Rural Harm Reduction : “ Below the Radar”

1. An exploration of substance use in rural Ontario Kathy Hardill, RNEC Doing the Work North Bay, July 2012 Rural Harm Reduction: “Below the Radar”

2. North Hastings • Town of Bancroft population 3,500 • 250 km NE Toronto • Just south of Algonquin Park • Mineral capital of Canada • Mining – uranium, iron, corundum • Logging

3. North Hastings • More likely to have low income, low education than rest of Ontario • High unemployment • “dry” town until 1970s – bootlegging • Religious fundamentalism • Political conservatism • Back to the landers • Visible drug culture • Where to go for drugs • Cannabis cultivation

4. “Below the Radar” - 2010 • Advanced Clinical Practice Fellowship RNAO and The Bancroft Medical Clinic • Literature review • Key informant interviews • Interviews with substance using individuals • 3 nurses developed q’aire • 2 administered survey • Flyers, postings, snowball sampling • 10 respondents • 4 more 1:1 interviews later

5. Rural substance use • More substance use • Fewer services (of all kinds) • More barriers to service • More stigma • Poverty, unemployment, class selective migration  generational poverty, similar risks as inner city neighbourhoods

6. Southeast LHIN

7. Ontario Student Drug Use and Health Study- SE LHIN • 70,000 Ontario students since 1977, CAMH • SE LHIN highest of all LHINs for: • student use of opioid pain relievers without a prescription (23.7% vs 18% Ont) • student drinking and driving(17.6% vs 12% Ont) • ecstasy use by high school students (7.9%)

8. North Hastings • Cluster 5 suicide deaths 2010 • Male, 18-55 • Ongoing substance use • Minimal contact with health care system • ongoing overdoses, suicides 2011, 2012 • “as (people’s) addiction increases, so does their isolation and their ability to access mainstream services becomes really limited”

9. Local data: interviews, KIs • Younger age – median age 40 • Child rearing age • Low incomes/precarious employment • Seasonal, part time, social assistance • 6/10 < $999/mo • Precarious housing • 7/10 renting, 1/10 homeless

10. Local data • Early drug use 9-15 years • 6/10 alcohol, 4/10 cannabis • Polydrug use – marijuana, percocet, benzos • 100% tobacco use • Top three drugs of choice? • “Oxycontin, Oxycontin, Oxycontin”

11. Local data • 7/10 named an opiate as drug of choice • 9/10 had been unable to obtain their DOC: • “It was horrible – I wanted to cut my legs off” • “I went through hell for a week – I thought I was dying”

12. Local data • Mental health – 6/10 depression/anxiety, 2/10 PTSD, 1/10 hx child abuse, 1/10 self injury, 1/10 hospitalized for suicidality • Pervasive low self esteem • “Low self esteem takes on a life of its own – there is just a hopelessness, a sense of not being able to accomplish anything, just an awful hopelessness”

13. Needle use, NEP • Bancroft NEP located in pharmacy • Long hours of being open • Lack of confidentiality, data, teaching • Exponential increase but why? • More aware of NEP? more trusting? • More drug use? use of drugs requiring more frequent injections? • NO ONE KNOWS!!!!!

14. Increased NEP use – why?

15. Needle use • Needles found in several parks by public works employees - town liability issue • Lack of education? Lack of material resources? Stigma? • Outdoor drug use inherently unsafe • Need to know who is using what, where, how • Lobby PHU to conduct research

16. Barriers and gaps - KIs • Diverse lack of services (72%) – addictions, counselling, primary care, residential treatment, crisis, child care, methadone • “It is our responsibility as a community to provide what people need, so they can get the help they need”

17. Barriers and gaps • Call for proactive, innovative collaboration between agencies • “We’ve got to stop being territorial about our clients and start thinking outside the box to reach people who will not be picking up the phone and calling to say they have a problem”

18. Barriers and gaps • Transportation • To counselling, detox, primary care, NEP, methadone • Price of gasoline, insurance, unreliable vehicles • Gas pumps - $7!!!

19. Barriers and gaps • Stigma/isolation “I kept my addiction very hush hush” “It’s harder in rural areas because labels stick, there is usually a small pool of providers, and some labels are even generational. The ‘mental memory’ of people and their family connections never fades”

20. Barriers and gaps • Lack of awareness/understanding by providers • 9/10 had primary care provider, only 1 could think of anyone to go to for help re drug use • “We have to remove the sense of being punished for revealing a health condition to your provider”

21. Barriers and gaps • Methadone maintenance therapy (MMT) • Replace opiate with prescribed methadone to stabilize people • Prohibitive zoning by-laws • “I used to hitchhike from Pembroke to Peterborough every week to go to clinic” (260 km one way)

22. Barriers and gaps • Lack of woman safe space – being “thirteen stepped” • When women attending 12 step programs are repeatedly approached sexually even after rebuffing advances and this is accepted in the culture of the group • “it becomes a balancing act to choose between your sobriety and your safety”

23. Challenges • distance and travel • poverty • lack of anonymity – not wanting to “out” oneself as a drug user • Lack of understanding of substance use, harm reduction by service providers • Lack of services

24. Below the radar……. • Questions? • Report available: • http://www.substanceusestrategynetwork.org/resources.html