Key concepts to consider when developing guidelines to support First Nations community alcohol policies

Key concepts to consider when developing guidelines to support First Nations community alcohol policies

Alcohol and Drug Abuse is a highly contentious topic among First Nation

But it cannot be bottled up and put on the back burner!

First Nations and Inuit people have described a systems approach to addressing substance use issues www.nnadaprenewal.ca Highlights a continuum of care in order to support strengthened community, regional, and national responses to substance use issues. It provides direction and identifies opportunities to make this vision a reality while ensuring that individuals, families, and communities have access to appropriate, culturallyrelevant services and supports based on their needs at any point in their healing process. (p.2)

The NNAPF Literature Review Specific to this discussion of alcohol policies for First Nations communities is the opportunity for renewal through community-driven alcohol policies which focus on health promotion, alcohol supply regulation, the steering of programs and practices, reductions in environmental risk factors, and broad-based actions to change drinkingrelated norms and values (p. 3) The review describes the context of community-driven alcohol policy since 1970 examine current dialogues in traditional healing methods to provide example on programs working effectively, to provide direction for program implementation and quality measurements.

% Adults: Drink Past 12 Months Male Female 90 80 70 60 50 40 30 20 10 0 83.5 79.2 78 70.8 66.1 61 48.8 44.1 44.5 26.3 68.3 69.3 61 61.7 80.2 73.9 18-29 years 30-39 years 40-49 years 50-59 years 60+ years RHS 2008/10 RHS 2002/3 Can population (15+ years)

% Adults: Almost daily/daily drinking (among those who drink) Male Female 16 14 12 10 8 6 4 2 0 13.9 10 6.6 5.6 5.9 4.6 4 3.3 3.1 2.3 1.8 1.6 1.1 1.2 1.5 1 18-29 years 30-39 years 40-49 years 50-59 years 60+ years RHS 2008/10 RHS 2002/3 Can population

% Adults: Weekly+ Heavy Drinking (among those who drink) Male Female 25 23.1 20 15 10 17.5 17.6 11.1 13.4 15.3 17.1 9.6 13.8 18.4 11.9 20.9 10.2 9.2 5 3.6 3.3 0 18-29 years 30-39 years 40-49 years 50-59 years 60+ years RHS 2008/10 RHS 2002/3 Can population

Youth: Drink Past 12 Months Male Female % 80 70 60 50 40 30 32.1 42.1 61.4 68.8 35.3 42.9 39.1 46.8 54.4 51.2 20 13.4 16 10 0 12 to 13 years 14 to 15 years 16 to 17 years RHS 2008/10 RHS 2002/3 Can population

% Youth: Weekly+ Heavy Drinking (among those who drink) Male Female 16 14 12 12.4 13.2 14.4 12 12 10 8 9.7 8.6 9 7.6 6 4 2 0 14 to 15 16 to 17 RHS 2008/10 RHS 2002/3 CAS, 2004 (15 to 17 years)

Alcohol and Mortality External causes such as unintentional (e.g., accidents) or intentional injury (e.g., suicide)are the primary cause of death in children and teenagers across FN/General populations However, for First Nation youth external causes have much higher proportions of all deaths. This increased rate of external causes comprises ICD-10 codes such as poisoning (often due to alcohol and/or drugs), vehicular accidents, burns, suicide and other causes involving environmental factors. These classes of intentional and unintentional injuries have all been related to alcohol and illegal drugs as risk factors (Lim et al., 2012; Popova, Rehm, & Patra, 2006; Rehm et al., 2010a; Shield, Kehoe, Taylor, Patra, & Rehm, 2012b).

Five Key Concepts Intoxicant by-laws on First Nations reserves The risk reduction approach to substance use Substance abuse and aboriginal youth Implementation and program evaluation Social cohesion, resilience and community capacity building

1. Intoxicant by-laws on First Nation reserves There are 239 intoxicant by-laws for 615 First Nation communities Some First Nation communities have passed by-laws banning all alcohol or have become dry communities Some communities have set limits on availability and consumption of alcohol through bans on selling and importing Certain reserves have enacted by-laws limiting the amount of alcohol that can brought into the community Some communities ban alcohol use among its members, but allow hotel guest to consume alcohol

Reason for enacting intoxicant bylaws Response to community alcohol related crisis Reduce car accidents Lower crime Prevent violence General initiative towards improving community wellness

Issues with enacted alcohol by-laws Community disagreement over the by-laws Lack of enforcement Over 80% of FN Communities indicated their intoxicant by-laws to be ineffective or only moderately effective in reducing harm Bootlegging Increased binge drinking Increased drug use (Opiates) with no / limited access to pharmacological interventions and alcohol is used to manage withdrawal

Ways to make by-law implementation successful Ensuring there are proper policies and programs in place to support by-laws Address alcohol issues in a community based health and prevention initiative Promoting wellness by widening the understanding of the treatment from an individual perspective, to a community perspective When alcohol by-laws are enacted, other factors such as historical oppression, social issues, and control measures need to be taken into account by-laws require reviewing and updating and may become more effective with proper development, implementation and funding

2. The risk reduction approach to substance abuse There 3 views among First Nations communities in relation to alcohol consumption 1. Allow alcohol with some restrictions 2. Banning all alcohol, becoming a dry community 3. Allow limited alcohol consumption at community events. This view is based on risk reduction

Risk reduction policies The main focus with risk reduction is ensuring that people who do abuse alcohol start drinking less and less alcohol without resorting to abstinence its managed alcohol use

Brief interventions for alcohol misuse Brady et al. (2002) addressed the use of brief motivation interviewing for hazardous alcohol use Concluded that brief increased general awareness and acceptability of addressing alcohol issues at health services Can be more effective to involve general practitioners in conjunction with traditional Native methods Brief Intervention is like planting seeds. Does the depth of the seed effect plant growth?

Problems and solutions to risk reduction Prohibition of alcohol inhibits the offering and expanding of risk reduction services Using Eurocentric models that do not take into account historical factors and current oppression tend to be unsuccessful The person is still using alcohol and with drugs, an illegal substance Risk reduction approaches must include First Nation models of handling addictions and healing Need to consider epigenetics and the impact of environmental impacts, across generations & that still exist as this increases the chance for addiction

Systems Approach to Risk Reduction This concept emphasizes that the improvement of mental wellness in First Nations populations is contributed to the strengthening of ethnocultural identity, community integration and political empowerment. Increase community capacity and awareness through cross-cultural training of local and mainstream service providers. (EL.5) Encourages clients to have support groups involving both family and community to stay focused on their healing journey. (EL.2) Provide care through informal means including community and family members. (EL.6) Promotes understanding of the role of culture as a part of a continuum of services that reflects cultural awareness and safety. (EL.2) Supports community-based programs in both intervention and relapse prevention (e.g. land-based camps). (EL.2) Support a culturally competent system-wide approach within treatment programs, through policy, program design and service delivery.

3. Substance abuse and aboriginal youth To understand substance abuse properly in aboriginal communities it is important examine it among aboriginal youth This is due to the connection between substance abuse and intergenerational trauma impacts that continue to exist Lack of awareness of colonization and displacement of culture

Causes and solutions to youth substance abuse 42% of First Nations youth admit to excessive drinking and also indicated that they suffer from hopelessness and depression Hopelessness causes depression, which in turn cause the youths to start drinking heavily to deal with depression To prevent heavy drinking it is important to put a larger emphasis on dealing with depression and learning to cope with out alcohol It is also important to incorporate First Nations teaching and healing practices into programs used to treat people with substance abuse problems & in community through purposeful decolonization processes

4. Implementation and program evaluation Three methods that ensure proper alcohol use in any given community are: 1. Effective controls on alcohol 2. Supportive environments 3. Inclusive decision-making.

Ensuring success with implementation and program evaluation The three methods have found success in First Nation communities, but to be a complete success there must also be an investigation on how addictions develop within a community This allows solutions to these issues to be customized to fit a particular community It has been shown that basing addiction programs on traditional Inuit, Métis and First Nation cultural beliefs is the most effective way to address substance use issues

5. Social cohesion, resilience and community capacity building There are four factors that need to be addressed in order to understand social cohesion 1. That it is a shared process 2. Defines community members 3. It has shared values 4. Attempts to work toward a resolution

Five dimensions required for social cohesion 1. Belonging 2. Inclusion 3. Participation 4. Recognition 5. Legitimacy

Ensuring risk reduction strategies are successful Must be an emphasis on community capacity building and community resilience Community resilience is facilitated as a process of awareness Need to understand impacts of discrimination and historical trauma of Aboriginal communities when identifying resilience traits Need to embrace spirituality, holism, resistance and forgiveness. Need to discard notions of co-dependency, lack of trust, and refusal of authority Cultural identity is one of the main components to resilience and cultural identities need to be reestablished and incorporate traditional practices

First Nations community alcohol guidelines Draws attention to the fact that alcohol abuse can start at an early age. This means there needs to be programs for alcohol abuse education through early intervention that are directed towards younger people in First Nations communities. This Information also indicates that alcohol is a learned behavior and is used as a negative coping strategy to fill the gap where services are not accessible or available. There are a number of mechanisms of support that First Nations alcohol polices rely on that non-native ones do not. Policies must address methods of social support and the impacts of social exclusion.

Implement and champion the community standard Ideally a First Nations holistic policy and a planning model champions the community standard best, in the context of nation building which also addresses the six challenges to enhance knowledge on First Nations social determinants of health. These include: A commitment to a multi-year dialogue to explore common issues for First Nations health and well-being. Stimulate and sustain First Nations health research. Facilitate and disseminate the transfer and translation of knowledge into potential applications and benefits through policies, interventions, services and products. Encourage the public exposure and championing of First Nations health issues, policy-making and research, accelerate the transfer of policy, research results and technology within and between communities, while also developing innovative policy and strategic interventions. Discuss First Nations contributions and visibility in health policy-making and research outlining support needed for large-scale, international initiatives. Encourage multi-lateral collaborative ventures among communities and institutions concerned with improving the health and well-being of First Nation s peoples.

Canadian Low Risk Drinking Guidelines LRDG Guidelines provide options for communities to consider Low Risk Drinking Guidelines Low Risk Drinking Guidelines can support the implementation of other evidence-based interventions such as regulating the price and availability of alcohol, brief intervention for early problem drinkers and the enforcement of drunk-driving laws. This information could be used as a health teaching material when educating First Nations on the dangers of drinking six or more alcoholic drinks at a time. It will also be useful to show the benefits of more controlled drinking or abstaining from alcohol.

Conclusion The main theme throughout the five key concepts is that it is important integrate First Nations ideas and practices into First Nations policies This is largely due to historical and cultural factors that are not usually taken into account

References Brady, M., Sibthorpe, B., Bailie, R., Ball, S. & Sumnerdodd, P. (2002). The feasibility and acceptability of introducing brief intervention for alcohol misuse in an urban Aboriginal medical service. Drug and Alcohol Review, 21, 375-380. HRVATSKO IZDANJE. (2013, October 30). Native Americans Stay Drunk for Days on Superjuice. Retrieved from: http://dalje.com/en-world/native-americans-stay-drunkfor-days-on-superjuice/199070 Kingi, T. R. (2007). The Treaty of Waitangi: A framework for Māori health development. New Zealand Journal of Occupational Therapy, 54(1), 4-10. Larsen, E., Gheorghe, P., Ialomniteanu, A., Popova, L., Rehm, J. (2013). Burden and cost of substance use among First Nations people living on reserve (Draft). Health Canada. National Native Addition Partnership Foundation. (2012) Literature Review, First Nations Alcohol Policies.

Bill Couchie, Research Assistant: bcouchie@nnapf-fanpld.org Carol Hopkins, Executive Director: chopkins@nnapf.org