A newly revised health policy has become the latest symptom of a provincial tug-of-war between government and harm reduction experts in Alberta.
At the behest of the UCP government, Alberta Health Services has revised its strategy on substance use, where the phrase “harm reduction” has been crossed out dozens of times and references to a “recovery-oriented approach” have been written in.
Though these are small changes within the text of a nine-page document, they send a loud signal about the ongoing debate between Alberta’s UCP government and substance use experts around the best way to tackle the province’s deadly struggle with addictions.
“Language matters,” said Cameron Wild, a professor of public health at the University of Alberta who specializes in studying addictions. “It really sets a tone, internal to the organization, inside AHS, about what is tolerable to even discuss.”
The Alberta government’s push to increase access to addiction recovery treatment has led some harm reduction advocates to worry that access to life-saving interventions could diminish. They say funding for needle exchange programs or supervised consumption sites could be at risk.
The revisions, requested by the government last year, affected the AHS policy on harm reduction for psychoactive substance use, according to emails obtained by CBC News.
“I think it demonstrates where we’re going in AHS to remove all language of ‘harm reduction’ from our organization, to align with government,” the AHS executive responsible for addictions and mental health said in a September email to staff.
The revised policy, renamed the Psychoactive Substance Use Policy, was given some language adjustments that included a stronger focus on a “recovery-oriented approach” to care. By the policy’s definition, that approach can include harm reduction.
According to a government spokesperson, the changes were not made to invalidate harm reduction approaches but to bring “balance” to how the health-care system handles addiction.
“Ensuring Albertans have access to a balanced continuum of care, inclusive of harm reduction and the other components, is not ideological,” Kassandra Kitz, press secretary to the mental health and addictions minister, said in an email.
“Harm reduction services play a significant role in our policy, but is balanced with the objective of ensuring all people who are struggling are represented and are receiving treatment where recovery and wellness is the goal.”
Patients before politics
Kerry Williamson, an AHS spokesperson, said harm reduction services like supervised consumption sites, needle exchanges and opioid replacement therapies are still available and that there has been “no change in practise.”
The policy update, he added, sought input from addictions experts and people with lived experience of addiction.
Harm reduction advocates argue access to those life-saving tools are more important than ever. By October 2020, Alberta had already set a new yearly record high number of opioid poisoning deaths. Overdoses surged near the beginning of the pandemic.
Harm reduction approaches, including the mass distribution of naloxone kits to help reverse an overdose, were particularly important when opioid poisonings began to spike in Alberta about six years ago, said Dr. Robert Tanguay, a Calgary addictions psychiatrist and pain physician.
But now, he added, Alberta needs a more comprehensive approach that leans on the “four pillars” of tackling addiction: harm reduction, recovery treatment, prevention, and reframing addiction as a health problem rather than a criminal one.
The biggest hurdle is the currently fragmented system in which none of these pillars work well with the others, he said. A patient who injects herself under supervision should be able to get treatment for addiction at the same location instead of being referred somewhere else, he added.
“Until we start working together we’re never going to be on the same page when it comes to the person in front of us,” he said.
An unbalanced approach
An increased emphasis on harm reduction during the opioid crisis swung too far for some publicly-funded services that embraced an abstinence approach to addictions recovery. Some feared their government grants were at risk.
The government said this was one of the reasons the AHS policy needed to change — to protect organizations that required clients to be sober to participate in recovery programs.
Since 1974, the Sunrise Healing Lodge in Calgary has led clients through a 12-step process to tackle addiction while integrating Indigenous cultural practices and traditions. The recovery centre is funded by AHS.
Executive director Leslie Big Bull, who has been in the role for 18 years, said AHS had always been pleased with the lodge’s work but said something changed in 2019.
The inpatient recovery program requires clients to abstain from any mind- or mood-altering substances, she said. Suddenly, AHS managers wanted the program to accept patients who were taking suboxone as a drug replacement therapy.
She said Sunrise was unwilling to do this as it conflicted with their philosophy.
“I’m not saying harm reduction is a bad thing, because there needs to be many options for people to be able to realize the life that they want to have,” she said. “It’s just not ours.”
Big Bull feared that turning away clients on suboxone would put Sunrise’s AHS funding in jeopardy, risking about two-thirds of their budget.
AHS has not repeated the request, she said.
Paper versus practices
Why should members of the public care what words the health authority uses in an aspirational document?
Patient advocates say the policy was created and adopted in 2013 because many people with addictions feel stigmatised and unwelcome seeking routine health care.
Petra Schulz, co-founder of support group Moms Stop the Harm, was part of a commission that reviewed the policy in 2017. It was important to clarify that people who use substances shouldn’t have to abstain from use to get health care, she said.
That part of the policy remains.
She worries the change on paper will lead to changes in which AHS programs and projects are funded and prioritized, and may even leave staff nervous to propose new harm reduction initiatives.
The wording of the policy seems to create a false dichotomy, pitting harm reduction against recovery, says Rachael Edwards, a harm reduction nurse and independent consultant in Calgary.
She worries the changes could lead to some health-care workers making decisions for patients based on their own beliefs, rather than what’s best for the patient.
Wild, the public health professor, said it’s important for AHS to have paperwork that clarifies harm reduction approaches are evidence-based health care.
However, he said it’s “offputting” to see government influencing AHS’s operational documents. He likens it to politicians telling surgeons how to complete a procedure.
Taken in context with other government moves, Wild said the policy revamp is part of a continued effort to “crowd out” harm reduction approaches.
Among them are a review the UCP government conducted of the neighbourhood impacts of supervised consumption sites without looking at health effects of the services. A criminology researcher who recently reviewed the methodology in the review called the report biased and flawed.
Patients in an injectable opioid agonist therapy (iOAT) program took the government to court over changes to that program. Government funding for the treatment will continue for two more years but no new patients will be enrolled.
AHS also disbanded an Edmonton-based addictions prevention training team last fall.
Critics have also slammed the government’s closure of a contracted supervised consumption site in Lethbridge. An audit found evidence of profound financial mismanagement at ARCHES. Alberta Health Services now runs a temporary service in a motor home in that city until a more permanent solution is arranged.
When running for premier in 2018, Jason Kenney promised he would deny funding to more supervised consumption sites in the province, stating that “helping addicts inject poison into their bodies is not a long-term solution to the problem.”
The UCP’s 2019 election platform said it would only endorse new supervised consumption sites with the buy-in of the surrounding community and if the operator also offers drug treatment services.
Since taking office in May 2019, the government has set aside $140 million over its four-year mandate to add 4,000 residential addiction and mental health treatment spaces.
The government is building five “recovery communities” based on a successful model from Portugal, and has effectively eliminated user fees for patients going into publicly funded inpatient recovery programs.
Addictions psychiatrist Tanguay said he fears patients will be the victims of this philosophical battle.
He is concerned about a lack of expertise in addictions and mental health among AHS leadership. He dreams about a world where addiction is treated like cancer or heart disease, with dedicated hospitals erected to tackle the problem alongside patient-led treatment.
“This shouldn’t be harm reduction, this should be health care,” he said. “We should treat people with compassion and caring. We should use shared decision-making person-centred care. We should work with the individual who’s in front of us, together, and never do anything to anyone.”
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