Prescription Drug Addiction – A Submission to the Standing Committee

Diane Kays, Alana Leard, and Rose Barbour

At its October meeting, the Advisory Council was please to hear from guest speakers to complete a series of consultations on addictions issues. Chairperson Diane Kays (left) welcomes Alana Leard, ED of AIDS PEI, and Rose Barbour, blogger at http://shadowsinpei.blogspot.ca/

Download this submission as a PDF

October 21, 2013

Dear Members of the Standing Committee on Health, Social Development and Seniors:

The PEI Advisory Council on the Status of Women (PEIACSW) is an arm’s-length government-appointed Council. Nine Council members are selected from among Island women who have demonstrated a commitment to women’s equality and who represent regional, cultural, and ethnic diversity.

The Council believes that women’s equality is the foundation for equality for all people. Women’s inequality continues to influence discriminatory attitudes and actions that affect our society and culture, our politics and laws, and our economies. Council believes that women’s independent social and economic security is key to equality and to freedom from physical, emotional, and sexual violence.

The current nine members of the Prince Edward Island Advisory Council on the Status of Women encompass many overlapping professional and personal perspectives on the issue of prescription drug addiction. Our members include people with backgrounds in social work, nursing, occupational therapy, law, legal education, small business, farming, public service, arts and culture, and journalism. They have worked in settings that include hospitals, mental health facilities, and counselling centres. Among our group are individuals who have dealt with addictions close to home, in their own homes or in their families. We have a great deal of empathy and compassion for the voices you have heard from in your public and in-camera hearings with Prince Edward Islanders in the past months.

The members of the PEI Advisory Council on the Status of Women are deeply concerned about the effects of prescription drug addictions on individuals, families, and communities. While we know the scope of your hearings is prescription drug abuse, we have concerns about all forms of addiction and the lack of care. We have given close attention to addiction issues in the past year, by providing important information to the Mental Health and Addictions Review, by examining addiction services for women in our 2013 Equality Report Card, by including the topic of addictions in focus-group discussions and consultations with individual experts and community organizations, by attending public forum events on addictions, by following submissions to your committee, and by inviting presentations by experts in the community. We also hear inquiries from women in difficult circumstances looking for help and referrals. We would like to share some of what we have learned and some of our reflections on what we have learned.

We have addressed addictions services in policy guides and in each of our Equality Report Cards. Our 2013 Equality Report Card notes:

A growing epidemic in use of prescription narcotics leads community groups to call for urgent action, including steps that ensure adequate time for medical detox from substances other than alcohol, treatment services available when people are ready for treatment, and a plan for longer-term residential care, especially for youth and young adults. Government is at beginning steps with a strategy – and very much requires community input.

While we recognize that there are supply-side issues related to prescription drug addictions, and we look forward to analysis of the prescription monitoring service, our focus is on addictions treatment because that is the side of the issue we have heard from women in the community. After all, limiting access to prescription drugs without supporting people to treat, manage, or overcome their addictions could have harmful side effects if desperate people seek new sources of the “fix” they need.

Prescription drug abuse is an issue of concern to women and needs a gender lens.

As our friends at the East Prince Women’s Information Centre (EPWIC) have eloquently said, addictions issues hit women in two ways: as individuals in need of treatments themselves; or, often, as parents or family members and advocates for people in need.

As a Province, we need to approach the issue of prescription addictions with gender in mind and recognize that some factors in the addiction issue affect women differently than men. Cultural and social factors may influence women’s addictions differently than men’s addictions. Gender-specific approaches to treatment are needed when treatments that work for men do not work as well for women, and vice versa. Plans and programs to support parents, caregivers, and advocates who are bearing the burden of living with addicted people need to recognize that women continue to be primary caregivers in families.

Women’s economic situations are already unequal to men’s economic situations (with women’s earnings trailing men’s, with more women in part-time or less traditional employment, and with women making up the majority of lone parents who are vulnerable to low income). This leaves women more vulnerable to both social and economic costs associated with addictions and caregiving for addicted people.

Violence against women remains a part of our social landscape in Prince Edward Island. Women are still more likely than men to experience serious harm from violence. While drugs and alcohol are not the reason for violence, nor the cause of violence, nor an excuse for violence, there is no question that addictions add to the volatility and danger of violent relationships. It is also true that women with addictions may feel more trapped in violent situations than other women because of the complexity of the problems they are facing.

Women dealing simultaneously with violence, addictions, and poverty face desperate, life-and-death choices, for themselves and for their children. When they reach out for help, they must untangle a complex web of choices about where even to start to ask for help. Should you go first to Anderson House to escape violence and find a safe shelter? Can you stay there with an active addiction, or do you have to get treatment first? Will you seek treatment first and leave your children with a partner who abuses you? Will you risk having your children taken away by Child and Family Services no matter where you turn for help? Thinking through these choices is hard enough when sober. Making good choices in the midst of the crisis of active addiction is nearly impossible.

These thoughts form a background to our comments on prescription drug addiction.

Gender-specific treatment options are needed.

In consultations with the Advisory Council on the Status of Women, EPWIC identified three major immediate needs:

  1. adequate time for medical detox from substances other than alcohol (right now, people just “survive” detox and are discharged when they are most vulnerable);
  2. beds available when people are ready to go for treatment (their readiness to seek treatment can’t wait) and ability to book a bed; and
  3. a strategy and plan for longer-term residential care.

EPWIC says the government is at the starting point on this issue, and they are glad that government is beginning serious work, but that the crisis has reached a boiling point.

Numerous community organizations have emphasized the need for addictions services in people’s home communities across Prince Edward Island, and especially in rural Prince Edward Island. Many have noted the inaccessible, isolating location of Mount Herbert. The centralized location of addictions services at Mount Herbert is a particular barrier for people with limited access to transportation. There is no access to this location by public transit. Sadly, prescription drug abuse is not a centralized or “urban” problem in PEI. Services and supports need to be present, visible and accessible in rural areas.

The recent community voices report by Women’s Network PEI entitled “Paths to Prosperity: A Community Response to Poverty” brings together responses to poverty from hundreds of Prince Edward Islanders. Their report finds that “Islanders say our addictions services are one-size-fits-all treatments,” and that the relentless focus on twelve-step and other abstinence-based programs is creating barriers for many women. People that Women’s Network spoke to said they “want access to different therapies, like Behaviour Modification Therapy, which use positive and negative reinforcement to get people to break their addiction habits.” We would like to emphasize that based on our research, it is our view that models used to treat alcoholism are not adequate for addictions to opiates.

Women’s Network also draws attention to a central, gender-related question:

Early childhood trauma like childhood sexual abuse is known to be at the root of addictions and other issues… In Canada, women are more likely to be victims of sexual violence. Aboriginals and people who live in the territories are also more likely to experience sexual violence. According to a recent Canadian survey of survivors of sexual violence, many victims use substance abuse as a way of escaping their negative thoughts and feelings. It said a lot of Canadians used drugs and alcohol as a way to cope with their childhood sexual abuse and continued to do this as a way to deal with adult sexual abuse and mental health issues.

In addition to gender, another factor that consistently came up in our consultations was age. The individuals and organizations we talked to are profoundly worried about the effects of prescription drug use and abuse among young people. More than one said we are going to experience a “lost generation” on Prince Edward Island as a result of addictions. Numerous individuals and groups we spoke to believe that for young people in particular there is a need for a program like Portage that is government-subsidized but not government run. Government addiction workers are great, but the structures, policies, and regulations they work under do not support (maybe do not allow) therapeutic communities for recovery. Community members and community groups we spoke with call on government to look at both voluntary and mandated treatment.

Government policy, programs, and services must move to a patient-centred approach and embrace values of coordination, communication, and cooperation among departments and services.

A parent spoke to our Council about her experience supporting a young adult with mental illness and prescription drug addiction. She said quite clearly that the system in Prince Edward Island is system-centred, not client-centred. This analysis strongly resonated with the knowledge and experience of members of our Council. It is time to treat the whole person: their addictions, their mental health, their social and economic well-being.

We would like to provide you with the same advice that we provided to the Mental Health and Addictions Review, because it holds true also for the particular problems associated with prescription drug addiction: government programs, services, policies, and individuals working in silos are part of the problem. Breaking down these silos is part of the solution.

Crucially, Prince Edward Island systems need to look to the most effective models in other provinces and regions. There are well-coordinated mental health and addictions services in many regions of Canada, and we do not have to look far for solutions. These services have overcome some of the communications and coordination challenges that hamper treatment systems here in Prince Edward Island by putting people in treatment at the centre: for instance, supporting them to make effective treatment plans and empowering them to make decisions about what information about them can be shared among collaborating agencies.

Prince Edward Island mental health and addictions services would benefit from “mentoring” with successful programs elsewhere, to learn best practices and incorporate those learnings efficiently.

We have heard too many reports of gatekeepers and barriers between mental health and addictions services, and these barriers cause harm for people who require treatment for both mental illness and addictions. Many of these are women. Some are in urgent need of trauma-informed approaches that treat their suffering holistically. It is hard to know where to intervene first with complex interactions of mental health and addictions, but this is no excuse for shuffling people back and forth between systems until untreated mentally ill individuals begin to self-medicate with addictive substances or until people struggling to manage or overcome addictions develop mental illness.

When we hear stories of a suicidal person sent home from the hospital because of their addiction to prescription drugs, then refused a bed at detox because they are suicidal; or when we hear stories of an individual trying to overcome addiction being kicked out of addictions programs as a result of medications they are taking to manage mental illness and/or withdrawal; or when we hear about instances of a lack of effective communication between addictions services and paediatricians who provide care to narcotics-affected newborns, we see the evidence of harm that results from two systems that are not collaborating. The consequences can be life-or-death.

Many of our informants in focus groups and meetings told us that the system-centred approach to addictions services in PEI means that as a province, we remain committed to policies and programs that don’t work. The system focuses on treatment options that are cost-effective for the short term but that are least effective for the long term. A systems-based approach struggles to change its course and to be proactive in prevention and responsive to individualized treatment plans. Why, in Prince Edward Island, do we tend to be fixated on isolating detox, rehab, and methadone/Suboxone services, when the evidence shows that combining methadone with rehab has the greatest success rate? (A pilot project including youth on Suboxone in the rehabilitative Strength program is promising.) Why do we insist that people try and fail at every locally available treatment program before we support them to get more intensive help that is more likely to succeed? The cost of maintaining a system that doesn’t work is the cost of keeping people in their addictions, keeping people in jail, and keeping people and their loved ones and communities in suffering.

Monitoring successes, analyzing failures, and responding with innovative practices that are proven elsewhere and supported by evidence will give us the best chance of success.

A health-based approach is best for prevention and treatment.

Just as there is a lot of juggling between mental health systems and addictions systems about treatment, there is also a lot of juggling of responsibility between health and justice for responsibility for the addictions file. We consistently hear from women that a health-based approach should be the first focus and is the best option for prevention and treatment. We are very concerned with the tendency to criminalize and punish addictions rather than treat root causes and support struggling human beings. Our Council is concerned about the puritanical attitude of too many Islanders and the tone of judgment and stigma that permeates our culture. Judgment about people’s choices and circumstances is a barrier to good policy for poverty, for sexual and reproductive health, for mental health, and for addictions. This is not the spirit of a “gentle Island” where we have strong, supportive communities founded on compassion and reliance on each other.
Thinking of youth and young adults, prescription drug addictions, and our schools, one focus group that considered this question in depth did not come out against police officers in schools – but their priorities were clearly elsewhere. Their emphasis was on adolescents needing resource people they can talk to – neutral people who will listen without judging and will answer their questions in the moment their need arises.

A possible solution that focus groups put forward was youth workers in the schools, especially counsellors certified to work in addictions. This would allow youth and young adults in trouble to get confidential help to go in a better direction. Council members also advocate for support for peer-to-peer support and education. Supports like this would reduce delinquency, theft, and imprisonment – breaking the endless chain of dependency.

The focus group discussed what kinds of role models and activities youth and young adults with addictions require: good role models and activities that are affordable for all budgets. The Quebec model of “maisons de jeunes,”* or youth centres, was discussed. Perhaps an open youth centre with well-trained staff who can offer help with problems and also offer varied programming (music, drawing, theatre, dance, sports, and so on) could help youth stay away from drugs and help discover hidden talents that would help their self-esteem, the foundation for a healthy life.

On the justice side of the equation, we are heartened that the province is researching therapeutic court options in our justice system. We have been advocating for almost ten years for a domestic violence court option in our justice system. In the last several years, the Province’s focus of interest has shifted to therapeutic courts that look at mental health, addictions, and domestic violence. Because mental health and addictions are not the cause of domestic violence, we continue to advocate for a domestic court option additional to any therapeutic court options. However, we see much potential in therapeutic courts that focus on mental health and addictions. As our 2013 Equality Report Card notes, “We are looking forward to the release of research on possible models for therapeutic courts and their viability in PEI. We wish to see domestic violence court options highlighted.” EPWIC calls on government to consult with the community, “not just professionals,” to develop a strategy.

We continue to look forward to hearing the results of the research on therapeutic courts. Further, we look forward to government marshalling resources to support treatment and healing options for people with violent relationships, mental health issues, or addictions that bring them into the justice system. Now is the moment to act!

Harm-reduction options need more support, and community-based organizations are the experts on this and can lead the way.

Punitive approaches to prescription drug addiction can create barriers to programs of harm reduction.

PEI’s needle exchange program is one important example of a harm-reduction program that merits attention and investment. The Advisory Council on the Status of Women has advocated for a strong needle exchange program since it was first taken on by the Province.

The urgency for effective needle exchange can be seen in the rate of Hepatitis C, which has doubled over the last 10 years. Part of this is due to increased testing, and it is helpful that people are finding out they have Hepatitis C. However, it makes it all the more essential that timely treatment options are available for people after they are diagnosed, so they can have the best health outcomes possible. We are concerned that too much of the testing takes place only in jails, and that tests for Hepatitis C and other infections could be limited as a cost-savings effort by Health PEI, which has created some barriers to screening for a variety of conditions.

According to AIDS PEI and media reports, 760 people currently are diagnosed with Hepatitis C in PEI, and the vast majority of newly diagnosed cases result from intravenous drug use. Women make up about 2/3s of those being tested. The use of the needle exchange program has increased greatly, with 88,000 needles distributed and over 75,000 returned for safe disposal in 2011. However, AIDS PEI emphasizes that given the extent of IV drug use in PEI, these are not huge numbers. What we are hearing in the community is that IV drug users are not sharing needles but are reusing their own needles, which still creates a tremendous risk for staphylococcus and other infections.

The closure of the needle exchange in West Prince offers an opportunity for analysis: What was the extent of need in the community for this program? Why was this service not being used? What would have made it more accessibly to IV drug users? Would lessons from West Prince apply more generally across PEI?

The needle exchange program needs to be expanded and to include more hours in more accessible locations (or possibly mobile locations) that protect people’s privacy and confidentiality and increase the likelihood that each intravenous drug user will use a clean needle every time and will never pass a used needle on to another user. “Accessibility,” in this case, needs to go beyond physical access and include the values of being welcoming and non-judgmental.

The methadone program is another example of a harm-reduction program, and we have heard calls for an expansion of this program, with more doctors licensed to prescribed methadone. We have also heard calls from the community for suboxone to be added to the provincial formulary as an alternative to methadone.

Harm-reduction programs are a prime example of an area where we can learn from successes in other parts of Canada; most notably, British Columbia has very well-developed harm-reduction programs. We call on government to take a proactive, preventive focus.

Another example of a punitive approach to addictions treatment is the ban on smoking anywhere on the grounds at Mount Herbert. Is it reasonable to ask people dealing with withdrawal from prescription drugs to simultaneously undergo withdrawal from smoking, a persistent and difficult addiction on its own? Women have told us that one unintended consequence of the non-smoking policy is that some addicts with severe cigarette addictions are seeking transfers to the Hillsborough Hospital, where there are exceptions to the smoking ban. This is another example of mental health and addictions systems offering either/or options – either treat mental health or addictions – instead of a coordinated, patient-centred approach.

We need to know more about how the prescription drug addictions crisis specifically affects women.

Looking at the issue of prescription drug addictions with a gender lens highlights several issues that specifically or disproportionately affect women and that require more attention and study. Too little is known about the following:

  1. the effects of the closure of Grandmother’s House and the lack of a homeless shelter for women in Charlottetown, and increasing pressures on emergency shelters for women fleeing violence.
  2. the extent of formal and informal sex work and sexual exploitation of women and men as part of the prescription drug crisis: escort services, dealers pimping, users “paying” with sex, with huge risks of violence and of disease.
  3. the current state of pregnancy and post-natal care for women and babies affected by prescription drug addictions.
  4. what gaps exist and what supports are needed for grandparents (mostly grandmothers) who have primary care and responsibility for grandchildren as a result of the parents’ prescription drug addictions.

We have heard chilling effects of all these issues and need to know more.

The community is waiting for the release of the Mental Health and Addictions Review.

Finally, we call on you to urge government to release the Mental Health and Addictions Review so that it can be reviewed and considered by the community. As members and staff of the PEI Advisory Council on the Status of Women, we look forward to providing a response based on gender and diversity analysis and informed by the voices of women from across Prince Edward Island.

The members of the PEI Advisory Council on the Status of Women are persuaded that the social and economic costs of not treating prescription drug addictions is far greater than treating them, and we urge not only investment in treatment services and in people in treatment, but investment of time, energy, and resources in shifting from a system-centred approach to a patient-centred approach. If you wish to hear some of these recommendations in the voices of Advisory Council members, we have recorded some of our comments on video and will make this available online at http://vimeo.com/peistatusofwomen by October 25th.

We are grateful for the opportunity to share our reflections with your Committee, and we wish you good luck as you develop recommendations.

Sincerely,

Diane Kays, Chairperson

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