Table 1 Patient experience and perspective of SIVAD

Robin is 38 years old and lives in Vancouver’s Downtown Eastside. She describes herself as a vibrant, active community member who has been injecting drugs for the last 14 years. She lost both of her parents in a tragic accident in her young adulthood, creating complex and strained family relationships. In her early 20’s, she started using stimulants and at age 25 began taking oxycodone for her osteoarthritis. At age 27, she began injecting drugs intravenously (IV). She receives injectable opioid agonist therapy (iOAT)¹ at an outpatient clinic, but iOAT alone has not been sufficient to treat her pain and opioid tolerance, and she continues to use additional non-prescribed IV drugs

Five years ago, Robin was admitted to hospital with a skin infection. It was around this time that she had run out of veins in her arm that she could easily inject into. Thus, she started injecting substances into her abdomen, legs, upper arms and jugular vein. Frequent vein misses (“missed hits”) resulted in many areas of skin breakdown and abscesses. A peripherally inserted central catheter (PICC) was inserted for her to receive IV antibiotics

She remembers being in a lot of pain and watching the nurses clean and flush the line, attach syringes loaded with opioids, and administer the medication so easily. She thought “I could do that.” She started collecting pre-packaged saline flushes accessible around the hospital unit and was relieved not to have to inject into her neck, and to have a way to avoid severe “dope-sickness” (withdrawal)

During subsequent admissions to hospital, she disclosed her PICC use to nurses and physicians and asked for sterile supplies. Sometimes the IV team inserting the PICC informed her about the risks of using it, and sometimes she was given supplies and education on how to use/access the PICC using sterile technique. One healthcare provider told her “You’re going to kill yourself” by using the PICC, but she was not told how or why this may be true

On a recent hospital admission for another infection, her desired discharge plan was to receive IV antibiotics as an outpatient. Unfortunately, this was declined because she disclosed PICC use to healthcare providers. Instead, her IV antibiotics were switched to oral and her PICC removed. This came as a surprise to Robin, who felt as though she was being punished for her honesty. She does not recall anyone talking to her about this change in discharge plans. Because of this situation and based on variability in provider responses to her PICC line use, she no longer discloses her PICC use because she fears it will compromise relationships with healthcare providers, and ultimately, her healthcare

Robin says that she frequently sees patients at community OPSs injecting into vascular access devices using unsterile technique. Often, she will intervene and offer advice when she sees unsafe practices but worries about the lack of education among people who inject drugs

A review of Robin’s medical record reveals that she has received care from addiction medicine, infectious disease, internal medicine and wound care specialists during several recent admissions. Notes indicate that clinicians were aware of Robin’s PICC use, with some notes referring to “tampering” or “abuse” of the line. One provider noted that the patient was instructed by community workers on how to use her PICC to inject. There were no notes regarding patient-provider discussions around the risks of PICC use or teaching about sterile technique. She was given general education on overdose prevention. On several occasions, notes indicate that Robin left hospital with her PICC in place, despite the team’s plans to remove it prior to discharge