Module 1: Epidemiology of Opioid Use – Topic E Recognize that there is no timeframe for the impact of various factors that can influence opioid use and the risk of opioid use disorder (e.g., impact of colonization, trauma).

Learning Objectives

By the end of this topic, the student should be able to:

• Describe how wider distal factors contribute and inform opioid use.
• Explain the definition of structural violence and how it relates to opioid use disorder.
• Describe the different forms of structural violence in our society.
• Identify the types of trauma that can impact the use of opioids.

Key Concepts

• There are causal connections between substance use disorder and societal factors, such as poverty, systemic oppression, substandard living, working conditions, and disparity in health.
• Structural violence, which refers to unequal power, restricted access to resources, and systematic oppression, results in the denial of basic needs, including health care and treatment of substance use disorder.
• Structural violence is structural because it is embedded in the political and economic organization of our social world; it is violent because it causes injury to the individual lacking power and access to resources and is often rooted in, or has features of, racism, classism, homophobia, ableism, and transphobia.
• Structural violence is multigenerational and is normalized by those who experience it and by those who exert it, including health and social service providers and educators.
• One consequence of this kind of oppression is traumatic experiences and subsequent trauma-related problems.
• The impact of structural violence and its effect on opioid use can be immediate or significantly delayed.

Colonialism, Trauma, and Substance Use Disorder

Trauma as a Result of Colonialism

The legacy of colonization resulted in erasure of First Nations peoples' culture and language, with far-reaching intergenerational trauma still experienced by many Indigenous people today. It significantly impacts health and well-being, especially in the context of substance use. Trauma as a result of colonialism, residential schooling, the Sixties Scoop, and cultural genocide has resulted in several negative outcomes in Indigenous communities, including

• higher rates of unemployment and poverty,
• lower levels of education,
• inadequate housing,
• a disproportionate number of Indigenous children in child protective services, and
• limited access to health and social service.

Protective social factors have been removed or damaged because of the "loss of language and connectedness to the land, residential school abuses, systemic racism, environmental destruction and cultural, spiritual, emotional, and mental disconnectedness" (Sullivan, 2013).

NOTE: It is critical that health and social service providers understand the impact of and relationship between the determinants of health above and the presence of substance use disorders to avoid reproducing oppression and avoid assigning blame to individual clients.

Colonialism continues to impact the health of Indigenous Peoples, who are disproportionately affected by opioid use and opioid use disorder. The impact systemic and structural racism has on Indigenous peoples results in higher mortality rates.

Mortality

• In British Columbia in 2017, the mortality rate for Indigenous people was five times that for non-Indigenous people (First Nations Health Authority, 2017).

Overdose

• "Despite representing just 2.6 percent of the total population, Indigenous Peoples [accounted] for 10 percent of overdose deaths. Indigenous women are eight times as likely to have a nonfatal overdose and five times as likely to have a fatal overdose as non-Indigenous women (Lavalley et al., 2018).

Substance Use

• In a survey conducted by the First Nations Information Governance Centre (2018) of Indigenous Peoples living in northern First Nation communities, the use of opioids (morphine, methadone, codeine) was identified as a way of responding to centuries of colonialism; poverty and economic disinvestment; intergenerational abuses by religious, education, and social institutions; poor or inaccessible health care; and lack of access to basic human rights, such as clean water and affordable and safe housing (First Nations Information Governance Centre, 2018).

Racism and Substance Use Disorder

In 2012, the federal Conservative government enacted Bill C-10 (the Safe Streets and Community Act) as part of the government's War on Drugs strategy that disproportionately targeted Black communities, even though large segments of the White population also engaged in drug use at similar rates (Khenti, 2014).

The consequences of police targeting Black communities resulted in significantly higher racialized mass incarceration (Khenti, 2014). Even before Bill C-10, in 2010–2011 for example, Black inmates accounted for 9 percent of the federal prison population, although Black Canadians only comprised 2.5 percent of the overall population (Khenti, 2014).

Incarceration as a result of racial profiling of Black men weakens family relationships, supports, and entire communities (U.S. Department of Health and Human Services, Office of Behavioral Health Equity, 2020).

Negative stereotyping of Black populations with respect to crime is not supported by evidence, although this stereotype continues to be perpetuated by certain groups and structures in society, including that of law and policy.

• Fordham (2020) found that criminal law in Canada continues to disproportionately harm Black and Indigenous communities at similar rates as in the United States, with such laws reproducing systemic racism.
• The International Drug Policy Consortium (2018) found that "higher arrest and incarceration rates for these communities are not reflective of increased prevalence of drug use but rather of law enforcement's focus on communities of colour".

Childhood, Intergenerational, or Transgenerational Trauma and Substance Use Disorder

Childhood trauma is linked to problematic substance use in adolescence and adulthood.

"Adults who reported five or more types of abuse were three times more likely to use prescription pain medication and five times more likely to consume substances through injection."

High rates of substance use have been documented among LGBTQ individuals, which may be linked to stigma, discrimination, and violence, and their impact on mental health outcomes (Marshal et al., 2008).

Childhood trauma is also connected to chronic pain in adulthood. Adults with a history of childhood trauma are more likely to report chronic pain later in life and more likely to be treated for pain, which increases exposure to opioids and the risk of developing a substance use disorder (Canadian Mental Health Association, 2018).

Adams & Clarmont (2016) found that:

• For Indigenous Peoples in Canada, intergenerational trauma is rooted in imposed social and legal injustices in the form of racist, colonial, and genocidal policies enforced by the Indian Act, such as:
•  the Indian reserve system,
• the Indian residential school system, and
• the Sixties Scoop.

These injustices are documented in

• the report of the Royal Commission on Aboriginal Peoples (1996)
• the report of the Truth and Reconciliation Commission of Canada (2015)

These reports document the consequences of these injustices, including

• geographic isolation,
• a lack of settlement supports and opportunities,
• poverty,
• a feeling of despair, and
• poor health outcomes.

"Many Indigenous people [carry] significant trauma as a result of violence and abuse experienced at home, passed on by parents and family members who were residential school survivors."

The need to cope with traumatic experiences is often addressed through the use of opioids.

New evidence is emerging to support the idea that children are affected by parental trauma exposures occurring before their birth. These exposures can result in a predisposition for anxiety and depression, both of which are prodrome conditions (early signs) for opioid use (Gottschalk & Domschke, 2017).

In addition to colonization, parental trauma events include:

• slavery,
• displacement trauma,
• genocide,
• war, and rape as a weapon of war, and
• famine.

Questions

Bill C-10 (Safe Streets and Communities Act) disproportionately affected which of the following subpopulations the most?

a. Indigenous populations

b. Black populations

c. Members of visible minorities

d. Immigrants and non-status immigrants

Correct! Bill C-10 (the Safe Streets and Communities Act) was part of the government's War on Drugs strategy that disproportionately targeted Black communities, even though large segments of the White population also engaged in drug use at similar rates.

Incorrect. The correct answer is b. Bill C-10 (the Safe Streets and Communities Act) was part of the government's War on Drugs strategy that disproportionately targeted Black communities, even though large segments of the White population also engaged in drug use at similar rates.

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True or false: The current opioid epidemic disproportionately affecting Indigenous Peoples can be traced back to colonialism.

a. True

b. False

Correct! The legacy of colonization resulted in the loss of Indigenous People's culture and language. Far-reaching intergenerational trauma is still experienced by many Indigenous people today and significantly impacts health and well-being, especially in the context of substance use.

Incorrect. The correct answer is a. The legacy of colonization resulted in the loss of Indigenous People's culture and language. Far-reaching intergenerational trauma is still experienced by many Indigenous people today and significantly impacts health and well-being, especially in the context of substance use.

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References