Last winter was a brutal one around Stand Off, in southern Alberta, with snowdrifts taller than trucks and record-breaking cold temperatures. Then, in late February, nature delivered yet another blow: a howling blizzard, icy roads, and snow whipping across fields and reducing visibility to near zero. At the same time, a particularly lethal shipment of opioids, known on the street as “super beans,” is reported to have arrived in the area. Officials would eventually announce that they suspected the drugs contained carfentanil, the powerful opioid 5,000 times more potent than heroin. People started overdosing almost immediately.
“It was a perfect storm,” says Esther Tailfeathers, a family physician in the small community, which is a forty-minute drive southwest of the city of Lethbridge. Stand Off is the administrative centre of Blood Reserve 148, the largest First Nations reserve in Canada and home to nearly 13,000 members of the Blood Tribe, also known as the Kainai First Nation (4,500 members live on-reserve). Tailfeathers says there were compounding factors that weekend: the shipment of deadly opioids, drug dealers “swooping in” because they knew it was payday, and the storm itself. “The graders and snowplows were working like crazy just to get to the homes where the overdoses had happened,” she tells me. “EMS and firefighters were walking through a blizzard, over deep snow, just to get to houses.” Paramedics on the reserve responded to 150 calls that weekend—a substantial feat, considering that the reserve covers an area more than twice the size of Toronto. In one home, Tailfeathers says, five people all overdosed at the same time. In ten days, thirty people overdosed on the Blood reserve and Lethbridge reported more than fifty others.
The opioid crisis has been claiming lives across North America, and the story in Alberta is no different. The number of Albertans killed by carfentanil overdoses increased by 430 percent from 2016 to 2017, and the number of emergency-department visits related to opioids in the province increased by 118 percent from 2014 to 2017. Rural and First Nations communities have been disproportionately affected, in part because of challenges that come with country life: the long distances for emergency services to travel and the limited access to support resources. A 2017 Centers for Disease Control study in the United States found that there were significantly more opioid-related deaths in rural areas than in cities. And, during a fifteen-month period beginning in January 2016, First Nations people accounted for 12 percent of all accidental opioid-related deaths in Alberta, despite making up only 6 percent of the population.
In areas where there is no public transit, where distances are too far to walk, and where some people don’t have regular access to a vehicle, providing harm-reduction services to prevent drug-related deaths is a major challenge. Even getting to a pharmacy or doctor’s office can be difficult. So when the Blood Tribe community tried to respond to this latest wave of overdoses with an overdose-prevention site—similar to those seen in Vancouver’s Downtown Eastside or Toronto’s Moss Park—in a desperate effort to reduce the number of deaths, they faced a geographic hurdle. This is rural Alberta, where long, straight highways stretch for miles across flat prairie and where a person can go for days without seeing much of anyone.
Geographic distances don’t cause opioid epidemics on their own, and as Tailfeathers explains, the origins of the crisis on the Blood reserve are complex. Tailfeathers has spent twenty years treating Indigenous patients, many of whom are dealing with a long history of colonialism and intergenerational trauma. “Part of my promise when I went to university was that I would work in Indigenous communities,” she tells me when I meet her in her office in Stand Off. She’s frank about the root cause of the opioid crisis in her home community. “Indigenous people have addictions and mental-health issues related to the history of Canada—colonization and Indian policy, reserves and reserve policy, and the amount of trauma that our people have experienced in residential schools.”
For many, the trauma is recent: in the nearby town of Cardston, the St. Paul’s residential school didn’t close its doors until 1975. “Indian policies in Canada have led to the level of poverty that we have,” Tailfeathers tells me. “We are basically living in apartheid on-reserve.” One community member I spoke with, Mark Brave Rock, attended St. Paul’s as a child, as did his father (his mother attended the nearby St. Mary’s residential school). “Now I can look back and I can see why my mother was the way she was. I can see why my father was the way he was,” he says. “They passed that on to me.” Brave Rock, now fifty-six, spends his days working with people living on the streets of Lethbridge and surrounding areas and struggling with addiction. “I feel what they’re feeling when they tell me,” he says. “I feel the anger and the frustration.”
Drug addictions are a symptom of pain, Tailfeathers says, and the community knows all too well the dangers that street drugs can mean for vulnerable friends and family members. A community billboard planted in the middle of the plains of the reserve puts the problem in simple terms: “DRUG DEALERS AND THEIR DRUGS ARE KILLING US!” There are plenty of theories about how the drugs got to the reserve. According to some residents, “pushers” arrived on the reserve a few years ago, and some even gave people drugs for free. “Give them a toke here and there, and then you’ve got your customers,” one man told me. In an effort to crack down on dealers, the Blood Tribe has since introduced a new system of permits for all nonresidents visiting the reserve, though the drugs are still coming in.
The spike in overdoses this past winter wasn’t the community’s first brush with the opioid crisis. The Blood reserve was the first community in Canada to declare a state of emergency in response to a spike in opioid-related deaths, in 2015, in an attempt to divert more resources to the problem and as a signal to the rest of the country that opioids were wreaking havoc in unprecedented ways. The community has tried a plethora of initiatives to curb the deaths since then. “The key in this community is ownership,” Tailfeathers tells me, referring to the importance of Indigenous-led solutions. People gathered to talk about what was causing the crisis—and, more controversially, what should be done. Would creating a supervised-consumption site encourage drug use? Were people dying because drugs were so stigmatized? Would elders support a campaign to destigmatize drugs? How could a community stop people from using drugs alone at home? “Our harm-reduction discussions were really heated, and they were long, long evenings of meetings in the community,” Tailfeathers says.
Harm-reduction strategies focus not on curbing drug use itself but on reducing the negative consequences surrounding it. In other words: reducing the number of deaths, reducing the number of diseases transmitted, and improving the lives of people who use drugs. Within the community, Tailfeathers says, there was reluctance at first to try any strategy that didn’t seek to stop the drug use outright, but as time passed and people kept dying, some members of the community appear to have softened their stances.
Discussions about harm reduction focused on raising awareness and sharing information about how to offer help to someone with an opioid addiction, and—crucially—how to treat an overdose at home using naloxone kits, which the Blood Tribe began distributing to its members before many Canadians had even heard of the medication. The community has also made progress in its plans to distribute Suboxone, an opioid replacement aimed at decreasing dependency over time. Government-funded vans will criss-cross the area, driving patients to pharmacies so they can pick up their prescriptions. In addition, the strides made in increasing awareness and mobilizing youth have set an example for the rest of the country. Over the years, the community has organized door-to-door campaigns where volunteers gave out information on opioid addiction and has handed out T-shirts that boast “I SAVED A LIFE” to those who have successfully used naloxone kits.
And yet, even after almost three years of extensive efforts to ease the crisis both on and off the reserve, people in the Blood Tribe still struggle with issues that those in big cities don’t have to face—including the massive barriers to getting people to addiction services in the first place.
Strategies for treating drug addictions have evolved in recent years, and many organizations now focus on harm reduction, with supervised-consumption sites and overdose-prevention sites becoming familiar concepts across Canada. In nearby Lethbridge—the city where many Stand Off residents go for groceries or move to for jobs or education—a supervised-consumption site opened earlier this year, run by ARCHES (AIDS Outreach Community Harm Reduction Education & Support Society), a medical not-for-profit.
The crisis in Lethbridge had been particularly dire. The number of emergency-room visits related to opioid poisoning are higher than the provincial average, according to Stacey Bourque, the executive director of ARCHES. The per-capita overdose rate in the area is higher than in major cities, including Calgary or Toronto, at nineteen fentanyl-related deaths per 100,000. Bourque tells me that she’s tired of the conception that overdoses are concentrated in big cities. “Overdoses don’t discriminate,” she says.
When I visit the Lethbridge site, the staff behind the counter are relentlessly friendly and greet each person by name. The atmosphere is reminiscent of a dentist’s office. “This isn’t a shooting gallery,” says Bourque. “It’s a medical facility.” A person wanting to use substances here tells the staff their name and what drug they have brought with them. There are currently ten booths, as well as a buffet, of sorts. The facility provides clean needles, glass pipes for cooking meth, sterile water ampoules for dissolving drugs to be injected, plastic cards to help snort powders, cutters for pills, lighters, and packets of citric acid, used for cooking brown heroin. If they didn’t provide the citric acid—which resembles a fast-food pack of ketchup—people would bring in a bottle of Coca-Cola or packets of vinegar from Arby’s to use as substitutes, Bourque tells me.
Once they’ve selected the supplies they need, people can inject, snort, swallow, or smoke at a booth, all under the watch of nurses. According to Bourque, Lethbridge has the first supervised-consumption facility in North American to allow the smoking of drugs, in enclosed booths with glass doors. If someone slumps over in the process, staff can press a red button on the other side of the glass door, which will clear the air fast enough for nurses (who also don breathing masks) to enter and intervene. If all goes well, though, the person moves on to the observation room after consuming their drug of choice, to relax while a nurse stands nearby. Once the patron passes the point when most overdoses would occur—about twenty minutes—they’re free to leave.
Within the first eight weeks, staff had reversed seventy overdoses, and Bourque notes that the facility reduced the demand for ambulance trips and ER visits. “This saves tax dollars,” she says. The facility is already planning an expansion in order to reduce wait times, which currently can be as high as one hour. The demand has been startling even for Bourque, who has worked in the community all her life. Within two months of opening, the Lethbridge site had nearly 8,000 visits, amounting to an average of roughly 270 per day (by July, the number of visits hit 40,000, and the average number of daily visits has hit nearly 500). For comparison, Canada’s first supervised-consumption site—Vancouver’s Insite, which opened in 2003—sees just over 400 daily visits. “I knew it would be used, but I’m surprised how heavily it’s been used,” Bourque says. “The numbers are surprising.”
Around the same time that the site opened in Lethbridge—and shortly after the February “perfect storm” had hit the community—the Blood Tribe declared another state of emergency to once again elevate the opioid crisis to the community’s highest priority and took a new step by opening a temporary overdose-prevention site. The Stand Off facility, housed in a trailer, was also staffed by ARCHES but was sparse, with just two staff at any given time. Still, it was a new resource, and the goal was clear: reduce the number of deaths.
Though the response to the supervised-injection site in Lethbridge has been positive, the reception in nearby Stand Off was not nearly as enthusiastic. When I visited the temporary site two months after it opened, a nurse on staff told me it can be difficult for people to use the facility knowing that their neighbours might see them enter. “It’s a small community,” she says. “Everybody knows everybody.” The atmosphere was visibly quieter than its sister site in Lethbridge, and the nurse told me visits had been few and far between. “There’s days where there’s nobody,” she says. In May, not long after my visit, the Stand Off site was shut down; a semi-truck picked up the trailer and took it away. “It wasn’t being used,” says Tailfeathers.
As it turned out, the overdose-prevention site in Stand Off was prone to challenges that are unique to more rural areas. People addicted to heroin, for example, may use as often as every six hours, making it unrealistic to travel long distances. A 2011 study published in The Lancet found that Vancouver’s Insite was by far the most effective for those living or spending the majority of their time within four blocks of the facility. A 2007 study found that travel to a supervised injection site was the single biggest hurdle for users. In a rural area like the Blood reserve—or for people living in other small communities where ARCHES has regular clients—this presents a significant barrier. It’s not feasible for many potential patrons to walk or ride a bike to a facility, and there aren’t public-transit options. Though Lethbridge is small city with a population of less than 100,000, many drug users are concentrated in the area around the supervised-consumption site, and those who aren’t are able to take the bus to the location. In Stand Off, it’s a long walk to the facility even for those who live right in town. And if a potential patron lives in one of the many houses scattered across the prairies, there’s no way to get to the supervised-consumption site without a vehicle. “In cities, the safe-consumption sites look at an eight-block radius of where the overdoses are happening,” Tailfeathers tells me. “In a rural reserve like this, we can’t do that. It’s happening everywhere.”
There’s also the stigma. In Lethbridge, patrons don’t necessarily need to worry that they might run into their cousin on their way to the supervised-consumption site. The Stand Off site, in comparison, was located in the hospital parking lot next to the administrative offices of the Blood Tribe. A person could reasonably expect to run into a family member or a neighbour on their way into the trailer.
Tailfeathers tells me there’s now talk of a starting a new site, one that’s a part of a location that houses different services, which might lessen the perceived humiliation of being seen going into the building. Tailfeathers advocates for a facility that includes social workers and mental-health and addictions workers. “It needs to be in the centre of town, and it needs to have wraparound services,” Tailfeather says, “so people are going there for other reasons, so people don’t feel like they’re being watched or stigmatized.”
Despite the challenges, Tailfeathers is proud of the work the community has already done. She describes the “perfect storm” at the end of February as a blip in the long road to recovery—one that will involve reimagining supervised-consumption sites, destigmatizing drugs, humanizing the crisis, and involving youth in solutions. And, she says, opioid-related deaths on reserve have decreased since the first state of emergency back in 2015. “In the end, it is a good story, because we’re not dying as much as we were,” Tailfeathers says. “We’re seeing our own strength, and we’re responding to this crisis in our own way.”
In May, I drove to Stand Off for a celebration that Tailfeathers had invited me to attend. The sun was low, its rays splayed out across the vast bald prairie and stubbly fields. The not-so-distant mountains formed a fringe on the horizon, an edge to the open expanse of the Blood reserve. The event, which was taking place in a massive dome-shaped building where the community gathers for basketball tournaments and meetings, was a follow-up to a previous community conference where teenage participants had rallied around their own messages for combatting the opioid crisis.
At the celebration, the crowd chatted at long tables and snacked on bannock and fry bread, while kids played on the surrounding bleachers. A documentary was screened, in which the community’s youth were adamant about the importance of art, sport, and companionship and the role these play in preventing addiction. Speakers reiterated the importance of an overarching community solution to the opioid crisis. Organizers were emphatic about the success of efforts so far but most also took the long view. As one speaker put it, standing behind the podium, “We’re planting seeds in the soil for trees we may never sit in.”