The Decibel - The ‘invisible’ opioid crisis in small towns

Episode Date: March 13, 2024

The dangerous effects of the opioid crisis could be distilled in a single afternoon in February: the town of Belleville, Ont., saw 14 overdose cases in just two hours. The scale of the opioid crisis is often associated with big cities; however, the reality in smaller cities is even worse. Despite smaller cities having higher rates of opioid deaths and hospitalizations, they get less attention.The Globe and Mail’s reporter and feature writer, Shannon Proudfoot explains the situation in some small towns in the country and how they are trying to deal with it despite having far fewer resources.Questions? Comments? Ideas? Email us at [e-mail]

If you ask someone to picture the opioid crisis, I think we all have a pretty consistent image in our heads, and it's the ones we see in the news all the time. It's a very urban landscape. It's sidewalks, you know, between big buildings, tent city, people sort of, you know, heaped in doorways. There's no doubt that it's a city that you're picturing. It's a big city. And I think that is where we conceptualize this problem as being located and as being worse. Shannon Proudfoot is a reporter and feature writer for The Globe in Ottawa, and she's noticed a trend. I've been thinking a lot about how small towns end up overlooked because we focus so much on big cities. I'm from Sault Ste. Marie. I grew up there and my family still lives there. And so I guess I always have sort of a bit of a chip on my shoulder or I like to think it gives me some extra journalist perception.

Because I notice the way we pay attention to everything that happens in a city and not necessarily what's happening in smaller places. But there can be an issue with focusing so much on cities, especially when it comes to the opioid crisis. If you look at the statistics, it's not just that opioid issues are the same or as bad in small cities and small towns as they are in big cities. They're actually worse. And it's as though it's invisible to us because it's just not where we're looking. It's not how we conceptualize the problem. Today, Shannon explains what we're seeing in small towns and cities across Canada, how they're dealing with their own opioid crises, and the consequences of focusing on bigger cities. I'm Maina Karaman-Wilms, and this is The Decibel from The Globe and Mail.

Shannon, thank you for being here. Thanks for having me. How pervasive is this idea that the opioid crisis is mostly a big city problem? Well, I think you can see how pervasive this is in the response to what happened in Belleville last month. So there was one day in a two-hour period where they had over a dozen overdoses downtown and shut down their downtown the way you would if there was like a train derailment or a big accident. And that incident got national news coverage. And the tone of all of it was this sort of wonder and surprise because Belleville is about 55,000 people, a smallish city in Ontario. It's sort of very bucolic, very beautiful along the water. And the tone of all the coverage was like, can you imagine in Belleville?

And I think the disconnect between the place and how we think about where this happens occurred to a lot of people, but probably not to people who work in this area in small towns. For them, it was more like, yeah, we've been telling you all along that this is what's happening. It's interesting. One of the most fascinating things I heard from the people I interviewed is that this idea is so pervasive that it even exists in the brains of people who live in smaller cities. So I talked to a bunch of different service providers and community leaders in smaller places. And at least two of them said to me that they hear it from the people they live amongst. So I spoke to a service provider in Whitehorse, and she said that what she hears from locals is this idea that, oh, the fact that

we have an opioid, a visible opioid issue here must mean that we're growing into a big city, like that these are effectively growing pains, that it couldn't be, let it inherently existed in Whitehorse as a small remote city in the first place. And I also spoke to a really excellent service provider, Catherine Colby in Powell River, BC, which is a really remote town on BC's Sunshine Coast. And she actually said that among herself and colleagues who work in this area, they have sort of a joking shorthand for it. They call it the magic school bus. And the idea is that there must be some magical school bus pulling into these communities and dropping off homeless people and people with drug problems. Because people within the community say this couldn't possibly be here.

Like this couldn't possibly be us and our neighbors and that it's happening among us. This has to come from somewhere else. Yeah, we often talk about the opioid crisis, right, in like Toronto or Vancouver, as you said, right? But let's actually look at the numbers behind this, though, because you went digging and tried to actually find out the numbers here. So what kind of data do we actually have on this? So I had one of those sort of tantalizing and initially kind of heart crushing journalistic experiences where I found exactly the kind of data I needed, but it was old. So the Canadian Institute for Health Information in 2018, pardon me, had put out a report where they looked at different community sizes and the rates of hospitalizations for opioid problems.

And I thought that's great. But six years is a very long time in this fast moving epidemic. So I asked them if they would recalculate with fresh numbers for me and very graciously they did. And so what they did is they put Canadian cities and towns into I almost thought of them as buckets by size. So there were five different buckets. So you had like small towns of under 10,000 people, you had 10,000 to 50,000, which I think we would again think of as pretty small towns, 50,000 to 100,000, 100,000 to 500,000, and then our biggest municipalities of half a million and up. And they found that when you look at rates, rates allow apples to apples comparison between cities, because it's how often something happens per 100,000. So it's effectively a per capita measurement. So it means that you can compare between a small place with a few 10,000 people with a big place.

So they found that rates of hospitalizations for opioid issues were actually highest in that middle bucket of cities of 50 to 100,000 people, which I think a lot of us would not think of those. Those are not our booming metropolises. And the other end of that is the rates were lowest in the biggest cities of 500,000 and up. And do we have, when we're talking about, I guess, the numbers even behind these initial numbers, like we're talking about emergency room visits, opioid deaths, do we have a sense of how that breaks down? Yeah. So in Ontario in 2021, Toronto, the biggest city in Canada, had 18.5 deaths per 100,000. So that was what you'd call the death rate and 117 ER visits. But Algoma Public Health, which is the public health unit that includes Sault Ste. Marie, is triple that for the death rate and double the emergency room visits. So it's a huge jump. So that's just one

point of comparison. And over and over, you saw that in Ontario, the smaller northern Ontario cities, higher rates than Peel Region, higher rates than Toronto, than Ottawa. In BC, so Vancouver's downtown east side is a vast outlier. And it's important to note that the rates there are almost literally off the charts. It's very, very high. But if you separate out that sector even of Vancouver, actually the highest death rate in BC in 2023 was Hope, BC, which has 6,700 people. Yeah, so that's really stark to see those numbers compared. And I think like what you're saying, probably not necessarily what everyone expects to see when you're looking at a small town. The big question then, Shannon, is why?

Like, why would we see such high rates of opioid deaths and hospitalization in small towns? So smaller places have fewer resources of all kinds, right? There's just fewer things because there's a smaller concentration of people. Also, if you look at the profile of people who tend to have opioid issues or the worst outcomes deaths, they are often people who work in manual labor, they work with their bodies. So they often work in resource extraction or blue collar jobs. They often have had injuries or chronic pain. And that can sometimes be a pathway to addiction because they start with a prescription, it goes from there. Well, smaller remote places have a lot more blue collar jobs that those tend

to be the things that the labor market is built on. Also, when I spoke to the mayor of Sault Ste. Marie, you know, he argues pretty straightforwardly that he thinks they would be closer to the average if they had some of the resources and supports that bigger places have. So it sort of becomes a bit of a chicken and egg argument because there are pre-existing reasons why smaller places might have worse rates. But then there's also the fact that they don't have the services and supports available, which in the eyes of a lot of people who work in those places, worsens the problem. Yeah. And when we're talking about access to resources, we know that emergency services and health services in general in small towns are often stretched thin, often across the country these days, unfortunately. But I guess I just wonder how that is affecting the crisis. Yeah. So, I mean, that would be sort of your first entry point would be your family doctor. If you think, you know, I'm having a

problem here, I need some help. And exactly that. We often know that the kind of primary care model is really, really stretched in these small places. A lot of people, both service providers, civic leaders, what they ask for is safe consumption sites or overdose prevention sites. A lot of people will call them OPS. And the idea is that if you want to get people into recovery, if you want to help them get better in some lasting way, you have to keep them alive first. And so that's often sort of the first kind of triage point. The other end would be recovery services. And that's also a huge hole in small towns and small cities. I mean, I would bet every city in Canada of any

size will tell you they need more detox beds, more recovery, more treatment spaces, but those often literally don't exist. There are none in these smaller places. So there are sort of lacking things all along the continuum of how you might respond to this. Shannon, it may be, I guess, hard to generalize here, but how does the crisis look different depending on the size of the city or town? Like I'm thinking like Toronto versus Sault Ste. Marie. How does that play out differently? Yeah. So I think this goes back again to our mental picture of it. And Catherine Colby out in Powell River had a really great way of illustrating this. She said, like, often people with really acute drug problems are highly visible in urban spaces.

They may be living in those tent cities or on the sidewalk. People can see them. Whereas she said in her community, they know that the people who are dying of overdoses, they often own their own house or their renters and they're still housed. They might be employed. They might've just been laid off temporarily. Like it doesn't necessarily follow the same population profile or the same visibility level. Like she said, that's part of the problem with people in a smaller place conceptualizing that this is happening here, because if they're not seeing homeless people or obviously unwell people in the middle of their downtown, they think, well, that can't possibly be happening here. Because if they're not seeing homeless people or obviously unwell people in the middle of their downtown, they think, well, that can't possibly be happening here.

But it's happening behind closed doors. That lack of visibility is, I think, a really important point, I guess. What are the consequences of that misunderstanding? Well, we know that resources tend to follow public pressure. And if the public doesn't know where this is happening, there's no impetus for political pressure or for sort of like a public discourse around what is needed. And so if resources are scarce, which they perpetually are, and maybe especially right now, and there's no public concept of this being a small town problem or small towns having needs, they tend to even have less clout, you know, politically, economically, big cities are where people concentrate with money and companies. And like, it goes back to my original chip on my shoulder, we just pay more attention to cities,

because it's where the stuff is. And like, I know that sounds glib, but I truly mean that. And so there isn't that same sense of kind of an engine of pressure, an engine of political push to get those resources in. We'll be right back. I wonder about how we approach this problem then, Shannon. Like, can we use the same tactics that we use in Vancouver and somewhere else like Hope BC, a smaller town? Yeah. So that is a really tricky, complicating factor is that even if you had all the money in the world or the policy inclination to do something about this in a smaller town, it's really hard. I mean, the reason all the stuff is in the big cities is because that's where people are

concentrated. You can't, you know, one of the researchers I talked to, who obviously is very tapped into this problem, said you can't have a safe consumption site in a town for four people to use. Like it's not, it's not practical. There's also geography, people in smaller cities or towns or remote places, they can't just hop on a bus or a train or walk a few blocks in a city environment to go to a pharmacy to pick up suboxone or methadone or to go to an overdose prevention site. They might live 40 kilometers away and have to drive in. There's also the privacy aspect. In a smaller town, people tend to be more interconnected. People do tend to know each other more. And you might not want to line up at a pharmacy where

the pharmacist knows your family or where your kid's teacher's in line behind you to pick up opioid agonist therapy. You might not want to be seen walking into a safe consumption site. Several of the ones I talked to have been really thoughtful and careful about how they set up their physical site so that people who were going in either could not be seen from the street walking in or where they would be walking in. They could be going to any number of businesses. And so I think even if there is a push to do this, to provide services, it's really hard. It's trickier in smaller, scattered places for the same reason that anything is harder to do in kind of a little bespoke way as opposed to a mass way. And I know, Shannon, that you spoke to the mayor of Sault Ste. Marie, which this is a small city. It's about 700 kilometers north of Toronto.

What did you hear from him about what their experience has been like and really how they've been managing? Yeah, so the mayor is Matthew Shoemaker. And I asked him this, and it's funny because he got to the end of his answer and he said, wow, I thought I'd have like two or three things and I gave you 10. Because I asked him, what does this look like on the ground? And he said, because they don't have a safe consumption site, people are using drugs in the open in downtown. So in alleyways, in doorways, in businesses, businesses are closing early or sort of locking their doors and only letting customers in with a key because they don't want to deal with that. Residents stay away because, you know, whether they're right or wrong, there is a perception that they don't want to be

there. They feel like downtown is either unpleasant or dangerous somewhere along that continuum. He said that their EMS services, their paramedics are effectively full-time overdose response units. They have four teams on at any one time. So you can imagine if you have a rash of overdoses, what happens to the other calls on the list and what delays spin off from that? He said police also are disproportionately responding to this kind of thing because if a resident does go downtown, say they have an encounter in a parking lot with someone who's on drugs, they don't know whether that person's dangerous or not. Or maybe they have a negative reaction to it and they don't know who else to call. So they call police. And the Sioux is working really hard to revitalize its downtown. When I was a kid or a teenager, it was a really lovely place. Like

we spent a lot of time doing laps and it was full of, you know, little mom and pop shops. And it's kind of a bit of a moonscape now. But he said, we can't work on revitalizing it economically and bringing in businesses when it's a place that no one wants to be. So I kind of came to think of it like once he described it, it's like, how would you train for a race if you had a sprained ankle? Like you couldn't, you couldn't try to get to somewhere better if you're basically backfilling an injury you're dealing with, which is kind of what it sounds like is happening in cities that have what is effectively like a citywide untreated drug problem. And you said Sault Ste. Marie does not have a safe consumption site, but they have been trying to actually get one approved. So what's going on there?

They've been trying really hard. So they've had an application. And so when Mayor Shoemaker was elected about a year and a half ago, he came in explicitly with this as part of his platform and got a good mandate. So it seemed like the city was on side. But because Ontario has paused the applications for these sites for funding them, they're sort of stuck. In Ontario, and in most provinces, you sort of have to do a two track application, you have to apply to the federal government for an exemption that basically makes it legal to consume drugs on the site so that not everyone there is breaking the law. And then you also have to apply to the province for funding for it. And so last year in Toronto, there was a shooting outside an overdose prevention site and a woman, a bystander was killed. And after that happened, which understandably caused huge concern in the public, the province paused accepting further applications or processing

them to do a review. Now, some people who are critical of that policy will point out that Premier Doug Ford, years ago when he was campaigning, said he didn't like them. He doesn't like it as a policy response. So some people believe that that was sort of a fig leaf to pause a thing that the Ontario government didn't prefer as a policy solution anyway. So they can go ahead with the federal application, which would be a legal exemption. And he said they feel some pressure there. And I heard this from other places across the country, because if in the next federal election, we flip over to a conservative government, which seems likely, Pierre Polyev has had

some things to say not so favorable about this type of way of addressing an opioid crisis. So the worry is that the federal exemption could be shut down. So Sudbury and Timmins, which are other Northern Ontario cities, they both have overdose prevention sites in place. And what happened with them is they got the federal exemption processed and approved before the province stopped processing applications for funding. But they're now in a really precarious place where they are literally month to month to be able to fund these sites because the province is not giving them money. You can imagine smaller cities don't have a huge tax base.

They don't have a lot of money. And so they're having to fund them themselves month to month. So when you were talking to Mayor Shoemaker in Sault Ste. Marie, Shannon, how does he feel about how much attention the province is giving them or maybe not giving them on this issue? Yeah, so his assessment of that is really quite blunt. He says that in his view, the Ontario government is focused entirely on the GTA and on its needs, that there's a fixation on things like the Gardiner Expressway, Ontario Place, that sort of everything that government is seized with and talks about in his eyes is about the Toronto area. He wrote a letter not long ago to the Premier, highlighting that within the last few months, the Minister of Mental Health for Ontario was in Sault Ste. Marie and

gave a media interview where he said, I'm waiting for the Sault to tell me what it needs. And it was actually a pretty clever piece of political communications, I have to say. He said in the letter to the Premier, here are 10 separate dates of communications that I, myself or the previous mayor have sent to the province telling you what we need. Let us know if any of this is unclear. And so in his mind, what he said is, I get expressions of sympathy. I get the province saying, this is so awful. We're so sorry. How hard for you. But the action and the money isn't following the sentiments to him. So, Shannon, what do we do as a solution here? Like, how do we change this idea that the opioid crisis is a big city problem, you know, without kind of waiting for the next small town tragedy last month was kind of a wake-up call, right? People were shocked. But to people who know this landscape, that wasn't so much a wake-up call

as it was, see, we told you. So as I say, it is a really a tricky policy problem to solve because you can't set up an overdose prevention site, probably. I mean, BC is sort of doing it, but even there, there's a limit to the size of the communities they can put it in. You can't put one everywhere. So some smaller places have sort of adopted the idea of like a mobile overdose prevention site where it could be a van or an RV or something like that, that drives around to different communities. I think part of the answer is we have to start paying attention to smaller places. We have to stop thinking that everything that matters happens in a big city in Canada or anywhere else. And just start thinking about what might be happening elsewhere,

which I guess that's what I bang my drum on about. Because even though I live in a big city now, I still care about a small one. But it is a tricky problem to solve. And it's going to require, you know, creativity, commitment, money, and like political impetus for the public to sort of say, like, we want this solved. As I said, these cities can't grow. They can't prosper if they're hobbling around on a broken leg. Shannon, thank you so much for taking the time to be here today. Thanks for having me. That's it for today.

I'm Maina Karaman-Wilms. Our intern is Manjot Singh. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin. David Crosby edits the show, Adrian Chung is our senior producer, and Angela Pachenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.