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1 Vancouver s Supervised Injection Site s 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. Insite 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 than one drug; people who experience both addiction and mental illness; people with a history of trauma; people who are homeless, live in shelters or live in substandard housing; men and women of Aboriginal descent; and people who have tried unsuccessfully in the past to beat their drug addiction. Vancouver Coastal Health, the health authority responsible for Insite, recognizes that no one goes from long-term, chronic drug addiction to abstinence overnight. No one goes from being vulnerable and marginalized to becoming fully engaged in treatment and care. No one goes from living a chaotic lifestyle to showing up at appointments regularly and on time. No one gets better without help and support. 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. 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 blood-borne diseases like HIV/AIDS and Hepatitis C diseases that can have a devastating effect on both the individual and the surrounding community. And the Supervised Injection Site serves as a point of entry into the full range of health care services Vancouver Coastal Health offers from primary care to treat disease and infection, to addiction counselling and treatment. The Supervised Injection Site was not designed to be a stand-alone facility. Rather it is an integral part of a comprehensive continuum of addiction services. For people with chronic drug addiction, Insite is the first rung on the ladder from chronic drug addiction to recovery; from being ill to becoming well.

2 diseases; it stabilizes peoples health; and it provides the opportunity to form relationships and encourage marginalized people to access health care services, including primary care and addiction treatment. Any one of these purposes would be reason enough to create a Supervised Injection Site but the four purposes working together make the facility a core component of a comprehensive continuum of care that is vital to both individual and community well being. have been using drugs for a long time. Their longterm drug use and chaotic living conditions have seriously compromised their overall health. For this population, addiction is a root cause of their health problems, but to become candidates for addiction treatment, they must first be assisted in stabilizing the basic elements of their daily life. Although many of these clients are currently unlikely candidates for addiction treatment until The Supervised Injection Site serves as a primary point of entry into the full range of health care services Vancouver Coast Health offers. Drug addiction in Vancouver It has been estimated that Vancouver is home to about 12,000 injection drug users, with more than one third living in the Downtown Eastside. The Downtown Eastside is the poorest neighbourhood in the city, and one of the poorest in the country. It is also one of the most troubled. Because it has some of the only affordable rental units in a city where property values are skyrocketing, the Downtown Eastside is a magnet for people living on social assistance, people who are unemployed or people living on fixed incomes. The impact of IV drug use is apparent in the community from open drug use and injection in back alleys, to discarded needles, to high rates of illness and disease. The Downtown Eastside has HIV rates that are comparable to developing countries, with three in 10 injection drug users are HIV positive. Nine in 10 have Hepatitis C. The overall mortality rate for Who uses Insite? In its first three years of operation, Insite attracted more than 7,000 injection drug users, most from the Downtown Eastside and neighbouring communities; some from other parts of the city. About 600 injections per day take place at Insite. Of the people who use Insite, about half are extremely marginalized, including people who are homeless or living in shelters, and people with significant untreated mental health issues. Many are older and Candidates for addiction treatment 50% their chaotic lives become more stable, Insite can play a key role in assisting them. These people are stable enough to benefit from more of an attachment to the overall health care system. For these individuals, a regular attachment to a health care facility like Insite enhances the opportunity to provide care for issues like wound infections, TB, and inoculations for pneumonia and flu. With a regular attachment to health care services, the likelihood of taking HIV/AIDS medications when needed, also increases. The remaining population that regularly uses Insite are candidates for addiction treatment. As their lives become more stable and as they develop trusting relationships with health care providers they are more likely to pursue withdrawal management (detox), addiction counselling and addiction treatment services. What Insite has already accomplished Accessing treatment Research shows that people using Insite are more likely to enter withdrawal management (detox) programs than injection drug users who do not use the facility. The likelihood of entering detox goes up even further if the person uses Insite weekly, and first speaks with an addiction counsellor. These findings make the 800 referrals to addiction counseling even more meaningful. Research also indicates that one in five injection drug users accessed detox services, which is particularly significant considering the Supervised Injection Site is reaching a group of injection drug users who are least likely to access care. Insite, as it was intended, is a residents in the Downtown Eastside is 14 times that of other BC residents. Insite has benefited from a comprehensive peer-reviewed evaluation process: the first This is the context in which the Supervised Injection Site came to exist. For many injection drug users living in the Downtown Eastside, housing is either very unstable or nonexistent. 50% such evaluation of a supervised injection facility worldwide. As such, the information available 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 four distinct, but overlapping purposes: it brings stability to the community by improving public order and reducing the number of injections taking place on the street; it keeps people from transmitting infectious Need care for other problems first In its second year of operation, Insite staff made more than 2,000 referrals to other services, with 800 of these referrals to addiction counselling. To remove any barrier to accessing treatment, an addiction counsellor works out of Insite. 1 2

3 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. If I had gone home and did that I probably wouldn t be here, cause no one was at home. I was by myself, so I definitely would have overdosed and I probably would have ended up killing myself. - Interview with in site client point of entry for the Downtown Eastside s highest risk injection drug users the first rung on the ladder to recovery. overall rate of needle sharing has been reduced in the wider community, which shows the impact Insite has had beyond its walls. In real numbers, of the 1031 people randomly selected to be enrolled in a research follow-up of use of withdrawal management services, 185 people began a detox program during follow-up. Improving health Reducing disease Elevated Hepatitis C and HIV rates in the Downtown Eastside are directly related to the practice of needle sharing. So using clean needles that are safely discarded immediately after use is an important way to reduce the transmission of these devastating illnesses. Research shows that people using Insite are 70 per cent less likely to share syringes than injection drug users who don t use the facility. In fact, the 3 Some people worry that a Supervised Injection Site sends the wrong message about drug use and may attract people who currently don t use drugs, or encourage people to use more frequently. The reality is that Insite sends drug users and the wider community the message that addiction is a health issue, and as the organization responsible for people s health in this city, Vancouver Coastal Health is finding innovative ways to bring people into care who currently are not being served by existing health care services. Insite is a health facility first and foremost a facility designed to treat and reduce infections and disease; reduce the transmission of infectious diseases; reduce the number of fatal overdoses; and ensure people receive health care services that contribute to improving their lives and making them well. Improving public order The research shows that patterns of drug use in the community did not worsen as a result of Insite, and crimes related to drug use have not increased. What did improve was this: a reduction of the number of people openly injecting on the streets and the amount of injection-related litter that was left behind. In evaluating North America s first Supervised Injection Site, it is important to measure its results against the objectives the facility identified at its inception. Was Insite designed to remove all drug activity from the streets of the Downtown Eastside? No, it was not. Was Insite designed to get 100 per cent of users into treatment? No. Health care staff understand that not all residents with addiction issues are ready to deal with their addiction, until they ve dealt what contributed to the addiction in the first place. On its own, Insite cannot turn the mean streets of the Downtown Eastside into a neighbourhood free of problems. What Insite can do, it has done move people off the streets and into a clean safe place to inject drugs; once they have a regular routine, engage them and bring them into the healthcare system where some of their physical health needs can be addressed; once their health improves, engage them with an addiction counsellor who can support and encourage them to go into a withdrawal management program to reduce or eliminate the use of injection drugs, reclaim their lives, and begin the process of recovery. Addiction is a health issue and Vancouver Coastal Health is finding innovative ways to bring people into care who are not being served by more traditional health services. 4

4 In their own words Why people use Insite The majority of people using the Supervised Injection Site. The primary reasons they use Insite are: the hygienic environment Insite offers, and a variety of perceived health benefits including increased ability to avoid overdose, reduced HIV risks and other injection related infections. I just feel safer there, it s more sanitary. There s less chance you re going to get AIDS. I m safe there I don t have to worry about it being dirty of whatever. I know I m not going to catch anything I just feel safe. The nurse is there. And she s got that Narcan if I ever O.D. that s nice to know. The secure environment offered by Insite also reduces a drug user s need to rush injection. This increases the likelihood the drug user will adhere to safe injecting practices practices that reduce the risk of transmission of HIV and Hepatitis C, and increase the chance of overdose. [In the alley] You re in a rush. You gotta look around you. You gotta watch. It s hard to explain And in the Insite, I sit there, get a spoon, cook it that kills the bacteria and dirt and filter it out. I can take my time I got all the supplies there. I just do the whole process there. I practice safe. It s not a back alley. [At Insite] you just don t have to worry about yourself as much. You have people who know what they re doing, show you how to do it properly, how to do it safely, how to do it cleanly. You still have to worry about what you re doing and whatever, but you have that backup security. Treatment and prevention of injection-related infections Injection-related infections are considered to be a primary cause of emergency room visits and hospital use among injection drug users. Treating these infections in a hospital setting is expensive and time consuming. And when not treated early, infections can result in long hospital stays that further add to increased costs of care. Insite has been designed to provide health care for issues like injection-related infections, before they have a chance to become serious enough to require hospital care. Having a nurse look at it, if they think you need to get something more done then they ll recommend you go to a clinic or whatnot. They re professional, so they ll know by looking if it sounds more serious, then they ll recommend that you go to a hospital or to a walk-in clinic or whatever. So, in that sense, it s good because you always have that professional nurse on-hand to guide you and give you a second opinion. Access to immediate nursing care For many Insite users, the availability of immediate and easily accessible nursing care translates into receiving health care services they would otherwise do without. I think some people would probably not be getting any attention at all if it wasn t for the fact that they re at the Insite. The only reason that they ve managed to see somebody within the medical profession is because somebody noticed them there and pretty much convinced them that they should get attention. One in five Insite users accessed detox services. Sometime at three o clock in the morning you ve got an infection or something. And so it s good to know that help is there at that time of day. Insite by the numbers From April 1, 2004 to March 31, ,648 unique individuals registered at Insite Women made up 27% of clients Aboriginal people made up 19% of clients Heroin was used in 42% of injections Cocaine was used in 26% of injections Morphine was used in 11% of injections 696 overdoses resulted in no fatalities Referral to withdrawal management: 618 Referral to methadone maintenance: 2 per week Daily average visits: 645 Average number of visits per month, per person: 11 Busiest day: March 28, 2007 (1034 visits in 18 hours) Number of nursing care interventions: 10,089 Number of nursing interventions for abscess care: 3,130 6,354 referrals were made with 40% of them made to addiction counselling 5 6

5 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 L.I.N.E.S.

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