Could you tell us something about harm reduction?
The aim of harm reduction is to keep people safe and to minimize death, disease, and injury from high-risk behavior. Harm reduction is a philosophy – a human rights approach that involves treating people with respect. Helping people to access the resources and support they need that enables them to be healthier. For example, simply advising teenagers to abstain from sex doesn’t work. We need to make sure that they are able to stay safe with access to contraception.
One of the tenets of harm reduction is that it meets people where they're at – substance use is a journey and not a straight line. People use for different reasons such as pain from physical, psychological, or spiritual trauma; therefore, not everybody is ready for treatment or wants to stop using substances. In clinical practice, we don't say we're not going to treat your diabetes until you lose weight, or we won't treat your chronic bronchitis until you stop smoking. Similarly, in the case of addiction, by adopting a client-centered approach that does not insist on abstinence we are able to provide people with the resources to be healthier and safer through harm reduction.
What is the perception regarding harm reduction amongst the general population?
When we talk to the public, we often start off by giving examples of harm reduction in everyday life - like wearing a bike helmet or a seat belt. Unfortunately, there is a lot of stigma toward harm reduction for addiction. There is a perception that providing harm reduction increases the use of substances in those suffering from addiction; but when we look at the evidence, there is none to support this. On the contrary, it helps them to be safer. Perhaps we aren't very good at informing the public. In addition, politicians and certain municipalities don't want people who use substances in their regions. This potentially comes from an ideological viewpoint instead of an evidence-informed one, and I think we have to get that evidence out.
Also, fear regarding addiction amongst families creates the ‘othering’ perspective that pushes people away from seeking help and telling their family members. Similarly, if people who have been on treatment or opioid agonist therapy start using illegal substances again, they often don’t tell their family members. That means people may hide their use and use in an unsafe manner, often increasing the risk of death from overdose. Currently, there are nearly seven deaths from overdose per day in BC. This means almost everyone has been affected in some way.
Another challenge we hear from the community is the perception that we should utilize resources on enforcement and treatment, but we need to understand that harm reduction does not work in isolation and that using substances is a journey - different things are appropriate at different times. The four pillars approach that was introduced and adopted by the City of Vancouver includes prevention, treatment, harm reduction, and enforcement. It's not an either-or approach; they work together. For example, when Insite first opened, the police were actually taking people down to the supervised consumption site so that they could use more safely. Engaging people in harm reduction enables building their trust and allows them to reach out for help with treatment. Also, the police test substances, and when there are unusual reactions, they inform public health authorities so that appropriate warnings or alerts can be issued. So basically, all the pillars work closely together.
Are deaths from overdose higher amongst those with a history of incarceration?
Yes, especially if substance use is reinitiated after a drug-free period, such as immediately after release from corrections. Opioids, especially fentanyl, are causing most deaths in BC and North America, and tolerance to fentanyl is lost fairly quickly. People may come out of a treatment program or corrections thinking that they can use the same dose as they did previously and overdose. We are aware that some people in corrections do have access to drugs, but they would have been using a lot less. Besides, it’s an unregulated market and there is no quality assurance in the illicit market. So, nobody knows exactly what's in their drugs, and that can have devastating outcomes.
In addition, there are a lot of reasons why people may restart using substances after being released. There is a lot of emotional stress and challenges when you leave corrections - finding somewhere to live, the stigma, being unemployed, and not being able to get a job potentially, etc. Also, they may have been on opioid agonist therapy in prison and may have difficulty continuing that after release.
In your opinion, how can we reduce this risk?
I think treatment - opioid agonist therapy (OAT) - is important, but we have multiple stumbling blocks with regard to access. If we consider the Levesque framework, we need to assess various aspects of access, including its availability, approachability, acceptability, affordability, and appropriateness for each individual. For example, one needs to be able to navigate the system and find somebody who can prescribe post-release. Some medication is provided on release presently, but access to general practitioners or addiction physicians for follow-up prescriptions has been a challenge in BC. This is despite efforts to increase qualified personnel through the training of nurse practitioners to prescribe OAT. Another example is that these clinics are usually open between 8.30 and 4.30, which makes it difficult for people with jobs to visit. This is important not just for people who have left prison, but also for others who seek treatment. This is further compounded by the fact that folks may be relocating after release or get released earlier giving the system no time to plan for their follow-up.
Also, as I mentioned earlier, it is a stressful time, and people return to their community where there is prevalent drug use. Having a general support system, for example, accompanying them to a physician appointment, helping them find accommodation, etc. can ease some of the stress and aid their recovery. In addition, we also need to look into what the individual wants and what is acceptable for them and address the trauma that led them to use substances in the first place. So, supporting the social determinants of health, meeting people where they are, identifying what their needs are, and being able to respond appropriately are all crucial parts of recovery.
Peer work appears to be a ‘win-win’ for all. While the perspective of those with lived experience is essential to organizations providing harm reduction services, peer work can be extremely fulfilling for workers with lived experience; but in reality is it this simple?
Even though organization personnel may undergo specialized training, their coaching follows a curriculum and isn't in the reality of using substances So, working alongside people with lived experience is generally preferred over the top-down approach, and people are more comfortable talking with peers than with those in positions of power. When I started trying to champion that peers should be considered experts and be engaged in all research, policy, planning, and evaluation, it took a while for people to accept that. It does take longer, but it's much more meaningful.
Another important aspect is that we tend to project our own perspectives on others. For example, some of the peer workers wanted to develop skills during the Peer2Peer project, one of which was CPR and first aid. After identifying St John's Ambulance as a course provider, we had a choice between a two-day intensive training followed by recognized occupational certification and a tailored course for people with lived experience. I assumed that they would prefer the latter since it would be less stressful; but no way! Everybody wanted to get that certificate. The lesson for me was don’t make assumptions on their behalf. We have to ask and find out what they actually want and that's why peer engagement and involvement is so important.
On the other hand, there is a huge stigma within some organizations, and peers are not always valued for their work and are certainly not remunerated appropriately for the expertise that they provide. Since we have a mixture of organizations that offer peer work, the extent of it depends on the organization. When you compare the work of a nurse or a social worker at a health authority with that of a peer worker, there is a clear difference. While the former receive benefits such as holidays and sick pay, and are able to switch off from their jobs once they go home, it isn’t as simple for peer workers. Not only is it hard for them because they are usually part of a community that has members who are using, but they may also get called upon at any time if anyone needs help. For example, they may get a knock on the door if someone overdoses, and every time they respond to such a call, it may trigger emotions. Although some peers may experience burnout over time, they are so committed to making a difference and helping their community, that they gain satisfaction through their work.
So yes, I think it's a win-win, but we do have a lack of recognition of the skills of peer workers and what people with lived experience can offer.
Could you tell us more about the Peer2Peer project?
During the Peer2Peer project, we conducted peer-led focus groups to investigate the needs of peer workers in order to support the delivery of overdose responses. The goal was to reduce emotional, mental, and social stress for them, thereby enabling them to work optimally.
Three major themes were identified from the needs assessment and formed the basis of the intervention model, “ROSE”; R-Recognition, O-Organizational Support, S-Skill Development, and E-for Everyone. For example, making photo IDs and business cards for everyone and creating a video describing a typical day in a peer's life gave them recognition (R).
Things like job descriptions and contracts along with activities such as team building days were methods of providing peer workers with organizational support (O). The CPR course that I mentioned earlier, cultural safety, trauma-informed care, mindfulness, and conflict resolution were some examples of skill development (S).
Finally, what motivated you to be a part of the THJRC?
One of the aspects of THJRC that I really appreciate is its person-centered philosophy. The cluster is culturally safe, engages with elders, and appreciative of the fact that there is a preponderance of people who identify as indigenous within our correctional system. So, it's really important to give people the support structure that they need, and that includes cultural safety and having elders.
Going back to 2006, I have a long history of working with prison health and with Ruth Martin. At that time, I was involved in community-based participatory research with women in prison, and have been associated with many projects since then. I have also worked closely with Mo and Pam for many years now. For example, when I was at the BC CDC, I introduced the Take Home Naloxone program that provides life-saving training and kits to people at risk of an opioid overdose. Mo and Pam had some valuable inputs for the follow-up survey questionnaire and we were able to identify ways to make a difference. I actually love working with people with lived experience because they keep me grounded. They are the ones that tell me “don't be so ridiculous” or “you can't do that”.
Amongst all my research, it’s applied public health that is important for me; that things are done for a purpose and there is an outcome that improves the health of the people we're working with, as opposed to looking at numbers and deciding - OK, this is what we found.