Module 5: Trauma, Violence, and Cultural Safety – Topic B Describe the potential impact of past and current experiences of trauma and social and structural violence on opioid use (e.g., colonialism, racism, sexual and sexual identity violence, gender bias, stigmatization, interpersonal and intergenerational trauma).

Learning Objectives

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

• Describe the systemic relationships between trauma and health.
• Explain how trauma can be a risk factor for opioid use as related to coping and structural violence.

Key Concepts

• Trauma, loss, poverty, family separation resulting from colonization, and a lack of culturally safe and trauma- and violence-informed care are widely understood to have had far-reaching and multi-generational impacts on social and structural determinants of health and the mental wellness of Indigenous Peoples, which has contributed to opioid use problems.
• Generally, Indigenous Peoples in Canada are experiencing good well-being; however, many Indigenous Peoples and individuals continue to face structural racism across many fronts, including access to health care. It is essential for opioid problems within Indigenous communities to be contextualized in this historical and ongoing socioeconomic context.
• The legacy of colonialism is imbued with various forms of sustained, ongoing, and compounded violence and trauma to Black and Indigenous people and other people of colour in Canada.
• Gender is a key factor, with women experiencing a higher prevalence of mental health diagnoses, opioid prescriptions, and trauma.
• The environment plays an important role in shaping mental health and how individuals are able to cope with stressful situations. Stressful environmental conditions, especially early childhood trauma, can increase the risk of substance use later in life.
• Opioids are used by people who live in stressful conditions and in chronic pain because they are powerful analgesics, or pain relievers.
• Stigma and implicit bias by health and social service providers and the public toward those who use or misuse opioids remains rooted in the moral and individualist belief that addiction is moral weakness or a willful choice.

Distal Factors and Structural Violence

Despite people having no power over them, distal factors exert influence on individuals’ and communities’ well-being and livelihood, including health behaviours and outcomes.

One way that distal factors result in poorer health is through structural violence.

Colonialism, Structural Violence, and Trauma

The legacy of colonization resulted in the loss of culture and language among Indigenous Peoples, with far-reaching intergenerational trauma still experienced by Indigenous Peoples today. Colonialism and neocolonialism significantly impact health and wellbeing, especially in the context of substance use.

Recall that social determinants of health include income, genetics, job security, employment opportunities, access to safe and affordable housing, childcare availability, food security, and inclusion or exclusion from society (World Health Organization, 2008). Although there is some crossover with the social determinants of health, Greenwood et al. (2018) identify determinants of Indigenous health as including:

• colonialism,
• gender,
• culture (e.g., connection to Indigenous language),
• early childhood development,
• the environment,
• HIV/AIDS,
• medicine, and
• geographical location.

Determinants of health reveal vulnerabilities arising from experiences of inequality that negatively influence health and health outcomes for Indigenous Peoples.

Structural violence is a term that refers to the existence of unequal power, restricted access to resources, and systematic oppression that results in the denial of basic needs, including health care or treatment of addictions. The arrangements are structural because they are embedded in the political and economic organization of our social world, and they are violent because they cause injury to people (typically, not those responsible for perpetuating such inequalities). See Module 5, Topic A for more.

Violence/trauma also has been identified as a key determinant of health (Morris, 2016; World Health Organization, 2013). Trauma as a result of colonialism and neocolonialism, residential schooling, and cultural genocide has resulted in Indigenous communities struggling with:

• high rates of unemployment and poverty,
• low levels of education,
• inadequate housing,
• addiction,
• a disproportionate number of children in child protective services, and
• limited access to health and social services.

Protective factors have been removed or damaged by historical and culturally specific factors that include:

• the loss of language and connectedness to the land,
• residential school abuses,
• systemic racism,
• environmental destruction, and
• cultural, spiritual, emotional, and mental disconnectedness.

It is critical for health and social service providers to understand the impact and relationship between the determinants of health and the presence of addiction, to avoid reproducing oppression within health policies, services, and practices.

Colonialism and neocolonialism continue to impact Indigenous peoples disproportionally in the form of addiction.

• In British Columbia, the mortality rate for Indigenous people who use drugs is five times as high as for other drug users. Despite representing just 2.6 percent of the total population, Indigenous Peoples account 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 (First Nations Health Authority, 2017).
• The 2008–2010 First Nations Regional Health Survey (First Nations Information Governance Centre, 2012) revealed that among Indigenous people ages 18 and older living on-reserve or in northern First Nations communities, 4.7 percent had past-year use of illegal (heroin) or prescription opioids (including morphine, methadone, and codeine) without a prescription, and 5.7 percent used non-prescribed sedatives or sleeping pills, including diazepam and oxazepam.

NOTE: Statistics related to Indigenous health need to be understood as variable; the impact of colonialism, neocolonialism, systemic racism, and so on, has not been the same for all Indigenous people and communities. Health and well-being have been shown to be associated with variation in acculturation histories, geography, protective factors, and so on (e.g., MacDonald et al., 2013; Napoleon, 2009).

Colonialism also has impacted Black populations in similar ways to that of Indigenous populations by:

• removing them from their ancestral lands,
• cultures,
• language, and
• connections through slavery.

Systemic racism and inequities embedded in social policies and practices continue to have a negative impact on Black communities, giving rise to social and economic exclusions and disproportional representation of Black people in the justice and child welfare systems.

Stigma, Substance Use, and Addiction

Stigma experienced by individuals with substance use disorders is persistently high, exceeding the stigma felt by those with mental illnesses or physical disabilities across cultural contexts.

Public understanding of opioid use continues to be overshadowed by the misconception that it is a moral weakness or a willful choice. This misconception has historically separated opioid use and its treatment from the rest of health care.

Within the substance use treatment community, many still believe that recovery depends solely on willpower to abstain from all opioids, including methadone and buprenorphine. As a result, many who provide residential services force clients receiving methadone or buprenorphine to taper off of medication as a condition of initial or continued treatment, and many counsellors consider taking medication a character weakness.

Language within health care mirrors and perpetuates the stigma related to the use and treatment of opioids.

“Clean/Dirty”

Studies have found that language perpetuates and reproduces the pejorative terms, including the terms for urine test results, which are called clean or dirty rather than positive, expected, negative, or unexpected. Clients with opioid use disorder are referred to as clean when they are in recovery or managing symptoms, and they are referred to as ,dirty if they are still demonstrating symptoms of their illness.

“Junkie”

Health and social service practitioners, and many laypeople, refer to people with opioid use disorder as junkies. While the term junkie originated with the heroin individuals were using, it now is broadly associated particularly with the people who use opioids.

Substance use is routinely associated with populations that already experience discrimination, which contributes to the “othering” aspect of stigmatization.

Another factor shown to be relevant to stigma is the ambiguous legal status of opioid medications. Opioids are available, legally, with a prescription, but they also can be purchased illegally. Connecting individuals with substance use disorders to other negative characteristics, such as engagement in criminal activity through possession of illicit substances, may heighten stigma, especially for some racialized minorities and Black people in particular.

Intergenerational or Transgenerational Trauma

Historical or intergenerational trauma is defined as a cumulative emotional and psychological wounding over the lifespan and across generations.

For Indigenous Peoples and Black people in Canada, intergenerational trauma is rooted in imposed social, economic, political, and legal injustices in the form of racist, colonial policies and practices. Genocidal policies such as the Indian reserve system and the Indian residential school system play a significant role in the intergenerational and transgenerational trauma of Indigenous Peoples.

These injustices are documented extensively in the report of the Royal Commission on Aboriginal Peoples (1996) and the report of the Truth and Reconciliation Commission of Canada (2015), and the national inquiry for MMIWG2LGBTTQIA+, among others. These reports document the consequences of these injustices, including:

• geographic isolation and an associated lack of settlement supports,
• lack of opportunities,
• poverty,
• brokenness, and
• poor health outcomes.

Systems and structures continue to uphold these conditions for First Nations, Métis, Inuit, and Black people. 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 and faced interpersonal trauma.

The need to cope with traumatic experiences is often addressed through many means, one of which is the use of opioids.

• New evidence is emerging to support the idea that children are affected by parental trauma exposures occurring before their birth, resulting in a predisposition for anxiety and depression—both of which are prodrome conditions for opioid use
• In addition to colonization, transgenerational trauma events include slavery, displacement trauma, genocide, war, rape as a weapon of war, and famine.

Racism, Substance Use, and Addiction

In 2012, the Conservative government enacted Bill C-10 (the Safe Street and Community Act) as part of the government’s war on drug strategy. One result was a police focus disproportionately targeting Black communities, even though large segments of the White population also engaged in drug use at similar rates.

A direct result of the police focus on Black communities was a pattern of racialized mass incarceration, exemplified by the overrepresentation of Black people within the federal offender population in prisons across Canada.

• In 2010–2011, Black inmates accounted for 9 percent of the federal prison population although Black Canadians comprised only 2.5 percent of the overall population.
• A report by the Ontario Human Rights Commission (2020) confirms that Black people are disproportionately arrested, charged, and subjected to use of force by Toronto police.

Incarceration as a result of racial profiling results in damaged individual and family lives and weakened communities forced to cope with increasing violence over generations of incarceration. The pejorative associations of Black people and crime have intensified levels of stigma that have existed for decades but remained tangential to the lives of Black Canadians, since few interacted with the criminal justice system.

Diminished self-esteem, perceived discrimination, and internalized stigma are the biggest health risk factors borne by Black cisgender men and youth, placing them at higher risk for opioid use as a coping mechanism.

Gender, Substance Use, and Addiction

Sex and gender must be considered when addressing the opioid crisis as there are key differences between men and women.

It is important to consider the specific needs of women, which may result from biological factors, socioeconomic status, family roles, reproduction, childcare responsibilities, and vulnerability to sexual and intimate partner violence.

Important gender differences relevant to the opioid crisis include:

• higher rates of prescription opioid use among women (64 percent of people who use opioid pain relievers are women),
• higher prevalence of many pain disorders, and
• higher prevalence of depression and anxiety disorders.

Other gender differences to note:

• Women are more likely to be prescribed drugs that confer added risk when combined with opioids, such as anxiolytics.
• Women are more likely to engage with problematic opioid use after being prescribed them and are more likely than men to be admitted to hospital for intentional opioid overdose.
• Women progress from use of opioids to dependence more quickly than men and suffer more severe emotional and physical consequences of drug use than men.

Data shows that a majority of women living with addictions have suffered severe trauma, such as childhood sexual abuse. Biological effects of trauma over time contribute to mental health disorders and chronic pain and increase vulnerability to substance use disorders. Women living with opioid use disorder are more likely to meet criteria for borderline personality disorder, which is often associated with a trauma history.

Questions

Which of the following are included in the term structural violence?

a. Social structures that oppress certain groups of people

b. Oppressive processes that appear normal

c. Educational systems that oppress

d. Health care systems that oppress

e. All of the above

Correct! Structural violence includes institutions that, over time, become normalized and invisible in how groups of people remain marginalized and othered. People become socialized to accept and not challenge such violent processes.

Incorrect. The correct answer is e. Structural violence includes institutions that, over time, become normalized and invisible in how groups of people remain marginalized and othered. People become socialized to accept and not challenge such violent processes.

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Why are colonialism and neocolonialism associated with addiction? (Select all that apply.)

a. They are causes of the trauma experienced by Indigenous Peoples.

b. Historically alcohol was more available.

c. Protective factors were removed by Eurocentric practices.

d. Textbooks state this is the truth.

Check

Please select an answer.

Correct! Colonialism removed linguistic, social, familial, and land practices and customs that served as protective factors. The outcome is intergenerational trauma, with substance use a means to cope with the pain.

Incorrect. The correct answers were a, and c. Colonialism removed linguistic, social, familial, and land practices and customs that served as protective factors. The outcome is intergenerational trauma, with substance use a means to cope with the pain.

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How is stigma perpetuated in addiction?

a. Addiction is seen as a moral failing.

b. Addiction is seen as a weakness.

c. Pejorative language is used when addiction is discussed.

d. All of the above.

Correct! Stigma is reproduced by the belief that substance use is a moral failing and a weakness in character, which individualizes a social issue. Language is constructed to reinforce these negative beliefs.

Incorrect. The correct answer is d. Stigma is reproduced by the belief that substance use is a moral failing and a weakness in character, which individualizes a social issue. Language is constructed to reinforce these negative beliefs.

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Why is the term intersectionality important to explaining addiction and trauma? (Select all that apply.)

a. It’s a pop culture term.

b. It’s a way of understanding how culture, history, race, identities, gender, and so on, play a role in creating discrimination.

c. It acknowledges how social, cultural, and political systems combine to marginalize certain groups and identities.

d. It’s a simple way of associating addiction and trauma.

Check

Please select an answer.

Correct! Trauma and substance use are not linear concepts with a single contributing reason. Constructs such as race, gender, age, and identity, among others, intersect, which intensifies the degree to which discrimination and stigma occur within marginalized groups of people.

Incorrect. The correct answers were b, and c. Trauma and substance use are not linear concepts with a single contributing reason. Constructs such as race, gender, age, and identity, among others, intersect, which intensifies the degree to which discrimination and stigma occur within marginalized groups of people.

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References