Health Committee on April 29th, 2024

[Dr. Marie-Eve Morin]

I can try in English.

I opened my own clinic in 2015 in Montreal dedicated only to addiction. I had to close the clinic in 2020 because the provincial government told me it was not a priority. The priority was COVID at that moment, so I had to close my clinic.

The name of the clinic was Clinique Caméléon, like the animal, the chameleon. I think if you want to work in addiction you need to be a chameleon; you need to change the context depending on the question. If someone wants to reduce drug use, it's already good. If someone wants to stop, it's very good too, but you have to adapt your approach to what the patient wants.

My mentor used to tell me that working in addiction is like working in intensive unit care: If you don't treat them when they're ready, they die. That's what we see, so we already have to be ready to help when they're ready.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Dr. Morin.

Dr. Caudarella, perhaps I'll pose the same question to you. Are you aware of federal government spending on prevention programs? What might an ideal prevention program look like to you?

[Dr. Alexander Caudarella]

Thank you.

With the evidence-based prevention we have, we know what doesn't work and we know what works. We really have to look at community-based, school-based and family-based programs, programs that build skills and resilience, and also ones that help people understand and create more linkages.

Many of the communities we're talking about around the country have a lot of strength within them. It needs to be tapped into. Often it's about supporting communities to figure out what the needs in their communities are and how to answer them.

Unfortunately, every jurisdiction in this country is guilty of responding to crises with a shorter lens. We responded by trying to treat everything that was downstream. As I said, with the first crisis declared eight years ago, those kids were 12 at that time. They're now the ones who are dying.

I hope that every government in this country, municipal, provincial and federal, is able to reinvest in prevention and see that it has a role as part of that continuum and that it also in the long-term hope of solving these bigger issues.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Caudarella.

Dr. Powlowski, you have five minutes.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Thank you.

A couple weeks ago we talked about the public disorder that characterizes a lot of downtown areas, seemingly swirling around drug use. I'm glad to see a couple of people here who were talking about mental health issues in part of this discussion.

I'd like to talk more about how much of the problem is drug use and how much of the problem is mental health disorders.

We've also talked about it being difficult to distinguish between the two, being a chicken-and-the-egg problem. Some drugs, like methamphetamines and even marijuana, can cause psychosis.

Maybe I can start with Dr. Mathew, but maybe go on afterwards to Dr. Morin.

How much of the kind of Downtown Eastside scenario of homelessness, drug use, crime and social disorder is really a drug problem, and how much is psychiatric problems that are being inadequately addressed?

With respect to that, in my last number of weeks in considering this issue, I've talked to psychiatrists about the availability of treatment and treatment for addictions. They said, Marcus, there are no beds. We discharge people from our psychiatric unit with rope burns around their necks from trying to hang themselves, so how are we going to find beds for them?

There are not enough beds, and certainly not enough outpatient services. I've also heard from someone in Thunder Bay who said there should be like a hundred people in Thunder Bay on court-ordered treatment, long-term anti-psychotics, but who aren't. Part of the problem is apparently concurrent disorders and distinguishing between psychiatric problems and addiction problems.

How much are these problems a result of there not being enough chronic care beds? We closed all the chronic psychiatric hospitals years ago, replacing them with long-term anti-psychotics. Should we be re-examining whether that's an issue?

I know I've talked about a lot of this, but maybe, Dr. Mathew, you could start by addressing some of those issues relating to the intersection between psychiatric illness and addictions.

[Dr. Nickie Mathew]

Sure. There's a lot to unpack, and I'll start with the last point you were mentioning.

When you look at schizophrenia, one of the most robust statistics that we have on it is that about 1% of the population will have schizophrenia. In British Columbia, where there are about 5 million people living in the province, there will be about 50,000 people with schizophrenia. Then, when you take those folks with schizophrenia, about 20% will be able to take medication, never have a relapse and live pretty normal lives. Meanwhile, 50% will have a relapsing-remitting illness, and 30% won't respond to medication.

What do you do with those folks who don't respond to medication? There's also a high amount of substance use within this population. If you have an intrinsic organic illness that causes you to have psychosis, a lot of times substances like crystal meth or cannabis-use disorder....

In my treatment facility, crystal meth is the most common substance used. It is used by about two-thirds of the clients, and about half also use cannabis. When they use these substances, it actually destabilizes them as well.

You were speaking about the closing of mental health facilities. Riverview closed down; that was the big asylum in British Columbia. My friend and colleague Dr. Christian Schütz did a study, and what he saw was that 10% of the folks in the Downtown Eastside were old Riverview patients. This was back in 2005, I think, so it's an older study, but it shows what happens when these folks aren't housed. We're talking about thousands and thousands of these people, so you do have to provide long-term supportive housing for these individuals. I think that's one of the key things that's missing in the spectrum.

At this moment, I'm in Switzerland trying to figure out how they are treating substance use and mental illness so differently and why they have much better retention rates. One of the things they have is wraparound services, and they have supportive housing, so every patient will get a social worker and a nurse and a family physician, and they'll get a psychiatrist, and these folks will follow them longitudinally in the community. Also, with the housing, they'll have support getting medications provided to them.

There's so much more support out there in the community, which we don't seem to have in Canada, in comparison with Switzerland.

Regarding your first question about violence and mental health issues, I actually don't have any statistics on that. I can tell you anecdotally what I've been seeing.

One of the things I do is overnight assessments for the courts. What happens is that someone commits a crime and gets arrested, and then there are concerns about their mental health and whether they should be at their bail hearing the next day. I am asked to assess the patient to see whether they are mentally well enough to go to court the next day.

Before the pandemic, roughly one in five folks I saw for overnight assessments were in for random stranger attacks. They didn't know the victim, and, for whatever reason, whether it was an intrinsic organic psychosis or a substance-induced psychosis, they went and attacked someone.

A couple of years ago, that became one in two. There was a dramatic increase in stranger attacks. Now I think it has decreased to maybe one in three, but there has been an increase. I think there are a lot of issues with this. I think one was the destabilization that occurred with COVID, and two—

[The Chair, Liberal, Sean Casey]

Thank you.

This is very interesting. I was reluctant to interrupt, but we were well over time.

Mr. Thériault, you have the floor for two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Morin, earlier you said that intensive care units have to be ready when the patient arrives and is ready to receive treatment.

The problem with the toxic illicit drug crisis is that patients do not necessarily come to intensive care by ambulance. Treatment has to be available where they are. Regardless of the treatment plan, which should take relapse into account, health care workers have to build a connection with these patients and be in contact with them.

What are your thoughts on that?

[Dr. Marie-Eve Morin]

Well, I can give you a very concrete example from Projet Caméléon, a non-profit I started in 2017 at the beginning of the opioid crisis.

Projet Caméléon sends a team of doctors, pharmacists, nurses, medical students, volunteers and outreach workers to electronic music festivals, where almost 95% of people are under the influence of drugs.

We respond to GHB and ketamine overdoses on site. You don't see a lot of opioids or alcohol at these kinds of festivals, but you do see a lot of psychedelic drugs, such as LSD and magic mushrooms.

The year before, we went to the Eclipse festival, which took place in Sainte-Thérèse-de-la-Gatineau near Gatineau. Twenty-seven ambulances were called to the site. There were paramedics on site, but no doctors.

The first year that Projet Caméléon provided on-site response, only four ambulances were called. Last year, we set a record: no ambulances were called.

We provide on-site treatment. We administer injectable antipsychotics, naloxone and benzodiazepines to treat panic attacks, among other things.

There's clear evidence that treating people on site prevents deaths and a large number of hospitalizations, hospitalizations that may not always be necessary.

A number of organizations, such as CACTUS Montréal and Spectre de rue, have street workers serving downtown Montreal.

We haven't covered everything today, but Projet Caméléon workers also do drug testing so people can have drugs tested before they use them. When we think we've found traces of fentanyl in a substance, we let people know, and they just don't consume it.

Someone said earlier that people are using street fentanyl. That's true. I think there is now a fentanyl addiction epidemic. Some people are now addicted to fentanyl.

I also want to point out that there are products on the street now that are much worse than fentanyl, such as carfentanil and isotonitazene. People can get all kinds of other opioids that are even more potent than fentanyl.

Drug testing is a service that can be provided on the street, and it can save lives. I hope it's available in Vancouver.

Contrary to what some people think, this service does not increase substance use. It actually tends to reduce it.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Morin.

Mr. Johns, you have two and a half minutes, please.

[Gord Johns, NDP, Courtenay—Alberni, BC]

I'll go back to Ms. Wilson, president of the British Columbia Association of Chiefs of Police, who said at our last meeting that, “we know that diverted safe supply and diverted prescription medications are not what's killing people”. She said as well that, “Also, when you consider the volume or the potential volume to scale up diverted prescriptions or diverted safe supply, it pales in comparison to what organized crime is doing in terms of fentanyl production, importation and exportation.”

Ms. Schulz, maybe you can talk about how easy it is to get toxic fentanyl on the streets of Canada and about how hard it is, or what the steps are, to get a safer supply in the provinces that allow it. My apologies to the other witnesses, but I'm giving you the rest of my time—a minute and a half—because I know that some politicians don't want you and other moms to be heard. I'm going to make sure you get that time to speak.

[Petra Schulz]

Thank you, Mr. Johns.

We all know how easy it is to get any illicit drugs anywhere in the country. Drug dealers don't check IDs. I gave the example of the young Olivia who died.

In terms of safe supply, there are huge barriers for people who need this to save their lives. In British Columbia, where it is available, it takes a prescriber who is willing to work with the person. Only a small number of people in British Columbia, roughly 5% of the people who could benefit from it, are on safe supply. In Alberta, thanks to a court injunction, we have one person left on safe supply who thankfully is doing well. She would be dead today, she told me, if it weren't for the court injunction.

We throw huge barriers in people's way for a life-saving measure, whereas it is easy to buy on the street. It is too often lethal. We also ignore that the people who die are not only those who need treatment; they're also people who use occasionally. They're people who use just once, like young Olivia. These are the people we need to see as well. That is where issues like drug-checking are important. We need to remove the barriers to save lives and implement evidence-based measures. Otherwise, the numbers in this country will continue to climb.

At the same time, we should start making treatment immediately available when somebody wants to work on prevention. What nobody talks about in prevention is poverty and the influence of poverty. You don't have prevention with just some education programs. You have to make sure that people have good lives.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Schulz.

Next is Ms. Goodridge, please, for five minutes.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you, Mr. Chair.

Dr. Mathew, B.C. developed protocols to prescribe recreational fentanyl to youth. I'm just wondering if you could share with the committee what your thoughts are on providing recreational fentanyl to youth rather than mental health and addiction treatment.

[Dr. Nickie Mathew]

One thing that's important is that I don't think we should rule out any intervention outright, but we need to apply the precautionary principle in the development of such protocols. What does that mean? There is an author, Nassim Taleb, who produced a paper in 2010. What he said was that you have to look at two factors. One, is the risk systemic or is it local? Does it cause a low amount of damage or a high amount of damage?

For something like this, where you're increasing the supply of fentanyl in the community, that would fall under systemic risk and high downsides, so that would be the type of thing you would apply the precautionary principle to. What you want to do is figure out if this works first.

If that were something that needed to be done, we'd need to look at small pilot projects that rigorously and objectively look at the upsides and the downsides, and many of the studies done so far in these areas do not look at downsides. That way we can measure the risks and benefits of such a program, and if such a pilot program took place and showed that objective benefits outweighed the risks, then that is something that should be implemented. However, if this has not been done, we should look at the precautionary principle when we have interventions that can increase the supply of addictive drugs in the community.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Do you think it's problematic to base political policy decisions on pieces that have not been rigorously studied and to look at only the impacts to people who are using drugs and not to community and public safety?

[Dr. Nickie Mathew]

I think we definitely need to have a 360° view in these things. We need to look at the upsides and downsides, not just for the treatment population, but when you're looking at the supply of addictive drugs you have to look at the population writ large.

In the nineties, when physicians were pushed to prescribe opioids, it was to treat pain as the “fifth vital sign”. It was Dr. James Campbell, who was the president of the American Pain Society, so this was a very respectable individual who was pushing this. However, this led to a huge number of downsides, so we really need to study the upsides and the downsides because, as a physician, you want to know that what you're prescribing has benefits that outweigh the risks.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you.

You brought up the OxyContin crisis. Are you seeing similar things when you're looking at the safe supply, which is flooding our streets with potent opioids? Are you seeing something similar to what existed in the nineties with the OxyContin crisis?

[Dr. Nickie Mathew]

I want to take my opinion out of this and I just want to look at what the government has produced. There is a document called “Youth Unregulated Drug Toxicity Deaths in British Columbia”. What they looked at were the years 2017-2022. What they found was that, if you looked at the deceased youths, there were zero per cent deceased youth with hydromorphone in their systems in 2017, 2018 and 2019. In 2020, the year safe supply came out, 5.5% of the deceased youth had hydromorphone in their systems. In 2021, 8.3% of youth had hydromorphone in their systems, and by 2022, this number had increased to 22.2%. What we're seeing is an increase in the number of youth who have hydromorphone in their systems at the time of death.

I want to be clear. This doesn't mean that the youth died from hydromorphone, but it certainly doesn't help to have hydromorphone in your system at the time of death. What I worry about is that this might be a marker for increased use among youth. We don't know. That needs to be studied more, but it's certainly something that needs to be looked into. The data for adults hasn't been released, so I just want to stick with the facts, and those are the statistics for that.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

I really appreciate the fact that you want decisions based on facts and not on pieces here, and I think this is one of the challenges. I know members of the NDP like to say that we're spreading disinformation, but the reality is I simply want public policy decisions based on facts and peer-reviewed science, not based on feelings and trying to save the world while allowing the next generation to succumb to addiction because we make drugs so much easier to access. If you could say something to youth right now, who are potentially thinking about using, going out and buying safe supply hydromorphone, what would you tell those youth in British Columbia?

[The Chair, Liberal, Sean Casey]

Answer as briefly as you can, please.

[Dr. Nickie Mathew]

I would tell them that any sort of opioid is addictive, and that with something like hydromorphone, if you become tolerant, you might actually move on to more dangerous things like fentanyl—to be careful around any sort of opioid use.

[The Chair, Liberal, Sean Casey]

Thank you.

The last round of questions for this panel will come from the Liberal side.

I believe it's Dr. Hanley.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

I will leave time for Dr. Powlowski, as well, especially if you remind me.

First of all, I just want to thank my colleague Dr. Ellis for bringing up Planet Youth and prevention.

I just want to emphasize again, as Ms. Schulz said, how vital that is. I'll also just note—because not everyone may know this—that there was $20 million in funding dedicated in the federal budget, starting in 2023-24, for Planet Youth initiatives, with up to $125,000 in funding per community initiative.

This is a great start, I think, down another avenue for prevention, which we need to be very aggressive at in supporting our youth.

Dr. Mathew, just very briefly, I really commend you for being in Switzerland. I wonder if you have also been in Portugal.

[Dr. Nickie Mathew]

I have not been in Portugal.