By Amanda Waldroupe, Staff Writer
Vancouver, B.C., knows how to deal with heroin addicts.
Vancouver is the home to North America’s only supervised injection site, and the world’s largest. Called Insite, it allows addicts to bring in their own drugs — more often than not, heroin and cocaine — and inject them in a booth supervised by nurses. Addicts can stay at Insite after injecting as long as they like afterwards; nurses are constantly available to provide immediate medical care if someone overdoses or experiences related medical issues. Clean needles and condoms are made available to users.
Insite is in a three-story building. The first floor is the supervised injection site. The second floor is a detox program serving 12 people, and the third floor houses an 18-bed drug recovery program called Onsite. Insite was intentionally designed that way to encourage people using Insite to enter recovery programs, and it also makes it as easy as going up a flight of stairs.
Insite opened in 2003 and is a partnership between the Portland Hotel Society, an affordable housing provider, and the city’s public health agency, Vancouver Coastal Health Authority.
Insite’s founding was a direct response to an escalating public health crisis in Vancouver. During the 1990s, there was a rampant and increased use of injection drugs, fatal overdoses, and transmission of HIV and Hepatitis C. Ground zero is an area in downtown Vancouver known as the “Downtown Eastside.” The area is five blocks by about 15 blocks wide, and it is home to Vancouver’s poorest and most vulnerable residents, including an estimated 4,000 to 7,000 injection-drug users.
There were 201 overdose deaths in Vancouver in 1993. That number had hovered between 30 and 50 in the prior decade. HIV infection increased along with the overdose deaths — in 1996, there were 2,100 cases of HIV transmission, and a United Nations report found that the Downtown Eastside area had an HIV rate of 30 percent, compared to Canada’s rate of 0.2 percent.
“These two things literally created a recognized health crises,” says Russ Maynard, Insite’s program coordinator.
Maynard says there was a recognition that increasing the number of needle exchange clinics would not help to solve the overdose and health crisis. The Vancouver Area Network of Drug Users (VANDU), a grassroots organization, formed and began pressuring Vancouver’s local government to open a supervised injection site modeled after sites already in operation in Europe and Australia.
“The luck is having a health authority and a city hall that, at that particular time in history, seemed to be open to new ideas,” Maynard says.
Since opening, Insite has had more than 1.5 million visits. There are 12,000 people registered with Insite (though not all of them may be using Insite at once). In 2009, Insite had 276,178 visits by 5,447 individuals. There were 484 overdoses, but no deaths. Insite made 6,242 referrals to social-service agencies, including housing placement and drug treatment programs.
Maynard says Insite’s biggest asset is not that it prevents overdose deaths or is an integral piece to Vancouver’s public health system. But rather that it allows people to change their lives. He frequently gives tours of Insite to the public, and he remembers one tour that he gave when a woman using Insite’s services began answering questions from the group and speaking with them.
“You don’t know what this place means to me,” Maynard remembers her saying. “They treat us as if we’re normal.”
Amanda Waldroupe: In what way was harm reduction available to the community before Insite opened?
Russ Maynard: There would have been street nurses walking around with a shoulder bag. There would have been needle exchanges. VANDU (the Vancouver Area Network of Drug Users) and other organizations would have had harm reduction classes to some degree. The problem is that it was piecemeal.
A.W.: How does Insite work?
R.M.: The first time you come in you have to register. The registration process is very unencumbersome. You’ll be handed a clipboard and directed to fill out 20, 30 questions. Obviously, if you have literacy issues, you’re dope sick, or have mental health issues, that can be a Herculean, if not impossible, task. (It’s) designed around the population. It asks for your birth date, which isn’t giving a lot of information. It asks your gender. It asks your ethnicity. Then you will make up a handle or a pseudonym. We don’t need your real name. We just want to get you in. That is very reflective of the bottom up design (of) Insite.
Hopefully your wait is very minimal. One minute, two minutes. They’re called into the injection room. The door is locked. They walk in. Right away, there’s a computer on their left. They self report to the nurse what they’re using. There are 12 booths. Staff are walking the floor back and forth about two feet from the booths. They are sitting in a cubicle with a large mirror in front of them, a stainless steel tabletop and two walls. That mirror does a few things. If they are stimulated, it allows them to have a sense of what’s going on behind them. It (also) allows them to look at themselves. If you’re homeless, you don’t have a mirror. You can see the sores on your face, your gaunt look. Staff are right there (if they overdose) and are intervening within minutes. They are trained to recognize the signs.
[caption id="attachment_3913" align="alignnone" width="500" caption="A woman demonstrates the injection process. The booths have mirrors to encourage another level of awareness toward recovery"][/caption]
A.W.: Can you describe the population of people that use Insite?
R.M.: It’s a really, really difficult population, people with extreme addiction and mental illnesses. The population is on average, 35 to 40 years old. 70 percent is male. 25 percent to 30 percent is Native Indian. Their average history for IV drug use is 7 to 10 years. Injection sites are meant to draw entrenched users — not people experimenting. There is a high level of distrust in this population.
A.W.: What sorts of drugs do they inject? Is it just heroin?
R.M.: You see about 60 percent opiates, and 40 percent stimulants. We see a lot of heroin and cocaine. There is a trend toward more and more use of crystal meth and crack cocaine.
A.W.: If Insite doesn’t supply the drugs, where do the users get them?
R.M.: They’re readily available on the streets. You don’t hardly have to walk a half a block to score $10 worth of cocaine or heroin.
A.W.: Are they all drug addicts? Are any of them on drugs because of a medical condition?
R.M.: No, really it’s all addiction. There are probably exceptions to that, but they’re small.
A.W.: Do you have any control over the drugs or the drug’s quality?
R.M.: No. People bring their drugs to the site. They pull it out of their pocket. Unless I was really attentive and standing in the booth, there is no way for me to know the amounts they’re taking. Generally speaking, it’s not something I need to worry about. They don’t want to overdose. They’re trying to do the right amount.
A.W.: Would it be illegal for Insite to provide the heroin? Is that something you would like to do?
R.M.: It would be illegal. We would like to in as much as research in Vancouver, Montreal, and Switzerland (Zurich, I believe) has shown that for deeply entrenched users stabilization around health, living conditions and even employment can be achieved through a prescription.
A.W.: Why do overdoses occur at the injection site?
R.M.: The crutch is the potency and the quality. When you and I go to the pharmacy, we know someone with a mask and gloves made this product, and we have directions on how to use it and how much to take. When you score on the street, ultimately, you don’t even know what you’re buying. That’s one of the things that motivate people to come into the injection site. They know that there’s a significant risk in buying this on the street and injecting it in their veins. The other big motivator is that anybody doing this for any length of time has seen someone overdose or has overdosed themselves, and it’s very scary.
A.W.: What clinical services does Insite provide?
R.M.: The clinical services we offer are very narrow in scope: overdose intervention, obviously, wound care — we bandage, clean and treat surface wounds. We know that a significantly large number of people coming to Insite are walking around with serious co-morbid diseases (i.e., have co-existing substance abuse disorder and a mental or physical health issue) such as HIV, Hepatitis C, pneumonia, syphilis. Nine out of 10 coming into Insite are Hepatitis C positive. (We) can diagnose them and try to get them to the hospital.
A.W.: How often do they come? Every day?
R.M.: Typically, yes. (There are about) 300 to 500 injections a day, and 700 to 800 visits a day, sometimes as high 1,000 or 1,100 visits a day, 365 days a year. Those are visits, not people. Addicts will come through anywhere from two to five times a day.
A.W.: What kind of attention has Insite drawn from other countries and communities?
R.M.: I regularly have guests from Europe, and from the states — Los Angeles, from San Diego.
A.W.: Anyone from Portland?
R.M.: Off the top of my head, I’m not sure.
A.W.: How do you deal with nimbyism?
R.M.: Originally, there was a lot of pushback. The Downtown Eastside is sandwiched in between two business areas, China Town and Gas Town. Gas Town is still on the fence. The Chinese merchants support us. The number of overdoses in the immediate area has gone down significantly.
A.W.: Do you think this model is necessary for communities dealing with drug addiction?
R.M.: Absolutely.
A.W.: Why?
R.M.: There’s one picture, where (addicts) are hardly ever around a nurse, and the other is that they’re around nurses and clinicians and healthy folks every single day, seven days a week.
We call it the engagement model — just having a place where addicts can use has the effect to encourage them to be more aware of and higher uptake in services. They’re just exposed to more positive influences, people who know about programs that are available, and people who know about housing opportunities. They look in the mirror, and their cheeks are conclave. They are at the end of their rope. They turn around and say (to a nurse), “Can we talk about going to Onsite?” Onsite can’t keep up with the demand from Insite.
A.W.: What do you think is the single biggest stereotype or misunderstanding people have about heroin addicts?
R.M.: That a drug or substance has control of them. All anyone needs to do is ask themselves if a substance can be inherently addictive. If so, why is it that the vast majority of people who try alcohol as teens do not develop a drinking problem? Consider the millions of people who, every day, are using opiates (morphine, dilaudid, fentanyl) for pain management with surgery, cancer, etc. yet who never develop an addiction. Addiction is likely an emotional-driven, complex, situation, from which someone can find relief.
A.W.: What do you think the challenges are to starting an injection site in the United States?
R.M.: Culture. We need to move away from the very high levels of emotional stigma around addiction and start insisting on an “evidence-based” model of intervention. We already know from copious research that supervised injection sites lead to higher levels of uptake into addiction services through referral, and that users are also costing the system less due to successful interventions around overdose. Any overdose happening in the streets or in a rooming-house will involve police/fire/ambulance and probably emergency room services and/or a coroner services. That is expensive and painful for families and friends, and of course, users. Overdoses are not unlike a drowning. They are very easy to intervene in and very time sensitive. If you reach a drowning person in a few seconds or a minute, chances are very good they will do well. That is what is occurring at injection sites all over the world.
A.W.: Portland is beginning to experience an increase in heroin use on the streets. Should Portland start exploring establishing an injection site? What effect would that have?
R.M.: Injection sites can be very small or large as in the Vancouver example. Portland should talk to users groups, learn about its particular street culture and design a program that addresses local user needs. Each city has a different culture and although Portland can use Vancouver as a model, the city still needs research and input about, and from, the local users.
A.W.: What would you say to public health officials who might be skeptical that an injection site would be unhelpful, impossible to implement, or other thoughts that would stop them from pursuing establishing one?
R.M.: Read the research — it is copious. Come to Vancouver and tour, discuss and investigate. We, and many other jurisdictions, have learned a lot and Portland can benefit from the public health successes in other situations.