Wednesday, October 17, 2007

Nursing focus in an excellent Globe & Mail article: The inside story of Vancouver's safe injection site

National News

The inside story of Vancouver's safe injection site; Supporters work to convince opponents that Insite saves lives, still fearing for the facility's long-term future

2549 words
6 October 2007
The Globe and Mail
2007 CTVglobemedia Publishing Inc. All Rights Reserved.

VANCOUVER -- Using heroin and cocaine can be a dirty business. That means Bethany Jeal sometimes has a lot to do as a nurse helping addicts at North America's first safe injection site.
The 28-year-old says she isn't shy about strolling off the nursing platform in the injection room of the Insite operation in the city's Downtown Eastside and going up to clients in one of Insite's 12 booths.

Each booth is brightly lit so addicts can find good veins into which to plunge a syringe's needle. But there are also mirrors, which allow nurses from across the room to get an idea of what addicts are doing – whether, for example, they are using alcohol swabs.

“We can see everything that's going on,” said Ms. Jeal, who added “there's a lot of unclean practices with regard to drugs.”

She explained that users do not always wash their hands. The drugs themselves, bought on the street are not sterile. (Insite allows the use of drugs, but does not provide them.) And people do not always use alcohol swabs before plunging needles into their flesh.

“I will definitely walk over to them, and if I don't know them, introduce myself and say, ‘Hey. There's a great way to do this. Why don't you use an alcohol swab first?' ” Ms. Jeal said in an interview.

Ms. Jeal, who has been a nurse for three years, once worked full time at Insite.

Now she pulls the occasional shift in the operation, which opened in 2003 with support from the province, city and Vancouver Police Department, among others, as a means of dealing with disease, overdoses and other problems related to injection drug use, largely in the poverty-stricken Downtown Eastside.

However, many Insite supporters now fear for its future because federal Health Minister Tony Clement this week agreed to only a six-month extension in the Controlled Drugs and Substances Act exemption that allows illegal drugs in the facility without legal sanctions. Insite opened with a three-year exemption granted by the then-Liberal government.

Some say the federal Tories want the issue of Insite's future off the table with the possibility of a fall election, especially since the operation is popular in B.C. – with Premier Gordon Campbell and, according to polls, with the public as well.

B.C. Health Minister George Abbott says Insite represents a practical approach to issues of injection drug use.

“The challenge we have is that for drug-addicted individuals, at least until they resolve to try to move beyond their addictions, they are going to be using. When they use, we want to minimize the public health hazards that are associated with intravenous drug use,” he said.

“No one is saying drug addiction is a good thing. It is clearly a very bad thing. It's how we manage those addictions in a thoughtful and humanitarian way that is the key to understanding Insite.”

Insite is open 18 hours a day and, in a rare look at its inner workings, The Globe and Mail had a recent opportunity to visit during working hours.

Despite its unusual business, the injection room was subdued and quiet. The exception was one client, who came in on his bicycle and rode it back and forth, within a range of about a metre. (The man likely kept his bike with him, one observer noted, because it would be stolen if he left it on the street.) There were seven men and one woman, largely focused on taking out their drugs, preparing them and using them under nursing supervision.

A poster on the wall warns: “Take care Of your veins. Avoid abscess, dirty hits, embolism and edema. Avoid injecting particles.”

With its track lighting, black tile and white walls, the injection room has the disconcertingly elegant feel of a furniture showroom in a slick Vancouver shopping district. But as they arrive, clients can pick up clean syringes, little aluminum plates for cooking their drugs, a match or lighter and tourniquet.

“We wanted it to be as calm as it could be, and simple,” said Mark Townsend, manager with the Portland Hotel Society that runs the facility with the Vancouver Coastal Health Authority, explaining the design.

Ms. Jeal was not on duty this day. She spoke about Insite during an interview at a café up the street from the injection site, which is laid out on one floor behind a storefront-style facade on East Hastings, the main street in the Downtown Eastside neighbourhood that is home to about 4,000 injection drug users.

During her shifts, she said, she tries to constantly walk around the injection room, interacting with clients. “That's how we get to know people, get a rapport with people, find out what their thoughts are. Maybe they have an infection going. Or maybe they really want to get into detox.”
The point is to head off unsafe practices that can lead to HIV or hepatitis C, or to direct addicts to detox programs. Sanctioning injection-drug use within Insite also allows for a quick response to overdoses that occur on site as nurses look on, sending them into a scramble of sudden treatment and calls to ambulances. There were no fatalities among 453 overdoses reported between April, 2004, and March, 2006, the last period for which statistics are available.

“You can read through the protocol and study what to expect, but you never really know until you experience it,” Ms. Jeal said on the overdose issue, recalling she was “scared shitless” six weeks into her work at Insite when a man fell off his chair after shooting up. With treatment, he

The Burnaby-raised nurse, who never came to the Downtown Eastside in her youth, said Insite is no doubt necessary.

“It's not so much sanctioning drug use. The whole basis of harm reduction is accepting that people use [drugs],” she said. “It's not saying it's a good thing. It's not saying it's a bad thing, or marginalizing people who use drugs. It's saying they do use drugs and taking means to prevent harm that might come from using. It's a moral obligation to do that.”

But the federal government has its doubts. Prime Minister Stephen Harper, announcing a $63.8-million national drug strategy in Winnipeg this week that balances prevention and treatment, said he remains a skeptic about Insite, calling it a “second-best strategy at best.”
The Prime Minister stated, “If you remain a drug addict, I don't care how much harm you reduce, you're going to have a short and miserable life.” He said his government will continue studies on Insite, en route to a conclusion about its value.

The B.C. government provided an initial $1.2-million in capital funding for Insite, plus $2-million for first-year operating costs. Since then, the Vancouver Coastal Health Authority has covered the $2-million annual cost, drawing on its funding from the province. Health Canada provided $1.5-million over Insite's first three years to cover the research aspect. And Ottawa has a key power over its fate because of the controlled-substances exemption.

“I would have preferred a longer extension but I will tell you this. It certainly is better than not having any extension,” Mr. Campbell said.

“I think it's important that the extension has been made and what we will do now is continue to work with, not just the city, but with the federal government to ensure an even further extension.”

Mr. Campbell, a former Vancouver mayor, acknowledged that people will have questions about whether Insite is working. “We believe it is making a difference. We think it is effective. So our job is to continue to work on behalf of the province, the health-care system and patients in this regard.”

The current mayor, Sam Sullivan, said that city council would like the exemption extended for at least 3½ years, and that he plans to continue to make the case for Insite with federal officials. “It's a great achievement to have an exemption,” he said. “I look forward to getting a further exemption.”

Insite has its critics. The Canadian Police Association and the RCMP have criticized the operation for, among other things, creating an enabling environment.

Although there have been a number of studies endorsing Insite for steering addicts into detox and addiction programs and encouraging safe injection practices, other studies have not been so enthusiastic. One, by the Drug Prevention Network of Canada that was released in the Journal of Global Drug Policy last May, said positive findings about Insite had been overstated while negative findings were not given prominence.

In an interview, Mr. Clement said he is awaiting more research on how supervised injection sites affect prevention, treatment and crime before a decision would be made on Insite's fate. Six contracts have been put to tender. Successful bids have been accepted for three.

Mr. Clement, who opposed safe injection sites when he was an Ontario health minister years ago, insisted that his government has yet to make a final decision on Insite's fate, and dismissed the allegations of critics that the six-month extension was intended to put Insite beyond debate in an election.

“When we have decided something, we will certainly let everybody know, but we have not made that decision,” he said when asked about the required federal exemption.

Mr. Clement, who toured Insite last year, said it isn't yet clear how the facility fits into the tough drug strategy announced in Winnipeg. The government's posture this week is all about research, he said.

“The researchers said, ‘We need more time in order to do proper research for you and for Canadians,' and we gave them more time. There's nothing more sinister than that,” Mr. Clement said.

Mr. Abbott, B.C.'s Health Minister, said Ottawa deserves some credit for continuing with exemptions for Insite that were launched by a previous Liberal government. But he said Insite is a key to B.C.'s goals on injection drug use.

“I have always made it clear to Tony that I am supportive of this facility, that we believe it is a valuable part of the continuum of care for the drug addicted, and have always made clear to him we're prepared to assist in providing whatever information they believe they need to support the extension of their support for this facility.”

Mr. Abbott would not speculate on what Victoria will do if Mr. Clement eventually rules out an extended exemption for Insite, saying he was reluctant to consider hypothetical questions.
“We'll cross that bridge if and when we get to it. I would like to think that over the next six months, we will be able to provide them with the evidence that would support what they need
to get their support for this,” he said.

But Insite's operators are thinking about a Tory-engineered demise for Insite, and Mr. Townsend of the Portland Hotel Society says the situation looks bleak. “I believe if the PM does the wrong thing, we will have no choice but to keep the site open,” he said. “We would try our best to carry on as we could.”

But, he said, it wouldn't be easy. “It's hard to run a medical facility, a hospital or a supervised injection site with volunteers. You can't run these things with bake sales.”

Letters have been written to the Prime Minister's Office, and there is a talk of a protest visit to Parliament Hill. Mr. Townsend's society and a pair of drug addicts even filed a statement of claim in B.C. Supreme Court arguing the closing of Insite would violate their Charter rights to “security of the person.”

One of those addicts, Shelly Tomic, warmly recalls the support she has received from Insite since its first day as she grappled with a hunger for heroin, cocaine, speed and meth. She is now in recovery, but visits Insite when she feels the need to inject heroin.

Ms. Tomic, who has tested positive for hepatitis C and is disabled and unemployed, said she once had a heart attack at Insite – nurses called 911 when they noticed she was in distress. She said the site is better than the alleys and bar bathrooms she once used to shoot up.

“In Insite, you've always got clean rigs every single time, and even if you could get clean needles before Insite, you didn't necessarily have a sterile place to do it,” said Ms. Tomic, 39.

“You have got clean rigs. You don't have to rush to get it into you for fear of being arrested, or somebody taking [your drugs] from you or [being] mugged for it. And if you overdose at Insite, you have got medical staff right there to help you.”

She added: “[Insite] is sort of like the show Cheers, for Norm,” she says. “That's how I feel about Insite. I go in. Everybody knows me.”

Milestones in Insite's history
November, 2002
Larry Campbell, Vancouver's newly elected mayor, promises to move quickly on the creation of a safe injection site, acting on debate over the issue that has been under way for years.

September, 2003
Insite opens as North America's first safe injection site, bolstered by $1.2-million in capital funding from the B.C. government, plus $2-million for first-year operating costs. (Since then, the Vancouver Coastal Health Authority has covered the $2-million annual cost of the operation, drawing on its funding from the province.) Health Canada allots $1.5-million over three years to cover research costs.

September, 2006
Federal Health Minister Tony Clement approves a 16-month extension in an exemption to Section 56 of the Controlled Drugs and Substances Act that allows Insite to operate. He rules out considering applications from other municipalities for such sites until the review is completed. Vancouver police salutes the minister's decision, noting the department “congratulates the federal government for making a very difficult decision on a complex issue.”

Oct. 2, 2007
Mr. Clement announces a six-month extension of the exemption to June 30, 2008, to allow for more research on issues around supervised injection sites.
Ian Bailey

Insite client data collected from April, 2004, to March, 2006 (the most recent statistics available):
CLIENT GENDER Female: 30% Male: 70%

Other: 20% Morphine: 12% Cocaine: 27% Heroin: 41%

There were 453 overdoses and no fatalities.
4,084 referrals were made with 40% to addictions counselling.
The busiest day was May 25, 2005, with 933 visits in 18 hours.
There were 6,227 nursing care interventions with 2,055 for abscess care.


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