An Exploration of Youth, Family and Provider-Identified Solutions to the Canadian Youth Opioid Health Threat

The editorial team of the Emerging Health Threat ‘At-risk Youth and Newer Users’ research working group are thrilled to be the first, in the history of the Canadian Journal of Addiction, to publish a supplemental issue in this journal. With the opioid overdose and health crisis rapidly growing and evolving in North America, this special issue provides an opportunity to present a series of studies involving investigators in this field from across the country. Our working group involves diverse expertise in disciplines including critical public health, sociology, psychiatry, psychology, and anthropology. This research was made possible through a unique research funding opportunity granted by Health Canada's Emerging Health Threat (EHT) Division to the Canadian Research Initiative in Substance Misuse (CRISM) network to rapidly study and understand the evolving opioid overdose and health crisis in our country and to develop recommendations for prevention, treatment, harm reduction, and policy. The current issue will present one of 12 programmatic EHT research projects funded by Health Canada through CRISM. It became apparent in the mid-2000s that the opioid overdose and health crisis was evolving rapidly and was beginning to impact youth and young adults. Epidemiological data until that point suggested that opioid use was primarily a problem for older drug dependent adults,1 but by 2018 evidence showed that youth in Canada had the greatest increases in hospitalizations due to opioid use.2 It was also simultaneously becoming evident that the opioid overdose and health crisis was manifesting itself differently among youth populations across Canada and that diverse youth populations have been impacted differently by this crisis, with important regional differences emerging across the country.3,4 Our project focused on at-risk youth and newer users of opioids, with youth defined as those between the ages of 15 and 25 years. Each site in our working group focused on a different youth population, also including guardians and caregivers of youth who had experienced opioid-related harms. The CRISM network's partnership with Health Canada on the EHT projects represented a unique opportunity of mutual benefit for both partners. Health Canada was able to readily access addictions research expertise from across the country through the CRISM network to mount these projects in a timely manner. The Health Canada EHT initiative also benefitted from the CRISM network's close ties with addictions services and people with lived and living experience of addiction, including affected family members, allowing for the research development to proceed in a more rapid timeframe than would have otherwise been possible. Members of the CRISM network also benefitted from the close working relationship with Health Canada on these projects, which allowed for the potential of more rapid translation of the research findings into public health policy. This research aimed to better understand a rapidly evolving health trend, to inform prevention and early intervention practices and provide guidance for public health and a comprehensive drug strategy. Given the desire for rapid response research, it was clear from the outset that the most pertinent research questions could not be answered using conventional large-scale epidemiological surveys or traditional randomized controlled trials. To improve understanding of this rapidly changing health crisis among youth and, more specifically, to better understand how opioid-related interventions could be improved for youth and emerging adults and their families, a mixed methods approach was necessary. Qualitative methodologies were considered particularly well suited for addressing our research aims due to these methods’ sensitivity to the depth, richness, and nuance(s) of young people's unique experiences with several relevant contexts (eg, social norms, personal opioid use, and involvement with services). Qualitative methodologies are also ideally suited to help us understand the affective and intimate nature of youth perceptions of this evolving health crisis. Alongside quantitative analyses and methods, qualitative insights can help explain unexpected or unusual quantitative findings, which was the case in some of the studies reported herein (eg, in the Isaacs et al (this issue) study, qualitative focus group findings helped clarify why a social norms intervention changed emerging adults’ social norms perceptions but not their behavioral intentions to use prescription drugs). Qualitative methodologies also have the built-in capacity to engage participants and cultivate relationships with the researchers that go beyond immediate data collection and analyses. A wonderful example of this is how one of our studies (ie, Nairn et al,5 this issue) resulted in such effective youth and stakeholder engagement that a youth research participant was nominated to attend and present on behalf of the project at the United Nations Office on Drugs and Crime youth meeting in Vienna in 2020. A four-pronged methodology was used in our project that involved four distinct but complementary methods addressing our research aims from different angles. Specifically, these included: a scoping review of the literature on current treatments for youth who use opioids or who may be at-risk of opioid use; a critical gap survey for youth-serving providers across the country to understand their needs and the gaps in opioid-related services for youth; focus groups and interviews with different demographics of youth across Canada; and a cross-national youth summit that engaged members of several different youth populations. A particularly innovative feature of this research program was the use of highly comparable qualitative research methods across sites, which allowed for the highest degree of comparison and integration across divergent study populations. The first paper presented in this supplement outlines a research protocol describing how a participatory summit was used at each site to enhance engagement of a specific target population of youth. The paper discusses how the summit methodology was particularly useful in engaging populations of youth that might be relatively less well studied or understood, and reports on both the successes and challenges experienced through this participatory research process. International reports have noted that there has been little dissemination of the processes, protocols, and outcomes resulting from youth engagement initiatives in substance use-related research and policy development.6 This protocol paper thus fills a gap that could be useful to others undertaking similar engagement initiatives with youth in future. The next article focuses on our pan-Canadian survey of service providers. This article outlines, from a service provider perspective, the nature of the services available to Canadian youth who are using opioids, the gaps in services available in our country, and service provider needs. A striking finding from this study was the relative lack of preventive services being offered to young people at risk of opioid use. These findings parallel those reported by this team in a previous publication on a scoping review of evidence-based solutions for youth at risk of opioid related harms.7 Both studies revealed that very few evidence-based treatments focus primarily on youth. The interventions that do exist focus primarily on youth experiencing opioid dependence (eg, opioid agonist therapies in combination with some psychosocial-educational adjuncts) and enrolled primarily men/males to the exclusion of women/females and other gender diverse youth. As mentioned, each site in our EHT project focused on a different population of youth. Five of the articles presented herein focus on a distinct population that has been uniquely impacted by the opioid overdose and health crisis: In British Columbia, where the opioid overdose crisis has had a longer history, the research team worked with youth who were street-involved and had experience with opioids. Their article discusses youth experiences with available treatment services, which were primarily pharmacological treatment programs, and presents several suggestions from affected youth for how these treatments could be improved to address a broader array of youth contexts, visions, and needs. The team in Calgary worked with guardians and caregivers of youth who were experiencing opioid use-related harms or who had died from opioid overdose. This article discusses the needs of this neglected population and outlines pragmatic suggestions for how to include and account for the needs of this vital group in the context of youth opioid use. Caregivers and guardians encountered both discrimination and stigmatization when seeking care for a loved one experiencing opioid-related harms and confusion about where and from whom to seek help for their loved ones. These guardians and caregivers also reported encountering a relative dearth of social, emotional, and mental health supports for themselves. The study presented by the Ontario team focused on youth who were already accessing substance-use services. Their article presents several themes with regards to improving opioid-related substance use services, from the perspectives of those who are already accessing and using opioid-related services. Youth had several suggestions for how to improve services, including an emphasis on the development of a harm reduction approach/paradigm, services that support youth autonomy, and (as with other contributions to this supplement) the elimination of judgmental and potentially stigmatizing interactions with healthcare providers. In Quebec, the team chose to focus on one of the historical factors that has contributed to the opioid crisis, namely, opioid prescribing. This unique study is one of the first qualitative studies to focus on youth who were being treated with opioids for pain management, regarding their perceptions about opioids. This article reflects on youths’ ambivalence in their perceptions around prescription and illicit opioids. The paper discusses how such youth experience dual stigma associated with both their health condition and their prescription opioid use. Noteworthy was youths’ concerns there were only negative portrayals of opioid use, which impacted their interaction(s) with healthcare professionals and family members. These youth also reported a desire for adjuncts to pharmacological treatments including greater mental health supports, as they were managing their health conditions and the emotional distress associated with their conditions. Lastly, in Nova Scotia the focus was on university students who had experience with prescription opioids, stimulants, and sedatives/tranquilizers. This team had previously showed that both medically sanctioned and non-medically sanctioned prescription drug use is a concerning reality on Canadian university campuses.8 In the present paper, youth were provided with a “social norms intervention” which challenged their overestimation of prescription drug use among their university peers using accurate norms data. This article discusses the potential rationale for why and/or how social norms interventions (and media campaigns more generally) may not be enough to alter or change youth opioid use behaviors when used alone. Qualitative findings indicated a lack of student buy-in around the corrective social norms information shared on the medically sanctioned and non-medically sanctioned use of prescription drugs by their peers. This lack of student buy-in may have explained the general lack of change in behavioral intentions to use following the social norms intervention. We would like to take this opportunity to highlight some key findings from these contributions and reflect on the ways in which strategies could be modified and/or developed to better impact opioid and polysubstance use among youth in Canada. It was evident through analyses of our survey results that service providers are working within a polysubstance use context that encompasses not only prescription and illicit opioid use, but also alcohol, cannabis, benzodiazepine, and stimulant use among youth. A general approach to youth substance use treatment in Canada should account for this polysubstance context, rather than focusing on specific substances as the source of the problem. What appears to be lacking in the Canadian context, is a comprehensive focus on the etiology of substance use, and the psychological and psychosocial drivers of substance use beyond the drug itself. It has become evident through our research that the contexts of youth opioid use are where the ‘real’ crisis manifests, and that it may be detrimental to focus solely on the (contaminated) substances or drug supplies. While focusing on a particular substance (eg, fentanyl and its analogues, methamphetamine) draws general attention to the harms the use of the particular substance may cause, substance use interventions and strategies need to account for and focus on contextual factors. The contexts of youth substance use include, but are not limited to, relationships with family members, peers, romantic and/or sexual partners, healthcare and teaching professionals, traditional and social media, socioeconomic status and/or positioning, and social/cultural norms about what constitutes a ‘normal’ life. Youth emphasized the lack of psychosocial-structural supports in the current pharmacologically focused treatment approaches or paradigms, and the need for changes in relationships and interactions between healthcare professionals and youth and their caregivers or guardians. Relatedly, youth across the country talked about feeling marginalized, judged, and stigmatized. Clearly there is a need for guidance and skills training for healthcare professionals, teaching professionals, and family members on how (eg, through modifying language use) to engage youth in non-stigmatizing, empathic, motivating, and empowering communication around their opioid and other substance use, that eliminates paternalizing and stigmatizing language and behaviors which may paradoxically increase or maintain their substance use. Another important message was that such non-stigmatizing approaches are also needed when providing more upstream services and preventive interventions that address early risk factors and contexts. Public health interventions need to avoid mass media campaigns, as evidence clearly indicates a lack of effectiveness of this type of intervention, poor resonance with younger audiences, and in some cases cause iatrogenic effects.9 Instead, we need to bolster services that could help young people manage some of the individual risk factors (eg, pain, mental health symptoms, personality factors) and contextual risk factors such as those mentioned previously and explored throughout this supplement. Our hopes in presenting this supplement are twofold: to encourage a shift in stakeholders’ approaches and mindsets toward those that authentically value and engage youth in the development of substance use policy and research agendas going forward; and to take up and integrate pragmatic and novel solutions such as those presented herein that address both youth-specific individual and contextual factors regarding their substance use. We will continue to support and advocate for the uptake of the youth-identified values and principles presented herein and sincerely hope others will join us in this profound shift in vision and practice.

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