Actions to Respond to the Drug Poisoning Crisis in Toronto

Data shows 531 confirmed opioid toxicity deaths among residents of Toronto in 2020, an 81 per cent increase compared to 2019. From November 1, 2020 to October 31, 2021, Toronto Paramedic Services responded to 5,776 suspected opioid overdose calls, including 351 calls involving death. This is a 61 per cent increase in the number of suspected opioid overdose calls compared to the previous 12-months, and a 53 per cent increase in the number involving a death. Fatal and non-fatal overdoses continue to increase, which are attributed to the unpredictable and toxic nature of the unregulated drug supply, as well as pandemic-related service reductions and physical distancing requirements. Toronto Public Health is leading City efforts and working with other City divisions and community partners to implement the Toronto Overdose Action Plan to prevent and respond to drug poisonings in Toronto's communities. On June 14, 2021, the Board of Health once again recognized the drug poisoning crisis as a public health crisis and reaffirmed commitment to supporting actions that are urgently needed to respond to the crisis and stem the tide of overdose deaths. These actions include calls for the immediate scale-up of safer supply initiatives, supervised consumption services and other harm reduction initiatives, as well as more affordable and supportive homes for people in need, including people who use drugs. At the same meeting, the Board of Health requested the Medical Officer of Health to convene a multi-sectoral working group to develop a health- and social equity-based alternative approach to criminal penalties for the possession of all drugs for personal use in Toronto, as a step towards requesting an exemption under the Controlled Drugs and Substances Act, 1996. The Controlled Drugs and Substances Act is administered by Health Canada and establishes the legislative framework that regulates the possession, distribution, and sale of unregulated drugs in Canada. Under Section 56(1) of the Act, the Federal Minister of Health has the authority to exempt jurisdictions, including municipalities and provinces, from provisions of the Act that criminalize drugs if the Minister deems it necessary for a medical purpose or it is in the public interest. The same authority has been used to allow supervised consumption services to operate in jurisdictions across Canada. There are now growing calls for decriminalization across Canada, with support from civil society organizations, institutions, and law enforcement. On November 1, 2021, the Government of British Columbia became the first province in Canada to seek an exemption from Health Canada under Section 56(1). This follows a similar request from the City of Vancouver, and the endorsement of decriminalization by municipalities, such as Kingston, Montreal, and Ottawa, and organizations, such as Ontario's Big City Mayors and the Centre for Addiction and Mental Health. Further, both the Ontario Association of Chiefs of Police and the Canadian Association of Chiefs of Police have called for decriminalization. Consistent with other jurisdictions, Toronto Public Health has initiated a consultation process as a step towards requesting an exemption under the Controlled Drugs and Substances Act from Health Canada for the possession of all drugs for personal use within Toronto's geographic boundaries (also referred to as the decriminalization of personal possession of drugs). This report provides an update on the process currently underway to develop an alternative approach to the criminalization of drugs in Toronto, including public and stakeholder consultation to inform an alternative model. There is widespread support for an alternative model that is grounded in a human rights and a public health approach in order to decrease stigma and harm for people who use drugs, while also improving the well-being of the communities around them. It is important to note that decriminalization alone will not solve the drug poisoning crisis. Seeking an exemption from criminal penalties for personal possession is only one part of a comprehensive approach. To be successful in reducing the harms associated with substance use and criminalization of people who use drugs, the removal of criminal penalties must be accompanied by new investments from the provincial and federal governments and improved access to safer supply programs, harm reduction, and treatment initiatives. While some people use drugs without experiencing health-related harms or developing a substance use disorder, significant investments are needed from all levels of government to ensure low barrier access to health and social services for those most at-risk of drug-related harms. On October 25, 2021, the Toronto Board of Health recommended that the Medical Officer of Health advocate to Health Canada and the Ontario Ministry of Health for funding for six key areas to address the drug poisoning crisis and to report back in December 2021 on the progress of funding negotiations as well as which areas should be funded immediately by the City of Toronto while funding from other governments is being sought. This report requests funding for the Toronto Drug Strategy Secretariat, including 10 positions to address the increasingly complex issue of substance use, for the City's consideration through the 2022 Budget process. The expanded team will support population-level research and data and coordinate with intergovernmental and community partners to reduce drug-related harm and increase community health outcomes through the social determinants of health. This report also requests City funding, for consideration through the 2022 Budget process, for the implementation of an overdose alert app in shelters and respite centres as well as other public spaces to help reduce fatal overdoses for those using drugs alone. This report also recommends that the Board of Health continue to request the remaining funding from the federal and provincial governments for new and enhanced programming as outlined in Item HL31.4, Toronto Public Health 2022 Operating Budget Submission . In addition, this report reiterates recommendations from the June 2021 Overdose Action Plan Update urging the provincial and federal governments to immediately scale-up critical life-saving programs including evidence-informed treatment, supervised consumption services, as well as develop a national framework to permit the simple possession of all drugs for personal use.

2. The Board of Health direct the Medical Officer of Health to submit a request to Health Canada by the end of 2021 for an exemption under Section 56(1) of the Controlled Drugs and Substances Act, thereby starting a process to decriminalize the personal possession of illicit substances within the City of Toronto's boundaries. Improving Access, Enhancing and Expanding Services 3. The Board of Health request the Medical Officer of Health to include funding to support the Toronto Drug Strategy Secretariat in the Board of Health Recommended Toronto Public Health 2022 Operating Budget Submission for consideration in the 2022 Budget process. 4. The Board of Health request the Medical Officer of Health to include funding to support the enhanced use of an overdose alert app in the Board of Health Recommended Toronto Public Health 2022 Operating Budget Submission for consideration in the 2022 Budget process. 5. The Board of Health request the Federal Minister of Health to fund an expansion of injectable opioid agonist treatment (iOAT) to increase program hours and capacity to support more clients, as outlined in Item HL31.4, Toronto Public Health 2022 Operating Budget Submission . 6. The Board of Health request the Provincial Minister of Health to: a. fund the remaining costs for the five proposals below, as outlined in Item HL31.4, Toronto Public Health 2022 Operating Budget Submission , to: 1. increase resources for the Toronto Drug Strategy Secretariat; 2. expand programming at The Works, including enhancing clinical and harm reduction services; 3. improve data collection and communication to address data gaps on disparities for those disproportionately impacted by the drug poisoning crisis; 4. expand overdose outreach response services outside of the shelter system to address spaces such as parks and drop-ins; and 5. deliver mobile consumption services to address the need for supervised consumption services outside of the downtown core; and b. fund the remaining request for approximately $4 million in annualized funding to increase the capacity of several organizations that are part of the Toronto Opioid Overdose Action Network, as outlined in the proposals from the Toronto Academic Health Science Network/Toronto Public Health Opioid Task Force, to offer expanded harm reduction and treatment services that respond to the intensifying crisis. 7. The Board of Health reiterate its requests in Item HL29.2, Toronto Overdose Action Plan: Status Report 2021 to the Federal and Provincial Ministers of Health to address key areas of the drug poisoning crisis, including: a. support the domestic production of diacetylmorphine to increase the accessibility of this medication; b. remove the current cap of 21 Consumption and Treatment Services permitted in Ontario; c. reinstate funding for the Overdose Prevention Sites operated by Street Health and St. Stephen's Community House, given the urgent and ongoing need for these lifesaving health services; d. establish and fund an Urgent Public Health Need Site program for Ontario; e. increase the availability of services that support people who use methamphetamine and other stimulants; f. fund enhanced training for service providers on supporting people who use stimulants alone or with other drugs; g. support and fund the implementation of a spectrum of safer supply options, including listing injectable opioid agonist treatment (iOAT) medication on the Ontario Drug Benefit Formulary; h. expand funding for supervised consumption and other harm reduction services to better address the needs of specific groups (including Black, Indigenous and People of Colour, Two-Spirit, lesbian, gay, bisexual, transgender, and queer (2SLGBTQ+) communities), expand services across Toronto, support the provision of supervised inhalation and smoking services, and allow for consumption services to remain open for longer hours; i. fund longer-term implementation of vital drug checking services and provide additional funding to create more locations in diverse settings to meet local needs; j. provide consistent and ongoing funding for grief and trauma supports for frontline workers responding to the drug poisoning crisis, people who use drugs, and family members; k. improve employment standards for frontline harm reduction workers, including increased pay and benefits coverage, by increasing funding for supervised consumption and other harm reduction services; and l. fund a comprehensive Substance Use Crisis Centre in Toronto.