Youth Voices on Treatment in the Shadow of the Overdose Crisis
Key recommendations and findings for care providers
The overdose crisis in British Columbia is having devastating effects on youth and their loved ones. Since an official public health emergency was declared in B.C. in April 2016, over 9,000 people, including over 1,600 young people under 30 years of age, have lost their lives to overdose in the province. Youth experiencing street involvement (i.e., those experiencing street-based homelessness or unstable housing) are particularly vulnerable to overdose in
Who this is for
This report provides guidance and recommendations for those caring for young people experiencing street involvement, to help care providers foster more constructive relationships built on mutual trust and respect.
It draws from a series of qualitative research studies conducted with youth experiencing street involvement on the unceded, ancestral and occupied territories of the Lheidli T’enneh, Syilx Okanagan, Musqueam, Squamish, and Tsleil-Waututh Peoples. These places are also known as Prince George, Kelowna, and Vancouver.
Key Recommendations & Findings
Many youth expressed ambivalence, suspicion, or aversion toward overly medicalized models of care that felt as though they were too focused on monitoring and pharmacotherapies, and less focused on relationship- and trust-building. Several youth viewed overly medicalized models of care as part of a continuum of institutional harms they had experienced across their lives and, in the case of Indigenous youth, across generations. Hospitals in particular were viewed as unsafe places, but youth told us that any institutional setting or setting of perceived intensive surveillance could signal danger.
Pharmacotherapies were framed by many youth as “quick fixes” that could not address the deeper issues they were contending with. When youth felt as though pharmacotherapies such as buprenorphine-naloxone were being “pushed on them” by providers in the absence of meaningful changes in their life circumstances (e.g., stable housing, employment), they frequently concluded that those helping them did not understand their treatment and recovery needs and goals. Several youth described avoiding treatment settings where they thought pharmacotherapies would be the primary focus of care.
Young people must be empowered with control over their treatment trajectories—including decision-making around pharmacotherapies and information gathering and sharing. They must be respectfully engaged as partners in their treatment and care, rather than approached from a position of authority. The focus should be on building relationships and fostering trust with individual youth, rather than on monitoring and pharmacotherapies.
Pharmacotherapies should always be presented as one piece of a whole that includes housing, employment, income, social, and cultural supports.
Youth were generally acutely aware of how their client files, patient charts, and other means of information sharing could impact their current and future interactions with services, including the child welfare, education, youth and adult criminal justice, and acute and community healthcare systems. Monitoring and surveillance could signal danger, particularly for youth who had experienced repeated institutionalizations across their lives and across generations. Again, several youth described avoiding treatment and care settings where they perceived a high level of monitoring and surveillance.
While many youth said that existing youth-dedicated services were essential supports in their lives, they also expressed concerns about information-sharing in these settings. They worried about “who knew what,” and the consequences of that knowledge being passed around, which they noted could include apprehension by child protective services. It was devastating when files, charts, and information-sharing seemed to reinforce a view that youth were “not making progress” or even “failing.” Some youth described trying to manage what did and did not end up in their files. Others, including a number of Indigenous youth, described avoiding care altogether in order to keep themselves safe.
Many youth emphasized that interactions with the providers who access their files and charts go better when providers first affirm where a young person is at in the present moment, rather than focusing on what has happened in the past or what is written down. “I am not my file” was a sentiment that we heard expressed on multiple occasions.
Youth valued individualized, multi-dimensional approaches to treatment that allowed them to work toward futures not defined by substance use and mental health crises. B.C. clinical practice guidelines recommend the longer-term use of OAT, and in particular buprenorphine-naloxone, as a first-line treatment for opioid use disorder
among youth. However, most youth did not envision being on OAT over the longer term.
Instead, they often viewed OAT as a short-term tool that could mediate withdrawal symptoms and jump-start their “full” recovery—which would ultimately be achieved without any pharmacological intervention.
Many youth also did not envision being on psychotropic medications over the longer-term. They desired a clear pathway to tapering off of OAT and psychotropic medications. When they were not offered this pathway, many decided to “do it on their own” and disengaged from care. With regard to self-tapering off OAT, the result was often relapse and sometimes overdose.
From the outset, OAT and psychotropic medications should be discussed with youth in terms of shorter timelines, with the possibility of tapering doses. Youth who had the most success with adherence to OAT were actively involved in decision-making around what kind of medication would work best for them, and for how long. Youth must have access to the full range of OAT, and not just buprenorphine-naloxone.
Because of the sense of danger associated with highly medicalized and institutionalized settings, many youth expressed a preference for treatment modalities that they could exercise control over and did not require professional oversight. Many youth spoke positively about using cannabis, psychedelics, and cigarettes as tools for harm reduction and treatment that they could manage independently.
The prevalence of cannabis use among youth experiencing street involvement in B.C. has been estimated to be as high as 98 per cent. Youth frequently spoke about using cannabis not only for its pleasurable effects, but also as a means of relieving longstanding mental and physical health issues—notably, depression, anxiety, attention deficit hyperactivity disorder, and chronic pain. They also used it to manage the harms of street-based homelessness, and to help them reduce their use of or eliminate more problematic forms of substance use, including the intensive use of alcohol, crystal methamphetamine, and heroin/fentanyl. Participants described using cannabis to carefully “taper” their use of these other more harmful substances. They explained that cannabis helped reduce the severity of their withdrawal symptoms and prevented relapse by satisfying cravings.
Many youth strongly believed that regular cannabis use was preferable to the longer-term use of pharmacotherapies, including OAT and psychotropic medications. They frequently described using cannabis to taper off of OAT, or indicated that they planned to use cannabis to get off OAT after undergoing treatment. Many argued that cannabis should be integrated into substance use treatment for youth.
Care providers must be responsive to the ways in which youth experiencing street involvement are using cannabis to navigate their everyday lives and needs. They should engage in conversations with youth about their cannabis use, discussing potential benefits and risks of cannabis in the context of their physical and mental health and substance use issues.
Who We Are
We are a group of academic and community researchers and activists working in Vancouver, Canada. Many of us identify as youth with lived and living experience of substance use and mental health concerns in the context of unstable housing and homelessness.
The members of our team’s Youth Advisory Council (YAC), and the youth who participated in the qualitative interviews, focus groups, and summit event that inform this report, represent a diverse group of men, women, and trans and non-binary individuals between the ages of 14 and 28. Those who chose to disclose their ethnicity self-identified as white, Indigenous, African Canadian, Middle Eastern, Asian, and mixed.
All participants self-identified as having past or current experience with substance use in the context of street involvement. The vast majority had also experienced concurrent mental health concerns. They were recruited from drop-in centres, shelters, and other services dedicated to youth experiencing street involvement, and from the At-Risk-Youth Study (ARYS), a prospective cohort of more than 1,000 street involved young people who use drugs in Greater Vancouver. Interviews with youth-focused care providers have also informed this report. These providers include family physicians, nurse practitioners, nurses, drug and alcohol counselors, and social workers.
While youth participants were diverse, many expressed similar desires for their futures. They told us they longed to move into stable housing that was safe, comfortable, and clean. They spoke about securing a reliable and adequate source of income, preferably via employment. They wanted meaningful ways to fill their days, such as spending time with friends, family and romantic partners, pursuing hobbies and leisure activities, working on school, and advancing a career.
Though some youth critiqued the phrase, many spoke about these goals and aspirations as longing for aspects of a “normal life,” and recalled hopes that substance use and mental health treatment might be a way to achieve this. However, in the absence of desirable housing and adequate income, youth were often left with the crushing sense that, despite their efforts, treatment would not ultimately help them to “get somewhere better.”