Caring In A Dangerous Time

LIFELINE Harm reduction advocate Chris Bigelow-Nuttall says far more resources and leadership are needed so community nurses like him can effectively address the province’s ongoing toxic drug crisis.

The numbers are in. And the numbers are not good.” So began an Update Magazine interview with BC’s chief coroner Lisa Lapointe published some two years ago.

These words could easily have been written today. The article spoke of “failed drug prohibition policies, institutional inertia and a shortage of political will that continues to protract the crisis.”

At that time, Lapointe was speaking to her annual Illicit Drug Toxicity Deaths report for 2021. She said, “It's hard to think of anything else happening in this province resulting in the deaths of six or seven people every single day that would not elicit a massive, coordinated response.”

Sound familiar?

Sadly, the numbers have only gotten worse. Unregulated drug toxicity is now the leading cause of death in BC for persons aged 10 to 59, accounting for more deaths than homicides, suicides, accidents and natural diseases combined.

Looking for good news about the toxic drug crisis only leads to disappointment. More deaths, more statistics, more mothers holding photographs of their lost children, but very few meaningful changes. And with Lapointe’s retirement in February, the provincial harm reduction community has lost one of its most articulate and qualified allies.

CRITICAL RESOURCES NEEDED

Nanaimo’s Chris Bigelow-Nuttall is a clinical nurse educator working in addictions medicine, substance use outreach services and community outreach response. Based primarily at Nanaimo Regional General Hospital, his work often involves helping the city’s at-risk population, such as those who are unhoused or living with mental illness.

Community nurses like Bigelow-Nuttall acknowledge the daunting task of advocating for a comprehensive, culturally safe and trauma-informed system of substance use care, incorporating the education, prevention, harm reduction, treatment and social support that were needed even before the public health emergency was declared. But he tries to remain positive about his team’s approach to addressing the crisis.

“There is no indication that prescribed safer supply is contributing to unregulated drug deaths.”

BC chief coroner (retired) Lisa Lapointe

“We're doing a lot of good things in the field of harm reduction that are saving lives and cutting down on the disease, disability and mortality associated with people who use substances,” he says, “especially in the age of highly synthetic, highly potent, unregulated toxic drugs.”

The spectrum of recent harm reduction approaches includes a broad category of prescribed opioid alternatives. Community nurses like Bigelow-Nuttall and his colleagues utilize a number of relatively new pharmacologic tools in their efforts to help individuals reduce their use of unregulated opioids. The most common of these has been hydromorphone, but other novel therapies, like Fentora, which is a dissolvable fentanyl formulation, are beginning to prove valuable, he reports.

“We have fentanyl patch programs and injectable opioid agonist therapy programs starting to become more commonplace in our communities, which have anecdotally helped a number of folks find some stability in their unregulated substance use, especially when followed by community or primary care teams or case management teams who are addressing some of the other barriers that these individuals face.

“But we're still bringing knives to a gunfight when it comes to the scope of the problem,” he remarks, and says that, despite the growing number of resources available in Island Health to help people struggling with substance use disorder, the response is still inadequate.

“The demand outstrips the supply. At our local intake office, there are up to 400 people on the waitlist to see a psychiatrist. Timely access to wrap-around mental health and substance use treatment continues to be a struggle for many.”

NUMBER OF TOXIC DRUG DEATHS PER YEAR IN BC

Bigelow-Nuttall, who is an addictions medicine consult service leader, says one of the biggest obstacles for community nurses trying to support people who want to address a substance use disorder is finding a safe place for them to live. If services are not available when they need them, many of these individuals are lost back to the street or lose the progress they have previously made.

“[Treatment and recovery] is a very dynamic, non-linear process of change. And when we're working with limited resources, that makes for big challenges,” he says.

This January, the provincial government announced funding for 83 treatment and recovery beds scheduled to open across BC this summer, adding to the 97 beds already funded in the past year. There are now 3,596 publicly funded adult and youth substance-use treatment beds in BC. But even with increased funding, advocates say the wheels are moving too slowly to effect meaningful change. The coroner estimates that as many as 225,000 people in BC remain at risk of unregulated drug injury or death.

Many of the treatment and support programs and services that Bigelow-Nuttall and other nurses provide to address the crisis will take years to expand and evaluate. The coroner’s expert review panel has argued that the current reality should spur the development of immediate initiatives to ensure that people who use drugs are not forced to rely on an unregulated drug supply until a comprehensive approach is available.

During her final news conference in February, Lapointe lamented a "one-off, beds and projects" response to the emergency that she said has claimed more than 13,000 lives in the past seven-and-a-half years.

"We see these ad hoc announcements but sadly what we haven't seen is a thoughtful, evidence-based, data-driven plan for how we are going to reduce the number of deaths in our province,” she said.

There is no question that, based on sheer numbers, the crisis is getting worse. The Coroners Service’s most recent report issued in January confirms that toxic, unregulated drugs claimed the lives of at least 2,511 people in the province in 2023, the largest number of drug-related deaths ever reported. The total number of lives lost in 2023 equates to an average of 6.9 deaths per day and is five percent more than the previous high of 2,383 deaths recorded a year earlier in 2022.

"As we approach the eighth anniversary of the declaration of the public-health emergency that has cost so many lives across BC, our province needs a coordinated, evidence-based response that is commensurate with the scale of this health crisis,” said Lapointe.

“Deaths due to drug toxicity are preventable and I urge our political leaders at all levels to collaborate on a thoughtful, comprehensive plan that puts people first.”

Bigelow-Nuttall and other community nurses know the death rate could be lowered if basic human needs were met.

“Whether people are using substances or not, if we can get them under a roof, into a bed, food in their belly, physical and environmental safety, their level of health and wellbeing will increase regardless of whether they're continuing their substance use,” he says, noting how these humane measures give health-care workers time to assess, stabilize and connect people to the appropriate resources while they wait for their detox or treatment bed to come up.

“Patients need timely access to supportive recovery infrastructure and programming to fill the gaps [when they are] between detox and treatment,” Bigelow-Nuttall explains.

For BCNU President Adriane Gear, the coroner’s most recent report is a reminder of how much work still needs to be done to address the crisis – and the devastating toll it is taking on some of the most marginalized in society.

“BCNU is renewing its call for an immediate expansion of harm reduction strategies, and in doing so, we acknowledge that the rate of drug poisoning deaths among Indigenous people in BC is over four times higher than that of other residents,” she says.

Gear is also calling on politicians to listen to nurses like Bigelow-Nuttall when responding to the crisis.

“Nurses and other health-care providers can offer their wisdom and knowledge to create a more equitable health-care system – one that approaches the health-care needs of persons coping with substance use issues from a perspective of harm reduction – with kindness and compassion,” she argues.

SUPPORTING A REGULATED SUPPLY

The gravity of the public health crisis has not prevented some politicians from ignoring the evidence and advice of health-care workers and harm reduction advocates and calling for the reversal of initiatives that have saved lives.

This includes opposition to even the limited expansion of safe supply programs to prevent more deaths. The most recent Coroners Service toxicological testing confirms that illegal fentanyl continues to drive the health crisis. Fentanyl and its analogues were by far the most regularly detected substances, appearing in more than 85 percent of test results conducted in 2023.

“There is no indication that prescribed safer supply is contributing to unregulated drug deaths,” wrote Lapointe in her final report.

Nevertheless, many public health advocates are frustrated by populist legislators like federal opposition leader Pierre Poilievre and Alberta Premier Danielle Smith, whom they say have been oversimplifying the issues for their own partisan interests, and are blaming substance users for their own deaths.

Bigelow-Nuttall believes disparate views on the correct path forward in an era of political and social polarization are stalling real progress. He points out the current NDP government’s reluctance to fully engage in harm reduction strategies surrounding broader access to a supply of consistently dosed, unadulterated, predictable, and regulated substances.

“I think they are hesitant to provide widespread access to safer supply, likely due to the large social and political backlash to the concept, and especially in an election year,” he notes.

“Until we address the elephant in the room, which is the ongoing illicit supply of toxic and unregulated drugs that are directly contributing to the deaths of so many people, I’m not optimistic we’re going to see the numbers of toxic drug deaths decreasing.”

Last November, Minister of Health and Addictions Jennifer Whiteside rejected the Coroners Service Death Review Panel’s urgent recommendation to expand safe supply by allowing agencies to apply for licensure and delegated authority to distribute regulated substances on a non-prescription basis. She responded that non-prescription models for the delivery of pharmaceutical alternatives are not under her ministry’s consideration, and noted the provincial government’s expansion of access to mental health and addiction care.

“When we're working with limited resources, that makes for big challenges.”

Chris Bigelow-Nuttall

Bigelow-Nuttall is not impressed with the oversimplified discourse surrounding the problem. “We often see the pitting of harm reduction against recovery,” he says. “But harm reduction is recovery, and recovery is harm reduction – it’s not black or white. There are many shades of grey in such a complicated and nuanced process of change,” he explains.

“And we have to recognize that we need investments in both harm reduction and recovery-oriented services. People can’t recover if they’re dead.”

In the meantime, Bigelow-Nuttall says public health orders expanding nurses' scope of practice and authorizing RNs and RPNs to prescribe pharmaceutical alternatives to toxic street drugs have been an important part of the solution to addressing the crisis.

“I know that having advanced practice nurses prescribing opiate agonist therapies is life saving for members of those communities where there is an acute shortage of prescribing physicians and a lack of addiction medicine specialty services,” he says.

KEEPING NURSES SAFE

Safeguarding members’ well-being will always be BCNU’s number one priority, and there is no shortage of health and safety issues health employers should be addressing more effectively. One of these is exposure to substances used by patients in nurses’ care.

On Jan. 31, 2023, the federal government granted the province a three-year exemption under the Controlled Drugs and Substances Act to remove criminal penalties for people who possess a small amount of certain illicit substances for personal use.

Decriminalization means people in possession of 2.5 grams or less of certain illicit substances will no longer be arrested, charged or have their drugs seized. The primary goal of decriminalization is to destigmatize substance use and thereby improve access to health and social services. The move is an important part of BC’s response to the toxic drug crisis.

Since the exemption, however, some nurses have raised concerns about patients’ possession and consumption of substances within health-care facilities. Gear says health employers need to be doing more to enforce policies that guide practice and keep patients and workers safe.

“It is imperative that all health employers have occupational health and safety policies and procedures in place to guide safe patient possession and consumption while in care,” she says. “This includes exposure control plans for illicit substances that contains effective risk assessment procedures to address patient possession and consumption.”

Gear says harm reduction strategies cannot come at the cost of nurses’ safety. She encourages any concerned member to talk to their manager, professional practice lead or clinical nurse educator, and to contact healthandsafety@bcnu.org if no guidelines are available or direction seems incomplete.

“I’m not optimistic we’re going to see the numbers of toxic drug deaths decreasing.”

Chris Bigelow-Nuttall

Bigelow-Nuttall echoes BCNU’s support for strategies that ensure the rights of nurses and health-care workers to facilitate harm reduction in safe and inclusive work environments. This includes psychologically healthy workplaces that reduce the moral injury community nurses confronting the toxic drug crisis commonly experience.

“We continue to see some folks getting discharged from treatment back to the streets, which is terrible. Some of those folks will die because of it, and most will inevitably relapse because of the current lack of longer-term follow-up supports,” he reports, adding that efforts to provide safe and affordable recovery-oriented housing must be dramatically scaled up.

The statistics on deaths from the poisoned drug supply are devastating, but Bigelow-Nuttall says he is not giving up.

“Looking to the future, I hope to see significant investments in longer-term supportive recovery housing and the development of holistic therapeutic communities that will help people maintain the positive changes they have made,” he says.

“Recovery from substance use disorder can be a long journey, and a diverse number of supports needs to be in place to maximize people’s chances of success.”

And with hope, soon, the coroner’s numbers will reflect those successes. •

UPDATE (Spring 2024)