Harm Reduction Discussions 2015
1. Excerpt from “Summary of Discussions May – July 2015” document:
• Separate the behaviour from use of substances
• Service needs to be “judgement-free” – people shouldn’t have to change/alter their lifestyle
choices to get the support they need (that’s “social control” not “service delivery”)
• Need to continue to serve people even when they are at risk of dying – the approach is
about harm reduction not harm elimination – people may still overdose/die because they
are engaging in high risk behaviours (those choices are not within our scope of influence:
we can’t stop people from using substances, so we accept it and promote safety instead)
• Adopting a harm reduction approach requires the ability to assess risk
o Is someone under the influence of drugs safe?
o How can we reduce harm by preventing overdose/injury/death where possible?
• Variety of questions to consider:
o Does the use of substances impact the congregate living environment? Need to
consider the safety and security of building, staff, residents/children on-site
o What are we responsible and accountable for? What is reasonable, given the
resources available? What is outside our scope of influence/control?
o How do we assess if medical or health care is required?
o What is the “duty to care”? What does “due diligence” look like?
• If use of substances does create an “unreasonable” level of risk in the living environment,
question becomes: How do we support people without requiring them to exit the program?
o Need to consider the program in the context of being part of an intentional “service
path” in the system
o If someone is asked to leave emergency shelter, their support needs must be met
elsewhere – e.g., from other programs/systems (perhaps less appropriate) or from
the broader community (which may become a public health concern)
• Need a more formalized approach that strives for consistency and transparency across the
system:
o What specific steps do we need to take when medical clearance is needed (e.g.,
calling 911)?
o What level of risk is considered reasonable at each emergency shelter? If there are
different levels, why?
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2. Excerpt from October 16, 2015 Minutes:
Insights about harm reduction in general:
 Harm reduction is about safer use and promoting safety, not safe use or ensuring safety.
 Covert use of substances makes it unsafe for everyone.
 Harm reduction is about being prepared for use that is already happening. People use
substances despite requests not to. Substance use happens, it’s just a fact. People use in
washrooms, in private bedrooms, etc. The best we can do is to support people to use in
ways that do not increase risk of harm – for themselves and for others (staff, peers,
community).
 The goal is to support everyone, regardless of their use. This may mean supporting them to
stay in shelter or in motel or through another option in the community.
 Staff engaged in harm reduction practices need to believe in harm reduction principles. In
doing so, they focus on choice, options, support, safety, and health. It is about treating
people with dignity at all times.
 Harm reduction is on a continuum. On the one end, there is a focus on abstinence and
resources dedicated to supporting people who make the choice to abstain as part of their
recovery. At the other end, the focus is on walking with people who are actively using
substances and suffering; meeting them where they are at – even to their death.
 Sharps containers should be placed in bathroom stalls to offer more privacy. Metal cages
around the containers are good for deterring people from breaking into them to get used
needles. This happens when people do not have access to clean needles – people break into
the sharps containers and their arms are cut in the process, exposing them to further
harms.
 Regular Board of Director harm reduction training is helpful (e.g., annual).
 Legal aspects:
o Criminal negligence is not an issue because agencies are not providing drugs or
forcing anyone to use them.
o Be careful/cautious and have policies/practices that demonstrate due diligence.
o There have been no cases brought to court to date regarding harm reduction
practices in a shelter environment.
Insights about harm reduction and housing:
 Housing is a humane response to suffering and resolves homelessness. We offer housing
options because people have a right to access housing.
 Housing is a safer environment than homelessness: quality housing reduces harms and
promotes health.
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Where people stay/live is a choice they make for themselves and has a lot to do with the
quality of housing options and support that are available to them.
Within the context of harm reduction and offering housing, the initial approach is always: I
care about you. What do you wish to do and to be? How can I support that?
Holding the “hope of housing” for someone is similar to “holding the hope” of abstinence or
health. The most important thing is that we accept people where they are at and do not
serve them in ways that reflect our personal bias and personal values on how/where we
think people should live.
Insights about learning at the Transitional Shelter:
 Implemented harm reduction in a communal living environment.
 Residents exited the shelter at night only under three circumstances:
o They wanted to leave.
o They left in an ambulance.
o They left with police.
 YWCA Transitional Shelter adopted the approach that it is “not their business” to restrict
people’s belongings. But because it was a communal space with very little privacy or safe
space to store belongings, they offered residents boxes for safe keeping during their stay.
People put wallets, pictures, etc. in the boxes at their discretion and had access to the boxes
when they wished. Weapons were never mentioned specifically as OK or not OK to store in
the boxes. Contents were returned to the person the next morning. If contents were not
reclaimed, they were given to the police a few months later.
 It is important to use the right term for these boxes – “Belongings Box” or “Safe Keeping
Box” is better than other terms that have been used as we’ve been exploring this idea as a
group. It’s important that our language is neutral and we don’t make assumptions about
what is in the boxes.
 At the beginning, police had concerns about the Transitional Shelter and they visited more
frequently. As the season went on, police came by much less frequently.
 In general, the residents that stayed there respected the space and kept it safe. For
example, if people had an open bottle of alcohol, they were encouraged to put it in a cup
instead – out of respect for the space and others around them. They kept their use of
substances discrete.
 Residents were encouraged to understand that it was a place to rest and sleep – not
socialize. The message was reinforced by placing furniture so that there weren’t large
groups of people gathering around others who were trying to rest/sleep, offering only decaf
coffee, turning the lights down low, not offering food. Residents were encouraged to access
St. John’s Kitchen for food, refreshments, and hospitality, if that’s what they were seeking.
 Things that supported the harm reduction approach:
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o Sanguen stopped by once a week with health promotion supplies.
o There was also a sharps container in the common room.
o They had a checklist for cleaning the bathroom – kept it clean and made sure there
was no paraphernalia.
o Used syringes and sharps were disposed of in secure/mounted containers.
About half of the residents used substances.
There was no real difference in YWCA Emergency Shelter and Transitional Shelter – just a
different type of space and some further considerations given the design (e.g.,
Belongings/Safe Keeping boxes).
Insights about harm reduction in a shelter environment – how it can be done:
 If staff suspect substance use, they approach the person and reiterate the preference not to
use on-site. They also reinforce that, if the person continues to use, they will be supported
to do so as safely as possible. The expectation to cap all used needles and put them in a
sharps container should be a firm boundary and safety standard. If residents can’t follow
this directive, they can’t stay at the shelter because it creates too much risk of harm to
others.
 The “Harm Reduction Matrix” used at the YWCA frames use in the context of whether or
not the shelter has the ability to manage the situation. It is a planning document that
informs how resources and support can be offered by the agency.
 The message is both: not to use on-site/in open spaces AND to use responsibly.
o People are responsible for their use.
o People are expected to use in ways that are safer for themselves and their
community.
o People are placed in the context of community: How would people like to be
treated? How do their choices affect others? How does it feel to experience being
included in community? How does it feel to have others include them?
 We can expect people not to use on-site. But we can’t reinforce a rule that states people
must not use on-site. And we shouldn’t use this expectation (that they don’t use on-site) as
a way to permit or deny access to shelter or housing. However, if use endangers others
(e.g., uncapped needles), then it makes sense to restrict access to a communal living space.
But not to deny access to all support or options. The question is how to manage the risk,
while still supporting the person in the system/community.
 The message to all residents when they are inquiring about shelter intake is that they will
likely encounter peers under the influence of substances or people who display behaviours
that they may not understand.
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At intake, if people are known to use substances and there have been issues in the past
with safer use, staff should have a quiet and gentle conversation about how to stay safe
during their stay, using a tone of mutual respect. Additional supports may include:
o Flagging residents as “banned” in HIFIS so that staff know they must offer them
personal sharps containers at intake (maybe 75-100 residents are flagged like this –
less than 5%).
o Flagging residents on the bed list to identify that the person requires extra support
related to safer substance use.
o Rooms where active substance use is possible can also be flagged for housekeepers
so that extra caution is taken while cleaning.
For shelters that have shared rooms, people who use substances should share a room and
people who are in recovery or abstaining should share a room. Other than this, though, it
should be clear that there is no way to “avoid” people who use or do not use substances at
a shelter.
Staff turnover and challenges with offering a harm reduction approach can be mitigated by
hiring the right staff for the shelter program. Shelter staff need to be fully informed about
the population they are serving and the philosophy of service that the system promotes.
This work is not a good fit for everyone. Good, harm reduction focused interview questions
can help to determine good fit.
Insights about the role that Public Health can play:
 Kathy McKenna noted that Public Health is available to support Emergency Shelters as
they implement harm reduction measures. This could include: training, increasing
needle disposal units at shelters, speaking to boards, education, etc.
 Kathy indicated that Public Health currently has formal contracts with the Cambridge
Shelter, oneROOF and The Working Centre to offer harm reduction supplies, including
clean needles and sharps containers.
 Public Health has access to a range of harm reduction supplies at no cost through their
Provincial network (Ontario Harm Distribution Program: http://www.ohrdp.ca/)
 Agencies are encouraged to consider how they can make use of Public Health and the
free resources that are available.
Insights about Sanguen and its role in harm reduction:
 Violet Umanetz noted that beginning in November, Sanguen will have a mobile van that
will operate during the day and some evenings (Thursday, Friday, Saturday nights from
9a.m. to midnight).
 The van will have a nurse and another staff member on board.
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The van will also be equipped with harm reduction supplies to distribute (including
condoms, sharps containers, meth pipes, etc.). The nurse will be able to do testing for
Hepatitis C, HIV, and various STIs.
The van will be white with a dragon painted on the side.
Insights about possible training opportunities:
 Noloxone and overdose prevention
 Safe sex
 Full continuum of harm reduction practices and how to support them
“Ask Me” box insights from group members:
 Harm reduction involves uncovering personal bias – paying attention to my expectations or
hopes for others, and how this bias impacts support offered.
 Harm reduction is necessary within our system. We can’t ignore the issue.
 This is long overdue – harm reduction is a way to respect the person.
 Harm reduction is misunderstood and/or not accepted by many people.
 It is hard to support people who are actively using substance use. They sometimes don’t get
better.
 Language is important. We need to continue to align our language in the system with harm
reduction: focusing on choice, options, support, safety, and health.
 Concern that we will create access policies that are too restrictive – out of fear – when harm
reduction is the right thing to do.
 Concern about lack of due diligence with supporting the necessary planning and
implementation of harm reduction. We can’t rush this.
 Concern that we are creating safe injection sites without the necessary support in place to
manage safety.
 What is the process of becoming a harm reduction specialist? Is there accreditation?
 How do you create an environment where harm reduction is supported, despite some staff
not being on board with the philosophy or service mandate?
 How can I support my colleagues and peers to deepen their harm reduction approach?
Some have a limited understanding of what it is. They need training and more conversation
about values, etc. in an open and non-judgmental space.
 How can I support the community to be more supportive of harm reduction? They need
education and communication.
 What other harm reduction practices can we place in shelter other than safe needle
disposal boxes?
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How can we gain confidence in offering a harm reduction approach, so that that we don’t
limit our innovation because we aren’t informed? We need different champions to speak to
the importance of harm reduction beyond our own system (e.g., police, courts, legal
opinions, Public Health, Canadian Harm Reduction Network). We need to offer support,
know the research and discuss it, talk about local experience and personal experience.
We need to work within our own locus of control.
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