Lethbridge Substance Use Discussion Paper EXECUTIVE SUMMARY 4 1. INTRODUCTION 6 1.1. BACKGROUND 6 1.2. OBJECTIVES 7 1.3. RATIONALE FOR ANALYSIS 7 1.4. REGIONAL CONTEXT 9 1.4.1. Geography 9 1.4.2. Demographics 10 1.4.3. Economy 16 2. METHODOLOGY 17 2.1. METHODS USED TO COLLECT INFORMATION 17 2.2. SOURCES OF INFORMATION 17 2.3. CHALLENGES AND GAPS IN INFORMATION COLLECTION 17 3. LITERATURE REVIEW 19 3.1. THE OPIOID EPIDEMIC 19 3.2. THE RISE OF METHAMPHETAMINE 22 3.3. THE CONTINUUM OF ADDICTION 25 3.4. COLONIALISM, TRAUMA, AND SUBSTANCE USE 28 4. SUBSTANCE USE HEALTH CRISIS SITUATION IN LETHBRIDGe 31 4.1. THE SIZE OF THE PROBLEM 31 4.1.1. SCS Visits 31 4.1.2. Emergency Department Visits: Opioids 32 4.1.3. Opioid-Related Deaths 32 4.1.4. SCS: Methamphetamine Use 33 4.1.5. Client Profile of SCS Users 35 4.1.6. Alberta Health South Zone 38 5. SOUTH ZONE WEST COMMUNITIES AND SUBSTANCE USe 45 6. THE IMPACTS OF THE SUBSTANCE USE CRISIS AND PUBLIC SAFETY CRISIS 49 7. PLAUSIBLE CAUSES OF THE SUBSTANCE USE CRISIS IN LETHBRIDGE 51 7.1. SUPPLY/DEMAND 51 7.2. SCS OPERATIONS 61 7.3. DETERMINANTS OF HEALTH 67 2 7.3.1. Employment and Working Conditions 67 7.3.2. Physical Environment 68 7.3.3. Access to Health and Health Care 71 7.3.4. Culture, Care Practices, and Beliefs 73 7.3.5. Mental Health and Stress 76 7.4. SPATIAL PROCESSES: SPILLOVER EFFECT 85 8. LETHBRIDGE REGION: INTEGRATING HEALTH AND SAFETY MEASURES 90 8.1. SYSTEMS MAPPING OF MENTAL HEALTH/ADDICTIONS SECTOR 90 8.1.1. Community Mental Health and Substance Use Programs 90 8.1.2. City of Lethbridge CSD Programs 91 8.1.3. Housing Options For Recovery For Individuals With Substance Use Disorder 92 8.1.4. Asset Mapping with Helpseeker 92 8.1.5. Lethbridge ARCHES Programs and Services 95 8.1.6. Opioid Dependency Programs 96 8.1.7. Health Care Summary 96 8.2. CRIME AND SAFETY 98 8.3. ANTI-SOCIAL BEHAVIOUR AND SOCIAL DISORDER 99 8.4. COMMUNITY STRATEGIES/STAKEHOLDER GROUPs 101 9. LETHBRIDGE NEIGHBOURING COMMUNITIES MITIGATION MEASURES 107 9.1. POLICE AND RCMP SUPPORT 107 9.2. MENTAL HEALTH AND ADDICTIONS SUPPORTS 108 10. RECOMMENDATIONS 113 1. Strengthen the Indigenous mental health continuum of care within/between Lethbridge and reserves. 113 2. Address psychological stress, distress, or post-traumatic stress related to substance use for both Indigenous and non-Indigenous individuals. 115 3. Broaden public health access, measures, and evidence-based treatment services for methamphetamines. 117 4. Integrated policy and planning for service delivery of the mental health and addictions at the systems level. 118 5. Applying a community health lens to law enforcement activities 119 11. CONCLUSION 121 Appendix 123 3 EXECUTIVE SUMMARY The opioid crisis has been claiming lives across Canada, and Alberta is no different. Yet, Southern Alberta and Lethbridge specifically have been disproportionately affected, with opioid death rates and overdose rates reaching an all-time high in 2018.1 To combat this, harm reduction interventions local to various communities have been mobilized. Treatment centres and supervised consumption sites have been established, physician opioid-prescribing best practices have been implemented, community support groups mobilized, mental health and substance use frameworks (indigenous and non-indigenous) developed, and health/wellness/addictions programming broadened. The high death rate has ensured the opioid crisis is a main focus of the media and has thus become a government priority; yet another substance, methamphetamine has seen rapidly increasing use across Canada. This drug has become a major challenge in Lethbridge. Methamphetamine users exhibit violent behaviour and are more likely than other drug users to commit property crimes.2 The negative impacts of methamphetamine use will continue if mitigating the harms of this substance are not prioritized. This paper examines the escalation of the substance use crisis in Lethbridge and compares similar situations in nearby communities. Data related to opioid and methamphetamine use are explored and the capacity of communities to provide treatment and support for the evolving nature of the crisis is investigated. The various data points collected provide evidence for plausible root causes of the substance use crisis related to social, economic, and political processes to be suggested. Broad recommendations to help address these root causes are proposed as a solutions-focused starting point. This work represents the first phase of this research project into the causes of the substance use crisis being experienced in Lethbridge. The focus is on census, health, and administrative data available to discern the driving factors behind Lethbridge and neighbouring communities’ substance use crisis and explores possible solutions. Qualitative research should be pursued and ethics approval will need to be obtained. The emerging findings from the analysis to date suggests that Lethbridge’s high rate of the Supervised Consumption Site (SCS) use is impacted by a number of interrelated and compounding factors: ● A decrease in prescription opioids has led to an increase in demand for fentanyl and methamphetamine; and supply routes in Alberta are not easily disrupted. ● As Lethbridge grows, urbanization pressures are emerging: expanding social and material deprivation within and between Lethbridge and neighbouring communities may intensify mental health and addictions issues for residents. 1 Government of Alberta. 2020. Alberta Opioid Response Surveillance Report Q4 2019. Retrieved from https://open.alberta.ca/dataset/f4b74c38-88cb-41ed-aa6f-32db93c7c391/resource/1044cc6d-3a29-4f4b-9f96- 6264e92e17e0/download/health-alberta-opioid-response-surveillance-report-2019-q4.pdf 2 Gizzi, M and Gerkin, P. 2010. Methamphetamine Use and Criminal Behavior. Peer Reviewed Publications. 9. Retrieved from https://scholarworks.gvsu.edu/cgi/viewcontent.cgi?article=1003&context=scjpeerpubs 4 ● Increasing movement between Lethbridge and neighbouring reserves related to kinship ties, housing, health care, and employment means social services in the city are strained. ● Localized core housing needs issues: unaffordable, inadequate, and unsuitable homes make for precarious housing and/or homelessness. ● Historical trauma, western impositions, residential school abuse, and racial discrimination have devastated Indigenous wellbeing across several generations and created inequities in health outcomes and health care. ● The Lethbridge SCS is the only SCS in Southern Alberta. It provides 24/7 operating hours, specialized staff, and additional support services such as inhalation rooms for methamphetamine harm reduction. ● Unaffordable/inaccessible mental health and addiction counselling and limited detox facilities, long-term mental health and addictions programming, and culturally appropriate Housing First programs for varying levels of acuity. Community leaders regionally have mobilized multiple health and safety measures to mitigate these impacts. These may be enhanced with the following recommendations: ● Strengthen the Indigenous mental health continuum of care within/between Lethbridge and First Nations Reserves. ● Address psychological stress, distress, or post-traumatic stress influencing substance use for both Indigenous and non-Indigenous individuals at the local level. ● Broaden public health access, measures, and evidence-based treatment services for methamphetamines. ● Integrated policy and planning for service delivery of mental health and addictions at the systems level. ● Apply a community health lens to law enforcement activities. A second phase of this research should be explored to ensure knowledge from outside the western paradigm broadens our understanding. In particular, Indigenous wisdom-seeking practices (IWP), worldviews, values, and beliefs particularly Niitsitapi (Blackfoot) and Métis worldviews can help enhance the current understanding of the substance use crisis presented in this document. This report is a snapshot in time: 2016-2019. Acknowledgements The report is the result of the efforts of many people including the staff at the City of Lethbridge and organisations in Lethbridge supporting people with mental health and substance use issues. The input of Kevin Cowan, Dr. Em Pijl, Colin Zieber, and the Reconciliation Lethbridge Advisory Committee is gratefully acknowledged. 5 1. INTRODUCTION 1.1. BACKGROUND As one of the seven primary service centres in Alberta, Lethbridge is recorded as being the community most disproportionately affected by the substance use-related health crisis in terms of fentanyl and non- fentanyl opioid deaths, methamphetamine use, supervised consumption use, and impact on the community.3,4,5 According to Alberta opioid surveillance reports, the number of fentanyl and carfentanil- related deaths were fastest rising in the Alberta Health South Zone, which includes Lethbridge.6 Recently released Q4 data now indicates a drop throughout Alberta. Despite this, Alberta Health’s South Zone represents the area of the province where rates of opioid use are highest among Indigenous people.7 Opioid overdoses in Lethbridge accounted for more than 25 deaths in 2018, more than any previous year on record.8 Final 2019 data is showing a decrease: Alberta Health’s Q4 data states 16 deaths.9 ARCHES, Lethbridge’s supervised consumption site operator, has recorded 419,897 visits by 1,599 unique individuals since opening in February 2018. Over 60 percent of clients are male, and almost 60 percent self-identified as Indigenous.