Bill C-224 (Historical)

Good Samaritan Drug Overdose Act

An Act to amend the Controlled Drugs and Substances Act (assistance — drug overdose)

This enactment amends the Controlled Drugs and Substances Act in order to exempt from charges for possession or charges related to the violation of certain conditions or orders a person who seeks emergency medical or law enforcement assistance for themselves or another person following overdosing on a controlled substance.

Health

[Bill Casey, Liberal, Cumberland—Colchester, NS]

Mr. Speaker, I have the honour to present, in both official languages, the third report of the Standing Committee on Health in relation to Bill C-224, an act to amend the Controlled Drugs and Substances Act (assistance — drug overdose).

The committee has studied the bill and has decided to report it back to the House without amendment.

[John Oliver, Liberal, Oakville, ON]

On a point of order, sir, I thought I had moved the motion that we end debate on this and begin our clause-by-clause study on Bill C-224.

[John Oliver, Liberal, Oakville, ON]

We have a very important bill in front of us, Bill C-224. We have to go to the clause-by-clause study. We have about 20 minutes left, so I am going to move that we waive further discussion on this motion.

[Len Webber, Conservative, Calgary Confederation, AB]

Thank you, all, for being here today.

Dr. MacKenzie, you mentioned that Canada is the number one country using opioids in the world. You also mentioned that there's been a 75% increase in deaths due to opioid overdose usage, one death every 14 hours. That's shocking.

Ms. Brown, you mentioned that this is the first step, Bill C-224, but that this is one of a multitude of strategies that can be implemented.

Dr. Buxton, you mentioned that there are 750 deaths in a year due to fentanyl and that we need to act now.

Mr. Poirier, you mentioned that this should be a federal initiative for a provincial mandate, that we need a national strategy, and that this is an epidemic.

I would ask Dr. MacKenzie first, is this a public health crisis?

[Sonia Sidhu, Liberal, Brampton South, ON]

The definition of overdose in the bill notes that a reasonable person would believe that the situation requires emergency medical or law enforcement assistance. Given that individuals in the circumstances encompassed by Bill C-224 may be impaired by drugs or alcohol, could the use of the reasonable person standard in the definition of overdose be problematic? Please explain why or why not.

My question is for Dr. Buxton.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thanks.

When we had Donald MacPherson from the Pivot Legal Society come before this committee in June, he talked about how such laws and policies should try to restrict police attendance to overdose calls. He said that police should maybe only show up if there are public safety issues.

Do you agree that restricting police attendance at routine overdose events would do what Bill C-224 is intending to do?

[Sonia Sidhu, Liberal, Brampton South, ON]

In the U.S., some states have laws similar to Bill C-224. Do you know of other places and jurisdictions with similar laws? Can you point to some of these laws? Are they very different from Bill C-224?

[Pierre Poirier, Executive Director, Paramedic Association of Canada]

Good morning. Thank you for the opportunity to speak today. My name is Pierre Poirier. I'm the executive director of the Paramedic Association of Canada.

There are approximately 40,000 paramedics in this country, and we respond to almost three million calls annually. I want to note that there are different classifications or designations within the term “paramedic” that cover different scopes of practice, and that's an important detail that I'll refer to later.

The Paramedic Association of Canada absolutely supports Bill C-224, although we have concerns about its application or whether it sufficiently meets the intent to save lives in a timely manner.

I've taken some excerpts from other presenters and have parsed some of their words.

Opioid overdose deaths are preventable with timely intervention. Good Samaritan legislation is one component of a comprehensive public health approach to overdose within a harm reduction paradigm. We need to improve the community response of Canada as part of a comprehensive response to overdose deaths. The community response must involve a comprehensive approach.

Let's make naloxone available, absolutely. Let's provide naloxone to the overdose victim in a timely manner, because seconds count. Let's coordinate the health care system on this important issue—and that's an important piece that I want to make reference to—with consideration of the alignment of a federal initiative with the provincial mandate in the health care system and with the way we approach health care.

This is an important piece that I want to spend a couple of seconds on. I have to admit that change has been rapid, but I still don't think our addressing of this issue has been fast enough. Paramedics regularly respond to incidents in which an individual has overdosed. We provide medical care. This is a life-and-death event.

Let me explain how a patient is treated. There is the 911 call, and paramedics are requested. Police are often asked to attend for safety and security reasons. Recognizing the triage system and that for a medical emergency it is the paramedic who is called and not necessarily that police go to attend to every call is, I think, an important point.

The paramedic will assess the patient and determine an overdose. This is the important piece: often the paramedic is required to call a physician for permission to administer naloxone, and oftentimes some paramedics may not have permission to provide this drug in this country. That's an important distinction. We have this law that approaches it in good Samaritan terms and as a public health issue, but we should also recognize that the individual providing care may not be allowed to provide the care that is really intended or that is life-saving. This is important as an issue.

Here is the problem. I noted earlier that seconds matter in this life-and-death situation. In the event I described, paramedics may not have permission to administer naloxone. That could happen in Saskatchewan, Ontario, Nova Scotia, and Newfoundland.

Also, if they do have permission.... They may be required to call for permission to administer. A paramedic who administered without permission would now be subject to discipline by the health care system or by a regulatory agency to which they report. This is a significant issue.

On the one hand, then, we would have legislation that supports an individual's providing it, but by the same token a paramedic on scene may not have that permission. How do we resolve this? There are a few things.

I have to admit that I'm not familiar with all the nuances of the prescription drug list and its relationship to the Controlled Drugs and Substances Act, but if we were to remove naloxone from schedule I of the Controlled Drugs and Substances Act, that might actually help the situation.

One question is whether there is really a need that naloxone continue to exist within schedule I. I think there are important lessons to learn. Paramedics often work under medically delegated acts or things with that description. When we went through the last 40 years of experience with AEDs, automated external defibrillators, we came to a point at which we made them publicly accessible, but we removed the designation of their use being a medically delegated act, which really benefited the community and all health care providers in that situation.

I'm not sure that we can consider Bill C-224 is applicable to all Canadians, and that would be a motivation behind this, because if you look at good Samaritan legislation, if there's remuneration, there is no longer the cover of the good Samaritan legislation. Paramedics in the performance of their duties are deemed to be providing a service and therefore being paid to provide that service, and therefore are not provided the cover of the good Samaritan legislation. That's an issue, and I think it can be resolved.

Last, we should consider other applications of the drug, and look at the provision of naloxone in a similar manner to the development of EpiPens. You don't need to provide it as an injection; it can be provided as a nasal spray or by other methodologies. That wouldn't require it to be a medically delegated act, and it would be a simpler, more accessible, easier way of providing a service to our community.

Thank you for the opportunity to speak today.

[Dr. Jane Buxton, Professor, University of British Columbia; Epidemiologist and Harm Reduction Lead BC Centre for Disease Control, As an Individual]

Thank you for the opportunity to present today. I'm a public health physician and a professor at the School of Population and Public Health. I'm also the harm reduction lead at the BC Centre for Disease Control.

I wish to provide some evidence about the overdose crisis in B.C., the emergence of fentanyl, and the importance of calling 911.

The BC Drug Overdose and Alert Partnership was developed following an increase in illicit drug overdose deaths in 2011. Members include stakeholders from health enforcement, emergency services, coroners, researchers, and people with lived experience. The goal is to coordinate communication and action to enable timely alerting and responses to illicit drug issues.

The B.C. take-home naloxone program was introduced in 2012 and provides overdose training and naloxone to people in the community. It enables naloxone administration by bystanders while waiting for any emergency health services to arrive. We've had over 2,000 overdose reversals reported.

An opioid overdose crisis is occurring in Canada. A public health emergency was declared in B.C. in April 2016 due to rising opioid overdoses. In 2015, there were 505 illicit drug overdose deaths, which is the highest number ever recorded, and in the first seven months of 2016, there have been 433 deaths. We're on route for 750 deaths in the current year.

The proportion of deaths where fentanyl has been detected increased from 5% in 2012 to 30% in 2015 and to a staggering 62% in 2016 year to date. Fentanyl is also increasingly identified in Alberta and across Canada. Fentanyl is a synthetic opioid often described as 80 times more potent than morphine. In an unregulated market, there is no control of the amount and dose of fentanyl in illegal drugs. The Health Canada laboratory has found pure fentanyl in powder sold as heroin and in varying, and sometimes fatal, concentrations of fentanyl in fake OxyContin tablets.

Although some people may intentionally take or seek out fentanyl, many don't know they have taken it. In a study performed in B.C. last year, we found almost three quarters of those who had fentanyl detected in their urine were unaware that they had taken fentanyl.

In an opioid overdose, the breathing slows and a person becomes unconscious. Lack of oxygen to the brain even for a short period of time can cause brain damage and death. The onset of a fentanyl overdose is much faster than other opioids. As we've heard, the effect of naloxone wears off after 20 minutes, and the high concentration of fentanyl in drugs requires large and often repeat doses of naloxone. It's vitally important to restore breathing as soon as possible and seek professional help for immediate and ongoing assistance.

People who administer naloxone in B.C. complete an administration form. The program emphasizes the importance of calling 911, and although the proportion that call 911 has increased over time, in 2015, 30% of people responding to an overdose did not call 911. It varies by region. Approximately 82% of people in Vancouver call 911, but less than 60% in regions outside of Vancouver do. The differences by region may reflect previous interactions with the police and policing policy, and the influence of other bystanders.

Enforcement members of the Drug Overdose and Alert Partnership have shared that most police would not make an arrest for simple possession of drugs in B.C., but this may vary by province. A good Samaritan act would ensure consistency across the country.

We also found people were more than 10 times more likely to call 911 if the overdose took place on the street rather than in a private residence. That may be because they're concerned about the residence being identified and the ability to flee if police arrive.

To explore reasons why people didn't call 911, we interviewed 20 naloxone program participants. They shared the barriers to contacting emergency services during an overdose, which included concerns about being arrested for illegal activities such as drug possession, breach of probation or parole, and outstanding warrants. Police were noted to be collecting the names of those present at an overdose scene and checking the police database.

We also heard stories about people who had overdosed being dragged down stairs into the street before 911 was called, and people calling 911 and then leaving the scene rather than staying with the person until first responders arrived.

According to a review by the U.S. National Conference of State Legislatures, good Samaritan or 911 drug immunity laws are enacted in 37 states and provide immunity from supervision violations and low-level drug possession and use offences. However, a recent study of young adults in Rhode Island found fewer than half were actually aware of the good Samaritan law.

It's important if Bill C-224 were to be enacted that this would be communicated broadly to the populations at risk of witnessing or having an overdose. Dissemination will require different approaches for youth experimenting with drugs and afraid of arrest and parents being informed compared to those with substance use disorders.

In summary, fentanyl prevalence in illegal drugs is increasing. Fentanyl has a rapid and long duration of action and overdoses may need large and repeat doses of naloxone. Therefore, it is imperative to call 911 and receive rapid and professional help. There is evidence that fear of arrest deters people from calling 911, and that good Samaritan laws can increase the likelihood of calling for medical assistance if people are aware. Expanding immunity in Bill C-224 beyond simple possession to include supervision violations could increase the rate of calling 911 and thus prevent further brain damage and save lives.

Thank you for your attention.

[Sarah Brown, Harm Reduction Worker, Centretown Community Health Centre]

Good morning and thank you for this opportunity.

I understand that you've received a great deal of evidence on the realities of overdose and the opioid crisis in Canada. I'm here today to offer a front-line perspective and talk about how Bill C-224 would improve community health.

I want to preface my statement by imploring this committee to hear from the community of folks who are most directly affected by overdose and criminalization, and that is the community of people who use drugs. I am here with one member of that community, my colleague, Christine Lalonde. I'm a front-line harm reduction worker at Centretown Community Health Centre, just 10 blocks from Parliament Hill. Every day I provide safer injecting and safer smoking supplies to people who use drugs in this city. In addition to distributing supplies and offering health education and referrals, I also listen, support, and build trust with people who use drugs. At times I am the first and only point of health care contact for folks who use drugs.

Nearly every person I talk to about overdose has had a personal experience with it. Either they have overdosed themselves or they have been present at an overdose. I have worked with people who have overdosed and died in Ottawa's parks, overdosed and been resuscitated in shopping centre washrooms, and folks who have had peers overdose and die in their homes. Community members continue to be apprehensive about calling 911 in overdose situations. Calls occur less than 50% of the time, according to Ottawa Public Health, due to concerns about police presence, fear of arrest, or being implicated in the overdose. Individuals who do call 911 often report being heavily questioned by the police, assumed to be suspicious rather than praised as quick-thinking witnesses.

If you are someone who has regular contact with police and the criminal justice system, you may be reluctant to involve the police in an overdose situation. Past charges and criminal records have a way of influencing police behaviour. One man I work with who has a long history with the police in Ottawa has instructed his partner to never call 911 if he overdoses. He knows he will face charges if that happens. The last time he overdosed, his partner ran to the nearest fire station and asked them to help but not to involve police. Criminalization impacts this community's health. People who use drugs are incredibly stigmatized in our culture. They are frequently judged for their behaviour and perceived as undeserving of care. This stigmatization plays out in health care settings and impacts people's decisions to seek care, be it with their own doctor, or by calling 911 for an overdose. While our law and law enforcement need to adjust their attitudes towards people who use drugs, so too do we as Canadians. Bill C-224 challenges criminalization and stigma by prioritizing public health and safety at overdose scenes.

There are a great many drug policies that you as decision-makers can implement to address the opioid crisis in Canada, which include decriminalizing the use of all drugs, supporting the expansion of supervised consumption services and take-home naloxone programs, increasing access to drug and alcohol treatment, opioid substitution therapy, and medical marijuana. The good Samaritan drug overdose act is just one of a multitude of strategies this country desperately needs to respond to the current public health crisis.

Like some of your previous witnesses and members of this committee, I feel the immunity outlined in this bill needs to be broader than possession. Nevertheless, I support this bill as a first step and I applaud MP McKinnon for proposing it and using his position to support the lives of people who use drugs. Bill C-224 is a harm reduction strategy that this committee has the influence to pass into law. A common definition of harm reduction is “any step towards greater safety is a step in the right direction”. Bill C-224 is a step towards greater safety.

Thank you.

[Dr. Meredith MacKenzie, Physician, Street Health Centre, Kingston Community Health Centres]

Good morning. Thank you for asking me to come to speak to this bill.

More than two years ago, this committee issued its report “Government's Role in Addressing Prescription Drug Abuse”, which recommended that the government consider overdose immunity law that would exempt individuals seeking help for themselves or others during overdose situations from criminal prosecution. Since this committee's recommendations more than two years ago, the situation in Canada has profoundly worsened. We're now the number one consumer of prescription opioids in the world. Non-medical use of prescription drugs is a public health crisis and there's an opioid overdose epidemic occurring across our nation.

In April 2016, British Columbia's provincial health officer declared a public emergency as more than 200 people had overdosed in the first three months of this year. In June the Coroners Service of B.C. reported that overdose deaths increased by 75% in 2016.

The situation here in Ontario is also grim, with opioid-related mortality increasing 463% between the years 2000 and 2013. This represents one death every 14 hours. Preliminary figures from Ontario's Office of the Chief Coroner show that fentanyl overdose accounted for one in every four opioid fatalities in 2014. So we see we've had 13 years of increasing and record-setting overdoses, more than double the number of drivers killed in motor vehicle collisions.

This government has acted to make naloxone available by amending the prescription drug list. Take-home naloxone programs have been available in most provinces for a few years. As you know, naloxone is a medication that is first aid for opioid overdose and can reverse fatal respiratory depression. Communities that do provide take-home naloxone and overdose prevention training have lower opioid-related overdose fatalities.

We know that 85% of overdoses occur in the presence of another person. Naloxone injections for opioid overdoses are most often given by bystanders, just like epinephrine pens are used for life-threatening allergies.

A critical step to surviving an opioid overdose is seeking medical attention. We know that more than 90% of people who have a heart attack will call 911 for help, but an Ontario study showed that only 46% of people will call 911 in an overdose situation. The primary barrier cited is fear of police involvement.

Opioid overdose is a medical emergency. Once naloxone is given to a person it lasts between 20 to 90 minutes. That means once naloxone wears off the overdose can recur. Calling 911 is a crucial step to survival and a cornerstone of opioid overdose treatment.

With the arrival of more potent opioids like powdered fentanyl and other fentanyl analogues across all communities in Canada, activating 911 is of particular importance. A shipment of one kilogram of carfentanil, an elephant tranquillizer, was seized in Vancouver by the Canada Border Services Agency in June of this year. This drug is 100 times more potent than fentanyl. Put another way, that's 10,000 times more potent than morphine, and this shipment contained enough drug to kill 50 million people. If people do not call 911, the risk of death is increased substantially.

We are also increasingly seeing drug contaminations in our communities. People who report non-opioid drug use are overdosing and dying because the drug they used unknowingly contained fentanyl. In Vancouver earlier this month there were nine overdoses in 20 minutes, in people who were using cocaine that was contaminated with fentanyl.

The best way to encourage people who have overdosed or witnessed an overdose to seek help from 911 is to provide protection from charges of possession. Early evidence in the U.S.A. indicates that 88% of people who overdose on opioids are more likely to call 911 after establishment of good Samaritan law and being made aware of its existence.

Many organizations have supported the adoption of Bill C-224. Some of these include the Canadian Medical Association, the Ontario Medical Association, the Municipal Drug Strategy Co-ordinator's Network of Ontario, the Canadian Drug Policy Coalition, and many boards of health and police agencies across Canada. A parliamentary petition garnered more than 700 signatures from coast to coast to coast.

This time of year many of our children head off to post-secondary schools. This is a time in life when they may make some dangerous or questionable decisions as their frontal lobes mature. They may be at a party and someone offers them a pill or something else to take. This pill doesn't look too dangerous. It looks like medication. We have seen fentanyl and other drugs being pressed into pills that look like prescription medication. The potential contamination of all drugs with highly potent opioids that are readily available in all of our communities makes overdose in this setting a very real possibility. Will their friends call 911 or will they be too afraid to call?

Constable Brian Montague, the media relations officer for the Vancouver Police Department issued a statement in June of this year confirming their position that they will not send a police officer to an overdose unless one is requested. He went on to describe that calls to 911 are not just coming from what he termed, “hard-core drug users”. He stated, “We're getting calls from 16-year-olds and 17-year-olds who are experimenting with drugs.”

The Vancouver police hope that this new strategy will mean that people who use drugs won't ever be too afraid of getting into trouble when they call 911. This government has already shown its commitment to bring forward a balanced approach to drug policy. Health Canada has supported access to supervised consumption sites like Insite in Vancouver. They have also revised the federal prescription drug list for naloxone. These are just some of the actions the government has taken to reverse the tidal waves of death across Canada.

The disaster of opioid overdose deaths across the nation requires every tool we can muster. Bill C-224 is not all that is needed to address this public health emergency, but it is a critical step forward. We need to protect the most vulnerable in our society. We must ensure that people feel safe to call 911. We must help Canadians in all of our communities to do the life-saving thing and to call for help immediately, without fear that their futures will be ruined by criminal charges. Canadians need this law passed now.

I thank the committee for your work on this legislation.

[John Oliver, Liberal, Oakville, ON]

What I would worry about is that those [Inaudible—Editor]

I was going to be getting into the business of Bill C-224, so I'll wait until you're through with the procedural matters. I did have a motion to make with respect to Bill C-224.

[The Chair, Liberal, Bill Casey]

Let's do Bill C-224 first, if that's all right.

[The Chair, Liberal, Bill Casey]

We have to decide what we're going to do with Bill C-224. We're going to have further witnesses. As to who they are going to be, we're going to talk about people and name the names of potential witnesses.

Dr. Carrie.

[Sonia Sidhu, Liberal, Brampton South, ON]

If Bill C-224 were to become law, it would be important that people be made aware that they would potentially be exempt from possession charges in the circumstances set out in this bill. In your opinion, how should these amendments be communicated to the public? Should they be part of a larger public information campaign related to preventing drug overdoses?