Reconciliation and Canada’s overdose crisis: responding to the needs of Indigenous Peoples

• Canada’s drug overdose crisis disproportionately affects Indigenous Peoples differently owing to a legacy of colonialism, racism and intergenerational trauma.

• Disaggregated data on Indigenous people are needed to understand more clearly how Indigenous Peoples are affected by drug overdoses.

• Indigenizing harm reduction and addiction treatment must involve integrating cultural and traditional Indigenous values that align with the principles of harm reduction.

• Reconciliation with Indigenous Peoples must include ending the war on drugs to address underlying structural conditions that produce drug-related harms, including overdose.

The Government of Canada’s commitment to address, through the Truth and Reconciliation Commission, the systemic oppression of Indigenous Peoples has occurred alongside an overdose crisis that disproportionately affects the same population. Far too many First Nations, Métis and Inuit (Indigenous) people who use drugs are dying from drug overdoses, and Canada must pursue Indigenous-specific solutions to address this growing crisis.

In Canada, there were about 4000 opioid-related deaths in 2017.1 In British Columbia, the mortality rate for Indigenous people who use drugs is 5 times higher than for other drug users. Despite representing just 2.6% of the total population, Indigenous Peoples account for 10% of overdose deaths.2^,3 Indigenous women are 8 times more likely to have a nonfatal overdose and 5 times more likely to have a fatal overdose than non-Indigenous women.3 The severity of this crisis is likely understated owing to poor disaggregation of data on Indigenous Peoples in many settings.

The devastating effects of the war on drugs have been widely documented,4^,5 and yet Canada, as a recent signatory to the US Global Call to Action on the World Drug Problem, has supported a renewal of this approach.6 The war on drugs has disproportionately targeted Indigenous Peoples and people of colour and resulted in substantial health and social harms, including an increase in overdoses.5 Factors that increase vulnerability to drug-related harms for Indigenous Peoples are framed by the historical and ongoing traumas related to colonization, including the residential school experience, poverty and child apprehension and involvement in the child welfare system, as well as inadequate access to education, health services and social supports.7^–10 The war on drugs intersects with, and reinforces, the oppression and racialized violence that shape the everyday experiences of Indigenous people who used drugs. Overpolicing and high rates of incarceration of this population, and other minorities,3 is not evidence based and violates human rights.

So far, the federal government’s responses to the overdose crisis have been insufficient to address the underlying structural drivers of the overdose crisis among Indigenous Peoples. Lack of support from policy-makers and all levels of government is also a major problem.

It is clear that drug decriminalization must be central to the Government of Canada’s reconciliation with Indigenous Peoples. While drugs remain criminalized, strides toward addressing the overdose epidemic among Indigenous people who use drugs will remain futile. Although harm reduction interventions — syringe exchange programs, supervised consumption sites and naloxone distribution — are being scaled up across Canada, drug criminalization and policing practices constrain their effectiveness. Canada must move on from the failed drug policies that have devastated Indigenous communities. It is imperative, however, that governments include Indigenous stakeholders and organizations when determining the future of Canada’s drug policy, as is consistent with the government’s commitment to reconciliation.4 Decriminalization policies should involve expunging criminal records as well as committing to reparations in Indigenous communities for those directly harmed by the drug war.

Alongside decriminalization, reconciliation must involve investing in Indigenous communities, including upstream investments addressing social-structural drivers of health inequities that contribute to the problem of drug overdose deaths among Indigenous Peoples. Although both federal and provincial/territorial governments have dedicated funding to address the opioid overdose crisis, Indigenous-specific funding has not been prioritized and is urgently needed. A public health approach to better supporting Indigenous Peoples who use drugs will require a commitment to Indigenizing harm reduction and addiction treatment policies, practices and supports by incorporating traditional Indigenous values. It also requires recognizing the impacts of colonialism and institutional racism, while acknowledging the strengths, abilities and inherent rights of Indigenous Peoples, and addressing the underlying conditions that drive high rates of overdose, such as those related to family, housing and access to health care.

Discourses about who qualifies as Indigenous limit how data on Indigenous people are collected. Data on Métis, Inuit and those living on reserves are scarce.3 This may mask the severity of the overdose crisis among Indigenous people who use drugs, placing Indigenous communities at increased long-term risk. This shortcoming must be addressed and, within broader themes of self-governance and self-determination, data collection on overdoses and related outcomes among Indigenous Peoples must be owned and controlled by Indigenous Peoples.11 Data collection frameworks and strategies at the BC First Nations Health Authority may be a model to emulate countrywide.

Reconciliation in Canada requires drug policy reform that combats systems creating trauma, accounts for the legacy of colonization and dismantles the structural forms of racism shaping Canada’s drug policies. Promises to solve the opioid overdose crisis that do not involve decriminalization will never address the deep racial disparities and injustices faced by Indigenous Peoples. To ignore the experiences of Indigenous communities in the context of the overdose crisis is nothing short of a public health failure.