Insite: Canada's landmark safe injecting program at risk

InSite is North Americas first supervised injection site and a landmark public heath initiative operating in Vancouver since 2003. The program is a vital component of that cities internationally recognized harm reduction approach to its serious problems with drugs, crime, homelessness and AIDS. InSite currently operates under a waiver of Federal rules that allow it to provide services as a research project. An extensive evaluation has produced very positive results for thousands of users. Normally such strong evidence documenting the successes of such a program, and the medical and public health significance of these positive outcomes, would be the basis for celebration and moves to expand the model and provide similar services elsewhere in Canada. Instead, there is a distinct possibility that InSite will be closed by the newly elected Canadian Prime Minister Paul Harper – a conservative who has traveled to the US to visit George WQ Bush and come back antagonistic to harm reduction in all its forms. Because InSites federal waiver is expiring and up for renewal in September, the fear is that Mr. Harpers will not renew the approval and that the program will be forced to close down. The risks associated with the potential closure of InSite need to be fully understood. This editorial lays out these public health risks and the associated economic impact if InSite were to be closed. In addition to preventable deaths and disease, InSites closure will cost Vancouver and British Columbia between $3.8 and $ 8.8 million in preventable health care expenses over the next two years.

E stimates indicate there are more than 12,000 injection drug users living in Vancouver, and at least one in three live in the Downtown Eastsidethe poorest neighbourhood in the city. For injection drug users living in the Downtown Eastside, more than nine out of 10 have Hepatitis C, and three in 10 are HIV positive -a rate that is 38 times the provincial average. Overdose deaths are not uncommon, and the overall mortality rate for this population is 14 times that of other BC residents.
Of the Downtown Eastside population, 1250 people live in substandard single room hotels; 650 people rely on shelters; and 200 are homeless.

Addressing the need
Community residents, drug user groups and activists called for an innovative response to the high rates of infectious disease and overdose death. Vancouver Coastal Health, in partnership with the Portland Hotel Society, responded with an innovative program -North America's first Supervised Injection Site. Called insite, it is a safe, clean place where people with addictions can go to inject drugs and connect with health care and addiction services. The partners were supported by the Vancouver Police Department, City of Vancouver, Province of British Columbia, Injection Drug Users, community groups, academic institutions and others. Collectively, they believed the Supervised Injection Site would have the ability to positively impact people's lives.
insite has been in operation since September 12, 2003 and was specifically designed to be accessible to vulnerable populations of injection drug users -men and women who use more than one drug; have both an addiction and a mental illness; have a history of trauma; have sought treatment but been unsuccessful and relapsed; live on income assistance; are Aboriginal; live in substandard housing or are homeless.

Evaluating Success
In addition to being the first Supervised Injection Site in North America, insite is also the first and only site to undergo an arms length, rigorous scientific evaluation, with all research results published in peer-reviewed journals. The British Columbia Centre for Excellence in HIV/AIDS received the contract to conduct the scientific evaluation of insite, and has been evaluating the facility in terms of meeting the following objectives: Increasing access to health and addiction care Reducing overdose fatalities Reducing the transmission of blood-borne infections like HIV and Hepatitis C Reducing injection-related infections Improving public order The remainder of this report draws on the evaluation results.

InsIte servIces
Staffed by a combination of clinical and nonclinical staff, including peers, program assistants, RNs, Alcohol and Drug Counsellors, coordinators Open 18/7: 10 a.m. to 4 a.m. Capacity of 850 injections/day 12-seat injection room Drugs not provided on site Supervision of injections, including emergency response to overdoses Assessments, immunization and wound care Injection-related first aid Referrals to addiction treatment and other health services Harm reduction instruction Access to sterile injection equipment Post injection space for observation and peer interaction

The Population
It hasn't been difficult to convince injection drug users that insite offers a safe, clean place to inject drugs. Since insite opened, more than 7,000 people have used the facility. Women make up one in three visitors, and Aboriginal people account for one in five -two audiences the facility particularly wanted to attract.
Every day, about 600 injections are supervised at the site, or about 18,000 injections each month -many of which otherwise may have taken place in back alleys using dirty needles and unclean water, or alone in hotel rooms.
And research shows that people don't come to insite just to inject drugs. They also make use of other services provided there -like addiction counsellors and nursing staff. Some people come to pick up clean syringes and other injection-related equipment. In all cases, insite Somethi ng you get at insite… if you want to talk, somebod y will sit down with you and talk…an d that's pretty importa nt because usually it's hard for, especi ally for street people and junkies , to find somebod y who will be sympath etic, and not be judged by just the fact that you're doing drugs. You walk into the insiteyou're a perso n.
Interview with insite client serves as a first point of contact into the health care system for people with addictions who often have trouble accessing care.
To have the most impact, insite wanted to attract people who are at high risk for HIV infection and overdose. Research shows that is exactly who is using insite most. insite users are also more likely to be homeless and have a history of injecting in public spaces -the precise client group the facility was designed to serve.
Researchers also compared the rate of detox program use among people using insite -before and after insite opened -with the rate of detox use going up substantially after people had been using the facility.

Saving Lives
Research results show that insite is playing an important role in managing overdoses that occur at the site -overdoses that would, in all likelihood, be occurring on the streets if the facility didn't exist, and could result in death.
Overdoses have been common at insite, with almost 500 occurring over a two-year period, but none resulted in a fatality. In fact, insite staff managed the majority of overdoses on their own, with only four in 10 needing ambulance support, and fewer than one in 10 resulting in a transfer to hospital.

Improving Access to Care
Drug users who live on the margins may have difficulty accessing health care. And without this care, the chances of improving health outcomes are slim. By visiting insite and being exposed to health care professionals in a non-threatening environment, many clients willingly ask for referrals to other health and social services. Over a one-year period, insite made more than 2,000 referrals to other services, with about 40 percent of the referrals to addiction counseling.
People using insite are more likely to enter withdrawal management (detox) programs, and people using insite who also talk with addiction counselors are even more likely to enter detox. In fact, one in five regular visitors to insite began a detox program, showing that insite is a proven entry-point for the Downtown Eastside's highestrisk injection drug users. Detox programs are an important marker of addiction treatment system use, as most addiction treatment programs first require people to complete a detox program.

Improving Health
Hepatitis C and HIV rates in the Downtown Eastside parallel those of developing countries. A key goal of insite is to reduce the high rates of transmission of infectious diseases. Sharing syringes used to inject drugs is a ready source of transmission, so supplying a safe, clean place, and making sterile equipment available, is one way to stop the spread of disease.
Research studies show that people using insite are 70 percent less likely to share syringes than injection drug users who do not use the facility or use it infrequently. And rates of syringe sharing in the community are lower than they were in the past, indicating insite has had an impact on behaviour well beyond the walls of the facility.
For injection drug users, soft tissue infections from injecting is the most frequent reason for hospitalizations, including visits to the emergency department, as well as overnight stays. Many infections are the result of injecting with unclean equipment, not cleaning the skin first, or using dirty water. One of the services insite offers clients is education on how to safely inject -with at least one in three people visiting insite receiving this education. And the education is working. Research shows that people using insite substantially increase their use of sterile injecting practices and decrease injecting in public -the latter a practice known to increase the risk for infectious disease transmission.

Impact on the Community
When insite was still in the conception stage, some people worried that a Supervised Injection Site would send the wrong message about drug use and prevent people from stopping using. Others thought insite would make injecting drugs more attractive. Some people still believe both of these to be true.
But the research shows these concerns are unwarranted, because drug use patterns in the community have not worsened as result of opening insite. And crimes related to drug use have not increased.

Creating a Safer Neighbourhood
While insite was developed to reduce drug related harms and improve people's health, it was also created to help respond to the growing problem of public disorder related to injection drug use in the Downtown Eastside. Prior to insite opening, researchers collected data on how much public injecting was taking place in the neighbourhood. They then collected the same information weeks after insite opened and found that the opening of insite resulted in substantial reductions in public disorder, including a reduction in the number of people injecting in public and the number of discarded syringes found on city streets.

Looking Forward
Scientific research studies prove that insite is making a real difference in the lives and health of people who use the facility. And it is meeting community needs for improvements in public order. The people who could benefit most from using insite are some of its most frequent visitors. Needle sharing, one of the highest risk factors for HIV and hepatitis C infection, has been dramatically reduced. And the education on safe injecting insite clients learn, they also practice when they are away from the facility.
Harms related to injection drug use are also on the decline -from transmission of infectious diseases to improved wound care; from more people accessing the health care system to more people with addictions accessing treatment.
Most importantly, people who overdose at insite, unlike many who overdose on the street or alone in a hotel room, live to tell the story.
Researchers from the BC Centre for Excellence in HIV/AIDS conclude that "insite is a highly innovative initiative that greatly complements existing services by providing a safer place for injection of illicit drugs.
It also provides a place to engage high-risk injection drug users, especially those who are not well connected to the health care system." For people with addictions, insite is proving to play an essential role as an entry point to health care services, including addiction treatment, and has become a vital part of the health care continuum. insite is decreasing drug-related harms, reducing the risk of transmission of infectious disease, reducing the incidence of injectionrelated infections, and most importantly -saving lives.