Ameliorating the Overdose Crisis in Underserved Rural Communities in Alberta

In 2018, there were nearly 4500 opioid-related overdose deaths in Canada. This amounts to approximately 12 lives a day; more than twice the number of fatalities resulting from traffic collisions. However, the overdose epidemic is not merely an urban emergency in Canada. Although often overlooked, rural and Indigenous communities in Alberta have the highest rates of opioid related emergency department visits per capita. In fact, some rural towns and Indigenous communities have hospitalization rates for opioid poisonings that more than double those in Canada’s largest cities. A lack of social, health care and harm reduction agencies, long distances for emergency services to travel, and intergenerational trauma all contribute to the unique overdose crisis facing rural and Indigenous communities. My name is Mason Schindle, and my stretch project this summer focused on ameliorating the overdose crisis in these underserved rural communities in Alberta by providing training on how to identify and respond to an opioid overdose, including how to use a naloxone kit. During this time, I was also lucky enough to shadow an addictions physician for two days in Calgary and also joined the Streetworks Overdose Prevention Team on the Needle-Exchange Van in Edmonton.

The contents of a naloxone kit include: 3 vials of naloxone hydrochloride, 3 syringes, a one-way valve breathing barrier, a pair of rubber gloves, and 3 antiseptic alcohol pads.
Apparent opioid-related deaths in Canada in 2018.

Over the summer my stretch project took me to Claresholm, Nanton, Ponoka, Redwater, Devon, High River and Morinville. I’m also currently in the process of arranging drop-in naloxone training in Westlock, Drayton Valley, and Vulcan for the month of September.

A map of the towns I visited this summer.

Each town offered a unique environment and I really loved interacting with the different community members in each town. In Claresholm I mostly trained truckers. In Nanton I trained a lot of ranchers. In Ponoka I trained a lot of lifeguards and Indigenous peoples from the neighboring Cree community Maskawacis. In Redwater I trained a lot of blue collar workers that were looking to augment their safety training.

I made the Claresholm Local Press! Still struggling with the fame.

In each town, I had a lot of great conversations (and sometimes heated debates) with rural community members regarding the overdose crisis. I deeply enjoyed the opportunity to educate rural community members on synthetic opioids (i.e., fentanyl) and the value of harm reduction initiatives (i.e., supervised consumption sites, naloxone kits) whilst also clearing up some common misconceptions. Below are some common questions I got:

“Doesn’t naloxone just enable drug users to continue using drugs? Or to use more drugs”?

Naloxone does not lead to more drug use or riskier drug use (Jones et al, 2017). In stark contrast, some studies have shown that naloxone may actually result in a decreased use of opioids (Wagner et al, 2010). There is also no evidence to support the notion that naloxone prevents people who use drugs from entering a treatment program (Bazazi et al, 2010).

“What’s the point of harm reduction initiatives like supervised consumption sites”?

Harm reduction initiatives like supervised consumption sites reduce overdose deaths, reduce the spread of blood-borne viruses (i.e., HIV/AIDS, hepatitis C), and reduce the social costs associated with drug use (i.e., legal system costs, healthcare costs). Arguments will arise to claim that augmentation of harm reduction interventions will merely encourage continued drug use and keep users ‘stuck’ in addiction, thereby exacerbating the overdose crisis. However, a wealth of research from across the globe disproves this claim and demonstrates that harm reduction programs dull drug use and serve as an effective bridge to treatment. I actually wrote a position paper on this topic for INTD306 (Topics in Leadership) during my first year in PLLC. It can be found here along with references to the aforementioned claims:

“Can fentanyl kill me if I touch it”?

Fentanyl cannot be absorbed through the skin.

Overall, I believe these interactions greatly enhanced my ability to teach, engage difference, appreciate and understand varying perspectives, and engage in meaningful and civil debate. As of today, I’ve trained over 100 rural community members how to identify and respond to an opioid overdose and have distributed 114 naloxone kits during this time. Originally, I was really hoping to expand this outreach to Indigenous communities as well but didn’t have much luck in this arena. However, my time in Ponoka was especially rewarding for this reason as I had the opportunity to train and speak to many First Nations peoples from Maskwacis. In the near future, I’m hoping to join Streetworks on a trip out to a reserve in Alberta to further augment this experience.

I was also fortunate enough this summer to shadow Dr. Monty Ghosh, an addictions physician, for two days in Calgary. During this time, I gained clinical exposure to individuals struggling with fentanyl, meth, crack and alcohol addictions; fentanyl being the primary culprit. For those of you who don’t know, fentanyl is a synthetic opioid that is 100 times stronger than morphine and has been responsible for the vast majority of opioid-related overdose deaths across Canada. This shadowing experience opened my eyes to the extent of the intersection between mental illness and addiction. Nearly all the patients we visited had some form of mental health complication, including schizophrenia, depression and bipolar disorder. Dr. Ghosh’s primary goal during our time at the hospital was to employ a tactic known as “motivational interviewing” to try and move people from a “non-contemplative state” to a “contemplative state” to mitigate risky drug-use behaviour and/or utilize harm reduction programs such as the Injectable Opioid Agonist Therapy Program at the Sheldon M. Chumir Health Centre. This is a clinical supervised treatment clinic for patients suffering severe Opioid Use Disorder and provides medically prescribed hydromorphone for direct injection. Opioid agonists, such as hydromorphone and suboxone, are long-acting opioids that prevent withdrawal symptoms.

A lethal dose of fentanyl relative to a lethal dose of heroin.

The second day I shadowed Dr. Ghosh we were at the Renfrew Recovery Centre. Individuals here were highly motivated to stop using illicit opioids and were receiving opioid agonist treatment. The goal in this case is to “stabilize” the patient on opioid agonists (i.e., methadone, suboxone) to prevent withdrawal symptoms and then slowly wean them off. Overall, being able to shadow Dr. Ghosh was an unforgettable experience that has greatly inspired me to pursue a career in addictions/rural medicine to care for one of society’s most vulnerable populations.

This summer I was also fortunate enough to join Patrick Black, a nurse with the Streetworks Overdose Prevention Team, on the Streetworks Needle Exchange Van. I was in charge of answering incoming calls and logging data as we visited injecting drug users in the city to recover their used needles and provide them with clean needles, syringes, naloxone kits, condoms, tampons, water, tourniquets, cookers, and needle disposal bins. I would like to thank Patrick very much for his continued support over the past year and throughout this stretch project; I wouldn’t have been able to accomplish this outreach without his help and all the supplies he provided me.

Overall, this rewarding outreach experience has consolidated my passion for harm reduction and my goal to enter the field of rural/addictions medicine following my undergraduate degree. I enjoyed this project so much that I plan to continue this project over the academic year and into next summer to provide naloxone training to more rural communities in Alberta and hopefully some Indigenous communities as well.

Rock art for International Overdose Awareness Day. These rocks will be placed around Medicine Hat, AB.

Tomorrow, August 31st, is International Overdose Day. I encourage you all to take some time out of your evening, wear something purple, and go to Victoria Park in the River Valley to commemorate those who have died as a result of the ongoing overdose crisis. There will be speakers from a variety of harm reduction organizations including MomsStopTheHarm, Healing Hearts Edmonton and Streetworks. The event starts at 7:45pm and there will be free naloxone training and a candle light vigil at 8:30pm. If you’re interested in naloxone training but can’t make this event, don’t hesitate to reach out to me (mschindl@ualberta.ca); I’d be more than happy to provide the training and it only takes 15 minutes.

— Mason

Literature Cited

Bazazi, A. R., Zaller, N. P. H. D., Rich, J. D., & Fu, J. J. (2010). Preventing Opiate Overdose Deaths: Examining Objections to Take-Home Naloxone. Journal of Health Care for the Poor and Underserved.21(4), 1108–1113. doi: 10.1353/hpu.2010.0935.

Jones, J. D., Campbell, A., Metz, V. E., & Comer, S. D. (2017). No evidence of compensatory drug use risk behavior among heroin users after receiving take-home naloxone. Addictive Behaviors71, 104–106. doi: 10.1016/j.addbeh.2017.03.008

Wagner, K. D., Valente, T. W., Casanova, M., Partovi, S. M., Mendenhall, B. M., Hundley, J. H., … Unger, J. B. (2010). Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. International Journal of Drug Policy21(3), 186–193. doi: 10.1016/j.drugpo.2009.01.003

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