From The Ground Up - Insite's role in accessing treatment and care by WillyWoodcock


									Vancouver’ Supervised Injection Site’
Role in Accessing Treatment and Care

                                                        GROUND UP
     Canada has long been regarded as a global leader in health care delivery and innovation.
     Since September 2003, Insite, North America’s first Supervised Injection Site, has kept
     that tradition alive by offering care to some of Vancouver’s more than 12,000 injection drug
     users. Health care providers from around the world are looking to Vancouver as a model for
     how to treat and care for people with chronic addiction and complex health issues.

     I nsite was specifically designed to be accessible to
       injection drug users who are not well connected to
     health care services – men and women who use more
                                                                  In addition to providing a clean place for people to
                                                                  inject drugs, Insite also offers safe injecting education,
                                                                  which helps reduce the risk of transmission of infectious
     than one drug; people who experience both addiction          blood-borne diseases like HIV/AIDS and Hepatitis C –
     and mental illness; people with a history of trauma;         diseases that can have a devastating effect on both the
     people who are homeless, live in shelters or live in         individual and the surrounding community.
     substandard housing; men and women of Aboriginal
                                                                  And the Supervised Injection Site serves as a point
     descent; and people who have tried unsuccessfully in
                                                                  of entry into the full range of health care services
     the past to beat their drug addiction.
                                                                  Vancouver Coastal Health offers – from primary care
     Vancouver Coastal Health, the health authority               to treat disease and infection, to addiction counselling
     responsible for Insite, recognizes that no one goes          and treatment.
     from long-term, chronic drug addiction to abstinence
                                                                  The Supervised Injection Site was not designed to be
     overnight. No one goes from being vulnerable and
                                                                  a stand-alone facility. Rather it is an integral part of a
     marginalized to becoming fully engaged in treatment
                                                                  comprehensive continuum of addiction services. For
     and care. No one goes from living a chaotic lifestyle
                                                                  people with chronic drug addiction, Insite is the first
     to showing up at appointments regularly and on time.
                                                                  rung on the ladder from chronic drug addiction to
     No one gets better without help and support.
                                                                  recovery; from being ill to becoming well.
     Vancouver Coastal Health understands that for many
     people, the Supervised Injection Site is the first step in
     the process of improving their health and their lives.
                                                                diseases; it stabilizes peoples’ health; and it provides   have been using drugs for a long time. Their long-
                                                                the opportunity to form relationships and encourage        term drug use and chaotic living conditions have
                                                                                                                                                                                    The Supervised Injection
                                                                marginalized people to access health care services,        seriously compromised their overall health. For this     Site serves as a primary
                                                                including primary care and addiction treatment.            population, addiction is a root cause of their health
                                                                                                                           problems, but to become candidates for addiction         point of entry into the full
                                                                Any one of these purposes would be reason enough
                                                                to create a Supervised Injection Site – but the four
                                                                                                                           treatment, they must first be assisted in stabilizing    range of health care services
                                                                                                                           the basic elements of their daily life.
                                                                purposes working together make the facility a core
                                                                component of a comprehensive continuum of care that
                                                                                                                                                                                    Vancouver Coast Health offers.
                                                                                                                           Although many of these clients are currently
                                                                is vital to both individual and community well being.      unlikely candidates for addiction treatment until
                                                                                                                           their chaotic lives become more stable, Insite can
                                                                Who uses Insite?                                           play a key role in assisting them. These people         Accessing treatment
                                                                                                                           are stable enough to benefit from more of an            Research shows that people using Insite are more likely
                                                                In its first three years of operation, Insite attracted
    Drug addiction in Vancouver                                 more than 7,000 injection drug users, most from the
                                                                                                                           attachment to the overall health care system. For       to enter withdrawal management (detox) programs
                                                                                                                           these individuals, a regular attachment to a health     than injection drug users who do not use the facility.
    It has been estimated that Vancouver is home to             Downtown Eastside and neighbouring communities;
                                                                                                                           care facility like Insite enhances the opportunity      The likelihood of entering detox goes up even further
    about 12,000 injection drug users, with more than one       some from other parts of the city. About 600 injections
                                                                                                                           to provide care for issues like wound infections,       if the person uses Insite weekly, and first speaks with
    third living in the Downtown Eastside. The Downtown         per day take place at Insite.
                                                                                                                           TB, and inoculations for pneumonia and flu. With        an addiction counsellor. These findings make the 800
    Eastside is the poorest neighbourhood in the city,
                                                                Of the people who use Insite, about half are extremely     a regular attachment to health care services, the       referrals to addiction counseling even more meaningful.
    and one of the poorest in the country. It is also one of
                                                                marginalized, including people who are homeless            likelihood of taking HIV/AIDS medications when
    the most troubled. Because it has some of the only                                                                                                                             Research also indicates that one in five injection drug
                                                                or living in shelters, and people with significant         needed, also increases.
    affordable rental units in a city where property values                                                                                                                        users accessed detox services, which is particularly
                                                                untreated mental health issues. Many are older and
    are skyrocketing, the Downtown Eastside is a magnet                                                                    The remaining population that regularly uses            significant considering the Supervised Injection Site is
    for people living on social assistance, people who are                                                                 Insite are candidates for addiction treatment.          reaching a group of injection drug users who are least
    unemployed or people living on fixed incomes. The                                                                      As their lives become more stable and as they           likely to access care. Insite, as it was intended, is a
    impact of IV drug use is apparent in the community –        Candidates for                                             develop trusting relationships with health care
    from open drug use and injection in back alleys, to                                                                    providers they are more likely to pursue withdrawal
                                                                addiction treatment
    discarded needles, to high rates of illness and disease.                                                               management (detox), addiction counselling and

                                                                                                                           addiction treatment services.
    The Downtown Eastside has HIV rates that are
    comparable to developing countries, with three
    in 10 injection drug users are HIV positive. Nine in
                                                                                                                           What Insite has already
    10 have Hepatitis C. The overall mortality rate for                                                                    accomplished
    residents in the Downtown Eastside is 14 times that                                                                    Insite has benefited from a comprehensive
    of other BC residents.                                                                                                 peer-reviewed evaluation process: the first
                                                                                                                           such evaluation of a supervised injection facility
    This is the context in which the Supervised Injection
                                                                                                                           worldwide. As such, the information available
    Site came to exist.

    For many injection drug users living in the Downtown
    Eastside, housing is either very unstable or nonexistent.
                                                                                50%                                        on patterns of use and outcomes is both
                                                                                                                           comprehensive and reliable. And the research
                                                                                                                           results speak for themselves.
    Having a safe and clean place to inject drugs serves
                                                                                                                           In its second year of operation, Insite staff made
    four distinct, but overlapping purposes: it brings
                                                                                                                           more than 2,000 referrals to other services, with
    stability to the community by improving public order
                                                                                                   Need care for other     800 of these referrals to addiction counselling. To
    and reducing the number of injections taking place on
                                                                                                   problems first          remove any barrier to accessing treatment, an
    the street; it keeps people from transmitting infectious
                                                                                                                           addiction counsellor works out of Insite.

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       In the words of an Insite user:
     “It was about 11 o’clock at night and I had gone in and I
     actually had gotten a huge amount of heroin…five papers.
     I had gone there and I decided to do it all in one…
     And it was like, lights out…I come to–I’m laying on my back
     and I don’t even know where I’m at. I’m very scared…I just
     remember seeing the in site lady talking to me, holding my
     hand, telling me that everything was gonna be okay. There was
     an officer there and there was a paramedic there.
                                                                                                                            disease; reduce the transmission of infectious           On its own, Insite cannot turn the mean streets of
     If I had gone home and did that…I probably wouldn’t be here,                                                           diseases; reduce the number of fatal overdoses;          the Downtown Eastside into a neighbourhood free
     cause no one was at home. I was by myself, so I definitely                                                             and ensure people receive health care services           of problems. What Insite can do, it has done – move
                                                                                                                            that contribute to improving their lives and making      people off the streets and into a clean safe place to
     would have overdosed and I probably would have ended up                                                                them well.                                               inject drugs; once they have a regular routine, engage
     killing myself.”                                                                                                                                                                them and bring them into the healthcare system where

     - Interview with in site client                                                                                        Improving public order                                   some of their physical health needs can be addressed;
                                                                                                                                                                                     once their health improves, engage them with an
                                                                                                                            The research shows that patterns of drug use in
                                                                                                                                                                                     addiction counsellor who can support and encourage
                                                                                                                            the community did not worsen as a result of Insite,
                                                                                                                                                                                     them to go into a withdrawal management program to
                                                                                                                            and crimes related to drug use have not increased.
                                                                                                                                                                                     reduce or eliminate the use of injection drugs, reclaim
                                                                                                                            What did improve was this: a reduction of the
                                                                                                                                                                                     their lives, and begin the process of recovery.
                                                                                                                            number of people openly injecting on the streets
                                                               overall rate of needle sharing has been reduced in the       and the amount of injection-related litter that was
    point of entry for the Downtown Eastside’s highest
                                                               wider community, which shows the impact Insite has           left behind.
    risk injection drug users – the first rung on the ladder
    to recovery.                                               had beyond its walls.                                        In evaluating North America’s first Supervised            Addiction is a health issue
                                                                                                                            Injection Site, it is important to measure its results
    In real numbers, of the 1031 people randomly
                                                               Improving health                                             against the objectives the facility identified at         and Vancouver Coastal Health
    selected to be enrolled in a research follow-up of
    use of withdrawal management services, 185 people          Some people worry that a Supervised Injection                its inception. Was Insite designed to remove all          is finding innovative ways to
                                                               Site sends the wrong message about drug use and              drug activity from the streets of the Downtown
    began a detox program during follow-up.
                                                               may attract people who currently don’t use drugs,            Eastside? No, it was not.                                 bring people into care who
    Reducing disease                                           or encourage people to use more frequently. The
                                                               reality is that Insite sends drug users and the wider
                                                                                                                            Was Insite designed to get 100 per cent of users          are not being served by more
                                                                                                                            into treatment? No. Health care staff understand
    Elevated Hepatitis C and HIV rates in the Downtown         community the message that addiction is a health
                                                                                                                            that not all residents with addiction issues are ready
                                                                                                                                                                                      traditional health services.
    Eastside are directly related to the practice of needle    issue, and as the organization responsible for people’s
    sharing. So using clean needles that are safely                                                                         to deal with their addiction, until they’ve dealt what
                                                               health in this city, Vancouver Coastal Health is
    discarded immediately after use is an important way                                                                     contributed to the addiction in the first place.
                                                               finding innovative ways to bring people into care who
    to reduce the transmission of these devastating            currently are not being served by existing health care
    illnesses. Research shows that people using Insite are     services. Insite is a health facility first and foremost –
    70 per cent less likely to share syringes than injection   a facility designed to treat and reduce infections and
    drug users who don’t use the facility. In fact, the

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    In their own words                                         “[In the alley] You’re in a rush. You                          Access to immediate nursing care                           “Having a nurse look at it, if they
                                                                gotta look around you. You gotta watch.                                                                                   think you need to get something more
    Why people use Insite                                                                                                     For many Insite users, the availability of immediate
                                                                It’s hard to explain…And in the Insite,                                                                                   done then they’ll recommend you go to a
    The majority of people using the Supervised Injection                                                                     and easily accessible nursing care translates
                                                                I sit there, get a spoon, cook it…that                                                                                    clinic or whatnot. They’re professional,
    Site. The primary reasons they use Insite are: the                                                                        into receiving health care services they would
                                                                kills the bacteria and dirt…and filter                                                                                    so they’ll know by looking…if it sounds
    hygienic environment Insite offers, and a variety of                                                                      otherwise do without.
                                                                it out. I can take my time…I got all                                                                                      more serious, then they’ll recommend
    perceived health benefits including increased ability to    the supplies there. I just do the whole                                                                                   that you go to a hospital or to a
                                                                                                                              “I think some people would probably
    avoid overdose, reduced HIV risks and other injection       process there. I practice safe.”                                                                                          walk-in clinic or whatever. So, in that
                                                                                                                               not be getting any attention at all
    related infections.                                                                                                                                                                   sense, it’s good because you always have
                                                               “It’s not a back alley. [At Insite] you                         if it wasn’t for the fact that they’re
    “I just feel safer there, it’s more                        just don’t have to worry about yourself                         at the Insite. The only reason that                        that professional nurse on-hand to guide
     sanitary.”                                                 as much. You have people who know what                         they’ve managed to see somebody                            you and give you a second opinion.”
                                                                they’re doing, show you how to do it                           within the medical profession is
    “…There’s less chance you’re going to
                                                                properly, how to do it safely, how to do                       because somebody noticed them there
     get AIDS.”
                                                                it cleanly. You still have to worry about                      and pretty much convinced them that
    “I’m safe there…I don’t have to worry                                                                                      they should get attention.”
                                                                what you’re doing and whatever, but you
     about it being dirty of whatever.”
                                                                have that backup security.”                                   “Sometime at three o’clock in the
                                                                                                                                                                                          One in five Insite users
    “I know I’m not going to catch anything…
     I just feel safe.”
                                                                                                                               morning you’ve got an infection or                         accessed detox services.
                                                               Treatment and prevention of                                     something. And so it’s good to know
    “The nurse is there. And she’s got that                                                                                    that help is there at that time of day.”
                                                               injection-related infections
     Narcan…if I ever O.D. that’s nice to know.”
                                                               Injection-related infections are considered to be a

    The secure environment offered by Insite also reduces
    a drug user’s need to rush injection. This increases
                                                               primary cause of emergency room visits and hospital
                                                               use among injection drug users. Treating these infections      Insite by the numbers
                                                               in a hospital setting is expensive and time consuming.
    the likelihood the drug user will adhere to safe
                                                               And when not treated early, infections can result in long       From April 1, 2004 to March 31, 2007
    injecting practices – practices that reduce the risk of
                                                               hospital stays that further add to increased costs of care.
    transmission of HIV and Hepatitis C, and increase the                                                                      •	7,648 unique individuals                            •	Referral to withdrawal management: 618
    chance of overdose.                                        Insite has been designed to provide health care for issues
                                                                                                                                registered at Insite                                 •	Referral to methadone maintenance:
                                                               like injection-related infections, before they have a chance
                                                               to become serious enough to require hospital care.              •	Women made up 27% of clients                         2 per week
                                                                                                                               •	Aboriginal people made up 19%                       • Daily average visits: 645
                                                                                                                                of clients                                           •	Average number of visits per month,
                                                                                                                               •	Heroin was used in 42% of injections                 per person: 11
                                                                                                                               •	Cocaine was used in 26%                             •	Busiest day: March 28, 2007 (1034 visits
                                                                                                                                of injections                                         in 18 hours)
                                                                                                                               •	Morphine was used in 11%                            •	Number of nursing care interventions: 10,089
                                                                                                                                of injections                                        •	Number of nursing interventions for abscess
                                                                                                                               •	696 overdoses resulted in no fatalities              care: 3,130
                                                                                                                               •	6,354 referrals were made with 40% of them
                                                                                                                                made to addiction counselling

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SIS PartnerS
Community Members
Vancouver Coastal Health
PHS Community Service Society
Vancouver Police Department
City of Vancouver
Office of the Provincial Health Officer
BC Centre for Excellence in HIV/AIDS
University of British Columbia
Vancouver Agreement Partners


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