According to the 2021 Census, more than 1.8 million people in Canada self-identify as Aboriginal, making up 5% of the Canadian population, up from 4.9% in 2016.385 Census data shows that Aboriginal peoples are  growing in Canada, though this growth was not as rapid as in years past.385

Historical and present-day colonialism, combined with discriminatory federal policies that disrupted generations of Indigenous peoples’ cultures and communities, has conferred a higher risk of morbidity and mortality from various health concerns.40,42,43 Specifically, First Nations people in BC face a disproportionate burden of substance-related harms. This disparity existed prior to the current drug toxicity crisis386 and is increasing in recent years: 15.9% of all toxic drug deaths in 2021 occurred in First Nations people, compared to 14.7% in 2020, while First Nations people comprise only 3.3% of the population.387,388 The proportions of harms by gender is also different in First Nations people compared to non-First Nations counterparts in BC. Toxic drug deaths in First Nations people were higher in men (68%) in 2020,389 which is same trend seen in non-First Nations people, where men accounted for 81% of the deaths.390 Furthermore, data from 2020 showed that First Nations men experienced 4.3 times more fatal poisonings than non-First Nations men, and First Nations women experienced 9.9 times more fatal poisonings compared to non-First Nations women.387 In addition to facing a high burden of substance-related harms, cohort studies in BC have found that provision of evidence-based care for OUD is low in Indigenous people. A 2011 prospective cohort study of young Indigenous people found that less than a quarter (23.4%) of those reporting lifetime opioid use had ever been on methadone.391 This aligns with a 2007 cohort study of people who inject drugs, which found that Aboriginal people were less likely to receive methadone treatment than non-Aboriginal people (AOR: 0.60, 95% CI:0.45–0.81).392

Recent research has highlighted the important role of culturally safe and informed approaches to reduce disparities in substance use care for Indigenous populations.70,393 This guideline strongly recommends that all health care professionals and staff undertake Indigenous cultural safety and cultural humility training to improve their ability to establish safe, positive partnerships with Indigenous patients, families, and communities (see Indigenous Cultural Safety).  The Calls to Action from the Truth and Reconciliation Commission Reports, recommendations in the In Plain Sight Report, and Calls for Justice from the  National Inquiry into Missing and Murdered Indigenous Women and Girls Final Report outline the necessary actions to address the legacy of colonialism in a range of domains including health care. A human rights-based approach is also essential, due to Canada’s history of discriminatory, unethical, and harmful treatment of Indigenous peoples in the mainstream health care system.49 In addition to incorporating Indigenous cultural safety and cultural humility in standard medical practice, several principles of providing ethical care to Indigenous peoples have been identified in the literature394: 

• Respecting the individual and their authority over their own health and healing journey
• Practising conscious communication, active listening, and paying close attention to how a person responds to questions and conversation, both in their speech and body language, to ensure patient comfort and safety
• Using interpreters if fluency in English or French is a barrier to communication
• Involving family members in decision-making and as key sources of support, and respecting an individual’s definition of family, which can include many extended relations
• Recognizing that some individuals may prefer alternative methods for communicating and receiving information about their health—the practice of “offering truth” ,395 and honouring a patient’s decision on the type of information they wish to receive and how they wish to receive it may be helpful in this context
• Practising non-interference in a patient’s decision-making, unless there has been a clear misunderstanding—strong advice or persuasive language from a person in a position of power (e.g., clinician to patient) can be interpreted as coercive
• Respecting that Indigenous peoples have the inherent and recognized right to access cultural practices as part of their health care

The Society of Obstetricians and Gynaecologists of Canada’s (SOGC) Consensus Guideline for Health Professionals Working With First Nations, Inuit, and Métis396 may be a useful clinical resource. While this guideline does include specific guidance on sexual and reproductive health care for Indigenous peoples, the majority of recommendations are relevant and applicable to general clinical practice and the Canadian health care system at large. Clinicians who provide care to Indigenous peoples should be familiar with the First Nations Benefit Program (Plan W) and the Non-Insured Health Benefits program, including eligibility and coverage requirements, and the exceptions and special permissions needed in some cases.  Clinicians should also be aware of regional and provincial resources available to Indigenous patients, families and communities in BC. There are several First Nations substance use treatment centres that offer culturally-based services in BC. Detailed information for each treatment centre, including eligibility requirements, can be found on the FNHA website. Each regional health authority in B.C. has an Indigenous or Aboriginal Health Program, which offer tailored services and programs to support Indigenous patients and families in accessing health and wellness services:

• Fraser Health
• Interior Health
• Island Health
• Northern Health
• Vancouver Coastal Health

Indigenous peoples in the Lower Mainland can also be referred to the Metro Vancouver Indigenous Services Society (MVISS), which offers culturally-based and trauma-informed individual, group, and family counselling, and other Indigenous healing and support services. The Metro Vancouver Aboriginal Executive Council (MVAEC) also maintains a directory of Indigenous programs and services (including substance use and recovery services) on their website. 

4.1 Indigenous Peoples (4.1.i Access to Cultural Practices)

Indigenous approaches to health are holistic, relational, and seek to balance physical, spiritual, mental, and emotional wellness.40 However, many clinicians who provide substance use care subscribe to a biomedical approach that is disease- and individual-focused—an approach that has been acknowledged as largely incongruent with Indigenous worldviews.397 Conventional substance use care has been shown to be less effective for and potentially harmful to Indigenous people, with some suggesting this is partially attributable to the lack of cultural practices incorporated into treatment interventions398 and delivery of care that does not adhere to Indigenous values and worldviews.40 The value of using the teachings of Mi’kmaq Elder Albert Marshall’s “Two-Eyed Seeing” approach, which respects and integrates the strengths of both Indigenous knowledge and Western medicine,399 has been increasingly recognized in holistic wellness and substance use care for Indigenous peoples.397  Further reading on this approach is available online.

There is widespread agreement among Indigenous Elders and healers, as well as researchers, that the inclusion of cultural practices in substance use care is essential to promoting healing for Indigenous peoples.400 Indeed, substance use treatment interventions that incorporate Indigenous cultural practices have been found to improve the physical, mental, emotional, and spiritual health of Indigenous people (e.g., reduced substance use, reduced rates of mental health issues, improved relationships, increased participation in cultural practices).400 Indigenous patients have an inherent right to access cultural practices as part of their health care, as acknowledged and highlighted by Call to Action #22 of the Truth and Reconciliation Commission, which calls on the health care system to recognize the value of Indigenous cultural practices and to use them in collaboration with Indigenous Elders and healers when delivering care to Indigenous people.401 In recognition of this, clinicians, care teams, and staff should ensure Indigenous people can access cultural practices as a component of their OUD care:

• Clinicians should inquire with Indigenous people about their interest in including cultural practices as part of their OUD care, while understanding that Indigenous people have differing levels of involvement and interest in cultural practices.
• Some Indigenous people may already be engaged in cultural practices, whereas others may have no interest in accessing cultural practices. In either situation, clinicians should offer support to the patient and be aware that the patient’s preferences for accessing cultural practices may change over time.
• If a patient is already engaged in cultural practices, clinicians should, with the consent of the patient, work collaboratively with the patient’s Elder or healer in care planning.
• Patients who do not have an Elder or healer may be connected to one within the care setting, if available, or in the community.
• Clinicians may also inform patients of any sacred spaces that are available to Indigenous people in the care setting (e.g., All Nations Sacred Space at St. Paul’s Hospital in Vancouver, BC, the All Nations Healing Room at the Royal Jubilee Hospital in Victoria, BC, and the Hummingbird Healing Room at the Red Fish Healing Centre for Mental Health and Addiction in Coquitlam, BC). Any patient requests to access a specific 

A diversity of cultural practices can be integrated into substance use treatment interventions, depending on resources, capacity, and expertise, including smudging, storytelling, teachings, fasting, carving, beadwork, land-based activities, pow-wows, traditional foods and medicines, language, talking circles, drumming, singing, community feasts, sweat lodges, and prayer.397  Clinicians may also choose to have the Four Sacred Medicines (cedar, sage, sweetgrass, and tobacco) freely available to Indigenous patients in their clinic. It is important to be mindful that traditions and cultural practices can vary across Indigenous groups and communities; clinicians should take care not to assume there is a pan-Indigenous culture.

Health authorities, hospitals, and First Nations Treatment Centres may be able to provide or link patients to patient navigators, interpreters, or sacred spaces. This may include connecting the patient to cultural supports in the community, working in partnership with the patient’s Elder or healer, or providing a space for the patient to engage in cultural practices. Indigenous patient navigators or liaisons can support patients and their families, clinicians, and care teams by402,403: 

• Connecting patients with Elders and other cultural supports
• Facilitating communication between patient and care teams
• Assisting with referrals within the health authority and to community organizations, acting as an advocate on the patient’s behalf
• Liaising with Indigenous communities and organizations
• Arranging for translators
• Guiding patients through the health care system
• When patients are eligible, connecting patients to First Nations Health Benefits (Plan W) at FNHA for medical and other coverage 

For more information on Indigenous cultural practices in clinical settings, clinicians can refer to Vancouver Coastal Health’s Aboriginal Cultural Practices: A Guide for Physicians and Allied Health Professionals Working at Vancouver Coastal Health. To find community organizations that offer cultural practices, clinicians can refer to Metro Vancouver Aboriginal Executive Council’s directory. Additionally, Friendship Centres offer cultural practices to Indigenous people across BC. Please see Indigenous Cultural Safety for further guidance on providing culturally safe care. Clinicians, care teams, and staff may also refer to the First Nations Health Authority to learn more about Indigenous wellness and cultural practices.