Beyond Harm Reduction

 

Just when it appears that that BC's toxic drug crisis can get no worse, the BC Coroners Service issues yet another monthly report worse than the one that came before it. The service recently reported 195 suspected drug toxicity deaths in May. At the current rate that number may see deaths in 2022 surpassing the 2,224 people in BC who died from drug poisoning in 2021, the deadliest year on record in Canadian history, and a 26 percent increase from 2020.

Despite significant efforts on the part of legislators and public health officials to address the crisis in the six years since it began, there is a growing feeling of helplessness as the number of deaths continues to rise.

The costs to the health-care system – both financial and human – are enormous and have yet to be fully measured. In the meantime, expanding access to harm reduction services has been the primary policy response to the crisis. This effort has largely focused on opening supervised drug consumption sites and providing naloxone to the public.

The persistently high death rates also highlight the fact that harm reduction, while an important emergency response, fails to address the toxicity of the drug supply, or reframe the way drug use is approached. If the illegal drug supply remains toxic, preventable deaths will continue to occur regardless of the number of supervised consumption facilities opened. Safe consumption sites also do little to address the ongoing problem of those who use drugs alone in private residences, where nearly half of all fatal poisonings occur, according to the coroners service.

Coquitlam's Samantha Chong remembers what it was like in the early days of the crisis, when expanding access to harm reduction services such as the widespread provision of naloxone and drug checking services was a priority.

"It was boots-on-the-ground frontline outreach going to the street and handing out harm reduction supplies," she recalls.

Chong is part of the Fraser Health Authority's wellness team for population and public health. This regional team is made up of mental wellness (formerly known as overdose) nurses, healthy schools nurses, community health specialists, and dieticians.

Many communities across the Fraser Health have a designated mental wellness nurse. Chong serves in this role for the communities of the Tri-Cities area (Coquitlam, Port Coquitlam, Port Moody, Anmore and Belcarra). Her position was created in 2016, the same year the province declared the toxic drug crisis a public health emergency in the wake of spiraling death rates.

But since then, Chong says programs and nurses' job descriptions have evolved in response to the changing nature of the crisis. In addition to harm reduction teams, Fraser Health now also employs overdose outreach teams, where staff connect with people hospitalized after experiencing an overdose to provide case management follow-up in the community, as well as teams that provide specialized support to homeless and underhoused individuals affected by the crisis.

"And then there is our team," says Chong. "We have an 'upstream' lens, and we are exploring how we can put brakes on the crisis, stop it from occurring in the first place and looking at where we can effectively intervene to make that happen."

That mandate means Chong's goal is to promote greater awareness of the devastating toll of the crisis in the Tri-Cities area, and to look for creative ways to reduce deaths. This could include outreach efforts to reduce the stigma associated with drug use and education on issues like trauma and the effect of adverse childhood events.

The community nurse was on-hand at the recent July 16 Multicultural Connections community event at Town Centre Park in Coquitlam. While there, she spent the day practising her craft by educating and informing individual community members about the nature of the toxic drug crisis, and the work she and others are doing to confront it.

Chong was joined by other members of the Tri-Cities overdose community action team (TCCAT). She and the members of this recently created team work with a range of interest holders, including non-profit organizations, varying levels of government, local businesses, concerned community members and people with lived experience.

Chong says the team aims to engage the wider community in a broader discussion about how to address the crisis – one that goes beyond the topic of addiction treatment services and harm reduction measures to one that addresses many of the root causes of the crisis, and deals with topics like access to a safe supply of drugs and decriminalizing people who use drugs.

"There is so much polarization when it comes to substance use because it is so stigmatized and it can be very difficult for people to understand," Chong reports. "When I talk to many people, it's very black and white. They feel that if it's not safe then just don't use it. It's that simplistic."

"Safe supply" is a policy position that's become increasingly common as the crisis wears on. It is also an upstream solution, and Chong works to educate the Tri-Cities community about what it means.

"Safe supply is always our hope," she says. "We have to do something so people are not dying."

What does Chong tell people who are sceptical about providing illegal drugs to the community?

"I explain that it's prescriptive treatment just as it would be for anyone with any kind of illness. Like, if somebody is diabetic and they require insulin they can get a prescription and they know that the drugs they are getting are not going to kill them and they are going to be able to manage their illness with the appropriate medication."

Chong likens the provision of safe supply to simply stabilizing a patient – a required course of action in any other health-care context, and one that's needed before care can be provided.

"Once stabilized with appropriate (safe) substances, people are also not committing crimes to access drugs illegally, they are no longer engaging in behaviours that would see them ostracized by their community, they can work and have families and contribute to the wellbeing of society as a whole with safe supply."

Chong says she also aims to educate the people she talks with about trauma and adverse childhood events that are known to have lifelong effects that can include substance use and often result in hardship and poverty.

"Nobody aspires to homelessness and marginalization when they are younger," she says. "I also talk about substances and ask people what they think a substance is to help broaden their vision. Many people use substances – coffee is a substance," she notes, and like any substance, it's safer when it is regulated.

Chong also works to address misconceptions about drug overdoses, and the common assumption that the crisis mainly affects Vancouver's Downtown Eastside. "I'm here to tell people that's not what's happening. That's not who's most at risk. It's people who are using recreationally alone in their homes because of stigma. That's what we see when we look at the coroner's statistics."

Chong's current role began in November 2021, and speaking with her, it becomes clear she's excited about the possibilities it brings. "It is so different from any nursing position I've had in my 27 years of practice!" she remarks. "One goal the TCCAT had this year was to develop a website. We launched in April and I'm responsible for contributing content."

Chong has worked in the community throughout her 27-year career. She spent many years working in homecare for the Vancouver-Richmond Health Board and worked for several years as a case manager in Home Health before returning to public health, most recently working to help confront the COVID-19 pandemic.

When the dedicated position for a mental wellness nurse for the Tri-Cities area was created last year, Chong applied and got the job. "I've always been frontline and task oriented. But this is very different, and I've had to change the way I think about what I do," she reports. "It's not a job I could do if I didn't have a passion for this kind of work."

Community nurses know the importance of "meeting clients where they are at." It's the foundation of the effective one-on-one relationship that's needed before options for positive change can be explored.

"The community is my client," explains Chong. "You really have to get to know your community and acknowledge their focus. If their focus is harm reduction then it's my job to walk along side them, help direct them to the right people for that, but also to say, 'okay, yes, harm reduction is important, but how can we begin to expand our focus so that we're not just doing crisis intervention, but actually preventing the crisis from happening?'"

Chong uses the metaphor of someone having fallen in a river when using substances to cope with the experience of traumatic life events to illustrate the upstream lens she applies to her work.

"Harm reduction is throwing them a life jacket to navigate the river and help scoop them out of it to keep them alive," she explains. "But what can we do to prevent these people from getting into the river in the first place? How can we intervene?"

The ultimate upstream goal, says Chong, is to have people standing on the bridge overlooking the river and bypassing it altogether.

"Programs that start in childhood to help prevent trauma or address the adverse childhood events that correlate to substance use – such as abuse and neglect, having a parent with substance use disorder, or an incarcerated parent. That's really upstream, right to the source," she explains.

In the meantime, as a member of TCCAT, Chong says she's always looking for organizations in her community to partner with.

"Recently, I had the Program Director of Health Sciences at Douglas College's David Lam Campus reach out to me to discuss how we may collaborate so I'm excited to explore this opportunity – anti-stigma? We shall see!"•

UPDATE (Summer 2022)