Author: Samira Prasad

From CTV

Paper fentanyl test strips are a simple way for people struggling with substance use to determine if fentanyl has been mixed into their drugs, but some advocates say they fail to help the people most at risk of dying from an opioid overdose.

The tests are low-cost and easy to use. Working similarly to a COVID-19 rapid test, a user mixes a very small amount of the drug they want to test with water, and dips the paper test strip into the solution.

“Then you wait for the result so then on your little test strip,” Karen McDonald, head of Toronto’s Drug Checking Service, told CTV’s Your Morning on Tuesday. “One line will present if your drug is positive for fentanyl, two lines will present if your test is negative for fentanyl.”

However, McDonald – who has 15 years of public sector experience, including in health policy – said the tests aren’t beneficial to people who are addicted to opioids and knowingly taking fentanyl. Someone who has no intention of using opioids and detects the presence of fentanyl in their supply of a different drug would likely alter their consumption in response, she said, but these types of contamination cause the minority of opioid overdoses.

For people who intentionally use opioids, knowing their drugs contain fentanyl is a very small piece of the harm-reduction puzzle.

“For over five years now, fentanyl has really saturated the unregulated opioid supply and is really the opioid of choice for most folks using opioids at this point,” McDonald said. “So, simply knowing if there is fentanyl in their fentanyl doesn’t really add value for folks.”

From The Globe and Mail

The numbers of babies born with syphilis in Canada are rising at a far faster rate than recorded in the United States or Europe, an increase public health experts said is driven by increased methamphetamine use and lack of access to the public health system for Indigenous people.

While syphilis has made a global resurgence over the last five years, Canada is an outlier among wealthy nations in its rate of increase: 13-fold over five years, according to Health Canada. The incidence of babies born with syphilis reached 26 per 100,000 live births in 2021, the most recent year available, up from two in 2017, according to the Health Canada data.

That total is on track to increase further in 2022, according to the preliminary government data obtained by Reuters.

Babies with congenital syphilis are at higher risk of low birth weight, bone malformations and sensory difficulties, according to the World Health Organization.

Syphilis in pregnancy is the second-leading cause of stillbirth worldwide, the WHO said.

Yet congenital syphilis is easily preventable if an infected person gets access to penicillin during their pregnancy.

Among the G7 group of wealthier nations for which data is available, only the United States had a higher incidence of syphilis at birth: 74 per 100,000 live births in 2021, triple the rate in 2017, according to preliminary figures from the U.S. Centers for Disease Control and Prevention.

There were 2,677 cases of congenital syphilis in the U.S. in 2021 for a population of 332 million, according to preliminary CDC data. Canada had 96 cases for a population of 38 million, according to Health Canada.

People experiencing poverty, homelessness and drug use, and those with inadequate access to the health system, are more likely to contract syphilis through unsafe sex and pass it to their babies, public health researchers said.

“In high-income countries you see it in pockets of disadvantaged populations,” said Teodora Elvira Wi, who works in the WHO’s HIV, Hepatitis and sexually transmitted infection program.

“It’s a marker of inequality. It’s a marker of low-quality prenatal care.”

What sets Canada apart are its Indigenous populations who experience discrimination and often have poor access to health and social services, said Sean Rourke, a scientist with the Li Ka Shing Knowledge Institute at St. Michael’s Hospital in Toronto, who focuses on prevention of sexually transmitted disease.

“It’s just the whole system, and all the things that we’ve done in bad ways not to support Indigenous communities,” he said.

Health Canada told Reuters it has dispatched epidemiologists to help provinces contain the increase in congenital syphilis. Spokesperson Joshua Coke said the federal government is expanding testing and treatment access in Indigenous communities.

From the Toronto Star

Another aching death in Toronto’s transit system — this time, the killing of 16-year-old Gabriel Magalhaes — has renewed a sweeping question the city has faced for months. What do we do now to respond to the thrum of violence that’s shaken the city’s public transit system?

It’s an urgent issue made all the more difficult by the varied circumstances of the alleged perpetrators. While there are signs that at least some of the accused in recent TTC violence cases were struggling with their mental health, experts caution against drawing broad links between mental illness and crime. Similarly, though some of the accused had been living on the streets or in shelters, and homelessness has become increasingly visible on transit, health and social service workers warn against placing blame squarely on that population.　　

While experts have warned there is no single cause or simple solution, a consensus has emerged in recent months that suggests faults in the city’s social fabric — with an increasing number of people in desperate circumstances without adequate supports. It’s an assessment backed by Gabriel’s mother, Andrea, who has been outspoken in the days since her son’s death about cuts to social resources, and inadequate access to mental health care.

So, what can be done — in both the short and long term — to meaningfully turn things around? Here’s what seven health researchers and practitioners, criminologists and police leaders, social service workers and mental health advocates would like to see in Toronto’s future.

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The idea: A case-by-case deep dive to analyze what’s really happening

While Stephen Hwang, a physician and St. Michael’s Hospital Chair in Homelessness, Housing and Health, can list some general circumstances that can increase someone’s risk factors for violence, he sees Toronto as being in the throes of a condensed string of offences — one that should be examined in detail versus relying on assumptions.

To do that, he suggests a multidisciplinary “expert panel” explore the circumstances of each alleged perpetrator leading up to the moment of violence. (One challenge, he noted, would be protecting the rights of people who hadn’t yet faced trial.)

What did their life look like leading up to that day? Had they sought help in past for their mental health and hit roadblocks? Had they dealt with increased isolation in the last few years? Were there any warning signs or missed interventions, or did it come truly “out of the blue”?

“As a scientist, the first thing you need to do is look for patterns in the data,” Hwang said, cautioning that speculating or painting all the accused of the same brush is “unwise.”

In the short term, Hwang said consistency is important, questioning the effectiveness of increasing police presence in the TTC, only to publicly end that effort within weeks.

“If you know there’s never going to be a policeman there again, then the deterrent effect goes away.”

First in a series of Healthy Debate articles exploring the results of the OurCare survey.

Family medicine is the front door of the health-care system. But for too many people in Canada, that front door is now closed.

Results from the OurCare national survey estimate that more than one in five Canadian adults – 6.5 million people – do not have a family physician (FP) or nurse practitioner (NP) they can see regularly for care, a situation that has become worse during the COVID-19 pandemic.

The survey was conducted between September and October last year and includes more than 9,000 responses from across the country. It’s the first phase of OurCare, a national initiative to engage the public on the future of primary care in Canada.

We found that the situation is particularly bleak in some parts of the country. In British Columbia, Quebec and the Atlantic provinces, approximately 30 per cent – almost one in three adults – reported not having a family doctor or nurse practitioner. Contrast that to 13 per cent in Ontario.

And some groups are worse off than others. Fewer adults who were racialized, lower income and in poorer health reported having a family doctor or nurse practitioner.

Thirty-five per cent of those age 18 to 29 said they didn’t have a family doctor. Some young adults may not think they need one. Indeed, 17 per cent of respondents who were without a family doctor or nurse practitioner said they weren’t looking for one, most commonly because they thought they were healthy and didn’t need one. Yet, as family doctors, we know the importance of being connected to primary care early in people’s lives.

At first glance, the numbers don’t seem as bad for older adults. But it’s a huge concern that 13 per cent of those 65 and older reported not having a family doctor – everyone in that age group needs access to primary care.

Primary care – the type of care provided by family doctors and nurse practitioners – is foundational to any well-functioning health system. Family practices are the first place you should turn when you have a new health concern. They manage ongoing health conditions and provide care to keep you well in the first place. They are the entry point into the health-care system, coordinating the care you get from others, including specialists. Without it, patients are lost and left alone to navigate a complex system.

From CBC

Toronto showed “significant unfairness” when it cleared encampments in the summer of 2021 and chose to act quickly despite there being no urgency to do so, an investigation into the controversial moves has found.

In a report released Friday, Toronto Ombudsman Kwame Addo says the city chose “speed over people” when it forcefully cleared encampments in Trinity Bellwoods, Alexandra and Lamport Stadium parks.

“Our investigation found the City displayed insufficient regard for the people it moved out of the parks,” Addo said.

“It failed to live up to its stated commitments to fairness and a human rights-based approach to housing.”

Addo’s office launched an investigation in September 2021 following the encampment clearings which saw police officers in riot gear clear the sites of residents and their supporters, and resulted in dozens of people facing charges.

The investigation focused on how the city planned the encampment clearings, engaged stakeholders and communicated with the public. It found a number of problems, including that the city treated the clearings as a “top priority” and chose expediency and enforcement despite there being no evidence to suggest the encampments were an emergency requiring an urgent response.

Addo found the city chose to clear encampments quickly rather than focusing on the needs of those living in them. As well, it said the city was aware people living there had complex mental health needs, “yet failed to include plans to address those needs.

“Encampments and supporting the people living in them are complex. But the City owes a particularly high duty of fairness to these residents,” he said.

Longtime street nurse Cathy Crowe called Addo’s report a thorough one.

“It essentially demonstrates that homeless people were treated like an infestation … the efforts were to stomp them out and never have them come back, as fast as possible,” said Crowe.

“It tells the tale of malpractice that led to violence and injury.”

Report findings ‘validating’ for advocates

Addo also found that the city failed to foster meaningful engagement with people living in them, but rather communicated in a way that was “confusing, lacked transparency and showed a lack of understanding about their reality.” 

They also did not provide any dedicated onsite staff for people living in temporary dwellings in local parks to speak with, despite the city knowing they had questions which had gone unanswered, the report adds. 

In an interim report released last July, Addo concluded that city staff rely on an outdated and inconsistent approach when it comes to dealing with unhoused people in public parks.

“I think it’s validating for a lot of people who were doing advocacy around the encampments who were struggling to get the truth out,” said Zoë Dodd, a community scholar at MAP Centre for Urban Health Solutions.

“The one thing the ombudsman talks about is harm and trauma, but it wasn’t just harm and trauma, it also led to people’s deaths.” 

Recent city data shows Toronto saw an average of more than three deaths per week among people experiencing homelessness last year, totalling 187 deaths in 2022.

From the CBC article

Toronto updated its 14-month-old decriminalization request to the federal government Friday, clarifying it wants a Health Canada exemption to cover young people as well as adults, and all drugs for personal use.

The city’s submission, an update to its initial January 2022 request, indicates Toronto wants the federal agency to go further than the exemption it recently granted to British Columbia under the Controlled Drugs and Substances Act.

It makes clear the city wants its exemption to apply to all drugs for personal use and shield young people from criminalization, a departure from the B.C. exemption, which only applies to adults and lists a select number of substances. 

Medical Officer of Health Dr. Eileen de Villa says the submission sent to Health Canada, co-signed by the city’s police chief and city manager, is a “made-in-Toronto” model reflective of a months-long consultation process. 

“We’re talking about a matter of health and a matter of human rights, not one that really is meant to be addressed or is best addressed with a criminal justice approach,” she said in an interview. “That’s why we’re pursuing this route.” 

B.C.’s three-year exemption under the Act was granted in June and came into force Jan. 31. While that exemption caps possession at 2.5 grams, the Toronto submission does not outline a specific threshold for what constitutes personal use.

Pace of approval process has garnered criticism 

Drug use and purchasing patterns are “exceptionally diverse,” the submission said, and can vary based in part on a person’s tolerance. All trafficking and drug production would remain illegal.

Whereas the B.C. exemption only applies to people 18 and older, the Toronto model would also apply to young people. A 2019 survey conducted by the Canadian Association of Mental Health indicated around 11 per cent of Ontario students in Grades 7 to 12 reported the nonmedical use of opioids in the past year. 

Eight people aged 12 to 17 died from opioid overdoses in Toronto between 2019 to 2021, the submission said. 

“Health issues are health issues regardless of the person involved,” said de Villa. 

“That’s why we feel that this is something that does have to apply to all so that we’re sure that even the youngest members of our community are having their health issues looked at and addressed through a health lens rather than through something like a criminal justice lens.” 

The pace of the approval process has garnered criticism from drug users and advocates who say it fails to match the urgency required of an overdose crisis that has kills hundreds of people every year in Toronto. 

“They’re moving way too slowly. So, it’s nice to see movement. It’s just whenever you see a little bit of movement, I think, for me at least, it hits home just how slowly this process is going — how much we’re dragging our feet,” said Dan Werb, director of The Centre on Drug Policy Evaluation at St. Michael’s Hospital.

Decriminalization will not make the street supply any less toxic, Werb says, but it could reduce the barriers people face to accessing services that help prevent them from dying of overdoses. 

From CBC

Ontario Provincial Police sounded the alarm last week after four people in the Simcoe-Muskoka area died from suspected opioid overdoses in a span of four days.

The warning advised the public that a “highly potent and potentially fatal strain” of illicit opioid may be circulating in Simcoe County and the District Municipality of Muskoka. But experts in the region say the area has been hit hard by the opioid crisis, and four overdose deaths in a week isn’t uncommon. 

Data from the Simcoe-Muskoka health unit at the end of 2022 shows an average of 13 people in the region wind up in emergency rooms each week due to suspected overdoses.

Dr. Lisa Simon, associate medical officer of health for the Simcoe-Muskoka District Health Unit, says like other parts of the country, there has been an escalation in drug-related deaths over the last few years.

“Unfortunately, this is part of an ongoing trend we have seen for several years now of a dramatic loss of life and like these individuals, it’s often young adults,” she said.

Simon says the shift started with the introduction of fentanyl into the street drug supply in 2017, and the number of deaths continued to escalate into 2019.

“At that time, it was clearly unacceptably high levels when alarm bells were already ringing. But then the pandemic hit and the rate of opioid related harms and deaths got even higher,” she said.

Simon added 2021 saw the highest number of suspected overdose deaths on record in the region — 95 in the first six months.

The data recorded 66 confirmed and probable opioid-related deaths in Simcoe-Muskoka in the first six months of 2022. Those numbers are lower than the same period in 2021, but still substantially higher than before the pandemic.

Simon says over the last few months the region has recorded an average of three deaths per week due to drug related overdoses.

The Simcoe Muskoka Drug Strategy — a large partnership of agencies and organizations — continues to work to address opioid related harms in the region.

Drug supply ‘incredibly unpredictable,’ expert warns

Dr. Tara Gomes, the lead principal investigator of the Ontario Drug Policy Research Network housed at Toronto’s St. Michael’s Hospital, says the Simcoe-Muskoka data mirrors what’s happening across the country.

“When we look at what’s happening with the illicit drug supply, which is that it’s incredibly unpredictable, we often see clusters of overdoses that happen,” she said, adding when a more potent fentanyl analog enters the supply, a spate of deaths can happen in a matter of days or hours.

“It might be in a particular city or region because the supply that is there at any given time might be much more potent than people are used to and it can increase the likelihood of overdose,” Gomes explained.

From the Toronto Star

When Dan Shaffer turned up at the St. Michael’s Hospital emergency room, it wasn’t for a medical crisis. In his early 70s, Shaffer had been evicted from his apartment and had nowhere else to go.

ER staff tried to get him into a shelter, but couldn’t. Beds, citywide, were full. They brought him to a small, warmly lit room in a side hallway, with pullout couches and reclining chairs that serve as a stopgap when someone doesn’t have a medical reason to be admitted. Staff offer food and warm clothes and add a tick to a whiteboard every time they can’t find shelter beds.

Shaffer remembers the turmoil of that night. He’d never been homeless, and was at a loss for what came next. “I’ve never been in a situation where my life was taken out of control,” he said.

Hospital staff called the city’s shelter intake line over and over that night. By the next day, they found one room at a north Toronto shelter hotel. Over the ensuing year, as Shaffer feared the remainder of his life would be stuck in the shelter system, a new outreach team from the hospital’s emergency room worked with him to find long-term, stable housing.

This is the reality inside the hallways of St. Michael’s; while Toronto hospitals have struggled with broader pressures on the health care system, their ERs are also on the front lines of the city’s mounting homelessness crisis. Carolyn Snider, the emergency room chief at St. Michael’s, says more than 4,500 homeless Torontonians came through the doors of the downtown trauma centre in the last year, about 15 per cent of them simply because there were no alternative shelter options.

From the Toronto Star

Toronto Council’s decision this week not to open warming centres around-the-clock to provide shelter for the city’s most vulnerable residents was beyond disappointing. It was a disgrace.

Those who objected to making the centres accessible threw up a fog of excuses — cost, staffing — and in the face of real human suffering, offered the most weakest of actions, the promise of further study and a punt to other governments.

On Wednesday, council voted 15-11 against a board of health recommendation to open the centres 24 hours until April 15. Ostensibly oncerned about the lack of funds — remember that councillors ponied up almost $50 million more for the police — council instead supported a motion to ask the federal and provincial governments for more support. And it will investigate the “feasibility of providing 24/7 drop in spaces.”

Certainly, all levels of government need to step up. But a feasibility study? What doesn’t council know? Doesn’t it know that about 100 people are turned away from temporary shelters every day?

Doesn’t it know that freezing temperatures present serious health risks to unhoused people? Doesn’t it know that unsheltered people are currently seeking refuge in public libraries, at all-night restaurants and on the TTC, and that this is one of the reasons police officers are now patrolling public transit?

Mayor John Tory, who voted against the motion to keep the centres open, has long stressed that permanent supportive housing is a better solution than temporary shelters and warming centres. That’s true, but when it comes to permanent or temporary shelter, this isn’t an either/or proposition.

Although undeniably important, permanent housing won’t be built overnight, which means temporary lodging will still be necessary. And even if there were enough homes to go around, that wouldn’t solve the problem.

Many unhoused people have experienced serious trauma — trauma that led them to the street and trauma that keeps them on the street. And transitioning to permanent housing is, for many, a further stressful experience.

From CBC

During Canada’s unprecedented mpox outbreak last summer, Montreal physician Dr. Antoine Cloutier-Blais noticed a concerning trend: Patients co-infected with advanced HIV were reporting lesions across their bodies, and systemic mpox symptoms.

“It was difficult at that time to confirm that suspicion with the data we had,” he said.

Now, new research in the Lancet medical journal backs up Cloutier-Blais’ early concerns.

The paper, a case study on mpox in individuals with advanced HIV infection, details an aggressive and serious form of the illness formerly known as monkeypox — at times involving skin cell death within lesions, nodules in the lungs, sepsis, and a high rate of death.

This form of mpox appears to be a “very severe skin and mucosal infection with high rates of sepsis and very severe lung complications,” said study author Dr. Chloe Orkin, a professor of HIV/AIDS medicine at Queen Mary University of London, in an email to CBC News.

The researchers studied a cohort of nearly 400 patients from various countries, including Canada, who caught mpox while living with HIV and low CD4 cell counts. (CD4 cells are a type of white blood cell that help fight off infections by triggering the immune system to destroy viruses and other pathogens.)

Mortality was roughly 15 per cent in individuals with advanced HIV-related disease, the researchers wrote, while the death rate for people with the most severe immunosuppression doubled to around 30 per cent, Orkin noted.

The staggering findings matter in large part due to high rates of mpox among individuals living with HIV/AIDS, who account for an estimated 38 to 50 per cent of people diagnosed with mpox.

“I think it’s an important reminder of how we must not get too complacent even in the face of low case counts, because if the virus encounters a person susceptible to such severe manifestations like people living with advanced HIV, then it can be really devastating,” said Dr. Darrell Tan, a clinician-scientist at St. Michael’s Hospital in Toronto, whose team contributed data for the Lancet paper.

Calls for more access to mpox vaccines

The takeaways of her findings, Orkin said, are that health-care workers need to be trained on the high mortality rate associated with mpox and HIV-related immunosuppression. 

“Every person with mpox should have an HIV test and every person with HIV and mpox should be tested for immunosuppression,” Orkin continued, noting those with advanced HIV infection should also be monitored carefully, given the significantly higher risk of death.