Substance Use in Canada

Differences in Substance Use

• Humans consume diverse substances including legal, illegal, natural, pharmaceutical, prescribed and purchased items
• Problematic substance use can lead to adverse physical, psychological, legal, social and interpersonal consequences, not always involving dependence
• Dependence is progressive, affecting physiological, cognitive, behavioral, and psychological dimensions of health
• The term "addiction" has been removed from medical diagnoses due to its difficulty in definition and negative connotations

Canadian Context of Substance Use

• Community Health Nurses (CHNs) can use epidemiological data on substance use to inform community health nursing interventions
• Tobacco use is a leading preventable death cause in Canada, with usage rates varying by age, sex, education and province
• Alcohol consumption in Canada has increased and the average age for first alcohol is about 15 years
• Cannabis is the most widely used illicit drug in Canada and second-most used by youth
• Health Canada has authorized marijuana for medical use and local communities have adopted a "Four Pillars Approach" to address problematic substance use
• The Four Pillars Approach includes harm reduction, prevention, treatment and enforcement
• A wide range of tools and solutions are needed; Canadian experts have developed a framework combining health promotion and enforcement

Relationships Between Problematic Substance Use

• Intersecting dimensions of oppression, dominance, and prejudice are often associated with mental illness, substance use, poverty, gender, race and sexuality
• These intersecting forces can create more or less disadvantage and impact health and well-being
• People's experiences, though possibly similar across dimensions, are differentiated by the disadvantages and advantages posed by their location across dimensions

Trauma, Violence, and Problematic Substance Use

• Interpersonal violence is associated with negative health effects, including problematic substance use and mental health issues
• Violence and trauma in the Canadian population strongly correlate with negative health outcomes, including problematic substance use and mental health
• Community Health Nurses should understand violence as a possibility in any person's life, whether in a healthcare setting or community context
• Problematic substance use often overlaps with violence, mental health issues, and is seen within the context of social and structural determinants of health

Problematic Substance Use and Health Inequities

• Tobacco use is declining in Canada overall, but not among low-income populations
• The historical legacies of racism, structural violence, and dehumanization like residential schools have led to health inequities for Indigenous peoples
• Problematic prescription drug use rate is two to three times higher among urban Indigenous youth compared to non-Indigenous youth
• Groups at risk for problematic prescription drug use include: military personnel, people experienced incarceration, homeless individuals, concurrent disorders patients, and healthcare professionals
• 4 key dimensions for understanding the essential elements of equity-oriented Primary Health Care (PHC) services when working with populations marginalized by social and structural inequity:
  • Equity-Responsive Care
  • Trauma- and Violence-Informed Care
  • Contextually Tailored Care
  • Culturally Safe Care

Stigma and Substance Use

• Stigma is a concept intersecting with or contributing to the harms of problematic substance use
• Stigma is an attribute associated with "difference" that is deemed to be an undesirable difference by a person
• Nurses experiencing problematic substance use are acutely aware of stigmatizing attitudes from colleagues
• Nurses' attitudes are shaped by societal norms and are a reflection of conversations in the social world
• It is crucial for Community Health Nurses to reflect on their own prejudices, biases, and assumptions regarding substance use to support destigmatizing approaches

Harm Reduction

• Harm reduction is designed to reduce drug-related harms without requiring drug use cessation
• Prominent harm-reduction strategies include medically supervised injection sites, street outreach, needle exchange and methadone maintenance treatment programs
• Harm reduction focuses on lowering the risk and severity of adverse consequences without necessarily stopping or reducing use
• Harm reduction should be goal-oriented, humanistic, and involve nonjudgmental acceptance with a person-centered approach

Levels of Prevention

• Primary prevention of substance abuse focuses on enhancing control over use and preventing addiction development
• Health-promotion activities include regulations, policies, health warning labels and elements of harm reduction
• Secondary prevention activities include screening, early identification, treatment, enforcement, and harm-reduction programs
• It is imperative that Community Health Nurses are familiar with screening and care planning for appropriate referrals for additional support, counselling or treatment
• Community Health Nurses should be skilled in recognizing the sign and symptoms of substance abuse and dependence and should be comfortable raising the topic with clients
• Primordial Prevention involves nurses supporting public policy making that reduces structural inequities
• Poverty is a significant systemic factor that increases risk related to substance use.
• Poverty is related to economic policies, employment policies, discriminatory histories and systems, access to social services, and related factors linked to public policy
• Secondary prevention involves early identification when substance use becomes problematic
• Secondary prevention involves rapid support to assist the individual in addressing root causes to reduce or end substance use
• Secondary prevention can involve substance use screening, tools, or conversations that allow for the detection of signs and symptoms of problematic use
• Tertiary prevention reduces harm from problematic substance use for both individuals and their families and communities
• Treatment can be a form of tertiary prevention as well as secondary prevention
• Tertiary prevention takes the realistic perspective that not everyone is ready or able to reduce their substance use at the moment Quaternary prevention addresses the stigma around substances within the health care system.
• Nurses ensure they follow the lead of individuals, families, and communities in determining if substance use is problematic.
• Health professionals are at risk of focusing on the behaviour of substance use versus supporting the individual in addressing root causes

Role of the Community Health Nurse

• No single community intervention can resolve community challenges related to problematic substance use
• Community Health Nurses should support communities in using complementary interventions, blending all prevention levels
• Community Health Nurses should recognize and address the structural differences and power dynamics within substance use services
• Community Health Nurses should ensure that access is barrier-free and outcomes are achievable