ABOUT POSITIVE LIVING NIAGARA:
A proud living wage employer, Positive Living Niagara is a community-based organization delivering innovative and proactive harm reduction, prevention and people-centred programming. The organization provides support, education and advocates for those at risk of and affected by HIV, HCV and STBBIs in Niagara. Positive Living Niagara’s diverse programming addresses the needs of the regions diverse populations including newcomers and migrants workers, African, Caribbean and Black community, women, men who have sex with men, the LGBTQ2+ and drug using communities.
ICAD would like to thank Positive Living Niagara and its StreetWorks team for giving us so much of their time to make this special Featured Member article. Thank you for sharing with us, for being so open and for your dedication and incredibly impactful, life-saving and life-changing work.
- Meeting People Where They’re At… and when
- Innovative Paid Peer Program… with a living wage
- Outreach Vans… meeting them where they’re at… literally
- “The Times They Are A’Changin'”
- Managing Grief and Trauma
- Innovative Partnerships
The Niagara Region is famous for its iconic waterfalls, endless tourist attractions and world renowned wines. But what most visitors aren’t aware of is what life outside of the major tourist destination is for many of its residents. A largely conservative area, the region is made up of 12 different municipalities and has a population of approximately 450,000. It also has one of the highest rates of poverty and unemployment in Ontario and, with a large drug using population in the Region, it is also experiencing one of the worst overdose epidemics in the province. In 2017, there were approximately 76 confirmed opioid-related deaths in the Niagara Region, nearly twice as many as the previous year. Preliminary data from 2017 reveals that in addition to the loss of 76 people from confirmed overdoses, Niagara Region’s emergency departments had 521 visits due to opioid poisoning. But these numbers really don’t represent the full picture of what is happening within the drug using community in Niagara. Coroner stats are behind and their reporting methods are out-of-date. This means that not all overdoses are being reported and some drug-related deaths, such as endocarditis, not accounted for.
HIV and Hepatitis C in Niagara:
Although the new HIV infection rate is relatively low in the Niagara Region with six identified since the beginning of 2018, the rate of hepatitis C in Niagara is above the provincial average. In 2017 there were 228 new hepatitis C cases and within the first six months of 2018, 120 new hepatitis C cases were confirmed.
Niagara’s local AIDS service organization and Coalition member, Positive Living Niagara, provides harm reduction services within the region through its StreetWorks program. The team at StreetWorks works tirelessly to address the overdose epidemic and the risks involved in using drugs. ICAD’s Kate Alexander spent time with the dedicated team at StreetWorks to learn about their program, what makes it a successful and innovative model, and how they’re addressing the overdose epidemic in their own backyard. With 25 years of harm reduction programming, they have a lot of expertise to share.
StreetWorks Needle Exchange and Beyond the N.O.D. Opioid Overdose Prevention and Naloxone Distribution Program
Meeting people where they’re at… and when
The StreetWorks team is comprised of innovative, hardworking, mindful, caring, and passionate and compassionate front-line workers and volunteers (this is true for all of the staff at Positive Living Niagara). Since 1993, StreetWorks has been providing harm reduction services which continue to expand and adapt to the needs of the c community it serves in the Niagara Region. Built on a foundation of trust and respect, the program maintains strong connections in the drug using community, engaging peers within their programming, and maintaining a strong network of community partners. Currently, the StreetWorks team consists of 7 core staff, 3 on call staff, and 2 peers. The program, like so many, relies heavily on its volunteers with 1,820 volunteer hours logged every year.
The program operates out of the Positive Living Niagara offices in downtown St. Catharines, the largest hotspot for drug use in the Niagara Region. Staffed by outreach workers, the site operates during regular business hours from 9-5pm where clients are free to come in to collect safe injection and inhalation kits while also receiving additional services such as case management, access to treatment, overdose prevention and response training, and more. The program also utilizes two mobile units (vans) and several satellite sites to distribute its supplies from 6-11 pm five days a week. With the Region spanning across 12 municipalities, and the largest hotspots being in three separate cities (St. Catharines, Niagara Falls, and Welland), the vans and satellite sites play a major role in meeting the large demand for supplies, linkage to care, and ultimately the prevention of infectious diseases such as, HIV and hepC, and overdose deaths.
The data coming out of the StreetWorks program paints a story of a region in crisis. The demand for harm reduction services is very real and the numbers don’t lie:
Needle and Inhalation Kit Distribution:
- In 2017, StreetWorks distributed 1,675,305 sterile needles, an increase of 20% from 2016 and a 201% increase over a five-year span (2013-2017). In total, over the last five years, 5,825,555 sterile needles were distributed within the Niagara Region.
- Inhalation kits contain two pipes, four heat resistant mouth pieces, screens, a push stick and alcohol swabs. The number of safe inhalation kits distributed in 2017 has increased by 89% over the previous year from 5,026 to 8,095.
Naloxone Training, Distribution and Usage:
- Since the program began in August 2013, StreetWorks has trained 1,134 clients and 1,252 service providers.
- 1,178 new kits have been distributed and a staggering 1,264 kits have been used, with 556 kits used between January and August 2018 alone.
StreetWorks is the only needle exchange program in the region and one of the first three naloxone training and distribution programs in Ontario. Important to note with regards to the numbers provided above is that all the supplies distributed, as well as the number of naloxone kits used, are through the StreetWorks program only and do not reflect the naloxone kits distributed through other service providers. In fact, in the very recent past, StreetWorks was responsible for 20% of all naloxone kits used in the province, a testament to the effectiveness of the program’s ability to get these lifesaving kits into the right hands. One thing is certainly clear: the scope of the issue is far larger than all of the numbers can ever reflect.
StreetWorks was responsible for 20% of all naloxone kits used in the province, a testament to the effectiveness of the program’s ability to get these lifesaving kits into the right hands.
So how does this small but mighty team of front-line workers have such an incredible, life-saving impact in the community?
By using diverse outreach methods, including the main site, two outreach vans that connect with people in their homes, multiple satellite sites, and engaging peer champions. All of which could not be successful without the trusting relationships between the program, its clients and community partners. These relationships are the backbone of this strong program. There are individuals behind all of the numbers and stats and, like one StreetWorks staff affirmed, data is meaningless if you don’t have the relationships.
StreetWorks staff work alongside their clients, approaching their work from a strong belief in respecting a person’s right to self-determination and reducing harms within that context. In addition to providing safe supplies, they work with their clients using a case management model that supports their clients where they’re at, addressing both housing and food insecurity and providing access to medical and support services, etc. Last year (2017), StreetWorks worked with 1,293 clients directly through its program, either through the main site or its outreach vans. By meeting people directly where they’re at (homes, motels, the streets, drop-ins, soup kitchens, etc.) the outreach vans have helped staff to be introduced to individuals not accessing their services (secondary clients) and a reach that is extensive and impressive.
“At the end of the day it’s people. Humans. It’s not just about needles in and needles out. It’s about human beings and the relationships we have with them.” – StreetWorks
Needle exchange and inhalation kit distribution has become the base to build trust, to further engage with clients and has been a critical access point for reaching additional clients and bringing them into care should they wish. This trusted harm reduction service acts as a gateway for some of the most disenfranchised people in the community to enter into the local assessment, care and treatment network. It’s also been an important avenue for engaging more people for naloxone training and distribution. The two programs seem to have a positive symbiotic relationship where the naloxone program has also become a valuable tool for bringing more people into the circle of care, strengthening existing relationships and increasing engagement
While many clients have received naloxone training, outreach workers are seeing many new faces and an increase in the number of family members and friends of someone at risk coming in to receive training.
The regular 9-5 office hour model doesn’t work when engaging with clients and being able to meet them where they’re at. The vans strengthen the client-centred approach of the program by adding a realistic approach to the population its serves, when they want to access services and how. Although the fixed site operates during regular business hours, making the services accessible during the daytime, the vans offer continued service and outreach during the evenings, when and where demand is.
The second van was introduced during the summer of 2017 and has really allowed for StreetWorks to meet increasing demand more effectively. With 12 cities and 1,854 km² to cover in the region one van just wasn’t enough to get to everyone. Relationships and links to services and naloxone training were being lost out on. The second van has helped dramatically by allowing more time for outreach workers to spend time with their people again and giving an opportunity for folks to become engaged in other ways (naloxone training, nursing, counselling, etc.). Having the capacity to immediately offer training to people in their homes increased trainings by 40% over the existing next day visiting model that was in use.
Every day at around 5:00pm the team opens the phone line, listening to messages and taking calls from clients who share their location and the supplies they need. The two vans divvy up the calls and head out to meet with their people, usually homes, motels, parking lots, etc. Every night looks different but generally the two vans cover about four cities every night. Each van also acts as a backup for each other should someone request naloxone training, for example. The multi-van model recognizes the immediacy of the need and the ability to live up to it.
Often the only contact that clients have with the health care system is the outreach worker. As a way of closing this gap and increasing clients’ access to important services, the StreetWorks vans have collaborated with key partners in the region and are joined regularly by a Niagara Region Public Health nurse (twice/week), an addictions counsellor with the Community Addiction Services of Niagara (CASON) (once/week), and a hepatitis C worker (once/month). The outreach nurse offers a variety of vaccinations and tests during each visit including HIV, HepC, other sexually transmitted and blood borne infections and pregnancy tests.
Going directly to the clients has a number of advantages, one of which is connecting with community “ambassadors”. Home deliveries through the outreach vans tend to reach more people, as often the person is acting as an ambassador and receiving a large amount of supplies to distribute within their peer networks. During 2017, there were 2,227 occasions when interacting with a client where they self-identified an ambassador, revealing an additional 8,153 secondary contacts who are receiving supplies via their peers and the StreetWorks program. It is this proverbial “tip of the iceberg” concept that comes in when trying to get a grasp on the actual number of people who are using the service.
StreetWorks has established a number of strong partnerships with methadone dispensing clinics, drop in centre for sex workers, food backs, etc. that act as satellite sites to help expand the availability of supplies to clients. The sites are particularly effective at reaching folks for evenings, weekends and holidays. The satellite sites cover six different municipalities in the Region in areas of high community demand, ensuring that more people have access to services without having to travel long distances.
Noticing a steady increase in the use of crystal meth in the Niagara area, the StreetWorks team identified the distribution of sterile meth pipes as a much needed tool in its harm reduction arsenal. Roll out of the new kits began end-May 2018 and has averaged 1,000 kits/month. Meth kits contain two meth pipes, four heat resistant mouth pieces, and ten alcohol swabs. Since the kits were introduced, staff have been hearing from clients that they’ve stopped injecting meth and are now smoking instead. This, is a harm reduction win. In fact, StreetWorks staff feel that crystal meth isn’t being talked about enough within harm reduction circles. In Niagara, and elsewhere, meth is becoming a drug of choice, posing a number of risks to users: overdose due to it being mixed with fentanyl and increased risky behaviour that could lead to contracting HIV, Hep C or other blood borne infections.
The more services a needle exchange program can offer, the more appealing it is for people to access it and, as a result, the more people who can be linked into care. It means bringing people in from the margins of society and providing them with services that will help keep to them healthy.
INNOVATIVE PAID PEER PROGRAM… with a living wage
StreetWorks engages with peers closely and involves them in a number of meaningful ways that allow direct involvement in programming which also helps staff to keep a pulse on what is happening in the community. Having such trusting and authentic relationships with their clients has allowed the team to tap into the local lived experience in a number of meaningful ways, including peer program that provides clients with an opportunity to get involved, share their invaluable knowledge and connections to their networks in the community. The Peer Program has four stages, from kit assembly and education to a new paid peer that provides a living wage. The drug using community in Niagara has been provided with the opportunity be involved, to use their lived experience, learn new skills and have their voices heard. They are mentors, liaisons between the program and community members, educators and are, in many ways, outreach workers:
- PHASE 1: A group of active and former users volunteer three times per month in two separate locations (St. Catharines and Welland). Peers meet for two hours to assemble safe injection, inhalation and meth kits and do community clean-up activities. The time also provides StreetWorks staff with an opportunity to share information and resources to clients and to learn about current trends and what is happening out in the community. It also provides peers with an important opportunity to connect with each other, discuss what is happening within the community and relate in a safe and judgement-free setting. Peers are provided a $20 honorarium for each two hour shift. A fourth session in St. Catharines has now been added specifically for youth peers.
- PHASE 2: For peers wanting to become more engaged in the work, this phase prepares them for the next stage with eight sessions of training. Peers are provided with a $20 honorarium per training session.
- PHASE 3: Peers connect within their own peer networks, providing harm reduction education, information and supplies (if they’re comfortable), referrals, and act as a link to the StreetWorks program by participating in regular check-ins with staff to provide updates. Peers are provided $50/month based on five hours of work.
- PHASE 4: Hired peers. The newest phase in the peer program currently has two hired peers (with the aim of four) working alongside the StreetWorks team at least once a week while earning a living wage. Hired peers provide naloxone training, replace kits, conduct community outreach, help with follow up through MHART and attend and actively participate at committee meetings for OPENN (more on MHART and OPEN below) This phase has experienced some challenges in recruitment as being in a small region you lose anonymity. However, with two very strong and engagement engaged peers in place, other clients are seeing what is possible.
THE POWER OF PEERS
Lived experience is a powerful tool and the first trial of “walking outreach” with a peer demonstrates this. During a walk together in the St. Catharines downtown core, a peer introduced a StreetWorks outreach worker to members in their community who have not previously been engaged in the StreetWorks program. Through this form of outreach, two visits over the course of one week engaged more new community members than the program has ever engaged before, either through the mobile units or the drop in at the StreetWorks office.
“Immediately you can see that the walls were dropped right away. People were engaged and already had a level of trust because a peer had done the intros.”
Interview: StreetWorks Peer Program
Dawn, a peer and client with StreetWorks shares her personal experience working in the peer program and how it has impacted her personally.
“THE TIMES THEY ARE A-CHANGIN’“
With the Niagara Region being a politically conservative area, the program has had to operate mostly under the radar since its beginnings in 1993 due to stigma associated with harm reduction, drugs, and the clients the program supports and serves. Harm reduction wasn’t a phrase you uttered easily among community partners and emergency response teams – until now, that is. In many ways, Positive Living Niagara and its StreetWorks team, have been able to “come out of the closet” and are now looked at as a leader within the community, receiving an incredible amount of support from funders, partners and citizens in Niagara. This, the StreetWorks team believes, is due in large part to the increased attention in the media, increasing political support, and more awareness of the issues and personal loss within Niagara’s residents. But all of this success in the Region would not have been possible without the hard work of colleagues in other cities such as Toronto, London and Hamilton who have been incredibly supportive; advocating tirelessly for increased harm reduction funding and services including overdose prevention and supervised consumption sites.
“We’re no longer ‘the uncle that nobody likes to talks about’. What’s been happening since the end of 2017 is every harm reduction workers dream.” – Talia Storm, Supervisor of StreetWorks Services
Overdose Prevention and Supervised Consumption Sites in Niagara:
Federal attention and support for harm reduction services brought with it new funding to the region, increased dialogue and partnerships among service providers, local government and emergency response teams. In 2017, the Federal government identified the Niagara Region as an area in high need of increased harm reduction programming and overdose prevention. As a result, Positive Living Niagara, with unanimous support from St. Catharines City Council and their community partners, was set to open a temporary overdose prevention site which would operate out of the StreetWorks office. As the number of overdoses and deaths continue to increase, the organization is also set to apply for a permanent supervised consumption site, with support from local government and emergency response departments. The agency had been working tirelessly to get the OPS ready to open and was nearly at the finish line when unfortunately, it was put on hold by the Ford government while it conducts an “evidence-based review”. The St. Catharines site is one of three sites in Ontario put on hold for the review.
Managing Grief and Trauma:
It would be remiss not to acknowledge how the trauma of the overdose epidemic has affected everyone involved. From clients, to family and friends as well as those working on the front-lines, the overdose epidemic and the high risk involved with using substances takes a heavy toll on everyone.
Clients and Community: StreetWorks provides in-formal support to clients on an on-going basis however a new program recently introduced, Single Session Counselling, provides folks with an opportunity to come in without an appointment to get solution-focused counselling support. In addition to this, StreetWorks is introducing a SMART Recovery group in October, 2018 for friends and family members who have a loved one using substances.
Supporting the Front-line: While getting to know the StreetWorks program and its team we also caught a glimpse of the emotional roller-coaster front-line staff experience regularly with the work that they do. The impact of losing clients and the high-number of overdoses among StreetWorks clients takes a heavy emotional toll. Recognizing the importance of addressing the grief and trauma and the need for self-care, Positive Living Niagara is currently taking steps to provide support and counselling for its staff. Staff also meet together regularly to decompress and share their personal experiences from the front-lines in an effort to relate and process their experiences.
Engaging deeply with local politicians, community partners and emergency response departments has been critical to supporting and reaching those in need of support. Positive Living Niagara has established some powerful and innovative partnerships with key stakeholders in the region:
Overdose Prevention and Education Network of Niagara (OPENN):
In the spring of 2016, the Overdose Prevention and Education Network of Niagara (OPENN) was formed. The Network is made up of 30 local community organizations, agencies, mother’s groups and school boards responding in various ways to the overdose crisis in the Region. The Network is co-chaired by Positive Living Niagara and the Niagara Region Public Health. OPENN is a unique collaboration amongst community to address the high rate of injection drug use and the overdose epidemic. The idea behind the network came from StreetWorks staff after noticing a significant spike in the number of naloxone kits being used in the community. Recognizing that other players must have information about the overdoses as well, StreetWorks approached the Chief of Police and asked him to invite key stakeholders to the table to talk about drug use, overdoses and opioids in the Niagara Region. At the time of inception, the purpose of OPENN was to come up with a mechanism for real time information sharing among partners in order to get a handle on trends in the region and to implement programming appropriately. Currently, the Overdose Prevention and Education Network of Niagara has identified pillars for a strategy including overdose prevention and supervised consumption sites, education, advocacy and surveillance.
When we asked if OPENN will include a peer seat on the Network, Positive Living Niagara’s Executive Director, Glen Walker, responded in a way that most would hope for, “We don’t believe in including a person as a token. We’re creating a peer advisory framework that will feed into the work of OPENN.”
StreetWorks – Mental Health and Addiction Response Team (MHART) Partnership:
There is a unique collaboration between StreetWorks and local Niagara Emergency Medical Services’ (EMS) new team called MHART – Mental Health and Addiction Response Team. The MHART team is staffed by paramedics and mental health nurses whose purpose is to provide follow up care and support to people who have experienced an overdose. Services include wound care, blood work, mental health care, and direct access to treatment. The collaboration between StreetWorks and MHART allows for a mutually supportive relationship that places care and support of the client first.
How will it work?
- The MHART team will connect consenting clients to the StreetWorks team who will follow up with case management, naloxone training, and other services needed. Should a client not consent to be put in touch with StreetWorks staff, they will be provided with the teams contact information should they wish to connect in the future.
- StreetWorks will connect clients (pending consent) to the MHART team who require support beyond StreetWorks’ abilities.
- With stigma and discrimination experienced within the healthcare facilities as a main barrier to accessing medical and mental health care, many clients do not want to seek care in hospital settings. To address this, StreetWorks and MHART will work closely to ensure that clients are transported directly to places for support other than the hospital, such as safe beds, detox, etc.
- StreetWorks may also call upon MHART to assist a client needing medical treatment (abscesses, for example) allowing for direct, judgement-free care for the client in need.
The MHART – StreetWorks collaboration is a great partnership model working to ensure that clients are not lost to care while receiving judgment-free support that puts their needs and where they’re at first.
The StreetWorks team took the time to share some lessons learned from their 20+ years of experience running its harm reduction program:
- Listen to the clients. They will teach you what you need to know.
- Don’t wait for people to come to you. Outreach is key: The success of StreetWorks is due, in large part, to the trust and respect established with their clients. In order to achieve this it’s important to provide services respectfully on their turf. This is essential to building trust and developing relationships with clients and community members. In addition to trust building, going directly to clients provides an opportunity for outreach workers to establish connections with people they wouldn’t normally be able to connect with.
- Volunteers, volunteers, volunteers: With 1,820 volunteer hours every year with StreetWorks, it’s safe to say that the harm reduction program wouldn’t be the success that it is without its volunteers. Every day StreetWorks is supported by 15 volunteers who help from loading the vans with supplies each night and assembling safe inhalation kits to data entry. Engage with community members, including peers, and get them involved in your program.
- Hours of Operation – stay client-focused: 9-5 hours of operation doesn’t work when engaging with clients and meeting them where they’re at. Although the StreetWorks office operates during regular business hours and experiences regular traffic from clients every day, the mobile units offer continued service and outreach during the evenings when and where demand is. What’s more, having satellite sites in place where clients can access injection and inhalation kits such as at methadone dispensing clinics, drop in centres for sex workers, food banks, etc. are effective for evenings, weekends, and holidays.
- Patience: Patience is critical when developing relationships with clients. Don’t expect your client to fully engage in the relationship from the start. It takes time for a client to develop trust with outreach workers. For new programs trust will be a challenge. Ensure you’re hiring the right people. Any judgement from you will cause your client to shut down.
- Language is so important: Always use person-first language. It reduces stigma and helps to build trust.
- Keep people engaged while they wait for access to care an treatment: So many people were lost to care because there was a gap between their decision so seek support and when they could gain access to the traditional service system. Interim case management support, warm transfers and bridging programs like SMART recovery and brief counselling can keep people engaged while they wait for admission to mental health and addictions programs.
- NEVER give up on anyone: Despite what people may say or do always circle back as people’s lives, and needs change from day to day.
StreetWorks has expanded in ways that the team has only dreamed of. Within a relatively short period of time the program has increased number of staff, from 3 staff to 7, from operating out a 9-5 office and one mobile outreach unit to two, and to expanding its peer program to offer paid work. Collaborations and partnerships with local emergency responders has opened dialogue and enabled StreetWorks to access information that helps them determine the growing areas of need. All of this means more people reached and engaged into the program, more infections prevented and more lives saved.
Would you like to contact Positive Living Niagara and the StreetWorks Program?
ICAD would like to thank Positive Living Niagara and its StreetWorks team for giving us so much of their time to make this special Featured Member article. Thank you for sharing with us, for being so open and for your dedication and incredibly impactful, life-saving and life-changing work.