Item - 2017.HL18.3

The Board of Health:  

1. Endorsed the report entitled Toronto Overdose Action Plan: Prevention and Response.

2. Requested the Ontario Ministry of Health and Long-Term Care to:

a. Develop a provincial overdose strategy urgently, in consultation with multi-sector provincial, municipal, public health, and community stakeholders, and people who use drugs and their family/friends;

 b. Dedicate a coordinator and funding to support implementation of the provincial overdose strategy across ministries, municipalities, and sectors (e.g. hospitals, prisons), and to align it with implementation of the Ontario Opioid Strategy;

 c. Work with an Indigenous facilitator to develop and undertake a dedicated process to engage Indigenous communities to identify overdose prevention and response strategies specific to Indigenous communities across Ontario;

d. Provide free naloxone to community services for distribution to clients, including agencies distributing harm reduction supplies;

e. Provide free naloxone to community service providers (e.g. housing programs, shelter providers, drop-in services) to include in their onsite first aid kits;

f. Provide nasal naloxone to community service providers, first responders and correctional facilities.

g. Expand funding to harm reduction programs to increase their capacity to respond to the current overdose crisis and future program needs;

h. Increase funding for full-time, appropriately paid positions for workers with lived experience to assist with overdose prevention and response and other harm reduction initiatives;

i. Direct the Local Health Integration Networks to develop overdose policies and protocols, including the availability of naloxone, in provincially-funded health care services, as appropriate, with an initial focus on the substance use treatment sector;

j. Work with the Local Health Integration Networks to ensure naloxone kits are provided to people in opioid substitution treatment, and people with a history of opioid use at discharge from mental health and substance use treatment services, and hospital emergency departments;

k. Consult with people who have been impacted by overdose to determine what supports and services are needed to help them cope with the trauma of these experiences. Groups to consult include people who have experienced a non-fatal overdose and their family and friends, and people working in health and social services sectors;

l. Confirm adequate funding for Toronto Public Health/The Works, Queen West-Central Toronto Community Health Centre and South Riverdale Community Health Centre to facilitate opening of the supervised injection services as soon as possible;

m. As part of the provincial overdose plan, identify and fund overdose prevention and response measures for the community, such as overdose prevention services and mobile medical facilities, as may be required in an emergency;

n. Fund community drug checking programs and research;

o. Work with Local Health Integration Networks to increase funding to expand the capacity of the substance use treatment system, and to expand the models of treatment, from harm reduction to abstinence, to ensure people can access appropriate services when they need them;

p. Work with the Local Health Integration Networks on improving the integration of substance use treatment services with primary and mental health services, including harm reduction services;

q. Work with relevant professional associations, Local Health Integration Networks, hospitals and community health centres to expand the availability of on-demand opioid substitution treatment options, including:

i. Expanding access to Suboxone™ in emergency departments, community health centres, and physician offices;

ii. Enabling Nurse Practitioners to prescribe and administer OST;

iii. Providing more low-threshold opioid substitution treatment options;

iv. Supporting the provision of injectable diacetylmorphine (prescription heroin) and/or hydromorphone, according to best practice, at appropriate health settings;

v. Expanding the provision of comprehensive and integrated supports for people receiving OST, including counselling and access to primary and mental health services; and

vi. Address medical regulatory and practice issues so that opioid substitution treatment is provided on a barrier-free, non-stigmatizing basis;

r. Ensure that no one is refused entry into a provincially-funded substance use treatment program because they have an opioid substitution treatment or any other prescription;

s. Consult with people who use drugs and other experts before changes are made to the availability of pharmaceutical drugs, such as delisting opioids from provincial drug plans, to ensure new regulations do not force people into illicit markets;

t. In consultation with people who use drugs, create protocols for health care providers for prescribing and tapering patients off of opioids that allow for a range of patient needs (e.g. develop individual transition plans);

u. The Chief Medical Officer of Health should expedite development of the provincial overdose surveillance and monitoring system, and align it with national and municipal efforts; 

v. Resource and mandate institutions with key roles in generating data related to overdose to compile and share data in a timely manner, as close to 'real time' as possible, including;

w. Provide resources to the Office of the Chief Coroner for Ontario and the Centre of Forensic Sciences to enable them to report quickly on the early results of toxicology tests;

x. Require hospital emergency departments to record data in a consistent and accurate way to provide systematic reporting on overdose incidents; and

y. Share weekly hospital overdose data reported to the Canadian Institute for Health Information with Public Health units as soon as possible to inform local surveillance efforts;

z. Fund three permanent positions at a cost of $374,709.95 gross/ $0 net in 2017 to implement Toronto Public Health actions in Toronto's Overdose Action Plan; and, if the Ministry of Health and Long Term Care does not provide this funding, the Board of Health directed the Medical Officer of Health to assign the necessary staff to implement the Toronto Public Health actions recommended in the Plan on an interim basis until the resource requirements to implement the Toronto's Overdose Action Plan can be considered by City Council as part of the 2018 Toronto Public Health Operating Budget process; and report back to the May 17, 2017 meeting of the Board of Health with an update on the above funding request from the Province of Ontario.

3.  Requested the Ministry of Community Safety and Correctional Services to:

a. Expedite the provision of naloxone kits to people at risk of overdose upon discharge from correctional institutions, and expand the criteria to include anyone with a history of opioid use;

b. Ensure people inside the correctional institutions who are known to be using opioids have access to overdose prevention and response measures, including naloxone;

c. Ensure all staff on the ranges in correctional facilities have access to and are trained in overdose prevention and response, including administering naloxone; and

d. Provide overdose prevention and response training, including administering naloxone, to staff at probation and parole offices.

4. Requested the Province of Ontario to:

a. Maintain existing and expand the supply of affordable and supportive housing, including harm reduction housing, and ensure that people are not evicted from their housing because of substance use; and

b. Expedite the implementation of poverty reduction measures, including implementing a basic income for all low-income persons, regardless of employment status, and increasing social assistance benefits and employment opportunities.

5. Requested Health Canada to:

a. Develop a federal overdose strategy urgently, in consultation with multi-sector provincial, territorial, municipal, public health and community stakeholders, and people who use drugs and their family/friends;

b. Dedicate a coordinator and funding to support implementation of the federal overdose strategy across ministries and sectors, and to align with the Action on Opioid Misuse Plan and provincial and territorial plans;

c. Work with an Indigenous facilitator to develop and undertake a dedicated process to engage Indigenous communities to identify overdose prevention and response strategies specific to Indigenous communities across Canada;

d. Approve the supervised injection service exemption applications for Toronto Public Health/The Works, Queen West-Central Toronto Community Health Centre, and South Riverdale Community Health Centre as soon as possible to enable these services to open;

e. Work with communities across Canada, including Toronto, to facilitate approval of Controlled Drugs and Substances Act Section 56 exemptions required to implement drug checking programs;

f. Clarify requirements for the use of reagent testing programs in community settings (i.e. are Section 56 exemptions necessary);

g. Facilitate rapid access to injectable diacetylmorphine (prescription heroin) and/or hydromorphone as an opioid substitution treatment option;

h. Consult with people who use drugs and other experts before changes are made to the availability of pharmaceutical drugs, such as delisting opioids from federal drug plans, to ensure new regulations do not force people into illicit markets;

i. Restrict pharmaceutical advertising to health care providers to help reduce overprescribing;

j.Require pharmaceutical manufacturers to contribute funding to overdose prevention and response initiatives; and

k. Mandate and fund institutions with data related to substance use and overdose to compile and share data in a timely manner, ideally on a real-time basis. For example, Health Canada Drug Analysis Service laboratories should conduct and report out on drug analysis tests for the community as well as for police.

6. Requested the Public Health Agency of Canada to:

a. Create a national overdose surveillance and monitoring system, in conjunction with the Canadian Institute for Health Information, Drug Analysis Service laboratories, the Canadian Association of Poison Control Centres, and provincial health and local communities, to ensure monitoring and sharing of information related to overdose.

7. Requested the Ministry of Justice to:

a. Develop a clear, broad-based awareness campaign about the Good Samaritan Drug Overdose Act for promotion with police departments and the general public, pending passage of the bill.

8. Requested the Government of Canada to:

a. Urgently pass Bill C-224, the Good Samaritan Drug Overdose Act;

b. Maintain existing and expand the supply of affordable and supportive housing, including harm reduction housing, and ensure that people are not evicted from their housing because of substance use;

c. Expedite the implementation of poverty reduction measures, including implementing a basic income for all low-income persons, regardless of employment status, and increasing social assistance benefits and employment opportunities;

d. Develop and implement evidence-based strategies to address stigma and discrimination against people who use drugs, in consultation with people with lived experience; and

e. Implement a range of options for people who come into conflict with the law because of substance use with a main goal of avoiding arrest and prosecution. Options should include restorative justice and community and court-based alternative diversion programs.

At its meeting of December 5, 2016, the Board of Health asked the Acting Medical Officer of Health to develop a Toronto Overdose Action Plan in response to the drug overdose crisis in Toronto. This report responds to that request.

Toronto Public Health (TPH) consulted with the Toronto Drug Strategy Implementation Panel and its Overdose Coordinating Committee in the development of a draft Action Plan that was taken out for consultation in January and February 2017. Diverse community input was gathered through an online survey and four open-invitation sessions that were held in downtown Toronto, North York, Etobicoke and Scarborough. Overall, there was broad community support for the actions proposed in the draft Action Plan, as well as additional ideas for consideration.

The final report entitled, Toronto Overdose Action Plan: Prevention & Response, provides a comprehensive set of actions to prevent and respond to overdoses, building on the work that is already taking place in the community, and by governments and other institutions. The Plan combines the knowledge and expertise of people who use drugs, their family and friends, and people working in the field with best practices and international research. The Plan is meant to be flexible to address new and emerging issues or situations going forward.

Implementation of the Action Plan will be aligned with implementation of the Toronto Drug Strategy as the drug strategy has complementary and overlapping actions, and structures in place to support this work. The TPH Drug Strategy Secretariat will lead coordination and implementation of the Action Plan. In order to do so within existing resources, implementation of other drug strategy recommendations and other epidemiological work will be delayed. A funding request for additional resources to support this work will be included in the TPH 2018 Operating Budget Request for consideration as part of the City's 2018 Budget process.

The community service sector also needs additional resources to respond to the overdose crisis. The Action Plan recommends targeted provincial funding to community-based health, treatment and harm reduction services. The Action Plan also includes a commitment from the TPH Toronto Urban Health Fund to prioritize funding and support for community services for overdose prevention and response, and other harm reduction initiatives. The purpose of this funding will be to increase the number of trained peers and to sustain community capacity to assist in overdose prevention and response.