman is based at The Works, a downtown Toronto public health office that includes a needle exchange, safer crack kit distribution, free condoms, methadone, testing (for HIV, Hep C and B, and syphilis) and vaccinations.

In 2007, after hearing about a similar program in Britain, Yeoman put out the word that she wanted to start an overdose training group, to help reduce overdoses and the use of emergency staff.

Ruth Yeoman

Yeoman was able to hire five peers, and spend two days training them in emergency first aid and CPR. After the training, two peers quit but another stepped forward: he was a former emergency worker who already had first aid and CPR training.

Over the following six months, the peers trained more than 120 crack cocaine and opiate users in emergency first aid and CPR, to use on friends they thought were overdosing.

Soon after the training ended, Yeoman heard of at least two cases where peers who had taken the training saved another person’s life. “It was phenomenal.” Now, Yeoman would like to provide Narcan (a trade name for the drug naloxone, which is used to counter the effects of heroin or morphine overdose), so that users could be trained to administer Narcan on those who are overdosing.

Overdose prevention program podcast, September 18, 2008.

Wet shelter provides a safe alternative for street-entrenched alcoholics

When Art Manuel describes Seaton House’s wet shelter, he begins by saying what it’s not. “It’s not a wild-west show at the O.K. Corral, it’s not crazy violent,” the program supervisor says.

Then he describes what it is: “It’s very much like any other shelter; it’s a pretty normal-ish living arrangement for people who choose to drink.”

This kind of normal-ish arrangement doesn’t exist in Vancouver where street-entrenched alcoholics are simply part of the landscape in much of the city. That was the scene in Toronto too, until about 12 years ago, following an earlier inquest into three homeless men’s deaths. The establishment of a wet shelter was seen as a way to give street-entrenched, homeless alcoholic men a place to live and receive food, clothing, medical care and regular, managed alcohol.

Art Manuel

That key piece, allowing the men to drink in the shelter, has meant that the men stay in the shelter and off the street. That doesn’t happen in other shelters, where alcoholics will try to smuggle in bottles or will drink the contents of full bottles before they’re confiscated; often, they’ll choose to leave if they can’t drink. “The difference was we finally had something that was of value to them,” Manuel said. “We created sanctuary.”

At the wet shelter, which takes up a couple of floors in the large Seaton House shelter, men smoke cigarettes in the television room, perch on chairs in the hallways, sit at tables in the dining area and then wander into the drinking room on regular intervals throughout the day to receive their allotted amount of wine (a few drink beer or spirits).

The wet shelter has the capacity to house 130 people; 30 beds are set aside as an infirmary.

The men accepted into the wet shelter are, as Manuel says, “really in bad shape; they’re the ones nobody else wants.” They’ve typically been picked up two or three times a week, by police or ambulance, for years.

By keeping each man in the wet shelter, the savings in social services, emergency calls, police calls and detox are between $50,000-$250,000 per person per year.

Manuel has looked at the community service savings the wet shelter provides and they are substantial. He said that by keeping each man in the wet shelter, the savings in social services, emergency calls, police calls and detox are between $50,000-$250,000 per person per year. In another number crunching exercise, Manuel discovered that in the first seven years, among wet shelter inhabitants there was an 87-per-cent drop in emergency room visits, a 91-per-cent drop in incarcerations, and an 89-per-cent drop in ambulance calls. Manuel pointed to a current resident who used to be the subject of four official police investigations a week. In the five years he’s lived in the wet shelter, he’s not been the subject of any investigations. He says that while the wet shelter can still be controversial, the police “get it in a big way”.

When the men arrive at the wet shelter, they go through a full consultation leading to a personal, medical, nutritional and managed alcohol plan. The alcohol plan is constantly revised:“It’s no different than medication,” Manuel says. (The cost of the alcohol is covered through each man’s personal needs allowance though welfare.) Every drink is prescribed and the person doling out the alcohol makes careful note of the type and amount of every drink each client receives. On average, the men have eight drinks per day, with a fresh drink every 90 minutes.

The alcohol plan is constantly revised: “It’s no different than medication."

It’s a delicate balance because the men must still be able to function, to eat and be coherent. But if they don’t feel some effects from the alcohol, they could leave the shelter for the street, in search of more alcohol. Doctors working out of the shelter constantly monitor each client’s healthcare plan and alcohol capacity; the latter changes over time as the client’s health improves or declines.

Manuel notes that about one shelter resident dies each month. In the 12 years it has existed, only one resident has left the wet shelter for housing and he went into a very heavily supported residence. Manuel realizes he’s providing palliative care so he’d rather see more of a supported wet housing model, with fewer clients in each residence. He said he’d still keep at least one wet shelter, which can serve as a pathway to housing.

In Canada, there are also wet shelters in Ottawa and Hamilton.

Wet shelter podcast, September 4, 2008.