Stemming the Tide in the Opioid Crisis: How British Columbia works with citizens to design public services and policies to stop drug overdose
Over the course of 2017 and 2018 I worked with the Ministry of Mental Health and Addictions (British Columbia Government, Canada) and the B.C. Service Design Team on the project “Behind the Numbers: Connecting Stories and Ideas on Overdose and Drug Use in Private Residences in B.C.”. Through co-designing services and policies with people who have lived experience using drugs, we sought answers to some very complex questions:
“Why do people use drugs alone in their homes in B.C., and what are their ideas for change?”.
(see ‘Background: the opioid crisis in B.C.’ below for more information about the drug overdose situation in British Columbia, Canada.)
Here I would like to share our innovative approach, practical outcomes and the knowledge artefacts that came forward from this project more widely. In a (forthcoming — ed.) blog series I will reflect on how we produced the journey map, the systems map, the 25 stories of people with lived experience using drugs alone and an opportunities booklet that contains 44 possible initiatives for change (also made publicly available by the Provincial Government here and here).
Unfortunately many people are still affected by the opioid crisis. The new numbers were just released: there were 1,489 suspected illicit drug overdose deaths across British Columbia in 2018. In my (humble) opinion not one single entity, not the Government, nor a service design team or any brilliant app developer can ‘solve’ the opioid crisis on their own. Just look at the sheer complexity of the situation on these maps below!
But by helping to open up this knowledge it is my hope that others who are working in this field may get an opportunity to interpret and use this rich knowledge themselves, and collaborate over it. It is only in the collision of multiple ideas and belief systems that new patterns and opportunities emerge, and new relationships are formed. Together we might be able to carve a way out of this complex societal challenge, and turn the tide for people like Ryan’s parents, or Tara and her mum Nancy.
*** A word on the word ‘crisis’: Evashkevich and Fitzgerald (2016) find that calling the situation in B.C. an “epidemic” or a public health “crisis” or “emergency” is problematic because it leads to rapid policy decisions that can be counter-productive. “The use of alarmist language of “epidemic” and “crisis” makes it harder to collaborate around resolving the issue, as it provides a desire for an immediate “solution” and thus encourages the tendency to present the problem as a tame one, rather than the wicked problem it actually is.” (p.61). For the sake of consistency, as the Government and media use the word ‘crisis’, I reluctantly use the word ‘crisis’ throughout this blog.
Background: the opioid crisis in B.C.
Finding innovative pathways for change in a complex societal issue like the opioid crisis was, and unfortunately still is, very needed. Since January 2017, more than 2.400 people have lost their lives to an opioid overdose in British Columbia alone. To put those numbers in perspective, that’s more than the total number of people who have died from homicide, suicide and car accidents combined (Source: Georgia Straight, March 2018).
Contrary to the popular belief that overdoses mainly happen to people who are living on the streets, the numbers tell a different story. In 2018, 86% of fatal illicit drug overdoses occurred inside, of which 58% in private residences, 25% in other residences including social and supportive housing (Source: B.C. Coroners).
Over 80% of the people had fentanyl — a substance up to 100 times more toxic than morphine — in their systems when they died. More than 80% of people that died were men, mostly aged between 30–59, and most died alone. The numbers also show that indigenous communities are disproportionately affected. But what is behind those numbers? “Why do people use drugs alone in their homes, and what are their ideas for change?”. What are people’s stories, beliefs and ideas? And, maybe more importantly, how can we bring people together to work on designing services to keep people safe(r), and help people to thrive?
The ‘Behind the Numbers’ project methodology
Collaboration and capacity building
The “Behind the Numbers” project was innovative and a first of its kind for the B.C. Government in terms of its approach. The Ministry of Mental Health and Addictions aimed to build capacity and knowledge within the Public Service, and build relationships across Ministries, organizations and citizens that work on this complex societal challenge. So instead of hiring a consultancy group and outsource the work, the Ministry partnered with the (internal) Service Design Team. Together they set out to work with the six provincial Health Authorities, local community action groups and other researchers to design an approach that involved reaching out to people with lived experience on this topic in a culturally sensitive, safe and appropriate way. The Province-wide “Reaching and Engaging People who Use Drugs Alone Task Group” was set up to consult on and verify research findings with experts throughout the duration of the project and all the findings were continuously shared with — and guided by — ministerial executives.
Co-design with people with lived experience
The Provincial Government wanted to hear directly from people who have experience using drugs. However use of non-prescription opioids is still an illegal activity in Canada and is surrounded with an enormous amount of stigma. We thought it would be difficult to find people who were willing to talk about their drug use with us, “the Government”. However, the team got to work with more than 100 people; those who use substances alone, their family and friends, and support providers (read their stories in the Stories Booklet). I think it helped that we made sure everyone’s identity was protected and we worked with organizations they already trusted. But overall I think people saw it as a chance to share their views and experiences directly with the Government. In this way they contributed to designing new services that could improve their lives. Co-design sessions were held with people who use substances to verify findings and explore ideas for better services on topics such as “Designing a Better Healthcare Experience”, “Safe Spaces to Use Drugs”, “Designing a Public Message and Campaign”, and “Designing Technology to Help People Be Safer”. Throughout the project we made sure to follow BCCDC’s guidelines for peer engagement.
Peer researcher
Throughout this project the service design team worked alongside a paid peer researcher. His name was “Voices” and his lived experience in using substances alone was invaluable (read his story in the stories booklet). When we first met him he was a surveyor for construction companies, and was running his own ‘safe injection site’ from his home. It was a ‘service’ he offered to his friends to keep them safe. Towards the end of the project he was a paid staff member at an overdose prevention site. He helped co-designing conversation questions, connecting the team to folks with lived experience, facilitating conversations, accompanying the team to stakeholder meetings, talking to ministerial executives and holding us accountable throughout. Without his expertise and connections it would have been much harder to gain the insights we now have. Plus his dry humour kept us from getting too discouraged or overwhelmed!
Outcomes
Due to the complexity of this situation, a truly ‘wicked problem’, it is impossible to pinpoint an absolute measurable project outcome. Besides identifying 44 opportunities for change there are 3 important outcomes of this project that i’d like to share and reflect on here.
1. Gaining a deeper understanding about the opioid crisis from people with lived experience and strengthened relationships between government and society
This Government project didn’t commission an external team to go out and gather more numbers. Instead a Government team worked and learned openly and collaboratively, especially with people with lived experience using drugs and their support providers (care givers, doctors, nurses, researchers etc.). Through this, the team formed new, strong and ongoing relationships between different ministries, health authorities, community organizations, and ultimately citizens. A more shared understanding of the situation, informed by facts and personal stories, has positioned people to better find and help each other, and exchange ideas and insights. For example, the Island Health Authority launched the ‘Perceptions’ campaign for staff to improve health-care providers’ sentiments about people who use substances. The campaign built on the insights from our project, the provincial government’s #stopoverdose campaign and initiatives from other health authorities.
Watch an Island Health video on Cheryl, a nurse whose son’s dependency on substances has forever changed the way she views her patients.
Another example is the Toronto Board of Health asking the BC Ministry if they could use their creative output for their own campaign. “They used different ‘real people’ images and revised the copy slightly to fit their audiences, but the look and messaging of their transit shelter campaign mirrored our print ads.” (Regan Hansen, Director of Partnerships and Engagement, BC Ministry of Mental Health and Addictions, Island Health Magazine, Summer 2018).
2. Supporting an evidence-based approach to designing new policies and services
With a deeper understanding of people who use substances alone, the team helped to reframe the issue for many folks, including Ministerial executives, public servants and the public. What if the opioid crisis was not solely about substance use, but instead about a problem that is rooted in social inequality and challenged by how society copes with mental and physical pain? What if the opioid crisis can lead to discussions about drug decriminalization?
The team’s research uncovered 44 opportunities for new services and policies, spread out over five themes and three areas of influence (society, public services, and policy; check out the Opportunities book!). The team helped shape and inform the Ministry of Mental Health and Addiction’s anti-stigma media campaign (January 2018, see www.stopoverdosebc.ca). The team also helped inform the strategies and activities of the Overdose Emergency Response Centre, a Provincial initiative and the first of its kind in Canada.
3. Increased human-centred design capabilities in the public sector
By taking a human-centred design approach, the team increased human-centred design capabilities within the Ministry of Mental Health and Addictions and provincial health authorities. Design- and complexity thinking are not yet common skills in the public sector. “Design thinking — an approach to innovation that uses empathy, logic and imagination to understand users’ problems and develop solutions — can have great benefits”, writes Prof. David Dunne (Design Thinking at Work: How Innovative Organizations Are Embracing Design, 2019), especially in the public sector (read Andre Schaminee’s new book — Designing with-in Public Sector Organisations, 2018). But, if implemented too simply and linearly, “design-thinking can easily preserve the political status quo”, thinks Natasha Iskander, an associate professor of Urban Planning and Public Service at New York University.
By taking a paid peer researcher on board as a team member, involving citizens in the design and outcomes of the project, and publishing the outcomes freely and openly, I think the Ministry has shown a willingness to be bold, innovative and progressive. And like in any complex situation, this Government is also not exempt from challenges and critique, like getting stalled by ‘timid bureaucracy’ and ‘frustrations about leadership’. No one said it was going to be easy. But if anything, this project has fostered public servants who have learned to break through status quo’s and find new pathways in problems they encounter in their work to serve societies.
Read more about:
- How public sector leadership can support innovative work practices
- The making of: journey map that explains why and how people use drugs alone (forthcoming)
- Systems mapping in service design: yay or nay? (forthcoming)
- Collecting 25 stories of people with lived experience using drugs and support providers (forthcoming)
- 44 opportunities for change (forthcoming)
- The role of a peer researcher in a service design project (forthcoming)
This blog is part of a series to shine some light on our service design work in British Columbia.
It is dedicated to Voices, our peer researcher who sadly passed away from cancer in December 2018. He is missed dearly but his generosity, kindness, and care for others had a lasting impact and are helping to make positive strides to help stem the tide of the overdose crisis.
