It's a weekday morning and Dr. Louisa Marion-Bellemare, 44, drives her minivan through the snowy streets of Timmins, Ont., to pick-up one of her patients.
With an opiate-overdose crisis gripping her hometown, this is the sort of thing she says you have to do.
"We'll do home visits and see patients and treat them for their substance-use disorder. It's not uncommon for us to do that. We meet patients where they're at."
Marion-Bellemare is in the fight of her life, and along with another doctor, has launched a unique program to address the tragic effects of opioids in Timmins.
Over the past few years, the death rate from opiate overdoses here has been among the highest in the country. In 2019 the rate in Timmins was 46.8 deaths for every 100,000 people – four times the Ontario average and twice as high as Vancouver, which is generally considered ground-zero for the opioid crisis.
In 2020 the death rate rose even higher to 72 deaths per 100,000.
"Our city of 42,000 people having had death rates higher than Vancouver, higher than Toronto, it didn't make sense," Marion-Bellemare said. "That's when I said wow, we have to change something here in our community. This is not right."
A major change in tactics in the fight against opioid addiction is what Dr. Marion-Bellemare, along with her colleague Dr. Julie Samson, have brought to the northern Ontario mining town.
A hospital that welcomes people with addiction
Casper Sutherland, 48, kicks the snow off his shoes and climbs inside Dr. Marion-Bellemare's vehicle. An opiate user for 10 years, Sutherland has been in recovery for six months.
"How's your day," he asks the doctor as they small-talk for a few blocks.
Sutherland is back living with his children and looking for work. It's still early in his recovery, but in a town in the middle of a crisis he is a glimmer of hope.
"I feel great. Like, I wake up with the smile," he said. "It's been a long, long time. I forgot how it feels to be normal."
WATCH | Dr. Louisa Marion-Bellemare talks with Casper Sutherland about how his life has changed now that he's in treatment:
Sutherland accompanies Marion-Bellemare inside the hospital for a check-in, but before Timmins revamped its approach to addiction the town's hospital wasn't a welcoming place for people like him.
"Before, I would come here and the doctors and nurses would just think I'm seeking pills and just totally ignore me," Sutherland said.
"Sometimes I would OD and I would come here. They would bring me here in an ambulance, and I would wake up here and I'd know how I'm getting treated right away, and so I'd just leave."
Chris Loreto, a long-time emergency room doctor at the Timmins hospital, admits that was true.
"We didn't have a formalized way of treating people with substance abuse. We termed them 'addicts,' and we just sort of said there were no resources available for their treatment," Loreto said.
"So we just sort of babysat them, gave them something for their anxieties, and then sent them on their way."
A year ago there wasn't a single detox bed in the Timmins hospital, even though use of the highly addictive drug fentanyl was rampant in the city.
And even when Dr. Marion-Bellemare persuaded the hospital to open two detox beds (she has since asked the provincial government for funding for 14 additional beds but hasn't heard back), some emergency room doctors weren't convinced that treating people with addictions was even their job.
"I've got to be honest, I was not a big fan of this program," admitted Dr. Loreto. "I didn't think we had the resources. I didn't think we had the time … I didn't think this population deserved it.
"I blamed the patient. I thought they were in that situation because of their own life choices — you know, if they want to stop they can stop."
Dr. Marion-Bellemare and Dr. Loreto have had many disagreements over the past year about how to care for people with addictions, and Loreto says he now sees things in a new way.
"You realize why I do this job to take care of people – because people matter," he said.
"You can't triage who we show compassion to and who you don't. And I think the fact that the team is able to convince an old-school guy like myself and some of my colleagues, I think it is a big step in the right direction."
A treatment strategy unlike any other
Making the hospital a place where people with addictions feel welcome was the first step, the other big change has been the treatment itself.
Brian Tomagatick lies on a hospital bed and holds a freezer pack against his belly. Tomagatick, a long-time opioid user, is getting his "shot" – his eighth.
The Timmins approach is to give a monthly injection of a drug called Sublocade, which delivers an extended release of buprenorphine. Once injected, the drug forms a small lump under the skin near the abdomen and lasts for a period of 30 days.
Each injection costs between $550 and $650. The goal of the treatment is to control the intense cravings that opioid users experience, and allow them to stop chasing their next high.
Dr. Julie Samson preps the syringe and asks if he's been experiencing any cravings. Tomagatick shakes his head.
"All right. Is it nice and frozen?" asks Dr. Samson.
It took courage, but Dr. Samson and the Timmins team decided to start a treatment method that nobody else in the country was doing.
"When I'm giving the injection I'm so happy for them, because they're doing so well and they haven't died," Dr. Samson said.
The regular protocol is to give a patient daily doses of buprenorphine, and only after a week start them on the injectable. But Dr. Samson says patients would almost never wait the week, and instead would leave the hospital and drop out of the program.
"We had five overdose deaths in seven days. We had to stop it," Samson remembered. "The nurses even asked us, why don't we change the protocols – and our clients too asked why we didn't go faster."
So what the doctors in Timmins did was to give the extended-release Sublocade shot almost immediately – within 24 to 48 hours of when a patient arrives in care.
"We don't have time to wait for data for randomized controlled trials," said Dr. Samson. "People are dying. We had to change what we were doing, because what we were doing initially and following the protocols wasn't working."
Since it started a year ago, 130 patients have come through the Timmins program. The doctors are currently looking at their data to determine just how successful the program has been.
"It seems to be pretty good," Dr. Samson said. "Anecdotally, I would say probably over 70 per cent of retention to our program."
Dr. Samson readies the needle, smiles at Brian Tomagatick and pushes it gently under the skin near his abdomen.
"It stings a little bit. Almost done. There we go," she said.
Tomagatick has been off opiates for nine months. He says when other people struggling with addiction see how well he's doing, they want in.
"They come over and we talk. 'How do you get on the program? I want to be clean like you. How do you make it look so easy?' I'm like, 'I got someone in the hospital who I can call,'" Tomagatick said.
"I usually pay their cab to the hospital or I bring them myself just to make sure they go," he added.
When asked why he would drive people or pay their cab fare to the hospital, Tomagatick's tone gets more serious.
"I have had a lot of friends die from the stuff. A lot of friends," he said. "Like, at least 20 friends around town within a short period of time."
Changes outside the hospital
Dr. Marion-Bellemare says the changes they have made inside the hospital in Timmins in the past year aren't enough, and more needs to be done out on the street.
"There are still a substantial group of people out there who want to quit using drugs, but actually can't and don't know how," Marion-Bellemare said.
This is why even in winter, doctors Marion-Bellemare and Samson walk the streets and alleyways of the city's downtown with local outreach workers to encourage people to join the treatment program. The doctors spend a few hours trudging through the snow, introducing themselves to everyone they meet.
"We need to be going to find them because the next day, if we don't find them and they want help, they could be dead," said Marion-Bellemare.
Two emergency doctors doing addiction outreach is surprising enough – but there's another big change on the streets of downtown Timmins.
Even though street opiates are illegal, the local police have started to do outreach as well.
Constable Leah Blanchette, a 20-year veteran, is the Outreach Community Safety Team officer on the force. For the past year she's regularly been out walking in downtown Timmins with her trademark box of muffins.
"When I started, people would run away from me. They would say to me, 'Well, we can't be seen with you, because you're a rat or you're in trouble if you're seen with the police,'" Blanchette said.
"That's why I started baking the muffins. And this way they would come to me and talk to me, and I would be able to offer my services while I was handing them the muffin."
It's tempting to see what Constable Blanchette is doing as a gimmick, but outside the downtown library as she hands out her muffins, a man named Norman asks for help with his drug use.
"OK. And do you think that you can go into a rehab centre or a detox centre and go without for a few days? Can you manage that?" Constable Blanchette asked the man.
He nods and takes the officer's business card.
"I'm proud of you for coming in and asking for help," she told him. "If there's anything more, give me a shout."
Someone admitting they have a drug problem to a police officer and asking for help is something remarkable that Timmins has accomplished. Constable Blanchette has referred more than 100 people to the hospital treatment program in the past six months.
Of course, those numbers are also further proof that Timmins remains a town in trouble. And doctors Marion-Bellemare and Samson see the effects of drug addiction every day.
On the street in front of the downtown shelter, accompanied by a crew from CBC's The National, they recently ran into Joey Perreault – a former patient in the program. Perreault came to the hospital in January of 2021 when Marion-Bellemare was working after he'd overdosed. He was given Narcan – an emergency medicine that helps people survive overdoses.
At that time Perreault was admitted to one of the hospital's acute withdrawal management beds, but he declined the Sublocade treatment and soon afterwards he left the hospital.
WATCH | Dr. Louisa Marion-Bellemare and Dr. Julie Samson reunite with Joey Perreault:
On the street, Marion-Bellemare reminds Perreault that their doors are always open.
"Joey, any time you want help, you go to the hospital and you ask for help, right?" she said. "You can go to the Emerg 24 hours a day and all you have to say is, 'I'm here to get help for my addiction.' And they will set you up."
"Sounds good," replied Perreault.
The doctors never saw Perreault again. A few weeks later, he died of an overdose.
Solving the addiction crisis is one of the toughest challenges for any town, but Marion-Bellemare and Samson aren't giving up. The calls they've had from other doctors and addiction programs across the country about what they've done in Timmins is recognition they say helps them keep going in the fight to help their hometown.
"I never would have thought in a million years that people would look at Timmins and say, 'Wow, that community is really trying their best to make a difference for people who are dying from opiates,'" said Marion-Bellemare.
"I think, to be honest, in our community everybody wanted something to change, but they needed a driving force to get it going. And I think we were the engine to do it."
WATCH | The National's feature about the opioid treatment program in Timmins, Ont.:
Watch full episodes of The National on CBC Gem, the CBC's streaming service.