Researching Prescription Drug Misuse among First Nations in Canada: Starting from a Health Promotion Framework

Abstract

The intentional misuse of psychotropic drugs is recognized as a significant public health concern in Canada, although there is a lack of empirical research detailing this. Even less research has been documented on the misuse of prescription drugs among First Nations in Canada. In the past, Western biomedical and individual-based approaches to researching Indigenous health have been applied, whereas First Nations’ understandings of health are founded on a holistic view of wellbeing. Recognition of this disjuncture, alongside the protective influence of First Nations traditional culture, is foundational to establishing an empirical understanding of and comprehensive response to prescription drug misuse. We propose health promotion as a framework from which to begin to explore this. Our work with a health promotion framework has conveyed its potential to support the consideration of Western and Indigenous worldviews together in an ‘ethical space’, with illustrations provided. Health promotion also allots for the consideration of Canada’s colonial history of knowledge production in public health and supports First Nations’ self-determination. Based on this, we recommend three immediate ways in which a health promotion framework can advance research on prescription drug misuse among First Nations in Canada.

Introduction

Despite the fact that Canada’s prescription drug rates rank among the highest in the world, current research detailing Canadian trends in intentional psychotropic drug misuse is lacking.¹ Available data on the non-medical use of prescription drugs and the health, social and economic impacts among Canada’s First Nations^a population is especially sparse. There is increasing public attention, however, to prescription drug misuse as a significant health concern.² This dates back to concern expressed by Canada’s Auditor General in 1997 and again in 2004 of opiate-based prescription drug misuse in First Nations communities.^3,4 The non-medical use of prescription drugs has been linked with the impoverished health status of First Nations across Canada; a growing number of First Nations have associated elevated rates with increased levels of violent criminality, illicit prescription drug trafficking, and suicide within their communities.^5–7 For example, in early 2012 Cat Lake First Nation in Ontario was the latest First Nations community to declare a state of emergency to federal and provincial officials due to the widespread use of prescription drugs.⁸ The most recent First Nations Regional Longitudinal Health Survey, released in 2011, reported that addiction was the primary challenge (83%) to on-reserve community wellness—a greater challenge than both housing (71%) and employment (66%).⁹ Despite increased public awareness and media attention and select national, provincial/territorial and local community action, a lack of empirical research renders the issue poorly understood and therefore somewhat sporadically responded to.

Research with First Nations in Canada has historically been a colonizing practice, with information overwhelmingly taken from communities with little regard for its cultural significance and meaning outside a Western worldview and without clear benefit to improving the health of First Nations. Over the course of the past decade, Canada has taken significant action to address this, with attention allotted specifically to ethics in research. For example, the revised Tri-Council Policy Statement for Research Involving First Nations, Inuit and Métis Peoples of Canada was released in 2010.¹⁰ The statement was developed from extensive community consultation and prior work, including the Canadian Institutes of Health Research Guidelines for Health Research Involving Aboriginal People and the First Nations Information Governance Centre’s principles of OCAP^b.^11,12 At the same time, Indigenous methodology scholars, such as Smith (1999),¹³ Kovak (2009),¹⁴ and Wilson (2008)¹⁵ have made major contributions to increasing understanding of the decolonizing potential of research. What remains fairly unexplored, however, is what Ermine (2007;2004) refers to as an ‘ethical space’; a space in which Western and Indigenous worldviews^c and researchers can come together.^16,17 Tait (2008) argues that researchers unfamiliar with Indigenous knowledge have moral and ethical obligations to gain an understanding and that this must be paramount in research with Aboriginal communities; this “ethical space facilitates [the] development of cross-cultural linkages that are ethically sustainable and strive for equality of thought amongst diverse human communities” (page 3).¹⁸

It has been our experience working with a health promotion framework that it can be a suitable starting point for generating an ‘ethical space’ in which Western and Indigenous worldviews can be concurrently considered. Essential to creating such an ‘ethical space’ is clarification of applied values, which in turn act to define the space and enable expanded collaboration between varying worldviews. Health promotion is about situating people’s health in relation to their environment, framed as a bio/psycho/socio/cultural perspective through an Indigenous conception of the determinants of health. At the same time, we have experienced that this framework has the capacity to recognize the protective influence of First Nations traditional culture and First Nations self-determination, while also realizing Canada’s colonial history of knowledge production in the health field. The prescription drug misuse research field is apt for its application, especially considering the limited amount of research undertaken to date and the current environment of heightened awareness of prescription drug misuse. We recommend three immediate ways that a health promotion framework can move research on prescription drug misuse among First Nations in Canada forward and in alliance with active initiatives such as the Canadian Centre on Substance Abuse’s lead on a national strategy in partnership with the Assembly of First Nations, First Nations and Inuit Health Branch, National Native Addictions Partnership Foundation and Non-Insured Health Benefits among others.

Aboriginal health and prescription drug misuse

There is considerable heterogeneity among First Nations populations, yet various commonalities contribute to a state of poor overall health status. Compared to other Canadian populations, existing data relay that First Nations’ health status is considerably poorer.¹⁹ Adelson correlates this with “[a] history of colonialist and paternalistic wardship, including the creation of the reserve system; forced relocation of communities [and] forced removal and subsequent placement of children into institutions far away from their families and communities; inadequate services to those living on reserves; inherently racist attitudes towards Aboriginal peoples; and a continued lack of vision in terms of the effects of these tortured relations”.²⁰ (page 46) Examining the pathways to prescription drug misuse, in comparison to the general Canadian population, First Nations adults have a higher frequency of chronic disease and some ailments are associated with physical pain, such as arthritis/rheumatism, high blood pressure, diabetes, asthma, heart disease, cataracts, chronic bronchitis, and cancer.²¹ Mental health issues (eg, emotional pain) also abound and stem from unresolved trauma (ie, colonization), with studies relaying that individuals are oftentimes unable to easily distinguish emotional and physical pain.^22,23 The determinants of health for First Nations, including poverty, loss of language, racism, and dissociation from the land, markedly contribute to decreased overall health levels, resulting in an average five to seven year lower life expectancy when compared with non-Indigenous Canadians.²⁴ First Nations women encounter further health disparities stemming from gender-based determinants, including increased incidents of family violence and the demands of single parenthood.²⁵

Although there is limited research specific to First Nations and prescription drug misuse, there has been emerging evidence over the past two decades pointing to a growing problem. Dating back to 1994/95, data from the National Native Alcohol and Drug Abuse Program (NNADAP) Treatment Activity Reporting System suggested an increasing trend in the abuse of narcotics and prescription drugs among First Nations accessing treatment in Canada.²⁶ In a review of prescription drug use from this same data system in the late 90s, Thatcher concluded that prescription drug abuse “is increasing among First Nations and Inuit people who are referred to NNADAP in-patient treatment programs”.²⁷ (page 4) Similarly, a general review of NNADAP in the early 2000s found that 35% of social service workers identified problematic prescription drug use as a frequent or constant problem in their community, and recommended that “the issue of prescription drug abuse … be examined”.²⁸ (page 18) More recent, the renewal of the NNADAP and Youth Solvent Abuse Program (YSAP) treatment system identified intentional prescription drug misuse as an area of increasing concern and research need in its regional needs assessments, with specific concern raised in Ontario, Alberta and New Brunswick and growing concern in Saskatchewan and Quebec (eg, OxyContin, methadone, codeine).²⁹ The YSAP program has identified in its database an increasing concern among youth admitted for treatment since 2006–07.³⁰ And lastly, it was recognized at the 2010 Assembly of First Nations Special Chiefs Assembly that opiate addictions and related harms are emerging substance misuse challenges that need to be addressed.³¹

Contextual issues, such as colonial history, geography and gender must be accounted for to understand the growing concern. To illustrate, post-traumatic stress is a common disorder diagnosed among residential school survivors and is frequently treated with benzodiazepines.³² In the province of Saskatchewan, substantial prescribing of benzodiazepines has been a concern, although it has decreased with the introduction of a prescribing awareness program but in place concern has emerged about the abuse of Ritalin and Gabapentin.³³ As another example, a 2007 Saskatchewan study found that “differences in prescription drug abuse exist between northern and southern Saskatchewan First Nations reserve communities. These differences are related to factors such as prescriptive practices and delivery of medications; geographical location (remote versus non-remote locations, proximity to urban centres); and, the accessibility and availability of illicit and licit substances. For example, physicians are employed on a contract basis in the north and therefore, the dispensing of medications/mood altering drugs is not as high volume driven as it is in the south where First Nations people access off-reserve physicians who are paid by the number of patients they see”.³⁴ (page 5) Additionally, several studies across the country have relayed that there is higher prescription rates for Aboriginal women in comparison to other populations, including Aboriginal men.^35,36

Alongside the devastating intergenerational impacts of colonization on the intentional misuse of prescription drugs, it is necessary to likewise acknowledge the protective influence of traditional culture on the health of First Nations in Canada. Research on the causes and best responses to prescription drug misuse need to better reflect culturally-based understandings of wellbeing. ³⁷ To date, many have argued that Indigenous health research has largely been undertaken from an individualized Western approach that tends to perpetuate the legacy of colonialism by denying the validity of First Nations understandings and practices of health.³⁸ Many traditional First Nations perspectives on health, healing and medicine are at odds with purely Western biomedical understandings.^39–41 Health is understood by various First Nations as a state of unity and balance across the biological, psychological, social, and spiritual aspects of one’s life—not simply the absence of disease. A 2006 meeting on the wellbeing of First Nations explained that “[t]he traditional ecological knowledge of Indigenous people [focuses on] the web of relationships between humans, animals, plants, natural forces, spirits, and the land forms in a particular locality, as opposed to the discovery of universal laws”.⁴² (page 4) In Canada, the 2011 Honouring Our Strengths renewal framework on First Nations treatment for substance abuse (NNADAP/YSAP) places culture at its core.⁴³ Carol Hopkins, co-Chair of the Renewal Leadership Team, shares: “It has been our own cultural ways that have upheld the truth of who we are and it is that knowing from which we will draw upon as our cultural evidence to facilitate renewal and revitalization”.⁴⁴ (no page, internet source)

Health Promotion Framework

Health promotion is a population-based, systemically integrated approach to addressing individuals’ health, while simultaneously accounting for individuals’ health choices. The World Health organization defines health promotion as the process of enabling people to increase control over the determinants of health in order to improve their health.⁴⁵ Inherent to this approach is an understanding that health is determined in large part by structural influences, commonly referred to as the determinants of health. The underlying assumption is that “reductions in health inequities require reductions in material and social inequities”.⁴⁶ Quite simply, “[t]he conditions in which people grow, live, work and age have a powerful influence on health. Inequalities in these conditions lead to inequalities in health”.⁴⁷ (no page, internet source)

A long-standing criticism of health promotion is that it does not ‘fit’ for populations who do not have access to the resources necessary to engage in health promotion initiatives; a key challenge has been putting health promotion theory into practice.⁴⁸ As Aboriginal ACT Now in BC notes “... despite an emphasis on health inequalities and determinants, health promotion is in many respects a ‘white, middle-class phenomenon’ that has [been] met with mixed results amongst ethnic, racial, and cultural minorities and poor populations”.⁴⁹ (page 7) In light of this criticism and the framework’s foundation in Western thought, health promotion has responded by adapting to the inclusion of culturally-based understandings of health and their application.^50–52 According to Mundel and Chapman (2010), in their application of the health promotion framework to a case study of an urban Aboriginal community kitchen garden, “[h]ealth promotion’s ... holistic conceptualization of health (for example, addressing the needs of the whole person), its preventative focus and its acceptance of the need to change social and economic conditions in order to improve health suggest that it holds greater potential for promoting Aboriginal health than relying solely on biomedicine”.⁵³ (page 167) This is also evident in the emergent attention to Indigenous-specific determinants of health in Canada and internationally, including historical trauma, language and land displacement, and poor standards of living.^54,55

An ‘ethical’ space

The work of authors of this paper (Dell, Hopkins & Dell) within the health promotion framework has appropriately enabled an ‘ethical space’ to transpire for our team members, that is, a space in which we could address working with both Western and Indigenous understandings of health. For example, our recent project titled From benzos to berries: An examination of the influence of culture in treatment offered at an Aboriginal youth solvent abuse treatment centre, considered the implications of taking into account culture within psychiatry’s individualized approach to treating mental disorders amongst youth solvent abusers. Our team’s initiation from within a health promotion framework enabled a space for divergent perspectives to be considered. For example, we contemplated in our work how Indigenous youths’ understandings of connection to self, community, and political context, alongside the determinants of health, can be accounted for together to understand treatment. Based on our experience with the framework, we concluded that “a health promotion perspective may be a valuable beginning point for attaining…understanding, as it situates psychiatry’s approach to treating mental disorders within the etiology for Aboriginal Peoples”.⁵⁶ (page 80)

Accounting for the protective influence of First Nations traditional culture

Much of the emerging health promotion literature describes the importance of acknowledging, understanding, reflecting upon, and incorporating varying cultural constructions of health.^57–61 As such, a health promotion framework provides an opening for consideration of the protective and healing influences of First Nations cultural understandings, teachings and practices of healing and medicine. In order to connect with Aboriginal peoples in Canada, health promotion efforts must include an understanding of the values which underpin the various benefits of community-based Indigenous healing traditions, rituals, ceremonies, medicines and practices that positively impact the health of First Nations. Due to the historical over-emphasis on biomedical explanations of health in Western society, however, empirical documentation of the inherent strengths and abilities of First Nations’ own health and healing are sparse.^62,63 In our From benzos to berries project, we explored an Elders’ simultaneous reliance on both an Indigenous (traditional medicine) and Western (behaviour modification) approach to treatment and healing, while at the same time respecting that some traditional cultural knowledge is not for documentation (eg, ceremonial process, ceremonial songs, and medicines). The health promotion framework enabled us to explore a bridging of the gap in understanding between Western psychiatric and Aboriginal understanding and practices, and thereby potentially positively impact client outcomes through the sharing of the knowledge we gained.⁶⁴ (page 75)

Accounting for Canada’s colonial history of knowledge production

Durie (no date), in his work on an Indigenous model of health promotion, argues that it challenges traditional public health models by confronting the colonial history of knowledge production and the privileging of a hierarchical notion of power.⁶⁵ A recent Canadian study concluded that effective approaches to health promotion with Indigenous peoples require decolonizing practices.⁶⁶ A population health approach has been cited as supportive to prioritizing Indigenous cultural understandings, teachings, and practices of healing and medicine in combination with Western principles of health research.⁶⁷ Mundel and Chapman (2010) wrote that “... a decolonizing approach to health promotion has the potential to address immediate needs while simultaneously beginning to address underlying causes of Aboriginal health inequities”.⁶⁸ (page 166) In our own work, the sharing of understanding in a culturally meaningful manner was central; we applied an Aboriginal method of knowledge translation—storytelling. Through it we illustrated the disjuncture between Western and Aboriginal responses to healing and suggested that it may be a valuable tool for knowledge transfer in the clinical setting as it allows the listener to see, hear and feel the findings rather than only reading about them in a traditional Western venue (academic journal, physician pamphlets) or being told about them by a physician.⁶⁹ (page 75)

Accounting for First Nations self-determination

The health promotion framework’s attention to individuals’ negotiation of their health has been identified as a form of “health self-determination”⁷⁰ and must also be understood within a broader context, that is ‘self’ is also interpreted to represent ‘First Nations’ as a collective and also within the context of environment such as the social determinants of health. Self-determination requires opportunities to improve capacity through access to culturally relevant services with self-empowerment as the goal. This is a necessary condition for socio-economic development⁷¹ and is congruent with First Nations’ understanding of attempts to secure self-determination for their individual and collective wellbeing.^72–74 A central feature of health promotion, community empowerment, coincides with self-determination; “At the heart of this process is the empowerment of communities—their ownership and control of their own endeavours and destinies”.⁷⁵ (page 3) Manifestations of self-determination were exercised in multiple ways in the From benzos to berries project, including it’s initiation from a community-identified need through to community co-authorship on the resultant paper. This latter point is an important consideration, as we concluded that there is a significant need for peer-reviewed, culturally competent, psychiatric research.⁷⁶ (page 75)

Recommendations for Moving Research Forward on Prescription Drug Misuse

Addressing intentional psychotropic drug misuse among First Nations in Canada demands an acknowledgement of the fundamental inequalities faced by First Nations communities that are evidenced by the disparities in the determinants of health and in Canada’s colonial history of knowledge production. Alternatively, research must also recognize the protective influence of traditional First Nations culture has on overall health and wellbeing and the importance of First Nations self-determination in research. As illustrated, to engage in decolonized research, it is necessary to establish an ‘ethical space’ in which Western health and First Nations understandings of wellbeing can be considered alongside one another. Based on this understanding, three recommendations are made for moving research forward that can inform the development of culturally appropriate understandings of, and responses to, prescription drug misuse. It is important that these recommendations be reviewed in the context of existing and on-going action in Canada (eg, CCSA’s initiation of a national strategy, Ontario’s First Nations Prescription Drug Abuse Strategy, implementation of the Honouring Our Strengths Renewal Framework).

1. With the health promotion framework amenable to accounting for the protective influence of First Nations traditional culture and the detrimental health impacts of colonization, including Indigenous determinants of health, it is recommended that research likewise account for a strengths-based approach to understanding First Nations encounters with problematic psychotropic drug use. For example, between 2006 and 2009 Drug Utilization Prevention and Promotion pilot projects were undertaken in various regions of Canada. The Timiskaming First Nation Community initiative in Quebec focussed on motivating healthy behaviour and life-styles related to prescription drugs by promoting traditional behaviours and enhancing self-esteem.⁷⁷ In order to measure the success of these health interventions, it is necessary to acknowledge and assess the impacts of community-based traditional approaches, such as Medicine Wheel teachings that account for the mental, physical, emotional and spiritual aspects of wellbeing, alongside Western indicators of effectiveness (which tend to be more deficit based, such as measuring an absolute reduction in prescription drug misuse).

2. With the colonial history of knowledge production in Canada recognized from within a health promotion framework, it is recommended that research support a participatory-action approach that places the First Nations community at the centre of the research process, and which demonstrably upholds the ownership, control, access and possession principles of First Nations research.⁷⁸ As the First Nations Information Governance Centre has demonstrated with the collection of health prevalence data, and others have established with qualitative-based studies (see Acoose et al),⁷⁹ this can be accomplished in both methodological realms. This will be necessary for the establishment of baseline data in the prescription drug misuse field and the evaluation of consequent practice-based response; it will be important to know why prescription drugs are being misused (eg, demand ranging from purposeful misuse to addiction from legitimate pain medication) to how they are being attained (supply ranging from overprescribing, inappropriate prescribing, to illegitimate sources).

3. With recognition within the health promotion framework that self-determination can effectively empower First Nations and contribute to wellbeing, it is recommended that community members, including traditional Elders, assume leadership roles throughout the research process.

Precedent research projects can be turned to for their leadership and lessons in prioritizing the wisdom and knowledge of traditional Elders⁸⁰ (see Bourassa et al).⁸¹ Community-based research ethics boards developed and run by First Nations communities are also a good example to learn from (eg, Six Nations Council Ethics Committee).⁸²

As the research history with First Nations in Canada has shown generally, attempts to move forward must be owned by the community and be based within community history and cultural knowledge, which in turn has the potential to help build cultural capacity to develop effective prevention and response efforts. Health promotion is not being proposed as the definitive framework to address the limitations of past research approaches, but it is presented as a potential beginning point or framework for addressing prescription drug misuse within which both Western and Indigenous worldviews can be considered. Although the framework has limitations (eg, foundation in Western thought), recognizing it as a beginning point has the potential to contribute to the development and evaluation of more suitable community-driven culturally-based responses that may ultimately improve First Nations health and wellbeing.