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