Health Committee on May 6th, 2024

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

Very quickly, Dr. Koivu, if we're talking about 2,500-milligram morphine equivalents, what would be the recommended amount that a prescriber should be very cautious about going over? I realize this is a different patient population from even the usual chronic pain population, but what would be a guideline for Canadians listening out there?

[Dr. Sharon Koivu]

The guideline is the equivalent of 100 milligrams of morphine per day or less.

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

And these people are receiving up to 2,500.

[Dr. Sharon Koivu]

Yes—or more.

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

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you.

We'll go now to the Liberals.

Dr. Hanley, you have the floor for the next six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much.

Thanks to all the witnesses for being here.

I'm speaking today from the traditional territory of the Kwanlin Dün First Nation and the Ta'an Kwäch'än Council in Whitehorse, Yukon.

Dr. Hopkins, I want to address the bulk of my questions to you.

Unfortunately, Chief Frost had to leave early during our vote, but I noticed that you were listening acutely to her testimony and you were nodding. I wonder if you can indulge me. Was there anything in particular that resonated, based on your knowledge and experience, from Chief Frost's testimony as chief of an isolated northern community?

[Dr. Carol Hopkins]

We typically assume that the issue with resources and capacity to respond to the toxic drug supply is remoteness, that it's geographical. We are not asking for or expecting hospitals to be built in every one of our communities, but the Canada Health Act says there should be universal access to health, and its objective is accessible health care without barriers to our wellness.

I mention this because there are lots of Canadians who live in rural and remote communities, but we are talking specifically about first nations people. They have a right to access health care close to home, where they need it. When it's not available there, they will find it someplace else, which often draws them to urban environments.

In urban environments, they don't always have access to the appropriate health care they need when they have opioid dependency or addictions to methamphetamine or other stimulants or even to sedatives like benzodiazepines, which I mentioned, or the “tranq” drug xylazine, which is not a controlled substance. All of them have substantial effects on people when they don't have any health care resources close to home.

That isn't just because of geography. That has to do with decision-making. If the Canada Health Act says there should be universal access to health care for every resident in Canada no matter where people live, then where are the policies that ensure access to physician care, prescribers, nurse practitioners, pharmacies, public health resources and harm reduction resources when they exist for the rest of the population? Why are those not made available to Canadians and first nations populations no matter where they live?

Often this is referred to as a jurisdictional issue. Who's responsible? The Canada Health Act is clear: Our rights as defined in treaties, the Constitution and now the UN Declaration on the Rights of Indigenous Peoples do not erase our rights under the Canada Health Act. This is a decision, a policy decision, not just a matter of geography.

[Brendan Hanley, Liberal, Yukon, YT]

If you don't mind, I'll jump in there, because my time is limited.

One thing Chief Frost referred to was having spent a million dollars of base funding from the VGFN to, in this case, send people out for treatment. I can't speak specifically to the number of individuals, but I think she mentioned 70.

We know that often when people go outside for treatment and come back into a community, they are at high risk not just for overdose but for relapse because the community supports—the aftercare—aren't there. Following up on your previous point, do you know of or could you describe models of care that work within a small community? Maybe there are success stories you know of or have seen about how care can be delivered within a community so that you have continuity through aftercare.

[Dr. Carol Hopkins]

There are communities, no matter how big or how small, remote or isolated, that have partnerships with local health authorities, physicians, prescribers and nurse practitioners, who deliver services by flying into the community from time to time or by monitoring their patients through video conferencing. There are partnerships with the chief and council and direction through a band council resolution on how health services are operating through the health centre, as well as these kinds of partnerships with elders and cultural practitioners. It's clinical support and medication, together with culture-based resources, that have made a difference.

I gave an example of a community in northern Ontario where that significantly reduced crime and the number of kids going into child welfare. Kids showed up to school with food in their stomachs, houses were filled with furniture, toys and food, and life returned to normal, because it's a whole-of-community approach and because the community, through a number of partners, had the resources it needed to respond to the whole population. It's not just about the impacts on the individual who uses drugs. It's about the impact on the family and the whole community.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Hanley. That's your time.

Mr. Thériault, you have the floor for six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

Thank you to the witnesses for being here.

Personally, I have no preconceived ideas about the crisis we're trying to understand and fix by means of recommendations. In listening to the various witnesses, though, I end up feeling a little confused. There seems to be no scientific consensus. In fact, increasingly, there appears to be a division within the scientific community or among the professionals working in the field.

Professor Pauly, you talked about safe supply, which saves lives. I guess that was the purpose.

First, does safe supply necessarily have to be temporary? If so, how can we assess that?

Second, why is access to opioid agonist therapy at odds with the impact of safe supply?

[Dr. Bernadette Pauly]

These are two very important questions.

I just want to speak for a second about the split in scientific evidence that the member referred to. There isn't actually a split when you look at what is considered peer-reviewed evidence or evidence that's been reviewed by multiple scientists in the field.

Our team did a study where we looked at all of the evidence for safe supply. There are close to 40 of these types of peer-reviewed articles, and the evidence is overwhelmingly positive: It connects people to a safer alternative, reducing overdoses; connects them to health care and other types of supports, as needed, like housing; and reconnects them back to family and community. I just wanted to mention that evidence.

Should safe supply be temporary? This is a good question, because when it was introduced in British Columbia, it was introduced as a temporary measure. However, it became clear that we needed it as part of a systems response. I really want to emphasize this piece about a systems response. In British Columbia, we had some evidence early on that when we combined multiple interventions, like take-home naloxone with opioid agonist treatment and overdose prevention, it showed some really good results. However, it wasn't enough. Safer supply comes in as another form of intervention within a comprehensive approach.

As to your question about why there's opposition, I personally don't understand why safer supply is being scapegoated, because the real harms here are coming from a very toxic and unregulated drug market. That is what's killing people.

[Luc Thériault, Bloc, Montcalm, QC]

For example, what's your opinion on Dr. Koivu's statement regarding scientific consensus around safe supply?

[Dr. Bernadette Pauly]

Our evidence has shown that it reduces overdose deaths, and I can point to other studies where it has not been shown to increase rates. Rates of addiction have not been increasing since we introduced safer supply. The description that Dr. Koivu gave is about the ever-escalating need for increasing dosages. That's not what I see happening in the way that prescribers in British Columbia are practising. In fact, in our study, we found that safer supply medications were, at least in the first 18 months, at a lower dose than we see with traditional opioid agonist treatment.

I do a lot of qualitative research. I interview people who are receiving safer supply, and I often ask them about their goals. I would say that, frequently, what they talk about is the goal of getting off safer supply. That might include using safer supply for a period of time and maybe transitioning to OAT, but they have a plan because they too want to live a full life and have a high quality of life. Those kinds of goals are, I think, really important.

That's some of the reality that I see within the work I'm doing.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Pauly.

Next is Mr. Johns, please, for six minutes.

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

Thank you all for your testimony.

I'll start with you, Dr. Pauly.

You heard from Dr. Koivu. She raised concerns about infectious complications for people using safer supply. Is this something you found in your research with people who were injecting fentanyl and then switching over to safer supply, or people who started on safer supply? Is this what you're seeing in your research as well?

[Dr. Bernadette Pauly]

I'll give you a bit of background. When people are injecting from the unregulated and toxic drug market, there are additives. My colleagues on the panel have spoken to this and to how harmful the additives in the unregulated market are. They often cause abscesses and injections.

I believe the committee had a brief submitted by Dr. Gomes, who looked at administrative data for people receiving safer supply—this was in Ontario—and the rate of infections went down when they went into a safer supply program, likely because they were no longer injecting toxic substances from the unregulated market. However, they also would have had a connection to health care, and that's a really positive outcome of safer supply types of programs. In British Columbia, we have more injectable formulations, so if there is a concern about injection-related infections, that may be why those are being used more in British Columbia.

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

Dr. Koivu, given what Dr. Pauly said, could you please submit, within 14 days, your own research to this committee that supports your claims on infections caused by hydromorphone?

Is it the will of the committee to get support for that?

Did the witness agree, Mr. Chair?

[Dr. Sharon Koivu]

I can—

[The Chair, Liberal, Sean Casey]

Well, if you've asked her to provide it and she agrees to provide it, I don't think you need everyone else's opinion.

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

I wanted to make sure that was on the record.

Thank you so much.

I'm going to go to Ms. Hopkins.

You were a co-chair on the expert task force on substance use. The expert task force was unanimous in recommending that we scale up safer supply, stop criminalizing people who use substances and ramp up treatment on demand, recovery, prevention and education.

You had a really wide spectrum on the expert task force on substance use. Can you speak about your disappointment, maybe, with the government not following through with the recommendations and your experience with how important it would be to reinstate the expert task force and implement those recommendations?

[Dr. Carol Hopkins]

We're talking about using evidence, and the question is about whose evidence is more credible. That's quite a common conversation when it comes to first nations people, whose world view and culture-based evidence are typically set aside. However, that does not mean, for example, that culture and safer supply are completely incompatible.

Safer supply is one more tool in the tool box. There is no silver bullet. There is not one medication. There is not one strategy, method or form of care that will solve the opioid crisis or the toxic drug supply. There are many strategies that have to be used together in combination, like—

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

I don't know if the question was heard properly. I apologize for that.

We just heard from the First Nations Leadership Council and the B.C. First Nations Justice Council. They're calling for an emergency cross-governmental and multilateral strategy that ensures the safety of people who use drugs.

Dr. Sayers, a BCFNJC member, said that “the toxic drug crisis needs to be treated and addressed as a public health issue, not a criminal justice issue.” Grand Chief Stewart said that how we're proceeding right now is “very much wrapped up in the destructive impacts of colonialism.”

Can you add your thoughts on those statements?

[Dr. Carol Hopkins]

I just want to emphasize the importance of safer supply. That's one tool that needs to be available to everybody.

In addition to understanding the context of first nations people, as I said earlier, we do not have the community-based resources necessary to address the impacts of opioid toxicity or the toxic drug supply. We don't have services close to home where people need them, when they need them. That often leads them to move, travelling off reserve for periods of time. Often, the crowds they find most welcoming are those involved in selling illicit drugs. Then they come back into the community, and now we're creating a new relationship that has significant impacts on families and the whole community.

For the first time ever, first nations communities are reporting murders, not by first nations people murdering first nations people, but by gangs from large urban environments coming onto reserves and committing these crimes. Gun violence and human trafficking have increased.

If we look at what the perception of that is, we could say that because of racism in Canada, first nations people will be blamed for those kinds of activities; they did this to themselves. That's the same sentiment for people who use drugs. They should just stop; they can just decide to. Why don't they choose something different when they're losing all these things? We're blaming the victims without supporting their right to health and social services.

The United Nations—