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Canadian Nurses lead the way in harm reduction

Nurses from across the country will be gathering in Vancouver at the Canadian Nurses Association Biennial Convention this week. As part of the occasion Insite and the Dr Peter Centre are each hosting special sessions on June 17th, providing opportunities for knowledge exchange on harm reduction policies and nursing practice.

Canadian nurses recognize that substance use, both legal and illegal, is an enduring feature of human existence and that abstinence is not always a realistic goal. As such, nurses focus on reducing adverse consequences and building non-judgmental, supportive relationships for the health and safety of individuals, families and communities.

There is a risk that the image of nurse-supervised injection is limited to a nurse hovering over a client while the injection takes place and nothing more occurs. I want to dispel this image.

The nurses of Insite have articulated their framework of nursing practice. Nursing care is client-centred with the focus on relationship building, maintaining dignity and respect, and creating an environment of cultural safety and empowerment. Primary nursing care at Insite includes safer injection education, needle-syringe exchange, first aid, wound care, overdose management, addiction treatment, reproductive health services and communicable disease prevention. These services are delivered as comprehensive harm reduction and health promotion programming nested in partnerships with the health and social service systems and community agencies.

In 2011 the Canadian Nurses Association released a discussion paper on Harm reduction and currently illegal drugs: implications for nursing policy, practice, education and research, which was endorsed by the Canadian Association of Nurses in AIDS Care. The values of harm reduction are consistent with the values guiding professional ethical nursing practice articulated in CNA’s Code of Ethics for Registered Nurses for the provision of safe, ethical, competent and compassionate nursing care; for the promotion of health and well-being; for the promotion of and respect for informed decision-making; for the preservation of dignity in which care is provided on the basis of need; and for the promotion of justice.

Considering this it really shouldn’t come as a surprise that Canadian nurses support harm reduction services. The origins of outreach nursing have been attributed to the Grey Nuns, founded by Marguerite d’Youville in Montreal, who by the mid 1700’s, were known for their care to the destitute. Inequity of access to health care and the basic determinants of health has led to “street nursing” practices in many urban centres.

Lightfoot-etal_09_Gaining-Insite Harm_Reduction_2011_e Hardill

BCCDC-STI Street Outreach Nurse Program

In Vancouver, after World War II nurses led a major effort to reach marginalized people who would not attend hospitals for the treatment of sexually transmitted diseases. In 1988 the BC Centre for Disease Control established the AIDS Prevention Street Nurse Program with a focus on needle and syringe exchange. With the epidemics of overdose deaths and the dramatic outbreak of HIV that Vancouver experienced in the 1990’s, the street nurses were some of the first to advocate for bringing injecting from the alleys into the safety of a supervised injection health service.

Just over one year ago, professional associations – Canadian Nurses Association, Registered Nurses Association of Ontario and Association of Registered Nurses of British Columbia and BC Nurses Union each acted as intervenors in support of Insite at the Supreme Court of Canada. Nurses across Canada cheered when the Supreme Court ruled in favour of Insite remaining open.

Look for nurses to be leaders in advocating for the expansion of supervised injection services locally, nationally and globally!

June 14, 2012
New Provincial Guidance for Supervised Injection Services in BC

Supervised injection sites help save lives and protect communities. This was the conclusion of over 30 research studies on Vancouver’s own supervised injection site known as Insite. And Canada’s Supreme Court agreed in September 2011, ordering the federal Minister of Health to grant a section 56 exemption to the Controlled Drugs and Substance Act to allow Insite to continue to operate.

To scale up harm reduction and support the development of similar services throughout the province, the BC Ministry of Health has now revised its Guidance Document for Supervised Injection Services. Written for health care professionals, it provides advice to health authorities and other organizations considering supervised injection services in their local areas.

Kenneth Tupper – B.C. Ministry of Health

At a recent public forum in Victoria, BC, Kenneth Tupper of the B.C. Ministry of Health affirmed the value of supervised injection as part of a “comprehensive program of harm reduction services.”

“The courts have ruled that supervised injection is a valuable approach to health care,” Tupper said, “and the new Guidance Document affirms the province’s support of these services.”

The “guidance document” could seem daunting for the uninitiated. It spells out a range of issues that should be covered by any organization considering a supervised injection site. This includes extensive knowledge of the local services, rates of HIV and Hepatitis C and any available estimates of drug use patterns. Interested organizations will also need to provide a detailed description of the proposed service and demonstrate how it will be consistent with the principles of harm reduction as spelled out by the B.C. Ministry of Health documents.

According to provincial policy, anyone who wants to offer this service will need to consider how they will sustain the support of local groups like medical health officers, police departments and other potentially interested groups. They will also need to plan services to be offered in conjunction with supervised injection even if the proposed supervised injection site is small or mobile and carefully consider how client data will be collected and how issues like the risks of substance use and expectations for conduct at the service are to be communicated and documented.

‘Harm reduction’ refers to policies, programs and practices that aim to reduce the negative health, social and economic consequences of using legal and illegal psychoactive drugs, without necessarily reducing drug use. Scaling up harm reduction for individuals, families and communities is core to the work of the CDPC.

We hope you will join us and help spread the word about the importance of services like supervised injection and help us scale up harm reduction in our communities.

June 8, 2012
Dr. Mark Tyndall – Supervised Injection sites are the lightning rod of harm reduction

I sat down with Dr. Mark Tyndall at the 21st Annual Canadian Conference on HIV/AIDS Research(CAHR) in Montreal this April. The theme of the conference was turning points and meeting new challenges. Tyndall is no stranger to confronting challenges and he is known as a national leader in HIV prevention and care. He worked for over a decade in Vancouver at UBC and the BC Centre for Excellence in HIV/AIDS, also as the head of Infectious Diseases at St. Paul’s Hospital. He now calls Ottawa home and serves as the head of Infectious Diseases at the University of Ottawa.

“supervised injection sites have become a lightning rod of harm reduction, but we all know and recognize that they are a very important way to try and engage people in some kind of continuum of care…and the need is still quite large.”

Having been at the forefront of Vancouver’s supervised injection site (INSITE), Tyndall knows that supervised sites and harm reduction services need to be scaled up.

Tyndall says that there is a public health crisis in Ottawa, similar in some cases to what he saw in Vancouver a decade ago. The big question he asks is, do we need to repeat the same research process and make many of the same mistakes, or can we learn from places like Vancouver, Frankfurt, and Sydney and implement harm reduction and supervised injection sites efficiently. Tyndall was a speaker at a press conference we held in Montreal during CAHR looking at injection sites Nationally, and he also contributed to the Toronto Drug Strategy report that we wrote about this spring. Please get connected and leave your comments to let us know what you think needs to happen in your community.

May 16, 2012
Health authority releases new cannabis harm reduction resource

Last week, Vancouver Coastal Health and the University of Victoria’s Centre for Addictions Research of BC published a valuable resource for individuals who use cannabis recreationally.

Take Care with Cannabis is a user friendly, concise, accessible one-page information source that outlines the potential risks of smoking and ingesting cannabis. Intended to protect the well being of individuals, Take Care with Cannabis provides insight into the impact of using the plant on a smoker’s lungs, cognitive abilities, and brain development during adolescence and early adulthood. It discusses how to stay safe when using cannabis and how to avoid toxic effects.

Take Care with Cannabis

John Carsley, Medical Health Officer for co-author Vancouver Coastal Health said,

“It’s our responsibility as health care professionals to ensure that anyone who chooses to use cannabis has clear information about how they can take better care when using.

While cannabis is illegal in Canada, the reality is that a significant portion of the population uses it. And when they use it, it’s our desire to see them be as safe as possible.”

‘Harm reduction’ refers to policies, programs and practices that aim to reduce the negative health, social and economic consequences of using legal and illegal psychoactive drugs, without necessarily reducing drug use. Raising awareness about the realities and benefits of harm reduction for individuals, families and communities is core to the work of the CDPC.

We know that the more informed people are, the more support there will be within communities for a comprehensive approach to reducing the harm from drug use.

We hope you will join us to get the word out and help scale up harm reduction in communities across Canada.

May 2, 2012
Groundbreaking EU study supports use of heroin-assisted treatment

On Friday, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA ) released a groundbreaking report examining heroin-assisted treatment for chronic heroin users, once thought to be untreatable.

Photo Credit: Jay Black

The report, New heroin-assisted treatment, provides the first state-of-the-art overview of research, examining the latest evidence and clinical experience on the topic in Europe and internationally. The findings show that for the small minority of entrenched opioid users who repeatedly fail to respond to prescriptions of other substitute drugs such as methadone, supervised use of medicinal heroin can be an effective second-line treatment.

The study’s findings show that Supervised Injectable Heroin (SIH) treatment can lead to: the ‘substantially improved’ health and well-being of this group; ‘major reductions’ in their continued use of illicit ‘street’ heroin; ‘major disengagement from criminal activities’, such as acquisitive crime to fund their drug use and ‘marked improvements in social functioning’ (e.g. stable housing, higher employment rate).

From the report:

‘New heroin-assisted treatment is an issue that has attracted much attention, controversy and often confusion’, says EMCDDA Director Wolfgang Götz. ‘With Europe at the forefront of investigating and implementing this novel approach, the EMCDDA is proud to present the findings of the major contemporary research studies on the topic and the clinical and policy experiences of countries providing it. Our purpose in doing this is not to advocate, but to inform. We hope that this report will help policymakers and practitioners draw their own conclusions about this type of treatment within their own national context’.

What do you think about expanding heroin-assisted treatment to communities in Canada? Do you think it’s time to scale up harm reduction and provide evidence-based treatment options for our most entrenched drug users? We want to hear from you.

April 25, 2012
Mark Haden: A Drug Educator’s Apology

Mark Haden is a drug educator. He has spent the last twenty-five years providing public education on drugs and working with addiction counselling services in Canada. Today he works as a supervisor at the Pacific Spirit Community Health Centre in Vancouver.

Haden knows that the Canadian Federal government spends approximately six million dollars a year educating parents, teachers, young people, law enforcement and communities about the risks and laws surrounding substance use. He also knows that drug education plays a key role in defining our relationships to mind altering substances.

“We have overemphasized the harms of drugs, we have neglected to mention the benefits of certain drugs and we have omitted mentioning the harms that drug prohibition causes….”

Reflecting on the complexity of the relationships we have to drugs, Haden feels that we do a disservice to young people by perpetuating certain myths and maintaining a system that fails to achieve healthy results. During a brief interview in his office, Haden suggested a number of regulatory tools that could be useful in redefining our relationship to drugs and drug education. He advocates for a public health approach that is rooted in human rights and harm reduction and proposes an alternative to prohibition and criminalization.

Haden is adamant that it is time to explore alternate regulatory frameworks that will actually make certain drugs harder to attain for young people, not easier. He admits that different drugs have different properties and risks and suggests that we consider each one separately, with different approaches taken to reducing the harms of each drug.

Haden believes that if we can open up discussion about drug use and create public health policies, we can also begin to develop healthy social norms that can minimize their associated harms. “We don’t drink alcohol with breakfast,” he says. If we stop the violence of prohibition and start telling the truth about drugs, then we can begin to develop healthy social habits around drug use.

Mark’s website has an extensive list of regulatory tools as well as many more resources for understanding and shifting our relationship to drugs towards a public health approach.

April 16, 2012
Toronto Drug Strategy Consumption Room Feasibility study released

Dr. Carol Strike and Dr. Ahmed Bayoumi (photo by Yuri Markarov)

In 2005 when the Toronto Drug Strategy was approved by Toronto City Council one of the main recommendations was to complete a needs assessment and feasibility study on the implications of establishing supervised consumption sites in Toronto.

The independent research project – expanded to include Ottawa – was carried out over four years by Dr. Ahmed Bayoumi, a physician and research scientist at the Center for Research on Inner City Health at St. Michael’s Hospital, and Dr. Carol Strike, an associate professor in the Dalla Lana School of Public Health at the University of Toronto.

The study recommends establishing injection sites, three in Toronto, two in Ottawa, that are fixed sites and should be integrated within existing service settings.

Download Report

The study does not call for the establishment of consumption sites for people who smoke drugs but does call for more research on how best to provide supervised consumption through inhalation. Evaluation and the importance of a comprehensive approach to substance use is also noted.

On September 30, 2011, the Supreme Court of Canada upheld the right of Insite, currently Canada’s only supervised injection site located in Vancouver, to remain open.

Read the full research report here and let us know what you think.

April 12, 2012
A Plague of Prisons: Ernest Drucker with a Lesson for Canada

On April 9, the Canadian Drug Policy Coalition along with End Prohibition, PIVOT Legal Society, the Vancouver Area Network of Drug Users (VANDU) and Western Aboriginal Harm Reduction Society will host free public event featuring author and professor, Ernest Drucker.

Ernest Drucker

The event will begin at 7pm at Pivot Legal Society’s offices, 121 Heatley Street in Vancouver.

Author of Plague of Prisons: The Epidemiology of Mass Incarceration in America, Earnest will be speaking about the war on drugs in the USA and the potential consequences of the Canadian Conservative government’s new crime legislation.

To get you warmed up, below is a segment of a book review written by Craig Jones, PhD, Former Executive Director, John Howard Society of Canada previous to the passing of the Omnibus Crime Bill C10.

Every student of epidemiology learns the story of the Broad Street pump (London, Summer 1854), which marks the birth of epidemiology. In A Plague of Prisons, Ernest Drucker uses that story as a metaphor to explain the explosion of incarceration in the United States that followed the 1973 enactment of the Rockefeller drug laws and to illustrate how political decisions act as vectors – pumps – and how these vectors can create a social epidemic of gargantuan proportions, such as the United States coming to incarcerate 1 out of every 4 incarcerated persons in the world.

Drucker’s book can be read in three ways: as an undergraduate introduction to the explanatory power of social epidemiology; as a non-technical analysis of how the United States achieved its historically unprecedented rate of incarceration; and as a warning to Canadians on the propensity of criminalization of non-violent drug users to become a contagion with multi-generational consequences. The book’s timing is apt: Canadians are enacting the political mistakes that produced the plague of prisons in the United States. What were those mistakes?

A Plague of Prisons

There were three elements embedded in the Rockefeller drug laws that transformed a public health issue into mass incarceration and transmitted that contagion to the entire country. These include the decision to criminalize drug use; the political reliance on punishment as the appropriate response; and, the attack on judicial discretion through mandatory minimum sentences.

Of the three, the criminalization of drug use featuring large-scale arrests of low-level drug users primed the pump that fueled the contagion of self-sustaining criminality.

There are important differences in the way criminal justice is done between the United States and Canada – some of those differences will insulate Canada from the worst effects of the plague of prisons. But there are a couple of lessons for Canadians too.

The first is that criminal justice policy is too often made in a consequentialist vacuum – that is, without deliberation over downstream effects on families and particularly children of the incarcerated who will likely be the next generation of the incarcerated.

The political imperatives that pushed US policy makers into adopting mandatory minimum sentences appealed to the short-term interests of private prison contractors, correctional officer unions, victims’ advocates, judges and prosecutors. Policies enacted for short-term political opportunity have long-term economic and social consequences, a long tail, but these are of little moment compared to the immediate electoral advantage.

The children of the incarcerated – who are at higher risk of incarceration themselves – have no one to speak for them, at least no one with the clout of correctional officer unions or private prison contractors.

The second lesson is that it is hard to reverse bad policy ideas once they take hold in the public imagination – even once the fiscal costs become unsustainable and the policy itself is clearly failing. As is now clear, the proliferation of mandatory sentencing regimes across the United States has pushed several jurisdictions – Texas, California, Ohio, Florida and New York – to the brink of insolvency, yet they have not achieved rates of crime reduction greater than those jurisdictions that did not embrace draconian sentencing practices.

Worse, the sentencing regimes are hard to unwind because they have created a political constituency where prisons have become a source of high-income, non-polluting jobs.

The third lesson Canadians should heed is that – in seeking to increase the burden of punishment – criminal justice systems engender a self-perpetuating underclass of non-violent but ever more marginalized persons who, because of onerous pardon requirements, may never be reintegrated. They simply cycle through the prison system and transmit the contagion of criminality to their children and family members.

This is a cautionary tale. Canadians would be wise to be more attentive to Drucker’s warnings on the self-sustaining dynamic that emerges out of deliberately growing the rate of incarceration for electoral advantage.

April 5, 2012
Insite withstands test of international drug control conventions

At the 55^th meeting of the Commission on Narcotic Drugs held in Vienna March 12 – 16^th Damon Barrett, Human Rights expert at Harm Reduction International spoke candidly in the plenary session regarding the erroneous statements made by the International Narcotics Control Board (INCB) in their recent annual report (2011) concerning Vancouver’s supervised injection site, Insite.

In paragraph 437 of the report the INCB clearly states: “drug injection and consumption outlets that allow illicit drug possession and use are not in line with the international drug control conventions”. This is an outright falsehood and the United Nations Drug Control Program’s own legal advice commissioned in 2002 admits as much. It can be read here.

Insite Press Conference

The fact that the INCB still carries on trumpeting this false information ten years after the UN’s legal opinion was sought makes a mockery of the INCB’s integrity and credibility.

Here is the offending paragraph from the INCB report:

437. In September 2011, the Supreme Court of Canada handed down its judgement with respect to the applicability of the Controlled Drugs and Substances Act to a supervised drug injection facility in Vancouver. The facility had been allowed to operate due to an exemption to the application of the law for “medical or scientific purposes” that had been granted by a previous Government. The Court ruled against the Government’s decision to refuse to extend the injection facility’s legal exemption, thereby allowing the facility to continue to operate. The Board reiterates that under international law, provisions of national law cannot be invoked to justify non-compliance with the international drug control treaties to which a State has become a party. The Board further reiterates its position that drug injection and consumption outlets that allow illicit drug possession and use are not in line with the international drug control conventions, to which Canada is a party.

Damon Barrett set the record straight for the INCB with this statement:

The recent Canadian Supreme Court decision on Vancouver’s safe injection facility is criticized as running contrary to article 27 of the Vienna Convention on the Law of Treaties. This states that national law cannot be used to justify non-compliance with international legal obligations. This is true. But the Canadian Supreme Court Case was decided on the basis of Canada’s Charter of Rights and Freedoms, a constitutional document. As the Board is aware, article 3(2) of the 1988 Convention relating to the requirement to criminalize possession for personal use is subject to States parties’ constitutional principles. Similar wording is used in relation to the penal provisions of the 1961 Single Convention. In addition, in 2002, the UNDCP legal affairs team stated in an opinion on the matter that such interventions do not breach the conventions.

INCB-legal-brief

Vienna International Centre

As such, there is no conflict between the Canadian Supreme Court ruling and the drug conventions. These provisions of the treaties, however, and the UNDCP opinion are not referred to in the Board’s analysis of the case. We would welcome clarification of the Board’s view of the Canadian Supreme Court decision in the light of these terms of the drug conventions and its view of the 2002 UNDCP opinion.

To Canada’s credit the Canadian delegation also spoke up and let the plenary know that Canada was indeed in full compliance with all of the international treaties pertaining to drug control. Now that this mater is settled in the international arena, we look forward to our Justice Minister Nicholson reaffirming these facts for the Canadian public.

April 2, 2012