Gaining Insite Harm Reduction in Nursing Practice

April 2009   Comments

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's history

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).

Insite’s objectives

  • 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 today

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.

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Beverly Lightfoot, RN

Beverly Lightfoot, RN, is a Clinical Coordinator, Insite, Vancouver, British Columbia.

Ciro Panessa, RN, MSN

Ciro Panessa, RN, MSN, is an Adjunct Professor, University of British Columbia School of Nursing, Vancouver.

Sargent Hayden, RN, BSN

Sargent Hayden, RN, BSN, is a Clinical Coordinator, Insite.

Meaghan Thumath, RN, BScN, MSCPH

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

Irene Goldstone, RN, BN, MSC, is Director, Professional Education & Care Evaluation, British Columbia Centre For Excellence In HIV/AIDS, Vancouver.

Bernadette Pauly, RN, PhD

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.

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