Danielle Cousineau

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What is your current role, and what kind of work does that involve?

I am a Registered Nurse and currently serve as the Clinical Coordinator for Insite and Onsite. I oversee the clinical part of the program for the supervised injection site, detox and transitional housing which involves supporting, mentoring and providing education to our registered nurses and physicians. I also engage in policy work to ensure that we are practising based on the most current evidence and scope of practice.

Do the RNs working at Insite generally come from a similar clinical background or skill set?

Our RNs have come from extremely diverse backgrounds in all areas of nursing. I would consider this one of our assets. We have had nurses with experience in addictions with strong skills and knowledge around referrals, detox programs, and alternative therapies. We've also had emergency room nurses who have contributed immensely as there is a need to have knowledge in emergency management. We also have nurses with experience in palliative care, medical/surgical and cardiac nursing.

That noted, there are also common skills and traits that our nurses have. These include: critical thinking skills, empathy, compassion, and the ability to develop therapeutic relationships with participants who are often marginalized or have had negative experiences in healthcare settings.

Can you tell us about the history of Insite, what the program involves, and how it has evolved over the years?

Insite came to be out of the health crisis happening on the Downtown Eastside in the 1990s. The high levels of HIV, primarily among intravenous drug users, were equivalent to some of the hardest hit sub-Saharan countries. The overdose death rate was shockingly high, with over 400 people dying per year. This led to a grassroots movement within the community which advocated for services to mitigate this crisis. Through this advocacy, Insite was established in 2003 initially as a research study.

We have been operating under an exemption from the Controlled Substances and Drugs Act (CDSA). When the 2006 Conservative Government came into power, The Insite application to stay open was denied. This led to a long legal battle which was heard in the Supreme Court of Canada. While the Court found that denying individuals access to these healthcare services was unconstitutional, we lost on the jurisdictional argument which was based on the premise that as a healthcare facility the province as the controller of healthcare should be in charge of these programs. As a result, we were forced to continue to apply for exemption from the Federal Government.

Insite opened under an initial mandate to reduce overdose deaths and harms associated with injecting drugs. One of the recent shifts that I have noticed is that while we are enacting harm reduction in the community, we have realized the need to enact it on a much broader scale. While we are able to provide a supervised environment and education, due to limitations in our hours of operation and lengthy waits to access the site, people are not performing every injection at the facility. We have been working to address this by providing harm reduction education and services so that people have the skills needed to be independent in their injection practice.

A key example of how far Insite has come in improving health outcomes is our participation in the Take Home Naloxone Program. This has reduced overdose fatality, especially with recent fentanyl overdoses. When I first started working at Insite four years ago, I remember that when we responded to emergencies on the street we would be the first to manage the airway, administer Naloxone, etc. A positive change I have noticed is that in many cases there is someone who has already started giving rescue breaths and/or administered the first dose of Naloxone. This shows how the work we have done has helped empower individuals to take control over not just their lives, but those within their communities as well.

The most recent changes to RN dispensing has been another great change towards improving health outcomes. On average, we have about 800 visits per day for all services, 600 of those are for supervised injection.

For nurses, what does working under a harm reduction model mean, and what are some principles?

It means having empathy and compassion, and in the case of Insite, looking at this work as more than providing a clean needle to someone. We're providing education and empowering people to take control of their health and lives. A big principle is providing judgement free care. The importance of this is clear when our participants begin to self-identify because they feel like Insite is a safe place and that they can trust the staff.

Can you speak about the populations that you typically serve?

The Aboriginal population is disproportionately represented. Many of our participants are homeless, living on welfare, or living in single room occupancy buildings. However, we do see a full spectrum of participants, including those often labeled as 'functional addicts' who are stably housed and have jobs. We also see a lot of participants with mental illness, HIV and HCV infections and individuals working in survival sex trade. However, sex trade workers who access Insite are actually underrepresented in relation to how many sex trade workers are injecting drugs. There seems to be a gap which needs to be addressed. We also see a steady trend of youth, (ages 16-25), but not in large volumes.

What does research say about the role of Insite in improving health outcomes?

There are over 30 peer reviewed articles published internationally that show services like Insite save lives. We have had thousands of overdoses and not a single fatality. Research has been conducted since the 1990s with individuals who use drugs on the Downtown Eastside and there has been a plethora of evidence indicating that supervised injection sites reduce HIV, Hepatitis C, and drug use related complications.

What do you think the future of Insite will look like, considering the introduction of Bill C-2 (Respect for Communities Act)?

Health Minister Jane Philpott has not only visited the facility but has stated publicly that she supports supervised injection sites. This gives us a great sense of hope and optimism. As well, along with the recent approval of the Dr. Peter Centre supervised injection site, we are now one of two legal supervised injection sites in Canada. This shows the Federal Government's support for these models and harm reduction in general.

As the professional association representing RNs and NPs, what can ARNBC do to support nurses working in harm reduction?

Choosing to focus on harm reduction as part of your policy priorities is already a good step. Developing a body of knowledge about harm reduction is huge. While a lot of research has been done on the impacts of Insite, not a lot of research has focused on the nursing practice in the area of harm reduction. Because it is such a unique setting to work in, it does create challenges in practice. Working in collaboration with nurses who practice in harm reduction will help create the knowledge and evidence base to address the current gaps. In my experience, there is still a huge gap in knowledge among nurses in understanding what harm reduction entails.