How Do You Measure Hope?

In the First Nations opioids epidemic, progress comes when addressing root causes and driving meaningful outcomes

“I consider myself one of the lucky ones,” says Roy Cutfeet. At age 40, he says he has never felt better. Cutfeet hasn’t touched Oxycodone for about three years, after kicking a habit that found him injecting it daily. “I fought hard to get clean,” he says.

Cutfeet was on a suboxone program for his addiction. He now helps others as a crisis coordinator in Kitchenuhmaykoosib Inninuwug (KI), Ont., also known as Big Trout Lake.

The Ojibway-Cree community, 580 km north of Thunder Bay, is accessible by air year-round, and by winter road from January-March. You’ll find a grocery store, community store (including banking, post office and gas), arena, bowling alley, new health centre, band office, community hall, and a JK-10 school (students must leave the community if they want to finish high school).

About seven years back, Cutfeet says KI started to face an opioid epidemic. The effects of addiction on the individual may be similar anywhere, but the cumulative impact is magnified here. In such a small community, the damage ripples. “It really did a number,” he says. “Everybody knows everybody.”

KI has a population of about 1,700 (960 on-reserve), and Cutfeet says its suboxone program now has about 135 patients. Given his own recovery, “I try to remain hopeful,” he says. But he knows that in battling opioid misuse and addiction, communities like KI face challenges. How can doctors rise to them?

As the use of opioids has increased in Ontario, the province’s 133 First Nations communities have been disproportionally affected.

A report for the Chiefs of Ontario (by the Institute of Clinical Evaluative Sciences) found that rates of prescribing opioids, doses dispensed and opioid-related hospitalizations are all higher in First Nations people compared to the general population. The rate of opioid-related deaths is also significantly higher, nearly four times as much. The report called this a public health crisis for First Nations communities.

In responding to this crisis, First Nations communities are dealing with a host of complex issues: funding, remote location, coordination of care, training, treatment program design, prescribing practices and, not least, root causes.

Dr. Anne Robinson, a family physician with added competency in addictions, has worked in the Sioux Lookout Regional Physicians Services for almost her entire career.

She says that, despite the prevalence of opioid addiction, First Nations communities have real capacity to overcome the obstacles. And some circumstances that might appear to be negative can, in fact, have positive consequences.

For instance, in a tiny and tight-knit community it’s harder to have anonymity. “That would be intolerable in a larger centre,” she says. “Everyone knows who’s on addiction treatment. For an outsider, that seems like a major disadvantage. But there’s also some strength to the community aspect,” she said. “The community doesn’t see this as an individual problem but as a community problem,” Dr. Robinson continues. “They come together as a community to figure out what to do. Because they know these people beyond their addiction. They don’t just see them as junkies. They see that by supporting them and their treatment, that’s beneficial to the community too. The community is invested in this. With the right resources, they can come up with wonderful community-based approaches.”

Culturally-appropriate treatment

Thunderbird Partnership Foundation, the national voice advocating for First Nations culturally-based addictions services, points to a success at the North Caribou Lake First Nation. They developed a treatment program that combined buprenorphine substitution therapy with intensive and culturally-appropriate counseling.

Patients got treatment in their home community, without having to travel to an outside clinic. Along with the positive interventions for the patients, the community as a whole benefited. The community clinic became more of a primary care centre, less of a trauma centre. Attendance at community events and sales at the general store were up. Meanwhile, drug-related violence fell. One year later, criminal charges were down 61%, child protection cases had dropped 58%, and school attendance was up 33%.

As the Thunderbird Partnership Foundation stated, the whole community participates in and backs the program, which is deeply focused on helping patients return to their community activities and responsibilities.

The treatment program was highlighted in Canadian Family Physician. One of the authors, Dr. Sharon Cirone, says it’s vital for places like North Caribou Lake to own the solutions. “There’s a sense of community and belonging,” she says.

The Toronto-based family physician specializes in mental health and addiction medicine. At least one week each month, Dr. Cirone works in northwestern Ontario First Nation fly-in communities. There, she provides opioid substitution therapy and concurrent disorders treatment.

“Keeping people with opioid use disorder alive is the easy part. The tough part is having the appropriate supports and community environment to address the underlying issues,” says Dr. Cirone.

Intergenerational trauma

Dr. Cirone says one can’t separate substance use disorder from some of the legacies in these communities — the individual, family and community harm that has occurred as a result of colonization.

“Many people have psychological wounds and scars, and have been affected by intergenerational trauma,” she says. “We know that early life trauma and adverse events contribute to substance dependence.”

Consider the impacts over time of loss of language and culture, assimilation policies (like residential schools), weakened connections to the land, high school dropout rates, lack of employment, inadequate housing, food insecurity, and reduced access to health- care services. The effect on identity and health — physical, emotional, mental and spiritual – can be enormous. Everything is related.

“For many Canadians, ‘intergeneration trauma’ and ‘truth and reconciliation’ are just phrases. For me, I see faces,” says Dr. Claudette Chase.

She helped pioneer a community-based addiction treatment program in a First Nation community in northwestern Ontario. Out of a population of 1,400 people, 200 are in the program. Dr. Chase doesn’t like to name the community out of concern for labelling it.

Institutional and nationwide racism still loom large, she says. The effects linger. She mentions residential schools, where children were separated from their families and taken somewhere with no affection. When they returned home, they often developed a detachment disorder. Survivors who were abused sometimes became abusers. Trauma has a long tail.

“People told me that when they tried Oxy it was the first time in their lives they felt relaxed. It was very seductive,” says Dr. Chase, who serves on the board of the Canadian Society of Addiction Medicine.

The best model of health

It’s vital to understand those stories. Dr. Cirone advocates a trauma-informed approach when dealing with substance abuse disorder. The addiction is a symptom of a larger problem. Until you address the underlying causes, no solution can be fully effective.

Dr. Robinson adds that some results are promising. She sees a higher retention rate to treatment than in typical urban-based programs. But consider the environment. “The challenge is the relapse, which is true regardless,” she says, “but especially when there’s this common experience, with so many people having these struggles.”

In July 2019, the Public Health Agency of Canada funded the Thunderbird Partnership Foundation to conduct separate adult and youth surveys. They’ll look at opioid use and its impacts on First Nations communities.

The goal is to inform the development and evaluation of local interventions.

Data will enable First Nations in telling a story of the inequities that must also be addressed for First Nations communities to survive the opioid crisis.

At the time of the funding announcement, Carol Hopkins, Thunderbird’s Executive Director, said that “Data will enable First Nations in telling a story of the inequities that must also be addressed for First Nations communities to survive the opioid crisis.”

There’s no shortage of ideas around prevention, prescribing practices, outreach, education, coordination, crisis response, treatment and wraparound care. That’s on top of efforts to deal with the diversion from legitimate prescriptions, and thwart the illicit flow of substances into the community.

Beyond the specific solutions, focus is on the model of health. Hopkins has talked about how action to address the crisis must be measured. You can track things like access to therapies, overdoses and child welfare cases due to addictions. That all matters.

But success rests too on the extent to which actions create mental wellness among First Nations. That means Indigenous-based outcomes like hope, belonging, meaning and purpose.

A strength-based approach also respects the core belief that everyone has inherent strengths, and that the community is resourceful and capable of solving its problems.

A 2018 session at TOPHC (the Ontario public health convention) dealt with the First Nations opioids epidemic in northwestern Ontario. Francine Pellerin, Health Director for Matawa First Nations in Thunder Bay, mentioned the chi kee way meno biimadeseyung strategy. In Oji-Cree, that’s a back-to-our-roots idea of walking in a good, healthy life.

Practice patient-centred medicine

While many solutions are unique to First Nations, Dr. Robinson says that in a few respects opioid addiction there should be viewed as it would anywhere.

First, see it for what it is. Dr. Robinson says that society, and the medical community too, has been slow to recognize that addiction isn’t a moral problem. It’s a chronic illness. She hopes family doctors will view this as a disease they can treat, like diabetes.

“Helping people overcome addictions is the most rewarding work I’ve ever done. If you just leave it to the specialists to manage this, there will be an awful lot of people who can’t access care.”

Second, hold off on assumptions and be curious. That’s true for all patient-centred medicine.

“Consider all of the contextual factors for your patient,” says Dr. Robinson. “If you work with one particular culture, learn as much as you can to be informed about where the patient is situated. Ultimately, you’re engaging with the patient as an individual. But you want the background to have a broader view.”

The kind of mindset that works for opioid response in First Nations can have broad applications, suggests Dr. Chase.

“We learned something that would work all across the province: approach the community,” she says. “Decolonize your thinking, to feel you always know best. Ask how you can help. Is advocacy needed? The doctor can be a voice. Start listening, and say to Indigenous people, ‘How might I support you?’ That’s the kind of transformation we need.”