National hotline a proven harm-reduction strategy in the drug-poisoning epidemic

Monty Ghosh. Photo supplied.

Jessica is alive today because of the National Overdose Response Service. At 17 she lived alone, several provinces away from her family in a harm-reduction facility for women. When it was too difficult to access a supervised consumption site — a 45-minute walk away — for in-person drug-use supervision and support, she called NORS where she formed relationships with peer operators who had firsthand experience of what she was going through. When she suffered an overdose while using the hotline, an operator called EMS to resuscitate her. Jessica was later connected with the support and treatment she needed, is now sober, reunited with her family and hopes to become a motivational speaker to help others. 

According to Government of Alberta statistics, a record high 2,051 Albertans lost their lives due to drug overdose in 2023 — tripling 2016 numbers. More than 90 per cent involved non-pharmaceutical opioids such as fentanyl, which is often tainted and highly unpredictable in intensity. Everyone was someone’s child, family member or friend. 

“Alberta has had the worst year on record for drug overdoses,” says Monty Ghosh, adding that low-barrier strategies to connect people who use drugs with harm-reduction services are urgently needed. Ghosh is an addiction specialist, internist and disaster medicine specialist in Edmonton and Calgary and an assistant professor at the University of Alberta and the University of Calgary. His research focuses on virtual harm reduction, drug surveillance and clinical/medical management of substance use concerns.

National Overdose Response Service

In December 2020, along with Grenfell Ministries founder Rebecca Morris-Miller — who sadly passed away from an overdose in 2022 — Ghosh was part of a team that launched NORS, a Canada-wide telephone, text and web-chat hotline aimed at preventing or reversing opioid overdoses by ensuring people don’t use drugs alone. NORS offers 24/7, toll-free, confidential, non-judgmental support and supervision for anyone in Canada using drugs. 

The success of NORS is directly related to peer support and connection — trained people who have a current or past relationship with substance use who are the heart of the project. It relies on its countless volunteers, students and relationships with frontline health workers. If a caller becomes unresponsive, the NORS operator will dispatch an ambulance if EMS is accessible in the caller’s area or enlist the aid of a local volunteer to perform resuscitation if the caller is in a rural location. 

“Our human family is struggling,” says Lisa Morris-Miller, operations director for NORS and sister to Rebecca. “Our tendency is to numb the sometimes painful experiences in life. Substance use is just one of many complicated relationships we form in an attempt to escape the discomfort that comes from being human.”

“The issue with substance use is that it is far more stigmatized than other patterns of destruction we create in our lives,” adds Morris-Miller. “Our participants are from all walks of life; the invisible substance-using population is huge.” 

“The line is incredibly busy. We’re having numerous overdose events,” says Ghosh. “But the great thing is that with 119 overdose events to date, there have been zero deaths and zero prolonged hospitalizations.”

Recent research

“We know that physical supervised consumption sites work, that they’re highly effective in reducing overdose deaths,” says Ghosh. “We wanted to know why people were using NORS and whether there were barriers to reaching a physical supervised consumption site, which is really the gold standard.” 

Funded by the Health Canada Substance Use and Addictions Program, Canadian Institutes of Health Research and Grenfell Ministries, Accessibility gaps of physical supervised consumption sites in Canada motivating the use of overdose response technology/phone based virtual overdose response services: a retrospective cohort study was recently published in The Lancet Regional Health - Americas. It shows that between December 2020 and July 2023:

• 57.7 per cent of NORS callers did not have access to a physical site — either because there was no site nearby (27.8 per cent), the site was closed (17.5 per cent) or the site did not allow them to smoke their substance (17.5 per cent).
• Over 30 per cent of clients preferred using NORS even when a supervised consumption site/overdose prevention site was nearby, open and supported their substance use route of choice, such as inhalation by smoking.
• A correlation was found between accessibility and the urbanicity of clients. For example, Alberta currently has only seven supervised consumption sites: three in Edmonton, and one each in Calgary, Lethbridge, Red Deer and Grande Prairie. Almost half (48 per cent) of Albertan callers to NORS had no physical site available.

“This study highlights that there’s a large demographic of Canada that has no access to physical supervised consumption services and overdose prevention sites,” Ghosh says. “We need to have more of these services available especially in rural parts of the country. And that includes having access to certain forms of inhalational routes and being open 24/7.”

Previous research shows that clients who want to access supervised consumption sites may face social barriers such as stigma, discrimination and vulnerability to law enforcement targeting in the vicinity. In addition, Ghosh explains that women and gender minorities generally prefer using NORS due to fear of gender-based violence and fear of losing child custody by being seen at a site. 

Looking ahead

Ghosh, Morris-Miller and their team have several studies underway to determine the cost-effectiveness of NORS, why certain groups prefer it, and what key aspects of the line people like or dislike.

Ghosh wants harm reduction groups to take note. “I’m hoping they’ll see that there’s a space for virtual harm reduction tools and that this can be an adjunctive measure to the gold standard of physical supervised consumption sites that provide so many more resources and supports. This is a tool to help people, especially if they’re using alone, and especially certain groups of people who may not be accessing physical supervised consumption sites.”

Current funding for NORS expires at the end of June 2024. But Ghosh and Morris-Miller are optimistic that Health Canada and other groups will continue to support such a successful program.

“I am grateful this service exists,” says Morris-Miller. “If NORS can prevent even one death it has all been worth it. Having lost Rebecca, founder of this service and my sister to an overdose, we will carry on her work.”  

“We have to make sure that the line is available for everyone using substances if they need it,” says Ghosh. “The line is really working; it’s helping people and people like Jessica are alive today because of it.”

Related: 

Receiving and providing virtual harm reduction and peer-based support
U of A research part of team receiving $2M from Health Canada to fight overdose epidemic