They decried the bio-politics of illicit substance use: the perspectives of people who use drugs on access to opioid agonist treatment in rural and remote communities of British Columbia

Abstract

Overdose toxicity claims the lives of 21 people per day on average in Canada, making the overdose crisis a leading public health concern. British Columbia (BC) has one of the highest rates of illicit drug-related overdoses in the country, with rural and remote communities being disproportionately affected by 30-50% increased risk of overdose mortality. Despite this, most research related to illicit drug use focuses on large urban centres and lacks research for the impetus defining increased overdose risk in rural and remote communities. Many people who use drugs (PWUD) are comorbidly diagnosed with opioid use disorder (OUD) for which the current gold-standard of treatment is opioid agonist treatment (OAT). OAT is prescribed by a medical professional and includes medications such as methadone or buprenorphine/naloxone and requires the observation of dose intake by a clinician, pharmacist, or nurse. OAT is said to decrease mortality risk and improve treatment outcomes for PWUD with OUD, albeit, its use and availability is lacking in rural and remote communities, owing to a multitude of intrinsic, extrinsic, and environmental factors, stemming from prohibitionary laws on drugs. Given the unique barriers faced by PWUD drugs in rural and remote settings, the resulting policy and program recommendations of urban centres cannot directly be translated to smaller settings. Accordingly, the primary goal of this thesis work is to understand the experiences of PWUD and their access to OAT in rural and remote communities of the qathet region in BC. This work is complemented with three sub-goals: firstly, to understand the perspective of using a virtual OAT application program to aid in OAT medication adherence; secondly, to acknowledge the individual participant stories in such a way that aids in fighting-back against drug policy; and thirdly, to illustrate the importance of selecting appropriate analytical frameworks that work to establish agency for the people who the research is about. These efforts are demonstrated within the manuscripts included in chapters 4 and 5. Chapter 4 utilizes a content analysis to describe participant experience with access to OAT in the qathet, with a focus on data related to the virtual application, Sonara Health, that was presented as a potential solution to problems identified in data from year-1 interviews. Chapter 5 uses longitudinal data from participant experience with access to OAT in the qathet to describe and exemplar the use of feminist relational discourse analysis (FRDA), an analytic tool rooted in Foucauldian discourse and a feminist epistemology, with a focus on individual and contrapuntal voices. These works utilized a qualitative research design involving a rapid ethnography taking place in 2024 and 2025 and is embedded within a larger longitudinal research project that began in 2022. These works involve a total of 32 PWUD and Indigenous-PWUD who had previous experience accessing OAT in the qathet. Semi-structured interviews were completed with participants in 2023 and 2024 years of the research study. These works utilized a community based participatory research (CBPR) design partnering with community organizations (qathet Community Action Team, Tla’min Health Centre) and involve the principles of ownership, control, access, and possession (OCAP) principles as it relates to data involving Indigenous participants. Taken together, these works establish the overall aim of the thesis: to aid in understanding the rural specific access barriers and facilitators to OAT for PWUD in rural and remote communities of BC, whilst simultaneously strived to use the research to empower PWUD by giving voice to their lived experiences. Accordingly, this thesis adds to the limited body of research regarding experiences of PWUD on OAT in rural and remote communities and presented a novel solution through gaining perspectives on the Sonara app. Additionally, this thesis involved the demonstration of FRDA as a promising analytic approach to showcase research with PWUD, which to our knowledge is the first of its kind. This work highlights the clear need to implement novel approaches to OAT service utilization in rural and remote communities whilst demonstrating the importance of focusing on the participants and their voices as primary to the research.