étude de cas / case study

Responding to Substance Use in Racialized Communities in Canada in the Current Polysubstance Era

Manisha Pahwaa, Chetan Mehtab

Résumé

Abstract

Les personnes racialisées subissent des dommages excessifs et évitables liés à la consommation de substances, ce qui soulève des questions sur la manière dont la justice doit être recherchée par le biais des politiques de santé. Cette étude de cas vise à montrer comment les perspectives bioéthiques peuvent contribuer à éclairer les approches de la justice raciale dans la prise de décision en matière de politique de santé publique concernant la consommation de substances psychoactives.

Racialized people experience excess and preventable harm from substance use, raising questions about how justice ought to be pursued via health policy. This case study is intended to surface how bioethical perspectives may contribute to informing approaches to racial justice in public health policy decision-making about substance use.

Mots-clés

Keywords

analgésiques, opioïdes, benzodiazépines, méthamphétamine, réduction des méfaits, racisme, antiracisme, éthique, équité en matière de santé

analgesics, opioid, benzodiazepines, methamphetamine, harm reduction, racism, antiracism, ethics, health equity

Affiliations

a School of Physical and Occupational Therapy, McGill University, Montréal, Québec, Canada

b Anishnawbe Health Toronto, Toronto, Ontario, Canada

Correspondance / Correspondence: Manisha Pahwa, manisha.pahwa@mcgill.ca

introduction

Substance use is a public health crisis in Canada (1); and racism is a key factor shaping how racialized people experience the harms of substance use (2). Within and outside of health care, racism is deeply embedded in the design and implementation of laws, policies, practices, and norms related to substance use (institutional racism) (3) and how racialized people who use substances are treated by service providers (interpersonal racism) (3). Racism leads to disparities in morbidity and mortality and social and economic costs that constrain the health and well-being of racialized people (4). In the context of substance use, racism causes Black and Indigenous people to be more likely to be blamed, arrested, and imprisoned for substance use and to suffer fatal and non-fatal overdose compared to White people who use substances (2,5-7). One of the locations where racism occurs is in harm reduction and treatment services, which are a main source of care for people who use substances. Harm reduction services have not been equitably accessible for racialized groups and these services have lacked cultural safety (8,9). This contributes to racialized groups experiencing high rates of morbidity and mortality from substance use.

Previous work has stated the need for antiracist and culturally responsive harm reduction and treatment services that centre and respond to the lived experiences, needs, social contexts, and values of racialized groups (8,9). Bioethics research and practice have contributed significantly to debates about harm reduction and the decisions of policymakers to implement supervised consumption sites as a matter of health equity; however, relatively less attention has been given to racism (10). The urgency of a bioethical perspective is magnified in the current polysubstance era, where combinations of opioids and other synthetic substances further increase the risk of death compared to the use of opioids (11) and are poised to deepen existing patterns of harm along racialized lines.

Substance use has been defined as the use and bodily absorption of selected substances that may lead to dependence and other harmful effects (12). Substance use continues to accelerate in Canada (13), transitioning from a crisis of overdose and death due to opioids only, to a crisis of even higher risks of overdose and death due to combined uses of synthetic opioids with stimulants and benzodiazipines (11). In this current polysubstance era, people who use substances include growing numbers of diverse racialized people. Treatment and harm reduction services are key for mitigating the health effects of substance use but may be of limited effectiveness for polysubstance use since they were developed for opioids only (11).

This case is an invitation to engage with the question of how public health policy ought to approach substance use in racialized communities in Canada in the current polysubstance era. It was developed for teaching in a graduate course on racism, intersectionality, and health equity in a Canadian school of public health (MP). It was informed by published evidence about substance use patterns and services in Canada, our identities and experiences as members of racialized communities, and our background in public health ethics and policy research (MP) and providing substance use care oriented to the needs of Indigenous communities (CM).

Case

Opioid use is a priority public health issue in a mid-sized Canadian city rapidly growing in population size and sociodemographic diversity. The city’s public health unit operates one supervised consumption site located where opioid use is concentrated. Service users do not need to provide health insurance or personal identification to access free treatment and harm reduction services at this site.

To help inform the renewal of federal and provincial funding for the site, the city’s public health unit conducted a quantitative study of opioid overdose and a qualitative study of emerging issues in the city. Key findings were that incidence rates of opioid overdose were increasing overall with the highest rates found among males employed in high-income construction work. There were no available quantitative data by ethnicity. However, in the qualitative study, supervised consumption site service providers reported a surge in polysubstance use, including among racialized young men who are newcomers and international students. Service providers also reported that these sites are beyond capacity, ill-equipped to treat and reduce the harms of polysubstance use, and that there is an urgent need for epidemiologic evidence and services tailored to racialized communities (14).

Based on this study, the city’s public health unit wants to request renewed funding for the existing supervised consumption site with additional funding to develop, implement, and evaluate antiracist and culturally responsive polysubstance treatment and harm reduction services. However, media reports have found a low level of public support for renewed funding. There is also public debate about whether antiracist and culturally adapted services are warranted and the need for funding for competing health issues affecting racialized communities in the city.

Ethical analysis

This case study presents a familiar ethical dilemma in public health, which is how to allocate limited public resources to improve the health of populations. At a coarse level, there is the question of whether to allocate resources toward substance use treatment and harm reduction, or other health issues that are important according to racialized people in this jurisdiction – health issues that are likely less stigmatized, well-documented in research, and more prevalent than substance use. At a more granular level, that is somewhat implicit in this case study, is the consideration of all potential pathways for public health to address polysubstance use in racialized communities; specifically, how much resources to allocate to social and political determinants versus treatment and harm reduction services. At an even more refined level – and what distinguishes this case study as a justice issue – is the question of whether antiracist and culturally adapted services are warranted. The key stakeholders in this case seem to agree that this is a resource allocation issue but have competing conceptions about which specific resource allocation issue is at stake and a lack of consensus about the justice dimension. Thus, the public health unit has two tasks: first, to justify their reasoning for their request to allocate resources for more treatment and harm reduction services versus other health issues and the determinants of polysubstance use, overdose, and mortality in racialized communities, and second, to justify why investment in antiracist and culturally responsive approaches is needed.

Discussion questions

1. Antiracist and culturally responsive care require institutions and service providers to effectively address power imbalances and provide safe and respectful care. What might this look like for racialized people in harm reduction and treatment services, and who should decide?
   2. Racism intersects with other forms of discrimination salient to polysubstance use, such as gender discrimination (15). How should intersectionality be considered when developing and implementing polysubstance treatment and harm reduction services for racialized communities?
   3. There is conflicting evidence about whether culturally and ethnically concordant health care promotes racial justice. What is the premise of culturally and ethnically concordant care, and should it be applied in this situation?
   4. Racial justice is often challenged by the lack of health evidence for specific racialized and ethnic groups in Canada. How do normative assessments about the value of quantitative and qualitative research influence public health policymaking about polysubstance use? What should be done by public health practitioners to uphold epistemic justice for racialized communities in policy decision-making?

Reçu/Received: 11/3/2024

Publié/Published: 2/12/2024

Remerciements

Acknowledgements

MP tient à remercier Ananya Banerjee et les étudiants de son cours d’hiver 2024 sur le racisme, l’intersectionnalité et l’équité en matière de santé à l’Université McGill, dont la demande d’apprentissage de la bioéthique par le biais d’une exploration de la consommation de substances dans les communautés racialisées au Canada a stimulé l’élaboration de cette étude de cas. MP bénéficie d’une bourse d’excellence, de diversité et d’indépendance en recherche (PEDR) des Instituts de recherche en santé du Canada (IRSC) en début de carrière.

MP would like to acknowledge Dr. Ananya Banerjee and the students in her Winter 2024 graduate course on racism, intersectionality, and health equity at McGill University, whose request to learn about bioethics through an exploration of substance use in racialized communities in Canada stimulated the development of this case study. MP is supported by a Canadian Institutes for Health Research (CIHR) Research Excellence, Diversity, and Independence (REDI) Early Career Transition Award.

Conflits d’intérêts

Conflicts of Interest

Aucun à déclarer

None to declare

Édition/Editors: Ji-Young Lee, Patrick Gogognon & Julien Brisson

Les éditeurs suivent les recommandations et les procédures décrites dans le Code of Conduct and Best Practice Guidelines for Journal Editors de COPE. Plus précisément, ils travaillent pour s’assurer des plus hautes normes éthiques de la publication, y compris l’identification et la gestion des conflits d’intérêts (pour les éditeurs et pour les auteurs), la juste évaluation des manuscrits et la publication de manuscrits qui répondent aux normes d’excellence de la revue.

The editors follow the recommendations and procedures outlined in the COPE Code of Conduct and Best Practice Guidelines for Journal Editors. Specifically, the editors will work to ensure the highest ethical standards of publication, including: the identification and management of conflicts of interest (for editors and for authors), the fair evaluation of manuscripts, and the publication of manuscripts that meet the journal’s standards of excellence.

references

1. Humphreys K, Shover CL, Andrews CM, et al. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. The Lancet. 2022;399(10324):555-604.
   2. Hagle HN, Martin M, Winograd R, et al. Dismantling racism against Black, Indigenous, and people of color across the substance use continuum: A Position statement of the Association for Multidisciplinary Education and Research in Substance use and Addiction. Substance Abuse. 2021;42(1):5-12.
   3. Needham BL, Ali T, Allgood KL, Ro A, Hirschtick JL, Fleischer NL. Institutional racism and health: A framework for conceptualization, measurement, and analysis. Journal of Racial and Ethnic Health Disparities. 2023;10(4):1997-2019.
   4. Elias A, Paradies Y. The costs of institutional racism and its ethical implications for healthcare. Journal of Bioethical Inquiry. 2021;18(1):45-58.
   5. The Alberta First Nations Information Governance Centre and Government of Alberta. Alberta Opioid Response Surveillance Report: First Nations People in Alberta. Edmonton: Government of Alberta; 2021.
   6. Substance Abuse and Mental Health Services Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. Publication No. PEP20-0502-001. Rockville, Maryland: Office of Behavioral Health Equity, Substance Abuse and Mental Health Services Administration; 2020.
   7. First Nations Health Authority. Overdose Data and First Nations in BC. Vancouver, British Columbia: First Nations Health Authority; 2017.
   8. Godkhindi P, Nussey L, O’Shea T. “They’re causing more harm than good”: a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs. Harm Reduction Journal. 2022;19:96.
   9. Ontario Agency for Health Protection and Promotion. Rapid Review: Race-based Equity in Substance Use Services. Toronto: Public Health Ontario; 2022.
  10. Vearrier L. The value of harm reduction for injection drug use: A clinical and public health ethics analysis. Disease-a-month. 2019;65(5):119-41.
  11. Fischer B. The continuous opioid death crisis in Canada: changing characteristics and implications for path options forward. Lancet Regional Health – Americas. 2023;19:100437
  12. US Centers for Disease Control and Prevention. Substance Use: U.S. Centers for Disease Control and Prevention. CDC National Center for Health Statistics; 2023.
  13. Public Health Agency of Canada. Modelling Opioid-related Deaths During the Overdose Crisis. Government of Canada; 2023
  14. Dayal P. Canada’s drug crisis affecting newcomers, but lack of data makes it hard to know severity of problem. CBC News. 25 Feb 2024.
  15. Vu M, Li J, Haardörfer R, Windle M, Berg CJ. Mental health and substance use among women and men at the intersections of identities and experiences of discrimination: insights from the intersectionality framework. BMC Public Health. 2019;19:108.

## Références

K, Shover CL, Andrews CM, et al. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. The Lancet. 2022;399(10324):555-604.

HN, Martin M, Winograd R, et al. Dismantling racism against Black, Indigenous, and people of color across the substance use continuum: A Position statement of the Association for Multidisciplinary Education and Research in Substance use and Addiction. Substance Abuse. 2021;42(1):5-12.

BL, Ali T, Allgood KL, Ro A, Hirschtick JL, Fleischer NL. Institutional racism and health: A framework for conceptualization, measurement, and analysis. Journal of Racial and Ethnic Health Disparities. 2023;10(4):1997-2019.

A, Paradies Y. The costs of institutional racism and its ethical implications for healthcare. Journal of Bioethical Inquiry. 2021;18(1):45-58.

5The Alberta First Nations Information Governance Centre and Government of Alberta. Alberta Opioid Response Surveillance Report: First Nations People in Alberta. Edmonton: Government of Alberta; 2021.

6Substance Abuse and Mental Health Services Administration. The Opioid Crisis and the Black/African American Population: An Urgent Issue. Publication No. PEP20-0502-001. Rockville, Maryland: Office of Behavioral Health Equity, Substance Abuse and Mental Health Services Administration; 2020.

7First Nations Health Authority. Overdose Data and First Nations in BC. Vancouver, British Columbia: First Nations Health Authority; 2017.

P, Nussey L, O’Shea T. “They’re causing more harm than good”: a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs. Harm Reduction Journal. 2022;19:96.

9Ontario Agency for Health Protection and Promotion. Rapid Review: Race-based Equity in Substance Use Services. Toronto: Public Health Ontario; 2022.

L. The value of harm reduction for injection drug use: A clinical and public health ethics analysis. Disease-a-month. 2019;65(5):119-41.

B. The continuous opioid death crisis in Canada: changing characteristics and implications for path options forward. Lancet Regional Health – Americas. 2023;19:100437

12US Centers for Disease Control and Prevention. Substance Use: U.S. Centers for Disease Control and Prevention. CDC National Center for Health Statistics; 2023.

13Public Health Agency of Canada. Modelling Opioid-related Deaths During the Overdose Crisis. Government of Canada; 2023

14Dayal P. Canada’s drug crisis affecting newcomers, but lack of data makes it hard to know severity of problem. CBC News. 25 Feb 2024.

M, Li J, Haardörfer R, Windle M, Berg CJ. Mental health and substance use among women and men at the intersections of identities and experiences of discrimination: insights from the intersectionality framework. BMC Public Health. 2019;19:108.