Ask a Nurse: How does a supervised consumption site really work

Taliesin Magboo Cahill, September 22, 2019 on Twitter

Is anyone up for a #tweetorial about what it's like to work as a nurse in a supervised consumption site? Not sure if I've seen one before and I feel like there are some things I could clear up. #harmreduction

FYI - It's not all nurses! Some sites don't have nurses at all! All sites in Canada have harm reduction workers (oft. with SW background) and people with lived exp of drug use employed in their sites. Some have RNs or RPNs as well. [Some sites have paramedics on staff to respond to overdoses and have limited nursing support to address other medical issues, such as infections, wound care, and other.](*) Supervised Consumption sites (SCS) and Overdose Prevention Sites (OPS)(**) are variable in terms of staffing, vibe, usage patterns. Personally, I've know of sites with as few as two booths and as many as 12. Staffed by 1 to 3 or 4 people.

Our main goal is to respond to overdoses (opiate and stimulant) and keep people alive, using stimulation, supplemental O2, and Narcan. We are also trained in responding to other medical emergencies (e.g., anaphylaxis, cardiac arrest, hypoglycemia) and mental health crises.

But we aren't a hospital! We have some medical supplies, but no advanced airways, no cardiac monitor. Common equipment includes MANY pulse oximeters, AED, ambubag and oral airway, BP machine, glucometer, maybe a vein finder. Any emergency requiring more than this - we call 911.

Although we are here to keep people alive, we only spend maybe 10% of our time responding to overdoses. We also do wound care, referrals to all different kinds of treatment/health care, and personally, I spend a lot of time playing DJ and just chatting.

At all sites in Canada, nurses or PWUD will give advice on safer injection techniques and finding veins to use. In a few sites in Canada, peers can help each other inject. The idea is to keep people using IN the site.

The sites vary in how medical they appear, but the idea is to make them welcoming for people who use drugs. Clean, but ideally a little more comfortable than a doctor's office. Welcoming, non-judgemental, fun. Or people won't use them.

Liability - in Canada, these rooms are exempt from laws against possessing and being around drugs. I'm not endangering my license as long as I am responding in an appropriate and safe way to an overdose.

Safety - Most sites don't have security as it exists in the hospital. No chemical or physical restraints. There are often panic buttons as there are in many community health settings. All sites have behaviour standards.

What is great about my job: getting to know/talk to all different kinds of people, the feeling of providing an essential service that saves lives, working in a team, having a standard intervention that I do over and over again so I become really confident in what I'm doing.

What sucks about my job: seeing ppl I know almost dying, hearing some very sad stories, and yes sometimes people are [angry/using foul language] (not very common). Mostly feeling powerless to help people in the long term. Sometimes overdoses are scary.

Addendums: - We don't provide the drugs! (although there are small pilot safe supply programs in Canada) - I get paid! I've done this work as a volunteer before but currently I get a paycheck/benefits/pension. As do the PWUD who work at the sites.

Vibe can lean medical or casual, but most have easily cleaned injection surfaces, lots of mirrors, decent lighting, sharps containers. Some play music. Some have time limits. Some have security. Some have a lot of rules, some have close to none.

Why do people use SCSs? The people who do use them could address this best, but I can try: preventing overdose, clean space, protection from cops, medical care. Access to wraparound services.

What drugs are people using? That varies as well although it's absolutely not all opiates - estimates from sites I've worked in or visited vary from 40 to 60 percent fentanyls or 'heroin'. Other drugs include meth, speed, rx opiates and stimulants, cocaine (crack).

Policing: That depends on the site, but they aren't just allowed inside to check for people without a warrant. Ideally, they aren't parked outside deterring people from coming in either.

Getting people help: Do you talk to your patients about their motivations for using, med assisted treatment, going to rehab/non-profit centers, getting clean? Yes we do, but when they are ready. When someone is dopesick, I know their motivation in the moment. Clients are the ones who will initiate conversations about motivation and recovery when they begin to trust us and feel safe in the space. Trauma/culture informed care is a must.

Sharing drugs:  People are not sharing because it's considered trafficking. It's unfortunate because people often buy together and want to split it at the site, but not sharing is one of the conditions of the exemption that let's us operate. [In most sites people are also not allowed to help each other inject, called “doctoring”, which is problematic, as some users inject in hard to reach locations or have difficulty injecting themselves This is more common for women than men, which might be a contributing factor in lower fatal overdoses in women.]

Link to the original tweet https://twitter.com/tmc_RN/status/1119269129293221888

(*) Text in [square brackets] was added by MSTH

(*) An Overdose Prevention Site (OPS) is a “supervised consumption site lite”. Approval is typically time limited (from a few days to 12 month), but can be extended. It is used as a response to an immediate crisis while steps for a full SCS are taken. It is at times in temporary locations, such as trailers/tents and has fewer or no auxiliary services, such as nursing, counselling, social work. Some are funded by government or grants, some through donations, most have paid staff, but some are run by volunteers. When approvals and funding for SCS in Ontario was put on hold by the Ford government volunteer groups managed to keep many of the sites open as an OPS, with federal approval and in some cases federal funding and fundraising. We might see this situation evolve in Alberta, depending on the outcome (expected November/December 2019) of the SCS reviews currently being held in that province.

SCS are an essential health service within the fabric of our Canadian Charter of Rights and Freedoms - SCS Review in YEG

Shelley Williams – Ex Director at HIV Edmonton for 8 years, I was Chair of the Coalition known as Access to Medically Supervised Injection Services Edmonton, and was the executive director of Bissell Centre for 10 years. Bissell Centre has been providing supports and services to people in these communities for over a hundred years. These are not new issues in the community. 

Crime, garbage, tent cities, homelessness, poverty, real estate prices, policing, and the success of businesses cannot be tied directly to SCS.

These issues and dialogues have been around for a long time and continue to be important.  We do need to address them but Consumption services should not be the punching bag for these or for the lack of governments’ leadership in addressing them.

Taking them away – the issues being identified will NOT disappear.

The indisputable evidence clearly shows that SCS has a positive impact in our community. The reversal of an overdose means a life has been saved! To support a person who inject substances by helping them out of the back alleys and into a safer and respectful environment is the right way to address a societal issue that has been shunned. Punishing, telling people to stop or putting our heads in the ground - hoping that it will go away -- hasn’t worked. It takes acknowledgement, effort and quite frankly leadership to develop a range of supports. I commend the community organizations for their leadership. Consumption Services is the first critical service within the spectrum that is necessary because it keeps people alive AND provides the opportunity to develop a relationship and information as appropriate, when people are ready, of other possibilities. 

Edmonton tailored a strategy to meet the complex issues of people who would be using the services. Rather than building one stand-alone, storefront facility, such as Insite in Vancouver, the unique model took one site of 13 booths and dispersed micro sized services within community agencies that are already within the area and where the people are - who would utilize the program. The three sites have booths of 5, 5, and 3 making up the equivalency of one site. This is important - they are not 3 stand alone sites as being suggested. They also provide other health and social supports. 

There is work to be done, we need solutions - more services, more innovation, support to communities, and better municipal, provincial and federal strategies to address the range of issues that have been brought forward. BUT it cannot be at the cost of SCS. It is an essential health service and one that is within the fabric of our Canadian Charter of Rights and Freedoms – both sections 7 and 15; legal and equality rights. It is an effective service to support the being in human being.

I implore the panel to be just and thoughtful. Ensure you decipher the comments heard appropriately, recommend that the document be public and make recommendations that include the continuation and expansion of SCS across the province. 

I stand in honour of my son's life & the lives of the lives of thousands of others who have died because of a poisoned drug supply.

Presentation to the SCS Review Panel in Medicine Hat

Kym Porter, September 3, 2019

My name is Kym Porter. I am a member of MSTH, the MH Drug Coalition and the MH SCS coalition. I stand before you tonight as an advocate for the marginalized, vulnerable, stigmatized, voiceless members of our community. After my son, Neil’s death from fentanyl poisoning, I retired as a director with the MH Catholic Board of Education. Grief encompasses every aspect of my life.

I stand in honour of his life and the lives of the over 11, 577 who have died because of a poisoned drug supply.

Because none of us can legitimately comment on the socio-economic effects of a supervised consumption site here in MH, and because this panel has access to the many reports containing such effects of these sites in this province, specifically I refer to the Alberta Community Based Report on Alberta’s Supervised Consumption Service Effectiveness, I will propose solutions to the crisis as I would see that as the overarching goal of this review.

As like all harm reduction advocates, we believe in evidence-based solutions.

As garnered from Chief Medical Health Officers across this country, the current drug policies are not only creating much of the harm, they are also a catastrophic failure. Drug policies are making things worse.

Solution # 1 -We need to end drug prohibition. The drug policies are as toxic as the drug supply. Read Chasing the Scream.

New policies, with a shift to a public health approach, instead of a political approach need to be developed quickly.

Solution # 2 - We need to deliver a safe supply as the toxicity will continue to drive the number of corpses increasingly higher.

Solution # 3 - We need to remove the barriers to harm reduction services, not take away what few life saving supports we have.

Solution # 4 - we need to connect people with life saving health services and supports such as safe care, ancestral healing practices, safe housing and income assistance.

Finally solution # 5 - we need to decriminalize possession for personal use.

In closing, I would like to share these words from Tommy Douglas, a pioneer and founder of Medicare:

We are all in this world together, and the only test of our character that matters is how we look after the least fortunate among us. How we look after each other, not how we look after ourselves. That’s all that really matters.

Thank you.

My son is still a human being! AND HE STILL DOES NOT DESERVE TO DIE!

A Letter to the SCS Review Board Hearing in Lethbridge AB -

Lori Hatfield, September 4, 2019

As a mother of a son struggling with addiction (going on 11 years now), I have walked the path of our broken systems alongside my son and I come with a different perspective than those suffering in the throes of addiction.

My son has at times lived at home, lived on his own, and been homeless. He has lived in Lethbridge, Calgary, Medicine Hat, Victoria, and Vancouver. My son does not want to be an addict. Some days he wins the fight, some days he does not. But he is still functional! He still loves. He still feels. He still does everything everyone else does. He is still a human being! AND HE STILL DOES NOT DESERVE TO DIE!

The Supervised Consumption Site is doing EXACTLY was it is designed to do – keep people from dying from using contaminated drugs. It also points its clientele towards available services – now if we had more services, we might be able to see some real decline in people in active addiction.

When I brought my son home from BC, we went to the SCS first thing on a Monday morning. He made contact with the Virtual Clinic and had a prescription for Suboxone later that same day. It was wonderful! Previously he would have had to wait 3 or 4 weeks for the “travelling addiction doctor” to be in town to either get a prescription or a change to his prescription. I can’t say enough about this service. For those that can’t abstain (which is not recommended by the experts anymore with regards to opiates), this service offers that window of opportunity when the desire for a change presents itself to someone suffering with addiction.

The main flaw in Lethbridge is that there is NOT enough wrap-around services for the amount of people suffering from addiction. When that window opens up where someone wants help, it can be weeks before that first step is available – the window has closed long before help is available and our vulnerable people are suffering due to these lack of services. Those proposing to stop funding to the SCS are playing God and they have no right to do so. We have the means and the know how to keep people alive – who has the right to say, “no you should die”. Which is exactly what will happen – people will DIE! DIE, DEAD, NO LONGER HERE. No chance for change, no window of opportunity. Addiction can be overcome. It does happen. It’s a very hard road to travel, but by God it happens every single day and we need to make sure that that opportunity is available every single day.

Stopping funding, thus closing the SCS is NOT going to change the needle debris in Lethbridge, it is not going to end addiction – it is only going to cause deaths. That will be the only outcome of this action. When my kids were little, we always searched the parks and playgrounds before letting our kids play – looking for broken glass and dog and cat feces. We searched then and you still need to search, only now you have to look for needles in addition to the other stuff. Yes it sucks, but it’s the way of life now in EVERY COMMUNITY – not just Lethbridge.

As far as crime goes, the SCS has been a dumping ground for blaming all that is wrong in Lethbridge. It is unfair and unwarranted. Nobody ever brings unemployment into the equation – that due to the slow down in Gas and Oil there are hundreds of people that were making very lucrative incomes and are now desperate to make ends meet – oh but they don’t commit crimes, they would never steal – its only addicts that do that.

Do you know how many people the death of one addict impacts – well there’s the mother and father, wife/husband perhaps children, siblings, aunts, uncles, cousins, friends . . . too numerous to count. Not only that, but children suffer the most from PTSD and the death of a parent. Imagine the environment of elementary, middle and high schools as these children grow-up.

I do not know what more we can do to make people realize the importance of Supervised Consumption Sites ALONG WITH ALL THE NECESSARY SERVICES that need to be available to people suffering from addiction. I do not think Lethbridge would be in this state of turmoil if we had had sufficient services put in place at the time of the opening of the SCS. There is only one reason the Supervised Consumption Site should have its funding stopped and that would be because there is safe supply and people do not need to worry about dying from using  contaminated drugs.

International Overdose Awareness Day 2019 with MSTH - Coast to Coast