The “shadow epidemic” lurking in the COVID-19 background is leaving another group of front-line workers battered and bruised. And Ontario’s opioid crisis is expected to get worse over the next six months, according to the latest data.
But unlike mainstream health-care providers, harm reduction workers do not have benefits like danger pay or strong unions to support them. With jobs characterized by low wages, stigma and political red-tape, overworked harm reduction professionals are seeing burnout on the front lines.
“I have watched harm reduction workers over the past two years, from the first wave, where they really quickly pivoted because they realized if supervised consumption sites closed, tons of people who were relying on their services would die,” says Gillian Kolla, postdoctoral fellow at the MAP Centre for Urban Health Solutions at St. Michael’s Hospital. “They literally moved mountains heroically from day to day, to still provide services in the midst of COVID. They did this with zero funding, they did this by begging and borrowing (personal protective equipment) in the initial wave. It was an absolutely heroic effort that went largely unrecognized.”
Supervised injection sites in Canada have been politically turbulent since their inception. The first site was sanctioned in Vancouver in 2003, a product of a Health Canada report detailing the benefits of safe consumption sites.
Dubbed Insite, in the heart of the Downtown East Side, it was approved only on the condition that it be considered a pilot project. As such, it was required to undergo rigorous scientific examination on the benefits of safe injection, its community impacts – keeping neighbours happy – as well as reducing public disorder, infectious disease transmission and overdose. To date, more than 40 peer-reviewed studies have been published on the extensive effectiveness of the pilot site as well as the demonstrable lack of negative impacts.
Insite remains open today, with more than 3.6 million visits, 6,440 overdose interventions and zero deaths.
Ontario was late to the game, and the path has not been easy. Continued advocacy brought the province’s first official injection site at Dundas Square in 2017, and more swiftly followed. Things froze after Doug Ford’s Conservatives were elected in 2018. He campaigned as being “dead against” safe injection sites and wanted them all closed. He was persuaded otherwise but capped the number in the province at 21.
‘We’ve not seen any kind of increase in resources’
“There was this stalling that happened in 2018,” says Kolla. “We have not had any kind of recognition of the way in which the overdose crisis has escalated; we’ve not seen any kind of increase in resources.”
Now, four years and a pandemic later, the crisis worsens by the day in Ontario with only 20 safe injection sites remaining open across the province.
The current surge in overdoses is due in no small part to an increasingly volatile and toxic drug supply. Adulterants like benzodiazepines, now found in more than half of all tested fentanyl samples in Toronto, lengthen overdoses from spanning minutes to hours.
“None of these chemicals that are in the drugs now have ever been used medically, so they’ve never been researched. So, we don’t even know what they do to people in the short-term, aside from anecdotally, and we definitely don’t know what they do in the long term,” says Matt Johnson, a harm reduction worker at the Parkdale Queen West Community Health Centre in Toronto. “And we don’t know what they will do to people when they combine these drugs. Are they going to have impacts on the brain? Are they toxic to certain parts of the body? We don’t know anything,”
The sites have had to become multipurpose centres for complex overdose monitoring and education about the threats of unregulated supply.
“These sites weren’t built with the idea of the current poisoned supply in mind. We are constantly playing catch-up,” says Johnson.
On top of monitoring, workers have taken on safer supply education, providing treatment resources and fostering legal safe havens for users. Changes in the landscape of the toxic drug crisis coupled with a lack of government response has caused safe injection sites to take on far more than their original mandate, what experts describe as “mission creep” for employees.
“The purpose that safe injection sites were supposed to fill has shifted dramatically,” says Kolla. “The volatility in the drug supply has continued to get worse. What that means is that the folks on the front lines are left to deal with this on top of everything else that they’re already doing,”
COVID-19 has also posed significant challenges to safe injection sites. A September 2021 report from the Ontario Science Table noted that opioid-related deaths increased by 60 per cent since March 2020. Meanwhile, many social services have closed, leaving at-risk populations to lean on harm reduction workers more than ever.
“Our health system almost fell apart, and our sheltering system is currently completely collapsing,” says Kolla.
Harm reduction workers have seen no recognition for the substantial increase in their scope of work. Instead pay freezes and lack of provincial funding has put added strain on a system already stretched thin.
“Other positions, emergency services, they get danger pay – they have strong unions, and we don’t have any of that,” says Matt Johnson. “We’re a low-paid sector, and a poorly funded sector, and you add all this chaos in it . . . People hit a point where they’re like, I can’t do this anymore and be healthy.”
For many harm reduction workers, pay has not even kept up with inflation. Pay freezes since 2018 have left workers stagnant at $45,000 to $55,000 a year in urban centres.
“People are so burnt out,” Johnson says. “We lost so many people over the fall and winter. This is like five or six people, but they accounted for multiple daily visits. And so, when you see a person die, you see how much they utilized us. It’s hard to see this amount of compounded death and loss and keep feeling like you have extra fight in you after your 9 to 5 job, which already feels like a fight.”
“It really comes down to how much you value people’s lives. How much do you value the lives of people who use drugs,” Johnson asks.
“I value the life of every person. Everybody in our country, everybody in the world. Everyone has the right to live and be safe, and that’s the service that we offer.”