Navigating treatment in the shadow of the overdose crisis: Perspectives of youth experiencing street-involvement across British Columbia

Abstract

Objective:

Youth experiencing street-involvement are particularly vulnerable to substance use-related harms. Since an overdose public health emergency was declared in British Columbia (BC) in 2016, there have been concerted efforts to expand youths’ access to integrated mental health and substance use treatment across the province. The present study sought to explore how youth were navigating this rapidly evolving treatment landscape.

Methods:

Focus groups were conducted with youth experiencing street-involvement in three BC cities, followed by a summit event in Vancouver. Audio recordings were transcribed verbatim and coded thematically alongside observational field notes. All activities were undertaken in collaboration with a Youth Advisory Council.

Results:

Across BC, youth expressed desires to achieve aspects of what some called a “normal life” following treatment, which required having “somewhere to go next.” In the absence of desirable housing and adequate income, youth were often left with the crushing sense that, despite their efforts, treatment would not ultimately help them to “get somewhere better.” Negative experiences in treatment settings were also shaped by the files that “followed” youth across care settings, inappropriate information sharing between providers, and an overemphasis on pharmacotherapies (namely, opioid agonist therapies and psychotropic medications).

Conclusion:

Our findings point to the inability of existing services and systems to address entrenched marginalization and chronic instability, and underscore the importance of relationship-, trust-, and future-building to providing treatment and care to youth. Young people must be empowered with control over their treatment trajectories, including decision-making surrounding pharmacotherapies and information sharing.

Introduction

In the Canadian province of British Columbia (BC), over 1600 youth ages 10 to 29 have lost their lives to overdose since a public health emergency was declared in 2016.¹ The overdose crisis is largely fuelled by the proliferation of illicitly-manufactured fentanyl and related analogues in the local, highly criminalized (and therefore unregulated) drug supply. Youth (<25 years of age) experiencing street-involvement (i.e., those experiencing street-based homelessness or unstable housing) are particularly vulnerable to overdose and other health and social harms.^2–5 Frequently, youth who are street-involved experience multiple, intersecting forms of exclusion along axes of race, class, gender, sexual orientation, and ability, deepening their vulnerability to these harms.^6–8 Many also navigate co-occurring substance use and mental health disorders, including anxiety, mood, post-traumatic stress, and attention deficit hyperactivity disorders, as well as periods of substance use-related psychosis.^9,10

Higher rates of substance use, overdose, homelessness and unstable housing among Indigenous young people are the result of historical harms which continue into the present.^8,11–14 Indigenous peoples have unique cultures, traditions, and languages, as well as shared experiences of settler colonialism. The settler colonial project in Canada has involved over a hundred years of racist policies aimed at the dispossession and assimilation of Indigenous peoples, including the Indian Act, the Potlatch Ban, the residential school system, and the ‘60s and Millennium Scoops (throughout which thousands of Indigenous children have been forcibly removed from their families by child welfare systems). Today, racism continues to pervade healthcare, child welfare, and criminal justice systems in BC,^15,16 with devastating effects. Acknowledging these historical harms and the ways that they continue into the present is essential to understanding the impacts of the current overdose crisis in BC, and its disproportionate effects on Indigenous young people.

The declaration of an overdose public health emergency in BC initiated numerous efforts to expand youth’s access to integrated, culturally safe substance use and mental health care.^10,17 In particular, “one-stop-shop” service hubs and intensive case management teams have been established across the province. The latter follow youth experiencing co-occurring substance use and mental health disorders across acute, community, and residential healthcare settings to improve continuity of care. New provincial clinical guidelines for the treatment of opioid use disorder were released in 2017,¹⁸ and a youth supplement was released in 2018.¹⁹ These guidelines strongly recommend against detoxification (detox) alone, and instead endorse the provision of opioid agonist therapy (OAT) to youth, such as buprenorphine-naloxone (trade name Suboxone), methadone, and slow-release oral morphine (trade name Kadian). OAT is often prescribed alongside a range of psychotropic medications, including antidepressants and second-generation antipsychotics (e.g., risperidone, quetiapine), which is consistent with recommendations that substance use and mental health disorders be addressed concurrently.^18,19

We undertook the present study to explore how young people experiencing street-involvement in BC were navigating this rapidly evolving treatment landscape in the shadow of the overdose crisis. A greater awareness of youth’s understandings of and experiences with treatment is essential to delivering services that are congruent with their needs and desires.

Methods

This study is part of a pan-Canadian project focused on the overdose crisis and youth that is described in detail elsewhere.²⁰ What follows is a description of the methods employed by the BC site, which was the only site to focus on youth experiencing street-involvement. In total, 63 youth between the ages of 14 to 24 participated in the BC component of the project. All participants self-identified as having past or current experience with substance use and street-involvement, and the vast majority had experience navigating concurrent mental health and substance use concerns.

Between September and October 2019, two focus groups were conducted in each of the following cities: Prince George (pop. 65,510),²¹ Kelowna (pop. 151,957),²² and Vancouver (pop. 2,264,823).²³ Each site is governed by a different regional health authority and considered a centre for healthcare services within its region. Each of these cities is located on unceded Indigenous territories, meaning that the settlers who came to what is now called BC never established formal treaty agreements to govern the exchange or sharing of land with the Indigenous peoples who had been living in the region for thousands of years. Prince George is located on the traditional territory of the Lheidli T’enneh, Kelowna is located on the territory of the Syilx/Okanagan, and Vancouver is located on the territory of the Musqueam, Squamish, and Tsleil-Waututh First Nations.

Youth participants were recruited through drop-in centres (i.e., service hubs that offer various recreational activities alongside the provision of food, harm reduction supplies, medical care, and support with obtaining housing and social assistance), shelters, and other services dedicated to youth experiencing street-involvement. Each focus group lasted between 90 and 120 minutes. A research coordinator (MT) and research assistant/graduate student (RC) conducted the focus groups using open-ended facilitation, which allowed youth to guide conversations according to their own perspectives and priorities. All participants provided written informed consent and were compensated for their time with a $30 honorarium.²⁴

In November 2019, a half-day summit event was held in Vancouver (unfortunately, our partners in Kelowna and Prince George did not have the resources to plan and host a larger event). At the summit, youth participated in various discussion-based activities, and worked with an illustrator to develop visual summaries of their discussions (see Figures 1 and 2). The summit also included a “chill room” operated by two harm reduction workers (including KS) for youth who needed to take a break and/or use substances during the event. All participants provided their written informed consent to participate and were paid a $30 to $60 honorarium (some youth chose to attend the entire event and received $60, while others attended half of the event due to their schedules, abilities, and interests).²⁴

Figure 1.

Illustration from the Vancouver summit in response to the question, “What core values should guide the delivery of youth-focused substance use services?”

Figure 2.

Illustration from the Vancouver summit in response to the question, “What should be included in substance use treatment?”

Audio recordings from the focus groups and summit were transcribed verbatim by MT and RC, and coded thematically alongside observational field notes by MT using NVivo 12 Software. Following this initial coding process, the BC team met with partners on the pan-Canadian project to create a master codebook based on similarities in the data across sites. MT then re-coded all transcripts using the master codebook, adding site-specific codes for any content that did not fit the master codebook. Findings from the BC site were triangulated by drawing on programs of anthropological and critical qualitative health research conducted by DF and RK since 2007 with youth experiencing street-involvement and their providers in Greater Vancouver.

In BC, the study team worked closely with a Youth Advisory Council (YAC; a group of 10 youth with lived and living experience of substance use, mental health concerns, and street-involvement between the ages of 17 and 28) across the study period. YAC members contributed to the development of all research questions and protocols and took the lead role in planning and facilitating the Vancouver summit. YAC members also regularly contributed insights to our emerging interpretations of the study data via semi-monthly meetings (which have been conducted virtually since March 2020 due to COVID-19 social distancing mandates). Four YAC members (HA, KK, KS, and RD) were particularly involved in developing the analysis presented herein.

All participant names appearing below are pseudonyms. Demographic information is provided where it is possible to link participants’ demographic questionnaires to their quotations (this is more difficult for the summit participants due to the larger number of youth who attended the event). Ethical approval was attained from the University of British Columbia, Interior Health Authority, and Northern Health Authority (#H18-02911).

Findings

Focus group and summit participants were invited to self-administer a demographic questionnaire (Table 1). Youth were told that they could refuse any question they did not want to answer, and several chose to omit certain demographic information (e.g., age, gender, race). This form of refusal was possibly related to their wariness towards the multiple forms of surveillance to which young people experiencing street-involvement are regularly subjected in our setting (we discuss this issue in more detail below).^25,26

Table 1.

Participant demographic information

Self-identified Demographics	Number (percentage)
Age (range, mean)	14–24, 21.1
14–19	11 (16%)
20–24	37 (58%)
Preferred not to say	17 (26%)
Ethnicity*
White	29 (45%)
Indigenous	24 (38%)
Black/African Canadian	2 (3%)
Asian	2 (3%)
South American	2 (3%)
Preferred not to say	14 (22%)
Gender*
Woman	29 (45%)
Man	19 (30%)
Non-binary	4 (6%)
Two-Spirit	2 (3%)
Another gender	2 (3%)
Transgender	2 (3%)
Preferred not to say	14 (22%)
Site of participation
Vancouver	41 (64%)
Kelowna	14 (22%)
Prince George	9 (14%)
Illicit substance use in last 30 days
Yes	29 (45%)
No	21 (33%)
Preferred not to say	14 (22%)

^*Participants could select more than one option

During the focus groups and summit, youth expressed desires to achieve aspects of what some referred to as a “normal life” following treatment, which required having “somewhere to go next.” In the absence of desirable housing and adequate income, youth were often left with the crushing sense that, despite their best efforts, treatment would not ultimately help them to “get somewhere better.” Negative experiences in treatment settings were also shaped by the files that “followed” youth across care settings, inappropriate information sharing between providers, and an overemphasis on pharmacotherapies (namely, OAT and psychotropic medications).

(Re-)building a “normal life” and having “somewhere to go next”

Most of the youth in this study expressed strong desires to make big changes in their lives. Ben (a 21-year-old white man) was determined to move from Kelowna across the country to Ottawa. Matt (a 24-year-old white man) detailed his plans to get a specific kind of construction job in Vancouver. Val (a 21-year-old woman living in Prince George who chose not to disclose her ethnicity) was working on being able to re-enter the life of her young son. In general, the changes youth longed for included moving into stable housing that was comfortable, clean, and safe; securing a reliable and adequate source of income, preferably via regular employment; and finding meaningful ways to “fill their days,” such as spending time with friends, family, and romantic partners, pursuing hobbies and leisure activities, working on school, and advancing a career. Several youth referred to these desires as aspects of a “normal” life (although it should be noted that other youth in our context have critiqued this phrase). These desires are reflected in the summit illustrations (for example, see the “human connection” section of Figure 1 and the “social connection” section of Figure 2). They are also reflected in how Matt, introduced above, described at the summit his experience with Kadian:

Kadian has been the only thing that’s allowed me to take away that mental obsession [with heroin/fentanyl] so that I can actually start working on the other aspects of recovery. You know what I mean? Like start working, and doing normal life.

As we will discuss below, not all youth spoke as positively about pharmacotherapies and their role in recovery as Matt did. However, many agreed that successful treatment engagement was largely defined by the extent to which it allowed them to move forward with things like securing employment and housing and working on school. Many youth told us that their decision-making surrounding treatment, including when to go, was powerfully shaped by the imperative to make housing- and income generation-related plans. As Ben, introduced above, explained:

My plan is to try to get to treatment. The financial piece is the only thing holding me back. I want to go to treatment and then get out and be able to go to Ottawa. Like, that’s my plan, right? So that’s why I chose not to go [to residential treatment], so I can work. I can’t move to Ottawa with nothing. Like, I need to rebuild something, right?

In general, younger youth (ages 14 to 18) and older youth (ages 19 to 24) often articulated similar kinds of desires for their futures that centered on homes, jobs, relationships, and leisure. However, there were some notable distinctions. Older youth (like Ben) were generally more concerned with securing income. While housing was important to both younger and older youth, older youth spoke most frequently about needing to find a permanent place to live, and younger youth talked about the difficulties of finding somewhere safe to stay temporarily when they needed to “take a break” from unstable family and government care homes. Indigenous young people ages 14 to 18 in particular talked about the need for safe houses or even motel rooms that they could access for periods of time without fear of child protective services involvement.

Unfortunately, youth indicated that inside and outside of treatment settings, they received little support in accessing temporary or permanent housing, employment, and income. Even when older youth were enrolled in employment programs or able to access government-subsidized housing, they often noticed that these programs and accommodations were short-term. They did not ultimately allow them to re-build or re-enter what many understood as “normal life.” Additionally, government-subsidized supportive and temporary modular housing environments could be sites of intensive poverty, drug dealing and use, and chronic instability, and could therefore feel unsafe. While a number of youth insisted on figuring out housing and income/employment before accessing treatment, others decided to try accessing treatment first, in the hopes that addressing their substance use and mental health issues might make it easier to unlock the kinds of futures they desired.

“I am not my file”

Most of the older and younger youth in this study had extensive experience interacting with a variety of health and social services across their lives, including the child welfare, education, youth and adult criminal justice, and acute and community healthcare systems. Youth were therefore distinctly aware of how client files, patient charts, and other means of information sharing could impact their current and future interactions with services. For many youth, accessing treatment represented an attempt to “improve” their files, and gain access to the kinds of housing, employment, income, and other supports that had thus far been out of reach. Many youth recounted being explicitly told by their case managers, social workers, parents, and caregivers that their lives would open up in meaningful ways once they had completed a treatment program, minimized or eliminated their substance use, and addressed mental health issues.

It could therefore be devastating when files, charts, and information sharing seemed to reinforce the view that youth were “not making progress” or even “failing.” For example, during the summit, Sam shared a story about going to a residential treatment centre and then returning to a detox centre a few weeks later. At the detox, a provider told Sam that they recognized his name from previous conversations with colleagues at the treatment centre that Sam had attended previously:

I was at a detox center not long ago, after, like, I got kicked out of a treatment center a couple months earlier. I said my name and the guy who was giving me my meds [at the detox] said, “Oh, you’re the person coming back from [name of treatment center].” And I was like, “Why do you know that?” It was really frustrating to me, ‘cause in my head it was like, what was discussed about me? It felt like, “Oh, you fucked up,” you know what I mean?

Youth told us that they often worried about whether previous “failures” would follow them into future engagements with treatment. Some youth described attempting to manage what did and did not end up in their files. Ellie described at the summit:

Going to [a local service hub], they hand out harm reduction supplies. You would think you’d be able to grab harm reduction supplies and leave, and have them not tell other people. But there, you get the harm reduction supplies, and then they write it down on a list that gets passed around to all the doctors, so now my Suboxone doctor knows I picked up harm reduction supplies, you know what I mean?

Many youth in this study praised service hubs and intensive case management teams as essential supports in their lives. However, Ellie and other youth explained that the information sharing and surveillance that characterizes these places and teams could lead some youth to avoid care, because they worried over “who knew what” about the things going on in their lives, and what the consequences of that knowledge might be.

While youth highlighted instances of inappropriate information sharing, they also emphasized that it could be important in some circumstances. For example, youth described how “draining” it is to explain “the same story over and over and over again.” Examples of information sharing that youth described in positive terms involved instances where providers worked with them on a case-by-case basis to decide what information should be shared, and with whom. After recounting the negative experience above, Sam gave an example of when he felt that information sharing had been more positive because he had retained an appropriate level of control over what was shared:

So my probation officer wanted to call my counsellor [about a recent trip to detox], and it was really nice that my counsellor, you know, wouldn’t answer the phone until they talked to me and figured out what I was okay with. Just giving me that heads up, like, “Hey I got a call, what are you okay with me sharing about what’s going on in your life as of this very moment?”

Like Sam, a number of youth emphasized that interactions with the various providers who are accessing their files and charts generally go better when they first and foremost affirm where a young person is at in that moment, rather than focusing on what has happened in the past. “I am not my file” was a sentiment that we heard expressed by older and younger youth on multiple occasions.

“They just pass you pills”

Youth across the province were unanimous in advocating for more youth-focused mental health and substance use services, including in- and out-patient treatment programs. However, their perspectives on pharmacotherapies, namely OAT and psychotropic medications, were much more mixed. Older and younger youth expressed ambivalence, suspicion, or aversion towards these pharmacotherapies, which they often felt were being “pushed on them” in treatment settings in the absence of other kinds of supports. Among those expressing concerns about pharmacotherapies, many of these youth understood them as “quick fixes” that could not address the deeper issues they were contending with. As Shayna, a 16-year-old Indigenous woman from Vancouver, shared:

When it comes to [mental health and substance use] treatment, it should not just be like, “Take this pill, you’ll feel better in two weeks.” It’s medication, it’s counselling, it’s therapy, it’s also just getting out and spending more time with other people. It’s not just medication and staying in one place [residential treatment]. It’s about the support you get, and the people around you.

Cory, a 23-year-old Indigenous man in Prince George, similarly explained:

[At a treatment center] you’re focusing on, like, your eating disorder, your depression, your drug use, and all that jazz. But they don’t really help you with your inner self. They just pass you pills, and kind of make you feel better – better for the day.

Youth openly questioned whether pharmacotherapies could make a meaningful difference in their lives when it came to priorities like finding housing and employment. In a number of cases, longer-term adherence to OAT was viewed as “just another addiction,” and therefore incompatible with how young people envisioned “real recovery.” Another source of ambivalence, suspicion, and aversion towards pharmacotherapies was the frequent changes made to youth’s prescriptions. Older and younger youth described how medications, doses, and dispensing guidelines changed at dizzying rates. These kinds of treatment trajectories were tremendously difficult for many to navigate, especially in the context of the everyday emergencies of street-involvement. For a number of youth, these frequent changes created confusion and frustration, particularly as broader life circumstances, such as unstable housing, unemployment, and disconnection from school, remained largely unchanged. Many youth concluded that adhering to pharmacotherapies “just wasn’t worth the hassle.”

Some youth connected negative engagements with pharmacotherapies to painful experiences of institutionalization that stretched across their lives. Youth framed hospitals in particular as potentially traumatic environments (see Figure 2), and the majority of Indigenous youth described experiencing racism in treatment and hospital settings. After a long discussion about traumatic and racist experiences in a hospital emergency department and psychiatric unit, Holly and Brooke, both 21-year-old Indigenous women from Prince George, described their experiences with being “given a lot of pills” at detox:

Brooke: They give you a lot of pills [at detox]. Like, a lot.

Holly: I don’t take pills.

Brooke: [Taking pills] is just as bad [as using illicit substances].

Holly: I just think there’s other remedies, like, other things that could help. Like marijuana. [Marijuana] just like, focuses your mind.

Doing it on your own

For many youth, avoiding certain kinds of treatment programs (e.g., pharmacotherapies, Alcoholics and Narcotics Anonymous programs) was as important as being able to access others. Several older and younger youth described avoiding treatment settings where they thought pharmacotherapies would be the primary focus of care, preferring instead to manage their substance use and mental health issues on their own. Like Holly, many spoke positively about using cannabis, psychedelics, and cigarettes as harm reduction and treatment. Youth told us they preferred these treatment modalities because they could manage “doses” and make decisions about stopping and starting without professional oversight.

Particularly for older youth, “doing it on your own” seemed to be the only viable option after many years of repeatedly experiencing frustration, confusion, and disappointment in their efforts to get somewhere better via treatment engagement. “I don’t believe in treatment,” Tony, a 24-year-old white man, told us bluntly in Kelowna. “I think we should stop focusing on treatment, and start focusing on housing.”

Other youth — and in particular Indigenous youth — told us that doing it on their own could be safer. This included younger youth, who often feared that accessing any kind of help could precipitate child protective services involvement and possible removal from their families of origin. For example, Danita, a 15-year-old Indigenous woman from Vancouver, told us that many of her friends avoided staying at the safe houses frequented by intensive case management teams, because of concerns that individuals from these teams might report their families to child protective services and they would be “taken away” and placed in group or foster homes. “[The child welfare system] is racist,” Danita stated plainly. “And once you’re in the system, you don’t get out.”

While the integration of treatment into settings like safe houses and shelters can increase access, it can also signal danger to those youth who have navigated institutionalization and racism across their lives, and are wary of professional surveillance.

Discussion

We join a growing body of literature advocating for structural responses to substance use and the overdose crisis.^14,27–29 In the present study, youth particularly emphasized the centrality of permanent and temporary housing and adequate income (preferably via steady employment) to realizing their treatment and recovery goals. Treatment interventions should be delivered alongside housing and employment programs that support young people’s efforts to “(re-)build” or “re-enter” the lives they want for themselves, or to simply “take a break” from the everyday emergencies of their lives, such as tumultuous home situations.¹⁴ Treatment interventions must foreground considerations of where youth are going next and their desires for the future. They should honor young people’s complex personhoods and capacity for change. These findings and recommendations echo two previous studies focused on youth perspectives on treatment and recovery, which found that youth valued individualized, multi-dimensional approaches to treatment that allowed them to work towards futures not defined by substance use.^30,31

Many youth expressed ambivalence, suspicion, or aversion towards a medicalized model of care: that is, a model of care that feels like it is primarily focused on surveillance and monitoring (e.g., via the patient charts and files that “follow” youth from setting to setting) and the provision of pharmacotherapies, and less focused on relationship-, trust-, and future-building. Youth desired meaningful connections with providers, and more control over the oftentimes precarious and chaotic trajectories of their lives.^14,32 They did not want to be approached as a “problem” to be solved through surveillance, monitoring, and pharmacotherapies. A medicalized model of care could actually signal danger to youth who had experienced multiple forms of institutionalization across their lives.³³ This includes many of the Indigenous young people who participated in this study, for whom a medicalized model of care could become entwined with other systems of control (e.g., the child welfare system) that continue to reflect settler colonial projects. Most Indigenous youth participants also described experiences of explicit racism within the healthcare and child welfare systems, which could further lead them to disengage with care altogether.^13,16

Our findings underscore the importance of non-institutionalizing, voluntary approaches to providing youth-focused treatment, which reflect the principles of cultural safety and humility.^32,34–36 It is imperative that young people are empowered with control over their treatment trajectories, including decision-making surrounding pharmacotherapies and information sharing. Connecting youth with harm reduction is another essential means of fostering their self-determination in and across treatment settings.^11,34 Moreover, we must listen to and acknowledge youth’s own harm reduction strategies (i.e., using cannabis) and work collaboratively with them to develop treatment plans and timelines.³⁷

While these are themes that emerged out of our work with young people experiencing street-involvement, they have much broader applicability. Providers should continually open up conversations with all youth regarding their desires to avoid, delay, or modify their engagement with specific treatment modalities, such as OAT and psychotropic medications, and find ways of working with youth towards shared goals, which may include making plans to taper a young person off of OAT, for example.³⁸ While the shorter-term use of OAT may not align with evidence-based addiction medicine guidelines, our findings demonstrate that when youth feel like pharmacotherapies are being “pushed onto them” – perhaps particularly in the absence of broader structural responses and meaningful changes in their life circumstances – they frequently come to the conclusion that the providers helping them do not understand their treatment and recovery goals, and ultimately decide to “do it on their own.”

Finally, our findings contribute to ongoing discussions about the tension between providing effective, integrated substance use and mental health treatment to youth on the one hand, and ethical principles such as patient confidentiality and self-determination on the other.^39–41 The youth in this study emphasized that integrated care and support can be problematic if it compromises their confidentiality (as in Ellie and Sam’s stories) or signals danger of unwanted intervention (as Danita described). Again, these findings have applicability beyond young people experiencing street-involvement. Youth’s confidentiality must be protected whenever possible, and should always be protected when it comes to accessing harm reduction programs. Foregrounding youth autonomy and self-determination is essential to building the kinds of relationships that are anti-racist and potentially life-saving in the context of a toxic drug supply.