What is the Program?
The Harm Reduction Satellite Sites Program at Parkdale Queen West Community Health Centre (PQWCHC) employs people with lived experience of drug use (peers) as satellite site workers (SSWs). SSWs provide harm reduction supplies (e.g., injection and smoking supplies), overdose response training and naloxone, safe needle disposal and other supports (e.g., referrals to health and social services) from their residences (referred to as satellite sites).
The goal of the program is to reach people who use drugs and who do not, or cannot, access traditional harm reduction programs. The program uses a “secondary distribution” model, where SSWs obtain supplies from a harm reduction program and then distribute these supplies to their networks and among neighbours in the buildings where they live.
PQWCHC is a community-based health service organization. Services offered include primary healthcare, dental care, harm reduction, health promotion, counselling and community development programming. The Harm Reduction Satellite Sites Program is embedded in the PQWCHC. It was started eight years ago on an informal basis and has since been formalized and expanded. The program is modelled after the Satellite Site program at the South Riverdale Community Health Centre, which was developed by drug user activist and harm reduction pioneer Raffi Balian.
Why Was the Program Developed?
The program was developed to reduce barriers that people face when trying to access harm reduction supplies, including barriers such as distance to services that distribute supplies, limited hours of operation of these services and the need for discretion when accessing harm reduction supplies. The program allows low-barrier access to drug use supplies, overdose response and other supports by expanding the coverage of existing harm reduction programs, both in terms of opening hours and geography. The program also provides a low-threshold point of entry to health and social services through informal referral networks created by SSWs.
The Harm Reduction Satellite Sites Program has evolved over time to increasingly address issues related to the overdose crisis by providing supports that are more specific to overdose prevention and response (e.g., SSWs provide naloxone and offer training on how to use it, and they share information about drug alerts and bad batches).
How Does the Program Work?
The Harm Reduction Satellite Sites Program operates out of the two sites of the PQWCHC. The SSWs are located in residential buildings in the PQWCHC catchment area. The SSWs distribute harm reduction supplies and provide education (e.g., on safer injection practices) and information (e.g., community referrals, alerts on bad batches of drugs) to their neighbours in priority buildings (i.e., satellite sites).
Priority buildings for harm reduction supports were initially identified through a needs assessment with community members. A variety of additional information sources are now used to identify priority buildings, including:
- street outreach teams
- Toronto emergency services data on overdose calls to identify “hot spots” where supports are needed
- communication with clients and community members who are using PQWCHC’s services
- ongoing consultation with the broader community of people who use drugs through a community advisory group (CAG)
The CAG advises PQWCHC on all aspects of the program, ensuring the program always has “an ear to the ground.” The CAG is composed of community members from priority populations as well as representatives and peer workers from partner agencies. The CAG has eight to 12 members and meets approximately four times per year.
The program is staffed by SSWs who live in identified priority buildings. SSWs are recruited through word of mouth and referrals by community members, and potential SSWs may also be identified because they voluntarily visit one of the two sites of PQWCHC to pick up large quantities of supplies for their friends and/or neighbours. The recruitment process includes a job posting and an interview. The program coordinator and current SSWs do the recruitment (e.g., sharing job postings, conducting interviews) for the program. Recruitment for positions is targeted in and around identified priority buildings or areas. SSWs are well-known and trusted members of their communities and are knowledgeable about the local drug scene.
The PQWCHC program currently has 10 SSWs at the time of writing. All SSWs provide the same core services from within their residences:
- distribution of harm reduction supplies
- naloxone distribution
- overdose response training
- referrals to other services (e.g., referrals to primary care, legal supports related to housing needs, and peer health navigators who can accompany clients to appointments)
- support and education on safer injection practices, including HIV and hepatitis C prevention, vein care and prevention of skin infections
- sharing of important and time-sensitive information (e.g., information about contaminated batches of drugs, referrals to community services and information on “bad date” lists for sex workers)
In addition, some SSWs allow trusted clients to use drugs in their residence, providing peer-supervised drug use for safety in the event of an overdose or other adverse reaction. Some SSWs become satellite peer leads, who are SSWs with more work hours and responsibilities (e.g., completing health promotion outreach events in residential buildings).
SSWs pick up the harm reduction supplies that they distribute on a weekly basis, and they are expected to record the number of encounters they have and the supplies they distribute on anonymous weekly stats sheets. They establish their own work hours (can be flexible), which are often outside of regular community health centre hours. The expectation is that SSWs distribute supplies four to six hours per week. SSWs are not on-call, and efforts are made to ensure that they are not over solicited in their role.
People typically learn about the program through word of mouth. Most SSWs operate discreetly to protect their own privacy, although some SSWs choose to promote their services in a range of ways (e.g., flyer on their door) when they feel comfortable doing so.
Attempts to gain the support of the management/operator of a residential building are made only when the SSW feels that it would be useful and that the building management/operator would be receptive. Identified buildings are sometimes receptive to having a SSW because of the supportive role they can play (e.g., increasing safe needle disposal, overdose reversal). Gaining the support of housing providers can be a long-term and ongoing process. Additionally, the program coordinator, satellite peer leads or other outreach workers do outreach to identified buildings to build support or to address misconceptions about harm reduction.
SSWs play an informal role through the use of their own networks, and therefore there is no formal memorandum of understanding (MOU) created between the program and the buildings where SSWs operate. Often health promotion events (e.g., drop-ins, health fairs in building lobbies) or outreach nursing are held in certain buildings to build relationships with building management/operators and to introduce the building to harm reduction programs. An MOU is created for more formalized outreach events.
SSWs operate as independent contractors. They receive an honorarium in recognition of their time ($60–$90/a week depending on the extent of their responsibilities and hours worked), with any additional team meetings, trainings or orientation being compensated at an hourly rate ($15/hour). Payment is tied to the program’s current funding arrangements.
Satellite Support Worker Training and Support
The program builds upon the expertise and experience of SSWs by providing ongoing team trainings and other training opportunities. SSWs are required to complete a variety of trainings during an orientation period within the first few months of service and then on a periodic basis. A series of six to eight mandatory team trainings and workshops are provided to SSWs per year, covering topics such as:
- safe needle handling/disposal
- stimulant and opioid overdose response training, including the use of naloxone
- asserting and communicating boundaries and the ethics of peer-based work
- conflict resolution and crisis de-escalation
- HIV and hepatitis C prevention, testing and treatment
- making effective referrals and pathways to care
- legal rights with police and the Good Samaritan Drug Overdose Act
- sex worker rights
Training sessions on other topics (e.g., presentations on atypical overdoses, active listening) are provided as needs arise.
Support for SSWs, particularly in the context of the ongoing overdose and drug poisoning crisis, is a critical and central component of the program. The program coordinator does weekly individual check-ins with SSWs, in addition to providing support around operating their satellite sites and around asserting limits and negotiating boundaries with clients. Additional support is provided as required (e.g., facing conflicts with landlords, legal issues). The program coordinator holds regular team meetings to discuss and troubleshoot issues that the SSWs are facing and to provide a space to process grief over the loss of other community members.
Required Resources
- A full-time program coordinator
- SSWs
- Community support (e.g., from landlords or housing providers) can be beneficial but is not required
- Resources for honoraria, training, meetings
- Cell phones for the SSWs so that they can be in communication with the program coordinator about potential health and safety concerns
- Harm reduction supplies (e.g., needles, pipes)
- Overdose supplies (e.g., naloxone)
Challenges
- The program operates out of a variety of buildings and there can be challenges with gaining access to new buildings or with satellite activity drawing unwanted attention to the SSW. Owing to the stigma faced by people who use drugs, some housing providers attribute any foot traffic or visits to the SSW’s unit as evidence of drug trafficking. The program supports SSWs in mediating any tensions with building managers or landlords and has housing legal resources that SSWs can access if they need them.
- Social/structural issues in the lives of the SSWs can affect their ability to run their satellite sites. Often these issues are related to the criminalization of drug use and possession, eviction threats based on stigma related to drug use, or health issues. The program provides flexibility, support services (from the program coordinator and others) and referrals to community services (e.g., legal supports related to housing and other issues) for SSWs, recognizing the barriers that workers and clients may face.
- The ongoing overdose crisis has had an enormous toll on the emotional well-being and physical health of all people who use drugs, including SSWs. Many SSWs have experienced personal loss and are regularly involved in reversing overdoses. Additional harm reduction and overdose supports such as pathways to counselling services have been put in place for both clients and SSWs, and the frequency of team meetings has been increased to provide a supportive space for SSWs.
Evaluation
In the one-year period between July 2018 and June 2019, the SSWs connected with 206 individuals who were not previously connected with the PQWCHC or other harm reduction services. The following approximate numbers of supplies were distributed among seven SSWs during this period:
- 78,000 needles
- 5,124 crystal meth and crack pipes
- 380 naloxone kits
Data gathered in June 2016 through client questionnaires administered by the SSWs (16 respondents) indicate that:
- 94% of individuals who accessed services at a satellite site reported encountering fewer challenges when accessing sterile needles (or other harm reduction equipment) at a satellite site than at traditional sites or via other methods of accessing sterile material.
- 25% of satellite site clients reported having accessed HIV or hepatitis C testing or treatment services as a result of accessing services at a satellite site.
- 100% cited convenience as the main reason why they chose to access their harm reduction supplies through a satellite site, 56% cited anonymity/discretion as the main reason, and 56% said it was because the satellite site allowed them to access supplies through a peer (person who uses drugs).
- 75% of clients of satellite sites reported knowing more about how to prevent, or respond to, an overdose since accessing a satellite site.
What SSWs say about the program:
“Knowing people are getting safe injection and smoking stuff, knowing that people are using safely and that I’m a part of making that happen, it feels good.”
“My biggest accomplishment? Definitely saving lives. Nothing beats that. I like to think also that I’ve made some difference in my role in my time as a satellite worker. These are pioneering jobs, and we’re defining them, in terms of what they look like, what needs to be done, and I feel really privileged to be a part of building something like that.”
“Definitely the flow of the information is so important – so I can share this with clients, so they have the best up-to-date information of where to spend their money when the stakes are so high for all of us. Bad batches, weak batches, batches that would require twice as much water, batches that cause weird reactions.”
Lessons Learned
- Ongoing support of SSWs (e.g., trainings on how to assert limits with clients, how to interact with clients and how to respond to eviction attempts and maintain tenancy) is crucial to ensure that people’s sense of urgency and their informal support networks are not being exploited. It is critical for SSWs’ safety that they be supported in asserting boundaries and de-escalating conflict and that they be supported as they grieve the loss of people to the overdose crisis (e.g., through weekly individual check-ins).
- Recognition that there is a need for ongoing consultation with the broader community of people who use drugs is crucial to ensuring that the satellite sites are in appropriate locations where they will have the greatest impact. The community advisory group of people who use drugs and other stakeholders (e.g., members of communities disproportionately affected by criminalization, HIV, hepatitis C and overdose) help to ensure that the program is reaching the communities most affected by the criminalization of drug use and related health issues.
Program Materials
Contact Information
Liam Michaud
Harm Reduction Satellite Sites Program Coordinator, Parkdale Queen West Community Health Centre
1229 Queen St W
Toronto, ON M6K 1L2
Email: lmichaud@pqwchc.ca
Telephone: (416) 537-2455 ext 1285