A comprehensive, collaborative, and compassionate population-level response is needed to address the various routes that opioids play. The following upstream, midstream, downstream interventions to the social determinants of health would be recommended to produce lasting positive population-level health outcomes.
- Upstream – Implementation of policies based on the principles of harm reduction: One harm-reduction approach to combat the opioid crisis is supervised consumption sites. These enabling environments provide substance abusers with a point of contact with the healthcare system, and allow for safe use of drugs; equipped with free access to clean needles, syringes, disposal bins, contraception and sexual health services. Medical professionals would be on-site at these facilities to inform drug users about the risks of their behaviours, and provide the space to expand detoxification programs for more people to get off illicit drugs and onto safer legal opioid-substitutions (i.e. methadone). There is an over-whelming body of research that show this intervention leads to decreased drug use, infectious disease (HIV and hepatitis C), and overdoses deaths which are endemic in First Nations reserves. (11) If we look at Portugal, a nation that experienced one of the worst heroin epidemics in human history, as a classic model for successful drug law reforms and see once the perception around drug use and addiction was seen as a health issue, rather than one of criminality, it removed the stigma and fear surrounding drugs which allowed for those suffering to seek out help without judgement. (11, 22) 15 years later, Portugal has has one of the lowest overdose rates per capita in all of Europe. (3) Thus, I would call on the Canadian government to incorporate this as part of the national drug strategy and provide funding to establish harm-reduction programs immediately to allow those in vulnerable First Nations communities to receive adequate healthcare and ultimately save lives.
- Midstream – multi-sectoral approach to tackle Indigenous determinants of health (specifically income, education, employment, housing, and water/sanitation) to effectively reduce health inequalities: There needs to be more collaboration and partnerships among all levels of government (federal, provincial, and territorial) with stakeholders (including HCPs, First Nations community leaders, individuals with lived experience amongst others) for health promotion and disease prevention strategies to increase the public’s awareness about the misuse of opioids and other substances is also needed. Specifically, more targeted funding by the federal government into mental health and pain management programs (non-pharmacotherapies) including opioid-substitution treatments to meet the needs of those afflicted with addiction must be prioritized. An asset-based approach to health would ultimately give the Aboriginal people control of their lives to develop, implement, and evaluate their own programs and services – healthcare, education, community facilities, and police/fire services – to strengthen their community capacity which empowers self-governance and allow them to be sustainable in the long-term.
- Downstream – evidence-based practice of clinicians: There needs to be better prescribing practices amongst physicians to prevent addiction, and reduce access to unnecessary opioid medications so reforming the current guidelines is a of importance. In addition, we must train physicians to look at the circumstances that surrounds these bodies so to gain better insight into the traditional knowledge, and integrate this with Western understanding of health and wellness to implement develop culturally sensitive and best practice to improve quality of life of First Nations.
Whether these recommendations will trickle-down and be effective remains to be seen. Now more than ever we need to adopt this glass-half full optimism and come to realize the perfect antidote lies not in the heart of the individual, but society after all to improve First Nations health and well-being. The first step to recovery, however, is admitting our defeat.
Conclusion
The burden of the opioid crisis has fastened its ghastly grip on Canada’s population. Given the social, cultural, and historical context that have shaped the health outcomes of the Indigenous, the First Nations communities are at a much higher risk of experiencing opioid-related addiction, overdoses, and deaths in comparison to the general population. This social analysis has highlighted the dynamic interplay between the First Nations and the healthcare system; the lack thereof complete Aboriginal health data; intense lobbying by big pharma and liberal prescription habits of physicians; deficient funding towards the management of opioid addiction, and; the inequitable distribution of resources in the rural and remote areas in Canada which, in turn, has been linked to poor health. To improve the health outcomes of this vulnerable population, it is imperative evidence-based and culturally-sensitive policies are adopted which addresses the crux of the Indigenous determinants of health.
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