Ending Canada’s opioid overdose crisis will likely require much more than sophisticated drug therapies. In fact, it might mean following the lead of First Nations health-care providers and transforming how we think about and deliver medical services.
First Nations people are dying of opioid overdoses at three times the rate of the general population. Hidden in that data are Canada’s most-neglected victims — Indigenous women.
Unlike in the general population where men comprise 80 per cent of the victims, Indigenous women are as likely to overdose or die as their brothers, fathers, husbands and sons.
They are eight times more likely to overdose than other women, and five times more likely to die from an overdose.
It’s not really surprising, says Dr. Evan Adams, the First Nations Health Authority’s chief medical health officer. The terrible numbers track other devastating indicators of how their health and longevity diverge from those of other Canadians.
“A lot of First Nations women who have substance-use disorders are exploited women. They are women who are victimized by the sex trade. They’re victimized by their partners,” said Adams, who worked for five years in Vancouver’s notorious Downtown Eastside, the epicentre of Canada’s opioid crisis.
What the opioid crisis highlights for him is the endemic problem of the western medical model, where people go passively to doctors’ offices and say, “Heal me.”
“Our (First Nations) model is that the doctor gives you a chance to get better. But, you make yourself better,” he said. “It’s your family that does most of the work of helping you get better, not that doctor who you visit for 15 minutes every week, if you’re lucky.”
Unlike in the western model, healing and wellness in the traditional Indigenous way involve mind, body and spirit. For First Nations men and women to achieve wellness, Adams said they require much more than medicine.
“They need healers who can do ceremony. Maybe they need love. They need justice.
“How can a woman recover from opioid use disorder when you won’t let her see her children? It’s disgusting,” he said.
The day Adams and I met, the FNHA offices were being “swept” by a group of elders carrying cedar boughs and candles using traditional ceremonies to restore the spirits of the people who work there.
“Some people would say an elder is less trained in opioids than an addictions physician,” Adams said. “But wouldn’t it be nice to have both?”
It’s not that FNHA rejects modern medicine. It continues to expand access to opioid agonist treatments such as methadone and Suboxone, which quell cravings, making it available at all FNHA nursing stations and at four of the nine FNHA-funded residential treatment centres. FNHA reimburses treatment fees charged by private clinics and has spent $2.4 million in grants to 55 communities for harm-reduction programs.
Yet, for Adams and his staff, drug therapies are only a small part of what he calls harm reduction’s suite of services.
“Harm reduction is not just, ‘Let’s make sure you don’t overdose.’ It’s the whole person that you have to treat, not just this one aspect of the person that is craving opioids.”
To incorporate First Nations wisdom into other programs, FNHA created two peer coordinator jobs at the Crosstown Clinic in the Downtown Eastside. Its compassion inclusion initiative has engaged another 144 Indigenous people with lived experience across B.C., and its Indigenous wellness team has taught indigenous harm-reduction and wellness programs in 180 communities.
“Opioid use disorder is everyone’s business. It’s yours and it’s mine and it’s everyone around us. It’s not just the domain of physicians with 24 years of training,” he said. “Why can’t Grandma help, or a family member?”
What concerns Adams about the response to the opioid crisis that is heavily grounded in the medical model is that it could widen the gap between his people and mainstream Canadians.
Indigenous people don’t necessarily trust health providers who don’t look like them or where there is no acknowledgment of the historical trauma they have suffered and their unique experiences in the world.
That’s just one more reason why the FHNA, which is unique in Canada, is so adamant that it must transform the way health care is delivered to its people so that they are empowered to help in their own healing within their own circles of trusted friends, family and elders.
This current crisis is rooted in the western medical model. The seeds were sown by an aggressive marketing campaign by Purdue Pharma, which falsely promoted its Oxycodone as being non-addictive. What followed was an epidemic of opioid over-prescription by physicians and other health-care professionals that eventually created a demand for synthetic opioids on the black market.
With so many deaths and no end in sight, this might be the time for all of us to reconsider whether the best responses to this crisis ought to be done within a much broader context of healing and an expanded understanding of what wellness really means.
Foster parents, adoptive caregivers, extended family members caring for children and Community Living BC (CLBC) home-share providers will each receive a boost in support payments – the first increase in 10 years – to make life more affordable and provide more support to some of B.C.’s most-vulnerable children and adults.
“Caregivers open their homes and hearts to children and adults who need their support,” said Premier John Horgan. “For 10 years, the cost of living has steadily increased while caregiver rates have stagnated. Our government is making different choices by increasing support rates for caregivers, to make life more affordable and build stronger, more inclusive communities.”
Budget 2019 provides approximately $64 million over three years to the Ministry of Children and Family Development and $45 million over three years to the Ministry of Social Development and Poverty Reduction to boost monthly caregiver rates.
“I have met with so many foster parents and family caregivers, especially grandmothers, who have been struggling to provide for the children in their care. Their stories resonated with me and I knew this was the right thing to do,” said Katrine Conroy, Minister of Children and Family Development. “The most important thing is that children are raised in a safe, loving home, and I am proud to be part of a government that is addressing a long-standing inequity for extended families, especially Indigenous families, and investing in the well-being of all children when they need it most.”
For family members caring for children through the Extended Family Program, support will nearly double and will be paid at the same rate as foster caregivers. This increase is part of government’s commitment to meaningful reconciliation with Indigenous peoples and addresses recommendations by Grand Chief Ed John.
“I am pleased the B.C. government is taking steps to address this key recommendation of my report, which identified the disparity between the caregiver rates and extended family rates as being a clear barrier to permanency for many children in care,” said Grand Chief Ed John. “Bringing these rates in line will undoubtedly lead to both an increase of permanent placements as well as an increased quality of care for children placed with extended family members. This is especially important for Indigenous children in care as it will result in greater opportunities for placements with extended family within their communities, thereby maintaining access to their culture and language.”
Budget 2019 will provide foster parents with an additional $179 each month to help cover basic necessities for children in their care, including food, shelter and clothing.
Eligible adoptive parents, many of them adding children with special needs and/or sibling groups to their families, will receive an additional $105 to $120 per month for post-adoption assistance to help meet increases in the costs of living.
“This announcement is a wonderful acknowledgement of the work that foster parents and other caregivers do to emotionally and financially support children and youth in B.C.,” said Russell Pohl, a long-time foster and adoptive parent. “It’s good to know that this government is looking out for us and valuing our contribution.”
Community Living BC home-share provider rates are based on the individual needs of the person in care. The $45 million in funding over three years is a 15% increase for the program. After 10 years without an increase in home-share provider funding, CLBC is updating the program rate structure to better align with the disability-related needs of each individual.
“Home-share promotes social inclusion and helps keep people with developmental disabilities connected to their communities,” said Shane Simpson, Minister of Social Development and Poverty Reduction. “Over the last year, we have engaged with individuals with developmental disabilities and their families to look closely at CLBC supports and plot a new vision for the next 10 years. This increase recognizes the important work of home-share providers. It is long overdue, well deserved and one more step in the work we are doing with the community to create a truly accessible and inclusive province.”
CLBC will be working with home-share providers over the next few weeks to work through the details. The rate increases will vary under the new rate structure, but all home share providers will receive an increase over the next two years.
In 2018, CLBC engaged with home-share providers to find out how government can better support them in their vital work. The primary concern reported was low rates, which had not kept up with rising household costs and growing demand for the program.
Rate increases for Ministry of Children and Family Development caregivers will come into effect April 1, 2019.
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The Supreme Court of British Columbia says a woman’s rights were violated when she was held in hospital for almost one year without being provided with any written reasons for the detention or an opportunity for legal advice.
In a ruling released this week, Justice Lisa Warren describes the 39-year-old woman as “highly vulnerable” and says she suffers from cognitive impairments, mental health issues and fetal alcohol spectrum disorder.
The ruling says staff at the Fraser Health Authority had good reason to believe the woman, identified as A.H. in a court document, had been abused and was at risk of serious harm when she was taken into care on Oct. 6, 2016.
But it says there is also no doubt the health authority could have promptly applied for a provincial court order authorizing the provision of support and services for her.
The decision says A.H. was held in conditions that violated her residual liberty, including being placed in mechanical restraints, not allowed out of a facility to get fresh air and restrictions were placed on visitor, phone and internet access.
A provincial court judge granted the required order to the health authority on Sept. 22, 2017, on the grounds the woman was abused or neglected, was incapable of deciding not to accept the services proposed and would benefit from the support.
VICTORIA — Auditor general Carol Bellringer says emergency ambulance response times in British Columbia’s urban areas are well below their time targets.
Bellringer says in an audit on emergency health services that missed response times in cities is significant because urban areas account for 86 per cent of B.C.’s life-threatening 911 calls.
Her report says when emergency response-time targets are not met, patients may not be receiving care when they need it.
The audit, for the period running April 2016 to December 2017, says ambulances in urban areas reached their nine-minute response time target on 50 per cent of life-threatening calls, while responses in rural and remote areas achieved and exceeded the time targets.
The report says B.C. Emergency Health Services has recently added more staff and introduced a new dispatch process, but data from 2018 indicates only a slight improvement in urban response times on calls to 51 per cent.
Bellringer’s report also calls for better co-ordination between ambulance services and fire departments, which often dispatch firefighters to emergency calls.
People walk past ambulances in the Emergency bay at St. Paul’s Hospital in Vancouver, B.C
Jim Mann wants everyone to know that he’s more than his dementia.
He was diagnosed with Alzheimer’s 12 years ago, but that doesn’t mean he can’t be involved in making decisions about his health.
The distinction is important for Mann — and many others living with dementia. The Surrey resident is thinking a lot about consent these days after being part of an advisory committee on health care consent for people with dementia. Their report, Conversations About Care, was released Feb. 27.
Mann, 70, said professionals in health care still make assumptions about people with dementia.
He recalled an emergency room incident when a nurse yelled his name and added “patient only.”
“My wife and I stood up and walked over. Halfway there, she (the nurse) yelled again ‘patient only.’ I got up to her and said ‘my wife needs to be with me. I have Alzheimer’s.’ She turned around and looked me up and down and said ‘well, you look fine.’ “
Mann said that while the public might not always understand that dementia is a cognitive impairment not a physical one and therefore not visible, he believes that kind of language isn’t acceptable in a health care environment.
“Within the medical system, I’m sorry, you should really know this by now,” he said.
The goal of the project’s Conversations About Care report is to ensure that the legal framework in B.C. remains strong enough to protect people living with dementia as well as those named as their legal substitutes.
In 2018, about 70,000 people in B.C. were living with dementia. By 2033, that number is estimated to increase to almost 120,000.
Krista James, national director of Canadian Centre for Elder Law at the University of B.C., said the report is intended to start a conversation about the rights of people with dementia.
“I feel that we’re missing that rights-based lens that recognizes the rights of older people to make choices about what happens to them,” she said.
“Although the law is different in each jurisdiction, and this report applies specifically to the experience in B.C., we need to open up that conversation to think about the citizenship rights of older people in a health care context. It’s really urgent.”
The report’s 34 recommendations were developed through a process that included consultation with people living with dementia, family caregivers, health care professionals, and others who deal with consent on a regular basis.
James said the origins of the report came from phone calls she received from family caregivers who felt frustrated that decisions were being made without consultation.
“From our perspective, the health care consent law in B.C. is super robust and I think fairly clear,” James said.
“It says if it’s not an emergency, you need to get that prior informed consent. The care facility regulations that govern long term care don’t seem to be consistent. There is a lot more wiggle room.”
That means some physicians, licensed practical nurses and care aids don’t understand the concept of prior informed consent for non-emergency care.
“I have talked to a few people who think that if the person is in the care facility they have consented to all the care that the people who work there think is the right care for them,” she said.
“Some of the staff don’t understand they have to get consent. They confuse admission to the care facility with consent to all the meds.”
One of the report’s recommendations calls for all licensed long-term care facilities to set out rules on restraints, including chemical restraints (medications such as antipsychotics used to control aggressive behaviour).
Other big concerns include the challenge of sorting out situations where family members making decisions about care for someone with dementia can’t agree on what to do. One way to address that, James said, is to have social workers involved in helping families find a solution.
James said the report recognizes that health care providers are never going to be experts on the law.
“They’re not lawyers,” she said. “We shouldn’t expect them to be experts on the finer details of the law. They need to have support so they can properly interpret the law.”
Recommendations of the report
• Improving health care decision-making laws in B.C. by adding language to recognize that people’s capacity to make health care decisions can vary from day to day and decision to decision, and that they be involved to the greatest degree possible in all case planning and decision-making.
• Address barriers to informed consent experienced by Indigenous people and people who need language interpretation, and create financial incentives to support physicians so they can spend time to talk with patients and families.
• Create a review tribunal to allow people living with dementia to review health care decisions made by substitute decision makers.
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