It starts with stigma: Summary of New Brunswick public health dialogue

“I wish people could understand…”

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Over two days and six hours of discussion with some 40 participants across New Brunswick, stigma surfaced as an important issue preventing services and resources from reaching people in need. This was because many in the public associate substance use disorder with criminality (and saw it as a choice rather than a health condition), making it harder to build the necessary public support for vital services like emergency shelters, supervised consumption sites, and even basic life-saving measures like naloxone. Where resources and services did exist, participants said they were harder to access for people who use drugs: “Stigma doesn’t help, because non-users are getting help faster than those dependent on drugs.”

“Many [people who use drugs] will refuse to go to the hospital for fear of the stigma.”

Many highlighted stigma in the health care system as particularly pervasive and harmful—dissuading individuals from seeking help when they needed it. One individual noted that “many [people who use drugs] will refuse to go to the hospital for fear of the stigma. In the emergency room, not every staff member but a lot treat people on methadone like second-class citizens.” People reported feelings of judgement from hospital staff, and the criminality and stigma associated with substance use also resulted in mixed messages and confusion: “In Saint John there is stigma towards users and having harm reduction. They say they can use it in the hospital, but also say they’ll arrest their friends if they bring in stuff for them to use in the hospital.”

Stigma also affected people’s ability to attend to their basic needs such as housing: “Without housing and having a […] place to go we’re not giving them much of a chance.” Widespread societal stigma also made it harder for people to come forward and talk openly about substance use, limiting the effectiveness of existing support services and treatment programs because people are less likely to disclose their substance use and take steps to access these services. The silence also reinforces the shame and prejudice felt by people who use drugs, thereby perpetuating a harmful cycle.

Lack of Resources, Services, and Knowledge

Over the two days, people reported a serious lack of resources, services, and a gap in knowledge around basic harm reduction, even by health care providers. Participants remarked that New Brunswick was 20 years behind the rest of the country in terms of advancements in harm reduction through initiatives like naloxone training and safe injection sites; and they underscored how rural, smaller communities were often the last to receive these lifesaving services. “New Brunswick government fights against itself. Don’t offer sharps containers, don’t offer free anything,” said one participant. People indicated that some nurses did not even know what naloxone was nor how to use it, resulting in individuals having to ask staff at other organizations how to properly administer this life-saving drug. This reveals how stigma can affect an entire system rather than just individuals, noted one participant.

Light at the end of the tunnel – We asked participants to draw their vision of a future free from drug policy-related harm.

People highlighted a need for expanded drug testing and the opening of safe injection and overdose prevention sites to provide safer spaces for people to use drugs. Pharmacists require free naloxone that can be handed out readily, and individuals also pointed to a reluctance by many doctors to embrace “safe supply” as an alternative to the contaminated illegal drug market because of the stigma and criminality associated with substance use. This resulted in people who use drugs relying on a dangerous supply of unregulated drugs purchased on the street, far removed from health care professionals and services. One participant commented that one pill in a safe supply prescription costs around 32 cents, a fraction of the cost to the health care system when someone overdoses because of a contaminated supply.

READ MORE: New Brunwick dialogue recommendations for change

This lack of services and resources often led to more harm; for example, one participant admitted to taking used needles from sharps containers because hospitals refused to hand out new supplies. Another noted that treatment for a single case of hepatitis C, which can be transmitted by using used needles, costs around $75,000. This is one public health intervention—providing new drug use supplies—that could save thousands of dollars by preventing disease transmission, while also (and more importantly) protecting the health and safety of individuals.

Brighter days – We asked participants to draw their vision of a future free from drug policy-related harm.

This lack of services and resources often led to more harm; for example, one participant admitted to taking used needles from sharps containers because hospitals refused to hand out new supplies.

Among the lack of services highlighted by dialogue attendees, one category stood out: mental health services. Mental health care was expensive and not covered by health benefits for many participants. Impossibly long waitlists for services were also an issue. One participant had to wait five years before they had a mental health care practitioner assigned to them. There were also unnecessary barriers like mental health services not being provided in certain areas, or only in certain clinical settings. People highlighted a lack of government funding and investment in mental health services, and that not enough was being done to teach youth coping mechanisms for anxiety and stress.

The word cloud above shows the key words and phrases that surfaced during conversations. The size of the words indicates how often they appeared. “Community” and “service” were strongly linked to conversations around a lack of services in rural and remote communities and the need for services that are responsive to the lived realities of community members; e.g., how “appointments” are difficult to make and keep for people struggling with housing.

Rural Isolation

The lack of resources and services was also closely tied to a sense of geographic isolation expressed by dialogue participants living outside city centres. Communities felt left behind. Drug treatment programs were often located far away with lengthy waiting lists that were untenable for people requiring immediate help. This results in a situation where “people using drugs have to wait until the system is ready for them,” as opposed to the other way around. People reported a lack of harm reduction supplies and basic public knowledge around drug testing and checking in rural communities as being particularly problematic. Even receiving basic health care was a challenge: “No family doctor in my area. I need to get to Moncton for example if I have urinary tract infection.”

“People using drugs have to wait until the system is ready for them.”

People from smaller communities also experienced more stigma relative to city centres because there was less willingness to talk openly about substance use and acknowledge it as a health issue. Individuals also felt that public awareness and anti-stigma campaigns took longer to reach those who needed to hear the message in their remote communities.

Housing & Poverty

One of the biggest areas of focus and discussion was the need for housing and poverty reduction strategies as the foundation for a public health approach to drugs. People indicated that the benefits from services and programs are diminished when the individual making use of them does not have a home to return to. “When you bring people in for detox, we’re gonna help them detox but then what happens after? They go back to the places where they know people. It sets them back,” said one participant. “There needs to be recovery houses where people can go to for recovery instead of back to the streets.” 

Hope – We asked participants to draw their vision of a future free from drug policy-related harm.

People revealed that most housing programs and landlords demand abstinence, which is a barrier to access. Rather, services should be about “providing the right environments for [clients] to thrive instead of expecting them to go down a path we have pre-determined”—in other words, meeting people where they are at and not withholding services or housing because someone is using drugs. Participants also highlighted long waitlists as a significant barrier to wellness and recovery. One person reported being on a housing waitlist for the past 4 years.

“When you bring people in for detox, we’re gonna help them detox but then what happens after? They go back to the places where they know people. It sets them back.”

The daily grind of poverty was also a significant barrier. Absent the necessities of life, such as a washroom, internet, and a working phone, it was nearly impossible for people to access and maintain a pathway to wellness. COVID-19 made this much worse as libraries and coffee shops closed, depriving people without homes of the ability to access information and go to the washroom—something so basic that, when taken away, robs an individual of dignity and self-worth. Participants also underscored the inadequacy of social assistance in relation to cost of living: “Client on Employment Insurance (EI) has opioid replacements and has to pay $300/month for methadone, but EI is only $950/month, so can’t pay bills. No mechanism to help her at all.”

Service Design

Stemming from people’s experience with poverty and homelessness was how the delivery of services wasn’t designed to meet their needs. People experiencing poverty and homelessness may not have access to phones, calendars, and internet, and attending doctor’s appointments and receiving health care services restricted to certain hours and locations creates understandable and significant challenges. Service providers are often the only conduit for reaching marginalized populations, and they are often stretched thin, relying on precious funding to provide vital services that few are able to offer.

“Don’t make appointments, they can’t make appointments. They survived yesterday and they have to make it through today.”

There is an entire constellation of factors that may lead someone struggling with homelessness and substance use to miss an appointment. “Don’t make appointments, they can’t make appointments. They survived yesterday and they have to make it through today,” remarked one attendee. Many identified a solution to this design flaw: mobile services that come to the clients who need them, when and where they are at. On-demand services were seen as essential in allowing someone affected by substance use disorder to get help when they needed it. Maintaining a strict, regimented schedule and process by which these services are provided betrays a lack of understanding of the lived realities of marginalized populations.

A drawing of four stick figures holding hands with the words "hope," "lifted," "together," and "joy"
Togetherness and community – We asked participants to draw their vision of a future free from drug policy-related harm.

Communications & Storytelling

Storytelling emerged as one possible way to counteract stigma, which fuels many of the harms identified above. Participants viewed first-person stories as an effective way to provide the public with an accurate look into the daily realities of people who use drugs so that perceptions could change and stigma could be reduced. “I wish people could understand…” was a phrase that often preceded explanations of how difficult daily life was when individuals are precariously housed and/or dependent on substances. Participants reported getting their homes (tents) bulldozed multiple times, and suffering through impossibly long waitlists for supportive housing. 

“Getting the public to our side is paramount.”

These stories reveal the immense challenges faced by community members trying to get to the next day—alive. Theirs is a range of experience the general public rarely must consider. Underpinning the emphasis on storytelling is the idea that understanding leads to perception change, which in turn reduces stigma. “Getting the public to our side is paramount,” remarked one participant. Public awareness campaigns targeting diverse groups like labour unions, health care providers, and firefighters were offered as important ways to “broaden the coalition of support… and collective will to make change happen.” Individuals highlighted positive stories of people with lived experience and/or service or health care providers who have made a difference as effective ways to counter negative portrayals of people who use drugs in the media: “What is needed is to show those who have ‘fought their demons’ so the public understands… hope is an important news story.”

About peterkimcdpc

Strategic Communications Manager, Canadian Drug Policy Coalition