Health Committee on Feb. 11th, 2014

[The Chair, Conservative, Ben Lobb]

Good morning, ladies and gentlemen. I thank everybody for attending this morning.

We have two witnesses here this morning on our continuing study of prescription drug abuse. Today we have Carol Hopkins and Peter Dinsdale.

Ms. Hopkins, if you're ready to start we'll get you to present. You have about 10 minutes to do your presentation. We have two witnesses today, normally we have four, so if you need to go over by a few minutes, that's okay.

[Carol Hopkins, Executive Director, National Native Addictions Partnership Foundation]

[Witness speaks in Ojibwe]

I'm from the Lunaapeew nation, otherwise known as the Delaware first nation of southwestern Ontario. I'm the executive director of the National Native Addictions Partnership Foundation. Thank you for the invitation to speak with you today.

I want to cover five different areas today if I have enough time. I want to give you an overview of some of the issues related to addressing prescription drug abuse with first nation communities, a little about public health, primary health care, and community development and those linkages. I want to talk to you about collaboration and integration, and then look at a systems approach and our broader ecological systems approach.

In terms of issues, common strategies to address prescription drug abuse are not readily available in first nation communities and are even more challenging in rural and isolated areas. For example, there's no public health or comprehensive primary health care systems in first nation communities. There's a lack of coordination and collaboration between public health and primary health care systems and first nation communities. There's a lack of coordination across jurisdictions: provincial, territorial, and federal health authorities. There's little understanding of the benefits of pharmacological interventions to address prescription drug abuse issues among first nations people.

There's also a lack of and no access to withdrawal management and opiate medication-assisted treatment such as methadone, buprenorphine, or naloxone, specifically as they are linked to or working in collaboration with first nation communities and community health programs. When methadone maintenance treatment is available, clients from first nation communities often have to travel long distances, putting strains on medical travel budgets administered by first nation communities, and this adds up to significant daily costs.

There's a lack of appreciation of the impacts of colonization among prescribers and service providers. Therefore there's a lack of trauma-informed care to first nations people.

Approaches to health promotion, prescription drug abuse prevention and treatment don't often consider broader issues such as the relationships between addictions, mental health, co-morbidities, concurrent disorders, pain, and chronic disease. Some of the impacts of those issues are increased use of alcohol to manage withdrawal and increased use of heroin. There's an increased risk of blood-borne communicable diseases, and there are accidental overdoses and deaths, and increased violence.

First nations children are 15 times more likely than the rest of Canada to be in care in the child welfare system. Drug trafficking is almost four times higher than the rest of Canada, according to Public Safety Canada. Rates of domestic violence are five times higher than in the rest of Canada, and mental health and addiction issues certainly play a significant role in employability.

The change required to address prescription drug abuse issues requires change in the way governments do business. We need more horizontal work across governments and between government departments with first nations as key partners. We need support for a comprehensive framework that can be used to guide communities, regions, tribal councils, health authorities, provincial and territorial governments, and federal departments in knowing how to adapt, optimize, and realign programs and services to be more responsible and flexible in meeting the needs of first nations people.

We need to recognize that first nation communities aim to achieve wellness, and that this perception of health is often distinctly different than a medicalized model of health because the first nations' focus on wellness is more holistic. It promotes an equal balance between mental, physical, emotional, and spiritual aspects of life.

The issues among public health, primary care, and community development are that they don't often work together, especially when it comes to working with first nation communities.

But there is good evidence that there are great benefits when they do collaborate—public health, primary care, and first nation communities—specifically in the areas of maternal child programs, communicable disease prevention and control, health promotion and health protection, chronic disease prevention and management, programs specific to youth, programs specific to women, and substance use and mental health issues.

Solutions have to focus on the social determinants of health for first nation communities, and they have to include and be reflective of indigenous knowledge and culturally relevant evidence. There's a need for increased support for protective factors, such as appreciation of culture and linkages to cultural identity, use of our traditional first nation languages, culturally relevant education, access to high school, recreational activities, and linkages to cultural practitioners and elders.

We need resources and policies focused on community development and capacity building, and increased support to identify, develop, promote, and evaluate evidence-informed and culturally safe practices. We need comprehensive workforce development in first nation communities.

One of the systems approaches that has been developed culminated over four years in the creation of what is known as “Honouring our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada”. This was a collaboration between the Assembly of First Nations, Health Canada, and the National Native Addictions Partnership Foundation. It describes an integrated, culturally relevant, client-focused system of services and supports for addressing substance use issues for first nations. The framework identifies best and promising practices to strengthen and support programs at the community, regional, and national levels and across related jurisdictions. The framework implementation to date has focused on strengthening a system of care; improving the quality of programming that currently exists in the national native alcohol and drug abuse program and the national youth solvent abuse program; ensuring better measurement, oversight, and research; and enhancing coordination and integration at all levels. The implementation of the framework represents an opportunity to support a comprehensive response to prescription drug abuse issues for first nations.

An example of some promising practices is this framework was used to inform a discussion between the Ontario Ministry of Health and Long-Term Care, the Chiefs of Ontario, and the first nations and Inuit health branch of Health Canada. There have also been community development programs in place, called mental wellness development teams in Ontario, that have a focus on community development and show promising practices.

There have been culture-based opioid replacement therapy programs, where first nations have invested their own funds in Suboxone for opioid replacement therapy, because it wasn't readily available to match the needs of the community. The community has found that it's easier to store than methadone, and easier to dispense in remote communities. They found it worked well with holistic treatment programs that were land-based programs that included counselling with cultural practitioners, culturally relevant community development initiatives, and life skills development.

Currently we're in the process of developing a broader ecological systems approach. It's called the first nations mental wellness continuum framework. It's currently under way, and it describes the vision for first nations mental wellness with culture as the foundation. It emphasizes first nations' strengths and capacities. It provides advice on policy and program changes that should be made to improve first nations mental wellness outcomes, and it focuses on cultural values, sacred knowledge, indigenous knowledge, language, practices of first nations, and understanding that these are essential to the social determinants of health for individuals, families, and overall community wellness. It has five themes, identified after regional discussions, national discussions, and discussions with federal government departments.

The first theme is that culture has to be the foundation. Two is community development and ownership, and the others are quality health systems and competent service delivery, collaboration with partners, and enhanced flexible funding investments.

What we've heard to date is that new investments are needed in addition to the realignment of existing resources. Also needed is improved information-sharing among federal departments, improved coordination of programs and services, and the mapping of authorities to see where collaboration is possible. There is a need for more flexible ongoing funding to support community-identified needs. There is a need to build on what is working in first nation communities, and align federal programs and services that impact mental health and addiction services for first nation communities.

Overall some of the key aims are to move from an examination of our deficits as first nation communities to a discovery of our strengths by focusing on culture. From the use of evidence absent of indigenous world views, values, and culture, we need to move to indigenous knowledge that sets the foundation for evidence in approaches for addressing prescription drug abuse. It also involves moving from a focus on inputs for individuals to a focus on outcomes for families and communities, and finally, moving from uncoordinated and fragmented services to integrated models for funding and service delivery.

I'm not sure where I am in time but I'm just going to keep talking until you cut me off.

[The Chair, Conservative, Ben Lobb]

You're slightly over already, which is okay. Do you have 30 seconds or a minute to wrap up?

[Carol Hopkins]

Okay.

[The Chair, Conservative, Ben Lobb]

If that's okay, or thereabouts.

[Carol Hopkins]

Some of the priorities for first nations are the provision of medically assisted treatment, and so greater access to methadone, buprenorphine, and naloxone maintenance. Withdrawal management is also absent from the first nations system and there's a reliance on provincial government services that often don't have enough services to address the needs of first nations people.

We need to have a focus on outcomes that are reflective of cultures, such as investment in spiritual wellness that promotes health, emotional wellness that promotes belonging, mental wellness that promotes having meaning in one's life, and physical wellness that facilitates having purpose in one's life. If hope, belonging, meaning, and purpose were our targeted outcomes of any approaches to addressing prescription drug abuse we would be promoting an indigenous wellness framework.

[The Chair, Conservative, Ben Lobb]

Thank you.

Very good, Ms. Hopkins.

Next up is Mr. Dinsdale for 10 minutes or thereabouts.

[Peter Dinsdale, Chief Executive Officer, Assembly of First Nations]

Thank you very much, and good morning. On behalf of the national chief and the national executive of the Assembly of First Nations, thank you very much for inviting us here to speak. I'd like to acknowledge, of course, that we're gathered here in traditional Algonquin territory and thank them for allowing us to gather here and do this work today.

I want to say at the outset that I'm joined by some very capable and knowledgeable staff who are here supporting me: Judy Whiteduck, Marie Frawley-Henry, and Jennifer Robinson. So I want to acknowledge them in reference to pulling this together.

It is my pleasure to speak before you today on the government's role in addressing prescription drug abuse in first nation communities.

First, I want to speak to the framework in which we operate. The UN Declaration on the Rights of Indigenous Peoples, in article 23, states:

Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.

Secondly, it has long been the goal of the Assembly of First Nations to close the gap in health outcomes between first nations and the general Canadian population. We're pleased to see that this objective is shared by Health Canada as demonstrated by the expressed mandate to address health barriers, disease threats, and maintain levels of health comparable to other Canadians. So we're simpatico.

While we clearly share the similar objectives, the facts remain that first nations people continue to suffer disproportionately with poor health, both mentally and physically.

Thirdly, any consideration of the government's role in addressing prescription drug abuse has to begin with an understanding of the history of colonialism and its effects on first nations and their interactions with the government. In Canada, this history includes legislation such as the Indian Act, the creation of the reserve system, the various legal status apparatus in which we operate, residential schools, the sixties scoop, inadequate services to those living on reserves, continued racism, and the lack of understanding of their experiences or consideration of the effects of all these experiences.

Further, we also need to acknowledge the connection between historical, cultural, economic, political, and legal factors affecting the well-being of first nations people, namely, through the social determinants of health. While the social determinants of health approach is necessary in policy discussions and the government's role in addressing prescription drug abuse, it's not efficient in and of itself and must be implemented in accordance with the values, attitudes, and aspirations of first nations peoples. This is in addition to the utilization of traditional and western practices and service delivery aimed at first nations. Programs and services designed without first nations involvement simply will not work for us. Programs and services must be community-based and community-designed with a strong understanding of the diverse needs, because no two communities are the same.

The system of health we need to create and the system of health care must ensure that the sustainability of resources is matched to population growth and health needs. Additionally, policies and programs must be consistent with the inherent treaty and aboriginal rights as defined in section 35 of the Constitution Act.

So with respect to mental wellness, over the years first nation communities and leadership have been calling for a coordinated and comprehensive approach to mental wellness programming. This has been evident by the numerous resolutions that have been passed at our assemblies that give us our mandate and policy direction. Other national initiatives and organizations such as the Mental Health Commission of Canada have also identified the description of a continuum of mental wellness services for first nations as a high priority. We've worked closely with them in developing strategic directions that state things such as the recognition of distinct cultures and mental health needs of first nations, Inuit, and Métis outlines the importance of a distinction-based program within mental health. The strategy was released in May 2012.

However, it is imperative that this process be undertaken through a coordinated approach that involves the full participation of first nations as partners at every level of the process. For example, the Assembly of First Nations has partnered with the first nations and Inuit health branch to jointly develop a first nations mental wellness continuum framework ensuring that the unique needs of first nations in remote, rural, and isolated communities are taken into consideration. As a result, we expect and anticipate the government will work together with us in support of first nations mental wellness approaches along that continuum.

The government's role in addressing non-insured health benefits includes the need to improve access to that program, regardless of where first nations reside.

More importantly, we want to register the current and alarming state of the non-insured health benefits program, which demonstrates more than ever the need for profound changes in the administration of these benefits to meet the needs of first nations and not merely the fiscal interest of the country.

In 2011, the Assembly of First Nations requested that the Senate Standing Committee on Social Affairs, Science and Technology undertake a comprehensive review of the non-insured health benefits. This request was denied.

As a result, in 2012, the chiefs in assembly requested the Standing Committee on Health undertake this review. Again, this request was denied. This led to a further resolution from our chiefs, mandating the AFN to call for a joint review of the non-insured health benefits program, in collaboration with Health Canada. This request is ongoing. We wrote to the minister in January 2013, requesting action on the resolution. The letter called for a meeting between the national chiefs and the minister to begin discussions on conducting a comprehensive joint review of the program. We have just been informed that in the very near future, the national chiefs and the Minister of Health will be meeting for the first time to begin to do this work.

Another key issue relates to OxyContin, a long-acting oxycodone drug that was discontinued in Canada in 2012. Following the withdrawal, the generic oxycodone recently became available in Canada, and Health Canada approved new generic formulations of it. These new formulations are addictive, and they are not tamper resistant. As such, they will impact first nations that are struggling with this ongoing addiction. The misuse of oxycodone is merely one aspect of a larger health crisis within our communities. It has disastrous consequences all across first nations, and I think most notably in Northern Ontario, as has been demonstrated through the media.

Therefore, sustainable and sufficient investments must be made across a broad range of social and health services, including basic infrastructure such as housing and others, and the ability to access mental health support services and addiction recovery services.

Currently, our engagement with the government is occurring through partnerships and strategies that include a multi-pronged approach on preventing prescription drug abuse. The AFN works with the first nations and Inuit health branch's program areas, which include prescription drug abuse strategies to specific first nation communities in the areas of prevention, treatment, and enforcement. These include the first nations and Inuit mental wellness strategic action plan, the national anti-drug strategy, the national native alcohol and drug abuse program, and the national youth solvent abuse program.

In addition to our partnership with the first nations and Inuit health branch, we have also participated on the prescription drug abuse coordinating committee with the Canadian Centre on Substance Abuse. To date, projects such as Honouring Our Strengths—as we referred to earlier, which was produced in partnership with FNIHB and the National Native Addictions Partnership Foundation—and First Do No Harm are the most recent efforts to jointly develop a first nations mental wellness continuum framework that illustrates that the foundation of a systems-based approach to prescription drug abuse programs begins with individuals, families, and communities as well as many other key stakeholders and players.

More recently, we participated in a symposium held last month with Minister Ambrose to discuss resource gaps and opportunities for collaboration in the areas of prevention, treatment, and enforcement related to prescription drug abuse. We welcome continued engagement and encourage continued collaborative efforts to address prescription drug abuse within the mental wellness continuum so that first nation communities can adapt, reform, and realign their mental wellness programs and services according to their priorities.

We continue to call for flexible and sustainable long-term funding to ensure that the solutions to prescription drug abuse are community-driven, so that our families can continue to heal from the impacts of colonization and move forward on the path to mental wellness.

Finally, we reiterate our call for a joint review on the non-insured health benefits program. First nations are the youngest, fastest-growing populations in Canada. This work is in all of our interest. Strong and healthy first nations make for a strong and healthy Canada.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Dinsdale.

That'll conclude our presentations.

First up for a seven-minute round of questions is Ms. Davies.

Go ahead, please.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Mr. Chairperson.

Thank you, Ms. Hopkins and Mr. Dinsdale, for two very informative and I would say comprehensive presentations. You covered a lot of ground. Thank you for providing that information. First of all, I want to say to both of you that I really appreciate and value the approach you take, which is based on community development and comprehensive overall wellness.

Carol, one of the issues that you touched on is moving from individuals to looking at families in communities and at outcomes. In one of the communities that I represent—the Downtown Eastside, where there's a high aboriginal population—that's absolutely the way we have to go. It doesn't really matter what program it is; it's the approach that's taken. I appreciate that you've put that point forward, and in the reports that you have done, it keeps coming through.

We have two national programs, the national native alcohol and drug abuse program and the youth solvent abuse program, which you mentioned. Then, of course, there's the non-Insured health benefits program. How well, if at all, do those programs reflect this approach that you are talking about?

What you are saying so clearly is critical, if we're going to change anything. Are those programs moving in this direction, would you say, or are we stalled? What can we do to encourage these national programs to reflect the delivery model and model of community ownership and development that you spoke about today?

[Carol Hopkins]

Both of the national programs that you refer to, the national native alcohol and drug abuse program and the national youth solvent addiction program, are residential treatment programs primarily focused on treatment for individuals. Some of the programs provide treatment for whole families in residential environments. Many of these programs are reprofiling so that they have capacity to address prescription drug abuse issues. The Honouring Our Strengths renewal framework is a framework that sets out a vision for reprofiling services, using existing funds, to be more community-based.

However, the funding that is available in both national programs isn't enough to expand to community-based services, although the Honouring Our Strengths renewal framework certainly does promote a continuum of care. Across Canada, different regions have reviewed the services in their regions through NNADAP and YSAP, and some have reprofiled so that they are more community-based. Primarily, those systems consist of 56 treatment centres across Canada; that is, residential treatment programs. Not all of them have the capacity to address prescription drug abuse.

[Libby Davies, NDP, Vancouver East, BC]

Are they all on reserve, or are some of them off reserve as well?

[Carol Hopkins]

A majority of them are on reserve.

[Libby Davies, NDP, Vancouver East, BC]

In B.C. we have the new agreement on health care with aboriginal people. It's pretty new, so there's still obviously a lot of evaluation taking place. I don't know how much you are involved in or aware of that agreement, but do you have a sense at all that the new agreement and the way programs will be delivered will produce a fundamental change? When you talked about community development mental health awareness teams, I think you were speaking about Ontario. Do you have any sense that this new agreement in B.C. is going to address some of the issues of mental health, addiction, prescription misuse, and so on, with that kind of model, doing so from a community development point of view?

[Peter Dinsdale]

Just recently I had conversations with the chair of the First Nations Health Council around some of these issues. Of course, this is very new; they are months into it. His description of it is that it allows them to focus their priorities on areas in which they need funding. He said that in previous developments, there occurred a lot of infrastructure development in association with which there weren't necessarily enough services in communities themselves. So they're going to reprofile some of the work they're doing in their existing envelopes to focus on community-based services.

The mix between the amount of health programs and others is to be determined by that council, but I think it has great potential to do exactly what you're talking about, to reprofile resources and use this ability to focus on community-based solutions.

[Libby Davies, NDP, Vancouver East, BC]

Do I have time for just one short question?

[The Chair, Conservative, Ben Lobb]

You have a minute and a half.

[Libby Davies, NDP, Vancouver East, BC]

Thank you for that. I think it's something that we should watch very closely because it does put forward a sense of hope that changes can come about.

I guess the last point I'd like to make, Mr. Dinsdale, is that I'm glad there is a meeting that's going to take place. You say it's been requested for a while. This issue of a joint review of the non-insured health benefits, depending on what comes out of that meeting I would hope very much that you might keep this committee apprised of whether or not progress is being made. We are the Standing Committee on Health and this is a direct federal responsibility so there's a clear jurisdictional issue. As you say it should be done in partnership and it should be comprehensive. So I think it would be very helpful if you could keep us apprised of that, given that there is a meeting now taking place and maybe it's something that we can help in terms of communication, or to take it up in some way. We hear your frustration that this is something that you requested for a long time and it hasn't yet happened.

[Peter Dinsdale]

Very quickly...absolutely. You should also know that we are also doing regional and national work on the non-insured health benefits program to strategize on our side, the first nations political leadership side, including a national forum to be held in Toronto in March, which is meant to be the culmination of a bunch of regional conversations. So we can certainly inform the clerk of it. If you're available to come and attend we'd welcome having any of the committee members.

[The Chair, Conservative, Ben Lobb]

Very good.

Ms. Adams you have seven minutes, please.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you very much for joining us today. All members of our committee were very eager actually to hear from you. It was a priority to ensure that you would come and present today so thank you very much for coming to Ottawa.

Ms. Hopkins, I would also like to thank you for partnering with Health Canada to create “Honouring our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada”. I know that the Minister of Health found the information here very important, so thank you for this very good work.

The federal government does currently fund a number of projects when it comes to prevention and treatment. As you can imagine we'd like to focus our resources on best practices and share those nationwide. Can you tell me which programs you think—if you would both please speak to this—are the most worthwhile?

[Carol Hopkins]

We are currently in the process of conducting some research around the impacts of culture-based interventions to address substance use issues. We're looking forward to gathering evidence over time about the impacts of culture-based interventions.

We have some good preliminary data on the outcome of residential treatment programs for first nations. Where those programs offer culturally based services there's a good indication that at least 65% of people leaving treatment going back into first nation communities are able to maintain a good level of wellness—meaning they're not using their primary choice of substance, and they're at least reducing another substance because first nations people are polysubstance users.

In terms of community-based programs there has not been enough investment in community-based services to get a good sense about the most effective programs. They're going based on what happens in residential treatment and the conversations that we've had over the development of the HOS renewal framework, and the recent first nations mental wellness continuum framework. First nations people are saying that culture has to be central—that's the HOS renewal framework—and in the first nations mental wellness continuum framework it says culture has to be the foundation. It can't be an add-on. It can't be the adaptation of western-based approaches. It has to be the foundation.

If we're going to make any significant long-term gains then that requires culture that is not marginalized in the workforce. So for example, cultural practitioners and elders have to be central. There has to be good collaboration across health care providers.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thank you.

Mr. Dinsdale.

[Peter Dinsdale]

That's the great thing about speaking after Carol, I don't have to say as much.

One of the things I may add though is that the B.C. agreement—the health devolution agreement—may really hold some promise for consideration across the country. I think here is an example where first nations themselves can set priorities to focus on local community control and to have local community responses as opposed to a one-size-fits-all national program, which sometimes is well-intentioned but sometimes will not be directly aligned at the community level. I think that will be an important agreement to watch and an important agreement to see how it does impact that kind of ability.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

You know, the non-insured health benefits program takes the opportunity to look at individuals who might be at a higher risk for abusing substances and starts monitoring the types of substances that are being dispensed to that individual.

We've seen some very good results. I'm going through some of the numbers here. Somewhere there's a 10% decrease in opiate use. Some others are citing 20%. Have you had a similarly positive experience with that?