Rural and remote substance use care and innovation

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SHOW NOTES

Summary

In this episode, journalist David P. Ball and rural generalist physician and current addiction medicine fellow, Dr. Alison Hamilton, discuss the most challenging and rewarding aspects of working in rural and remote communities. They also speak with Charlene Burmeister, former guest from Season 1, about how the Coalition for Substance Users in the North (CSUN) and other peer-led organizations are meeting the needs of drug users without stigma or judgement. Next, they speak with Juls Budau, former overdose prevention site (OPS) manager in Prince George, about an innovative approach to harm reduction. She also shares her story of opioid use and treatment. Finally, we hear from Jadyn Koldweihe, nursing practice consultant working with rural and remote First Nations communities in BC. Jadyn speaks to infrastructure and geographic barriers to effective substance use care, noting the importance of supports like Traditional Healers and Knowledge Keepers, outreach workers, and community champions. And she models person-centred, trauma-informed, and culturally tailored harm reduction and care.

Learning Objectives

1. Identify and discuss gaps in effective substance use care for individuals in rural and remote communities.
2. Discuss the importance of peer-led organizations and community-based innovations, especially in a rural and remote context.
3. Understand the value of learning about the specific rural, remote, and/or First Nations communities where you provide care, whether in-person or virtually.

Lineup

In this episode, you’ll hear:

• 3:05 – Dr. Alison Hamilton, Co-host – Family physician and current addiction medicine fellow, with locum experience in 13 rural and remote communities across six provinces and territories in Canada
• 7:37 – Charlene Burmeister, Guest – Founder of the Coalition of Substance Users of the North (CSUN) based in Quesnel, BC
• 15:17 – Juls Budau, Guest – Former Northern Regional Overdose Response Services Consultant at Preventing Overdose, UNdoing Stigma (POUNDS) Project on unceded Lheidli T’enneh territory in Prince George, BC
• 22:52 – Jadyn Koldeweihe, Guest – Nursing Practice Consultant – Harm Reduction and Substance Use, First Nations Health Authority; born and raised in Northern BC from Tsimshian First Nations

Clinical Pearls

Here’s what listeners can take away from this episode:

1. Sometimes, a substance use care service or resource is technically open and available, but this does not mean it is accessible to everyone it intends to serve. Consider the logistics involved in substance use care, including pharmacy hours, travel times, and weather considerations, and discuss these factors with your clients to determine if the care is accessible.
2. Remember the strength that we get from rural communities, and the inherent resilience that’s built into having these tight-knit communities that have been learning from each other for hundreds or thousands of years. Examples of this include the power of community champions, the importance of learning from the stories of others, and the need for peer inclusion to support shared goals of keeping community members safe and alive.
3. Innovation in rural and remote communities is important and often can be lifesaving, as with the example Juls Budau shared on incorporating overdose response into Pokémon Go. Or the reframing of harm reduction that Jadyn Koldeweihe provided to adapt care and teachings based on the needs and goals of the community. These innovations and adaptations help meet individuals and communities where they are at on their harm reduction and substance use care journeys.

Resources

Supports for clients

• Brave App: Connects people who would otherwise use drugs alone with remote supervision and overdose support, while protecting their privacy, anonymity, and autonomy
• Lifeguard App: Goal is to reduce harm and prevent unintentional deaths for people of all ages
• NORS Line (National Overdose Response Service)
• BC Rural Health Network
• Rural Coordination Centre of BC
• First Nations Health Authority: Treatment Centres

Supports for care providers

• Rapid Access to Consultative Expertise (RACELine) – Addiction Specialists: 1-877-696-2131 or 604-696-2131 (0800-1700 Monday to Friday)
• 24-7 Addiction Medicine Clinician Support Line: 778-945-7619
• Provincial Opioid Addiction Treatment Support (POATSP)
• BC Ministry of Health: Patients as Partners Initiative: Rural and Remote Engagement Tip Sheet
• BC ECHO on Substance Use

Virtual clinics offering substance use care

• Vancouver Coastal Health Lighthouse Virtual Substance Use Care Clinic
• Interior Health Virtual Addiction Medicine (VAM)
• First Nations Virtual Doctor of the Day
• Opioid Treatment Access Line
• Northern Health Virtual Substance Use Clinic

Indigenous harm reduction principles

• First Nations Health Authority (FNHA). Indigenous Harm Reduction Principles and Practices: Fact Sheet.
• FNHA. Not Just Naloxone Program. FNHA.
• Communities Alliances and Networks (CAAN). Indigenous harm reduction = reducing the harms of colonialism. 2019.
• BC Centre on Substance Use (BCCSU). Strengths-based approaches to healing and wellness in rural and remote Indigenous communities. Addiction Practice Pod. February 22, 2024.

Reports, news, and statistics

• BC Gov News. Disproportionate impact of toxic drug crisis in rural and remote communities. BC Gov News. 2023.
• Canadian Institute for Substance Use Research. Alcohol consumption in BC: Consumption by region. 2024. University of Victoria.
• Government of British Columbia. Rural and Indigenous Overdose Action Exchange: October 1-2, 2019 Kamloops. 2019.
• Government of Canada, Statistics Canada. Focus on Geography Series, 2016 Census – Province of British Columbia. 2017. Updated April 10, 2019.
• Interior Health Authority. Medical Health Officer Report: Alcohol and Health in BC’s Interior Region. 2020.
• McInnis et al. Urban and Rural Student Substance Use. 2015. Ottawa, Ont.: Canadian Centre on Substance Abuse.
• Statistics Canada. Population growth in Canada’s rural areas, 2016 to 2021. 2022. Updated December 15, 2022.

Journal articles

• Bardwell G, Lappalainen L. The need to prioritize research, policy, and practice to address the overdose epidemic in smaller settings in Canada. Can J Public Health. 2021;112(2):215-223.
• Bolinski R, Ellis K, Zahnd WE, et al. Social norms associated with nonmedical opioid use in rural communities: a systematic review. Transl Behav Med. 2019;9(6):1224-1232.
• Dell CA, Lyons T, & Cayer K. The role of ‘Kijigabandan’ and ‘Manadjitowin’ in understanding harm reduction policies and programs for Aboriginal Peoples. Native Social Work Journal. 2010;7:109-138.
• Hu K, Klinkenberg E, Gan W. Disproportionate impact of fatal overdose in rural areas. BC Centre for Disease Control. 2022;14(2):123-130.
• Irvine K, Kuo M, Buxton J, et al. Interventions in overdose prevention: small and mid-sized communities. Harm Reduct J. 2019;16(1):13-17.
• Levine S, Medley A, Norton A. Putting Indigenous harm reduction to work: Developing and evaluating “Not Just Naloxone”. Int J Indig Health. 2021;16(2):244-263.
• Mema SC, Buxton JA, et al. Challenges of mobile supervised consumption services. Addiction Matters. 2019;25(1):78-82.
• Moustaqim-Barrette A, Papamihali K, Mamdani Z, Williams S, Buxton JA. Accessing Take-Home Naloxone in British Columbia and the role of community pharmacies: Results from the analysis of administrative data. PloS one. 2020;15(9):e0238618.
• Pijl EM, Alraja A, Duff E, Cooke C, Dash S, Nayak N, Lamoureux J, Poulin G, Knight E, Fry B. Barriers and facilitators to opioid agonist therapy in rural and remote communities in Canada: an integrative review. Subst Abuse Treat Prev Policy. 2022;17(1):21.
• Scow M, McDougall J, Slaunwhite A, Palis H. Peer-led safer supply and opioid agonist treatment medication distribution: a case study from rural British Columbia. Harm Reduct J. 2023;20(1):83.
• Slaunwhite AK, Macdonald S. Regional Variations in General Practitioner Visits for Alcohol-Attributed Diseases in British Columbia, Canada. Int J Ment Health Addict. 2016;14:952-968.
• Yang Z, Henson C, Smith K. Mail-based harm reduction supply distribution. Subst Use Misuse. 2021;56(11):1572-1578.
• Weintraub E, Greenblatt AD, Chang J, Himelhoch S, Welsh C. Expanding access to buprenorphine treatment in rural areas with the use of telemedicine. Am J Addict. 2018;27(8):612-617.