Supporting People Who Inject Drugs Utilizing a Socioeconomic Model

Mental health and addictions is a term used to cover a wide range of issues. The Ontario Ministry of Health reports:

Directly, or indirectly, mental illness and addictions affects one in five Ontarians. It can affect our personal lives, extended families and workplaces. It also affects Ontario's health care system and the provincial economy…

On June 22nd, 2011, with the support of the Ministry of Health and Long-Term Care, the Ministry of Children and Youth Services and the Ministry of Education, the government released Ontario’s Comprehensive Mental Health and Addictions Strategy.

Open Minds, Healthy Minds offers a comprehensive approach to transforming the mental health and addiction systems through a clear mission, forward-thinking vision and long-term strategies for change. The Strategy aims to strengthen services, create a responsive and integrated system and build awareness and capacity within communities.

Through strong collaboration across sectors, at both a provincial and local level, we can transform services so that all Ontarians have timely access to an integrated system of coordinated and effective promotion, prevention, early intervention, community support and treatment programs.

Open Minds, Healthy Minds takes a long-term view to this transformation and the first three years started with children and youth. The focus was on early identification and support, fast access to high-quality services and helping vulnerable kids with unique needs.

In Sudbury there is a movement to support People Who Inject Drugs (PWID) to prevent additional health complications. Safe injection sites have been developed in other jurisdictions, yet there is not yet one site in Sudbury that has been approved. Collaboration has been key and community engagement is ongoing.

One hospital in Calgary decided to provide safe injections within its facility. Studies show that PWID use unsterile supplies and are infecting themselves, and allowing safe injections in an acute care setting will help decrease infections (Wituik, 2019, Sharma et al, 2017). As the manager for Infection Prevention and Control (IPAC), my team of Infection Control Nurses (ICNs) is responsible to send out notifications of exposures of staff who were not wearing the appropriate personal protective equipment (PPE) to the Occupational Health and Safety Services (OHSS) department. Increasingly, these notifications are for infectious Group A Streptococcus (iGAS). From speaking with the ICNs many of the patients are repeatedly admitted for this and other infections which include, but are not limited to bacterial endocarditis, Methicillin-resistant Staphylococcus aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Hepatitis C, and HIV.Research has shown that patients that inject IV drugs prior to admission continue to use IV drugs while in hospital.Abstinence-based approaches such as the one at many acute care facilities are known to be ineffective at prohibiting drug consumption.

From A review of Frameworks on the Determinants of Health, (2015), the socioeconomic model is most commonly used.

Utilizing this, one tries to understand and subsequently support an initiative such as the one in the Calgary hospital. Yet, there are many reasons that this may not have greater support within our own institution.

The Institute of Health Equity (2018) proposes principals to guide the National Health System (NHS) in the UK.

Professor Sir Michael Marmot, in an interview discussing this model (2018) utilizes the following terms: "proportionate universalism", that "some need it more than others", and that the "effort is proportionate to the need". PWID need support to first help prevent infections. Safe injection sites, whether within a hospital or in a community-approved building are required. Once this support is initiated, other supports can be provided to understand the circumstances that lead to PWID using, and then look at how the community can improve those circumstances utilizing this framework also from the Institute of Health Equity:

One can find the interview here: https://www.youtube.com/watch?v=gghNP56N0Nk

Looking at this figure, one must understand first how to assess the culture of the organization to recognize the ability to implement such a change, then to understand how to implement this change. Engaging first the leaders responsible for the mental health and addictions program in understanding the need and the implications in decreasing the demands on the hospital system (decreasing hospitalization rates, decreasing hospitalization days, decreasing “Code White” incidents when patients cannot access their drugs) may support the implementation.

This program can be utilized within the safe injection site framework developed by the community. Public Health Sudbury and Districts is the lead on developing their Community Drug Strategy and their work along with data on overdoses, naloxone can be found on their website.

Supporting PWID in a safe environment, however does not get to the root of the issue. Socioeconomics can help understand why some people turn to using drugs.

· Individual lifestyle factors: sex (males) and heredity (individuals have shown to have addictive tendencies) are more likely to use drugs.

· Social and community networks: friends/relatives supportive or not?

General socio-economic, cultural and environmental conditions are further broken down as below.

· Agriculture and food production: easy/close access to healthy food

· Education: generally those with higher education are less likely to use drugs to the extent of requiring multiple admissions for infections from intravenous drug use (Jarrin et al, 2007)

· Work environment: stress/co-workers who use drugs

· Living and working conditions

· Unemployment: higher levels of unemployment may lead to housing insecurity (see below)

· Water sanitation

· Health Services: safe injection sites/mental health support/support in the local emergency department, or are they considered “frequent flyers”?

· Housing: If inadequate low income housing, do they “couch surf” with others? Are they living on the streets?

If we can understand the various factors that can lead to individuals turning to drug use, we may be able to help mitigate the risks of unsanitary intravenous drug use and support them to do so safely. Using this information may help make the cultural changes within health care facilities to support safe injections for PWUD while admitted, decrease their days of stay and decrease their admissions due to infections. Within the community, understanding how to support PWUD using this framework may eventually decrease the amount of PWUD.

References

Canadian Council on Social Determinants of Health (20150. A review of Frameworks on the Determinants of Health, retrieved from http://ccsdh.ca/images/uploads/Frameworks_Report_English.pdf

Community Drug Strategy for the Greater City of Sudbury, retrieved February 22, 2021. https://www.phsd.ca/health-Social topics-programs/alcohol-drugs/community-drug-strategy/

http://www.health.gov.on.ca/en/public/programs/mentalhealth/

Institute of Health Equity (2018). The NHS, health inequalities, and the Social determinants of health.

Institute of Health Equity (2018). Reducing Health Inequalities Through New Models of Care - Interview with Michael Marmot. [Video]. YouTube.

Jarrin, I., Lumbreras, B. ,Ferreros, I., Pérez-Hoyos, S., Hurtado, I., & Hernández-Aguado, I. Effect of education on overall and cause-specific mortality in injecting drug users, according to HIV and introduction of HAART, International Journal of Epidemiology, Volume 36, Issue 1, February 2007, Pages 187–194, retrieved from https://doi.org/10.1093/ije/dyl231

Sharma, M., Lamba, W., Cauderella, A., Guimond, T., & Bayoumi, A. (2017). Harm reduction in hospitals. Harm Reduction Journal, 14(32), 1-4. doi:10.1186/s12954-017-0163-0.

Wituik, C. A case for integrating substance use harm reduction into IPAC practice in acute care settings. Canadian Journal of Infection Control, Fall 2019, Volume 34, Issue 3, pp. 146-147.