Three pressing issues the City of Toronto must address to support people in high need

This summer, Casey House was pleased to contribute our insights on the current state of the City of Toronto’s drug policy and programming, including our clients’ perspectives on decriminalizing personal drug possession. In view of the upcoming municipal election, we are highlighting some of the most pressing issues our clients face, and key actions the city must prioritize to improve the health and well-being of Torontonians in high socio-economic need.

For many people, substance use is a way to cope with intersecting challenges such as trauma, poverty, homelessness and mental health concerns, which can create multiple barriers to having one’s basic needs met. At Casey House, our clients face many of these hurdles, which have an impact on their health and well-being. Our hospital is committed to understanding our clients’ health concerns in the broader context of their lives, and to actively dismantling barriers to care and safe living. All levels of government have a vital role to play in addressing the social factors that determine health and well-being, and in improving health care and outcomes for people in high need. While considerable progress has been made in recent years, there is much more work to do.

In Toronto, three pressing issues that any municipal policy or program must consider and address are:

1. Deep poverty: inadequate income and chronic homelessness
2. Toxic supply of unregulated drugs and growing risk of drug-related harms
3. Criminalization of drugs and the people who use them

1. Deep poverty: inadequate income and chronic homelessness

For many of our clients, an extremely low income creates barriers to safe and healthy living. For those who qualify for income support programs, the amount of money a single person receives is not nearly enough to cover basic needs and shelter. For instance, many clients receive support from the Ontario Disability Support Program (ODSP) or Ontario Works (OW) – the maximum monthly rates for which are $1,228 and $733 respectively. Even in stronger economic times, these rates are far below the poverty line, let alone during this period of high inflation, when even higher income earners struggle to make ends meet.

Unsurprisingly, a related challenge is access to safe, affordable, and supportive housing – the demand for which far exceeds supply. The constant lack of emergency shelter spaces affects the ability of hospitals like Casey House to safely discharge unhoused patients so they can manage their health beyond their stay. As one long-time Casey House nurse expressed, “We call Central Intake [for emergency shelter space], and no beds are available…I’ve never seen it worse.” The situation is further aggravated by obstacles to obtaining required documentation to apply for potential housing. Our team of social workers see these roadblocks far too often: “getting ID is a nightmare for people” because of the limited services available, and “it can be difficult for people without housing to get their taxes done regularly”.

Even when people are housed and have access to programs like ODSP, it is still not enough to pay for food, transportation, and other basic needs.

Actions for the City of Toronto:

  1. Champion income support programs and policies at all levels of government that respond to the cost of living (higher benefit rates), and provide people with the income they need when they need it (such as bi-monthly payments)
  2. Prioritize and/or leverage city resources to increase and improve:
      • Immediate access to safe, high quality emergency shelter spaces that don’t require abstinence from substance use, and storage services for personal belongings
      • Access to transitional and supportive housing for people struggling with substance use and mental health challenges
      • Access to affordable housing, such as rent-geared-to-income (RGI) housing, that integrates vital harm reduction strategies and supports
      • Access to tax clinics and identification clinics with citywide locations and hours of operation that respond to the practical reality of people’s lives

2. Toxic supply of unregulated drugs and growing risk of drug-related harms

Since 2016 there have been more than 30,000 opioid toxicity deaths in Canada, an accelerating crisis that is claiming lives in communities across the country. In 2021 , Toronto Public Health reported 574 opioid-related deaths. As recent research from the Office of the Chief Coroner for Ontario shows, there has been an increase in stimulants contributing to opioid-related deaths, the circumstances surrounding drug-related harms have been changing significantly, and there is an urgent need for harm reduction services that respond to the diverse needs of people who use drugs.

In Toronto, many harm reduction services are available, but limited. Supervised consumption services (SCS) are contained to the downtown core; don’t always accommodate the range of drugs used and varying effects they have on the mind and body; and often don’t include vital drug checking services, which help people make more informed decisions about their drug use. The few options for safer supply (prescribed alternatives to the illicit drug market) have long waitlists and are limited to opioids.

In addition, many people providing support do not have lived experience of drug use, which can limit the full potential of these services. As one Casey House client expressed, “you want someone who ‘speaks your language’” when accessing care.

Actions for the City of Toronto:

  • Increase and improve low-barrier access to:
      • Safer supply programs, including for drugs beyond opioids
      • Safe spaces for substance use beyond the downtown core, that tailor services to different types of drugs (stimulants and opioids) and different modes of drug use (injection and inhalation)
      • Drug checking services, both within and beyond supervised consumption services, on a permanent basis
      • Mental health and substance use treatment services that don’t require abstinence from drug use
  • Engage more people with lived experience of substance use to provide support for, and build trust with, people who use drugs, and update best practices for people working in these peer support roles

3. Criminalization of drugs and the people who use them

While substance use is a health issue, it is treated as a criminal justice issue in Canada which creates barriers to health services, particularly for people living in deep poverty. It leads health care providers to require that people stop using drugs in order to receive care; deters people from accessing services and supports which would build their resilience and improve their well-being; and drives the inevitable market of illegal drugs which have become increasingly toxic. Moreover, federal drug policy is rooted in colonialism and racism, not in science or public health, and disproportionately impacts Black and Indigenous communities.

In Toronto, promising work is underway to address this systemic barrier: Toronto Public Health’s request to Health Canada to decriminalize illicit drug possession is a decisive policy action. Allowing the possession of drugs for personal use is imperative for decreasing stigma, creating pathways to health care, and improving health outcomes for people who use drugs. Equally critical is how policy change is implemented: people who use substances need to feel safe, supported, and respected, and all front-line service providers and first responders must be well-equipped to operate in a new environment that allows for personal drug possession.

Actions for the City of Toronto:

  • Equip service providers and first responders with the training and education to embrace a trauma-informed approach that:
      • Accepts and understands the impact of trauma on one’s health and well-being
      • Provides an opportunity for people to express their needs and experiences
      • Cultivates safety in every interaction to build trusting relationships with the community
  • Equip service providers and first responders with the training and education to gain a strong understanding of:
      • The realities of drug use (i.e. types of substances, quantities for personal use, recognize paraphernalia)
      • The impact that different drugs can have on different people (i.e. tolerance levels, reactions to various substances)
      • Optimal supports and services for immediate, crisis intervention
      • The difference between ‘sharing drugs’ for personal use and ‘trafficking’, to ensure that people who use substances are not targeted
  • In the Toronto Drug Strategy, re-define the pillar of “enforcement” to focus on: protecting people from a toxic drug supply; reducing the harms of substance use, including stigma and discrimination; community-led solutions to respond to mental health crises and wellness checks; and respecting the health, dignity and human rights of people who use drugs

Casey House recognizes and acknowledges that systemic inequities deeply affect our clients, and believes it is our responsibility to advocate for compassionate and socially-just health care. Our advocacy seeks to address the structural barriers that prevent optimal health, and improve the well-being of all people living with or at risk of HIV. To learn more, visit Advocacy.