Category: Needle exchange

Insite Inside Out

Insite, “is that the place where people shoot up heroin? Do you shoot heroin?” a border officer asked me when he saw the sign on my T-shirt. I was puzzled by his questions, but glad he knew about Insite.

Inside works; inside out! The research proved it. This blog pays tribute to the enormous efforts of researchers, administrators, staff and clients of the supervised injection facility (SIF), who keep Insite working. Setting up SIF is feasible and other sites should be encouraged to do so.
 

photocredit: huffingtonpost.ca

June 2009: 33studies in 15 journals
(Full summaries of quoted studies are available from http://uhri.cfenet.ubc.ca/images/Documents/insite_report-eng.pdf)
1)     SIFs (Insite) may have a unique ability to address several outstanding public health and public order concerns related to injection drug use
2)     The primary cohort used to evaluate Insite was based on a random sample of IDUs recruited from within Insite
3)     Insite was being successfully integrated into the community
4)     Insite attracts drug users who are at a particularly high risk of health problems and who were previously public drug users.
5)     Frequent users of Insite are most likely to be those individuals who are also at highest risk of HIV and overdose as a result of their high-intensity injection practices
6)     Insite is used by IDUs with a high burden of HCV infection, as well as a substantial number of uninfected individuals, and therefore has the potential to help reduce risk of disease transmission.
7)     Insite has attracted a large number of hard-to-reach IDUs and that the existence of the facility presents an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject.
8)     Insite has succeeded in attracting young highrisk injection drug users.
9)     Insite’s benefits on reducing the high-risk behaviours of IDUs and on increasing public order have not been offset by negative effects on drug use patterns among Vancouver’s IDU population
10)   Insite has not promoted illicit drug injecting, but rather that it has attracted individuals with long histories of injection drug use.
11)   Insite is facilitating entry into detoxification services among its clients
12)   Insite encourages IDUs to enter detox
13)   Insite has not contributed to an increase in drug-related crime in surrounding neighbourhoods.
14)   Improvement in public order was a result of the presence of Insite
15)   Insite successfully plays a role in managing overdoses among IDUs
16)   people who use heroin at least daily are more likely to report overdose
17)   Insite plays an important role in reducing overdose risk and in safely managing those overdoses that do occur
18)   Prompt medical attention at Insite prevented as many as 12 overdose deaths per year over a recent four-year period
19)   Reductions in syringe sharing observed among Insite users only occurred after Insite opened, suggesting that Insite may have been responsible for this important behavioural change
20)   Insite appears to be helping to reduce syringe sharing, the key risk factor for HIV transmission
21)   Regular SIF (Insite) users have reduced their likelihood of sharing syringes by 69%
22)   Insite’s clients who are HIV-positive used condoms with their sex partners
23)   Individuals who require help injecting were among those most likely to receive safer injecting education within Insite
24)   Insite is helping to reduce some of the health risks associated with unsafe injecting
25)   Insite nurses are reaching the high-risk injectors, particularly female injection drug users
26)   Insite is providing a safe environment in which people who inject drugs are able to learn about and adopt practices that will help them to avoid serious injection-related harms
27)   Insite may help to address barriers which normally make it difficult for injection drug users to access medical services
28)   Insite clients’ lower rate of skin infections could be a result of the medical care and treatment provided
29)   Insite is providing an opportunity to coordinate policing and public health efforts
30)   Insite’s waiting time limits its use by IDUs who continue to inject in public
31)   Insite was associated with an array of community and public health benefits and, despite rigorous evaluation, no identified adverse impacts
32)   Insite might be improved by longer hours of operation, a washroom and reduced wait times
33)   Insite is providing a safe space, away from the dangers of the street-based drug scene, for women who inject drugs
List of Published Studies until June 2009
1.     Wood E, Kerr T, Montaner JS, Strathdee SA, Wodak A, Hankins C, Schechter MT, Tyndall MW. Rationale for evaluating North America’s first medically supervised safer-injecting facility. Lancet Infectious Diseases, 2004; 4(5): 301-306.
2.     Wood E, Kerr T, Lloyd-Smith E, Buchner C, March DC, Montaner JSG, Tyndall MW. Methodology for evaluating Insite: Canada’s first medically supervised safer injection facility for injection drug users. Harm Reduction Journal, 2004; 1(1): 9.
3.     Tyndall MW, Kerr T, Zhang R, King E, Montaner JG, Wood E. Attendance, drug use patterns, and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, 2006; 83(3): 193-198.
4.     Wood E, Tyndall MW, Li K, Lloyd-Smith E, Small W, Montaner JSG, Kerr T. Do supervised injecting facilities attract higher-risk injection drug users? American Journal of Preventive Medicine, 2005; 29(2): 126-130.
5.     Wood E, Tyndall MW, Qui Z, Zhang R, Montaner JSG, Kerr T. Service uptake and characteristics of injection drug users utilizing North America’s first medically supervised safer injecting facility. American Journal of Public Health, 2006; 96(5): 770-773.
6.     Wood E, Kerr T, Stoltz J, Qui Z, Zhang R, Montaner JSG, Tyndall MW. Prevalence and correlates of hepatitis C infection among users of North America’s first medically supervised safer injection facility. Public Health, 2005; 119(12): 1111-1115.
7.     Tyndall MW, Wood E, Zhang R, Lai C, Montaner JSG, Kerr T. HIV seroprevalence among participants at a supervised injection facility in Vancouver, Canada: Implications for prevention, care and treatment. Harm Reduction Journal, 2006; 3(1): 36.
8.     Stoltz JA, Wood E, Miller C, Small W, Li K, Tyndall MW, Montaner J, Kerr T. Characteristics of young illicit drug injectors who use North America’s first medically supervised safer injecting facility. Addiction Research & Theory, 2007; 15(1): 63-69.
9.     Kerr T, Stoltz JA, Tyndall M, Li K, Zhang R, Montaner J, Wood E. Impact of a medically supervised safer injection facility on community drug use patterns: A before and after study. British Medical Journal, 2006; 332(7535): 220-222.
10.   Kerr T, Tyndall M, Zhang R, Lai C, Montaner J, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. American Journal of Public Health, 2007; 97(7): 1228-1230.
11.   Wood E, Tyndall MW, Zhang R, Stoltz J, Lai C, Montaner JSG, Kerr T. Attendance at supervised injecting facilities and use of detoxification services. New England Journal of Medicine, 2006; 354(23): 2512-2514.
12.   Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 2007; 102(6): 916-919.
13.   Wood E, Tyndall MW, Lai C, Montaner JSG, Kerr T. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Substance Abuse Treatment, Prevention, and Policy, 2006; 1(1): 13.
14.   Wood E, Kerr T, Small W, Li K, Marsh D, Montaner JS, Tyndall MW. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Canadian Medical Association Journal, 2004; 171(7): 731-734.
15.   Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. Drug-related overdoses within a medically supervised safer injection facility. International Journal of Drug Policy, 2006; 17(5): 436-441.
16.   Milloy M-JS, Kerr T, Mathias R, Zhang R, Montaner JS, Tyndall Mark, Wood E. Non-fatal overdose among a cohort of active injection drug users recruited from a supervised injection facility. American Journal of Drug and Alcohol Abuse, 2008; 34(4): 499-509.
17.   Kerr T, Small W, Moore D, Wood E. A micro-environmental intervention to reduce the harms associated with drug-related overdose: Evidence from the evaluation of Vancouver’s safer injection facility. International Journal of Drug Policy, 2007; 18(1): 37-45.
18.   Milloy M-J, Kerr T, Tyndall M, Montaner J, Wood E. Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS ONE, 2008; 3(10): e3351.
19.   Kerr T, Tyndall M, Li K, Montaner J, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet, 2005; 366(9482): 316-318.
20.   Wood E, Tyndall MW, Stoltz JA, Small W, Lloyd-Smith E, Zhang R, Montaner JSG, Kerr T. Factors associated with syringe sharing among users of a medically supervised safer injecting facility. American Journal of Infectious Diseases, 2005; 1(1): 50-54.
21.   Milloy M-J, Wood E. Emerging role of supervised injecting facilities in human immunodeficiency virus prevention. Addiction, 2009; 104(4): 620-621.
22.   Marshall B, Wood E, Zhang R, Tyndall M, Montaner JS, Kerr T. Condom use among injection drug users accessing a supervised injecting facility. Sexually Transmitted Infections, 2009; 85(2): 121-126.
23.   Wood E, Tyndall MW, Stoltz J, Small W, Zhang R, O’Connell J, Montaner JSG, Kerr T. Safer injecting education for HIV prevention within a medical supervised safer injecting facility. International Journal of Drug Policy, 2005; 16(4): 281-284.
24.   Stoltz JA, Wood E, Small W, Li K, Tyndall MW, Montaner JSG, Kerr T. Changes in injecting practices associated with the use of a medically supervised safer injection facility. Journal of Public Health, 2007; 29(1): 35-39.
25.   Wood RA, Wood E, Lai C, Tyndall, MW, Montaner JSG, Kerr T. Nurse-delivered safer injection education among a cohort of injection drug users: Evidence from the evaluation of Vancouver’s supervised injection facility. International Journal of Drug Policy, 2008; 19(3): 183-188.
26.   Fast D, Small W, Wood E, Kerr T. The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility. Harm Reduction Journal, 2008; 5(1): 32.
27.   Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T. Accessing care for injection-related infections through a medically supervised injecting facility: A qualitative study. Drug and Alcohol Dependence, 2008; 98(1-2): 159-162.
28.   Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Risk factors for developing a cutaneous injection-related infection among injection drug users: A cohort study. BMC Public Health, 2008; 8(1): 405.
29.   DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T. Police and public health partnerships: Evidence from the evaluation of Vancouver’s supervised injection facility. Substance Abuse Treatment, Prevention, and Policy, 2008; 3(1): 11.
30.   McKnight I, Maas B, Wood E, Tyndall MW, Small W, Lai C, Montaner JS, Kerr T. Factors associated with public injecting among users of Vancouver’s supervised injection facility. American Journal of Drug and Alcohol Abuse, 2007; 33(2): 319-325.
31.   Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association Journal, 2006; 175(11): 1399-1404.
32.   Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JS, Wood E. Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 2006; 32(5): 1088-1093.
33.   Fairbairn N, Small W, Shannon K, Wood E, Kerr T. Seeking refuge from violence in street-based drug scenes: Women’s experiences in North America’s first supervised injection facility. Social Science & Medicine, 2008; 67(5): 817-823.
I wrote this post using conclusion quotes from summaries of research summed up in the document
Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite. Vancouver: British Columbia Centre for Excellence in HIV/AIDS (June 2009). 

The evaluation of Insite keeps going. Check out the newest research at http://uhri.cfenet.ubc.ca.

International AIDS conference and the role of Drug Policy #‎IAS2015

Dr. Evan Wood speaks at ‪#‎IAS2015 conference in Vancouver, on How Drug Policy should respond to the HIV Epidemic. International AIDS conference 2015’s daily plenary sessions feature some of the world’s most distinguished HIV scientists, policy specialists and community leaders.

Tuesday July 21, 2015:

When Dr Wood led the writers of the Vienna declaration at the AIDS conference in 2010, I was a fresh research assistant in Dublin, Ireland. As a Slovakian, I followed preparations of the conference with great excitement. Bratislava, our capital, was only 30-mins drive from the conference. All my former colleagues went the www.ODYSEUS.org needle exchange attended the conference in Vienna.

 
Dr Evan Wood (photo credit:http://bc-cfe.tumblr.com/)

It has never crossed my mind that five years later, I’d be working alongside this giant brain and great leader, Dr Wood. This time, I got to see his talk at the conference in Vancouver, Canada.

 

What is the problem?

Drugs are not the problem, addiction is. A neuroscientist, Dr Carl Hart, thinks that more dangerous than drugs is ignorance about drugs. Most people who use drugs do so relatively without problems or addictions. Our understanding and definition of addiction evolved over time. Experts now think it’s a disease; some say a disease of the brain. In the past, addiction went from being considered as a moral failing, to medical condition, to psychosocial, bio-psycho-social, and to bio-psycho-social-spiritual disease. Reducing it back to the brain component seems to go against the flow of time and our evolution of knowledge.
“Addiction is a disease — a treatable disease — and it needs to be understood.”
– Dr. Nora Volkow
Dr Wood told us a story of the epidemic of HIV among people using drugs in Vancouver, BC. If you’ve lived in British Columbia, you’d seen a miraculous 90% reduction in new HIV cases over the years. It was well over a decade before HIV has emerged among people who used drugs. Historically, single room occupancy hotels served fishermen and loggers – seasonal workers. Poverty took over these hotels a century later. People went up into these buildings where the likelihood of interacting with police is less, but provision of clean needles or HIV tests is very problematic. In 2002, the only needle programme closed at 6PM each night.  The illegal Marijuana-growing industry in BC is closely linked to the Cocaine industry.  People who inject cocaine need to do so many times a day. Without an access to clean needles, this led to huge health problems. Almost 1 Fatal overdose per day happened during the HIV epidemic.

What is the solution?

 
Treat everyone. Access to care is a human right. Is it feasible? Treatment rates are low, but does everyone need the treatment? In U.S. only about 10 percent of people with addictions get treatment, out of an estimated 23.2 mi people affected.  Although treatment may not have the solution or capacity to help those millions of people, the progress in addiction science has led to new, effective medications. They can mean the difference between life and death for some people, especially those living with HIV.
The empowerment of the community in Vancouver, BC, really turned the tide of the HIV epidemic. They urged the city government to take action that came up with a 4-pillar approach to drug problem in Vancouver: 1. Peer-to-peer syringe provision – in 2010, there were over 30 places where you could get clean needles; people are moving away from injecting despite the availability of clean needles; 2. Safe-injecting rooms preclude the opportunity for needle-sharing. Dirty needles don’t end up on the society. None of the 2mi injections of drugs in the safe rooms has led to a fatal overdose; 3. Expansion of methadone treatment; it’s not just that methadone protects against HIV but there’s advantages in terms of antiretroviral therapy; 4. Treatment as prevention impact of the viral load in the community is the strongest drive for people becoming HIV positive. In the population of people who have been considered hard to treat, only about 3% are not on antiretrovirals.

What does it mean for early-career addiction scientists?

 
The mandate of addiction science is to find evidence to help people with addiction. We’ve studied drugs for decades and learned that their effects are predictable, mainly: the higher the dose, the higher the likelihood of toxic effects.  Moving on from studying the effects of drugs, we should study the effect of contexts where drugs are being used. How do these contexts change the effect of drugs on people? What’s the role of milieu in addiction?
“What is far more important – studying the brain or studying behavior?”
– Dr. Carl Hart

When the HIV epidemics happen, they do not occur by accident. They are the consequence of an un-orchestrated happenstance. They have their origins in harmful policies and circumstances, limitations and harms of criminal justice approaches. In this context, the importance of community empowerment and the value of integrating harm reduction, addiction- and HIV- treatment cannot be underestimated.

See What Happens: My First Week in the Addiction Research Paradise

Abundance of data, army of eager support staff, in-house statisticians and hi-tech infrastructure – what else could an addiction researcher dream of? The Urban Health Program at the British Columbia Centre of Excellence in HIV/AIDS offers endless opportunities for investigators. My first week in this paradise was full of awe, new learning and new people.

Starting on Tuesday, October 21st, Carmen Rock, the Project Coordinator, gave me an orientation to the Urban Health Research Initiative (UHRI), tour of office, and let me sign the confidentiality agreement. UHRI is located on the top, 6th, floor of the St Paul’s hospital, which was recently renovated to meet the needs of researchers. As we walked down the hallway, Carmen stopped for a moment and we could “hear” the data buzzing in the ether.
Chanson Brumme, Data Analyst, gave me a tour of the laboratory. More precisely, tour of laboratories. Although lab research isn’t my specialty, I soon realised the importance and extent of the blood analyses that went on around us. Robots and laboratory assistants were lifting, extracting, ejecting and processing samples taken from the research participants.
photo credit: uhri.cfenet.ubc.ca
Mint Ti, Research Associate, sat down and went through a UHRI 101 tutorial with me. This introductory set of slides is available to all staff and faculty through the local intranet. Having seen the slides in advance, I was able to ask her more focused questions, such as the process of research product development and data requests to statisticians.
My last meetings of the day were with Drs. Evan Wood, Director, and Michaela Montaner, Special Projects Coordinator. Michaela’s work focuses on knowledge translation, including the Addiction Medicine education, which will be the focus of my fellowship. With Dr Wood, we were able to sketch out and quickly dip into the endless opportunities which the centre offers for investigators.
Continuing on Wednesday, October 22nd, Cody Callon, Research Coordinator, told us about the At-Risk Youth Study (ARYS), and its office systems; Amy, a Master’s student, joined us. Together, we travelled to the VIDUS (Vancouver Injection Drug Users Study) office. Elaine Fernandes, Clinical Trials Research Coordinator and Steve Kain, Nurse Coordinator, briefed us on the history of the study and new studiesthat take place in the building.

Ethnographic Tour with Ryan McNeil, Postdoctoral Research Fellow, finished my orientation on Tuesday, October 28th.  Downtown Eastside (DTES) is a well-known deprived area. We walked by and talked about the key agencies and objects of the area: the Vancouver Drug Users Union (VANDU), Insite supervised injecting room and many single-room occupancy hotels SRO’s. Ryan’s radiated excitement as he described the socio-cultural phenomena happening in the area which give an ethnographer a chance to study them in vivo. Gentrification of the area is a problem for many neighbourhood citizens. The policy of the Canadian conservative government poses serious challenges for the injecting room. The authorities try to push the scene out of downtown, for example by relocating the bottle depo site. The scientists are eager to “see what happens” next.

Families of opioid users in Ireland may be given drug to stop overdose deaths

Article from The Sunday Times, 21 September 2014, p4

The department of healthis reviewing distribution of Naloxone, a drug that reverses overdose, to buddies and families of heroin users. A similar scheme is in use in Britain. The department is in discussions with the Health service executive (HSE) to make the emergency drug more widely available. Currently, it is a prescription-only medication and can only be used by the person for whom it is prescribed, or by ambulance crews and medical staff.
[…]
On July 6th, 2012, The Ana Liffey Drug Project, a national addiction service, set up a Naloxone Advisory Group. Tony Duffin, the group’s director, said that while the government’s discussions on Naloxone are welcome, it would be more beneficial to fast-track legislative changes. “I don’t know why we haven’t prioritized this in Ireland,” he said. “It’s an innocuous drug. Its only purpose is to stop opioids working. If you haven’t taken opioids, it won’t have any effect. It’s a WHO recommended medicine, so the evidence is clear. It is important that we see it widely available so we can save people’s lives.”
A [our] study* published last week, which was compiled by the medical school at UCD and the Dublin Fire Brigade recorded 496 overdoses over a 12-month period, 13 of which were fatal. The majority of these were young men on the street, including in affluent areas of south Dublin. Most overdoses occurred in daytime, with a high incidence within 1000 meters radius of addiction services. Gerard Bury, a professor in general practice at UCDand one of the authors of the research, said: “Literature from other countries shows that bystanders, peers, or family members of overdose victims are most often the initial emergency responders and are best positioned to intervene immediately when the first overdose symptoms appear. These lay persons save lives if they are provided with Naloxone.”
Bury said Naloxone in a form of intranasal spray, available in America and Scotland, may be a more effective intervention than the injectable type planned by the department. “The Department of Health statement doesn’t indicate any intention to address the issue of the intranasal route, which, they told us, contravened the current regulations,” he said. “There isn’t any of the sense of urgency which you might expect in dealing with a situation in which people are literally dying in the streets.”
To read the magazine article, go to: http://www.thesundaytimes.co.uk/sto/
Related articles:
*Cited study: Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services http://www.ajemjournal.com/article/S0735-6757(14)00510-5/abstractby Jan Klimas, PhD, Martin O’ReillyMairead Egan, Bc, Helen Tobin, BSc, Gerard Bury, MD. Published Online: July 30, 2014
See also, my previous posts summarizing the quoted study: Urban Overdose Hotspots: New Paper out Now
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.

Three years post doctorate

27 April 2014
Transitions are life changes that allow us to pause, reflect and plan. Here’s a short history of my transition from the pre-doctoral to the post-doctoral stage. Read the full story here.
Hungary 2007. My Hungarian adventurewas a real turning point in my career. I had to commute to work and spent long hours in trams. Bored of watching cars and people, I started to read open-access articles about addiction. When I found something really relevant to my PhD, I felt like a gold miner who just dug his jewel out of piles of dirt. My passion grew stronger with every new paper.
Figure 1. Jano in transition
Ireland 2008. When we arrived to Ireland in late 2008, I had a small EU grant, with a budget of 3000 euros, and an unclear host organization. We survived for almost a year living from my wife’s EVSstipend and seasonal part-time jobs. My PhD and the EU grant took most of my time, leaving only a couple of hours for job-hunting. When I eventually ran out of money, it was late winter and the job market had dried up. Finally, I found an academic job, initially advertised as a PhD in Translational Medicine but my potential boss – Prof Walter Cullen – told me at the interview that I should apply for a p/t job on the same project. That’s how I came to research drinking among methadone patients in primary care at UCD.
Oregon 2013. In July 2011, only two months after receiving PhD, I have attended a summer school on addiction in Amsterdam, Netherlands. Dr McCarty, the school director, lectured about various policy models and evidence-based treatments for several days. Two years later, I did a NIDA fellowship with Dr McCarty at Oregon Health& Sciences University. Read this post about how I got there.

Lessons learned from junior post-doc

1) Write a lot. Like some teenagers, I used to write poems, songs and short stories. Then I stopped for many years. In Oregon, my wife surprised me with a Prompt-based creative writing course for my birthday. She thought it would be good for me and that I would enjoy it. Dr McCartyencouraged me to submit an essay to the Wellcome Trust Science Writing competition and to write a lot. Since then, writing became the core of my work.
2) Learn a lot. If you think of life as a huge learning experience, you welcome trouble as a gift.
3) Keep at it. Perseverance is critical in science. Progress takes years. New knowledge accumulates slowly. And the desired change is uncertain. While I was distributing clean needles to injecting drug users in inner-city Bratislava, Slovakia, I could see the effect of my work immediately. Now I have to wait ages and the change may not come in my life.
I’ve learned many more lessons than just these three, but I’ve learned how to separate the weed from the wheat from the chaff too. I don’t write about the minor lessons.

Future plans for senior post-doc

  • To stay true to myself
  • To reach a position of independence by:
    • conducting a randomized controlled trial
    • supervising work of junior investigators
  • To maintain a happy work-life balance
  • To pass the accumulated knowledge and skills on other:
    • Doctors and helping professions, by helping them become more competent and confident in addiction medicine research
    • Medical students, by helping them discover and master addiction medicine research