Toronto’s Medical Officer of Health recently announced that the three clinics currently providing safe injection services are planning to apply to the federal government for permission to operate safe injection services. There is a strong case for providing integrated supervised injection services as part of a harm reduction approach to drug use. Supervised injection services serve two important purposes: 1) they provide a safer environment for drug users to inject pre-obtained drugs under medical supervision, and 2) they provide basic public health and health care services to drug users who may not otherwise come into contact with these services. These are important functions and can help to improve the health of drug users, who are a highly stigmatized population with poor access to health care services.
Beyond this, there is a critical third role for safe injection services: the role that these three services can play in addressing the social determinants of health for drug users. Integrated Supervised injection services in existing health care facilities can provide critical referrals to health and social supports like additions treatment, primary health care and housing services that can improve the health and well-being of drug users.
The social determinants of health are the causes of the causes of poor health. We know that people who have access to safe and affordable housing, adequate income, healthy food and other essentials of life have better health outcomes than more disadvantaged members of our society. Simply put, Torontonians with low income and other dimensions of disadvantage are less healthy throughout their lives and die earlier than those who are better off. This group is represented among those Torontonians served by these three proposed supervised injection service agencies – The Works, South Riverdale Community Health Centre and Queen West Community Health Centre.
While drug users come from all parts of our society evidence shows that drug-related morbidity and mortality is greater among groups with lower socioeconomic status. The connections between socioeconomic status and drug use are bi-directional. This means that some populations who fare poorly in the social determinants of health may be more likely to become drug users and that drug users are, in turn, more likely to fare poorly in the social determinants of health. For example, people with low income are at greater risk of becoming drug users and drug users are more likely to be poor. Strategies to reduce the harms of drug use must therefore address both drug use behaviours and the social determinants of health.
Research from the InSite supervised injection service in Vancouver found clients who were in contact with the service were more likely to enter addiction treatment services than those who were not. In 2012, InSite referred around 5,000 people to other social and health services, primarily for detox and addiction treatment. Once drug users enter these kinds of treatments the path toward improved housing stability and income security becomes much clearer. But they cannot find that path if they die due to overdose.
Housing referrals are an especially important aspect of supervised injection services. Evidence shows that inadequate housing increases the likelihood of infectious disease transmission among intravenous drug users. We also know that people who lack stable housing are the group of intravenous drug users who are most likely to use supervised injection services. Supervised injection services can be the critical link between an especially high-risk subsection of the homeless population and referrals to social services, like supportive housing.
Establishing safe injection services that include referrals to services that address the social determinants of health for drug users is a proven way to improve health for this particularly vulnerable population. Drug users are highly stigmatized and have poor access to health and social services. With safe injection services we have an opportunity to not only reduce the harm of drug use but also to take action upstream to address the social determinants of health for drug users. Establishing integrated safe injection services at the three proposed locations is an important move to improve overall health and well-being in Toronto.