Insite is the only legal supervised injection site in North America, located in the Downtown Eastside neighbourhood of Vancouver. After a lengthy legal struggle, on September 30, 2011 the Supreme Court of Canada unanimously ruled that Insite should immediately be granted an exemption under the Controlled Drugs and Substances Act (CDSA) and remain open (http://scc.lexum.org/en/2011/2011scc44/2011scc44.html). The ruling stated that closing Insite would prevent injection drug users from accessing needed health services and threaten their health and their lives. This would undermine the purpose of the CDSA, which includes public health and safety, and violate Section 7 of Canada’s Charter of Rights and Freedoms.
What did we need to do to get Insite and keep it open? -- Public health crises, tenacious advocacy, ethical interpretation of professional practice standards, rigorous science and legal battles!
Despite establishing a needle exchange program in 1988 and the BC Centre for Disease Control street nurse program in 1989, in the early 1990s the City of Vancouver experienced high levels of death due to overdose of heroin and, in the mid 1990’s, a dramatic outbreak of HIV and hepatitis C. The overdose deaths led to a province-wide review by Coroner Cain who recommended the implementation of innovative harm reduction programs, including facilitating safer use of illicit drugs.
Consumer and community based advocacy and political and professional leadership created the climate that made Insite possible. A series of conferences, demonstrations, dialogues and a documentary film contributed to broad based public support for Insite. Nurses were at the forefront every step of the way, advocating and educating about the importance of harm reduction for people who use injection drugs.
While the focus was on Insite, the nurses of the Dr. Peter Centre were facing the same issues. At that time, the Executive Director and nursing staff turned to the RNABC which confirmed that supervision of injections is within the scope of registered nursing practice in order to prevent illness and promote health. Legal counsel for the Centre advised that, with the nursing practice clarification, the risk was greater in not offering supervised injection services. Supervised injection was integrated into the Centre’s range of harm reduction services in April 2002, eighteen months prior to Insite’s opening.
Political leadership began under Mayor Philip Owen. The November 2002 mayoral election saw Larry Campbell, a former RCMP narcotics officer and coroner for the City of Vancouver, run on a promise to introduce a supervised injection site. He won with 64 per cent of the vote and Insite opened in September 2003.
Under the CDSA, the Federal Minister of Health was required to approve Insite’s opening with an Exemption 56 for “reasons of public health or research”. The exemption was granted for scientific and research purposes.
Since the opening of Insite, more than 35 papers published in leading scientific journals have shown that there has been a decrease in public disorder, an increase in accessing addiction treatment services, significantly reduced needle and syringe sharing and no deaths due to overdose despite an average of 587 injections/day over an 18-hour period.
The exemption was renewed in 2006 and extended in October 2007 to June 30, 2008. Although the short-term renewals caused intense anxiety for clients and staff, they also generated strategic advocacy. In August 2007, the PHS Community Services Society, two clients of Insite and the Vancouver Area Network of Drug Users filed a statement of claim in the BC Supreme Court to keep Insite open. In May 2008 the BC Supreme Court ruled in favour of Insite and its clients. Although the Attorney General of Canada appealed the decision, the BC Court of Appeal dismissed the appeal and allowed Insite to continue. At this point, the Attorney General of Canada filed an appeal with the Supreme Court of Canada, which led to September’s ruling.
There are many lessons to be learned from the Insite experience. Most notably, this opportunity to highlight the role of nursing in changing practice and health policy reminds us why it is so important that we rebuild a professional nursing association in B.C. While other organizations serve us well in their particular domain, a nursing association that represents all nurses in BC has the ability to advocate for important changes to public policy. Throughout my career I have witnessed the power that is gained when the nursing community comes together under one nursing vision. With an Association to put that vision into practice, we can continue to change policy and practice.
I congratulate ARNBC for joining forces with the RNAO and CNA as interveners in the Supreme Court hearing and taking a stand in favour of keeping the doors to Insite open. Nurses should be proud of the role we have played and continue to play in educating our colleagues and the general public. I urge all BC nurses to make courageous health policy a continuing priority for our profession.
For further reading:
http://canadian-nurse.com/index.php (see Back Issues and enter search term ‘Gaining Insite’ or go to April 2009)
Research on Insite: http://uhri.cfenet.ubc.ca/content/view/57/92/
Adjunct Professor, School of Nursing University of British Columbia
Irene Goldstone retired as Director, Professional Education and Care Evaluation, British Columbia Centre for Excellence in HIV/AIDS, Providence Health Care Vancouver in June 2010. Irene’s involvement with inpatient and community based HIV/AIDS care and education for health care professionals began in 1984 while serving as Director, Medical Nursing, St. Paul’s Hospital (1982-1992). Irene taught nursing and interprofessional electives in HIV/AIDS in collaboration with colleagues at the University of British Columbia (1994-2010). Currently Irene serves on the Board of the Dr. Peter Foundation, on the advisory committee of Simon Fraser University’s Literacy Lives project, and on REPAC of the Canadian Working Group on HIV and Rehabilitation. Irene remains active in drug policy issues through her work with the Canadian Drug Policy Consortium.