Health Committee on Dec. 11th, 2023

[Dr. Keith Humphreys]

That's a fair question.

I have talked to some people who do this. We do not have this in my country. You would be right to say that I'm looking at this from far away.

We do though, of course, have the experience of opioid prescribing. When it was OxyContin, many of those people getting it were addicted and did addict other people. If we wanted to know if that phenomenon had somehow stopped for some reason with safe supply—I don't know why we would assume that, but if we did—what we would do is run something that has not been done. There's nothing of this sort in the literature. You would run urine screens on every single person on safe supply every day, and any day when they did not have the drug supplied in their urine, you would ask them, “Where did that drug go?” Then you would find that person and see if they overdosed, fatally or non-fatally, or whether they had initiated an addiction with that medication.

That has not been done. That's what I would do if I were really monitoring this closely and I was concerned about harms to the community. We were very casual about that possibility for a very long time with OxyContin, and we regretted it. Because that has not been done, I am frankly worried that we're doing the same thing again.

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

Dr. Humphreys, there have actually been over 20 published studies. What published peer-reviewed literature have you read to understand safer supply?

[Dr. Keith Humphreys]

What I just said is based on those studies. There are studies of people enrolled in the programs. There are not studies that track community effects of diversion, which is what you would do. When they did not take the medication, you would find out who took it, what happened to them, whether they overdosed fatally or non-fatally, and whether they initiated an addiction.

That is not in the literature. I've read all of the studies. There is no study like that.

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

I'm going to come back to you in a minute.

Dr. Werb, I'm going to go to you.

What have you observed in terms of safe supply and how it's been described in the media or by critics, versus how safe supply actually operates? Can you tell us where the media and critics are misrepresenting the evidence on safe supply?

[Dr. Dan Werb]

Sure.

I don't know if anyone is wilfully trying to misinterpret or misrepresent anything. I will note that I'm the principal investigator of a national evaluation of safer supply pilot programs in Canada, which is funded by Health Canada and run by the Canadian Institutes of Health Research. I can speak a little bit about that.

One of the issues that I find troubling is that there is a conflation of quite a number of different approaches into this idea or term of “safer supply”. Sometimes when people are talking about safer supply, they're talking about regulating the currently unregulated drug market, which I would be happy to talk about. Sometimes they're talking about prescribed clinical guidelines, which are in place in British Columbia. Sometimes they're talking about pilot programs, like the ones that our national evaluation is studying, which are integrated into existing harm reduction and social care programs. All of these programs are very different.

In these programs generally, safer supply is a component of a broader comprehensive approach to meeting the needs of clients, members or patients. All of these programs refer to these people differently. I would echo Dr. Humphreys that the evidence is still emerging. These are programs that have been in place for only two to three years.

I really want to make the point here that the prescribed safer supply guidelines in B.C. are quite different. These are just the opportunity for clinicians to provide a particular type of medications for a particular condition among their patients, which is different from these wraparound, integrated pilot programs.

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

We know OxyContin is not safe supply. OxyContin caused a fraction of overdose deaths compared to fentanyl. We saw overdose deaths in the U.S. grow 275% between 2016-2021, more than in Canada, where they doubled.

We can look at Alberta's record. In April, it had a record number of overdoses. Lethbridge already surpassed it by August this year, and last year was a record year. Lethbridge has closed its safe consumption sites.

Can you talk about the effectiveness of harm reduction interventions like drug checking, supervised safe consumption sites, and how many lives are saved?

[Dr. Dan Werb]

Sure. In the case of Alberta, only about 5% of fatal overdoses have prescribed opioids implicated in them.

I will echo what I said earlier around supervised consumption sites. We have worked with the chief coroner's office of Ontario to map overdose mortality across the city of Toronto year over year. What we found was pretty remarkable. Up to five kilometres away, we saw about a two-thirds reduction in the rate of overdose mortality across neighbourhoods. We're trying to figure out why that is, because that's a really powerful effect.

We think that beyond people's access to these programs on site, they are also hubs of harm reduction services. These are places where people feel safe, where they can pick up naloxone and where they are provided with safer education about how to avoid overdoses. That's really critical.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Werb.

We're out of time for this round of questions, but I'm sure there will be further opportunities to reinforce the point.

Next we have Mr. Majumdar for five minutes, please.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

Thank you very much, and thank you to both witnesses for appearing before this committee.

I will direct my first questions to Dr. Humphreys if that's okay.

In our committee, there has been a lot of discussion about the Portugal model, often held up as a beacon of hope for Canada and for others. Based on the survey of literature that you have been able to take into account, is the Portugal model comparable to Canada's? Is this comparing apples to apples?

[Dr. Keith Humphreys]

I have read that literature and I have also spent a lot of time in Portugal. Actually, I was just talking to the director of that program a week ago.

Portugal is going through a hard time right now. Overdoses are at about a 12-year high. At least early on, the program did seem to have some benefits from the great expansion of services around addiction. The HIV rate among people who used drugs dropped, and that was certainly very positive.

Portugal also has dissuasion committees, which are able to put some pressure on people who have problematic drug problems to change their behaviour. That is something that was often forgotten when people talked about the Portugal model. They think it's libertarian, and everyone does whatever they want. That is really not the case.

A big difference that goes beyond policy is that the cultures are very different. Portugal is different from both the U.S. and Canada in that it is a country that has a very strong Catholic history, a very communitarian society and a lot of social control on behaviour. When it backed off from the legal control, there was still tremendous social control from families and communities. There was disapproval of drug use, which is particularly less common in the western U.S. and western Canada.

Places that have tried to copy that approach—for example, the city near where I live, which is San Francisco—as well as the cities of Portland, Seattle, and Vancouver haven't had the same results as Portugal. With the same policies and different cultures, you get different results.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

Thank you for that.

I would like to pick up on one of the items you mentioned, which was the increased overdoses in Portugal. Could you describe what the origin story for that might be?

[Dr. Keith Humphreys]

There are a couple of theories about it. One is the financial crisis part of the services. Portugal did cut services pretty dramatically. That cannot help.

It is also true that the EU is open, so people can move now from all over the EU to different places. Over time, places that have liberal drug regimes may attract people who like to use drugs or like to be able to do so without any hindrance. We see that, certainly, in San Francisco. I can say that for sure. That may also have made the drug problem more complicated as people moved in to use drugs.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

I have a quick question. They're not dealing with a fentanyl crisis like we are in Canada, are they?

[Dr. Keith Humphreys]

They aren't yet, but fentanyls and nitazenes are arriving in Europe. There was a big bust the other day in Britain. There have been a few cases around Europe. All my European colleagues are quite frightened about the arrival of synthetic opioids of some form in the coming 18 months, because the Afghan heroin supply is being restricted by the Taliban right now.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

If I could bring that in to Canada, in your professional opinion, do you believe that the current government's approach on safe supply policies is working?

[Dr. Keith Humphreys]

No. I wouldn't expect it to work, because it's essentially a replication of the policies that we had in the 2000s of distributing opioids in the community and trusting that because they are legal and because they're of known quantity, nothing bad will happen. It will take a while to see that.

I realize that the discussion is on overdose, but you also have to think about addiction. If you're generating new cases of addiction, that will not show up in overdoses for five or 10 years, but it could definitely be happening. That is exactly what happened during the era of OxyContin.

I would point out, by the way, that the main drug being used, hydromorphone, is a very strong opioid. It is not a low-strength drug by any means. It can certainly be addictive, particularly to novice users. That's why it would be very important to evaluate whether any of those drugs are being diverted to, for example, people who are younger as their first drug experience and their first experience getting access. Whether or not that's happening is something that I think should be studied.

[Shuv Majumdar, Conservative, Calgary Heritage, AB]

In this context, has there been any evidence from jurisdictions to support the claim that safe supply contributes to a positive result—less crime and disorder, more people transitioning to the workforce, fewer drugs flooding illicit markets? Have you seen any evidence of that yet?

[The Chair, Liberal, Sean Casey]

Give a brief response, please, Dr. Humphreys.

[Dr. Keith Humphreys]

In the literature, there are certainly people on safe supply who report appreciating the program and valuing the program. They still do use a lot of illicit drugs. I don't think that there's anything linking it to broader community effects such as employment or the drug supply or addiction and overdose occurring among people not enrolled in safe supply.

[The Chair, Liberal, Sean Casey]

Thank you.

Next is Dr. Powlowski, please, for five minutes.

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

My initial question is for Dr. Humphreys.

I share a bit of skepticism about the safe supply position for the same reasons that you've already talked about. However, do you not think that it's possible that there is a certain subset of the population that would benefit from safe supply? Some people are dependent on narcotics and perhaps dependent on a fixed level of narcotics. Then there is the fact that they can't get the narcotics, so they buy them on the street, where often they're contaminated with fentanyl or carfentanil.

Do you think it's possible—although, perhaps in general, safe supply is not a good idea for everybody—that there may be a subset of the population for which, in fact, it is a good idea?

[Dr. Keith Humphreys]

Thank you for that question, Doctor. It gives me a chance to clarify something that I think has been misunderstood, perhaps.

The commission is very positive about opioid agonist therapy, like methadone, like buprenorphine. In Canada, you also have slow-release oral morphine and hydromorphone, which we don't have. You have diacetylmorphine too. We're very positive about the effects of all those, and for multiple reasons.

Yes, people are avoiding the illicit supply, but it's also because of the stability they provide and the links that they provide to other health services. All those things are true.

When you start distributing, though, without any real monitoring in a community, you have to think not just about that person, even if they benefit a bit, but also about everybody else. If those drugs are going out and harming other people, the net effect could be negative, even though there is a particular person who benefits from them.

That's why doing very careful audits of where these drugs are actually going—in other words, looking at the people around the people in these programs—is really important before we make a judgment, which you can't really make just based on what that person says and experiences.

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

I'd like to turn to a second issue: safe injection sites. I'd like to ask both of you about this. I think you both agree that they reduce mortality.

Dr. Werb, you talked about the potential closing of two safe injection sites in northern Ontario. I'm the member of Parliament for Thunder Bay—Rainy River. I would say—and I want you to address this issue—that there is a very heavy component of NIMBY—“not in my backyard”—with regard to safe injection sites. I have to say that I have a certain amount of sympathy for it. Would I be happy if a safe injection site were to open right next door to where I live? Probably not, especially when you combine it with decriminalization. What you tend to see around those sites is an accumulation of people selling drugs. Very rapidly, those become not very desirable parts of town.

Although in general there seems to be good evidence that these are a good idea, how do we address the problem of the crime and the social problems that tend to accumulate around those centres?

Perhaps I will start with Dr. Werb.

[Dr. Dan Werb]

Thanks. It's such a good question.

I'll just note that these sites are implemented in places where there is drug-related activity, right? That's generally where they are placed, so that they can benefit as many people as possible. I think it's important to remember that.

We've been looking at this question. In Toronto, there was some violence—unfortunately, a fatal shooting—less than a hundred metres from a certain supervised consumption site. We worked with the coroner's office to analyze spatial data on homicides, fatal shootings, that could be potentially related to drug market activity across 10 years in Toronto. What we found is that there's no association between the location of homicides and the location of these sites.

On that at least, I think there's evidence from Toronto suggesting that these sites aren't necessarily attracting increased fatal violence. We're still going to look at other measures of violence to see whether they agree with our initial analysis.

I also understand people's desire to ensure that the programs in their communities are run and managed as well as they possibly can be. I fully understand people being concerned about their public safety.

What I found galvanizing is that the conversation that has happened, at least in Toronto around this issue, hasn't gone to the extreme of saying that we need to close these sites. A lot of the conversation is about how we design them and how we can better manage these sites.

Unfortunately, what happens is that these sites are designed for the estimated number of clients they're going to have, and then budgets are often cut and resources aren't provided for them to provide the services to the number of clients they actually have, so you're starting at a deficit. You have waiting lists. People show up and then they leave without actually being able to access the services.

I think a key component here needs to be resourcing these services sufficiently so that they can meet the needs of their client base.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Werb.

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