Young Indigenous people who use drugs in BC 13 times more likely to die than young Canadians

Pictured: A March 2015 Cedar Project Partnership meeting. The Partnership are the Indigenous governance for the Cedar Project, and co-authored the research.

A new study by The Cedar Project demonstrates that young Indigenous people who use drugs in BC are dying at an alarming rate – nearly 13 times Canadians their age. The findings point to concerning associations between death and Hepatitis C infection, having previously tried to commit suicide, and recent non-fatal overdose.

Researchers followed 610 young Indigenous people who use drugs in Vancouver and Prince George. Forty participants died between 2003 and 2014. Mortality rates among young women were almost double those of young men. Among those who took their own lives, 80% were young women; among those died by overdose, 73% were young women; and among those who died of illnesses including HIV and Hepatitis C, 73% were young women.

“These deaths involve our relations, our loved ones. They carry with them deep personal sorrow. Since this analysis was completed, we have lost 26 more of our children – 16 women and girls. Why do our children continue to die?” said Mary Teegee, Executive Director of Child & Family Services at Carrier Sekani Family Services who is Gitk’san and Carrier from Takla Lake First Nation and chair of The Cedar Project Partnership. “Keeping our young women safe means pursuing justice for those who have been murdered and are still missing, looking at the root causes of vulnerability, and providing holistic, cultural services for families and communities.”

Published this month in the Canadian Medical Association Journal, the study is a collaboration between The Cedar Project Partnership, an independent body of Indigenous leaders, Elders and experts who govern the entire research process, and researchers from University of British Columbia; Canadian HIV Trials Network; Canadian Aboriginal AIDS Network; BC Children’s Hospital Research Institute; Vancouver Native Health Society; Vancouver General Hospital; Splatsin te Secwepemc; and the University of Northern British Columbia.

“We honour our young people who have passed away and offer condolences to their families. These statistics are more than just numbers. They are our children, our relations,” said Kukpi7 Wayne Christian, Chief of Splatsin Secwepemc Nation and co-Principal Investigator of the Cedar Project. “These deaths represent emotional pain, spiritual pain, and mental pain caused by complex traumas that lead our young people to turn to opioids and substance use. Overdose is a symptom of a deeper crisis – our own nations and service providers in urban areas must address the cause of the opioid emergency.”

Overdose was the leading cause of death in the study. Recently experiencing a non-fatal overdose was associated with a three-fold increase in risk of death, suggesting that the period immediately after a non-fatal overdose is a critical time for intervention.

Professor Martin Schechter

“The illicit drug supply is now catastrophically and irrevocably toxic. The addition of fentanyl, carfentanil and their analogs — many of which are thousands of times more potent than heroin and morphine — has transformed each use of illicit opioids from a risky activity into a potential death by lethal injection,” said Dr. Martin Schechter, UBC Professor and co-principal investigator of the Cedar Project.

Living with Hepatitis C was the most significant predictor of death in the study. Ensuring that young Indigenous people who use drugs living with Hepatitis C have access to new therapies is critical to preventing early mortality.

“Participants living with Hepatitis C, when they joined the study, were nearly three times more likely to die. This reinforces the urgent need to work with this community to increase levels of trust in order to support diagnosis and treatment.” said Dr. Eric Yoshida, Professor of Medicine and Past Head of the Division of Gastroenterology of the University of British Columbia and Vancouver General Hospital. “Disturbingly, it indicates that Hepatitis C may also be a surrogate marker of premature mortality from all causes, suggesting that its associations are much more complex than a simplistic chronic infection that results in cirrhosis.”

Deaths witnessed in this study are in no way natural or inevitable, but are the tragic result of failure to meaningfully address harmful historical and lifetime trauma, note the Indigenous leaders and Elders of the Cedar Project Partnership. Cedar participants have been acutely affected by the legacy of colonization through removal from their parents into the child welfare system, the lifetime impact of childhood sexual abuse, and harmful effects of substance use to numb the pain of trauma.

“How can we create a safe place where people can be comfortable to talk about the complex trauma our communities have faced? We know that culture is such a huge part of that, such a huge part of healing,” explains Sherri Pooyak (Cree) of the Aboriginal HIV & AIDS Community-Based Research Collaborative Centre and Canadian Aboriginal AIDS Network. “We cannot forget about the loved ones of our participants who are dealing with grief and loss. Their deaths can cause a ripple effect. It’s so important that friends and loved ones are supported with culturally safe services to say goodbye and heal.”

The study findings were released by The Cedar Project, a collaborative, community-governed research initiative that addresses HIV and hepatitis C-related vulnerabilities among young Indigenous people who use illicit drugs in British Columbia. It is funded by the Canadian Institutes of Health Research (CIHR).

To read the paper, please visit CMAJ or contact us for a copy.

To view the visual abstract for the study, please click here.

Additional context

Historical Trauma: Between 1874 and 1996, over 150,000 Indigenous children were removed from their communities and placed into the Indian Residential School System. Widespread atrocities were experienced in the schools, including sexual, physical, psychological, and emotional abuses and persistent devaluation of cultural identity and knowledges. Many former students struggled to cope with their experiences after they returned home and unintentionally transferred unaddressed grief and pain onto their families. Indigenous scholars refer to historical or intergenerational trauma as collective emotional and psychological injury over the lifespan and across generations. Removal of Indigenous children from their families continues through apprehensions into the child welfare system.

Opioid crisis: In April 2016, BC declared a public health emergency as a result of a surge in overdoses related to the introduction of fentanyl and carfentanyl into the drug supply. Preliminary data on the impact of the opioid crisis among status First Nations people residing in BC has recently been released by the First Nations Health Authority (FNHA). Between January 2015-July 2016, 10% of all overdose deaths in BC occurred among First Nations people, despite that they comprise just 3.4% of the population. First Nations with status in BC were three times more likely to die due to an overdose than non-First Nations people. FNHA has called for culturally-safe, trauma informed responses in four action areas: (1) Prevent people who overdose from dying; (2) Keep people safe when using substances; (3) Create an accessible range of treatment options; (4) Support people on their healing journeys.

Missing and Murdered Indigenous Women and Girls: The disproportionate number of Indigenous women and girls who have been murdered or are missing is a national crisis. Though counts vary, a 2014 report from the RCMP identified more than 1000 missing and murdered Indigenous women. Families and loved ones assert that this is an underestimate. When the Truth & Reconciliation of Canada’s final report was published in 2015, it echoed long-standing calls by Indigenous families, communities, and organizations for a national inquiry (Call to Action 41). In September 2016, the Government of Canada launched an independent National Inquiry into Missing and Murdered Indigenous Women and Girls. The mandate is to examine and report on the systemic causes of all forms of violence against Indigenous women and girls in Canada by looking at patterns and underlying factors. At the one year mark of the inquiry, expert hearings have begun.

Hepatitis C: A previous Cedar Project study demonstrated that 34.8% (59% among those who inject) of participants had Hepatitis C when they joined the study. Having Hepatitis C at baseline was associated with daily opiate injection, reuse of syringes, having a parent who attended residential school, being female, and duration of drug use. Young women were more likely to be living with Hepatitis C at baseline, compared to young men. Indigenous leaders, community service providers, and health experts are concerned that complex barriers have impeded Indigenous people’s access to life-saving Hepatitis C treatments. Recent advances in direct acting antiviral (DAA) Hepatitis C therapies are dramatically changing the landscape of treatment, as they offer shorter durations, higher rates of sustained viral response, and greater tolerability. It is essential that young Indigenous people who use drugs living with Hepatitis C receive care that acknowledges the impact of colonization and historical trauma and supports strength and survival in the face of complex adversities.

Grief & loss: Deaths observed in this study “carr[y] with them personal sorrow and family desolation that cannot be described statistically”. They are a continuation of the multiple losses sustained by families and communities as a result of colonization. Accumulation of grief among those left behind may result in fatalism, loss of hope, and escalation of drug use as a way to cope, contributing to increased vulnerability to drug-related harms, blood-borne infection, and mortality. Young people who use drugs, as well as their families and loved ones, must have access to culturally-safe resources to support healing and grief coping.

The Cedar Project: The Cedar Project is an ongoing, two-city cohort study addressing HIV and HCV-related vulnerabilities among young Indigenous people who use non-injection and/or injection drugs. The study began in 2003 in Prince George, a forestry and mining town in the northern interior of B.C., and Vancouver’s Downtown Eastside. Since the study’s inception, Indigenous collaborators and investigators, collectively known as The Cedar Project Partnership, have governed the entire research process. Knowledge translation and community engagement is a hallmark of The Cedar Project Partnership. The Cedar Project is funded by the Canadian Institutes of Health Research (CIHR).

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