Can you provide a brief description of your hospital and the harm reduction measures you have in place right now?
We are a large tertiary care hospital in Northern Ontario that supports a very large demographic and geographical area — around 500,000 people live in the surrounding area. Our organization is an acute care setting. We treat all ages through the lifespan and support all medical concerns that come through.
From a harm reduction lens, we have an Addictions Medicine Consult Service, which started in 2019, to support people with any substance use concerns who are admitted to the hospital. This service has expanded to the emergency department, and to outpatients on a referral basis.
We also opened an Addictions Medicine Unit in 2021, which offers a specialized service for patients who are admitted to the hospital for a medical reason and who also have a substance use concern. Patients receive addiction support while they are completing their hospital stay for a medical ailment. This unit provides an option for admission where a harm reduction philosophy is embedded, people are free from stigma and judgement, and they have a safe space to disclose substance use that provides an opportunity for community linkages. That opened in 2021.
We also have a Harm Reduction Committee that focuses on infusing a harm reduction philosophy throughout our organization. The priority is around risk behaviours and advocating for a patient-first, collaborative decision-making approach. The aim is to move the hospital away from the paternalistic, abstinence-based focus and shifting internal biases. By shifting from exclusively focusing around substance use and incorporating all risk behaviours, the hope is to integrate harm reduction principles into all our hospital services and for all people.
This committee is chaired by our Vice President for Social Accountability and is well supported by our hospital’s Senior Vice President.
Why are you looking to set up supervised consumption services at your hospital?
In 2022, we began harm reduction kit distribution with the support of our Public Health Unit, where we are able to give our drug use supplies to patients who continue to use substances during their hospital stay. One limiting factor is that our hospital has no supervised consumption site, so patients are required to leave the hospital property to use substances and the kits we give them. Some patients have reported this to sends mixed messages. It was one of the driving forces behind pursuing an exemption for the supervised consumption site in our hospital.
We know that people who use drugs are using them on-site in unsafe locations like washrooms. Needles and used supplies have been found on hospital property or in the patient rooms. Patients are leaving the units and being located in less busy areas of the hospital accessing washrooms or other risky places to use their drugs. We are also based in Northern Ontario where our climate in the winter months is not favorable to have people leave property to use their drugs.
Based on all these observations, we had a conversation with the hospital’s senior leadership about creating an in-hospital supervised consumption site, with great success and support. Which will allow us to maintain safety and align with harm reduction philosophy.
What resources have been required so far and what resources do you anticipate needing in the process of getting the site up and running?
Resources obtained so far for our hospital distribution program include:
- Public Health partnership: Our public health partners provide us with the supplies for our harm reduction kits (excluding needles, purchased by the unit/program) along with naloxone.
- Senior leadership support: Not having buy- in from our senior leadership team would make it very difficult to implement a hospital-based supervised consumption site. Our senior leadership team appreciates the impact this will have on our patients who use drugs and also provides our staff an option to offer a safe space that is monitored, helping decreasing overdose risk for our patients.
Resources that we still need include:
- Physical space: Finding an appropriate space is likely going to be one of the biggest barriers, given the reality of space limitations and overcrowding. We have high numbers of alternate level of care patients, which has led to a lot of unconventional spaces used for admissions. There is limited extra space for a supervised consumption site that would be accessible to everyone who would require it.
- Administrative support: Going through the paperwork required to apply for the exemption will take time and staff resources.
We also have some lived experience staff on our Addictions Medicine Unit as peer workers/lived experience outreach workers who use a harm reduction lens when they engage with the patients on the unit.
How will you evaluate the outcomes, objectives, or goals of the supervised consumption site?
I know there would be a lot more outcomes that will likely be required from an organizational lens, but from a person-centered lens, some hypothetical metrics would include:
- decreased internal incident reports, such as:
- decreased incidence of sharps or supplies being found on site
- decreased incidence of patients entering staff-only areas
- increased disclosure about intention to use substances.
Patients feel safe informing staff on the Addiction Medicine Unit that they are going to use and will usually disclose the substance they used, allowing the staff to appropriately care for the person and adjust observations as needed. So I think we will see an increase in disclosures if we implement the supervised consumption site.
What are some other barriers that you and your team have encountered so far and how did you address them?
One barrier is definitely the lack of space in the hospital. The other barrier is lack of buy in among staff and physicians who are not part of our Addictions Medicine Unit. Working on breaking down bias and stigma attached to drug use among hospital staff—the “I know what’s best for you” view. I feel this will be a large hurdle to initially overcome. It's an attitude that we definitely run into now. I know we are not any different from any other organization that struggles with stigma.
We are working on education workshops, different presentations to influential groups in the organization, and revisions to orientation programs to incorporate harm reduction and care for substance use concern in our hospital setting. Shifting the culture around substance use and risk behaviours will be a step in the right direction and will set the stage for when we are able to open the doors to the supervised consumption site.
What do you wish you had known before embarking on this journey? Or what has surprised you the most so far?
The amount of work to get an exemption to be able to move this forward was a big eye opener. I do understand that we're going against what our current laws and practices are, but I did not anticipate the manpower that would be required.
What factors do you think will influence implementation success?
I think it will be hospital staff buy-in. If we can educate/inform people and get the staff buy-in, I think this will help to influence the success. I do think that we are unique with the fact that we do have an Addiction Medicine Unit already focusing on harm reduction and acceptance. This should provide us with a starting point for implementation along with success and the ability to share our successes cross-organizationally to help shift the thinking.
Any final words of advice to other hospitals looking to implement supervised consumption services?
What I've found with moving any kind of harm reduction initiative or any out-of-the-box thinking, is that engagement is critical. Engagement from senior leadership and getting support and buying-in from as high up as you can, will really help break the ground to move any of these initiatives forward. Also, starting small, such as starting with naloxone kit distribution even just on one unit or one area, as a pilot, then measuring success and building capacity to spread further. Any little step can help with staff buy-in and will help at least open up the conversation.
Also understanding that no one is alone in this fight, we are all fighting the same kind of battle, to help care for people. Patients have not just recently started using substances in the hospital setting. This has been an ongoing concern, just not spoken about openly. We are finally making it visible and trying to actually find a solution to a problem instead of just wiping it away.
Adele Bodson BScN, RN
Interim Quality and Education Lead for Addiction Services
Phone: 705-523-7100 ext: 2495