As I walk through the community wellness section of Eastern Health’s facility on Bell Island, the Dr. Walter Templeman Health Care Centre, I see a man in his 40s leaning against a wall, checking his phone. He looks up, smiles, and says, “I think I’m waiting for you.” When I introduce myself, he holds out his hand to shake mine. “Hi, my name is Thomas. Tom,” he corrects himself. Tom’s name has been changed to protect his privacy.

Tom is engaging. He loves to talk, making eye contact throughout the conversation. He is outgoing and friendly but also a little nervous. He is a brother, a son, a boyfriend, a father and a grandfather. He is also receiving treatment at the opioid treatment clinic. Eastern Health opened the doors to the clinic in April 2019.

Tom was 11 years old when he started drinking and 12 years old when he first started using drugs. For most of his life, Tom has used drugs, progressing from marijuana to cocaine, painkillers and opioids. His substance use has affected relationships with his son, his family and partners.

“My ex-girlfriend and I were talking about the drugs not too long ago,” Tom says. “She watched me go downhill. When she saw me with the syringe, it was all over. She cried and cried.”

Tom pauses and takes a deep breath. “She didn’t want to wake up and find me lying there dead. The needle freaked her out and I’m the type of guy who goes big with everything.”

Throughout his substance use, Tom has been able to hold down a variety of jobs, mainly to help pay for his addiction.

“I always made sure the groceries and bills were paid but then the rest was for drugs. I didn’t want anything for myself like clothes. Nothing. I never treated myself at all. Just drugs. Even if I was thirsty, I wouldn’t spend it on anything because I needed that dollar for the drugs,” says Tom.

It was while working that Tom realized that he had to seek treatment. But it was also working which became a barrier for him to seek treatment. Tom wasn’t able to travel from Bell Island to St. John’s every day for treatment and hold down a job. He tried self-medication for his opioid use first but when the Bell Island Opioid Treatment Clinic opened, Tom had another option.

Community Advisory Committee Identifies Addiction and Mental Health as Top Two Issues

In the fall of 2018, Eastern Health held public consultations for primary health-care needs on Bell Island. This consultation was twofold. It helped identify people within the community who were available to sit on a Community Advisory Committee and it would identify the issues residents felt needed to be addressed.

Over the last year and a half, Eastern Health has worked diligently to put in place Community Advisory Committees throughout the region. These committees are made up of members of the community or region who understand the specific health needs of the people who live there. This direct engagement is important to ensure that Eastern Health is taking the right approach to meet residents’ primary health-care needs.

It was already well-known from advocacy groups located on Bell Island, such as Heal Bell Island and In Good Hands, which is made up of mostly mothers affected by their children’s substance use, that addiction and mental health were significant issues for Bell Island. With a Community Advisory Committee in place, for the first time, advocates from these groups were sitting on the same committee with Eastern Health and administrators of the Dr. Walter Templeman Health Care Centre.

“This process helped us get more formally connected with advocacy groups such as In Good Hands,” says Carol-Ann Mason, site manager of the Dr. Walter Templeman Health Care Centre. “We heard loud and clear that what the clients wanted themselves was access to opioid treatment here on Bell Island because the biggest barrier for them to get well was access. Some of them didn’t have the ability to get to town to see a physician, to get a prescription or even to go to a pharmacy every day to get medication. They had many reasons, but the lack of transportation and the lack of funds were the main ones.”

A sub-group of the committee came together to determine what would be needed to offer the service at the health care centre and in February 2019, the provincial government announced that the clinic would open in April.

“We kicked into high gear then to be open in seven weeks,” says Carol Ann. “And seven weeks later, we did our first intakes. In between we had to hire staff, find space, establish pharmacy support, complete some renovations and write policies. This was the first time we would have a nurse administering this type of medication in an out-patient setting. Nurses have been administering opioid treatment medication in in-patient settings like the Grace Centre, the Recovery Centre and in acute care from time-to-time but we had to develop a training program for the nurses and then establish procedures that would guide nurses in the administration process. It was a busy seven weeks and lots of time and energy went into it by everybody.”

Bell Island Opioid Treatment Clinic Officially Opened

On April 1, 2019, the Bell Island Opioid Treatment Clinic opened as a satellite out-patient spoke of the Methadone Treatment Clinic at the Recovery Centre located in Pleasantville. The Bell Island clinic is dedicated to a client-centered approach. This includes not only medication administration and on-site counselling, but also arranging connections with other providers as the need is identified. The clinic is staffed with a registered nurse, two physicians and one nurse practitioner prescriber, a mental health and addictions counsellor and supported by on-site clerical staff. Social work services are provided in part through existing personnel and two individuals have been recently engaged from the mental health outreach team to provide counselling services, on-site, one day per week.

Pharmacy services are provided from the Waterford Hospital. When pharmacy was asked in February 2019 to develop a procedure to provide service to outpatients on Bell Island, they knew they had a significant task ahead of them, especially because Eastern Health does not have a pharmacy in the Dr. Walter Templeman Health Care Centre. With direction from Eastern Health’s Regional Director of Pharmacy Services, Elizabeth Reelis, clinical pharmacy specialist at the Health Sciences Centre and Andrea Woodland, regional professional practice consultant – pharmacy, consulted with the Newfoundland and Labrador Pharmacy Board, front-line pharmacy staff and the other members of the Bell Island team to work out a process to provide this service remotely from the Waterford Hospital.

“This work represented uncharted territory and presented unique challenges including transporting medications daily via ferry and client and staff consultation sessions with the pharmacist by telephone,” says Andrea. “Despite the challenges, our pharmacists feel strongly that the people of Bell Island should have access to opioid dependence treatment and have been instrumental in planning and adapting to ensure a safe, high quality service that mirrors as much as is possible what would happen if they were face to face with the clients every day.”

The clinic started with six people receiving treatment and has grown to 41 clients with 34 people on active treatment. The clinic provides medication in the morning and offers one-on-one counselling with its mental health nurse in the afternoons. On Tuesdays, individual counselling is offered by the mental health outreach counsellors and there is a group session on Wednesday afternoons led by the clinic nurse.

The program aims to be as adaptable as possible to meet individual client needs. This may include arrangements for clients who are working off the island, or attending school, to be able to access their medications outside regular clinic hours. The clinic will also help clients connect with another clinic or provider if they transfer out to move elsewhere in the province or even out of province. That allows for seamless treatment at a new location.

Vanessa Ezekiel is the team lead of the clinic. As a registered nurse, Vanessa is the first point of contact for those who come to the clinic. Her passion is mental health and addictions and even calls it her “niche”. When she got into nursing, she wanted to spend more time with patients and, during her mental health and addictions rotation, she knew she found her calling. Her position at the clinic was originally for six weeks while the position was advertised.

“By the second day, I said I’m staying and I’m applying for the position and I got it,” says Vanessa with a smile on her face.

Her commitment to the clinic is obvious and she’s had a significant impact on the clients. Tom credits Vanessa with helping him stay on track and says the counselling can be better than the medication.

“Every time I’m having a tough day, I can call Vanessa and she will book an hour,” says Tom. “That means the world to me. This wouldn’t be working so good without that support. I don’t want to let her down. She takes the time out of her days – it feels like she cares and she’s helping. That means a lot.”

Both agree that counselling makes all the difference. In fact, Vanessa says taking the prescribed medication, either methadone or suboxone, is only one piece of the recovery process. Once stable, counselling is the next step and will help clients to process any past traumas, the cycle of addiction, and coping strategies to name a few. Without both the medication and counselling, the recovery process could be more difficult for some.

Getting started with the recovery is not easy and involves the client making themselves vulnerable. In order to start suboxone, clients must be in withdrawal, a process that makes them extremely physically ill. Once a client is on medication, their physical condition is transformational.

“You have a client that comes in and they’re very, very ill,” says Vanessa. “But even that same day, they start to look different. Their face looks different. Their whole being is different. After the third day, they’re a different person. They’re making eye contact, having conversations and they’re engaging. You see them flip and they do well as long as they put in the work and you’re supporting them along the way.”

Carol Ann agrees: “The biggest impact the clinic has had on me, was seeing how quickly this medication worked. When you looked at people who came in on a Monday morning, so sick in withdrawal and they don’t make eye contact. Then they get this medication and within 72 hours, they are looking you straight in the eye, and saying good morning and they look better.”

Changing Attitudes

One of the barriers people face when they’re seeking treatment for opioid addiction is stigma. For many of the people on Bell Island who use opioids, stigma is a very real issue.

“Not everyone wants to come to the hospital because we’re on a small island,” says Tom. “People will say look at all of us going to the hospital to get our dose. I don’t care about that anymore. A lot of them were telling me for years to get some help but now I’m getting help. They don’t know how good I’m doing since I started coming here.”

One of the things the clinic did early on was ensure staff at the health care centre had training about harm reduction and stigma. Carol Ann says arming staff with information has had a positive effect on changing attitudes. That and having champions, people who advocated for change, made a real difference.

“We had a couple of people on staff who were real advocates and they challenged attitudes,” she says. “This made people think about their attitudes. We had people who wanted to be involved in the program and the administration of the medication and they did the training so they could be involved.”

Carol Ann says a lot of the stigma comes from fear but once you get to know the clients and learn their stories that fear starts to go away. “You can’t meet these individuals and hear their stories and not be affected by it. Suddenly they become a person, a person with a story. People are fearful and until you receive education, gain experience and meet and talk to the individuals, it’s then they realize they’re people. They have lives, wants, needs, fears, anxieties and stresses – the same as everybody else.”

As time has moved on, clients, including Tom, have been encouraging others to come to the clinic for help because it’s working for them and the environment is welcoming and open. Vanessa believes one of the things that helps is that she is not from Bell Island.

“I’m a neutral person. I’m not from here and so I didn’t know them. I didn’t know anything about their history. I didn’t know anything except what they wanted to tell me. So that was a huge step for them. I had an advantage because I was a fresh face for them,” says Vanessa.

Stigma is still a real issue, but Vanessa believes that will change with time.

“The clients and those still using opioids do have good support here with the needle exchange program and a couple other support groups such as Heal Bell Island and In Good Hands. However, there is still a divide as people are still struggling with stigma around addictions. Some clients have come to my office upset because there have been interactions in their community where people have been disrespectful towards them. On the other hand, clients have also come in and said people tell them how good they are looking so they are starting to get some positive comments and feedback from their community. And as these clients get stronger, it will only make the whole community stronger.”

The Future

Carol Ann and Vanessa both emphasize the difference the clinic has made for the clients and Carol Ann has short and long-term goals for the clinic.

Tom’s future is also bright. The medication and counselling have changed Tom’s life in many ways. For instance, eating lunch is something many people take for granted but not Tom.

“Do you know the nicest thing about getting on suboxone and getting off the drugs was? I could eat on my breaks,” Tom says laughing loudly and clapping his hands to emphasize each word. “When I finally stopped and I was eating a sandwich and drinking a coffee on my break, I said wow, this is what life is about off the drugs.”

Tom would like to help others who are recovering from substance use or are still using substances. Referencing the transportation barriers Bell Island often faces, he would like to one day help people with their resumés and drive them to work in the St. John’s area.

But perhaps the most significant change for Tom has been the reconnection with his family. He says when he was using drugs and drinking, they did not want to be around him but now they love to be with him, often asking him to join them for meals. He’s also reconnected with his son.

“My son and me are talking now. But I lost 25 years. Since I got on the medication, he heard I was cleaning up. He started calling me old man when I got on medication. It was always Tom before. He said you actually do care about yourself. I couldn’t believe it. I will remember that for the rest of my life. I told him I do care about myself and I care about you too. He said he loved me and I said I love you too. That meant the world to me.” ■

This story was written by Vanessa Colman-Sadd, a communications manager with Eastern Health.