Drinking, Disease and Distance: Access and use of primary health care services for treatment of alcohol-attributed diseases in rural BC

Since the turn of the century, there has been a sharp decrease in the proportion of the population that resides in rural and remote British Columbia (BC) communities. In 2011, 86% of British Columbians (3,790,694) lived in urban areas, whereas only 14% of the population, or 609,363 persons, resided in rural communities. Although a much smaller proportion of the population lives in rural areas, these communities have disproportionately higher rates of alcohol consumption and alcohol-related hospitalizations than urban areas of BC, such as Vancouver and Richmond. These higher rates of alcohol-related harms, when combined with poor access to health care, can result in greater disease severity and increased rates of alcohol-related deaths. Although these challenges have existed for many decades, we still have an incomplete understanding of the barriers to obtaining addictions treatment services, which is important information that could be used to inform health care policy and resource allocation decisions throughout the province.

For the past two years, I have worked with my former PhD Supervisor, Dr. Scott Macdonald, to address this lack of knowledge by examining access and use of primary health care services by persons with alcohol-attributed diseases in rural BC. I focused on primary health care physicians because they are the most accessible type of health care provider available in rural and remote communities that often do not have hospital-based substance use treatment services. Family doctors are ‘gatekeepers’ to specialist services, and have a significant role to play in the identification and treatment of alcohol-attributed diseases early in their development.

For these projects, I studied both geographic (spatial) variations in primary health care use, as well as place-based physician experiences treating persons in rural communities. In the first project, I used physician-billing data to model use of general practitioner services by persons with alcohol-attributed diseases from 2001-2011 with administrative health data provided by Population Data BC. We were surprised to learn that from 2001-2011, cases of alcohol-attributed diseases in primary health care practices grew significantly (53.3%), from 14,882 cases in 2001 to 22,823 cases in 2011.1 We also found geographic inequities in alcohol-attributed disease cases among primary health care populations by Health Service Delivery Area (HSDA). Rural areas generally had much higher rates of alcohol-attributed disease cases than highly populated areas of the province. For example, in the Northwest HSDA (which includes Smithers, Prince Rupert, and Kitimat) cases rose 77.2% from 57.1 per 10,000 in 2001 to 101.3 per 10,000 in 2011. The 2011 rate of alcohol-attributed disease cases per 10,000 in the Northwest HSDA was the highest in the province – almost double the provincial average of 48.2 cases per 10,000. In comparison, several urban areas such as Vancouver, Richmond, and Fraser North had no significant increases in alcohol-attributed disease cases during this same period.

In the second study, I distributed a mail and online survey to general practitioners in rural areas that were defined using the Rural Coordination Centre of BC’s system for defining rural communities. We received responses from 22% of participants (for a total of 67 completed surveys) who overwhelming reported that they experienced significant challenges in referring their patients to treatment in urban areas. Physicians cited long waitlists and a lack of residential treatment facilities and inpatient services as the main challenges to referring patients. In many of the surveys, physicians wrote about personal experiences working in their community, and the challenges associated with delivering appropriate health care in isolated communities. They also stated that travel costs, distance to treatment facilities, and responsibilities in their hometowns prevented patients from obtaining required services only available in other communities. Even when services were acquired outside of the community, many physicians reported difficulties upon returning home and; as one physician summarized: “relapse on return [to community] from treatment is the rule rather than exception. We want local treatment [Family Physician, #038].”2

The outcomes of our research suggest that an increasing number of British Columbians are presenting with alcohol-attributed diseases to general practitioners, and there are large geographic inequities in the incidence of alcohol-attributed diseases in primary health care patients. We also found that rural family doctors frequently experience significant challenges when referring patients to treatment. Addressing these challenges requires that we work with residents and health professionals in rural places to develop innovative – and cost effective – methods for enhancing the continuum of services provided to rural residents. In this study, several physicians suggested having a centralized referral phone number for substance use treatment services in urban Vancouver, Victoria, and Nanaimo, which would not require a large public sector investment. Additional participatory research, and accompanying policy development processes, is required to articulate and implement these suggestions for service improvement in rural areas where populations disproportionately experience alcohol-related harms and related diseases.


1 Slaunwhite, AK., Macdonald, S. (2015). Primary health care utilization for alcohol-attributed diseases in British Columbia, Canada 2001-2011. BMC Family Practice. (in press).

2 Slaunwhite, AK., Macdonald, S. (2015). Alcohol, Isolation, and Access to Treatment: Family Physician Experiences of Alcohol Consumption and Access to Health Care in Rural British Columbia. Journal of Rural Health. (in press).

A photo of Amanda Slaunwhite

Author: Amanda K Slaunwhite, Collaborating Scientist, Centre for Addictions Research of BC; Post-Doctoral Fellow,  University of New Brunswick.

*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Harm Reduction in BC: We set the pace, but can we keep it up?

The harm reduction series on CARBC’s Matters of Substance blog has spent the past three months examining the scope of harm reduction as an approach to reducing harms of drug and alcohol use. These posts explore harm reduction as we know it today by going beyond evidence of injection drug users engaged in HIV prevention programs; rather, we establish that harm reduction now includes a wide range of user-informed, user-specific initiatives. For instance, some of the blog contributions include introductions to crack kit distribution, safe consumption services, syringe access for prisoners, opioid substitution treatment, managed alcohol programs, Housing First programs, and even e-cigarettes. Such initiatives have shaped a public health landscape in BC that focuses not on drug and alcohol use itself, but instead on the determinants of health which influence safer substance use environments.

This blog series has shown that harm reduction works – and as a pragmatic approach to public health, it is only appropriate that we highlight some more recent research taking place in the harm reduction field. The post by Ashraf Amlani and Dr. Jane Buxton reveals that B.C.’s Take Home Naloxone Program has saved an overwhelming 55 lives from 600 naloxone kits distributed since 2012. Among the over 30 research studies conducted at Insite, we learn that supervised consumption sites increase access to drug treatment, decrease drug use and disease transmission, and eliminate on-site overdose deaths – collectively, a social benefit worth approximately $6 million per year. We also learn that such approaches work across populations, with crack pipe distribution decreasing crack cocaine use and disease transmission in Vancouver.

These examples and other evidence have helped change both the political and public health climate in British Columbia. Harm reduction expert Dr. Carol Strike used such evidence to develop best practices, setting a higher precedence for public health practices across the country. Perhaps one of the main themes in these best practices, and our blog series overall, is user-informed, user-involved public health practice and policy. Actively engaging the people who are affected by drug and alcohol use not only makes sense and provides insight, but also creates a trusting environment, increases legitimacy and contributes to the self-worth of the community itself – a “win-win-win” situation.

An early post in the harm reduction blog series reveals that over three-quarters of British Columbians support harm reduction. Exciting, right? But even after 10 years of passionate debate, evidence building and community organizing, all of our guest bloggers acknowledge that there is still a lot of work to do.

Donald MacPherson, the Director of the Canadian Drug Policy Coalition, points out that one of the biggest hurdles we face is advancing public health policy in the face of criminalization of drug use. As such, MacPherson argues, we must continue to urge the government to eliminate criminalization of drug use in an effort to maximize a more comprehensive approach to drug problems. Without action, we risk perpetuating more harm being caused by these policies.

And although the public is becoming more comfortable with needle exchanges (over 72 percent of British Columbians are in support), they are still warming up to supervised injection sites across the country. One reason for this may be a more limited public perception and understanding of sometimes counterintuitive, non-traditional approaches to substance use, such as managed alcohol use programs and a Housing First model.

So what’s next? The fact remains that while we have gained momentum in public health, there is still a lot of work to do. Over the next couple years, we have the opportunity to translate evidence and public opinion into policy and connect it to a more comprehensive approach to public health. We’ll get there by raising our voices, continuing to present evidence and working to inform best practices. We certainly look forward to continuing the conversation.


Author: Alissa Greer, Centre for Addictions Research of BC

*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC