22 March 2024
In our first ‘Ask the…’ interview, we sat down with Danielle Myrah, from the Infectious Disease Clinic at Regina General Hospital in Canada, to get a deeper understanding of what it’s like working as a harm reduction nurse.
We discuss everything from practical advice on securing funding, how to change people’s views on harm reduction, dealing with the trauma seen day-to-day, as well as Danielle’s hopes for the future, including a lot less stigma and a lot more wraparound care.
We have a growing number of nurses in the INHSU network, including a Nurses Committee which convenes specialist harm reduction and HCV sessions at our annual conference, taking place in Athens, Greece from 8-11 October. Nurses receive a discounted membership to INHSU and the conference.
Tell us a bit about your work
I work as a harm reduction and research nurse specialising in clinical trials for conditions such as HIV, hepatitis C, and hepatitis B, among others. I also run outreach activities, visiting pharmacies, opioid agonist therapy clinics, drop-in centers, and detox facilities, to conduct nurse-led clinics. This includes prescribing HCV as well as other STBBI treatment via a remote ID physician
I also provide healthcare services at the Regina Provincial Correctional Centre, including monthly treatment sessions for inmates diagnosed with or with a history of Hepatitis C.
What inspired you to specialise in harm reduction instead of other nursing disciplines?
I actually wasn’t sure what I wanted to specialise in when I came out of nursing school, but during a placement at AIDS Programme South Saskatchewan in Regina I immediately saw the impact on the community, and the impact on each individual. It gave me a passion.
There’s not much of a focus on community nursing in Canada. Students often lack exposure to this field and receive limited education on harm reduction and STBBIs. It’s not considered ‘sexy’ nursing, like ER or ICU, until you experience its impact firsthand.
There’s a lot of misconceptions about harm reduction which you must experience being on the frontline. How do you handle this?
I’m from Saskatchewan, which is a very conservative province. We face a lot of stigma, discrimination, and just general lack of funding and prioritisation of harm reduction initiatives. It can be very frustrating and it’s hard not to focus on all the challenges sometimes. For example, recently, we’ve had funding revoked for inhalation supplies in our needle exchanges. They say the taxpayers aren’t in support of it.
But our team here is amazing, and everybody is very passionate about harm reduction and its principles. So, we actively take on the role of being advocates within the healthcare system and in the community. A big part of that is through education. I find that just having a simple conversation with people sometimes is what makes a difference. Just listening to their concerns and taking the time to answer.
A focus on these conversations is often debunking myths or misinformation on Harm Reduction services such as OAT or needle exchanges. A common misconception is that these services are “enabling” ‘addiction instead of providing safety and access/linkage to care.
But once you listen to those concerns, sit back and then explain the purpose behind it, usually you start to see a change. If it’s not instant, it’s later when they come back with some more questions. But you have to be willing to have those conversations.
Funding for harm reduction services can be challenging. How do you handle that?
Oh, I definitely understand that frustration. We have a need for a full-time harm reduction nurse but no funding to support it. It’s difficult because as people working on the ground, it’s easy to see what’s missing and find a solution for it. But you have to have the backing, the funding, and the support from the entire team. So, what I’ve learned is to start from the top down and use data to your advantage.
For example, we’ve created hyper-local reports based on outreach activities that we’ve completed. We wanted to prove that we were testing more people, catching more infections, treating more people and linking people to care who otherwise may not have presented.
Since we started doing that we’ve added even more check boxes and alongside HCV, can now show how many people we’ve linked to care for STIs, PReP, birth control etc. Doing this allows you to really show your impact and get buy-in for program continuation.
Another point worth noting is the importance of seeking grant funding. There’s a decent amount available if you can justify what you’re doing. Other than that, I just don’t often accept ‘no’ as an answer.
For example, there was initial hesitation about me treating syphilis in case someone had an allergic reaction. We put together an anaphylactic kit and asked ‘What’s the reason, now?’
Share one of your favourite stories of success?
One particular thing I’m proud of was being part of the team that managed to get Buprenorphine injections into a correctional facility. For background, there is a really high chance of overdose within 24 hours of leaving corrections and we knew something needed to change.
There was one patient who was admitted to hospital and whilst there, our physician started him on Suboxone, and then transitioned him to Buprenorphine injections. He was able to do this because he was in hospital, not prison at the time.
These new injections were life changing for him. Not only could they help prevent overdose when he was released, but he knew he wouldn’t be spending his time on the streets trying to get money to buy drugs and get that next fix.
It allowed him to focus on his basic needs. For example, he needed to get his government ID. He needed to secure housing. He hadn’t visited his children in years. One injection was life changing for him.
It also gave us an opportunity to demonstrate the benefits of Buprenorphine injections to the correctional facility. We seized it, delivered four educational seminars to the facilities nurses and management teams and now everyone is on board. I think there are ~70 people on Buprenorphine injections in that facility now. Sometimes with other forms of OAT there is pressure to spit out pills, or split or share. Injections can remove this pressure.. But we had to move quickly when we saw the opportunity.
What’s the biggest failure or mistake you’ve made along the way?
With this population, it’s over promising and under delivering. As harm reduction nurses I feel like we want to do everything for everyone. And when I started, that was my goal. To meet the needs of every client that I saw. I found myself over-promising, and although I always had good intentions, I felt like I let some people down.
It’s very easy to lose people’s trust, and often there are very few people they can actually trust and rely on to start with, especially with institutional discrimination and stigmatization they have experienced in the health care system. As a healthcare provider we need to be one of the people they trust, because you’re changing their view on health care when you’re having these interactions. If you can’t follow through, it takes time to rebuild that relationship again.
Now, I always say that I am going to try my best to do whatever we’ve discussed, but that I’ll let them know if I can’t.
If you had to choose, what’s the one thing you think would improve care for people who use drugs?
We need to break free from the traditional mindset of scheduled appointments in hospital or outpatient settings. With high rates of homelessness and addiction struggles, it’s challenging for people to access care. We have to adopt a proactive approach by bringing services directly to them through mobile clinics offering comprehensive wraparound care.
By providing everything in one place, including opioid agonist therapy (OAT), testing, and support, we can address immediate needs and reduce the risk of delayed care. This approach requires expanding access to prescribers and involving more nurses to ensure holistic care for those in need.
What’s one of the most impactful experiences that you’ve had?
Oh, there are so many little moments in this line of work that really stick with you. It sounds so simple, but even just asking a client, what do you need today? What are your goals today? And just listening to their story. It’s surprising how people don’t get asked that question. Because we’re in healthcare, I feel like we’re so hyper-focused on what our goals are and that may not align with the clients that day. We need to recognise that that’s okay. And that we need to ask them what their goals are that day and focus on that.
More specific and often overlooked moments are when you get to tell people that they don’t have STBBI’s such as HIV, or that their HCV is cleared. There was one woman recently who was convinced she was HIV positive and I got to tell her she wasn’t. She just started crying. She left that day saying she wanted to start taking better care of herself as she has assumed for years she was, in her words, “dirty”. She also engaged with an OAT prescriber that day which she had never attempted to do before.
How do you cope with the trauma you encounter in your work?
Dealing with trauma is a significant aspect of this line of work. We see a lot of it and it is easy to take on that trauma yourself. Thankfully, I have an incredibly supportive team here. We share the same values, goals, and commitment to patient-centered care. So, when faced with challenging situations, we debrief together.
For instance, during a community visit to one of our HIV clients, they had overdosed and I had to administer Narcan. Thankfully it worked, and I felt fine afterwards. But my social worker (who is also my sister) made sure that I knew she was there to talk. I said I was good.
But then the tears come, even when you don’t realise they’re going to. It’s moments like these where having supportive colleagues makes all the difference.
We often forget that we can also take on trauma from stories or life experiences that are shared and that our clients can re-experience trauma when sharing these stories. Awareness, self-care, support and debriefing have all been valuable
Any final pieces of advice?
I think my biggest thing is to just meet clients where they’re at. We tend to put things into boxes and view them as separate things, when in fact wraparound care is just so important in this setting.
I was recently at a meeting in Ottawa about HCV initiatives. And it’s kind of like, why are we talking about just HCV when there’s co-infections with HIV, syphilis, etc? We need to look at this as an all-encompassing issue. And you can’t look at any of it without also looking at harm reduction and supporting people with their addictions first.
In conclusion…
Danielle’s experiences underscore the importance of breaking down barriers, both in access to care and in challenging societal misconceptions. By prioritising wraparound care, proactive outreach, and advocacy efforts, nurses like Danielle are making tangible differences in the lives of those they serve, demonstrating the transformative power of harm reduction principles in healthcare.
