Bearing witness

N Siritsky, RSW

The stories behind the numbers

Defining the problem

We’re at the intersection of multiple and compounding crises. Still reeling from the devastating effects of the pandemic, struggling to recover from Hurricane Fiona’s destruction, inflation, housing insecurity, a straining health care system whose workers are burning out, many amongst us are having a difficult time. For those amongst us who were already dealing with a post-industrial decline, and especially for those who have inherited intergenerational trauma and continue to be disproportionately impacted by all of these dynamics due to systemic racism, queerphobia and colonization, it is not surprising that a growing number of individuals self-medicate to cope.

Alternative approaches that emphasize cultural safety

I spoke with a number of individuals trying to spearhead change in their communities to better understand the problem, as well as to begin to consider what solutions might actually help make a difference in the lives of all those affected.

Five years ago, Ryan Gould and a group of childhood friends co-created the Membertou Men’s Society, a non-profit organization as a result of the lack of culturally specific services that were available to meet his needs. They offer support to Indigenous and non-Indigenous men in the Membertou area. “We strongly encourage our men to love themselves enough to speak up without being judged, seen as being weak, or vulnerable,” says Gould. “We want to end the stigma against men speaking out about their feelings or emotions.We want to end the stigma of how society is treating, labelling, shaming people suffering from mental health and addictions. This way our men are able to receive the support and services they need to take care of themselves, their family, and when they’re ready the whole community.”

Being able to feel safe to access stigma-free and culturally safe support drove Liane Khoury, health promoter at Nova Scotia Health (NSH) and Patrick Maubert, a Dalhousie BSW student, to co-found Untoxicated Queers.This weekly virtual peer support group for 2SLGBTQIA+ individuals began in the spring of 2020. The project first developed in a social work classroom, but quickly grew to meet what Maubert calls “the absolute huge void in services that are provided.”

Khoury explains: “I feel like for a lot of us, accessing mental health and addictions services, like rehab, detox or whatever they are calling it right now, a lot of us don’t feel safe going there. We don’t know who you would be rooming with, if they’re homophobic, if they’re not, if they’re not comfortable staying in the same room as a queer person overnight. It’s the ridiculousness of the internalized homophobia that most people have, and transphobia and the use of pronouns. … The respect to treat us like humans, and not misname us, dead name us or misgender us.”

“I think we need to queer the system,” Maubert elaborates. “In that, let’s smash that binary, because it’s not working. I have been both a service user, as well as a service provider, in the realm of substance use and addiction. Looking here in Nova Scotia … a facility that is specifically queer and trans, would be a huge help … because it’s scary going into a facility that pretty darn straight, heteronormative, and you just don’t know what the vibe is going to be like. Both from other service users, but more importantly, which I have run into, is the staff who are just blatantly homophobic. Whether it’s overt or an unconscious bias. So creating spaces that are specifically queer needs to happen.”

Patrick & Liane, co-founders of Untoxicated Queers

“It’s soon to be 2023,” Maubert continues, “and we know that there is plenty of research that shows that folks from the queer community are affected by substance use and addiction on a much higher level than our heteronormative counterparts. Which is pretty shocking and looks at that kind of intersectionality, that combination of shame, shame of our queer identity, as well as the shame of our substance use and addiction. That intersection can really create a real firestorm of a desperation to be able to get the help that has been needed for fear of discrimination. Rightfully so. The amount of discrimination that is shown for both substance users, but also queer service users in the healthcare system, is staggering.”

Even for communities that do have resources dedicated to culturally specific services, the gaps in service, and influence of bias, are significant, leading NSCSW member Afolake Awoyiga to cofound a not-for profit community organization for youth of African descent called Generation 1 Leadership Initiative six years ago.

Through this work she has observed that “systemic and structural barriers disproportionally impact mental health in communities of African descent” including “key systemic and structural barriers that … can limit access for youths and mothers of African descent” in particular, the ”lack of culturally responsive care, geographical and location barriers, cost of mental health and addictions services, racism, discrimination and lack of cultural safety.”

Awoyiga asserts, “We have to do more than educate, and transform all the anti-racist education into action. Social workers and other health care providers need to understand their professional responsibilities for addressing racism. We need to utilize intersectional, African centred, trauma informed, anti-racist, systemic approaches that acknowledge and address the structural, historical, social and economic root causes of the mental health disparities in communities of African descent”.

Awoyiga is not alone in recognizing this. Sam Krawec is dedicated to creating alternative and community models of care. Krawec, health case manager for Mobile Outreach Street Health (MOSH), spends his days trying to bridge the gaping divide between existing health care and addiction services and those who need them most.

The MOSH model of care is innovative, but sadly this model is not replicated (yet) elsewhere in the province.

Krawec says that he works “within a harm reduction and social determinants of health framework, which means contending with the ways that barriers to health care are built into the capitalist system and reinforced by patriarchy, white supremacy, and settler-colonialism. The people we serve are diverse and resilient. We serve people who are not served by the current system, who survive and thrive on the margins of it: Women, Two Spirit and non-binary people, Indigenous peoples, Black and African Nova Scotian people, and other oppressed groups. My role is to help overcome barriers to care with marginalised people and improve health outcomes in these communities so we can live and resist joyfully together.”

Tara Downey, who serves as the African Nova Scotian outreach social worker at the North End Community Health Centre, says, “I feel like self-medication is a way for individuals to escape the reality of what they are going through day-today. Whether that is racism that they are facing, homophobia, all sorts of different things. That self-medication allows them to give them a time-out from having to live that reality. Then, within that, that then trickles down to the addiction and mental health piece, which you’re self-medicating, but then that self-medicating of feeling that warmth turns into the addiction mental health piece. Like a continuous cycle: start medication, start medicating yourself because it feels good. It allows you to step away from what’s happening in the world, but then what I’ve noticed is that there is not a stopping point for that. That is when sometimes it turns into that addiction piece, where then individuals have a harder time meeting those basic needs or day-to-day activities that they normally would do.”

The role of stigma

Indeed, as Downey affirms: words matter. Terms like “addiction” and “self-medication”, or labels like “addict” or “illicit drug user” are not interchangeable; each conveys a different set of ideas and values, be it pejorative or pathologizing or neutral.

Increasingly, the term “people who use drugs” (PWUD) is being used as part of a larger commitment to destigmatizing this issue. For the Cape Breton Association of People Empowering Drug Users, the stigma surrounding drug use can impair a person’s ability to access services for treatment, as well as the quality of care that they experience from the healthcare system when they do seek services. Furthermore, this stigma impacts their ability to find housing or employment, which further negatively impacts their health and quality of life.

The words that we use create distance between us, keeping us from recognizing the ways in which this issue impacts everyone. Khoury notes that even if for those who don’t identify as having an addiction to a chemical substance, other activities to try to self-soothe during times of stress or crisis, such as “doom scrolling on Instagram is detrimental to your mental health {and are] kind of addicting.”

Maubert adds, “I think we medicate in so many ways. That really comes out a lot in our meetings, whether it be our relationship with food, our relationship with body image, with body dysmorphia, our relationship with spending and excessive use of our phones.”

For all of the people with whom I spoke, there was consensus that effective solutions must be embedded within communities, rather than expecting people to travel long distances to adhere to the scheduling needs of those with power and privilege, namely those employed by the government to try to manage or cure those who are “sick”. The real sickness is not the addiction. The real disease is lack of funding and prioritizing mental health. The real sickness is the systemic and structural injustices leading so many to turn to self-medication to try to cope.

Connecting treatment, research & lived experience

It is clear that there is a deep disconnect between the research on best treatment outcomes, the experiences of those with lived experience and clinicians and the policies currently in place in Nova Scotia.

Maubert says that current services such as those using relapse prevention groups are “so out of touch with the actual needs. … they’re still supporting this old model and this punitive model. […] In [a relapse prevention] meeting, they ask every person as they come in, have you used in the last 24 hours? If they say yes, they put them out in the waiting room, and as a group discuss if it’s okay for them to come in. This is NSHA Mental Health & Addictions. That is completely dangerous.”

“There’s always such a deep sense of shame when I was using in the past,” Maubert elaborated. “There was so much shame that I had brought with me. Shame of how family would see me, friends would see me, my respect in my work, respect in community. So, to be accessing a service that is meant to provide support, if there is any barrier of any kind, and if I’m turned away from that meeting, why would I ever go back or try. If the one place that is meant to help me at my lowest, isn’t there to offer support, then how can I keep up the momentum going if I know they don’t actually believe in me or believe in the work that I can do.”

Tragically, this disconnect between treatment, research and lived experience is contributing to the preventable deaths of far too many individuals, harming their families and communities, and adding to the moral distress of health care providers across the province.

For this reason, growing numbers of health professionals, including the NSCSW, recommend a broad and integrated public health approach to prevention, health promotion (social determinants of health), harm reduction, treatment, and recovery and wellbeing related to opioid use and opioid use disorder. We also advocate for the integration of first-voice advocates into the development of any policy or treatment plan.

Reliance upon chemical substances, be they alcohol or drug use, or other behaviours increased dramatically during the pandemic. For communities already struggling with disproportionately high addiction, like Cape Breton, these numbers are skyrocketing. And it’s estimated that addiction currently costs Canada over 50 billion dollars a year as a result of health care costs, lost productivity, and reductions in health-related quality of life.

And the reality is that this is a community problem: no one exists in isolation. Despite the neo-liberal myth of individualism, and our medical system’s addiction to focusing on the individual at the expense of treating all those impacted by the problem, every social worker knows that behind every statistic is a family and community.

The current reductionist and failing efforts of our still colonial systems can be seen in the lack of holistic and interdisciplinary treatment options that are community specific and culturally safe, reflective of diversity and effective at bringing justice and healing to the communities where these problems are most dire.

False binaries remain encoded in our thinking and in our systems, for example the lack of integration between physical health services and mental health services. The result: a health system that is designed not to treat mental health challenges unless it reaches a crisis point.

Krawec explains his understanding of the problem: “With the options currently available, people who are unwell and traumatised are forced to make hard choices about how to care for themselves. This is the basis of self-medication. People use substances for pleasure, but many people use substances to alleviate suffering related to trauma and mental illness. Often the ‘drug of choice’ is not a choice at all, because using a given substance may be the only way for a person to relieve intolerable agony and continue living. Recognising this is an essential starting point for improving health outcomes for people who are unwell and traumatised”.

Shame and judgment remain deeply embedded in most government-funded initiatives, which rely on outdated and under-researched treatment frameworks.

Furthermore, the continued criminalization of certain drugs exacerbates the problems that people face, increasing stigma and adding further obstacles to treatment and recovery.

“Decriminalisation is only the first step,” explains Kraweck. ”To really address criminalisation, overdose rates, and the drug poisoning crisis, we need Safer Supply, the provision of pharmaceutical medications to adults who would otherwise rely on illicit street drugs and be exposed to greater risks. People have been calling for a safer supply of drugs for a long time, and there are different models for it. The medical model used at MOSH involves regulated health professionals who can prescribe pharmaceutical drugs to reduce some of the harms related to addiction. … this kind of change is inevitable, but as it takes longer more people are going to die or be criminalised. This is why fighting for social change needs to be part of our harm reduction practice.”

Health care and social service workers, including many of our members, experience moral distress from being tasked with delivering services that do not work, in ways that cause more harm than help, while reinforcing the stigma that makes it more difficult to get help. It is unsurprising that so many health care workers are burning out. The time has come for a real change.

N SIRITSKY, RSW, is the professional practice and advocacy consultant for the Nova Scotia College of Social Workers.