Support for Healing Centered and Indigenous-Forward Approaches to Opioid Poisonings

by the Opioid Poisoning Committee

September 6, 2023

As one of its final actions, the Opioid Poisoning Committee sought to develop this guidance document to raise awareness and change practice among healthcare providers, and to promote Indigenous-forward discourse and decision-making by policy-makers.

It is important to acknowledge the territory which we currently inhabit and the territory from which we come, not only because of what it means in terms of land and place but also people and spaces. We have heard many Indigenous peoples often refer to ongoing connection to land and that our lives are in the land. This idea deeply influences how people approach the spaces they enter and the people connected with therewithin. Territorial acknowledgements and locating ourselves socially and ethnogeographically are more than just a reflection on how we relate to this land as visitors or settlers - but how we relate to the Original Peoples of this land, one another and each other within these spaces.  

Amiskwacîwâskahikan, “Beaver Hills House” (the literal translation of the Original Name for “Edmonton”), is located within the Northern Prairies of Turtle Island (the Original Name for North America). For thousands of years, this has been, and continues to be, a common territory to many peoples including the Cree, Sioux, Stoney, Dene, Metis, Blackfoot, and many more. This place is also called Métis Nation of Alberta Region No. 4 and Treaty 6 Territory. By nature of these living provincial and national agreements and legislation, regardless of whether we are new to this place or our families have been here for generations, we are all relations and Treaty relatives.

Indigenous peoples are disproportionately affected by the opioid poisoning crisis due to historical and ongoing coloniality resulting in multigenerational trauma and barriers to accessing social and medical equity. It is in the spirit of connection, community, and healing-centered care that the Opioid Poisoning Committee convened to listen, learn, and (where permission is given) amplify knowledge guided by a Two Eyed Seeing approach.

In the spirit of transparency and authenticity the Opioid Poisoning Committee recognizes there is a diversity of Indigenous governing bodies, representations, organizations, and services, and we were able to seek guidance from many but not all of these groups. We acknowledge with deep gratitude the expertise and experiences willingly shared by the Committee’s Indigenous and non-Indigenous partners. We share their vision for healing-centered care.

CONTEXT

Indigenous peoples experience inequitable access to and quality of healthcare, which contributes to poor health outcomes i. Part of this inequity can be attributed to experiences of racism when seeking care i, ii, iii.

A legacy of chemical control and surveillance exists for many people who use drugs, in particular the racialized and colonized; self-determination is critical to the assertion of body, mind, and data sovereignty iv, v, vi, vii. People who use drugs should share in any decision-making about the models implemented to address this legacy.

First Nations people represent approximately six per cent of the Alberta population, yet they represent 22 per cent of all opioid poisoning deaths in 2020viii. First Nations people are also experiencing a disproportionate year-over-year increase in opioid poisoning deaths compared to the general Alberta population viii.

Each person who dies is grieved by their families and communities, and many communities are experiencing the cumulative grief and trauma of losing multiple members, with subsequent impacts of trauma on health ix, x. 

Pharmaceutical opioids are playing a decreasing role over time, whereas non-pharmaceutical drugs are playing an increasing role viii.

Indigenous concepts of wellness are holistic and inclusive of both proximal and distal determinants of health, such as decolonizing and indigenizing available supports. Harm reduction is accordingly defined broadly; rather than being focused on substance use alone, it also involves reducing the harms of colonization xi. Personal responsibility is balanced with collective responsibility; personal vulnerability is de-emphasized in favour of structural and system accountability xii.

ACTION

  1. Stop Victim Blaming: Recognize the many precursors to substance use (e.g. adverse social circumstances including unmet social determinants of health) and ensure these precursors are addressed in both policy and clinical practice.

  2. Practice Self-Reflection on Power and Privilege: Understand the living colonial legacies of land dispossession; child apprehension; missing and murdered Indigenous women, girls, and two-spirit persons (MMIWG2S+); and criminalization of Indigenous peoples and their impact on treaty relationships today, including within healthcare.

  3. Support Body Sovereignty xiii and Self Determination v in Healthcare Delivery: Body sovereignty refers to having agency over how one’s body is defined, monitored, and cared for. Provide sustainable funding for Indigenous-led substance use care, within a continuum of goals (e.g. abstinence, harm reduction, recovery) as defined by people who use substances. There are existing examples of successful Indigenous-led models to inform future initiatives xiv, xi.

  4. Shifting the Power Imbalance Back to Oppressed Individuals and implementation of non-interference in medical provision. Tools for this action include:

    • Widely implement anti-oppressive care: including but not limited to anticolonial, antiracism, etc. Ensure antiracism accountability within healthcare.

    • Widely implement trauma informed care, with a healing centered approach ii, iii.

    • Widely implement Patient and Culturally centered care: Culture is harm reduction. Provide access to cultural services within healthcare settings. Include kinship-oriented supports that allow couples, families, etc. to not only remain together with people who use drugs within care spaces, but also provide care for caregiving kin. Ensure that services define healthcare wholistically in support of spirit, mind, and bodily health. Culturally centered care is defined by those receiving care, not those delivering it.

  5. Fund Anti-oppressive Centered Programming with sustainability and flexibility across the life cycle, i.e., from childhood to older adulthood. Avoid funding contingencies/restrictions unless they are defined by Indigenous communities. Include Indigenous indicators of success and accountability. Ensure real time access by Indigenous communities to all data that are collected about them and that can inform community-led actions.

SUMMARY

Indigenous Peoples: siblings, parents and children, old and young, from all walks of life are being harmed by the Opioid Poisoning Crisis. Alberta can be national and international leaders in Indigenous-forward approaches to addressing this crisis.

We can do this by redefining our ways of thinking on three barriers to reconciliation in the opioid poisoning crisis response:

  1. Oppression

  2. Racism

  3. Coloniality/Colonialism

The redefined ways of thinking point to important and tangible actions that government, health and social organizations, community, and individuals can take to respond to the opioid poisoning epidemic. Anti-oppressive and decolonial actions must be taken. This includes implementing trauma informed and culturally safe care for all people, sustainably funding Indigenous-led and -evaluated programs grounded in community strengths, and partnering with Indigenous and racialized people who use drugs to develop supports that align with their values and priorities.

Redefining ways of thinking may create discomfort for many, however, understanding these concepts are central to understanding the experience of Indigenous peoples, and leaning into this discomfort will support meaningful action.

DEFINITIONS  

Redefining Ways of Thinking xv:

  1. Dismantling Oppression: The discrimination that occurs and is supported through the power of public systems or services, such as health care systems, educational systems, legal systems and/or other public systems or services; discrimination backed up by systemic power directly results in multigenerational trauma of people who use drugs. The intersections of race (Indigenous, other racialized communities) and gender (2S/LGBTQ+) amplify the risk of oppression.

    Anti-oppression is a practice consisting of strategies, theories, actions and practices that actively challenge systems of oppression on an ongoing basis in one's daily life and in social justice/change work. Though they are complementary, anti-oppression is not the same as diversity and inclusion. Diversity and inclusion is the acknowledgment, valuing, and celebration of difference, whereas anti-oppression challenges the systemic biases that devalue and marginalize difference.

  2. Dismantling Institutional Racism: Systemic racism is enacted through routine and societal systems, structures and institutions such as requirements, policies, legislation and practices that perpetuate and maintain avoidable and unfair inequalities across ethnic or racial groups.

    Antiracism is the practice of identifying, challenging, preventing, eliminating and changing the values, structures, policies, programs, practices and behaviours that perpetuate racism within our healthcare and judicial systems.

  3. Dismantling Colonialiality: The Government of Canada, the profession of medicine, and the Alberta healthcare system are all living legacy agents in the disproportionate over-representation of Indigenous peoples affected by the opioid poisoning crisis. For example, the use of chemical restraints in Indian Hospitals, Residential Schools and ongoing in Indigenous communities have resulted in many Indigenous bodies becoming dependent on opioids. 

    Anti-coloniality examines systemic power structures that create and maintain racism and oppress the human rights of peoples targeted by colonialism and implements corresponding mechanisms to counteract colonialism. Historic racism of colonialism and the modern-day equivalent of colonialism are continuously examined with the goal of social justice for peoples oppressed by colonialism.

  4. Reconciliation in Opioid Poisoning Crisis Response: There are many ways to understand wellness and health. This is deeply influenced by lived and living experience as well as cultural worldviews.  For many Indigenous peoples wellness is inextricably linked with kinship, land, language and the interconnectivity therein. Approaching wellness with Two Eyed Seeing in an ethical space (reconciling and bringing together White Euro-Canadian and Indigenous worldviews) can redefine health from a strengths-based and healing-centered perspective of healthcare provision xvii, xvii.

references

i McLane P, Barnabe C, Mackey L, Bill L, Rittenbach K, Holroyd BR, et al. First Nations Status and Emergency Department Triage Scores in Alberta: A Retrospective Cohort Study. CMAJ 2022 Jan 17;194(2):E37-45.

ii Came H, Humphries M. Mopping up Institutional Racism: Activism on a Napkin. J Corporate Citizenship 2014;54:95-108.

iii Mental Health Commission of Canada. Structural Stigma. Accessed April 25, 2022.

iv Gillon A. Fat Indigenous Bodies and Body Sovereignty: An Exploration of Re-presentations. J Sociology 2020;56(2):213-28.

v Halseth R, Murdock L. Supporting Indigenous Self-Determination in Health: Lessons Learned from a Review of Best Practices in Health Governance in Canada and Internationally. Prince George: National Collaborating Centre for Indigenous Health, 2020.

vi Daniels C, Aluso A, Burke-Shyne N, Koram K, Rajagopalan S, Robinson I, et al. Decolonizing Drug Policy. Harm Reduction Journal 2021;18:120.

vii Schnarch B Ownership, Control, Access, and Possession (OCAP) or Self-Determination Applied to Research: A Critical Analysis of Contemporary First Nations Research and Some Options for First Nations Communities. Int J Indigenous Health 2004;1(1):80-95.

viii Alberta Opioid Response Surveillance Report: First Nations People in Alberta. The Alberta First Nations Information Governance Centre, 2021.

ix TIP Project Team. Trauma-Informed Practice Guide. BC Provincial Mental Health and Substance Use Planning Council, 2013.

x Kenny KS, Kolla G, Khoee K, Bayoumi AM. Understanding the Grief Responses of People Who Use Drugs in the Context of the Overdose Crisis. In APHA’s 2019 Annual Meeting and Expo.

xi Indigenous Harm Reduction = Reducing the Harms of Colonialism (Policy Brief). Canadian Aboriginal AIDS Network and Interagency Coalition on AIDS and Development, 2019.

xii Katz AS, Hardy BJ, Firestone M, Lofters A, Morton-Ninomiya ME. Vagueness, Power and Public Health: Use of “Vulnerable” in Public Health Literature, Critical Public Health 2019. DOI: 10.1080/09581596.2019.1656800.

xiii Gillon A. Fat Indigenous Bodies and Body Sovereignty: An Exploration of Re-presentations. J Sociology 2020;56(2):213-28.

xiv Tailfeathers EM, Johal A, Pinillos F, Roach M, Smith P, Feng K, Abahmed A. Kímmapiiyipitssini: The Meaning of Empathy – with Elle-Maíjá Tailfeathers.

xv Government of British Columbia. Addressing Racism: Working Glossary. Accessed April 25, 2022.

xvi Bartlett C, Marshall M, Marshall A. Two-Eyed Seeing and Other Lessons Learned Within a Co-Learning Journey of Bringing Together Indigenous and Mainstream Knowledges and Ways of Knowing. J Environmental Studies Sciences 2012;2:331-40.

xvii Crowshoe R. Ethical Spaces: Elder Reg Crowshoe and Elder Willie Ermine.