Abstract
Objective To understand experiences of recovery from opioid use among First Nations individuals living in a small remote community.
Design Qualitative phenomenologic study.
Setting Northwestern Ontario.
Participants Sixteen First Nations individuals living in a remote community who had participated in or completed the community opioid agonist therapy program.
Methods Extensive community consultation took place to ensure local acceptance of the study and permission for publication. Semistructured telephone interviews with consenting participants were audiorecorded between November and December 2021 and transcribed. Transcripts were reviewed and discussed in meetings with Indigenous and non-Indigenous research team members who conducted thematic analysis using immersion and crystallization.
Main findings Participants described their opioid use as a form of self-management of trauma. Their recovery processes were multifaceted and included developing cultural and self-awareness. Motivation for change often arose from concerns about family well-being and finances. Traditional cultural practices and time spent on the land were identified as important wellness experiences. Barriers to healing included limited clinical and holistic addiction services, particularly around dose weaning and opioid agonist therapy discontinuation.
Conclusion Community-based addiction programming for First Nations patients needs to be robust. It requires resources for trauma-informed clinical and addiction care, culturally appropriate addictions education, aftercare support, and land-based activities.
The number of fatal toxic events from opioid use has risen dramatically across Ontario over the past decade, with First Nations populations being disproportionately affected.1-3 First Nations people in Ontario have experienced an increase in the rate of hospital visits for opioid-related poisoning from 5.1 per 10,000 people in February 2020 to 7.2 per 10,000 people in May 2021.2 Comparatively, non–First Nations people experienced an increase from 0.6 per 10,000 people in February 2020 to 0.8 per 10,000 people in May 2021.2 Annual deaths in Ontario related to opioid use have continued to increase since 2016, though the rate of increase among First Nations people was approximately 4 times higher than that among non–First Nations people in 2019.3
Opioid agonist therapy (OAT) remains the most commonly prescribed treatment for First Nations people with opioid use disorder in northwestern Ontario.3 Combination buprenorphine-naloxone is more often prescribed in remote and rural locations compared with other OAT formulations.4 In 2019, 2.2% of First Nations people in Ontario began a new course of OAT compared with 0.2% of non–First Nations people in Ontario.3
Opioid agonist therapy programs in remote First Nations communities in northwestern Ontario operate on a limited budget provided by Indigenous Services Canada. Due to limited financial means, OAT programs are typically restricted to dispensing only, with dispensing being done by community members. Physician support of OAT in this community is provided by monthly community physician visits and a dedicated addiction physician who visits in person and provides telehealth consultations every 3 to 4 months.
Descriptions of community-based OAT programs are uncommon in academic or gray literature, and it remains unclear whether these programs operationalize a prescribed biomedical model of wellness or if they integrate holistic elements of wellness into daily operations. Given the disproportionate incidence of opioid use among First Nations people in Ontario, culturally informed solutions and treatment options are needed.5 The purpose of this study was to better understand First Nations individuals’ experiences of recovering from opioid use in a rural, remote community in northwestern Ontario.
METHODS
This study enrolled participants from a remote First Nations community in northwestern Ontario based on consultation with and expressed interest from community leaders, health staff, and physicians. Given the intention to explore and understand individuals’ experiences with and perspectives of healing from opioid addiction through participation in the community OAT program, we chose a qualitative, phenomenologic design for this study.6,7
Participants
Targeted sampling methods were used to invite participants who had attended or completed the community-based OAT program. Snowball sampling identified additional participants who were actively healing from opioid use. Participation was voluntary and independent of treatment. Each participant was provided with a $100 gift card to the local community store. Initially 17 individuals participated in the study, but 1 subsequently withdrew their interview (N=16).
Data collection
Semistructured individual interviews were conducted by 2 non–First Nations researchers (S.M. and A.R.) in Sioux Lookout, Ont, between November and December 2021. Owing to COVID-19 travel restrictions during that time, interviews were conducted over the telephone and audiorecorded, and both researchers wrote field notes. The interview protocol was developed collaboratively with the local First Nations health authority to ensure cultural safety and relevance. Participants could use their personal telephone or the OAT program landline in the community. Each participant provided informed verbal consent to participate in a 30- to 60-minute interview.
Analysis
All interviews were audiorecorded and transcribed nearly verbatim. Interviewer notes were used when the audio-recordings were indiscernible. Transcripts were reviewed and discussed in meetings with Indigenous and non-Indigenous research team members who conducted phenomenologic thematic analysis. Three members (S.M., A.R., and L.K.) independently identified preliminary codes using immersion and crystallization methods, which were discussed with Indigenous team members who redefined and reinterpreted coding when needed.8 Data were analyzed within the codes and preliminary themes were developed. Analysis was conducted between April and May 2022.
Ethics
This study adheres to Canadian Tri-Council guidelines for ethical research involving First Nations, Inuit, and Métis participants and to First Nations principles of ownership, control, access, and possession related to data and information.9,10 Findings were shared with participants and community leaders to obtain permission for publication. Ethics approval was obtained from the Sioux Lookout Meno Ya Win Health Centre Research Review and Ethics Committee.
FINDINGS
Sixteen participants (4 male, 12 female) were asked to describe their experiences with recovering from opioid use. Questions regarding motivation to change, challenges, sources of support, and reflections about “the best of now” were asked to prompt discussion, with common themes among responses summarized in Figure 1.
Summary of themes from participants’ stories
How substance use started
Many participants shared their experiences with substance use and its relation to their personal histories of trauma. Most participants recounted a long history of substance use, and some spoke of childhood exposure to substance use within social environments. Many recounted traumatic events or abuse in childhood, adulthood, or both. Participants discussed interactions with child and family services either as a child or as a parent as well as interactions with police authorities. Some mentioned having been incarcerated for use. Feelings of depression were often discussed, as well as the use of substances to manage painful feelings, events, or memories:
I just needed somebody to talk to or somebody to listen.… Then finally I had enough, couldn’t cope with my feelings. I couldn’t deal with what I was going through, so I went to my friends and that’s when I started using … oxycodone, and then that led to shooting up. (Participant 5)
Making a change
When asked about the decision to address opioid use, participants discussed specific life events as well as motivations related to their children and themselves. Some participants discussed the need to address addiction at difficult life events including incarceration, hospitalization, or child apprehension. Illustrative comments are provided in Table 1. Participants who discussed motivations related to family most often identified the emotional and financial burden of addiction on their children’s well-being: “I started to realize I needed to stop [because of] what I was putting my kids through” (Participant 2); “I really thought about the things I wanted, the things I needed and how could I support my kids” (Participant 1). Participants recalled the financial impact on children and “having no food and having no stuff for my kids” (Participant 11). Two participants discussed how pregnancy was a motivator in that “when I found out I was pregnant I decided to get off [opioids]” (Participant 15). Some participants discussed motivation related to self, indicating that “I needed to work on myself, I needed that to get better” (Participant 4) or that “I felt like I wanted to not do it anymore. I wanted to stop what I was doing” (Participant 3).
Qualitative data describing moments in participants’ opioid use healing journeys
Challenges in recovery
Many participants discussed experiences with relapse, citing family or friends, personal injuries, depression, and peer pressure as triggers for relapse. When asked about factors that challenge recovery, participants discussed limited social and professional support and the need to develop new strategies to manage triggers.
Participants mentioned the challenge of abstaining given proximity to friends and family members engaged in ongoing drug use. It was “difficult to try and stop on my own while the person I was living with was still using” (Participant 4), and “being around friends was hard, [because] they were asking and like to joke with me, if I want to do it and stuff” (Participant 14). Others distanced themselves and “stopped talking to people” (Participant 1), saying “I’d isolate myself from others that were using or that were talking about drugs or trying to ask me can [I] get this or that” (Participant 1), with some feeling “like I’ve lost all my friends” (Participant 18).
Many identified insufficient professional support and several discussed hesitancy in accessing counselling and health services due to lack of anonymity and confidentiality associated with living in a small community, where “everybody will hear about it; it’s kind of hard to participate” (Participant 11). Counselling was often referenced but difficult to access because “we don’t have that much services or resources to get appointments for counselling” (Participant 1). While some found counselling helpful “because I know I needed to work on myself” (Participant 4), another participant expressed “I wasn’t interested in it, but I just answered the questions anyways” (Participant 9). One participant found accessing services challenging: “I looked for help in my local resources and they kept pushing me to another person or another department, so I gave up” (Participant 5).
Participants shared experiences with sobriety:
Relearning how to be a human again was pretty weird and I don’t think people realize [that] if they’ve been on [OAT] for a couple of years now. I think they would forget how it is to be a sober human.… They’re scared to feel their feelings. (Participant 5)
Finding new strategies to manage triggers was difficult for some participants:
[It] was hard for me. Like every time when I get into any situation or when I stressed myself over nothing, little or big, something that I couldn’t control, that’s when [it is] in my thoughts like temptation. (Participant 1)
Others explained that drug use helped manage trauma:
[Drug use] kind of helped with numbing all the stuff I went through as a child. I think that’s what I used it for. Like when you take it, everything just goes away. (Participant 6)
Support in recovery
Factors identified that support recovery included learning about addiction, having social support, staying busy, spending time on the land, and being more spiritual. Specifically, participants found that learning about their addiction “to understand more of why these things are happening around me” (Participant 1) was helpful in recovery. Through learning, counselling, or awareness events, one participant discussed how “being an addict has made me realize that I have so much problems and trauma in my younger days” (Participant 1), while another identified the importance of “look[ing] within themselves for what issues they need to work on personally” (Participant 4).
Some participants felt that they had no help in recovery, though many also highlighted that they received support from partners, siblings, or other family members. Several cited support and encouragement from peers, while others indicated new-found self-awareness.
[I] started paying attention on myself and my family and things that were happening so fast and things that I couldn’t control. That’s why I wanted to change myself, the way I was feeling, the way I was starting to pay attention to self and family—understand what I can and cannot control. The impacts on self, family, and others. (Participant 1)
Only one participant indicated they had had support from a physician in generating a plan for withdrawal.
Some participants found that staying active physically or through employment was helpful in recovery, especially when “I get these thoughts of going back to it, I just try to distract myself by coming to work and not think about it” (Participant 9). Others found exercise to be helpful: “I exercised, I walked. I was active and that helped me get off [OAT]” (Participant 5). Being out on the land helped participants stay physically active:
[It] helped me a lot. It makes you realize and makes a lot of things come to you, like I mean everything about your past, lots of reflection, something about the future. (Participant 1)
Participants discussed going out on the land for wood harvesting, fishing, walking, and spending time with children: “Going out on the land when you have time helps come off the [OAT] program” (Participant 2).
Many found support from spiritual practices, including sweat ceremonies, smudging, traditional medicines, and sharing circles. For some, attending ceremony “was refreshing; coming out there and not worrying about using needles, I could cope” (Participant 3).
[It] was an eye-opener for me about Indigenous peoples and what they had way back in the day, prior to White man came. They had like these powers, spiritual powers. It was a spiritual awakening for me. (Participant 1)
Opioid agonist therapy with combination buprenorphine-naloxone
Although this study was not designed to collect details regarding combination buprenorphine-naloxone use, participants volunteered their experiences with it—either prescribed or illicit—elaborating on its benefits, desires to wean, and experiences of withdrawal. All participants discussed either past or ongoing use of the drug. Most participants were prescribed the medication, some supplemented prescription with illicit use, and others accessed only illicit sources.
Some referenced benefits of having accessed the program, including reduced cravings for illicit opioids, thereby stabilizing their finances and enabling participants to “help [themselves] as well with … other problems” (Participant 2). Regardless, most participants discussed wanting to wean themselves off the program entirely, with many describing the medication as “just another drug to take” (Participant 4): “I felt like I was trapped … like you know, an assembly line or something, waiting to get my dose every morning” (Participant 16). Two participants discussed feeling that the OAT program provided structure: “When I wasn’t on the Suboxone program I felt like I was alone, like I lost somebody” (Participant 8). However, there were also feelings of resentment toward the program: “Like it was holding me back in my life. I just didn’t want it to be part of my life” (Participant 2).
Additionally, many described feeling unlike themselves while taking buprenorphine-naloxone: “[It was] killing me, killing my feelings, my thoughts, my dreams” (Participant 5). Participants described side effects to combination buprenorphine-naloxone use such as tooth decay, body aches, pain, fatigue, or illness. Dose weaning and discontinuation were inadequately supported. Several participants discussed self-weaning: “I felt that [the medication] was too strong and nobody paid attention to me and kept giving it to me.… I started weaning myself off … because nobody would listen to me” (Participant 5). Anticipation of withdrawal symptoms from the drug was discussed by most participants, and those with experience discussed the physical challenge of withdrawal: “I was able to cut down, but I wasn’t able to stop because withdrawal was so bad” (Participant 9). Participants indicated they had not received program preparation, education, or support regarding withdrawal: “No, there was never really any help.… Withdrawals are really bad” (Participant 7). One person pointed to the need for a family-based approach:
If [they] really wanted to help they would … focus on one family at a time, ’cause it’s going to take a lot of work and support if you want them to get off … [opioids] and when they ask for help.… That is what we are lacking here ’cause everybody seems like they’re overworked or have no support. (Participant 4)
Best of now
Some participants who had moved beyond the OAT program spoke of enhanced awareness.
Awareness of myself and awareness of my surroundings and how life is. I am more aware of everything, of the world.… My current situation is not really that good, but I’m not turning to drugs to deal with my situation or deal with myself, I know not to do that. (Participant 5)
Others expressed gratitude for “each and every day that I get do all the things that I like to do” (Participant 4) and a sense of liberation for “not having to go to the clinic every day to get the medicines, stuff like that” (Participant 4). However, recovery was described as a long and holistic process:
Took me probably 2 years to really learn about the human being.… My sense of taste came back and all those emotions I didn’t feel when I was on Suboxone all came out. I cried anywhere, anytime. I don’t know … it’s so weird like, like I was learning how to be a human again. (Participant 5)
Others highlighted the importance of starting the healing journey with the mind.
You got to [decide] it’s time to stop. The seed will grow. It doesn’t take right away … you have to work on it to actually stop, to believe that you can do it. You’ve got to find yourself, find your truth, and stick by your truth; that’s what I’ve been trying to do. (Participant 16)
Despite being at various stages of recovery, many said they were “still on [a] healing journey. I don’t think that will ever stop for me to learn about life” (Participant 4).
DISCUSSION
This study portrays the difficult healing journeys of 16 First Nations participants recovering from opioid use. Many described opioid use as a coping strategy for past and ongoing trauma and highlighted difficulties in accessing comprehensive, trauma-informed, holistic, and ongoing care in their community. Personal decisions to address opioid use were often prompted by concerns about direct effects on children and family. Use of OAT reduced cravings and illicit drug use, though its long-term use was discussed as being problematic, with adverse physiologic symptoms, disruption of daily routines, and challenging withdrawal experiences.
Recovery often required a journey of self-discovery, and many participants recounted the power of traditional ceremony. Ceremony elicited reflection on self and life, providing support through connection to identity, language, and land; teachings regarding medicines, ways of knowing, and the healing journey; and songs about healing, kindness, and seeking help—all of which can be used as coping strategies during hardship and times of vulnerability (personal communication from D.S., Sioux Lookout, Ont; May 27, 2022).
Findings from this study align with others that have noted the importance of First Nations culture and ceremony to healing and well-being. Tempier et al found that cultural identity, practices, and values were instrumental in spontaneous recovery from substance use for Indigenous people in Canada.11 Similarly, a qualitative study conducted in a northern Ontario Indigenous community found that land-based programming helps individuals reconnect with past relatives and spirits of nature, ultimately helping heal from trauma.12 Research by Coyhis and Simonelli supported these findings, describing the benefits of the land and culture for patients healing from addiction.13
While OAT was identified as being helpful for cravings and personal finances, its long-term use was found to be an inadequate solution to addiction. Many participants cited negative effects from OAT related to physical, mental, and emotional well-being, and there was a sense of replacing an illicit addiction with a prescribed one.
Addressing opioid use among First Nations individuals living in remote communities must include elements beyond physiologic symptoms and must include the emotional, mental, and spiritual dimensions of holistic health. In 2011 the Honouring Our Strengths framework was released to address substance misuse given the connection between addiction and the historical and ongoing displacement of Indigenous languages and cultures.14 Future research should consider how best to integrate these factors into community-based OAT programs and should consider the perspectives of workers from these programs to help capture the efforts and challenges of OAT programming in the community.
Limitations
This study was designed by an interdisciplinary team of both Indigenous and non-Indigenous researchers with strong community support. While the cross-cultural nature of the research team allowed for robust interpretation and analysis, data collection may have been affected due to collection by non-Indigenous researchers, which could have limited participants’ ability to speak in their language when explaining experiences and reflections. Due to COVID-19 travel restrictions, interviews relied on telephone service, which affected the quality of audiorecordings at times and the ability of interviewers to discern nonverbal cues. The study took place in one First Nations community, so these findings on opioid use, health, and use of traditional practices cannot be generalized to other communities. Even with participation in the OAT program, some participants still used illicit drugs. Patients did not distinguish between descriptions of some physical symptoms ascribed to OAT and possible symptoms of withdrawal.
Conclusion
Opioid use by participants in an OAT program in a remote northwestern Ontario community was associated with self-management of trauma. The recovery process was multifaceted and included cultural and self-awareness. Motivation for change often arose from concerns about family well-being and personal finances. Traditional cultural practices and time spent on the land helped with wellness. Barriers to healing included limited clinical and holistic addiction services, particularly around dose weaning and OAT discontinuation. Community-based First Nations addiction programming requires resources for trauma-informed clinical and addiction care, culturally appropriate addictions education, aftercare support, and land-based activities.
Acknowledgment
This study was supported by the Northern Ontario Academic Medicine Association AHSC Academic Funding Plan with collaboration and administrative support from First Nations community leadership and the Sioux Lookout First Nations Health Authority.
Footnotes
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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