Use of stimulants, and in particular methamphetamines, has been rising in Canada. Even with a rise in methamphetamine use, people who use stimulants have not historically been prioritized in harm reduction programs and services. Programs have had to adapt the way that they are delivering services to better consider the potential health needs and behavioural supports that people who use stimulants may need and want.
We talked to three programs that provide services specifically for people who use stimulants in Ontario and Manitoba to learn more about the services that they provide, how they do it and the challenges and lessons learned from their work.
- Maticus Adams, harm reduction programs coordinator, MAX Ottawa, Ottawa, Ontario
- Sarah Hansen, project manager for the Meeting the Moment Project, Nine Circles Community Health Centre, Winnipeg, Manitoba
- Tomas Mirabelli, drop-in coordinator, St. Stephen’s Community House
Maticus Adams, harm reduction programs coordinator, MAX Ottawa, Ottawa, Ontario
What needs were identified in your community in relation to serving people who use stimulants?
One of the biggest needs we have heard from the community is the desire for mental health first aid for folks who use stimulants, in particular for when folks over amp or experience paranoia, emotional distress or psychosis. Folks who party and play (PnP), or use drugs to facilitate or enhance sexual encounters, want to be able to manage these situations, especially when hosting events where PnP will take place. If a person goes into distress after using a stimulant (e.g., crystal meth), people fear reprisals or charges from law enforcement personnel, who may come with the ambulance if they call 911.
Right now, the common practice is to try and calm the person in distress down, and people are looking for information on how to do this. If people are unable to manage the potentially erratic behaviours of people who are using stimulants, people may be kicked out of events, which can be complicated (e.g., people can get picked up by police, get lost, lose possessions, cause issues for people hosting events). Folks who PnP have a long history and a community built on taking care of each other. We aspire to give them the tools they need so they can continue to do so.
How is your organization working to provide services to people who use stimulants? What changes have been made to your services, if any, to better serve people who use stimulants?
At MAX, we have a Safer Partying Advisory Committee, which is made up of folks from the PnP scene. The committee provides feedback about our programming for folks who PnP and informs us about the needs of the community.
Through our Tea 2 Go Program, we offer harm reduction supplies to guys who PnP. This includes a variety of safer partying, overdose prevention, safer sex and safer hormone injection supplies. We developed the program with guys who PnP in mind, with the goal of setting up the programs with as few barriers as possible. To address barriers, we enable clients to order supplies through an online form, where they can use an alias, an email address is not required and no intake is required. Participants can choose to have their order delivered within Ottawa and the area served by Home and Community Care Support Services Champlain, or they can pick up the order at our office. Everything is packaged in plain brown paper bags and boxes to try and make the supplies look like other non-descript deliveries (e.g., an online shopping purchase).
We are re-launching our drop-in support group Tea Party, which is a bimonthly, peer-led drop-in for folks from the PnP scene. Folks can come and share experiences, create connections with other community members and talk about subjects that are important to them. Topics are determined by peer facilitators and can include education related to stimulant use or other relevant topics.
What have been some of the challenges associated with providing these services? What are some lessons learned you could share with others working with people who use stimulants?
The conversation around stimulants seems to sometimes get lost as so much focus, and with good reason, is applied to opioids as a result of the ongoing drug poisoning crisis and all the lives lost. Folks who use stimulants may often assume that programs aren’t geared toward them, so I’d suggest making sure marketing and promotion explicitly say that programming is for people who use stimulants.
Sarah Hansen, project manager for the Meeting the Moment Project, Nine Circles Community Health Centre, Winnipeg, Manitoba
What needs were identified in your community in relation to serving people who use stimulants?
Meeting the Moment (MTM) Project is a pilot project through Nine Circles Community Health Centre in Winnipeg, Manitoba. The community served is people who use drugs (PWUD) or experience housing instability or social exclusion and live in Winnipeg’s core (Downtown and Point Douglas). This community struggles with racism, poverty, housing instability, stimulant and other substance use, and sexually transmitted and blood-borne infections.
People using stimulants and other substances experience significant barriers to accessing healthcare and are often unable to attend a healthcare setting for an appointment. Barriers include mental health challenges, addiction, trauma and discrimination. This program aims to reduce barriers to healthcare for this community by helping them to engage with multidisciplinary primary care to address their identified health needs.
Half of the MTM clients report using substances. The most common reported substance type is meth (36%) and the next most common is alcohol (19%). Meth is highly addictive and very difficult to quit. Unlike other substances such as opioids, there are no approved replacement therapies or medication-based therapies for meth yet. Meeting people where they are and building trusting therapeutic relationships is the first step to providing care.
How is your organization working to provide services to people who use stimulants? What changes have been made to your services, if any, to better serve people who use stimulants?
MTM partners with community organizations to pilot and evaluate low-threshold multidisciplinary services in community settings (e.g., community centres, emergency adult and youth shelters, and street outreach) to reduce barriers to accessing care and meet people where they are.
The program provides street outreach, harm reduction, primary care and addiction medicine, and cultural and social services. It tries to connect clients to primary care providers (PCPs) or specialists for follow-up for chronic or complex health issues. The program also distributes harm reduction supplies, including safer injecting kits, bowl pipes (i.e., “bubbles”) for people who use crystal meth and stems for people who use crack.
All team members are given tips on how to recognize signs of stimulant overdose and how to respond, as well as signs of psychosis induced by meth or other stimulants and how to respond. Team members have knowledge of, or are provided training on, mental health first aid and the resources available in the city to support people in crisis or with mental health needs. We are also looking into alternate options for getting clients emergency help that does not involve police or emergency medical services (e.g., services that help to transport people to and wait with them in emergency departments). Team members (including the entire multidisciplinary team) are provided with a variety of training opportunities on topics such as harm reduction 101, naloxone use and overdose prevention, trauma-informed care, conflict resolution and cultural learning (e.g., medicine picking).
MTM meaningfully engages peers (members of the priority population) in all aspects of the project including design, promotion, implementation and evaluation, and social workers have created a peer orientation to support this. Orientation includes topics such as gender, safe space, inclusivity, equity, cultural sensitivity, stigma, confidentiality, power and privilege, boundaries, harm reduction principles, Indigenous-centered approaches to harm reduction and substance use and HIV 101.
Capacity building occurs among team members, community organizations and clients. There is mutual mentorship as we all learn from each other about how to support our community.
What have been some of the challenges associated with providing these services? What are some lessons learned you could share with others working with people who use stimulants?
Challenges:
- Many of our clients have experienced discrimination and trauma at healthcare settings and require a lot of support and encouragement to get their urgent health needs met, and they will refuse to accept transportation via an ambulance.
- As MTM is a pilot project, the funding model limits us to offering interventions on two days a week, and we are able to provide only acute episodic care. We try to connect clients to primary care providers (PCPs) or specialists for follow-up for routine care and care for chronic or complex issues, but there is a shortage of PCPs, and the existing pool of PCPs lacks capacity to provide all of the needed services.
- We had some setbacks due to COVID-19, which were related to interventions being delayed and additional strain on healthcare and social services.
- There is a high demand for services from community members and organizations, and meeting the demand is a challenge.
Lessons learned:
- Stimulants can cause people to feel agitated or anxious, and stimulants can be related to experiences of psychosis. These experiences may lead some individuals to respond in aggressive ways — sometimes out of fear. Service providers should have training on how to safely de-escalate situations that may involve aggression or violence and a contingency plan for if de-escalation doesn’t work.
- It is important to have a multidisciplinary care team that includes a prescriber (nurse practitioner or physician), a cultural support worker, peer support workers, a social worker and a nurse. Clients value and take advantage of access to a multidisciplinary team.
- Addiction, poverty, housing instability and social injustices intersect to increase clients’ risk of ill health. Acknowledging this and providing care from a non-judgmental, trauma-informed and harm reduction–focused lens are essential in supporting our clients.
- Working with peers is new to us, so there have been many mutual learning opportunities. Peer engagement informs practice and builds trust within the community. The biggest learnings so far have been that we need to make decisions collaboratively with peers at all levels, actively seek and be receptive to feedback, and approach interactions with compassion and humility.
- Offering services outside traditional health settings that are flexible and responsive to the needs of the community shows promise for increasing access and reducing barriers to care.
Tomas Mirabelli, drop-in coordinator, St. Stephen’s Community House
What needs were identified in your community in relation to serving people who use stimulants?
One of the key needs that our community identified was for a safe place for people who use crystal meth, such as an afternoon drop-in. Having a safe place was important because there are very limited services for people who use crystal meth in our area, and we wanted to provide a low-barrier program for users. It’s important for users to have a space of their own where they feel safe to be themselves among peers who will not judge them. Users should feel free to express themselves and trained staff at our organization are able to support them and take the time to listen to them.
How is your organization working to provide services to people who use stimulants? What changes have been made to your services, if any, to better serve people who use stimulants?
Our agency decided to open three afternoon drop-ins from 12:00 to 3:00 pm on Mondays, Wednesdays and Fridays specifically for people who use crystal meth. During these dedicated drop-in hours, we take a number of steps to make the space more comfortable for people who use crystal meth. For example, we dim the lights and we make sure there are quiet rooms available. We have also implemented a bike group, art groups and sessions for making harm reduction supply kits for people to participate in during these times. We also offer shower and laundry services at the drop-ins.
While we have core staff on site, peers run the drop-ins and do outreach. We have a doctor on site on Mondays to meet with clients and a nurse on site four days/week.
What have been some of the challenges associated with providing these services? What are some lessons learned you could share with others working with people who use stimulants?
COVID-19 proved to be challenging as the number of people we could allow inside the drop-in had to be reduced. We also had to work to assure people that police would not be present at the drop-in and that it was a safe space for everyone.
One of the key lessons we learned was that it takes time to set up a program specifically catering to crystal meth users and involves making a few changes to the way programs are delivered. Additionally, we learned that:
- When we are getting ready to close the drop-in, we need to give clients more time to prepare to leave and gather their belongings than we do for our other clients. Rather than giving 15 minutes’ notice before closing, we now make sure to give notice an hour before we close.
- When clients are talking, it is important to let them finish their thoughts, rather than jumping in and making assumptions about what they are saying. This builds rapport with the client and allows them to be heard.
We never say “yes” to a client if we are uncertain about how to answer a question. This is important to prevent disappointment when an issue cannot be resolved in the way we might have hoped. Rather, we explain that we will see what we can do or we will look into the matter, and then we follow up with a plan. We try to never let a client down, as this can damage the rapport and trust we have built so far.