In this study, client participants presented with significant levels of co-occurring illnesses including schizoaffective disorder, mood disorders, depression, anxiety, suicidal ideation, alcohol and drug use, HIV, Hepatitis C and PTSD associated with complex trauma. Several participants were residential school survivors and most had long histories of trauma, beginning in early childhood and for many, continuing into the present. These factors have been long understood to be associated with mental health and addiction issues. For example, residential schools which included industrial schools, boarding schools, student residences, and hostels, located throughout Canada, the last of which closed in 1996, have been the most often cited cause of the mental health concerns of Aboriginal people in Canada. Although residential schooling was not uniformly negative for all people,5 its overall impact has been devastating [48–53]. In response to this understanding, in 2006, the federal government announced the approval of the Indian Residential Schools Settlement Agreement and the new Truth and Reconciliation Commission [54].
Many of the client participants in this study reported being on methadone, an aspect of the study, we report on in this paper. Further, all of the health care providers worked with clients who had previously accessed MMT or were attempting to access MMT. Using an intersectional analysis, we use the findings of this study to underscore the importance of understanding how harm and benefit are differentially experienced by clients of mental health and addictions services dependent on their histories and social location/position.
The key findings were that a) stigma and discrimination intersected with other disadvantages to profoundly shape people's lives and their access to and experiences with MMT, b) the policy context of MMT constrained people's lives, with significant consequences and these experiences and consequences varied with people's social locations, and c) in concert with poverty and other disadvantages, these constraints contributed to housing instability and homelessness for many. Although harm reduction is based on the values of non-judgment and non-coercive approaches to service delivery [5] and there are many positive outcomes associated with MMT, many of the participants in this study experienced 'harm' associated with "the intersectionality of disadvantages" (p.763) [55].
Stigma and Discrimination
In keeping with the findings of several authors [21, 25, 56], the attitude of providers was cited as a barrier to access to care in particular settings by several client and health care professional participants. Our findings provide a glimpse into how stigma and discrimination shape access to MMT. The following interview exemplar illustrates the stigma experience of several client participants (CP),
And its easy to kick a wounded dog, I mean, you know, I mean that's what happens down here, [service providers] don't mean to do it, they don't get up in the morning with a plan to go 'I'm going to go kick ten junkies today,' they don't do it, its just as the day builds, as the day builds they just desensitize, year after year they get desensitized to needs and then they just start dealing with what the immediate needs are.
For this participant, his identity as a "junkie" intersected with a perception of provider (physician) desensitization and/or stigmatization of the "junkie" to explain discriminatory treatment within the site where he accesses methadone. Although this may not have been a case of enacted stigma, i.e., where a person is actively discriminated against [22], this participant may have perceived stigma [22, 57] because of the negative thoughts and feelings associated with an expectation of stigma and discrimination e.g., through fear, shame and guilt. It is not uncommon, for example, for clients to experience "MMT as punitive and shaming rather than therapeutic even when the professional may be trying to follow guidelines designed to protect the client" (p. 15) [21]. Regardless of the dynamic or form of stigma, stigmatization is a powerful force that often interferes with access to MMT [21, 27, 56]. Indeed, research has shown that 'drug user' status can be a barrier to accessing health care and can affect the quality of care received [4, 21, 56, 58, 59]. A slightly different experience of discrimination is expressed by another client in the following,
Within the system there is some prejudice people in there and I try not to get too mad with them when I find out that they're prejudice, they don't like Natives and they don't like drug addicts.
For several participants in this study, in addition to substance use as an axis of discrimination, stigma (enacted or perceived) also was attached to an expectation of racialization, a process that is neither neutral nor without consequence. Given their multiple social locations, many people in this study expressed uncertainty about why they were treated poorly by some providers. For example, living as an Aboriginal person in Canada carries with it the "burden of history" [60], and prejudice and racism continue to manifest as new forms of colonial processes and practices erupt; however, persons living with mental illness and/or substance use issues and/or HIV/AIDS and/or Hepatitis C also live with stigma and prejudice associated with those diagnoses [26, 61–63] and consequent life circumstances, such as poverty and incarceration. Sadly, the social construction of identity/identities (including disease or illness associated and group identity (p. 3) [26]) interferes with both the ability of people to access and remain in MMT. In keeping with the perspective of Stuber, Meyer, & Link [64], in our research, we have found that analysis of the issues using a singular focus on racism or classism or problematic drug use (as examples of oppression), misses how the meaning and experiences of stigma and prejudice intersect with other important variables to create new forms of discrimination. The stigma associated with drug use is usually only one aspect of an intersecting set of stigmas (p. 47) [27].
Applying an intersectional approach to analyses of experiences of stigma and discrimination has numerous advantages. It acknowledges the complexity of how people experience stigma and discrimination and recognizes that the experience of discrimination may be unique. It also takes into account the social context of the group. It places the focus on society's response to the individual as a result of the confluence of various factors and does not require the person to slot themselves into rigid compartments or categories, i.e., it captures more fully the reality of stigma and discrimination as it is experienced by individuals. This approach allows the particular experience of stigma and discrimination, based on the intersection of factors involved, to be acknowledged and remedied. Attention to multiple disadvantaged social statuses is important to identifying the root causes of health disparities [65] and to designing effective interventions [64].
In the following interview example, a provider (P) working in a harm reduction setting discusses methadone maintenance treatment,
Those on the methadone program...their ultimate objective is to get on methadone and stay on methadone and stay off heroine and then they can use other drugs and there's no consequence to that, other than its affecting their health and it affects the, you know, the methadone and so on ... and because I'm an addictions counselor I have a hundred and twenty patients on the methadone maintenance program. So those patients are referred to a counselor for support and for counseling and also to deal with any other substance abuse that they may be experiencing. In about eighty-five percent of the cases those on the methadone program have a dependency on crack, cocaine or some other drug so my role is to do an assessment and refer them to day programs or treatment centers or to out patient counseling to help them more in a harm reduction philosophy... My preference is abstinence, abstinence because of the health, you know, it promotes health...
This excerpt reflects the policy context in which MMT is situated, i) a shoestring approach is supported (120 clients), ii) there is an absence of attention to the social determinants of health, and iii) policies are constrained by the criminalization of drug use. It obviously also reflects the attendant discourses taken up by some health care professionals working in the field. Although our observations of the care provided in this setting suggest that the community of professionals within the organization, including this individual, generally were committed to the provision of compassionate non-judgmental care within a harm reduction framework, the ideology projected by this provider belies a frustration with MMT and drug use more broadly - a reflection of the perspectives of many people in broader society.
Today, many people believe that MMT perpetuates drug use because of the misconception that it merely replaces one addictive opioid with another rather than seeing it as a treatment for opioid use [32]. As Cheung observes, this school of thought often is associated with the idea that abstinence-oriented treatment is the only way to achieve a "drug-free" state in society [32]. This ideology is also perpetuated in treatment programs that do not accept clients on methadone. As one client participant noted, "Yeah, I think that they should put more treatment centers out there that are accessible to methadone [patients]...because a lot of them don't accept methadone [patients]." Societal and institutional stigma, reflected in the political commitment and resources available to harm reduction programs, client positioning within the health care system and attitudes of health care professionals can pose significant barriers to the accessibility of MMT and other harm reduction programs for opioid dependent individuals [4, 66]. As Keane notes:
Prohibitionist policies threaten the freedom of users, damage their health and constitute them as marginal and stigmatized subjects excluded from normative categories of citizenship such as 'the general public' (p.229) [67]
Participant experiences of health care in this study were not influenced by one dimension of inequity, rather they were influenced by differential access to the social determinants of health and related multiple intersecting dimensions such as racism, classism, abilism and so on - dimensions that intersect with dominant ideologies regarding drug use and attendant assumptions, stereotypes and values. As Benoit notes, "[t]hose who face serious health concerns and at the same time are subject to multiple stigmas by virtue of their age, sex, gender, sexual orientation, race, ethnicity, socioeconomic or other social determinants, are less likely to access key resources and therefore differentially positioned to buffer themselves against the damaging impact of intersecting stigmas" (p. 5)[26].
Constrained Lives: Harm Reduction, MMT and Individual Agency
Although MMT supports access to other interventions (e.g., anti-retroviral therapies) and there can be numerous positive outcomes, some participants found MMT highly restrictive; individual choice and freedom were limited by the policies and practices attached to MMT. As Young notes in her examination of the notion of 'inequality,' institutional structures and processes (including institutional rules and policies) "can inhibit the capacities of some people" at the same time as they expand the options of others (p.10) [68]. Many of the participants in our study described the ways in which their lives have been constrained by MMT. Individual agency was affected in several ways. Limits were placed on the freedom of some people to move from one area to another and choices were limited by power inequities. For example, several of the women in the study had children, who had been apprehended by the state as a consequence of the complex intersections of poverty, gender and problematic drug use and attendant social circumstances such as difficulties accessing safe housing; they described difficulty visiting their children because they could not access enough methadone (carries) to make the trip i.e., they were on daily doses of methadone and/or they could not access a pharmacy that dispensed methadone where their children were living, and/or they could not afford reliable transportation (sometimes needing to hitchhike) to see their children.
Although many people (Aboriginal and non-Aboriginal) experience the effects of the limits placed on agency through restrictive guidelines regarding MMT, Aboriginal experiences of MMT are impacted by sociopolitical factors that are unique to their experience. For example, Aboriginal children represent approximately 40% of the 76,000 children and youth placed in care in Canada [69] - a fact associated with poverty, problem substance use and inadequate housing [70](notably Aboriginal people only comprise 4-5% of the overall Canadian population). These conditions mediate the extent to which women report substance use patterns and access MMT and other harm reduction services. To provide effective and safe harm reduction, including MMT and other services, it is necessary to understand the social context(s) in which these experiences emerge [71, 72].
In a similar but slightly different vein, several participants experienced MMT as being incompatible with a "normal" life and improved quality of life. In the following example, a client participant discusses such limitations,
... I'm going to be up there this summer or next summer [to see my relatives], but I'm on methadone right now so I have to get off the methadone, I'm only on twenty-two mls (milliliters) but by June I should be off.
A health care professional also discusses this issue in the following,
How can you travel with a drug habit? A raging drug habit... try and get that [methadone], it would be a nightmare to try and get that, some doctor in another province or something or other community to prescribe it, good luck... try and navigate that whole thing on your own...
For the client participant above and as the health professional notes, MMT can be highly constraining, including the lack of freedom to travel because of the inability of many to access methadone in other locales. However, what was also problematic in this case, as noted in a later discussion with this participant, was that MMT was not experienced as an informed choice. He believed he had been coerced by his doctor inappropriately; he perceived that he had used heroin minimally and now, six years later, he experienced MMT as seriously constraining - an experience shared by several other participants.
In keeping with the perspective of this client, a health care professional critiques the issue of "recruitment" to MMT as problematic in the following interview example, "I mean look at the methadone scene, I mean these drugs started to pop up all over not because they care for the people, [but because] there is money!" In our study, there was a general cynicism expressed regarding how MMT is being offered by some providers. Although most participants (clients and health care professionals) accepted MMT as a harm reduction approach, several believed that it was being used by some in power, such as a few "doctors... and pharmacists", as a means to make money "off of the backs of addicts." In our study, these views were fueled by a Canadian Broadcasting Corporation (CBC) news headline on September 11, 2008 that read, "Methadone kickbacks could lead to criminal investigation"; allegedly, several local pharmacies were reported to be paying "drug addicts" a fee each time they were dispensed methadone - money that was reportedly being used by some to buy illicit drugs [73]. In addition, the practice of charging daily dispensing fees rather than weekly dispensing fees ($15/day) was alleged to be the practice in some pharmacies, even though "weekly dispensing" was written on the prescription. The experience of 'being taken advantage of' because of being an "addict" in addition to the rules and regulations associated with MMT engendered a sense of vulnerability, and, to a belief by some participants, that they were being punished for their drug use. Although people with problematic substance use are not inherently vulnerable to stigma, they do face disadvantages relative to their ability to access resources and enact agency, i.e., enact control over their bodies and lives.
The "regime of control" has been reported elsewhere in the methadone literature in relation to random drug tests and urine screens that are used to ensure people using methadone are not "topping up" with illicit heroin or other drugs [74] as well as methadone consumption [25]; according to Vigilant, there is a 'felt' or 'perceived' stigma associated with these sorts of institutional regulations [74, 27]- a perception that is created by policies that reinforce societal biases, e.g., those biases based in a moral stance against drug use, rather than those that focus on the sociopolitical and cultural context in which drug use occurs. For people most marginalized by social and structural inequity such as Aboriginal people, 'constrained lives' may make them the target of profound stigmatization that may appear as insurmountable because of other intersecting issues, poverty, homelessness and so on. In addition to the constraints posed by treatment itself, many of the participants in this study (79%) were also constrained by unstable housing and limited options related to same.
Harm Reduction, MMT and Homelessness
Women and men whose poverty leads them to live in unsafe housing units in sections of the city where problematic drug use surrounds them, whose need for access to MMT and antiretroviral treatment leads to confinement to particular urban settings, and whose Aboriginality may further limit their housing choices within particular areas, exemplify the need to examine harm reduction and MMT using an intersectional analysis. An Aboriginal participant who was accessing MMT in our study describes his living arrangements in the following, "... Native housing, you know what, it's a real crack house right?... I wish I worked there, you know, at nights, I wish they hired me at nights not to let people in, I wouldn't." For this participant and many others, housing conditions acted as a barrier to positive outcomes. Here, an intersectional lens draws attention to the disturbing ways that homelessness, poverty, substance use and racialization intersect to exacerbate peoples' experiences of social suffering, i.e., to those human conditions with roots and consequences associated with social, economic and political power - suffering that is both created by the way power is inflicted on human experience and how this power shapes the response to it. As noted by Kleinman et al., "the trauma, pain and disorders to which atrocity gives rise [ongoing colonial processes and practices] are health conditions; yet they are also political and cultural matters" (p.ix) [63]. Another participant, an Aboriginal woman who lives with HIV illness, Hepatitis C and mental illness, describes her experience in the following,
There must be something wrong with me, I won't go shower, I take sponge baths in my room... the hotel is so skungy...we share a bathroom...like if its catchable...
For this woman, the hotel she was living in generated tremendous fear of further health compromise. The vermin and filth of the hotels where many of the participants in this study reside is well documented in other places [75]. Although the lives of the Aboriginal men and women with mental health illness on MMT who are living in poverty resemble those of other impoverished people, the intersection of poverty, mental illness, HIV/AIDS, Hepatitis C, and gender (as examples) brings with it a special set of circumstances and challenges to successful harm reduction. We argue that intersections across these multiple axes of differentiation do not have additive effects; rather the findings of our study suggest that peoples' experiences, although similar across some dimensions, are differentiated by the disadvantages (and advantages) posed by their location across these axes.