Over­dos­ing Alone

Why big-city so­lu­tions to the opi­oids cri­sis don’t work in ru­ral com­mu­ni­ties

The Walrus - - CONTENTS - by Sharon J. Ri­ley

Last win­ter was a bru­tal one in south­west­ern Al­berta, with snow­drifts taller than trucks and record-break­ing cold tem­per­a­tures. Then, in late Fe­bru­ary, na­ture de­liv­ered an­other blow: a howl­ing bliz­zard, icy roads, and snow that re­duced vis­i­bil­ity to near zero. At the same time, a par­tic­u­larly lethal ship­ment of opi­oids, known on the street as “su­per beans,” ar­rived in the area. Of­fi­cials would later say that they sus­pected the drugs con­tained car­fen­tanil, the pow­er­ful opi­oid 5,000 times more po­tent than heroin. Peo­ple started over­dos­ing al­most im­me­di­ately.

“It was a per­fect storm,” says Es­ther Tail­feath­ers, a physi­cian in Stand Off, a small com­mu­nity that’s a forty-minute drive south­west of Leth­bridge. Stand Off is the ad­min­is­tra­tive cen­tre of Blood Re­serve 148, the largest First Na­tions re­serve in Canada and ter­ri­tory of the Blood Tribe (also known as the Kainai First Na­tion). About 4,500 mem­bers live on-re­serve. “The graders and snow­plows were work­ing like crazy just to get to the homes where the over­doses had hap­pened,” Tail­feath­ers says. Paramedics re­sponded to 150 calls that week­end— a sub­stan­tial feat, con­sid­er­ing the com­mu­nity cov­ers an area twice the size of Toronto. In one home, Tail­feath­ers says, five peo­ple over­dosed at the same time. Over ten days, thirty peo­ple over­dosed on the Blood re­serve, and nearby Leth­bridge re­ported more than fifty oth­ers.

The spike in over­doses wasn’t the com­mu­nity’s first brush with opi­oids. The Blood re­serve first de­clared a state of emer­gency in 2015 to sig­nal that opi­oids were wreak­ing un­prece­dented havoc. The com­mu­nity has since been on the lead­ing edge of im­ple­ment­ing harm­re­duc­tion strate­gies, which fo­cus on re­duc­ing deaths and dis­ease transmission and im­prov­ing qual­ity of life. There were door-to-door cam­paigns where vol­un­teers gave out in­for­ma­tion on ad­dic­tion, and nalox­one kits were dis­trib­uted be­fore many Cana­di­ans had heard of the med­i­ca­tion. Com­mu­nity mem­bers handed out T-shirts that boasted i saved a life when some­one suc­cess­fully used the kits and also pro­moted Subox­one, an opi­oid re­place­ment aimed at de­creas­ing de­pen­dency. Gov­ern­ment­funded vans now criss-cross the area, driv­ing pa­tients to phar­ma­cies so they can pick up their pre­scrip­tions. “The key in this com­mu­nity is own­er­ship,” Tail­feath­ers tells me.

And yet, af­ter al­most three years, peo­ple were still over­dos­ing. Shortly af­ter the “per­fect storm,” the Blood Tribe de­clared an­other state of emer­gency, and the com­mu­nity took a new step by open­ing a tem­po­rary over­dose-pre­ven­tion site. Sim­i­lar sites, where drugs can be used, are of­ten con­tro­ver­sial, but they’re also seen as a cor­ner­stone of ef­fec­tive harm-re­duc­tion strate­gies and have been cre­ated in Toronto’s Moss Park and Van­cou­ver’s Down­town East­side. In the lat­ter, over­dose deaths de­creased by 35 per­cent within a few years. The Stand Off fa­cil­ity was housed in a trailer and staffed by the med­i­cal non-profit arches (aids Outreach Com­mu­nity Harm Re­duc­tion Ed­u­ca­tion and Sup­port So­ci­ety). It had a clear goal: save lives.

By May, how­ever, the over­dosepre­ven­tion site was shut down; the trailer was driven away. The rea­son: lack of use. “There’s days where there’s no­body,” said one nurse who worked on staff. Why this site failed may have been due in part to ge­og­ra­phy—the iso­la­tion that ru­ral com­mu­ni­ties face means small towns can’t al­ways just im­port ad­dic­tion pro­grams that are suc­cess­ful in larger cities. This is ru­ral Al­berta, where long, straight high­ways stretch for miles across flat prairie and where a per­son can go for days with­out see­ing much of any­one.

THe opi­oid Cri­sis has been claim­ing lives across Canada in re­cent years, and the story in Al­berta is no dif­fer­ent. Fa­tal car­fen­tanil over­doses in­creased by 430 per­cent from 2016 to 2017, and the num­ber of opi­oid-re­lated emer­gency-depart­ment vis­its in­creased by 118 per­cent from 2014 to 2017. Ru­ral and In­dige­nous com­mu­ni­ties have been dis­pro­por­tion­ately af­fected, in part be­cause of cer­tain chal­lenges of coun­try life: long dis­tances for emer­gency ser­vices to travel and lim­ited ac­cess to re­sources.

Ge­o­graphic dis­tances don’t cause opi­oid epi­demics on their own, and the ori­gins of the cri­sis on the Blood re­serve are com­plex. Tail­feath­ers is frank about the root cause in her com­mu­nity: “In­dige­nous peo­ple have ad­dic­tions and men­tal-health is­sues re­lated to the his­tory of Canada—col­o­niza­tion and In­dian pol­icy, re­serves and re­serve pol­icy, and the amount of trauma that our peo­ple have ex­pe­ri­enced in res­i­den­tial schools.” In 2016, First Na­tions peo­ple ac­counted for 12 per­cent of all ac­ci­den­tal opi­oid-re­lated deaths in Al­berta, de­spite mak­ing up only 6 per­cent of the pop­u­la­tion.

When con­sid­er­ing ad­dic­tion prob­lems, politi­cians tend to dis­cuss na­tional or pro­vin­cial strate­gies. But harm re­duc­tion, when ef­fec­tive, is done per­son to per­son and com­mu­nity to com­mu­nity. What works for one city does not nec­es­sar­ily trans­late to an­other.

This be­comes clear when com­par­ing Stand Off with Leth­bridge. Leth­bridge is a city of fewer than 100,000 peo­ple, and it’s where many Stand Off res­i­dents go for gro­ceries or move to for work. Like in Stand Off, the opi­oid cri­sis had been par­tic­u­larly dire. The num­ber of emer­gen­cy­room vis­its re­lated to opi­oid poi­son­ing was higher than the pro­vin­cial av­er­age, ac­cord­ing to Stacey Bourque, ex­ec­u­tive di­rec­tor of arches, and the per capita over­dose rate was higher than Cal­gary’s and Toronto’s. In Fe­bru­ary, be­fore the over­dose-pre­ven­tion site opened in Stand Off, Leth­bridge opened a lo­ca­tion of its own, also run by arches. Un­like the one in Stand Off, the Leth­bridge lo­ca­tion is a suc­cess.

At the Leth­bridge site, the staff be­hind the counter are friendly and greet each per­son by name. “This isn’t a shoot­ing gallery,” says Bourque. “It’s a med­i­cal fa­cil­ity.” There are ten booths for drug con­sump­tion as well as a buf­fet of sorts: the fa­cil­ity pro­vides clean nee­dles, glass pipes, ster­ile wa­ter am­poules for dis­solv­ing drugs, plas­tic cards to help snort pow­ders, cut­ters for pills, and pack­ets of cit­ric acid, used for cook­ing and in­ject­ing brown heroin. If the or­ga­ni­za­tion didn’t pro­vide the acid—which re­sem­bles a fast-food pack of ketchup — peo­ple would bring in Coca-cola or pack­ets of vine­gar from Arby’s to use as sub­sti­tutes.

Pa­trons can in­ject, snort, swal­low, or smoke, all un­der a nurse’s su­per­vi­sion. Leth­bridge has the first fa­cil­ity in North Amer­ica to al­low smok­ing in en­closed booths. If some­one slumps over, staff can press a but­ton that will clear the air fast enough for nurses to in­ter­vene. If all goes well, the pa­tron moves on to the ob­ser­va­tion room to re­lax while a nurse stands nearby. Once the pa­tron passes the point when most over­doses would oc­cur—about twenty min­utes—they can leave.

Within the first eight weeks, staff in Leth­bridge had re­versed seventy over­doses. By July, the site had recorded nearly 40,000 vis­its, an av­er­age of nearly 500 per day—van­cou­ver’s In­site, for com­par­i­son, sees just over 400 daily vis­i­tors. “I knew it would be used, but I’m sur­prised how heav­ily it’s been used,” Bourque says.

That the site in Leth­bridge suc­ceeded when the Stand Off lo­ca­tion did not is a harsh truth about harm man­age­ment: com­mu­ni­ties are of­ten re­quired to find new so­lu­tions to long-stand­ing prob­lems. “I don’t think [over­dose-pre­ven­tion sites] are any less needed in smaller cen­tres,” Bourque tells me. But, she says, the model may need to look dif­fer­ent.

THe over­dose-pre­ven­tion site in Stand Off was prone to chal­lenges that are unique to more ru­ral ar­eas. Peo­ple ad­dicted to heroin, for ex­am­ple, may use as of­ten as ev­ery six hours, mak­ing it un­re­al­is­tic to travel long dis­tances re­peat­edly each day. A 2007 study found that travel to a su­per­vised­in­jec­tion site was the sin­gle big­gest hur­dle for users. In Leth­bridge, many peo­ple who use drugs are con­cen­trated in the area around the site, and oth­ers can hop on a bus. In Stand Off, there is no pub­lic transit, and it’s a long walk to the fa­cil­ity even for those who live in town. And if a po­ten­tial pa­tron lives in one of the houses scat­tered across the prairie, there’s no way to get to the site with­out a ve­hi­cle. “In cities, the safe­con­sump­tion sites look at an eight-block ra­dius of where the over­doses are hap­pen­ing,” Tail­feath­ers tells me. “In a ru­ral re­serve like this, we can’t do that. It’s hap­pen­ing ev­ery­where.”

There’s also the stigma. The Stand Off site was lo­cated in the hos­pi­tal’s busy park­ing lot, next to the com­mu­nity’s ad­min­is­tra­tive of­fices. A nurse who worked at the fa­cil­ity noted that it’s dif­fi­cult for many peo­ple to use the site, as there’s a good chance a neigh­bour or rel­a­tive might see them. “It’s a small com­mu­nity,” she says. “Ev­ery­body knows ev­ery­body.”

There’s no doubt that op­er­at­ing a su­per­vised-con­sump­tion site in a ru­ral area comes with unique chal­lenges, but Tail­feath­ers says it can still work. She says that the dis­ap­point­ing results of the first over­dose-pre­ven­tion site don’t mean that the com­mu­nity is giv­ing up on the re­source. “It was well in­ten­tioned, but we just weren’t pre­pared for it,” she says, not­ing that there’s talk of a start­ing a new site that would also house other com­mu­nity ser­vices. Ex­pand­ing the scope of the fa­cil­ity might lessen the per­ceived hu­mil­i­a­tion of go­ing into the build­ing. “It needs to be in the cen­tre of town, and it needs to have wrap­around ser­vices,” Tail­feath­ers says, “so peo­ple don’t feel like they’re be­ing watched or stig­ma­tized.”

Tail­feath­ers de­scribes the Fe­bru­ary “per­fect storm” as a blip in a long road to re­cov­ery. And, Tail­feath­ers ex­plains, opi­oid-re­lated deaths in the com­mu­nity have de­creased since 2015. “In the end, it is a good story,” she says, “be­cause we’re not dy­ing as much as we were.”

For more on the opi­oid cri­sis, visit our on­line series: the­wal­rus.ca/opi­oids.

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