Apr 01, 2009, By: Beverly Lightfoot, RN , Ciro Panessa, RN, MSN , Sargent Hayden, RN, BSN , Meaghan Thumath, RN, BScN, MSCPH , Irene Goldstone, RN, BN, MSC , Bernadette Pauly, RN, PhD
Insite, a supervised injection facility in Vancouver, British Columbia, is an evidence-based response to the ongoing health and social crisis in the city’s Downtown Eastside. It has been shown that Insite’s services increase treatment referrals, mitigate the spread and impact of blood-borne diseases and prevent overdose deaths. One of the goals of this facility is to improve the health of those who use injection drugs. Nurses contribute to this goal by building trusting relationships with clients and delivering health services in a harm reduction setting. The authors describe nursing practice at Insite and its alignment with professional and ethical standards of registered nursing practice. Harm reduction is consistent with accepted standards for nursing practice as set out by the College of Registered Nurses of British Columbia and the Canadian Nurses Association and with World Health Organization guidelines.
Harm and harm reduction
The effects of illegal substance use present significant challenges to civil society. Addiction to illegal substances reflects a complex milieu of unmet health needs and co-existing issues such as mental illness and cultural dislocation that lead to a loss of social cohesion (Alexander, 2008). Unsafe injection of illegal substances such as heroin and crack cocaine is associated with blood-borne pathogens such as HIV and hepatitis C (HCV), injection-related infections, endocarditis and death due to overdose. Those addicted to such drugs are vulnerable to poor health and will benefit from the health and social support that nurses provide (Pauly, 2008). Harm reduction is a philosophy that allows nurses to work with individuals “where they are at,” without requiring a reduction in drug use (International Harm Reduction Association, n.d.) and is an essential element of the prevention, care and treatment continuum and an integral component of mental health, addiction and primary care delivery. Illegal drug use has long been associated with concerns about morality. Not surprisingly, harm reduction practices have been criticized as unethical and, by extension, inconsistent with the ethical practice of health-care providers.
INSITE PAST AND PRESENT
Insite, a supervised injection facility, is part of a coordinated response to the ongoing health and social crisis experienced by residents of the Downtown Eastside in Vancouver’s urban core. This crisis, precipitated by a marked decrease in social housing and a mass deinstitutionalization of people with mental illness (Wood & Kerr, 2006), resulted in a concentration of impoverished and vulnerable people living in this area. This situation, combined with a ready supply of illegal drugs, led to one of the worst HIV and HCV epidemics in the western world, with HIV prevalence rates of between 17 and 30 per cent and HCV rates that are greater than 90 per cent among those who use drugs (Tyndall et al., 2006).
Insite opened on Sept. 22, 2003, following strong advocacy efforts by community stakeholders and health and social service professionals to augment existing resources with access to supervised injection, and with political leadership from three levels of government (Gold, 2003; Small, Palepu, & Tyndall, 2006). The federal government provided an exemption for Insite under Section 56 of the Controlled Drugs and Substances Act; the site opened with the support of the Vancouver Police Department, which recognized that public order would best be served by referring people who use injection drugs in public spaces to a health service (DeBeck et al., 2008).
- Improve the overall health of drug users, including reducing the incidence of overdose death and disease transmission.
- Reduce the harms associated with illegal drug use (e.g., crime, discarded needles, public drug use) that affect communities.
- Increase access to health and social services by intravenous drug users.
- Reduce social, legal and incarceration costs associated with drug use.
Positive outcomes well documented
Positive outcomes have been documented in over 25 peer-reviewed journals since Insite opened. Milloy, Kerr, Tyndall, Montaner and Wood (2008) report that despite over 1,000 overdose events at the facility, no deaths have occurred. These authors suggest that between two and 12 deaths per year may have been prevented. The facility has also been associated with reductions in HIV risk behaviours (Wood, Tyndall, Montaner, & Kerr, 2006). Weekly attendance at Insite and contact with a supervised injection site addictions counsellor were associated with more rapid entry into detoxification programs, and there has been a 30 per cent increase in the use of detoxification services, associated with entry into longer term treatment and less use of the site (Wood et al., 2006; Wood, Tyndall, Zhang, Montaner, & Kerr, 2007). Reductions in open public injecting, fewer discarded syringes and drug-related paraphernalia, and no observed increase in drug dealing around the site have been noted (Wood et al., 2004; Wood et al., 2006). Clients have reported less rushed injecting (80%); injecting less outdoors (71%); and fewer incidents of unsafe syringe disposal (56%) (Petrar et al., 2007). Bayoumi and Zaric (2008) found that Insite is a cost-effective program as a result of preventing overdose events, reducing risk behaviour associated with the transmission of HIV and increasing referrals to methadone treatment.
An external advisory panel, appointed by Health Canada to review the evidence related to supervised injection sites, concluded that Insite has had a positive impact on the public health of the community and on clients and neighbourhood residents, service providers and business owners (Expert Advisory Committee, 2008). No adverse effects were found in relation to drug use patterns, crime or public disorder.
Insite is operated by Vancouver Coastal Health (the regional health authority) in partnership with the not-for-profit PHS Community Services Society. It provides a range of low threshold, client-focused health-care services, including needle exchange, harm reduction education, primary nursing care, health and social care referrals and addiction treatment. Insite is one of the city’s most widely used needle and syringe exchange sites — a place where used syringes and needles can be safely disposed of and where sterile equipment to prevent HIV, HCV and other blood-borne illnesses is provided. In addition, it provides a key point of access for health and social services. An integrated team of registered nurses and registered psychiatric nurses, mental health workers and peer workers is available from 10 a.m. to 4 a.m. daily. On average, between 700 and 1,000 clients utilize Insite in an 18-hour period. Under nurses’ supervision, they inject pre-obtained illegal or prescription drugs. Nurses, who do not provide or administer any substances, offer pragmatic guidance, health teaching and care so that potential harms associated with injections are minimized and opportunities to engage clients in health care and addiction treatment are optimized.
Clients are greeted in the reception area by a mental health worker. At the first visit, a client (who is referred to as a participant) can either register with his or her own name or with an alias (to ensure confidentiality and reduce barriers).
Once space permits, individuals enter the injection room, inform staff of what substance they intend to use and take a seat at one of 12 well-lit, mirrored booths. (Due to limited capacity, the ability to meet the high volume of clients in need of this service is a serious challenge.) Sterile injection equipment for preparing drugs, water, alcohol swabs, tourniquets, filters and bandages are provided.
Clients then prepare to inject; this is an opportune time for nurses to engage in health teaching and health assessments. The central position of the nursing station in the injection room enhances the nurses’ ability to observe clients for overdose symptoms, anaphylaxis, risky injection practices and injuries. After injection, some clients approach nurses to receive assistance with a variety of health and social concerns. The adjoining treatment room is used for confidential one-on-one addiction counselling and for primary nursing care services. Clients are invited to rest in the chill-out lounge, where nurses can continue to observe them. The lounge is a place to connect with peer workers and with staff, who can make referrals to the Onsite withdrawal management and treatment program (located upstairs) or to other external services. The lounge also gives clients an opportunity to rest and enjoy coffee or juice — a much-needed respite from the street.
Insite nurses provide vital health services to a highly marginalized population, using a comprehensive nursing framework (see figure on page 20) that is rooted in client-centred relationship building and primary nursing care activities that are guided by a harm reduction philosophy and core principles of health promotion.
Relationship building. Insite clients experience health inequities that are exacerbated by poverty, homelessness, racism and social isolation (Small, 2005). Many are burdened with chronic and concurrent medical conditions such as HIV, HCV, mental illnesses, pneumonia, cellulitis, osteomylitis, endocarditis, septic arthritis, acute injuries and physical disability. People experiencing addiction and homelessness encounter a number of barriers to accessing mainstream health care, including lack of financial resources, lack of transportation, stigma and discrimination (Butters & Erickson, 2003; Crockett & Gifford, 2004; Ensign & Panke, 2002; Hwang & Gottlieb, 1999; Napravnik, Royce, Walter, & Lim, 2000). Past or current status as a “drug user” has been reported as a significant barrier. Nurses use a holistic approach that focuses on developing dignified, caring and trusting relationships and building foundations for change through personal empowerment. Through these relationships, nurses gain insight into practical strategies appropriate to addressing identified individual client care needs.
A high proportion of clients identify as aboriginal. Nurses emphasize a culturally safe approach to care that builds trust and empowers clients by reinforcing the idea that each person’s knowledge and reality is valid and valuable. This approach facilitates open communication and allows the client to voice concerns about nursing care that he or she may deem unsafe.
Primary nursing care. Insite can be a client’s first point of contact with the health-care system. Primary nursing care activities include overdose management, basic and advanced first aid, rapid point of care HIV testing, immunizations, acute and chronic wound care, reproductive health, screening and treatment for sexually transmitted infections, counselling, and referrals to external health and social services. The facility circulates the “bad date” list of dangerous patrons of sex trade workers and provides support and crisis management for clients in the event of sexual assault.
Education. Clients are often most receptive to health teaching after they have injected. In small group settings or one-to-one, nurses educate them on the importance of handwashing, the filtering of drugs prior to injection, the use of sterile injecting equipment and sterile water, the cleansing of skin with an alcohol swab, vein care, and proper needle insertion. They also instruct clients on overdose prevention by advising on how to assess drug purity and encouraging them to never inject alone.
Partnership and referrals to health and social systems. Nurses work with community partners to promote health and address the complex social needs of clients. Partnering with programs like the Vancouver Native Health Clinic for HIV care and treatment, Sheway pregnancy outreach program, and the BC Centre for Disease Control’s street nurse program for STI screening supports Insite’s continuum of care philosophy. Nurses also regularly refer clients to resources for housing, income assistance and food support.
PROFESSIONAL AND ETHICAL STANDARDS
Nurses in any practice setting may encounter ethical concerns associated with illegal drug use; they may find themselves caught between evidence and ethics on one hand and policy and law on the other. Nursing practice at Insite has come under attack from the public, politicians and health-care professionals who have suggested that it is not compatible with professional and ethical standards. However, previous analyses have demonstrated that the values of harm reduction and the practice of supervised injection are consistent with existing professional and ethical standards of nursing practice (Griffiths, 2002; Pauly, Goldstone, McCall, Gold, & Payne, 2007; Wood, Zettel, & Stewart, 2003).
The Code of Ethics for Registered Nurses (Canadian Nurses Association, 2008) states that nurses have a responsibility to use current research in their practice. Additionally, the College of Registered Nurses of British Columbia (CRNBC) professional standards (2008) direct nurses to base their practice on the best evidence available from nursing and other sciences. A growing body of research indicates that Insite offers a safe environment where overdose deaths have been prevented, risk behaviour associated with the transmission of blood-borne diseases has been reduced and referrals to detoxification services have increased (Milloy et al., 2008; Wood et al., 2006). Furthermore, needle exchange, counselling, referral and safer injection education services are consistent with current evidence and best practices for reducing the harms of drug use (World Health Organization, 2008).
The provision of supervised injection education falls within the scope of practice as set out by CRNBC, and it is an accepted disease prevention approach for those who use drugs (Wood et al., 2003). The code of ethics states that nurses have a responsibility to provide “persons in their care with the information they need to make informed decisions related to their health and well-being” (CNA, 2008, p. 11).
Nurses can experience difficulties in maintaining relationships with and continuing to provide care for clients in the face of challenging interpersonal situations. Nurses at Insite provide care on the basis of need and do not discriminate in the provision of care based on social attributes. They preserve dignity through their respect for humanity and their acknowledgment of the inherent worth of each individual, helping to counteract the judgments that those who use drugs encounter every day. At all times, they strive to remain non-judgmental.
Insite has pushed the boundaries of community-based health care in North America, and nurses, as key participants in advocating for the development of Insite, have helped reduce barriers to accessing health-care services. Through partnerships with other agencies and organizations, they are engaged in trying to improve clients’ access to affordable housing and adequate income. Current Canadian drug laws that criminalize certain psychoactive substances bring tensions between law enforcement and public health responses to illegal drug use to the forefront. There is mounting evidence that these laws are actually contributing to the harm done to society and to individuals who use these drugs (Haden, 2002). In the face of uncertainty about the federal government’s willingness to continue to extend exemptions from Section 56 of the Controlled Drugs and Substances Act, the PHS Community Services Society and the Vancouver Area Network of Drug Users took legal action to seek relief from the need to obtain ongoing extensions. Last May, the B.C. Supreme Court ruled that Insite should remain open and continue to operate as a health-care service. The Court gave the federal government until June 9, 2009, to make necessary changes to the current drug laws. Further, it ruled that closing Insite would be a violation of the right to life, liberty and security under Section 7 of the Charter of Rights and Freedoms (PHS Community Services Society v. Attorney General of Canada, 2008) and would deny individuals access to an essential health-care service.
Educational tool focuses on harm reduction nursing
Two street nurses are out on their daily rounds when they run across Becky, a heroin addict they know well. She is living behind a trailer in an alley with her pregnant teenage daughter, who is also a drug user. Becky is in terrible shape; the nurses suspect she has suffered a stroke and may have pneumonia. But she refuses to go to the hospital, and the nurses are faced with the dilemma of what to do next.
That real-life scene comes from Bevel Up: Drugs, Users and Outreach Nursing, an interactive DVD that is the brainchild of Vancouver’s street nurses, who saw the need for a specialized teaching tool to help other nurses like themselves. Co-produced by the BC Centre for Disease Control and the National Film Board of Canada, the DVD consists of a 45-minute documentary and an instructional component.
The documentary, directed by Nettie Wild, is a hard-hitting look at the life of drug addicts. It follows a team of nurses who do their work on the streets and in the rooming houses and back alleys of Vancouver’s Downtown Eastside. They give out clean needles and condoms, teach safe injection techniques, encourage clients to get testing for HIV and STIs, help to find housing for those who are willing to take it, and deal with minor medical issues. The documentary is followed by eight instructional chapters that cover such topics as communication, legal and ethical issues, relationship building, sex work and health, and safety. Interviews with experts are used to launch more in-depth discussions, and the comprehensive teaching guide that comes with the DVD contains suggestions for questions to ask after each video chapter.
The film, which premiered in Vancouver at the 2007 Canadian Association of Nurses in AIDS Care conference, has been shown at nursing schools and universities across the country to audiences of instructors, students, community workers and health-care professionals.
Bevel Up is available for purchase through the National Film Board of Canada atwww3.nfb.ca/webextension/bevel-up/index.php?vw=1
The individual, population and health system benefits of Insite are well documented (Wood et al., 2006). The practice of its nurses is guided by core principles of harm reduction and health promotion that are central to achieving Insite’s objectives and consistent with professional and ethical standards.
All nurses should be well informed about harm reduction interventions and their place in the prevention, care and treatment continuum, so that they can humanely care for those who use drugs by referring to and advocating for all types of evidence-based addiction supports.
Acknowledgment: The authors are indebted to Insite clients, who have taught them much about surviving a life of severe marginalization. The authors acknowledge the support and encouragement of Sarah Evans and Dr. David Marsh and the support of Vancouver Coastal Health, the PHS Community Services Society and the British Columbia Centre for Excellence in HIV/AIDS in the preparation of this manuscript. Kevin Pendergraft assisted in the preparation of the manuscript, and Lori Campbell, Misty Bath, Greg Slawson and Jamie Fortier were involved in developing the figure.
Alexander, B.K. (2008). The globalisation of addiction: A study in poverty of the spirit. Oxford, U.K.: Oxford University Press.
Bayoumi, A.M., & Zaric, G.S. (2008). The cost-effectiveness of Vancouver’s supervised injection facility. Canadian Medical Association Journal, 179(11), 1143-1151.
Butters, J., & Erickson, P.G. (2003). Meeting the health care needs of female crack users: A Canadian example. Women and Health, 37(3), 1-17.
Canadian Nurses Association. (2008). Code of Ethics for Registered Nurses. ` Ottawa, ON: Author.
College of Registered Nurses of British Columbia. (2008). Scope of practice for registered nurses: Standards, limits, conditions. Vancouver, BC: Author. Retrieved March 4, 2009, from http://www.crnbc.ca/downloads/433-scope.pdf
Crockett, B., & Gifford, S.M. (2004). “Eyes wide shut”: Narratives of women living with hepatitis C in Australia. Women & Health, 39(4), 117-137.
DeBeck, K., Wood, E., Zhang, R., Tyndall, M., Montaner, J., & Kerr, T. (2008). Police and public health partnerships: Evidence from the evaluation of Vancouver’s supervised injection facility. Substance Abuse Treatment, Prevention, and Policy, 3, 11.
Ensign, J., & Panke, A. (2002). Barriers and bridges to care: Voices of homeless female adolescent youth in Seattle, Washington, USA. Journal of Advanced Nursing, 37(2), 166-172.
Expert Advisory Committee. (2008). Vancouver’s INSITE service and other supervised injection sites: What has been learned from research? Final report of the Expert Advisory Committee on Supervised Injection Site Research. Ottawa, ON: Health Canada.
Gold, F. (2003). Supervised injection facilities. Canadian Nurse, 99(2), 14-18.
Griffiths, H. (2002). Dr. Peter Centre — Removing barriers to health care services. Nursing BC/Registered Nurses Association of British Columbia, 34(5), 10-14.
Haden, M. (2002). Illicit IV drugs: A public health approach. Canadian Journal of Public Health, 93(6), 431-434.
Hwang, S.W., & Gottlieb, J. (1999). Drug access among homeless men in Toronto. Canadian Medical Association Journal, 160(7), 1021.
International Harm Reduction Association. (n.d.). What is harm reduction? Retrieved March 4, 2009, from http://www.ihra.net/Whatisharmreduction
Milloy, M.-J.S., Kerr, T., Tyndall, M., Montaner, J., & Wood, E. (2008). Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS ONE, 3(10), e3351.
Napravnik, S., Royce, R., Walter, E., & Lim, W. (2000). HIV-1 infected women and prenatal care utilization: Barriers and facilitators. AIDS Patient Care and STDs, 14(8), 411-420.
Pauly, B.B. (2008). Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing practice. International Journal on Drug Policy, 19(3), 195-204. Epub 2008 May 7
Pauly, B., Goldstone, I., McCall, J., Gold, F., & Payne, S. (2007). The ethical, legal and social context of harm reduction. Canadian Nurse, 103(8), 19-23.
Petrar, S., Kerr, T., Tyndall, M.W., Zhang, R., Montaner, J.S., & Wood, E. (2007). Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 32(5), 1088-1093. Epub 2006 August 22.
PHS Community Services Society v. Attorney General of Canada. (2008). BCSC 661. Retrieved March 4, 2009, from http://www.cfdp.ca/ sif_bcsc.pdf
Small, D., Palepu, A., & Tyndall, M.W. (2006). The establishment of North America’s first state sanctioned supervised injection facility: A case study in culture change. International Journal of Drug Policy, 17(2), 73-82.
Small, R.D. (2005). Looking into the cultural mirror. Addiction, secret lives and lost personhood. Visions Journal, 2(6), 29-30. Retrieved March 4, 2009, from http://www.heretohelp.bc.ca/sites/default/files/images/6.pdf
Tyndall, M.W., Wood, E., Zhang, R., Lai, C., Montaner, J.S.G., & Kerr, T. (2006). HIV seroprevalence among participants at a supervised injection facility in Vancouver, Canada: Implications for prevention, care and treatment. Harm Reduction Journal, 3, 36.
Wood, E., & Kerr, T. (2006). What do you do when you hit rock bottom? Responding to drugs in the city of Vancouver. International Journal of Drug Policy, 17(2), 55-60.
Wood, E., Kerr, T., Small, W., Li, K., Marsh, D.C., Montaner, J.S.G., & Tyndall, M.W. (2004). Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Canadian Medical Association Journal, 171(7), 731-734.
Wood, E., Tyndall, M.W., Montaner, J.S., & Kerr, T. (2006). Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association Journal, 175(11), 1399-1404.
Wood, E., Tyndall, M.W., Zhang, R., Montaner, J.S., & Kerr, T. (2007). Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 102(6), 916-919.
Wood, R.A., Zettel, P., & Stewart, W. (2003). The Dr. Peter Centre. Harm reduction nursing. Canadian Nurse, 99(5), 20-24.
World Health Organization. (2008). Policy guidelines for collaborative TB and HIV services for injecting and other drug users: an integrated approach. Evidence for Action Technical Papers. Geneva: WHO Press. Retrieved March 4, 2009, from http://whqlibdoc.who.int/publications/2008/9789241596930_eng.pdf
Beverly Lightfoot, RN, is a Clinical Coordinator, Insite, Vancouver, British Columbia.
Ciro Panessa, RN, MSN, is an Adjunct Professor, University of British Columbia School of Nursing, Vancouver.
Sargent Hayden, RN, BSN, is a Clinical Coordinator, Insite.
Meaghan Thumath, RN, BScN, MSCPH, is Clinical Practice Initiatives Lead HIV/AIDS, Vancouver Coastal Health and an Adjunct Professor, UBC School of Nursing.
Irene Goldstone, RN, BN, MSC, is Director, Professional Education & Care Evaluation, British Columbia Centre For Excellence In HIV/AIDS, Vancouver.
Bernadette Pauly, RN, PhD, is an Assistant Professor, University of Victoria School of Nursing and a Research Associate, Centre For Addictions Research of BC, Victoria, British Columbia.