Health Committee on Feb. 29th, 2024

[The Vice-Chair, Bloc, Luc Thériault]

I call this meeting to order.

Welcome to meeting number 105 of the House of Commons Standing Committee on Health.

Today's meeting is taking place in a hybrid format, pursuant to the Standing Orders. To ensure that the meeting runs smoothly, I'd like to pass on some instructions to the witnesses.

Please wait until I recognize you by name before speaking. For those participating by video conference, click on the microphone icon to activate your mike, and please mute yourself when you are not speaking.

As far as interpretation is concerned, those taking part remotely using Zoom have the choice, at the bottom of their screen, between floor, English or French. Those in the room can use the earpiece and select the desired channel.

As a reminder, all comments should be addressed through the chair.

In accordance with our routine motion, I am informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Pursuant to Standing Order 108(2), the committee is resuming its study of the opioid epidemic and toxic drug crisis in Canada.

I would like to welcome the witnesses joining us today.

Appearing as an individual is Dr. Elaine Hyshka, associate professor and Canada Research Chair in Health Systems Innovation, School of Public Health, University of Alberta.

From the University of Toronto, we also have Dr. Meldon Kahan, associate professor, Department of Family Medicine.

Joining us from Simon Fraser University is Dr. Bohdan Nosyk, professor and St. Paul's Hospital CANFAR chair in HIV/AIDS Research.

Also with us is Dr. Marie-Ève Goyer, physician, Clinical and organizational support team in addiction and homelessness.

We will now proceed to opening statements. You will each have up to five minutes for your statement. We'll begin with Dr. Hyshka, followed by Dr. Kahan, Dr. Nosyk and Dr. Goyer.

Dr. Hyshka, you have the floor for five minutes.

[Dr. Elaine Hyshka, Associate Professor and Canada Research Chair in Health Systems Innovation, School of Public Health, University of Alberta, As an Individual]

Thank you for the opportunity to appear today. My name is Elaine Hyshka, and I am a Canada research chair in health systems innovation, and an associate professor at the University of Alberta's school of public health. I am joining today from Edmonton, on Treaty No. 6 territory, the traditional lands of first nations and Métis people.

My opening remarks outline the current situation in Alberta, how we got here and where we need to go provincially and nationally to achieve sustained reductions in drug-related morbidity and mortality.

In Alberta, 2023 will be the worst year on record for opioid poisoning deaths. Between January and November, we lost five people per day—a total of 1,706 people—to fatal opioid poisoning. This annual death count, though still incomplete, is nearly 19 times higher than that observed at the height of the prescription opioid crisis in 2011, when 91 Albertans died from opioid overdose. The situation is so severe that it is contributing to declines in population life expectancy.

What accounts for this substantial increase in mortality? The preponderance of evidence indicates that the exponential increase in deaths in Alberta is the result of fundamental and, presumably, permanent shifts in the illegal drug supply, which have made using drugs much more dangerous than ever before. It is not the result of a significant increase in the prevalence of addiction or opioid use disorder. We currently have no data showing that there has been a huge increase in the number of people who have developed opioid use disorder or addiction in Alberta since 2011. Instead, well-intended efforts to reduce prescription opioid use beginning in 2012 led to a rapid reduction in prescribing and a 50% reduction in the total population flow of prescription opioids by 2018. Unfortunately, the death rate did not decline. It surged as the illegal drug market moved to fill this gap with highly toxic, clandestinely produced novel synthetic opioids. Complicating the situation further are increasing rates of stimulant co-use, and contamination of opioid products with benzodiazepines and other sedatives.

We have now lost 10,060 Albertans to toxic drugs. To put this number in perspective, 3,861 more people have died in this crisis than have died from COVID-19 in Alberta. Most people dying are young and middle-aged. Many are first nations people, who as a result of colonization, racism and discrimination, die at seven times the rate than non-first nations people in Alberta, contributing to a seven-year decline in their life expectancy between 2015 and 2021 alone. The potential years of life lost and the impacts on surviving children, parents, families, friends and communities are enormous, and they are devastating.

Reversing this trend will require an evidence-informed public health response that we have yet to see anywhere in Canada. COVID-19 demonstrated how coordinated and well-resourced public health efforts can achieve rapid advances in science and avert substantial morbidity and mortality over time. We need a similar societal response to toxic drugs to save lives, promote health equity, reduce pressure on health systems, and avert billions of dollars in lost economic productivity attributable to toxic drug deaths.

Critical components of this response include estimating the number of Canadians at risk for drug poisoning, and then using this data to optimize and expand proven interventions, like opioid agonist treatment and supervised consumption, to ensure we meet needs across the population. It also includes acknowledging the reality that the majority of people at risk for drug poisoning in Canada do not meet criteria for opioid use disorder and will not routinely seek health care for drug use. This means continuing to trial novel models of prescribed and non-prescribed safer supply with the aim of reducing exposure to toxic drugs. Equally important, we must address the underlying factors that increase vulnerability to drug-related harm. This requires concerted efforts to improve management of chronic pain and mental health conditions, improve health and social status of indigenous peoples, and reduce rates of housing insecurity and poverty nationally.

Finally, we need to invest in implementing and evaluating community-wide, universal prevention programs for children, youth and families, which have strong potential to reduce rates of early adolescent drug use, and would pay dividends in many realms of social life.

Thank you again for the invitation to appear today and for your thoughtful study of this issue.

[The Vice-Chair, Bloc, Luc Thériault]

Thank you, Dr. Hyshka.

There is currently a vote in the House. I would like to ask my colleagues if they wish to continue with the meeting or if they wish to take a break while the vote takes place.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Continue with all the testimony.

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

Mr. Chair, I suggest that we hear the opening remarks of the other witnesses and then take a break for the vote.

Does everyone agree?

[The Vice-Chair, Bloc, Luc Thériault]

Everyone is in agreement. We will therefore continue the meeting.

The next witness is Dr. Kahan.

Mr. Kitchen, would you like to make a comment?

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you.

I have a point of clarification.

We have three more witnesses. Is that correct? They're going to speak for 15 minutes and we have 30-minute bells.

Okay.

[The Vice-Chair, Bloc, Luc Thériault]

Yes, that's right.

Mr. Johns, you have the floor.

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

Can we agree, when we break, to vote here from our apps?

Okay. Thank you.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

I'm sorry. I believe I should be in the House.

[The Vice-Chair, Bloc, Luc Thériault]

So we're going to continue the meeting and hear the evidence. Then we'll take a break for the vote.

Dr. Kahan, you have the floor for five minutes.

[Dr. Meldon Kahan, Associate Professor, Department of Family Medicine, University of Toronto, As an Individual]

Thank you for giving me the opportunity to speak on the opioid crisis. My talk will focus on opioid agonist treatment—or OAT—and safer supply.

Opioid agonist medications, including methadone, buprenorphine and slow-release oral morphine, are usually dispensed under supervision at the pharmacy. Take-home doses are given when the patient reduces high-risk opioid use. All four medications are long-acting, potent opioids. At the right dose, they relieve withdrawal symptoms and cravings for a full 24 hours.

Research has shown that opioid agonist therapy reduces opioid use, injection-related infections and overdose deaths, even among people who use fentanyl. Unfortunately, only a minority of fentanyl users are engaged in opioid agonist treatment, and retention rates may be declining. There are several strategies to improve access to OAT and to improve treatment retention rates.

Opioid agonist treatment should be available, on site and immediately, to patients in emergency departments and hospitals, withdrawal management services and rapid-access clinics. In order to accomplish this, emergency departments and hospitals should have on-site addiction services.

Opioid agonist treatment should be available to people regardless of where they live. This can be accomplished through virtual care. Alberta's virtual opioid dependency program is highly successful and a model for the rest of the country.

There is a need to pilot and evaluate innovative medication protocols that provide quick and substantial relief of withdrawal symptoms and cravings—for example, methadone combined with slow-release oral morphine.

Community clinics that provide opioid agonist treatment should have on-site access to wraparound services—that is, primary care, mental health services and case management.

Now I'd like to discuss, briefly, safer supply programs. In these programs, hydromorphone tablets are dispensed to high-risk opioid users, sometimes in combination with opioid agonist treatment. Several studies have found that these programs are associated with a reduced risk of overdose. However, safer supply has not been directly compared to opioid agonist treatment with respect to overdose rates or rates of injection-related infections. The programs typically dispense hydromorphone tablets as a take-home medication. Patients are sometimes prescribed 30 to 40 tablets per day to take home. Safer supply patients might sell these tablets, which is called “diversion”, or they might inject them.

Diversion of take-home hydromorphone tablets appears to be common, based on clinician reports, reports from patients and families, media reports and qualitative studies. Diversion has been a major factor in other drug epidemics, including the OxyContin epidemic of the nineties and early 2000s. Reports indicate that hydromorphone tablets are being sold not just to people who use fentanyl but also to youth and to people on opioid agonist therapy. Hydromorphone tablets are very inexpensive, and even high school children can afford them. Criminal gangs are clearly involved, and these tablets are now being sold in remote communities.

Researchers in Canada have not looked at the harms of diversion and take-home hydromorphone tablets, but early research has found that youth who used diverted prescription opioid tablets were at higher risk for subsequently injecting the tablets and for switching to heroin. I personally have had patients who switched from diverted hydromorphone tablets to fentanyl. Fentanyl is also inexpensive and produces a more sustained euphoria and withdrawal relief than the tablets.

Unsupervised injection of hydromorphone tablets is also a serious problem. Evidence indicates that injection of prescription opioids increases the risk of life-threatening bacterial infections such as endocarditis.

There are several practical and evidence-based strategies that safer supply programs can undertake to improve the safety of their programs for patients and the public.

One strategy is to dispense hydromorphone tablets under supervision. Research has shown that supervised dispensing of opioid agonist medications markedly reduces the harms of diversion and unsupervised injection, while having minimum impact on treatment retention rates.

Another strategy is to combine hydromorphone with optimal doses of opioid agonist medications. Opioid agonist medications are long acting, and, thus, more effective at relieving withdrawal symptoms than hydromorphone tablets. OAT will also reduce the need to prescribe large numbers of hydromorphone tablets.

[The Vice-Chair, Bloc, Luc Thériault]

If you could wrap up, Dr. Kahan, your time is up.

[Dr. Meldon Kahan]

I'm basically done. Thank you very much.

[The Vice-Chair, Bloc, Luc Thériault]

Dr. Nosyk, you now have the floor.

[Dr. Bohdan Nosyk, Professor and St. Paul's Hospital CANFAR Chair in HIV/AIDS Research, Faculty of Health Sciences, Simon Fraser University, As an Individual]

Good morning. Thank you for the invitation to attend this meeting.

My name is Bohdan Nosyk. I'm a professor and St. Paul's Hospital CANFAR chair in HIV/AIDS research at the faculty of health sciences at Simon Fraser University. I'm also senior author of a study evaluating B.C.'s risk mitigation guidance, what I'll call "RMG". It was later termed “prescribed safer supply”, and was published in the British Medical Journal in January 2024.

I'll focus my opening statement on this study, as I know it is of interest to this committee.

The study was conducted at a true provincial scale—

[The Vice-Chair, Bloc, Luc Thériault]

Excuse me, Dr. Nosyk. There is no interpretation at the moment.

[Dr. Bohdan Nosyk]

I'm sorry. Can you repeat that?

[The Vice-Chair, Bloc, Luc Thériault]

There was no interpretation, but it's working now.

You may continue with your speech. We apologize for any inconvenience.

[Dr. Bohdan Nosyk]

Okay. Are we ready?

Good morning. Thank you for the invitation to attend this meeting.

This study was conducted at a true provincial scale using B.C.'s linked health administrative datasets. My research team has specialized in the use of these data over the past 17 years and has been supporting the province's response to the overdose crisis since its declaration.

In its first 18 months, just under 6,000 of the estimated 250,000 opioid and psychostimulant users in British Columbia accessed the program. These 6,000 included just over 5,000 people with an opioid use disorder, of whom we estimate there are over 100,000 in British Columbia.

Those accessing the program tended to have long histories of substance use disorders, were socially marginalized and were at high risk of overdose death. As the program was designed to reduce the risk of overdose and death among recipients, we focused on these outcomes to determine whether the initiative had its desired effect. We otherwise focused on the immediate effects of RMG dispensations given the fact that—like birth control pills or insulin for diabetes or even opioid agonist treatment—their effects should only be expected to persist while in use.

As the guidance was issued provincially and on an emergency basis at the onset of the COVID-19 pandemic, a randomized control trial was not possible. As such, a population-based study using extensive linked health administrative data represents a best possible study design. Moreover, we executed the study at the highest possible methodological standard. As noted, it was recently published in one of the highest-impact medical journals.

The intended mechanism of the RMG program was to separate individuals from the toxic illicit drug supply. Our findings suggest this mechanism was realized. People had lower risk of death while they were receiving RMG dispensations, and more frequent receipt was associated with a stronger protective effect. That's a crucial piece of evidence. It's what we call a “dose response” effect, and it's one of the key conditions that we look for in a causal effect in epidemiology.

These effects were independent of any concurrent opioid agonist treatment prescription or other potential confounding factors that were apparent at baseline or which may have changed over the course of time after individuals initiated RMG. These effects otherwise held true, whether we considered drug-related or all-cause mortality, and we found comparable effects for stimulant RMG dispensations, though far fewer people received them and so there was a greater degree of uncertainty in these findings.

The risk mitigation guidance has been a controversial program, drawing criticism within B.C. and across Canada since its implementation long before our study's publication. Scholarly debate—that is, debate based not on ideology or anecdote but on scientific evidence—is a useful and constructive part of the decision-making process. In that spirit, our team systematically and with additional analysis and evidence addressed each of the critiques we received after our study was released via public presentation delivered on February 7, which has been posted online.

I've made this presentation and all other peer-reviewed articles and reports that I'll be referring to available to the committee; I think we need some time for the French translation to come through.

To summarize, our study demonstrated that for the relatively few people who were able to access it, the RMG program or prescribed safer supply saved lives.

Moving forward, we hope these facts and the lives of some of the most vulnerable Canadians are sufficiently considered and will inform debate and decisions about this intervention, one of a continuum of different services that we require to address the opioid crisis.

Thank you.

[The Vice-Chair, Bloc, Luc Thériault]

Thank you, Dr. Nosyk.

Dr. Goyer, you now have the floor for five minutes.

[Dr. Marie-Ève Goyer, Physician, Clinical and organizational support team in addiction and homelessness, CIUSSS Centre-Sud-de-l'Île-de-Montréal]

Good morning.

I'll be doing my introduction in English, but my talk in French. I'm happy to take questions in English or French—whatever works best.

First, thank you for having me here. I also thank you in the name of my patients, who are dying very regularly.

I'm happy to see that we are all together in the same boat now, trying to find solutions together. It's very important for me and my patients.

I'm an “all addictions” doctor now. I have been doing this for 20 years as an in-patient and outpatient doctor. I have a master's degree in public health and a certificate of added competence in addiction medicine.

I am the chief of addiction and homelessness medical services in downtown Montreal. I have been working for many years now in the low-threshold opioid use disorder clinic. I'm an OAT prescriber. I'm a safer supply prescriber.

I am also the director of the ESCODI team, which would resemble what you know about BCCSU, or META:PHI in Ontario. What we do in my team is offer clinical tools and build guidelines for the whole province of Quebec.

I'm also a co-chair for CRISM. I had a chance to work abroad with Doctors of the World to help implement OAT in low-threshold countries.

What I want to say to you today, in two parts, is very similar to what has been said so far. First of all, as a physician, I like to have a clear diagnosis before discussing treatment. The current diagnosis, in 2024, is not a diagnosis of drug diversion or a diagnosis relating to pharmaceutical products, but a diagnosis of drug contamination on the illicit market.

I'd like you to imagine an iceberg. On top of the iceberg, there are deaths from opioid overdoses. My colleagues have set out very clearly what needs to be done. We know a number of things that work. We need to promote them even more, and above all we must not back down. We need to move towards things that work, not only access to treatment and molecules such as methadone, but also a safer supply. We can talk about this again if you like. At the moment, we're not doing any real safer supply. What we do is prescribe drugs, under the supervision of professional bodies, in a clear, highly defined clinical context for specific patients, following a rigorous assessment.

What works? Supervised injection services, access to consumption equipment and naloxone, and drug analysis services. We must have these services now and everywhere. In 2024, it's not right that most emergency departments in Canada don't have access to treatment or takeaway naloxone. It's not right that, in most provincial prisons, inmates don't have access to treatment and that you can leave a Canadian medical school without being able to prescribe methadone. So there's a real urgency to put in place the things that work. That's the tip of the iceberg.

What lies beneath? My colleague, Dr. Hyshka, addressed this very well. We need to ask ourselves who is currently dying. We need to think about social inequalities in health and the social determinants of health. Our health care system is neither truly accessible nor truly universal. Our health care system is inverted, whereas it's the people who are the sickest and have the most comorbid health problems, such as people with mental health problems, the homeless and first nations people, who should be the first to receive integrated and comprehensive services.

We need to ask ourselves why this is still not the case, despite the crisis. So we're going to have to talk about stigmatization and control, in other words, public health policies that control substances. We need to be creative and innovative in revising our public health policies. We need to talk about decriminalization. We need to realize that our current policies perpetuate social inequalities in health and perpetuate the vicious circle of poverty and marginalization. As such, we need a robust response that focuses first and foremost on those who are most likely to die and who are most vulnerable.

[The Vice-Chair, Bloc, Luc Thériault]

Thank you very much, Dr. Goyer.

I'm going to suspend the meeting for 20 to 25 minutes while we vote.

[The Vice-Chair, Bloc, Luc Thériault]

If you don't mind, since we have a quorum, we'll resume the meeting. Mr. Kitchen should be here shortly. The meeting has been interrupted for more than 25 minutes.

Before we resume, I would like to ask the members of the committee if they are prepared to continue until 1:30 p.m. at the latest. I'll also ask the witnesses.

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

Yes.