In Ontario, roughly 85,000 people are homeless, and 75% of this population has some sort of substance abuse or mental health challenges. Current research suggests that at least 40% have addiction issues.

The provincial government is pursuing an initiative with the stated goal of addressing addiction among vulnerable citizens while also protecting the safety of children and families. Many organizations, however, argue that Ontario’s approach may deprive unhoused individuals with addiction of the services they need and could even exacerbate some of the problems it purports to address.

The Ontario provincial government is investing roughly $550 million to open 28 Homelessness and Addiction Recovery Treatment (HART) hubs that will emphasize recovery and treatment. These sites will replace 9 of the province’s 23 supervised consumption sites (SCS). SCS are safe, hygienic environments where people can use their own drugs under medical and harm reduction supervision.

SCS have long been a point of contention in Ontario and other provinces. Their clients are mostly unhoused individuals with many social, physical, and mental health challenges. The rationale for the nine SCS closures has been the alleged safety hazards (eg, gun violence) resulting from their proximity to schools or childcare centers. So far, the provincial government has not defined these safety hazards more specifically. Instead, it has focused on legislation passed in 2024 that prohibits injection sites from operating within 200 m of schools and childcare centers.

Despite Ontario’s public commitment to provide comprehensive recovery services and buildalmost 900 supportive housing units, the provincial government’s new plan for HART hubs does not include harm reduction strategies.

The drafters of the plan also did not consider two provincial reviews that suggested ways to improve safety in communities with SCS following a July 2023 shooting that killed a woman near Toronto’s South Riverdale Community Health Centre. According to news reports, Ontario Health Minister Sylvia Jones rejected these recommendations, citing higher crime rates and complaints from neighbors and parents.

Risk for Unsatisfied Needs

The omission of harm reduction strategies has raised strong objections among mothers who’ve lost children to overdose. Other critics include community-based organizations and national groups such as the HIV Legal Network, the Canadian Civil Liberties Association, the Registered Nurses’ Association of Ontario, the Centre for Addiction and Mental Health, and the Canadian Public Health Association. These organizations argue that removing SCS will likely increase preventable fatal and nonfatal overdoses and strain paramedic services.

“The evidence for SCS isn’t clear. We don’t have any evidence about transmissible infections or injuries from injection or if harm reduction is a slam dunk,” Don Husereau, PhD, adjunct professor of epidemiology and public health at the University of Ottawa in Ottawa, told Medscape News Canada. “On the flip side, only certain types of people are going to go to HART hubs, and the people at highest risk of mortality [the unhoused and mentally unstable] might not be the ones volunteering to go to these places,” he said.

HART hubs might not be an acceptable compromise for a population that distrusts public institutions and has complex problems that require individualized solutions. Not only were people with lived experience of drug use left out of policy discussions related to the hubs but also research has shown that treatment and recovery programs often fail unhoused people because they emphasize sobriety and abstinence without providing the resources needed to maintain that sobriety (eg, stable housing, food, and safety).

The COVID pandemic created an environment in which the drug-using community “lost all of its norms,” Rob Boyd, CEO of healthcare organization Ottawa Inner City Health, told Medscape News Canada. The SCS offer a safe alternative to the streets and attempt to re-establish some of these norms. The goal of the SCS is to guide drug users into recovery on the latter’s terms and timelines.

“People struggling with substance use usually have some deficit in their lives. They’re homeless and traumatized, dealing with mental health challenges, brain injuries, or experiences of racism and colonialism,” said Boyd. He explained that factors such as family connection, employment, responsibilities, and access to recreation provide individuals with the resources (or assets) to become sober.

“The unhoused community with addiction challenges have no recovery capital, nothing in their current state to work with,” said Boyd. “So our approach is to pay attention to the recovery capital needs they have, break down barriers to get them into housing, connect them to their community and culture, and provide opportunities for meaningful work and recreation,” he said. “This is what treatment looks like for a marginalized population that experiences barriers to recovery.”

“We get to know the person, their background and history, and what happened in their lives,” said Louise Beaudoin, RN, director of clinical services at Ottawa Inner City Health. “People start opening up about their mental health and the help they need. When they stabilize their mental health, they say they’re tired of their lifestyle and want to stop using. Then we can connect them to the type of treatment that would fit,” she said. “All the pieces need to be aligned for it to work. It takes a long time and a lot of trust for clients to open up to us,” Beaudoin said.

An unhoused person who is put into a treatment system is unlikely to adhere to it, mainly because his or her life outside the treatment facility is not going to be better, said Boyd and Beaudoin. “It’s a mismatch, in terms of what they need right now to support their recovery versus what they will hopefully need a few years down the road, once things have stabilized a bit for them,” said Boyd.

Public Drug Use May Increase

Harm reduction refers to strategies such as SCS, drug-checking services (which test for fentanyl or other potent adulterants), opioid substitutions (eg, suboxone), take-home naloxone, and safe supply (ie, the prescription of pharmaceutical-grade opioids and stimulants to individuals at a high risk for overdose).

In 2021, Canada’s Drug Agency (formerly the Canadian Agency for Drugs and Technologies in Health) published a policy insight briefing note that underscored several benefits associated with harm reduction strategies. These benefits include reducing harms associated with drug use, potentially increasing access to support programs and social services, and reducing the stigma associated with drug use. SCS have been associated with an increased sense of community and safety.

The SCS closures are certain to bring drug use back into streets and alleyways, said Beaudoin. “When the opioid crisis started, I remember buying headlamps and knee pads for my nurses and backpacks with oxygen and Narcan. My nurses would be jumping fences into garbage bins because people were hiding to use [drugs] and then overdosing in those areas. So now people are going to be using drugs on people’s front porches, in their backyards, and on the streets where these sites used to operate,” Beaudoin said.

Harm reduction strategies such as SCS are only one component in the “four pillars” approach to drug use. The other pillars are prevention, treatment, and drug enforcement strategies. The four-pillar approach has proven to be one of the most effective public health responses to illicit drug use. It has proven successful in European cities such as Geneva, Zurich, and Frankfurt and was adopted by Vancouver in 2001.

“Abstinence is a very small corner of recovery,” said Boyd. “I don’t think that the public, politicians, or many people in healthcare understand that. The people we’re working with are the people for whom the bureaucratic system doesn’t work. In many cases, they internalize failure as their failure, not as our failure to find things that are going to work for them.”

“We should be looking at what others are doing and conducting large-scale public policy experiments that allow us to measure the impact of these programs over years,” said Husereau. “All these interventions should be designed with evaluation in mind. Sometimes what we think might be a good idea ends up being a bad idea for reasons we didn’t foresee,” he said.

Boyd and Beaudoin reported having no relevant financial relationships. Husereau reported performing consultant work for for-profit life science organizations.

Liz Scherer is an independent health and medical journalist. She frequently reports on Canadian and Global health news.