Results from the Community Consultation Process

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 and 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. 

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 the root causes of addiction (Waterloo Region Crime Prevention Council, 2011).  These interventions may include approaches such as:  promoting healthy families, mentoring programs, and 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 the number of opioid overdose cases in Ontario, and difficulty in 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. One of the best approaches to address opioid use is to intervene before it occurs (Hahn, 2011).  Education and prevention activities should be implemented to increase awareness of opioid use, its 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, and 37% of comments from the forum and open-ended survey questions support this.  

“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 and its associated risks.  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 opioids and 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 online 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 and recognizing 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 towards 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, in addition to 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, and 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 in 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 the survey respondents mentioned the need for better 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 at 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 people who are not using drugs but 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 Unit (county) porgrams, as responders/crisis workers who can help people 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.