Part 1: The Who, What and How of Drug Use that Impact Overdose Outcomes
Over the past several months, several of PAN’s staff have been sitting down to consult with Candice Norris about her observations and experiences with the opioid overdose public health emergency. Candice is an Aboriginal woman from the Cree/Dene nation who has been in recovery from substance abuse for more than seven years. She was diagnosed as HIV+ 22 years ago when pregnant with her now 21 year-old (uninfected) daughter and she has been active in research, evaluation and advocacy projects related to people’s experiences with living with HIV for more than a decade. Candice became involved with PAN as a Peer Evaluator for the PLDI Impact Evaluation and is currently a consultant to PAN on the opioid overdose crisis.
As a resident of the Downtown Eastside, Candice has experienced the loss of neighbours, friends and family members as a result of the opioid overdose public health emergency, and is a member of many advocacy and healing activities that the community has initiated in response to these losses. This two-part blog post series was inspired by discussions with Candice about her perceptions of the data she read in a report by the BC Coroner’s Service, and from our talks with her about her contributions to the incredible peer-based initiatives that have emerged in response to the overdose crisis. We hope that you will find these posts, a contextualized look at the current crisis from the perspective of an Aboriginal woman trained as an evaluator and deeply involved in a hard hit, but resilient and activist community, as insightful and thought-provoking as we do.
This conversation started at a meeting about the opioid overdose crisis, when Candice told us about how she had been reading April publication of the BC Coroner’s Service report on Illicit Drug Overdose Deaths in BC (this link clicks through to the latest update of the report). Looking at the data through her evaluator’s lens and with her own experiences in mind, Candice offered some ideas about the context for the information being presented in the report. In this two-part blog post series, we will share some of Candice’s thoughts about the statistics from the report and her perceptions of the crisis’ impacts on frontline workers and peers.
Looking at the coroner’s report, Candice highlighted the number of men being affected by overdose deaths as compared to the number of women; according to the latest Coroner’s Service report, 786 men and 192 women died from illicit drug overdoses between January 1 and June 30, 2017. One of Candice’s explanations for the higher rate of death for men is that there are more resources and programs aimed at supporting women as compared to men. She said The Dudes Club at Vancouver Native Health Society is one of the few wellness programs geared toward men. Candice also explained that women who are street-entrenched are more likely to have someone nearby to reverse them from overdose as compared to street-entrenched men. This explanation is supported by research by Will Small et al. (2012, p. 492), who state the women are twice as likely as men to need help with injecting drugs. While this need for assistance might make women more likely to be in the company of someone who can reverse an overdose should one occur, Candice and the research also explain how this situation puts women at higher risk of engaging in syringe sharing and experiencing violence (Small et al. 2012, p. 492).
That said, the rate of overdose deaths among First Nations men and women in BC is sharply different than the 80% to 20% gendered difference described above. According to an announcement by Dr. Shannon MacDonald, the First Nations Health Authority’s deputy chief medical health officer, overdose deaths are more evenly split between First Nations men and First Nations women. First Nations women are also eight times more likely to overdose on drugs than non-First Nations women, while First Nations people in BC are five times more likely to experience an overdose than non-First Nations people in BC. Among those individuals who overdose, they are also three times more likely to die as compared to non-First Nations BC residents. Dr. MacDonald explained that these tragic differences are the result of racism, stigma and intergenerational trauma, saying “”Many of our women have been traumatized by unspeakable experiences. We’re talking about a pain problem; people are taking care of their pain. We are concerned about our women… it’s very, very clear that we are being disproportionately impacted by this overdose crisis.”
Candice also described how the drug supply has changed. While those of us who read the news are well-aware that fentanyl is being found in many of the non-prescription street drugs available for purchase – including cocaine, heroin, methamphetamines and amphetamines, for example – Candice explained how more people are intentionally seeking out fentanyl as a result of the stronger and cheaper high it provides. She also explained there used to be more of a culture of respectful drug use, where, for example, people would put away the supplies related to drug use when children were walking by. Candice explained how this behaviour has changed, something she attributes to the increased presence of methamphetamines and amphetamines in the drug supply, which from her perspective has made the behaviour of those who are using more unpredictable.
Looking at the locations where overdose deaths occur and the frequency of their occurrence, Candice explained that it made sense that the greatest number of fatalities (as per the April 2017 report) were on Wednesdays and Thursdays because social assistance cheques are distributed on Wednesdays, and on Saturdays because people are out socializing and partying. When I asked her to explain the link to partying, she explained that it is not uncommon for people who have a bit too much to drink to do a line of cocaine to sober up to stay awake and party for a little bit longer.
Unfortunately, there seems to be a lack of awareness among many drug users that cocaine is one of the most fentanyl-contaminated drugs. According to the August 2017 BC Coroner’s Service report, cocaine was detected in 48.6% of the illicit drug overdose deaths they investigated. While naloxone availability and the Take Home Naloxone program has been helpful for many groups of people who use drugs, it may not be as effective of an intervention for people who may be experimenting with drugs for the first time or in a group of people who don’t have access to and/or are not familiar with how to administer naloxone, or for those who are using alone. The BC Coroner’s Service report states that the majority of overdose-related deaths are occurring inside – mostly in people’s private residences – with only 9.9% of the deaths occurring outside.
Relatedly, Candice did not find it surprising that the highest rates of overdose were happening in the colder months – November, December, January – when people are inside rather than outside. In fact, the December 2016 drop in temperatures and increased risk of people using inside and alone is what prompted BC’s Health Minister at the time, Terry Lake, to give the go-ahead for the opening of overdose prevention sites throughout the province. In an interview, the now-former Minister described how he came to the decision on Wednesday December 7, saying: “I woke up between 4 and 4:30 a.m. and I could feel the cold in the hotel room. It’s not the first time I’ve been kept awake by the fentanyl crisis. I started thinking about people on the street, and the pop-up tents, and was almost overcome by how inhumane that is. We need to do something that will keep people warmer and safer.” When people use outside or in the presence of others, there is a better chance that someone with naloxone can find them and, if needed, be able to reverse an overdose and save their life.
It is essential that we look into what meaning statistics have: what do they say about the people they represent? It is only when we delve deeper to understand and address the social and structural determinants that create environments for overdose that we will be able to change the options people have in their lives and, ultimately, the drug-use outcomes we are experiencing in this opioid overdose public health emergency.
Part 2: Impact of Overdose Care on Frontline Peers
Questions? Feedback? Get in touch!
Heather Holroyd, PAN’s CBR and Evaluation Coordinator at [email protected]