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Sault Ste. Marie and communities of similar size often face higher overdose rates than big cities, but they don’t get the same amount of national attention or resources. Local advocates say that has to change

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As concerns mount about drug use in Sault Ste. Marie, Ont., some businesses now close early in Jamestown, the blue-collar neighbourhood near the Algoma Steel factory. The Sault's population of 72,000 puts it in a cohort of cities that, according to recent health data, have the highest rates of opioid hospitalization.Kenneth Armstrong/The Globe and Mail

One afternoon in early February, an alarming number of people started dropping on the sidewalks of Belleville, Ont. When the overdoses piled up to 13 in just two hours, police warned residents to stay away from downtown, the way you might cordon off a mass accident scene, so emergency responders could rush in to help.

Belleville hugs the Bay of Quinte, its downtown watched over by a clock tower above City Hall that looks like it’s made of gingerbread. The city of 55,000 is home to a profusion of good manufacturing jobs and hosts a big walleye fishing derby as a Kiwanis fundraiser every spring.

The rash of overdoses – none of which were lethal – shocked outsiders and generated national news coverage because the crisis seemed so incongruous with the setting.

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Residents of Belleville, Ont., take shelter in tents beside the Bridge Street United Church.Fred Lum/The Globe and Mail

In our minds, there’s a familiar landscape to the opioid epidemic: tent cities extending their lurid tendrils across vacant urban lots and sidewalks; downtown streets abandoned by anyone who doesn’t have to be there; anonymous hollow-eyed humanity heaped in alleys and doorways.

“If you ask a Canadian today, you would hardly find anybody who hasn’t seen pictures about Vancouver Eastside,” says Jurgen Rehm, senior scientist at the Institute for Mental Health Policy Research at the Centre for Addiction and Mental Health (CAMH). “For a normal Canadian, Vancouver Eastside is the drug scene in Canada. It symbolizes how much could go wrong.”

Opioids and their corrosive spin-off effects are the epitome of big-city problems; everyone knows that.

Except they’re not.

By virtually every marker, the scourge is not only just as severe in Canada’s small cities and towns as in its largest cities – it is often much worse, in part owing to fewer resources and support to tackle the problem.

The Canadian Institute for Health Information (CIHI) produced new data for The Globe and Mail looking at the frequency of opioid hospitalizations in different community sizes. CIHI sorted cities and towns across the country into five categories based on their size and found that toxic drugs were most likely to land people in the hospital in small cities of 50,000-99,999 people, followed by the smallest municipalities of fewer than 10,000 residents.

Hospitalizations were least common in the largest cities of over half a million people. Those patterns are long-standing; CIHI did these same calculations for a report published in 2018 with similar results.

Other national statistics are difficult to come by, but provincial numbers show the same pattern – on a per-capita basis, negative outcomes such as opioid deaths, hospitalizations, emergency room visits or ambulance attendance are consistently more common in smaller places.

In Ontario, for instance, the Toronto Public Health region had 117.5 emergency room visits and 18.5 opioid deaths per 100,000 people in 2021, while Algoma Public Health, whose biggest municipality is Sault Ste. Marie with 72,000 residents, saw rates of 226.4 for ER visits and 55.5 for opioid deaths.

Vancouver’s Downtown Eastside is indeed an outlier, but beyond that grim hot spot, Hope, B.C., with a population of 6,700 people, had the highest unregulated drug death rate in British Columbia last year.

Alberta discloses drug poisoning death rates only for its seven largest cities, and Lethbridge, with a population of 98,000, had the highest in the province last year.

The statistical reality simply doesn’t match what we think is happening, and where.

Opioids are not a big-city problem that sometimes seeps into smaller places; they are a small-community problem hidden in the shadows cast by our fixation on cities.

The dark irony is that the places most acutely in need of resources such as safe consumption sites, detox beds, treatment spaces and other supports to keep drug users alive and then give them a chance at recovery are least likely to have them. Even basic public attention, and the political pressure that comes with it, are absent in the smaller places that are begging for the services big cities have.

“Street-entrenched and street-involved people are super-visible in urban spaces. And that is where we associate most of the drug use,” said Kathryn Colby, manager of community development at Lift Community Services in Powell River, B.C., a small town 170 km north of Vancouver. “In rural and remote spaces, sure, that might happen to some degree. But what we actually know is that it’s the people who are home owners who are working or maybe on a long-term disability pension or just got indefinitely curtailed at the mill – those are the folks that are dying in our community.”

Because drug use in small and remote places often doesn’t fit that recognizable package that combines poverty, homelessness and crime, “it’s like it doesn’t exist,” she says.

She riffs through some of the characteristics that help explain why small places have been so hard hit. Rural and remote places have fewer mental health and addictions resources – and fewer health and human resources, period. And statistics show people who develop opioid addictions often work in manual labour and have a history of injuries or chronic pain, which fits with smaller places where resource-based jobs are often dominant.

On top of the reasons smaller places are struggling more with opioids in the first place, many of these communities are now essentially living with an untreated collective drug problem.

How do you solve a crisis when everyone is looking somewhere else?

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On its welcome arch, the Sault bills itself as the 'friendliest city' in Algoma, a Northern Ontario region spanning Lake Superior's eastern shore and Lake Huron's northern shore.Kenneth Armstrong/The Globe and Mail

Downtown, a memorial pays tribute to Sault residents lost to overdoses, while a mannequin looks out at a street where, as in Jamestown, many shops now close early. Kenneth Armstrong/The Globe and Mail

Sault Ste. Marie has been trying to open a supervised consumption site for a year and a half, ever since the 2022 election that propelled Matthew Shoemaker into the mayor’s chair after he made it a central campaign issue.

In Ontario, opening an overdose prevention site (OPS) is a two-pronged process. A federal application provides a legal exemption for the consumption of drugs on site, while the provincial process provides funding. But Ontario stopped accepting new applications last year in order to conduct a review, after a woman was killed by a stray bullet outside a supervised consumption site in Toronto.

“We would expect to be in the average if we had access to the same services,” Mr. Shoemaker said of his city’s high rates of opioid issues. “Certainly, supervised consumption is one of the significant ones. You can see, in fact, from the hospitalization data in Sudbury and Timmins, when they opened their supervised consumption sites in 2022, their hospitalizations dropped off a cliff.”

Those two northern neighbours had the federal exemption in place when the provincial process was halted, so they went ahead and opened their OPS, but they’re now in a precarious place as they scrape together funding month by month. Sault Ste. Marie would like to avoid that if it can, Mr. Shoemaker said.

Last month, he wrote to Ontario Premier Doug Ford underlining the latest figures showing the Sault’s opioid hospitalizations were three times the provincial average and ER visits were double. Mr. Shoemaker noted that Michael Tibollo, the minister of mental health and addictions, had recently visited and said publicly that he was waiting for the Sault to tell the province what it needed. In the letter, Mr. Shoemaker listed off the dates of 10 separate communications, going back to 2019, in which he or his predecessor had done just that.

“I wanted to take this opportunity to reiterate what is outlined in the aforementioned correspondence in the event what we are seeking isn’t clear or readily apparent,” he wrote.

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Mayor Matthew Shoemaker wants to bring a supervised consumption site to the Sault, but needs provincial support to make that happen.Kenneth Armstrong/The Globe and Mail

Mr. Shoemaker’s assessment is that the Ford government is “focused almost exclusively on the needs of Toronto,” with issues like the redevelopment of Ontario Place, the Gardiner Expressway and Don Valley Parkway sucking up all the oxygen at Queen’s Park.

“It in my view is a straight disconnect between the mindset of the provincial decision-makers and the reality of the situation on the ground in smaller areas,” he said.

Because there is no designated place for people to use drugs, they take to doorways, sidewalks and businesses, he said, and trying to revitalize downtown feels impossible when people stay away as a result. The city’s paramedics have turned into a “response unit for addictions services,” the mayor said, and police are doing what is essentially social work, because when residents have an unpleasant or scary encounter with someone on drugs, that’s who they call.

City council constantly debates safe consumption sites or how to fund medical treatments – both of which are provincial responsibility, Mr. Shoemaker underlined – instead of focusing on core functions such as economic development or recreation programs.

Hannah Jensen, spokesperson for Ontario health minister Sylvia Jones, highlighted $525-million the province has spent on addiction treatment services and supports since 2019, which she said is aimed at communities where extra help is needed, as well as the 5-per-cent bump in funding for community mental health and addiction organizations.

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Hours of ferry travel separate Powell River, population 14,000, from Vancouver and its Downtown Eastside, but their worlds are not so far apart. In 2017, Powell River had more overdose deaths per capita than anywhere in B.C. outside the Downtown Eastside. Local efforts have since helped to change that.Jen Osborne/The Globe and Mail/The Globe and Mail

Powell River’s overdose prevention site has trained staff and clean paraphernalia to help people use drugs safely. On a given day, it can get 90 to 120 unique visitors, local organizer Kathryn Colby says. Jen Osborne/The Globe and Mail
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Kathryn Colby, manager of community services at the non-profit group Lift, says big-city approaches to the opioid crisis ‘will never work in a small town and small-town solutions will never work in an urban space.’Jen Osborne/The Globe and Mail

In contrast to Ontario, which has 17 provincially funded overdose prevention sites (OPS), B.C. has 50 of them for a population one-third the size, including one in Powell River, where Kathryn Colby lives. The town is home to about 14,000 people; it announces both its remote Sunshine Coast location and its personality on bumper stickers declaring, “Two ferries can’t be wrong.”

Their OPS sees between 90 and 120 unique visitors a day, Ms. Colby said, and their staff are specially trained peers who have their own lived experience with drug use.

In 2017, Powell River had the highest per-capita rate of overdose deaths outside the Downtown Eastside, but in the last few years, it’s tumbled down the list. Ms. Colby attributes that in part to other B.C. communities climbing the grim rankings, but also to a full-court press of funding, effort and co-ordination in her town, of which the OPS is just one part.

“All of these resources have started coming into the community as we have started addressing these issues, which is really the reason that our overdose rates are down,” she said. “We went four consecutive months last year with not a single overdose death. That’s the first time since the public-health emergency.”

But even if the policy or funding inclinations are there, many of the characteristics of smaller municipalities – indeed, many of the exact qualities that lead us to idealize them and blind ourselves to their opioid realities in the first place – make it more challenging to offer services and supports.

“Urbanized approaches will never work in a small town and small-town solutions will never work in an urban space,” said Ms. Colby. “That’s just real.”

Those idyllic small towns where everyone supposedly knows and looks out for each other might have one or a handful of pharmacies. If you could get a prescription for methadone or suboxone to treat addiction and withdrawal – often a big ‘if’ – you might not want to pick it up with your neighbour in line behind you, or from a pharmacist who knows your family.

Getting to a supervised consumption site is much harder in a place with no public transit or where you might live 40 kilometres away than in an urban core where you can walk a few blocks or hop on the train. Even just living as a person with addiction and reaching for a fresh start is a different thing in a small community than in a city where you can melt into any number of crowds.

“People call it the goldfish bowl,” said Ms. Colby. “It feels harder to ask for a second chance if you’ve had a hard time, coming into recovery and you maybe have a criminal past. Being in a smaller environment can be incredibly difficult for people to foster change because of the stigma, rumour, innuendo, reputation. It feels like it follows you forever.”

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Powell River's overdose prevention site has a dedicated room for users who inhale drugs rather than injecting them, a practice that accounts for a large share of overdose deaths.Jen Osborne/The Globe and Mail

Powell River began life as a pulp-mill town in the 1910s, but the industry here has dried up since the pandemic, adding economic uncertainty to a community facing an opioid crisis. Jen Osborne/The Globe and Mail
Ms. Colby stops at a beachside bench set up by Moms Stop the Harm to raise awareness of overdoses. She says seeking help in a tight-knit place like Powell River can be difficult for many. Jen Osborne/The Globe and Mail

When a smaller city does succeed in starting up a new program, sometimes the demand can catch even advocates and experts off-guard. Whitehorse opened a supervised consumption site – the first and only in the Yukon – in September, 2021, said Jill Aalhus, executive director of Blood Ties, a community organization that helps operate the site.

“I knew it was needed and I was a big part of opening the site and I’m very proud of it, but I didn’t anticipate the uptake that we’ve had,” she said. “I don’t think anyone did.”

On their busiest day so far, in January, they had 125 visits, in a city of 28,000 people.

And still, denialism about where opioids live is so pervasive that it exists even in the heads of people who live in smaller places that have been deeply affected.

“I think there’s this sense that it’s an urban problem,” said Ms. Aalhus. “That is something I hear even in a small town. The idea is that, ‘As the community I live in is growing, that’s why we’re seeing these issues,’ and that it’s coming from the city up here.”

That’s not just in Whitehorse. People often seem to apply a strange chicken-and-egg illogic to resolve their cognitive dissonance about small-town life and drugs.

“You know what is the most controversial – and dare I say, the most hilarious – thing that I hear from every single remote community and small community? ‘The service providers have brought these people in,’ ” said Ms. Colby.

She and her colleagues have adopted their own joking shorthand for this thinking: the magic school bus.

“Every community has a magic school bus that just magically appears and drops off homeless people,” Ms. Colby said, guffawing. “It’s like it’s so hard to believe that that would happen in your community.”

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Ms. Colby is dismissive of small-town assumptions that vulnerable people have appeared from somewhere else, as if dropped off by a 'magic school bus.'

Over the years, Marie Pollock has seen these societal mind games come and go. There is a history of poverty, mental illness and self-medicating in her family, and she started experimenting with pills when she was about 12 and was injecting cocaine by 17. Now in her 50s, she takes prescribed opiates and hasn’t consumed street drugs in five years, and she’s active as an advocate in Capreol, Ont., 45 minutes north of Sudbury.

Ms. Pollock is relieved that society has mostly moved past misguided ideas like certain people being born to addiction, but she sees plenty of other myths still stuck in our collective heads.

“It happens to anybody and it does not matter the colour of your skin, and it doesn’t matter how heavy your pocket is,” she said. “It does not pick and choose. That’s a reality, and it’s a hard reality for some people to swallow or admit.”

She serves on several advisory boards and she’s active in multiple grassroots advocacy and harm reduction initiatives seeking to fill the gaps in her northern community. When Ms. Pollock heard about a Vancouver organization that accepted mail-in drug samples for testing, she started sending street drugs off and posting the results on social media, hoping to “raise a ruckus” and inform Sudbury about rampant contamination in the drug supply.

Ms. Pollock has no patience for endless go-nowhere chatter about the problem, or for excuses about funding shortages preventing real solutions.

“If you want to talk about money, it costs you more money with those EMS calls and doctor visits, hospital visits and a funeral and everything else,” she said. “And if you were to just listen and do what we’re telling you, there’s evidence that it works.”

She is a staunch advocate of decriminalization and safe supply, because when the fentanyl on the streets was from pharmaceutical sources, people weren’t finding their friends and loved ones dead, she said.

“You need to start accepting the reality of this, and stop trying to change people. Because it doesn’t work – you can’t force, you’re doing more harm,” Ms. Pollock said. “Keep them alive long enough, make them feel worthy enough and then you’d be surprised how much they make those changes on their own.”

Editor’s note: A previous version of this article incorrectly attributed statistics regarding Ontario's funding of addiction treatment services and supports since 2019 to the office of Michael Tibollo, the minister of mental health and addictions. The information was provided by a spokesperson for health minister Sylvia Jones. This version has been updated.

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