Member interview: Supervised injectable opioid-assisted treatments


Twinkle Ruparel is an HSA member and pharmacist at Providence Crosstown Clinic in Vancouver. Crosstown Clinic is like no other in North America. It is the only clinic on the continent “to offer medical-grade heroin (diacetylmorphine) and the legal analgesic hydromorphone within a supervised clinical setting to chronic substance use patients,” according to the Providence Healthcare website.

“We’re a clinic that has pioneered an injectable opioid-assisted treatment,” said Ruparel. The clinic – as it exists today – originated as a site for two major studies that sought to identify the effectiveness of opioid-assisted treatment through clinical trials. Grounded in a model executed in Europe, the North American Opioid Medication Initiative (NAOMI) was launched in 2005.

Following NAOMI, the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) was launched at the site, which tested and compared hydromorphone and diacetylmorphine in opioid-assisted treatment. Once the results of SALOME were published in 2015, Crosstown clinic was established as a permanent clinic to provide medical and social services in response to substance use.

“The trials built the foundation and paved the way for supervised injectable opioid assisted treatment (SIOAT).” said Ruparel.

As a pharmacist, Ruparel works with a team of health science professionals to provide pharmaceutical services to the clinic’s clients who are opioid-dependent. HSA spoke to Ruparel about her work at Crosstown Clinic, the clinic’s health care model, and how Crosstown is serving the needs of the surrounding community.

Can you tell me a bit more about the model of healthcare used at the clinic and how your team works together across professions?

I am proud to work in such a setting. We have physicians on site who are the experts in the field of opioid addiction. They are the pioneers who helped institute the clinic and were part of the studies.  As an allied model of care, physicians, pharmacists, nurses and allied professionals interact with clients on a daily basis. Our clients have individual care plans focused on achievement of optimal health outcomes.

Crosstown Pharmacy provides comprehensive pharmaceutical care to our clients. An inbuilt database system adopted by our clinic connects all health professionals on a common platform in the continuum of medication management. When a prescription is received by a pharmacist, a thorough verification and dispensing process is undertaken to prepare the medication. The medication is then shipped to our nursing department, which leads the care in terms of  of administration oversight and assessment of clients. Clients who pass pre-administration assessment are let into a supervised injection room where a nurse provides their medication for self-injection. The clients are discharged from the clinic once they pass a post-administration assessment.

For a lot of our clients, maybe their housing is in crisis, or perhaps they live in sub-standard conditions. As health professionals, we overcome challenges in this client group with a relationship of trust and mutual respect.

It’s not just a matter of: come to the clinic, get your medication, and leave. Clients are supported by social workers, we have dietitians on site, and a psychiatrist visits the site once a week. We have outreach workers that help our clients find stable housing, do their taxes for them, and help them to and from their appointments. Retention within the program is key.

It’s a community model that highlights the importance of health science and allied professionals working in a common setting to achieve positive health and personal outcomes for our patients. We work together with our clients to provide support and resources in all facets of their lives.

How does the clinic respond to the needs of substance users and the opioid crisis more broadly?

In 2016, the province of British Columbia declared a public health emergency in response to the rise in drug overdoses and death related to illicit opioids. Detailed findings lead to the formation of a task force which came up with a number of findings and recommendations to address this crisis and reduce the number of illicit opioid related overdoses.

Since the task force was formed, the clinic has served as a model standard to various members of the public, including those from other provinces. Personnel visiting from all over the country consider ways of instituting our model within their care settings.

Since the emergency declaration, we have opened our doors to new clients through referrals and through the Rapid Access Addiction Clinic (RAAC) at St. Paul’s Hospital. We have initiated care of new clients recognizing the urgent needs of a vulnerable population – a small percentage of the population that needs this help, and needs it immediately.

What do you like most about working at Crosstown clinic?

We are a holistic support clinic and do not solely aim to treat our client’s opioid dependency. This is what makes us unique. There have been many successful outcomes, and that is what makes it worthwhile.  Everything just falls into place for you as a healthcare professional when you know you have made a difference.

There are definitely a number of complexities involved in the operations of Crosstown Clinic, but it is gratifying to see our clients stabilize and thrive in our community. We know we have given them a second chance.

This article is featured in the March 2019 issue of The ReportClick here to view the full issue.