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General Manager, Shelter, Support and Housing Administration Purpose: This report updates Council on harm reduction and abstinence based programming in Toronto’s shelter system and responds to Council requests for information on the distribution of cigarettes and alcohol in shelter programs. Financial Implications and Impact Statement: There are no financial implications arising from this report. Recommendations: It is recommended that this report be received for information. Background: City Council, at its meeting of April 15, 2004 passed Motion 8 related to Clause No. 30a of Report No. 2 of the Policy and Finance Committee, recommending “…that the Commissioner of Community and Neighbourhood Services report to the Community Services Committee on alternative harm reduction programs, such report to address the possible gradual elimination of providing alcohol to shelter clients.” Further, City Council, at its meeting of April 26, 2004 passed Motions 4 and 6 related to Clause No. 2 of Report No. 3 of the Policy and Finance Committee recommending “…that the Commissioner of Community and Neighbourhood Services be requested to report to the Community Services Committee on a process that could be utilized to establish statistics on the harm reduction programs (alcohol, cigarettes and substance abuse)” and “…that the Commissioner of Community and Neighbourhood Services be requested to report to the Community Services Committee providing alternatives to the distribution of cigarettes and alcohol at Seaton House.” This report responds to these recommendations. Comments: Harm reduction is an approach that places a priority on reducing the negative consequences of substance use (including alcohol use) rather than on eliminating the substance use. Harm reduction programs reduce the level of harm an individual does to him/herself due to certain behaviours (e.g. drinking toxic alternatives to alcohol such as cooking wine or mouthwash). (1) In Toronto shelters, specialized harm reduction programs are available that have a high tolerance for behaviours related to alcohol, drug addiction and/or severe mental health issues. The focus is on the behaviour of the individual and not on the substance use or mental health issue. If an individual’s behaviour is not causing harm, they receive the same access to services as any other client. Historically, most shelters had policies that excluded people who had consumed alcohol. Certainly, people were not allowed to bring alcohol into shelters. Because of these policies many homeless people who had drinking problems would not even bother to try to get into the shelter system. Knowing that they would be refused admission they simply never tried, choosing instead to stay out on the street. In the late 1980’s shelter staff began to reconsider this approach to shelter access. Chronic alcoholics, forced to choose between shelter and drinking, would very often choose to continue to drink even if it meant staying on the street. At this time, harm reduction policies and practices were beginning to take hold around the world, starting with needle and condom distribution programs, as a means of reducing the spread of infectious disease. Harm reduction as a concept quickly expanded to include managed alcohol programs for people with alcohol addictions. Some men’s shelters in Toronto established policies that permitted clients to turn in their alcohol to staff and have it returned to them in the morning. The result was that a whole group of men who had not previously been willing to access the shelter system were now able to do so. In January and February of 1996, three homeless men died of exposure in Toronto. In two of the cases, the coroner concluded that their deaths were the result, at least in part, of their alcoholism. The Coroner’s Jury made two recommendations that were particularly relevant to the introduction of harm reduction programming in shelters. First, they recommended that Seaton House introduce an alcohol storage program for clients. Second, they recommended that: “The Municipality of Metropolitan Toronto should adopt a pilot project harm reduction hostel and day drop-in centre to provide shelter over 24 hours. We suggest that the beds have privacy barriers. We suggest a supervised lounge area where drinking would be permitted as opposed to drinking throughout the whole hostel. All clients’ alcohol would be stored in a central location. Staff should work with hostel users to access appropriate harm reduction treatment programs. The success of the pilot project should be reviewed after 3 months.” The Inquest Jury’s rationale for this second recommendation was that the program would reduce the added risk of exposure to clients with “round the clock” alcohol addiction. On the basis of these recommendations, the City developed the Annex Harm Reduction program at Seaton House in 1996, and the shelter system as a whole moved towards the adoption of a harm reduction service framework. This process was formalized as part of the process of revising, in consultation with shelter operators and homeless service providers, the Toronto Shelter Standards. In 2002 Toronto Council approved the following principle as part of the Toronto Shelter Standards: “People who are homeless, like other members of our community, may use substances to varying degrees. Everyone is entitled to shelter services whether or not they use substances. As a result, admission, discharge and service restriction policies must not be based on substances use alone, except for those shelters operating on an abstinence basis. To increase the accessibility of the shelter system and to respond to diverse resident needs, a range of service approaches from abstinence to harm reduction must be available within the shelter system.” Toronto Hostel Services promotes a harm reduction approach across the shelter system consistent with the directions outlined in the Standards. The Shelter Standards direct that with the exception of abstinence based shelters (which are discussed later in this report) admission and discharge decisions cannot be based on substance use alone, but should be based on behaviour. Shelter operators must be open about their admission and discharge policies so that clients and referring agencies know whether someone will be permitted or denied access if they are under the influence of alcohol or other drugs. Admission to a shelter must be based on a resident’s behaviour and not on their substance use. In addition to following this general principle, a small number of shelters have specialized harm-reduction programs. These programs provide a high tolerance of behaviours associated with substance use but also provide a high level of support to people who are substance users, many of whom also have health and mental health issues. Supports provided include supportive counselling, assistance in obtaining identification, referrals for health and mental health supports, and referrals to housing, detox or treatment programs as appropriate. As of October 2005 there are a total of 149 beds for homeless men, women and youth in shelters that have designated harm reduction programs. This represents about 4 per cent of the beds in the shelter system. The following shelters offering varying degrees of harm reduction programming: (a) Seaton House Annex Program (Ward 27) – Directly operated by the City, the Annex is a 140 bed Program with 105 beds devoted to serving men with severe addictions to alcohol or facing other health and social challenges. The other 35 beds are connected to the Infirmary program that, in partnership with St. Michael’s Hospital, provides health care to the neediest of the Seaton House population. Appendix A provides further details regarding the clients and programs in the Annex including the managed alcohol program. Women’s Residence Lounge Program (Ward 20) – A 14 bed program for single adult women that is directly operated by the City as part of the 103 bed Women’s Residence shelter. This program serves homeless women with severe alcohol or drug addictions that also experience significant mental health problems. The needs of these women are complex and there is not sufficient space for the number of women seeking assistance. Staff are currently conducting a review to consider how the physical facility of the Lounge Program could be expanded and enhanced. No alcohol or cigarettes are distributed in this program. Eva’s Satellite (Ward 23) – This is a 30 bed overnight program for youth between the ages of 16 and 24. It provides a high tolerance, high support program for youth who may use alcohol or drugs. The City is currently working with Eva’s Satellite on the development of a new site that will provide 24 hour programming and support. No alcohol or cigarettes are distributed in this program. This program is operated by Eva’s Initiatives, a community non-profit organization that also operates Eva’s Place – a youth shelter, and Eva’s Phoenix a transitional shelter and employment program. Harm Reduction in Shelters and the Toronto Drug Strategy During recent public consultations for the Toronto Drug Strategy, which is currently before Council, participants highlighted the need for more harm reduction services in shelters. The Toronto Drug Strategy noted that while the provision of harm reduction services to homeless persons is important that it must be remembered that “shelters are not health care providers nor are they addiction services although they often fulfill these functions for people who are homeless.” With respect to Toronto’s shelter system, the Toronto Drug Strategy recommends that: “The City of Toronto work with the Ministry of Community & Social Services, the Ministry of Health & Long-Term Care and other relevant ministries, institutions and community groups to determine what additional harm reduction services may be needed within the shelter system and to determine appropriate service models and sources of funding to better respond to the needs of homeless people with substance use issues.” Harm Reduction in Shelters and the Streets to Homes Strategy In February 2005, City Council approved the Streets to Homes program that is targeted at finding permanent solutions to end street homelessness. The Streets to Homes report noted that a number of individuals who stay on the street struggle with alcohol and drug addictions and that specialized strategies are needed to help these individuals leave the street. To date many of the individuals encountered through the program have had alcohol, substance use and/or mental health issues that would make them ideal candidates for specialized programs like the Annex, the
Lounge and Eva’s Satellite.

Some homeless individuals, particularly those who abstain or who are recovering from addictions, want to be in a sober and supportive environment where the use of substances is not permitted. Since April 2004, shelters can apply to the City to have their facility, or a portion of their facility, designated as an abstinence based program. An abstinence-based program is defined as an emergency or transitional shelter which provides an environment for residents who choose not to use or be exposed to other persons who use alcohol or drugs. Shelters without medical resources, expertise and the ability to provide high-levels of client support should not undertake withdrawal management (de-tox) or otherwise attempt to force clients to be sober. Agencies must demonstrate to Hostel Services that they have the appropriate expertise, programming and mandate in order to receive approval to operate as an abstinence based program. Specifically, the Shelter Standards state that: “Shelters operating on an abstinence model must identify how abstinence is defined within their program, and have City approval to operate an abstinence based facility. When a shelter cannot accommodate a resident under the influence of a substance, a referral to another shelter must be made. Referral agreements with shelters that can accommodate people using substances will be established and will include the following elements: a list of shelters with which referral agreements are in place; a process for contacting the receiving shelter to ensure the resident can be accommodated; a process for providing support to the resident to help them reach their destination; a process for follow-up with the receiving shelter to ensure the resident has arrived.” The City of Toronto currently funds 166 abstinence based beds in five approved shelters: - The Good Shepherd- Transition Program (Ward 28) – 25 beds The Salvation Army- Maxwell Meighen- Turning Point Program (Ward 28) – 20 beds Native Men’s Residence (Ward 21) – 63 beds Seaton House- Downsview Dells (Ward 9) – 28 beds Street Haven Women’s Shelter (Ward 27) – 30 beds This represents about 4 per cent of the total number of shelter beds presently available in the system. In addition, Covenant House, with 94 beds, has made an application to the City of Toronto to operate as an abstinence-based facility. This submission is in the final stages of approval. Based on the information provided by agencies, the following services are offered at these programs: supportive individual and group counselling; life skills sessions; 12 step in-house meetings; relapse prevention; leisure and recreational programs; stress management; anger management; employment preparation; and, housing and health care referrals. Smoking and Smoking Cessation in Shelters Many homeless adults and youth are smokers. Research indicates that up to 84 per cent of Toronto’s homeless smoke. The Seaton House Annex program is the only shelter program in Toronto that distributes cigarettes and it does so for fewer than 50 clients. Quitting smoking is a challenge for homeless clients given the prevalence of smoking among the population, the powerful nature of the addiction, as well as the lack of access to nicotine replacement therapies (NRT). The most commonly used therapies, nicotine gum, nicotine patches and anti-depressants (bupropion, trade name Zyban), are not covered by Ontario Drug Benefits (ODB), on which most homeless clients rely for coverage of their prescription medication costs. The nicotine patch costs approximately $120 per month (with a treatment period of 6 weeks to 6 months). Bupropion is only available through ODB when prescribed specifically for depression, and not for smoking cessation. Although cheaper than the nicotine patch, it also has numerous side effects and drug interactions to consider. The patch tends to be a safer form of NRT. In any case, counselling and other supports must be provided in conjunction with NRT to ensure efficacy of the therapy. Despite the challenges associated with reducing tobacco use, or quitting smoking, the health and economic benefits are obvious. Commencing in 2006, Hostel Services, Toronto Public Health and the Centre for Addiction and Mental Health will be collaborating to develop programming that can be used with clients and staff in homeless shelters. Toronto Public Health will provide smoking cessation and education workshops to shelter staff in order that they can support and refer clients who are interested in quitting and provide on site quit smoking workshops for interested residents. Public Health will be contacting the Ministry of Health and Long Term Care to discuss how smoking cessation supports for the homeless might be developed under the Provincial Tobacco Cessation Program Strategy and to advocate with the Ministry for fully subsidized NRT for homeless clients. City staff will also be consulting with the Centre for Addiction and Mental Health as to how their smoking cessation programs may be modified or made available to shelter clients. Staff are also reviewing the issue of smoking in shelters in anticipation of the new Smoke-Free Ontario Act which comes into effect in May 2006. Currently the City’s no smoking by-law (Municipal Code 709 – Smoking), with which shelters comply, prohibits smoking in workplaces and public places but has exemptions to permit smoking in approved Designated Smoking Rooms (DSRs) or in rooms that are deemed to be residential. The Smoke-Free Ontario Act has much stronger provisions to protect workers and will only permit smoking in Controlled Smoking Areas (similar to DSR’s). However, these areas are only permissible in: - a residence as defined in the Nursing Homes Act, Charitable Institutions Act or Homes for the Aged and Rest Homes Act; a residential facility that is operated as a retirement home and that provides care, in addition to accommodation, to the residents of the home; a supportive housing residence funded or administered through the Ministry of Health and Long-Term Care of the Ministry of Community and Social Services; a psychiatric facility as designated in the regulations; or a facility for veterans as designated in the regulations. Use of the smoking room is limited to residents of that facility and a resident who desires to use the room must be able, in the opinion of the proprietor or employer, to smoke safely without assistance from an employee. An employee who does not desire to enter the room shall not be required to do so. Hostel Services is working with Toronto Public Health to assess the impact that this legislation will have on shelters. (6) Possibility of Gradual Elimination of Providing Alcohol and Cigarettes to Shelter Clients The distribution of alcohol and cigarettes to homeless men is controversial. Opposition to harm reduction approaches often centres on moral objection that it is allowing or enabling a person to use alcohol or other drugs. However, worldwide research and practice continue to demonstrate that harm reduction approaches are effective at reducing harm both for the people who use substances and for the communities in which they live. The managed alcohol program at The Annex is recognized across the country as an effective model for reaching severely addicted, chronically homeless men. A recent literature review found a substantial body of evidence-based research demonstrating the effectiveness of harm reduction approaches for alcohol use. The research found that providing a choice of goals within a range of services increases people’s commitment to treatment and improves their feelings of success in meeting their goals. For some chronic alcoholics, treatment may never be an option. For this group, reducing their level of use and working to improve any associated health and mental health issues may be the best measure of success. For the clients in the managed alcohol program, abstinence is not possible. Providing their alcohol in a controlled environment reduces the damage that they do to themselves and to the community in which they live. This program meets a specific need for a small group of people who would otherwise be living on the street or in local parks. Staff believe that elimination of alcohol distribution to this group of shelter clients would increase the damage that they do to themselves and to the community in which they live. Staff believe that cigarette distribution continues to be an effective practice with a small number of clients. Nicotine cessation programming will be introduced and participation encouraged in 2006. Given the Provincial Legislation that will be coming into place in 2006, staff will be reviewing the practice of distributing cigarettes. Staff will also consult with the Centre for Addictions and Mental Health (CAMH) as they have already decided to make their Toronto
facility 100 per cent smoke-free.

(7) Statistics
Statistics are already maintained on the number of people using harm reduction programs and on the distribution of cigarettes and alcohol in the Annex Program (see Appendix A). A major research study conducted by City of Toronto staff in collaboration with St. Michael’s Hospital has evaluated the effectiveness of the Annex Harm Reduction Program. The study followed 60 Annex clients and compared them to 120 control clients over a 6 year period. The study showed significant improvements in health care utilization, shelter services and less encounters with corrections after entry into the program. These results were particularly pronounced among those who participated in the managed alcohol program. Conclusions: Hostel Services has, over the years, worked with community based service providers to develop a broad spectrum of shelter services, including harm reduction and abstinence-based, in order to respond to the diversity of need among people who are homeless in our city. Harm reduction programs, including managed alcohol and cigarette distribution programs, are important tools used to connect and maintain a connection with a small group of homeless men, women and youth who have histories of drinking or drug addiction and who suffer from social isolation as well as neglected mental and physical health. These programs reduce the harm to which individuals are exposed and also reduce the impact these individuals have on local communities in which they live. In addition to providing harm reduction programs, abstinence based programs are available to homeless men, women and youth who wish to be in an environment where substance use is not permitted. Contact: Anne Longair, Director, Hostel Services Phone: 416-392-5417 Fax: 416-392-8758 E-mail:alongair@toronto.ca General Manager, Shelter, Support and Housing Administration List of Attachment: Appendix A - Seaton House: The Annex Harm Reduction Program Seaton House: The Annex Harm Reduction Program The Annex Harm Reduction program began in November 1996, and became a 24-hour shelter program in January 1998. The opening of the Annex program was in direct response to the 1996 Coroner’s inquest into the deaths of three homeless men. While they had many other health and mental health issues in their lives, the three men were all alcohol dependent. The Coroner’s jury recommended that in order to prevent future deaths that a program be developed where alcohol was permitted. Who Uses the Annex? The men served in the Annex Program have a history of intense social service use and addiction. Often the alcohol addiction is so severe in these men that before being part of the Annex they consumed non-palatable alcohol such as mouthwash, after shave or cooking wine. These men generally have an extensive history of shelter use, as well as periods of incarceration, and a revolving door relationship with detoxes and residential treatment programs for their substance use. Underlying all of this, the men tend to have severe and persistent health and/or mental health issues. Often, there has been a tremendous use of emergency medical services (ambulance and fire) and hospital emergency rooms. In 2004, 241 different individuals stayed in the Annex Harm Reduction Program. The men who stay at the Annex come from various locations. Some are self-referred from the street. Others are referred from other shelters or street outreach providers. In some instances a man currently staying at the Annex will pass the word on to former associates on the street or in other shelter programs who will themselves seek admission. Some men come from hospital settings. In many cases, these men have been unsuccessfully involved in various types of detox and withdrawal management programs that have tried to intervene in and address their addictions and health issues. Upon referral, clients are assessed to determine if they are a good fit for the program. During the assessment process, and throughout the course of their stay in the program, the men in the program are provided an array of options to reduce harmful behaviours in their life. Abstinence and detoxification are options provided to each man who participates in the Annex. How Does the Annex Program Work? The Annex is a 140 bed program with 105 beds devoted to serving men with severe addictions to alcohol or facing other health and social challenges. The other 35 beds are connected to the Infirmary program that, in partnership with St. Michael’s Hospital, provides health care to the most needy of the Seaton House population. Managed Alcohol Program: There are two components to the managed alcohol program in the Annex program. In the first component a client staying in the shelter may choose to purchase their own alcohol and use the Annex as a safe place to store and access their alcohol. Those storing their alcohol have regulated access. In the second component the client is given controlled access to wine that is purchased by the shelter. To participate in this program, a client signs over part of their monthly income (if they have one) to cover a portion of the costs of the wine. The participant must agree to stop drinking on the street and only drink from the wine program in the shelter. Wine is dispensed by staff each day starting at 8:30 a.m. until 12:00 midnight. One drink per person is served every 90 minutes up to a maximum of 10 drinks per day or at longer time intervals depending on an individual client’s case plan. Each drink is slightly less than 7 ounces. Each drink dispensed is marked down in a consumption log and staff have the ability to suspend a person’s consumption if their behaviour indicates it is necessary. At any given time approximately 70 of the clients in the Annex will be participating in the managed alcohol program. Other support services: While the managed alcohol program tends to be the program that receives the most focus from the outside, the other supports provided are as important to the men who are staying in the program. Supports provided include banking and budgeting, health care management, re-unification with family members, palliative care, assistance with legal issues, and connection to long-term care, housing or treatment placements. It should also be made clear that men in the Annex program, through their involvement with health care professionals, are provided an option of supported abstinence and detoxification. Some have been able to take advantage of these referrals, but this is unusual given their history of trying various detoxification and residential treatment programs. Cigarette distribution: In the Annex/Infirmary program, a small number (10-15) clients are provided with cigarettes on a regular basis. Another group of approximately 20-30 clients receive a limited number (on average 4 per day) of cigarettes. Distribution of cigarettes can facilitate a client’s co-operation with hygiene, attendance at medical appointments and can be used to help de-escalate an agitated client. Additionally, for those who may be inclined to retrieve used cigarette butts from public places, the distribution of cigarettes may serve an infection control purpose. Seaton House uses between 5 and 8 packs per day for its tobacco program. What are the impacts of the Annex Program? From a client perspective, the Annex provides an opportunity to decrease the amount of alcohol each individual consumes and ensures that the alcohol that is consumed is safer and less toxic. Given the severity of health issues that the men present with, the Annex also provides a safe environment for health professionals to properly assess their health needs and establish a plan to address, and where possible, remediate or stabilise the health issues. There are also impacts on the community at large. When compared to a control group of other hostel residents, prior to admission to the Annex the clients had spent more than twice as many nights sleeping outdoors on the streets than had other hostel users. Other community benefits that are more difficult to quantify include a decrease in panhandling, public drunkenness and disorderly public conduct amongst these clients resulting in a reduction in the impacts associated with those behaviours on neighbourhood and business. The Annex also has an impact on health care usage. While there is an initial increase in the utilisation of health care resources upon entry into the Annex program as referrals are made and health care staff work to stabilize the person’s health conditions, as the man stays in the program their use of hospitals, emergency rooms and EMS services decreases. What are the costs of the Alcohol and Cigarette Distribution in the Annex Program? Alcohol: In 2005 the projected net cost of the alcohol distributed through the Annex Harm Reduction Program is $79,016 ($140,348 gross minus $61,332 client contribution). This provides for the distribution of 30,247 litres of wine at a cost of $4.64 per litre. This translates into $216 net per day, which is approximately $3.10 per person involved in the program, with the cost per drink less than $0.40. When compared to the community impact (Police, Emergency Medical Services, hospitals, and businesses) that many of these individuals have historically had before entering the program this represents a worthwhile investment. Wine for the program is purchased through a contract with Mondiale Wines. Cigarettes: In 2005 the projected cost of cigarette distribution is $20,000. Cigarettes are purchased through a contract with Dairy Foods and are ordered on an as- needed basis. The contract sets the price of 200 cigarettes at $55.00 or $0.275 per cigarette.

Source: http://www.toronto.ca/legdocs/2005/agendas/committees/cms/cms051108/it011.pdf

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CME Renal Medicine on therapy in renal disease. Arch Intern Med 1981; 141 :1039–41. Richard S, Jothy S. A prospective study on Liam Plant MB MRCPI FRCPE, Consultant the impact of the renal biopsy in clinicalRenal Physician, Department of Renal management. Clin Nephrol 1986; 26 :217–21. 5 Cohen AH, Nast CC, Adler SG, Kopple JD. Medicine, Cork University Hospital, Cork, Clinica


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