It’s time to allow assisted injection in supervised injection sites

KEY POINTS

• Assisted injection is currently not permitted in supervised injection sites in Canada.

• Requiring assistance with injecting is associated with an increased risk of harms.

• Prohibiting assisted injection negatively affects the most vulnerable subgroups of people who inject drugs and puts them at greater risk of harms.

• Assisted injection is permitted in other countries and could be allowed in Canada if new policies and regulations are put into place.

Assisted injection is necessary to ensure equitable access to supervised injection sites based on individuals’ health care needs, not their capacity to inject.

About 90 supervised injection sites have been implemented in Europe, Australia and North America; these include Insite and the Dr. Peter Centre in Vancouver.¹ Health Canada recently announced the approval of supervised injection sites (including mobile sites) in Montréal, Toronto, Ottawa, Vancouver, Surrey, Kelowna and Kamloops. For people who inject drugs, these sites are long overdue. However, for people who need assistance with injecting, these sites will have little to no impact on their health, safety and likelihood of overdosing and potentially dying.

Assisted injection is not permitted in Canada. In fact, current regulations prohibit someone from getting injection assistance from a peer or a nurse at a supervised injection site. In other words, people are welcome to use the site if they can inject on their own, at which point they can receive education on safer injection, use sterile equipment and access care and services. However, if they cannot self-inject because of difficulty with venous access, symptoms of withdrawal or disability, or they lack the knowledge and skills because they are usually injected by someone else (i.e., a partner, friend or “hit doctor”), they cannot access the supervised injection site.² In their evaluation of Insite, Wood and colleagues³ found that people who required assistance were less likely to use a supervised injection facility. And although Insite has been shown to increase access to safer injection education and capacity for self-injection, people who require assistance turn to the street for help when needed.⁴

Assisted injection is prohibited for two reasons.⁵ First, there is no legal protection for the person doing the assisting.⁵ If harms were to result from the injection (i.e., injury, overdose, death), that person could face criminal or civil prosecutions. Second, there is no clear professional guidance for nurses.⁵ Although nurses administer medications intravenously as part of their scope of practice, administering an illegal drug is quite different.

In Canadian studies, the prevalence of people who require injection assistance varies between 25% and 50%.^6–8 Women, youth and people with disabilities are much more likely to require help from others to inject.² Women are more likely to be injected by an intimate partner and are less likely to know how to inject, both of which put them at risk of harms.² Similar patterns are reported among Canadian youth who inject.⁷ The lack of experience that comes with being a new user is another reason why assisted injection is so common (49%) in youth.⁷ People with disabilities are particularly vulnerable when it comes to assisted injection. In a study conducted in Vancouver, McNeil and colleagues² found many instances where people who could simply not inject were forced into situations of extreme violence, exploitation and abuse. Overall, studies have shown that requiring help to inject is associated with an increased risk of syringe-sharing, injection-related injury or infection, HIV and overdose, as well as street- or partner-related violence, abuse and exploitation.^2,4,8,9 It is safe to say that prohibiting assisted injection negatively affects the most vulnerable subgroups of people who inject drugs and puts them at greater risk of harms.

Over the years, many clinicians, researchers and legal experts have called for existing regulations to be changed, citing examples of countries where assisted injection is possible.^2,5,10 For example, in a survey of 39 supervised injection sites in the Netherlands, Germany, Switzerland and Spain, Kimber and colleagues¹⁰ found that staff provided assistance in exceptional cases (e.g., the client has a physical disability), and six sites allowed clients to assist each other. Another example is Barcelona’s supervised injection site, EVA (Espacio de Venopunción higiénica Asistida), where nurses are allowed to provide injection assistance when required.¹¹ In Canada, the Vancouver Area Network of Drug Users operated an outreach peer-led injection support team for four years.¹² The team was composed of established “hit doctors,” each with more than 10 years of experience with assisted injection.¹² Findings from this grassroots initiative revealed that peer-led assisted injection led to safer injection (through education and verbal or physical assistance), decreased risk of infection and blood-borne virus transmission, and increased safety for people seeking help.¹² Finally, we know that Crosstown clinic in Vancouver, where people inject prescription heroin (diacetylmorphine) or hydromorphone under the supervision of a nurse, provides assistance with intramuscular injection. Extending assistance to intravenous injection would not require a change in regulations in this particular case, as it would fall within the scope of administering a prescribed medication — as opposed to an illegal and unknown substance.

Legislative reform could be one way of making assisted injection possible in supervised injection sites.⁵ However, it would require a lengthy process and extensive evidence showing that prohibiting assisted injection is a deprivation of the right to life, liberty and security and is discriminatory.⁵ There is currently enough empirical evidence to show that this is true. Additionally, there is enough evidence to justify why this practice needs to be embedded in supervised injection sites. Other options could include modifying the exemption under Controlled Drugs and Substances Act s. 56 and s. 55 to allow a nurse or peer to provide injection assistance while also protecting them from being found guilty of criminal offence with respect to drug possession and trafficking.⁵ A policy of nonprosecution could also be developed to protect those who engage in assisted injection in a supervised injection site.⁵ Last, nursing regulatory bodies could help to support this process by developing a clear position and providing guidance on assisted injection — and how to implement this in practice.

Canada now has 16 supervised injection sites across three provinces and more are expected to be approved in the upcoming months. Ensuring that regulations act as facilitators and not barriers is imperative if we want to have a real impact on the health, safety and lives of people who use drugs. When regulations prevent the most vulnerable people from accessing supervised injection sites, force them to seek help on the street and increase their likelihood of experiencing harms, we cannot claim to be offering a harm reduction service. Now, more than ever, it is time to allow assisted injection in supervised injection sites in Canada to ensure equitable access based on people’s health care needs, not their capacity to inject.