Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region

Transcription

1 Baseline Study of Substance Use, Excluding Alcohol, in Waterloo Region June 20, 2008

2 Project funded and managed by Region of Waterloo Public Health. Research activities and report development completed by the Centre for Community Based Research.

3 Executive Summary Illicit substance use is an important public health issue in Waterloo Region, but patterns of use are not well researched. There is a general understanding that drug use occurs in each community in the region; however, local information about the extent of illicit substance use and the implications of this use is vague and often anecdotal. The overall purposes of the Baseline Study of Drug Use, Excluding Alcohol, in Waterloo Region are to develop a detailed description of drug use in Waterloo Region, to determine if existing programs and services are meeting the needs of persons who use drugs, and to understand challenges faced by service providers who work with this population. This study conducted local analysis of existing data from hospitals, needle exchange programs, addiction treatment programs and provincial research projects. The research team also conducted face-to-face interviews with 32 persons who use drugs regularly and 33 local service providers. Overall, drug use and trafficking were reported to occur throughout Waterloo Region. Crack, cocaine, cannibis and prescription opioids appear to be the most prevalent illicit substances used. Heroin, ecstasy and other hallucinogenic drugs were also said to be widely used. The use of crystal methamphetamines is reportedly increasing. Drug use was not limited to one demographic group or sub-group; however, patterns of drug choice varied for individuals enrolled in senior elementary or high school. Hallucinogens, cocaine, and crystal methamphetamine use seemed to be more prevalent among this population. Patterns of drug use varied by geographic area. Participants described drug use in Cambridge and Kitchener as more open and visible (e.g. used in shelters, parks, downtown core, on the streets) than in Waterloo or the Townships where drug use (more frequently) occurred in private dwellings. Drug use and trafficking was carried out by Waterloo Region and non-waterloo Region residents. People who use non-injection drugs appear to be unaware of the health and safety risks associated with sharing their equipment (e.g. crack pipes, sterile water, cookers) and reported that sharing occurs at high rates. Many of the individuals interviewed for the study had significant health issues, including poor dental health, inadequate nutrition, and having a communicable disease (e.g. hepatitis C and human immunodeficiency virus [HIV]). Despite the fact that participants were aware of available services, many chose not to access care because of lack of access to health providers trained to meet the needs of people who use drugs, fear of discrimination and/or the potential for criminal repercussions. Over half of the participants reported that their social network would be unlikely to seek medical help on their behalf in the event of an overdose. People who use drugs have diverse and complex social needs, including appropriate housing, job readiness training, and job related skill development. Isolation and insufficient social supports are also major challenges for many people who use drugs. Those who desire support in overcoming their addictions in Waterloo Region often face barriers including limited hours of service availability, pre-requisites of pre-treatment sobriety and assessment tests, and the presence of potential triggers in areas that surround services. For those who live in rural areas, a Final Report - June 20, 2008 i

4 lack of transportation to city-based services is an additional challenge. Extensive waitlists for services were an additional barrier to accessing services; over 80% of individuals seeking residential treatment programs went outside of Waterloo Region to receive care. Participants reported that there are an array of harm reduction services for those involved in injection drug use in Waterloo Region, but similar supports for those who use non-injection drugs may not be as readily available. Satisfaction with social supports and services seems to be high; those who access support through social services described mainly positive experiences with their service providers. Waterloo Regional Police Service representatives highlighted the differing mandates between the police and service providers, and how this sometimes hindered the growth of collaborative relationships between these groups. Representatives from the police also expressed a desire to assist persons that use drugs in terms of seeking treatment. Interviewees previously approached by outreach workers reported the contact as helpful; however, interviewees who had no previous experiences with outreach workers were reluctant to consider this type of contact. Outreach by all participants was considered to be more effective if it were guided by a community-wide unified approach, and if workers provided information about services, how to overcome barriers to seeking services and treatment, and offered immediate healthcare services and supplies. The ideal characteristics of an outreach worker were: people with prior drug use experience, supportive, compassionate and non-judgmental. Gender balance is also considered essential. The methods and principles used in the Waterloo Region Baseline Study of Drug Use are based on the World Health Organization s Rapid Assessment Response guide. This approach builds on accepted social science research methods, but has the advantage of assisting jurisdictions to rapidly and economically compile data from multiple sources to quickly respond to health problems or emergencies. While the approach is an effective way to assess current realities and develop targeted interventions based on the key findings; however, it is not a substitute for longterm or in-depth studies. In addition, the service providers and individuals using drugs who participated in this study were volunteers, and although the research team took care to seek out a diverse set of participants, it may be that their experiences do not fully reflect the range of experience or opinion in the region. This is acceptable in the Rapid Assessment Response framework which recognizes that studies using this approach rely on convenient or diverse samples that may not be fully representative of the study population. Final Report - June 20, 2008 ii

5 Acknowledgements Many parties collaborated in the initiation and carry-through of this research project and the creation of this report. Special acknowledgement is made to the Waterloo Region Harm Reduction Network for its contributions throughout the process. This research project was funded and managed by Region of Waterloo Public Health. Members of the research team included: Karen Quigley-Hobbs, Karen Verhoeve, Daniela Seskar-Hencic, Judy Maan Miedema, Marg McGee and Chris Harold. Special thanks to Chris Harold for his significant contributions to the background research, methodology development and creation of the final report. The research activities and report were guided by an advisory group of stakeholders within Waterloo Region. Members who served as a committee member at some point in the process include: Pat Allan, Centre for Addiction and Mental Health Brice Balmer, Waterloo Region Harm Reduction Network Steve Beckett, Waterloo Regional Police Service Sandy Bell, Reaching Our Outdoor Friends (ROOF) Marion Best, The Bridges, Cambridge Shelter Corporation Susan Collison, Grand River Withdrawal Management Centre Rosemary Mackenzie, Ministry of Community Safety and Correctional Services Cathy Middleton, Waterloo Region Harm Reduction Network Coba Moolenburgh, St. Mary s Counselling Service Frances Moriarty, Community Link Empowered Against Narcotics Rob Smith, Waterloo Region Harm Reduction Network Leesa Stephenson, Aids Committee of Cambridge, Kitchener, Waterloo and Area Brent Thomlison, Waterloo Regional Police Service Karen Verhoeve, Region of Waterloo Public Health Special acknowledgment is also made to Dr. Margaret (Peggy) Millson, Associate Professor, University of Toronto, for her contributions to the study s research methodology and data analysis. The research activities, including the creation of this report was prepared by Centre for Community Based Research. Team members were Andrew Taylor, Suzanne Field, Gabriela Novotna, Brian Barlett, Don Johnson, and Leesa Stephenson. The information learned through this report was made possible by those who participated in the interviews, focus groups, and surveys. The research team wishes to offer a sincere thank you to everyone who shared their stories, experiences, and opinions in this way. For more information, please contact: Andrew Taylor Centre for Community Based Research 73 King St. W., Kitchener, Ontario N2G 1A7 Andrew@communitybasedresearch.ca Final Report - June 20, 2008 iii

6 Abbreviations Abbreviation AIDS CAMH DART DATIS HIV ID LSD PCP OERWR OHRDP OSAB OSDUHS PWUD RAR THC WHO Name Acquired immunodeficiency syndrome Centre for Addiction and Mental Health Drug and Alcohol Registry of Treatment Drug and Alcohol Treatment Information System Human immunodeficiency virus Injection drug Lysergic acid diethylamide Phencyclidine Outcome Evaluation Report Waterloo Region Ontario Harm Reduction Distribution Program Ontario Substance Abuse Bureau Ontario Student Drug Use and Health Survey Participant or person who uses drugs Rapid Assessment Response Tetrahydrocannabinol World Health Organization Final Report - June 20, 2008 iv

7 Contents EXECUTIVE SUMMARY...I ACKNOWLEDGEMENTS...III ABBREVIATIONS... IV SECTION 1: INTRODUCTION... 3 FRAMEWORK... 3 ETHICS... 4 RESEARCH METHODS... 5 Research Team... 5 Data Gathering... 5 Interviews, focus group, and questionnaires: Participants who Use Drugs... 5 Focus Groups: Service/Healthcare Providers and Police Officers... 7 Online survey for service providers... 8 Analysis of secondary data... 8 REFER TO APPENDIX N FOR A GLOSSARY OF TERMS. STUDY LIMITATIONS AND FUTURE RESEARCH CONSIDERATIONS... 9 STUDY LIMITATIONS AND FUTURE RESEARCH CONSIDERATIONS Study Limitations Future Research Considerations SECTION TWO: DESCRIPTION OF DRUG USE IN WATERLOO REGION TYPES OF DRUGS USED IN WATERLOO REGION: GENERAL POPULATION TYPES OF DRUGS USED IN WATERLOO REGION: HIGH SCHOOL STUDENTS CHARACTERISTICS OF PEOPLE WHO USE DRUGS ACCESSING SUBSTANCES IN WATERLOO REGION Prescription pills Poly drug use Geographical regions DRUG-RELATED TRAVEL TO THE REGION BY NON-REGION RESIDENTS PERCEPTIONS OF SAFETY: PURCHASING DRUGS PERCEPTIONS OF SAFETY: USING DRUGS Sharing drug instruments SAFETY CONCERNS RAISED BY SERVICE/HEALTHCARE PROVIDERS SUMMARY SECTION THREE: HEALTH NEEDS AND COMMUNITY RESPONSE HEALTH ISSUES FACING PEOPLE WHO USE DRUGS Hepatitis C and Human Immunodeficiency Virus (HIV) Source: Ministry of Health and Long-Term Care and Region of Waterloo Public Health Mental health Dental health Nutritional intake RESPONSE TO HEALTH PROBLEMS Overdoses Many persons who use drugs regularly find health care services accessible and respectful Broader systemic issues sometimes act as obstacles to access for health care Some individuals report experiences of discrimination when dealing with the health care system Some health care providers are naming the need to improve their service to this population SUMMARY SECTION FOUR: A HOLISTIC APPROACH TO SUPPORT FOR INDIVIDUALS WHO USE DRUGS; SYSTEMIC ISSUES, SOCIAL NEEDS AND THE COMMUNITY RESPONSE Final Report - June 20, 2008

8 SOCIAL DILEMMAS FACING PERSONS WHO USE DRUGS REGULARLY Balancing a need for appropriate housing with a need to work towards treatment goals Overcoming shame in order to deal with isolation Managing a job or job-readiness training while dealing with the effects of drug dependence The importance of hope KNOWLEDGE OF HARM REDUCTION SERVICES AND PRACTICES DRUG USE AS A SOCIAL ISSUE: PRINCIPLES TO GUIDE AN APPROPRIATE RESPONSE The importance of a comfortable, non-judgmental atmosphere The importance of a timely response The importance of making supports available in more than one geographic location The importance of after-hours supports The importance of a coordinated response capable of meeting individuals wherever they are at. 41 Importance of close collaboration between police services and social and healthcare organizations42 The importance of equipping service organizations with resources to effectively support persons who use drugs SUMMARY SECTION FIVE: OUTREACH - LINKING PEOPLE WITH SERVICES EXPERIENCES WITH REFERRALS AND OUTREACH WORKERS SUGGESTED APPROACH TO OUTREACH Hard-to-Reach Populations Geographic Areas where outreach occurs...47 QUALITIES OF AN IDEAL OUTREACH WORKER SUMMARY CONCLUSION REFERENCES APPENDIX A - INVITATION TO PARTICIPATE IN AN INTERVIEW: PWUD APPENDIX B - INVITATION TO PARTICIPATE IN A FOCUS GROUP: PWUD APPENDIX C - INVITATION TO PARTICIPATE IN A FOCUS GROUP: SERVICE/HEALTHCARE PROVIDERS APPENDIX D - INVITATION TO PARTICIPATE IN A FOCUS GROUP: POLICE OFFICERS. 55 APPENDIX E - CONSENT FORM TO PARTICIPATE IN AN INTERVIEW: PWUD APPENDIX F - CONSENT FORM TO PARTICIPATE IN A FOCUS GROUP: PWUD APPENDIX H - DISCUSSION GUIDE FOR INTERVIEW WITH PWUD APPENDIX I - DISCUSSION GUIDE FOR FOCUS GROUP WITH PWUD APPENDIX J - DISCUSSION GUIDE FOR FOCUS GROUP WITH HEALTH CARE PROVIDERS APPENDIX K - DISCUSSION GUIDE FOR FOCUS GROUP WITH SERVICE PROVIDERS APPENDIX L - DISCUSSION GUIDE FOR FOCUS GROUP WITH POLICE SERVICES APPENDIX M - QUESTIONNAIRE APPENDIX N - GLOSSARY APPENDIX O: ONLINE SERVICE PROVIDER SURVEY Final Report - June 20, 2008

9 Section 1: Introduction Illicit substance use is associated with a number of adverse health effects. Unsafe substance use practices such as sharing needles and other drug paraphernalia place people who use illicit substances (herein referred to as drugs) at a higher risk for contracting and transmitting blood borne pathogens such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and hepatitis B and C viruses. Unsafe practices from impaired judgment associated with substance use place people who use substances at a higher risk for contracting sexually transmitted infections (STIs). There are also documented concerns about other health care issues (e.g. dental care) and access to services in general. In addition to the health effects associated with drug use, there are numerous social effects. Often, there are stigmas associated with individuals who use these substances and many are from already stigmatized populations. Additional social effects include, but are not limited to: issues related to isolation, difficulty accessing services, and the lack of affordable housing. Patterns or trends and the associated effects of illicit substance use (similar to those listed above) in Waterloo Region are not well known or well researched. There is a general understanding that drug use occurs in each community in the region; however, the extent of illicit substance use, and the related issues or implications of this use, (specific to this region) is vague and often anecdotal. This Baseline Study of Drug Use in Waterloo Region was conceived by the Waterloo Region Harm Reduction Network in recognition of a need to better understand the scope and effects of illicit substance use in Waterloo Region. The main purpose of the report is to provide local information on illicit substance use that can be used to guide current and future program planning initiatives and service development. Five objectives were identified to guide the Waterloo Region Baseline Study of Drug Use: 1) To better understand illicit substance (drug) use in Waterloo Region; 2) To identify general areas where people who use illicit substances frequent in order to develop effective outreach strategies to connect with these populations; 3) To document the service needs of the substance-using populations and assess whether programs and services are meeting their needs; 4) To identify any existing barriers to accessing currently available services as perceived by people who use illicit substances, service providers and existing documentation; and 5) To understand the challenges faced by service providers in Waterloo Region. The study findings, related to these key objectives, are presented in this report. Framework The methods and principles used in the Waterloo Region Baseline Study of Drug Use are based on the World Health Organization s Rapid Assessment Response (RAR) guide. The approach or framework is designed for those who wish to assess, within a city or region, the current situation regarding drug injecting and who wish to use this information to develop interventions to reduce the adverse health consequences of injecting (WHO, 1998, 3). This approach builds on accepted social science research methods, but has the advantage of assisting jurisdictions to rapidly and economically compile data from multiple sources to quickly respond to health Final Report - June 20,

10 problems or emergencies. It is traditionally used when conventional social science and public health methods are not suitable (Stimson et al., 2006). The RAR guide and principles have evolved over time and have been used in studies conducted at the national and local level. At the local level in North America, the approach was used to complete both injection and non-injection drug-related studies in Victoria (Stajduhar et al., 2004), Peel Region (Calzavara et al., 2003), and Buffalo (Erie County, 2003). Further, Dr. Margaret (Peggy) Millson, who consulted on this study, was a consultant to the World Health Organization in the development of the RAR methodology. This study s approach is therefore consistent with accepted practices in the research community that studies populations that use drugs. Ethics The research methods were designed to minimize potential harm to participants and the community. The project received ethical approval to proceed from the Region of Waterloo Public Health Ethics Committee on October 11, 2007 and from the University of Waterloo Office of Research Ethics on January 22, Participating in the project was voluntary and consent from each participant was obtained before proceeding. Participants were free to choose the extent to which they wanted to participate. Each participant/person who uses drugs (PWUD) received a $25 honorarium for participating, and was informed at the onset of the interview/focus group that they would receive the money regardless of their level of participation. Each participant received a copy of their consent form. Service and healthcare providers and police officer participants did not receive remuneration. An informed consent page was also included at the onset of the online survey. Please refer to Appendices A to G for the invitation/information consent letters and forms to participate in an interview or focus group for PWUD, service/health care providers and police officers. To maintain and protect confidentiality, interview participants were not required to provide their name or a pseudonym; all forms were coded numerically. When the participant provided permission, the key informant interview was audio recorded. Audio-taped recordings were transcribed and proofed for accuracy. Focus group participants were asked to keep all information confidential; however, participants were informed that the Centre for Community Based Research or Region of Waterloo Public Health could not fully guarantee that other focus group participants would not disclose their participation to others or the information discussed in the focus groups. If appropriate, at the end of each interview and focus group, participants were provided information on local services and programs. Throughout the study, all data and notes were stored in a secure location at the Centre for Community Based Research. Only members of the research team at the Centre had access to raw data. The study coordinator and research team at Region of Waterloo Public Health had access to summary notes. All recordings and notes will be destroyed within 60 days of study completion. Final Report - June 20,

11 Research Methods Research Team The project was managed and funded by Region of Waterloo Public Health and carried out by a research team from the Centre for Community Based Research. The research activities and report were guided by an advisory committee of healthcare providers, service providers and a police officer in Waterloo Region. The committee was involved in the planning, data gathering and report finalizing stages. In addition, three community researchers with awareness of local drug-related services and issues were hired to conduct the interviews with PWUD. They also provided assistance and guidance in the planning and creation of research activities. Members of the Waterloo Region Harm Reduction Network were also involved in the data gathering and report finalizing stages. Data Gathering Five methods were used to gather the data: individual interviews with PWUD, a questionnaire for PWUD, a focus group with PWUD, focus groups with service providers and healthcare providers and the Waterloo Regional Police Service, an online survey for service and healthcare providers, and a review of secondary data sources. Refer to Appendices H to O for the research tools used in the data collection process. Recruitment of participants varied, depending on the method, and will be described below. Interviews, focus group, and questionnaires: Participants who Use Drugs A total of 26 key informant interviews were conducted with PWUD. One focus group, comprised of 6 individuals, was also conducted. Interview and focus group questions focused on description of drug use in the Waterloo Region, social and healthcare needs, social and healthcare service in Waterloo Region, perceptions and practices of safety and harm reduction, perceptions of and responses to outreach activities, and strategies and ideas for Waterloo Region. Interviews were conducted by community researchers who were chosen in part on the basis of their demonstrated ability to build rapport with the populations of interest. Before each interview, participants completed a questionnaire that recorded their demographics, types, methods, and frequency of drug use, and service knowledge and use. Selection Criteria Persons who participated in the interviews were individuals who: Self-identified to have used drugs illegally (including misuse of prescription drugs) on a regular basis. Regular basis was defined as using drugs at least six times in the past 12 months. 1 Are currently living, or lived within the past year, in Waterloo Region for at least three months and has used drugs at least two times while living in the region. 1 Note: An analysis of the interview data reveals that most individuals interviewed used drugs on a daily or weekly basis. Final Report - June 20,

12 Recruitment While no specific demographic criteria were used in the selection process, the recruitment process was strategically developed to obtain a broad representation within the study population. The demographics of participants were tracked and, as the recruitment process progressed, recruitment activities were altered in an attempt to connect with groups that were not yet represented. The following factors were considered when selecting individuals for the individual interviews: Age Socio-economic status Ethno-cultural identity Geographical location Experience using services Type and method of illicit substances used Recruitment activities included hanging posters in high traffic public areas, in service agency washrooms, in primary care offices, pharmacies, community health centres and the University of Waterloo; connecting with individuals through service providers; word of mouth through other participants; and direct outreach through workers at service agencies. Demographics Self-identified Gender Frequency % Female 8 25 Male Total Year of Birth Frequency % 1960 to to to to present 1 3 Did not disclose 4 13 Total Municipality Frequency % Cambridge Kitchener North Dumfries 1 3 Waterloo 1 3 Wilmot 1 3 Total Final Report - June 20,

13 Income Level Frequency % Under $15, $15,000 to $ 24, $25,000 to $49, $50,000 to $74, $75, Total There was limited representation from Waterloo and the surrounding townships, individuals with higher incomes, students and seniors. Targeted recruitment strategies were followed in an attempt to increase representation from these groups. Study findings indicate that persons belonging to these groups are less visible and open with their drug use, suggesting a hesitation to willingly identify as using drugs. Focus Groups: Service/Healthcare Providers and Police Officers Two focus groups were conducted with service providers in Cambridge and in Kitchener one with healthcare providers, and one with the Waterloo Regional Police Service. A total of 33 individuals participated in the four focus groups. Focus group questions differed slightly for the various groups, but overall focused on the same areas as those for PWUD: description of drug use in the Waterloo Region, social and healthcare needs, social and healthcare service in Waterloo Region, perceptions and practices of safety and harm reduction, perceptions of and responses to outreach activities, and strategies and ideas for Waterloo Region. Selection Criteria The following criteria were used when inviting community professionals to participate in the above mentioned focus groups: Service/Healthcare Providers: An employee that currently (or within the past year) provides a service to individuals that use drugs. The study placed emphasis on providers of programs or services intended to treat, help cope with, or reduce the harm of drug related issues to persons living in Waterloo Region. An employee who has worked in this capacity in the Waterloo Region for at least 1 year. Waterloo Regional Police Service: An individual who has experience, through the course of their work in policing, interacting with persons who use drugs in Waterloo Region. An individual who has worked in this capacity in the Waterloo Region for at least 1 year. Recruitment Service Providers representing the following groups were invited to participate: Rehabilitation Services Counselling Services Harm Reduction Workers Final Report - June 20,

14 Outreach workers School Board (youth care workers) Shelter Workers Community Housing Other Key Community Service Providers Healthcare providers were invited from the following groups: Urgent Care Clinics Community Health Centers Public Health Hospital Emergency Hospital In Patient Mental Health Workers General Practitioners Pharmacists Diversity in geographical area served was also considered in the recruitment process. Police officers were recruited to represent diversity in the location of work within Waterloo Region, involvement with illicit substances, and gender of the officer. Online survey for service providers At onset of the study, researchers at Centre for Community Based Research and Region of Waterloo Public Health recognized that there may be a broad range of providers that service PWUD even if the drug-related services do not fall under their organizational mandate. An online survey was developed allowing for a wide range of data and opinions to be collected from service providers. A general was sent to over 200 providers inviting them to complete the survey if they have clients that use illicit substances or if they provide services to the population that uses these substances. Over 75 service providers responded to the survey. The data was used to inform the focus group sessions with service providers and to triangulate the research findings. Analysis of secondary data The research process included secondary analyses of existing data about drug use from a number of sources. The Centre for Addiction and Mental Health Monitor (CAMH Monitor) The CAMH Monitor is an ongoing telephone survey of the adult population of Ontario, designed to provide substance use and mental health indicators. Two hundred respondents are selected randomly each month. For the purpose of this study, data was obtained on 345 residents of Waterloo Region who completed the survey between 2002 and Ontario Student Drug Use and Health Survey The Ontario Student Drug Use and Health Survey (OSDUHS) is administered every two years to 4,000 students attending grades 7 through 13 in the public or Catholic education systems in Final Report - June 20,

15 Ontario. The sampling frame excludes students enrolled in private schools or special education classes, and those living in health or correctional institutions, on Native Reserves, Canadian Forces Bases, and in the far northern regions of Ontario. For the purposes of this study, data was made available form the 2005 and 2007 surveys. In 2005, 322 students from 6 Waterloo Region schools participated. In 2007, 386 students from 6 schools participated. Drug and Alcohol Treatment Information System (DATIS) Treatment services funded by the Ontario Substance Abuse Bureau (OSAB) of the Ontario Ministry of Health and Long-Term Care are required to participate in an ongoing client-based information system, the Drug and Alcohol Treatment Information System (DATIS). This information system monitors the number and types of clients seen and the services they have received. Client demographics, substance use information and referral source are collected at the initiation of a service episode. In , 2925 individuals who were residents of Waterloo Region sought some form of treatment for an issue related to drug or alcohol use, and were recorded in DATIS. This number includes all cases that were open at some point during the year, including those that carried over from the previous year. HIV Diagnostic Testing Data Information on HIV testing and diagnoses were provided by Waterloo Region Public Health. These data describe the total number of HIV tests conducted in the region between 1992 and June They also identify the reasons for the test and some information about the conditions under which the test took place (i.e. whether a name was provided). Needle Exchange Data Statistics on the number of needles distributed in the region were provided by Region of Waterloo Public Health. Reportable Disease Data Reportable disease information on the number of cases of HIV, hepatitis C and hepatitis B for each year from 1995 to 2007 was provided by Region of Waterloo Public Health. Emergency Room Visits All three local hospitals (Cambridge Memorial, Grand River and St. Mary s General) provided detailed statistics on the number of emergency room visits that were coded as drug overdoses or related to drug use. These data are broken down by year, month, age, and gender. Refer to Appendix N for a glossary of terms. Final Report - June 20,

16 Study Limitations and Future Research Considerations Study Limitations The Rapid Assessment Response framework used for this study is a cost-effective means of collecting data on, and analyzing descriptions of, substance use in a defined geographic area. The approach is an effective way to assess current realities and develop targeted interventions based on the key findings; however, it is not a substitute for long-term or in-depth studies. In addition, the service providers and individuals using drugs who participated in this study were volunteers, and although the research team took care to seek out a diverse set of participants, it may be that their experiences do not fully reflect the range of experience or opinion in the region. This is acceptable in the Rapid Assessment Response framework which recognizes that studies using this approach rely on convenient or diverse samples that may not be fully representative of the study population. It is also important to remember that secondary data sources, though very useful, are data collected for other purposes. While they often address the key questions guiding this research project, the linkages may be indirect and should be interpreted with caution. Future Research Considerations Future research on drug use in Waterloo Region should build on existing knowledge as summarized in this report, secondary data sources and other related publications. Given the difficulty in recruiting participants from certain segments of Waterloo Region s population, priority should be given to research projects that further explore drug use of: High school students College and university students Individuals with children Individuals with high incomes Individuals 60 years of age and older Individuals with concurrent disorders (mental health and addictions) Individuals with a disability Throughout the research process, several topics were identified and explored on a cursory level, but may warrant more focused research. These topic areas include: The extent and effects of the misuse of prescription drugs Treatment programs, particularly pre-treatment care and aftercare stabilization Overdoses The root of substance use (e.g. sexual or physical abuse, trauma, stress disorders) Evaluating Waterloo Region s harm reduction services Where possible, efforts should be made to collaborate with and avoid duplication with other ongoing studies. Community research approaches, rooted in accepted social science methodology and participatory in nature, should be adopted. Final Report - June 20,

17 Section Two: Description of Drug Use in Waterloo Region Main Messages of this section: This section describes the extent, type and patterns of drug use in Waterloo Region, drawing on data from multiple sources. The findings from this section indicate that crack, cannabis, and prescription opioids are the most prevalent drugs in Waterloo Region, with indications that use of crystal methamphetamine is increasing and use of heroin may be decreasing. Drug use and trafficking is widespread throughout the region, often involving non-waterloo Region residents, and is not limited to any one demographic sub-group. Patterns of use within the surrounding townships seem to be different from those in the cities. Safety concerns while buying and using did not seem to be prominent for participants; however, some common descriptions of drug use raised questions about the level of awareness of potential safety risks. Comprehensive data on drug use among adults in Waterloo Region is not available. However, there are a number of local statistics that depict rates of use. Combining these statistics with the observations and experiences described by the participants in this study has created a reliable indication of substance use patterns and trends in this region. The reader should, however, be cautioned that the findings do not fully describe the extent of drug use, or its associated effects, within Waterloo Region. Data from the CAMH Monitor 2 tells us that about 16.7% of adults in Waterloo Region surveyed between 2002 and 2005 reported use of cannabis within the last 12 months and this rate is close to the provincial average. An indication of the number of persons using injection drugs was provided by Region of Waterloo Public Health. In 2008, Dr. Robert Remis of the University of Toronto used data from Region of Waterloo Public Health to estimate that there were 1470 intravenous drug users in Waterloo Region. 3 Information about the extent of drug use by high school students is available through the Ontario Student Drug Use and Health Survey (OSDUHS). 4 Overall, about 26% of the participating students reported some use of an illegal drug (including cannabis), and 2 The CAMH Monitor is a random, province-wide ongoing telephone survey about addiction and mental health issues. For the purposes of this report, data gathered between 2002 and 2005 is used. During this period, 9,169 individuals from across Ontario participated in the survey. Of this number, 345 were from Waterloo Region. 3 Estimate based on modelling by Dr. Remis using a capture-recapture analysis from human immunodeficiency (HIV) laboratory database data. 4 This study gathered data about drug use from 6,323 students in grades 7 to 12 across Ontario. In Waterloo Region, 386 youth from 6 different schools participated. Final Report - June 20,

18 13.8% had used an illegal drug other than cannabis. If these figures are representative, about 8811 students have used some form of illegal drug in last year. 5 These rates were close to the provincial averages, and similar to those reported in In 2007, about 9% of students between grades 7 and 12 in Waterloo Region reported having been drunk or high at school, and 16% reported that they had been offered, given or sold a drug at school. Both of these rates appear to have dropped in the last two years locally. In 2005, about 16.2 % reported having been drunk or high at school, and 27.7 % reported that they had offered, given or sold a drug at school. Types of Drugs Used in Waterloo Region: General population All of the methods used in this study (interviews with various stakeholders, surveys, and analysis of secondary data) pointed to similar conclusions crack, cocaine, cannabis and prescription opioids appear to be the most prevalent illegal drugs in Waterloo Region. Heroin, ecstasy and other hallucinogenic drugs were also said to be widely used. The secondary data source which comes closest to telling us something about the relative prevalence of different drugs in the region as a whole is DATIS. It provides information about the presenting problems of individuals seeking treatment for an addiction. DATIS statistics from suggest that excluding alcohol, cannabis, crack, cocaine and prescription opioids are the substances most likely to be mentioned as problems by residents of Waterloo Region when seeking treatment. Our interviews with persons who use drugs (PWUD) 6 supported the conclusion that cannabis use is common. Many PWUD described a disregard for the illegality of cannabis. Thus, many described using in open public spaces, for example, while walking down the street. A common reported use of cannabis is to help come down off of a high from a stimulant such as cocaine. Another study that suggests which drugs are used most frequently wave one of the Ontario Harm Reduction Distribution Program s 2007 Outcome Evaluation Report for Waterloo Region (OERWR). The OERWR looked at drug use patterns of persons who use injection drugs. It lists cannabis, crack and cocaine as the most commonly noninjected drugs used by persons who also use injection drugs. Seventy-nine percent of persons in this group used cannabis at some point in the past six months, with 22.9% describing it as their most commonly used non-injection substance. In the CAMH Monitor survey of 2002 to 2005, 16.7% of Waterloo Region adults reported using cannabis at some point in the last 12 months, which was close to the provincial average. Seventy-five percent of participants in the OERWR reported using crack in the past six months, with 37% listing it as their most common non-injection drug used. In addition, 5 According to the 2006 census, there are 33,890 youth aged in Waterloo Region. 6 Throughout this report, we have used this term to refer to the individuals interviewed for this study who used illegal drugs regularly. Final Report - June 20,

19 the percentage of participants who reported using cocaine in the past year (75%) equaled those who used crack; however, far less participants (11%) reported cocaine to be their most common non-injection drug. The rates of persons who inject drugs who reported also using OxyContin, Dilaudid or Percocet in the past six months were 56%, 49% and 44% respectively. Thirty percent of persons who inject drugs reported smoking crystal methamphetamine in the six months prior to their interview. Twenty percent had injected heroin in the six months prior to their interview and 18% reported using heroin at some point during the same time frame without injecting. Ecstasy use by this group was reported at a rate of 35%. Our interviews with people who use drugs and service providers generally suggested similar conclusions about types of drugs used and offered additional insights into the trends and patterns of local drug use. Crack was described to be one of the most accessible drugs believed by many to be available anywhere, anytime (person who uses drugs). Frequent use of crack does not seem to be limited to any one demographic group. Crack is the biggest substance I see on a daily basis. But I am seeing more people using crack who are not street involved: husband and wives, grandmothers They are getting involved with it basically to cope with some stressful event (service provider). While the numbers are low compared with other demographic groups, one service provider observed an increase in the number of senior people who are dependent on crack-cocaine. A second service provider described crack cocaine and crystal methamphetamine as being the two most prevalent drugs used with youth who are homeless or who are at risk of becoming homeless. Some service providers described prescription drugs as having replaced heroin as the primary reason people seek assistance from local methadone clinics. Frequency rates for drugs used by people seeking treatment in methadone clinics were not available to support or dispute this perception. The most commonly misused kinds of prescription pills in Waterloo Region, as described by service providers and PWUD, were opiates such as Percocet, OxyContin, and Dilaudid and barbituates. Misuse of prescription pills is said to be particularly prevalent amongst seniors. One service provider noted high rates of benzodiazepines (e.g. psychoactive drugs used to treat anxiety and insomnia) and opiate analgesics (e.g. pain killers) among this population. Reportedly, misuse of prescription pills is often overlooked by the people who use them and other community members because they are not recognized commonly recognized as addictive drugs. Additionally, the greater public and service providers are described as having low awareness of drug use by seniors. Many of those interviewed who are dependent on prescription opioids reported using their pills to quickly come down off of a crack-cocaine high or to reduce physical pain. Several PWUD and service providers spoke of a pattern in prescription pill dependence where the individual was first prescribed the pills by their doctor for a medical condition. Final Report - June 20,

20 A dependence on the pills developed, and upon noticing the dependence, their doctor discontinued the prescription. Without a prescription, the interviewees then turned to the streets for their pills. I know one woman who had a Tylenol 3 prescription for years for a back injury. One day, she got a new doctor who told her I don t prescribe narcotics. This woman is significantly disabled with a back injury. So where does she go for medical help? She goes down to the corner there and gets Percocet or OxyContin. (service provider) Consistent with the secondary data findings, interviewees told us that crystal methamphetamine was less prevalent than crack, other forms of cocaine, prescription opioids or heroin. However, some service providers and PWUD reported its use to be growing, particularly among youth. Its cheaper cost compared to crack may be one contributing factor to this growth. Crystal meth is really starting to take its place as the front runner. I have seen more people over the years from being in the shelters and whatever who were addicted to crack and are now are addicted to crystal meth. (Person who uses drugs). Several PWUD and service providers described a decreasing trend in the amount of heroin use that they see as compared to their observations of the drug in previous years. Despite this common observation, police officers described seeing an increase in heroin seizure reports. Reasons for this discrepancy are only speculative. Participants in this study also reported seeing greater amounts of heroin use in Cambridge versus Kitchener or Waterloo. A legal intoxicant herb called salvia divinorum was described by service providers as becoming more common among youth. The perennial herb, said to be derived from the mint plant family, offers short-lived intense hallucinogenic experiences, reportedly often lasting only minutes. This drug is sold legally, for example in local convenience stores. Service providers who participated in the online survey had somewhat different perceptions about the frequency with which various types of drugs were used, depending on where they worked (Refer to Figure 1). Kitchener-based service providers saw the use of prescription opioids and steroids as more common, while those based in Cambridge rated cocaine, crack, and ecstasy as more common than did their counterparts in other cities. Participant response from rural areas was not sufficient enough to produce reliable results. Final Report - June 20,

21 Figure 1: How Common Is Use of Specific Drug Types?: Perceptions of Service Providers Based in Different Cities Methamphetamines Ket amine Heroin Waterloo (n=6) Ecst acy Dilaudid, Oxys, and pain relief pills Kitchener (n=18) Cambridge (n=14) Cocaine & Crack Cannabis Anabolic Steroids Not at All Very Common Respondents whose primary focus was working with PWUD saw most types of drug use as more common than did service providers whose work was not primarily in addictions. In particular, experienced providers expressed more concern about some of the lesserknown drugs like ketamine and some types of prescription pills (Refer to Figure 2). Final Report - June 20,

22 Figure 2: How Common Is Use of Specific Drug Types?: Perceptions of Service Providers Who Work With Users vs. Those Who Work with Various Populations Methamphetamines Ketamine Heroin all of our clients use regularly (n=6) Ecst acy Dilaudid, Oxys, and pain relief pills Cocaine & Crack Cannabis more than half of our clients use regularly (7) about half of our clients use regularly (n=16) Anabolic Steroids Not at All Very Common More experienced service and healthcare providers tended to see crystal methamphetamine and cannabis as less common problems than their less experienced colleagues. They tended to see stimulant use as more common than their less experienced counterparts (Refer to Figure 3). Final Report - June 20,

23 Figure 3: How Common Is Use of Specific Drug Types?: Comparing Perceptions of Service Providers with Varying Levels of Experience Methamphetamines Ketamine Heroin Ecst acy Dilaudid, Oxys, and pain relief pills 10 years or more (n=20) 4 to 9 years (n=10) 1 to 3 years (n=5) Cocaine & Crack Cannabis Anabolic Steroids Not at All Very Common Types of Drugs Used in Waterloo Region: High School Students The OSDUHS results from 2007 suggest that the patterns of drug use are somewhat different among youth who are enrolled in school than the general population. Although the absolute percentages from DATIS and OSDUHS cannot be compared directly, differences in the rankings of specific drugs across the two sources may be instructive. Overall, they suggest that cocaine use is a more serious problem among the general population than it is among students, and that hallucinogen use is more prevalent among students than it is among adults. There is some suggestion of a downward trend in cocaine use among students both in Waterloo Region and elsewhere in Ontario over the last two years. The OSDUHS report provided indications of types of drug use among high school students, suggesting cannabis and opiates as the most common drugs used. In the OSDUHS study, 21.8% of local students surveyed in 2007 reported using cannabis at some point in the last 12 months. Provincially, the rate was 25.6%. At 18.3% of respondents, students were more likely to have tried opiates for non-medical purposes than they were to have smoked cigarettes (11.4%). Non-medical use of pain relievers in 2007 was slightly lower in Waterloo Region than the average provincial rate of 20.6%. In 2007, 3.9% of the local students surveyed reported use of cocaine, as did 3.4% of youth from across Ontario. Provincially, 1% of respondents reported using crack. OSDUHS analysts were not able to make a reliable estimate of local crack usage rates. Final Report - June 20,

24 About 3.4% of local youth reported use of ecstasy in 2007, which was close to the provincial average (3.5%) and similar to the local rate reported in 2005 (4.4%). Other common types of drug use among grade 7 to 12 students in 2007 were hallucinogens other than LSD or PCP (7.8%), over the counter sleeping medication (6.7%), solvents (6.6%), glue (5.4%), and other stimulants (5.1%). Grade 7 to 12 students in Waterloo Region appear to have higher than provincial average usage rates for sleeping medications, glue, and hallucinogens (Refer to Figure 4). Although there is some suggestion in OSDUHS that OxyContin use among students is rising at a provincial level (from 1% in 2005 to 1.8% in 2007), the OSDUHS was not able to produce reliable local estimates of the rates of OxyContin use. Figure 4: Rates of Use Reported by Students (Source: OSDUS 2007) Any Illicit Drug, including cannabis Cannabis Opioid Pain Relievers (non-medical use) Any Illicit Drug, excluding cannabis Cigarette Smoking Other Hallucinogens OTC Sleeping Medication (other purpose Solvents Glue Stimulants (non-medical use) Cocaine Ice (Crystal Methamphetamine) Ecstasy (MDMA) LSD Students in Ontario (n=6323) Students in Waterloo Region (n=386) 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% % of students reporting use at least once during past It should be noted that the Ontario Student Drug Use and Health Survey gathers data on drug use among students in publicly funded high schools. These figures should not be taken as representative of the drug use among youth who live on the streets. Characteristics of People who use Drugs Information from the DATIS database tells us that approximately 2925 local residents sought some form of case management or community treatment for drug or gambling addictions in 2006/07, and that the vast majority found these services locally. 7 Residential withdrawal management services were used by 1067 individuals from 7 In addition, 191 family members of persons who used drugs sought treatment during the same period. Therefore, the total of all individuals seeking treatment is Final Report - June 20,