Stigma, the opioid crisis and first responders:
New MHCC research lays bare challenges and opportunities

When Stephanie Knaak, Ph.D., talks about her new research you can hear the urgency in her voice. Knaak is the Mental Health Commission of Canada’s (MHCC) co-lead researcher on a soon-to-be-released study looking at how stigma affects first responders’ ability to provide care amid Canada’s opioid/overdose crisis.

“We need to clarify what’s happening in this country,” said Knaak. “The term opioid crisis is somewhat misleading. It’s more of a poisoning crisis. What we are dealing with extends far beyond opioids.  Canada must come to grips with a poisoned drug supply – that includes heroin, but also cocaine and black-market prescription drugs. That’s important because we need to understand who is actually at risk…and it’s basically anyone who buys any kind of drugs on the illegal market.”

The MHCC’s research is showing that harm reduction efforts are working, but that they aren’t reaching everyone equitably. Safe consumptions sites, for example, tend to be used only by people living within a one-kilometer radius of the site. “We’re learning that upwards of 80 per cent of overdoses aren’t happening in public view. That stereotype of people dying on the streets, for example, is far less ubiquitous than the reality of people dying in their cars or behind the closed doors of their bedrooms.” Knaak goes on to explain that the shame associated with drug use drives people to hide.  “They use in private, which of course is one of the biggest risk factors for death if you happen to get a tainted dose.”

Stigma, said Knaak, is at the heart of what’s keeping people from stepping forward and getting help, and practicing harm reduction. “It’s pervasive. The stigma surrounding opioid and other drug use problems eclipses anything we’ve seen in terms of the stigma associated with mental illness.”

That’s why the MHCC is using its Opening Minds anti-stigma program – traditionally focused on mental health – and is training that lens on substance use. Understanding the biases that colour the perception of first responders is an important first step in identifying training programs and other approaches that will combat the stigmatizing attitudes and behaviours that may interfere with care.

“We went around the country and we sat with groups of first responders, health care providers and people with lived experience of opioid and other drug use to try to untangle this complex interaction,” said Knaak.

The findings are startling. “First responders are expressing a real moral ambivalence around emergency rescue treatments like Naloxone. They know that it’s a key life saving measure. But we are also hearing that its widespread use can create a dynamic between patient and care provider that is increasing compassion fatigue across the first responder and emergency room community. This is especially true among people experiencing high recidivism,” explained Knaak. “So, you have this life saving ‘treatment’, but it causes people to experience such severe withdrawal symptoms that they will often rush out immediately to relieve those symptoms, and the cycle continues.”

The research also revealed high levels of system mistrust among people who use, especially among more marginalized populations. “We heard so many people say that they actively avoid health care and other services because of past experiences. They spoke about being mistreated, degraded, and being made to feel unworthy of care. “

As Knaak and the research team were conducting their focus groups, they also asked about drug use among the first responder community. “Of course, it happens, it’s inevitable. In big organizations, there is going to be drug use – particularly when you look at the vulnerabilities and stresses wrought by the job. But the response we got, across the board, is that they knew of no drug use problems among first responders and health providers. Full stop. Alcohol consumption was the only substance use they acknowledged might be happening within their own workplaces.”

That, says Knaak, points to a desperate need for conversations, information, education and massive efforts towards stigma reduction.

“We’ve got to destigmatize substance use. There are so many misperceptions, misconceptions and missed opportunities. We’ve got to understand where people are at and then meet them there. It’s on all of us to create communities where we understand the nature of addiction and treat it with the respect accorded to other physical and mental health problems and illnesses. We need to create an environment where people are unafraid to seek help, where they feel safe when they do reach out, and where there is access to high quality best practice treatment for all. We’ve got a long way to go.”

The MHCC’s forthcoming research will shed light on how a lack of understanding about the root causes of addiction, compassion fatigue and burnout, as well as entrenched stigma, are affecting not only the ability of first responders to do their job – but also how people seek help. This compelling new research is widely anticipated to appear in scientific literature in the coming months.