Health Committee on Dec. 9th, 2013

[The Chair, Conservative, Ben Lobb]

Good afternoon, ladies and gentlemen.

We have another busy meeting here. This afternoon we have four different groups and organizations presenting. We'll do what seemed to work well the last number of meetings. We'll have the individuals and groups here via video conferencing go first, and then we'll have the people who are here in person go next.

Just to get a little bit of housekeeping out of the way before we start this afternoon, this is our second-last meeting for 2013. In the spirit of Christmas or anything else you celebrate at this time of the year, we have a bit of wine from the good riding of Huron—Bruce. After the meeting, if anyone would like to have a test run, there's some wine back there. It will be available until the votes. We will have to go and vote, and then anybody who's left here can finish it off, I guess, if they want to.

Without further ado, let's start with Mr. Buckley from McMaster University.

Go ahead, sir.

[Dr. Norman Buckley, Professor and Chair, National Pain Centre, McMaster University]

Thanks very much. Are we all set?

[The Chair, Conservative, Ben Lobb]

Yes. Go ahead, sir.

[Dr. Norman Buckley]

Thanks very much for the opportunity to appear today.

My name is Norm Buckley. I'm a professor and chair of the Department of Anesthesia at the Michael G. DeGroote School of Medicine at McMaster University. I also serve as director of the National Pain Centre at McMaster University, an endowed centre with the mission and vision to support best-practice pain management through the dissemination and creation of guidelines for care.

We currently hold the copyright for, and have agreed to disseminate and update, the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, affectionately called “the Canadian opioid guideline”.

I'm also chair of the Canadian Pain Society's special interest group on education. I co-lead, with Professor David Mock of the University of Toronto's school of dentistry, the Canadian Centre on Substance Abuse implementation group for education as part of the First Do No Harm strategy on the issue of misuse and abuse of prescription medications. During the development of the CCSA strategy, I chaired the expert advisory committee on education.

These affiliations notwithstanding, my appearance here today is not as the representative of any of these organizations. I'm appearing at your request. The leaders of these groups are aware that I will be appearing, but they are not in any way responsible for my opinions or my responses. My dean has some mild anxiety about my appearance here, but he's a very brave individual.

My disclosure statement follows in two parts: fiscal and belief.

From the fiscal standpoint, I'm a physician who derives the largest part of his income from fee-for-service clinical earnings. I receive an administrative stipend as chair of the Department of Anesthesia and earnings for academic activities supported by the Hamilton Academic Health Sciences Organization alternate funding plan. I provide some medical legal opinions and I also engage in consulting through a consulting organization, as well as consulting for two provincial health committees.

I carry out research that is funded by a number of sources, including pharmaceutical companies, although funding from peer review sources, such as the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Ontario, exceeds industry funding substantially. Research funding is on a cost recovery basis, and I do not receive income for carrying out research except through the alternate funding plan. In particular, I do not receive income for research from industry.

I have received speakers' fees from a variety of organizations, including industry, medical, legal, and other professional societies.

Since the problem of finding a solution for prescription drug misuse is complicated by issues to do with belief, clinical perspective, and a variety of other issues, it is probably of greater interest to know my beliefs and my clinical perspective. I come from the position of a clinical practitioner in pain management. My patient population is the patient with acute pain or chronic pain, a problem that continues to be poorly understood and a topic that is very poorly taught and treated in our health care professional training programs. Some of these patients also present with mental health disorders, including mood disorders and addiction.

Given the proportion of Canadian population that suffers now and is likely to suffer in the future with pain, and the impact of that suffering on the health care, social, and economic systems, it is my belief that there must be a dramatic change in the function of the Canadian health care system to provide rapid access to appropriate treatment, including early assessment and treatment, with active intervention and physical rehabilitation and psychological treatment as the situation dictates.

The problem of prescription drug abuse seems to be several different things, perhaps depending upon perspective. Selling of prescription medications or diversion of prescription medications into the recreational or abusive sphere for money strikes me as being theft or fraud, and should be treated as such.

The epidemiology of crime is outside my purview today, so I will not comment upon the magnitude of this element, except to say that law enforcement is the appropriate source of information in this regard. Part of the solution may be found in improving communication between health care providers and law enforcement and improving understanding of each other's goals while recognizing that health care professionals are not the police and law enforcement is not health care. There does need to be collaboration.

Use of prescription medications by the addicted patient to meet the demands of their addiction represents addictive behaviour, which is a medical condition. Again, I'm not an expert in this field, and I will limit my comments on this topic, but medical conditions should be identified as such, and treated appropriately. According to Health Canada, behaviours that represent addiction are present in approximately 10% of the population. Since pain is present in approximately 12% to 20% of the population, depending on the study you look at, one would expect a certain amount of crossover amongst these groups. This creates a complicated clinical situation if an abused medication is otherwise appropriate for a pain condition.

The patient who buys medication on the street or borrows medication from a family member or friend because he or she has an untreated pain problem or an undertreated pain problem seems to represent a failure of appropriate medical care, and it should be treated as such.

Prescribing of medications by physicians is a professional practice issue. When this occurs for inappropriate indications, in inappropriate doses, or in an incautious fashion, which may tacitly permit diversion or abuse, this should be amenable to educational and administrative interventions if the appropriate data-gathering tools are in place and directed interventions are undertaken.

When a physician fails to prescribe when appropriate or fails to offer treatment because he or she does not have the knowledge to treat, this should be addressed by directed educational activity. When patients die because they have combined the prescription medication with other intoxicants, intentionally or by accident, this is a tragedy. When it is the result of inability to gain access to appropriate treatment for mood disorders, addiction, or pain, it is a failure of the health care system, and should be treated as such.

There are several models of successful community interventions to address local cultures of prescription drug abuse and diversion. These have been reported elsewhere, but include Project Lazarus from the United States and a community action in Inverness, Nova Scotia.

Lazarus is a broad-based community intervention, which includes physician practice education, community education about pain and addiction, distribution of narcotic antagonists to make emergency treatment of overdoses in their early state possible, law enforcement involvement to address diversion issues, and availability of pain and addiction treatment programs. This program resulted in a dramatic reduction in unintentional death due to overdose and a reduction in diversion and abuse of prescription medications, while not reducing the prescribing of opioid pain medications for patients requiring these. It is noted in passing that the diversion behaviour seems to have translated itself to neighbouring communities, but this does not in any way negate the demonstration of the effective program.

In Inverness a small medical community undertook to implement a pain-management practice guided by the Canadian opioid guideline and to engage the entire community, including pharmacy, law enforcement, and other health care professionals. The result was a dramatic change in prescribing practice; no loss of capacity to treat patients with pain problems, within the context of the guidelines; and a significant reduction in diversion-related health care interactions and criminal activity.

My own observation, from attending several years of meetings having to do with prescription drug misuse and hearing of interventions that have been undertaken, is that one of the common characteristics of communities facing problems having to do with drug misuse is the disruption of the social fabric of that community, or disruption of the social structures in which the drug-abusing individuals function. Returning communities to a functional state seems to be a necessary element of successfully addressing the problem.

Earlier today I forwarded three editorials by Dr. Mary Lynch, past president of the Canadian Pain Society and co-leader of the Canadian Pain Society's national strategy on pain. My goal is to make the case that improving pain education and establishing an understanding of the appropriate response to patients with pain problems can, to a large extent, address problems of prescription drug misuse by providing care that can limit the inappropriate prescribing of medications that may become diverted and/or abused. If pain is appropriately treated, then the patient who seeks out analgesics because his or her pain is not being treated will no longer need to do so. Addiction is a separate medical problem, which also needs to be addressed through appropriate diagnosis and treatment.

Acute pain typically occurs as a result of the reaction to an injury or a metabolic or inflammatory process. This can occur from a variety of sources, including trauma, surgery, arthritis, metabolic disorders such as diabetes, infections such as shingles, the direct effect of cancer or an effect of surgery, radiotherapy or chemotherapy to treat cancer, peripheral nerve injuries due to trauma, central nervous system injuries due to spinal cord injury or stroke, and a variety of other causes.

A great deal is known about the treatment of acute pain, and effective treatments exist that can significantly reduce pain and support recovery. Some pain resolves spontaneously as the underlying disorder is treated, but some does not. Despite knowledge of the physiology and treatment of pain, it is still the case that within our acute care health systems, patients often experience moderate to severe pain. That is pain that can delay recovery or contribute to additional morbidities such as cardiac events, sleep disturbance, and delayed activation and discharge. This can occur up to 75% of the time following surgery for the first few days. In some patients, up to 30% of them, this can persist for as long as three months or more after surgery.

It is possible to do considerably better than this with appropriate education and implementation of treatment systems. Since poorly treated acute pain is one of the predictors of the development of chronic pain, improved treatment is a necessary goal.

Chronic pain states are in some ways analogous to mental health problems, because they are frequently subjective and not immediately apparent to the external observer. They are even less well understood and treated than acute pain states. Its simplest definition is that it occurs when pain has persisted for more than three months, or after the expected resolution of the triggering injury or illness.

Chronic pain interacts with the underlying psychological makeup of the patient and their social situation, to have a behavioural impact that extends beyond the sphere of physical or biological injury. This relationship is well described by a conceptual model referred to as the biopsychosocial model of pain.

[The Chair, Conservative, Ben Lobb]

Excuse me, Mr. Buckley.

We're over 10 minutes here. How much more do you have before you conclude?

[Dr. Norman Buckley]

My apologies. I think the simplest thing to do would be to conclude by saying that a variety of issues have to do with chronic pain treatment.

A lot of the issues have to do with the ability to provide appropriate care, which is currently possible in some situations and in some areas, but not in others. A great deal has to do with providing appropriate pain care, which will go a long way towards addressing many of the problems of prescription drug misuse.

I think that's the simplest and most concise statement.

[The Chair, Conservative, Ben Lobb]

Very good. Thank you very much.

As the meeting continues, I'm sure many of the colleagues around the table will ask you questions that maybe you didn't have time to address in your opening remarks.

[Dr. Norman Buckley]

You mean I get a chance to use the rest of the brilliant speech?

[Voices]

Oh, oh!

[The Chair, Conservative, Ben Lobb]

Well, you could hand it over to Ms. Cooper, if you like, and she could finish it off, but....

Ms. Cooper, you have 10 minutes, please.

[Lynn Cooper, President, Canadian Pain Coalition]

Good afternoon, Mr. Chair, and esteemed committee members.

This is the third time I have presented before this committee on pain issues, representing the Canadian Pain Coalition. The CPC is a partnership of people living with pain, pain organizations, health organizations, health professionals treating people in pain, and scientists looking for better ways of managing pain.

Our primary goal is to promote the sustained improvement in the understanding, treatment, management, and prevention of all types of pain in Canada, and we do this through our national awareness initiatives. We provide education for individuals living with pain, and we advocate for improved pain management.

The Canadian Pain Coalition commends the Standing Committee on Health for undertaking its study into the extremely serious issue of prescription medication abuse in Canada. The CPC is confident that in its recommendations this committee will strongly balance providing appropriate pain management for Canadians with reducing risks and devastating harm from prescription drug abuse and deliberate misuse. CPC's role in this discussion is to provide the person-with-pain perspective, and highlight for your consideration who is affected by pain, the burden of pain, and what Canadians need for effective pain management, which often includes the use of prescription pain medication.

The CPC is committed to working towards determining and implementing solutions to these problems. Canadian research reveals that under-managed pain is in epidemic proportion in Canada. Those affected include one in five, or almost seven million Canadian adults, including our veterans. One in five Canadian children have weekly or more frequent chronic pain like headaches or stomach aches. There are 5% to 8% of our children and teenagers who suffer from chronic pain severe enough that it interferes with school work, social development, and physical activity. All people associated with the individual living with pain are impacted, with the greatest devastation most common in families. Among these populations are individuals who may develop or who are currently living with the disease of addiction.

The burden of pain is staggering. Pain costs Canada an estimated $56 billion to $60 billion annually in lost productivity and health care costs. Costs for individuals like me are approximately $17,000 each year in lost income and out-of-pocket expenses for treatment modalities that are not covered.

The stigma of being labelled as malingerers, drug seekers, druggies, and pushers is denigrating and disempowering. The backlash continues to grow, creating fear of taking medications that could reduce pain and improve functioning as part of a well-rounded pain management plan. Misunderstandings about pain, like the difference between addiction and physical dependence on a medication, fuel fear of becoming addicted to pain medications. This negatively impacts compliance in taking prescriptions, or accepting prescriptions that could reduce pain.

Chronic pain happens to average, honest people, to someone you know, to someone you love, to someone who looks like me. This disease negatively impacts every aspect of a person's family, work, social, school, personal, and spiritual life. It dramatically reduces our quality of life and well-being. At the very least, living with under-managed pain is devastating and demoralizing. At its worst it is depressing, disabling, and dehumanizing. It can turn deadly, as research tells us that people with pain have double the risk of suicide compared to those without chronic pain.

The burden of pain is overwhelming and likewise is the need for effective, best-practice, multidisciplinary pain management, which is not provided by Canadian health systems. We have the knowledge and we have the technology, but we cannot get it to the patient within the current structures. For instance, physician visits are covered, while access to other pain-relieving modalities, such as physiotherapy, occupational therapy, and psychology are dependent upon having extended health benefits or the ability to pay. Many Canadians with chronic pain have neither. As a result, there is a heavy reliance on prescribed medication as treatment for chronic pain, while research has revealed that pain relief may be as little as 30%.

When their pain is not managed, individuals return to their doctors, such as Dr. Buckley, who may decide to provide other or stronger medication. Again, the relief provided is not enough.

Many Canadians believe that pain medication is their only option. A CPC 2010 survey revealed that 45% of people suffering moderate to severe chronic pain believed that there was nothing that could help them with their pain. Out of desperation, the person may use more medication than prescribed, or they may combine over-the-counter medications with their prescription. A dangerous vicious cycle can develop. People can encounter that slippery slope, which no one intends to happen, unless awareness and accessibility of other management options are made available. Sadly, some individuals take their own lives with the very medication that they expected would relieve their pain. This happening to one person is one too many. Sadly, I know of many.

Experience shows us that effective pain management occurs when a personalized combination of health care modalities are working in concert with learned coping strategies, the person's knowledge of their chronic pain condition, an attitude shift, and lifestyle adaptation. People will experience an increase in their quality of life, their productivity, and their functioning when all the pieces of a pain plan are working together.

Of key importance to this inquiry is the fact that, based on each person's success, pain medication dosages are often used more effectively or may be reduced. Length of reliance on medications may also be reduced or even eliminated as other pain strategies are successfully integrated into one's lifestyle.

Canadians living in pain require timely and best practice delivery of acute pain and chronic pain treatment within our health systems. We need health professionals who receive standardized training in effective pain management and who are supported to subscribe and monitor appropriate medications for individuals with and without the disease of addiction. We need them to be using best practice guidelines.

Individuals with pain require the widest variety of prescription medications for their pain, because a medication that provides relief for one individual may not work for another. As well, combining medications with different mechanisms has been shown to dramatically reduce pain.

People with pain require improved pain education opportunities so that we can make informed decisions, take responsibility for becoming actively involved in our pain management, and feel equipped to create a pain plan and to work our pain plan every day. This education would include the benefits, risks, and realities of taking prescription medications for pain, as well as prescription safety to prevent harm to others. We can get involved in that. The public education and working group of the national faculty associated with the DeGroote National Pain Centre and the Canadian Pain Coalition have created just such materials for people living with pain.

Medications play a key role in chronic pain management for Canadians. A balance must be struck to provide access to medications within a well-rounded pain plan while ensuring protection against potential harm for the patient and others. This is not a simple task, but one that is necessary for the well-being of all Canadians.

The 2012 national pain strategy for Canada, a document that CPC helped to create and launch, and best practice guidelines—

[The Chair, Conservative, Ben Lobb]

I'm sorry to interrupt you, Ms. Cooper. Are you close to concluding your opening remarks?

[Lynn Cooper]

Yes, I am.

[The Chair, Conservative, Ben Lobb]

Okay. Briefly, please.

[Lynn Cooper]

What I would like to finish with is that we need to utilize awareness programs and best practice guidelines, and consult with pain experts and addiction experts. We need a federal government-led initiative that would ensure uptake of these valuable resources and set the tone for responsible, respectful treatment of chronic pain while protecting Canadians.

I would like to tell you that the Canadian Pain Coalition is committed to working with you to establish solutions.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

The next witness we will hear from this afternoon is Ms. DeGroote of the Wellbeing Pain Management and Dependency Clinic.

Ms. DeGroote, you have 10 minutes, please.

[Peggi DeGroote, Founder and President, Wellbeings Pain Management & Dependency Clinic Inc.]

Thank you, Mr. Lobb, and congratulations on your appointment as chair.

Welcome to the committee members as well.

Thank you very much for inviting me this afternoon to be part of this experience and to share with you my knowledge and my passion for addressing the needs of patients in light of prescription drug use and pain management.

Just over five years ago, I was challenged to become a volunteer in a methadone clinic. I had never given any thought to working with those people before, but it changed my life. I knew that changes needed to be made to the model that existed for methadone treatment for addiction, and my master's was in decision-making modelling, and I came up with a new model just over five years ago. It was a multidisciplinary best practice evidence-based model.

In September 2010 when the CPSO came out with their recommendations in their “Avoiding Abuse, Achieving a Balance” paper, I felt vindicated that in fact what we were doing was of benefit and could be taken to a larger model, not just in my own little community, but to other communities around.

There was a 2007 task force report that was written on methadone that stated that there were four under-serviced areas in Ontario, and Halton, where I lived, was one of them. I couldn't believe that people in Halton, which seemed to be an upscale kind of place, would not be able to get the kind of medical care they needed and deserved.

So I birthed Wellbeings and built it on a Field of Dreams kind of vision: build it and they will come, and they did come. It wasn't without a lot of fanfare at the beginning because I was almost publicly lynched in 2008 and 2009 when people said, “You're not bringing those addicts to our area, we don't want those people in our community.” Little did they know that they are, as Ms. Cooper says, your mothers, your fathers, your kids, your aunts, and your uncles. They are just regular people we know who have to cope on a daily basis with living in pain and who might suffer from addiction, and as a result they may also have mental health issues.

I have assembled a slide presentation that you can see behind you if you like, and there is also a set of notes there as well. I thank very much Marc-Olivier who helped me to do the French translations for everything. Thank you very much.

If you have any questions afterwards or later on, please feel free to ask me. I'd be happy to answer them.

We have two Wellbeing clinics presently, one in Hamilton and one in Burlington, and we hope to be opening a third very soon in January, because we have over a one-year wait-list now for people who suffer in pain. We're actually on the short end in the Hamilton area for people to get some help within a year as opposed to other funded hospitals where people can wait several years to get help.

In terms of addictions, the physicians who work in Wellbeings clinics see people within 24 to 48 hours. Sometimes we see people who just walk in the door. Our model is not that of a walk-in clinic, but if somebody walks in and there's a doctor available, they will get the help and the attention they need because we do know from the addiction side of the model that when people are in that pre-contemplative mode, when they know today is the day they really need help and they come and ask for it, you can't turn them away. You can't say you'll see them in three weeks' time because it may be too late in three weeks' time.

The physicians who work in our clinic are remunerated by OHIP. The clinic is funded by moneys the doctors pay to me—a percentage to me—and is also funded as part of my philanthropic entrepreneurialism, because the model that exists in Ontario does not fully fund a best practice evidence-based model, unfortunately.

I have been working and trying to bring it to that level. I'm happy to report that last year we helped over 1,100 families, and I think we're actually saving the Ontario government tens of millions or hundreds of millions of dollars. I've asked just for a percentage of that so we can roll this out in lots of other communities, but we know it's really making a significant difference in people's lives.

The analogy I'd like to make to you about addiction and mental health is one where people shouldn't have to let others know why they are going to see their doctor. People should be able to go and see their physician in a private atmosphere, in one of respect, and one where they are well treated, and there's compassion and good clinical management.

As a result of that, I thought to myself that if I were to open an erectile dysfunction clinic, and I hung a big shingle outside that said “Erectile Dysfunction”, I don't know how long I would have to wait for people to walk in my door, but I could imagine that it would take an awfully long time. Erectile dysfunction is one of the symptoms we have as part of addiction because when people are addicted, they find they are not able to have sexual relations.

But nobody should know why you go to see your doctor. When people walk into the Wellbeings model, they could have just hurt their shoulder and they're coming in for a pain treatment. It could be that they're coming to see the psychiatrist or the addiction doctor as well. We have people who come on a Thursday when all three areas are covered, as well as having our case manager who is a local RN who was given to us from the ADAPT program. A person could literally spend hours there seeing all the people they need to see. We hope to be able to get people functional again, get them out of pain, first of all, so we can work on titrating their medications to lower what they're taking or get them off everything, and to make sure they have a good outcome in their mental capacities as well.

Imagine if you were hurt in a car accident five years ago and you're still suffering and you can no longer go to work and your wife is on your case because you're not bringing in any money and your mortgage is due and your car payments aren't being made. It can be overwhelming for people and they need help in all these areas. Those are the areas we have to help them in.

I saw that Dr. Buckley gave his disclosures, and I'll give one now and another in a few minutes. One is that I receive no remuneration whatsoever from this. My work there is completely voluntary. My staff are amazing because, first of all, they haven't gotten a raise in five years—because my CFO says I can't give them one and she knows what the money situation is—and second, because we have a group of people who care passionately about helping others and want to make the model work. So to that end, I have to give a lot of credit as well to the people who work in this model. We're a kind of Doctors Without Borders, except we're local. This is happening in our community.

I really want to be the Maytag repairman. I want to have no one who suffers from pain. I want no one to have any addiction issues, and I don't want anyone to have to have any mental issues whatsoever. So our model works as a success model when nobody gets to come to us anymore.

One thing I'd like to talk about in terms of a national strategy for pain and addictions is the work of the CCSA and the Canadian Pain Society. They both have national strategies, and I know you've heard from other members before. I've read your minutes, so I'm not going to spend any time on this. I just want to emphasize that you should keep up the good work and ensure that we have national strategies for pain and addiction. You have endorsed national strategies for cancer as well as mental health, and I will tell you that pain and addiction are inextricably interwoven with cancer and mental health. They can't be separated. So please give serious consideration to your continued funding of the CCSA and the Canadian Pain Society in developing a national strategy. We can be world leaders here, and I think it behooves us all to do what we can for people in our community.

The International Association for the Study of Pain came out with a statement in 2011 that said that access to pain management is a fundamental human right, and it is. There are no cookie cutter solutions for people. If you have 100 different people you could have 100 different solutions for their pain management, for their addictions. We see a lot of polysubstance abuse in addictions. So it may be that there is an opioid addiction—which is the reason a person may come to Wellbeings, because we really only focus on opioid addiction—but we also find in urine drug screens things like cocaine and alcohol and THC, and all kinds of other things. There's a whole lot of things that people will do for self-medication because they're in pain in most cases, and whether that's a mental pain or a physical pain—because they all come out in somewhat the same manner lots of times—we need to help them get well.

The most important thing here, I think, is that patients need timely access to care. Imagine that you hurt yourself and your body should heal itself in a month or so but it doesn't and it continues to get worse. Say you were in a car accident and six months or a year down the road, you're still suffering in pain. You can no longer go back to work. You can't do these things.

Are we surprised that people are addicted to the pain medications that their physicians wrote for them and continue to titrate up because the pain medication no longer seems to do the job? The pain got worse. I'm not blaming physicians. We need to work together to make sure that people have timely access to care. Ms. Cooper mentioned that as well.

Government decisions on health funding should be driven by science and reasoning, not by scare tactics and community uproar. Opioids can be effective pain relievers for some period of time for some people who have chronic pain, but there are lots of alternative things that need to be done as well. The other thing that we do at Wellbeing are trigger point injections. A physician receives $8.85 for each trigger point injection and is restricted to doing four as a maximum.

For example, I may have an anaesthesiologist who's doing pain management, and a patient may go in for 20 minutes and get four injections . That's four times $8.85. Physicians should be well remunerated for what they do. If there is a simple and elegant solution to a problem like a trigger point injection, we should use it. We should be looking at the easiest ways to treat things first.

Our first medical director did a study on knee replacements out of Queens University, and 55% of the people, after receiving pain treatments, did not get their knees replaced. The people really only wanted to get rid of the pain. They didn't want new knees. They just wanted to be out of the pain. There are things we can do, but the model that exists right now may not support that. It takes a lot $8.85 injections.

[The Chair, Conservative, Ben Lobb]

Excuse me, Ms. DeGroote. We're up against the clock here again. Is there a chance you could just summarize in 30 seconds or less?

[Peggi DeGroote]

Absolutely. There are solutions that address the issues of misuse and diversion. Dr. Buckley talked about Project Lazarus. We don't necessarily need to decrease the opioid prescriptions to decrease opioid deaths.

There needs to be evidence-based research for alternative, effective, and low-cost treatments for pain. We need to accept that this is a community problem; it's not just a medical problem. We need to get people involved through education. We need strategies to take leftover medications back in drug take-back programs. That's huge. You heard about that in your last meeting. We need better national data in order to plan targeted approaches to medication misuse, and patients need timely access to care in their local communities.

These are the faces of why we do the work we do. A young man passed away from an opioid overdose in Oakville. Two months later, a friend of his passed away from opioid overdose. They had not been doing anything for quite some time, but their tolerance levels changed. They went back one time only to try what they had done before, and they no longer are with us.

We need to help these kids. They're the targets where we can make a difference, just like when we had our seat-belt rules 30 years ago. None of us wore seat belts before. We need to go back and make sure that people keep things safe. Each of you today will get a medication lock-box. It's critical. We lock medications up in a pharmacy. Then we take them home. Our Ontario Student Drug Use and Health Survey, which CAMH will present on Wednesday, indicates that 20% of kids misuse medication drugs that were legally prescribed to their aunt, uncle, grandmother, or father. We need to make sure that those kids don't get addicted. We need to keep things safe.

I hope you'll safely store your things at home. We'll make a change. It'll take us awhile, but we can get there.

[The Chair, Conservative, Ben Lobb]

Thank you.

The last presenter for this afternoon is Dr. Bromley from the Narcotics Advisory Board. You have 10 minutes

[Dr. Lisa Bromley, Physician, Ontario Ministry of Health and Long-Term Care, Narcotics Advisory Board]

Thank you. I'll strive to stay within that limitation.

Ladies and gentlemen, honourable members, it is an honour and a privilege to be invited to speak to you today. Thank you for this opportunity. I also want to thank Marc-Olivier Girard for arranging for me to come here today.

I am a Canadian born in the 1960s. In my lifetime I have been witness to Canada making really huge strides in so many domains in our society in combating and rejecting stigma, discrimination, and hate, and I think this is a defining feature of our country and it makes me really proud to call myself Canadian.

Of course, where I am going with this is that there is still an area where we need improvement. There's a group of people that still need our understanding and compassion. In our society, hospitals, medical clinics, and criminal justice system it is still okay to denigrate and at times excoriate a person who is struggling with prescription opioid abuse. Problematic opioid use encompasses a wide range of behaviours, the extreme of which is injection drug use. Today I'm here to change your minds about what and who someone in trouble with prescription opioids really looks like.

My name is Lisa Bromley. I am a family physician here in Ottawa. I am here as a former member of the narcotics advisory board of the Ontario Ministry of Health and Long-Term Care.

I work in a community health centre less than one kilometre away from this building, the Sandy Hill Community Health Centre at the corner of Rideau and Nelson Street. I have a focused practice in opioid addiction treatment as a prescriber of methodone and buprenorphine/naloxone. I am one of the health care providers on the front lines of the prescription drug abuse epidemic. Let me tell you: these are my people.

We have members of our panel today from the pain world and we still have much progress to make in ensuring access to adequate and comprehensive pain treatments, including but not limited to receiving a prescription for an opioid medication.

Many of my opioid addiction patients once were and continue to be pain patients. The difference is that they developed a relatively uncommon but recognized and devastating complication of prescription opioid use, which is opioid addiction.

It has already been mentioned that when pain and addiction coexist in the same patient, that makes for a very challenging area of medicine. What you are going to hear from me today is squarely from the addiction perspective. Sometimes we view good addiction treatment and good pain treatment as being in conflict for some reason, and I am going to invite you today to consider these two things as synergistic.

Very basically, addiction is a disease of the motivational system in our brain. We all have a motivational system, otherwise none of us would be in this room today, right? It broadly comprises two functions in our brains, the feel good dopamine reward system, which is really responsible for our enjoying our daily comforts, and then the executive planning system, which is our long-term planning and future thinking system. In someone with addiction, that motivational system is malfunctioning. The substance tricks our brain into thinking that the drug is more important than other things in our lives. That is why many people with substance abuse disorders lose their homes, their families, and their jobs.

In medicine every day, we treat patients, we treat people, whose body functions have been impaired and altered by disease. This is the business of being in medical practice. We haven't always connected the dots that a person with an addiction disorder indeed has a brain disease and that the function of an important component of their brains has been impaired and altered by disease.

I was asked to address the needs of patients, the scope of the problem, the population most at risk, and to give you ideas for promising strategies to address the issue at the community level. So, here's my shopping list.

Anything you can do to decrease the stigma of the disease of addiction in society will be helpful. I'm going to ask you to be careful here because anti-stigma does not mean embracing the disease. There can be confusion that compassion for someone with a substance abuse disorder is the same as giving them exactly what they're asking for. You have to be careful in being compassionate that you are not facilitating or enabling the disease, but nurturing the patient's spirit.

As for the criminal justice system, the ultimate stigma of addiction is the incarceration of people with a substance abuse disorder. I want to be very clear here: it is absolutely essential that every person with an addiction, no matter who they are or where they are, be held accountable for his or her behaviour. This is actually a fundamental pillar of any good addiction treatment. Having said that, jail is the least therapeutic environment I can think of for recovery from addiction. My request is that we embed more treatment into the criminal justice system so that people whose criminal behaviour is driven by a brain disease, by an illness, can have a chance to get better. And once they get better they will quit hurting other people with their behaviours.

I'd like to comment on abuse-deterrent formulations of prescription opioids. The pharmaceutical industry has developed different types of abuse-deterrent formulations, which I see as an opportunity. It's like adding a seat belt to a car. It is not the only solution to traffic fatalities, but it helps. I believe it can make a difference. I think all of us in the addiction world were disappointed when the decision was made to allow generic long-acting oxycodone. I believe this was a narrow reading of the evidence by Health Canada. In order to make good decisions, you have to have a larger picture.

This brings me to how we know what the larger picture is. What data can we draw on? In Canada, one thing we are lacking is good, comprehensive data collection on substance abuse in the population. What we have, in terms of data collection, is piecemeal. The United States has a comprehensive and excellent system that I believe we should copy completely to the letter, and shamelessly. That is the RADARS System, Researched Abuse, Diversion and Addiction-Related Surveillance System, which is based in Colorado. It's comprehensive. It draws data from many different areas. I'm going to read you something from their website: The RADARS System measures rates of abuse, misuse and diversion throughout the United States, contributing to the understanding of trends and aiding the development of effective interventions.

This system would be inexpensive to implement because in the U.S. the majority, if not all, of their funding actually comes from industry as a requirement for them to fulfill a federal obligation to monitor the safety of their products. So here's a chance to hold industry accountable for the impact of their products on the population.

Regarding first nations and effective treatments for opioid addiction, not all such treatments are funded for all first nations people. Specifically, while methadone is funded and buprenorphine-naloxone is funded for patients living on a reserve, buprenorphine-naloxone is not funded for first nations people not living on a reserve. This is a vexation that I see daily. There's an easy remedy, which is to fund all available treatments for opioid addiction for to all first nations people, no matter where they live.

We've touched on naloxone and overdose reversal kits. I'm going to skip over that to come in under the 10 minutes I have here, but would just mention it as a very inexpensive, safe, and effective way to save people's lives.

On my next point, I expect contention, because what I'm going to talk about is an intervention that will affect relatively few people. For those people, it does have the potential to make a big difference. What I'm talking about is supervised injection sites. We need more of these in Canada.

I made sure to dress nicely to come to the meeting: I put on a skirt and put on some lipstick, but fundamentally my identity is that of an inner-city methadone doctor. The person you have standing in front of you is a soldier on the front lines of this epidemic. I'm faced with this issue every day.

And if you say that people with addictions should get treatment, not injections, I'm going to give you some analogies. The thing is that in medicine we know that treatment does not always work, especially for patients with severe and advanced diseases. Diseases are still smarter than we are. People succumb to diabetes, cancer, and heart disease hourly in our country. And we don't claim that our treatments work in all cases and we accept that there are times when our best treatments fail, despite our best efforts. Does this mean that we send cancer patients to jail if they fail treatment? That thought is horrific, laughable, and humourous. But that's exactly what we do to people who exhibit criminal behaviour because they have a brain disease.

The way I'm inviting you to look at this is that a supervised injection site does not mean the difference between injection or no injection. It's the difference between supervised injection and unsupervised injection. And guess what? Within probably a 500-metre radius of this room, in the Byward Market of Ottawa, there is probably injection drug use going on. You can have it in a place where people suffering from the most severe form of this illness can protect their remaining health and hopefully be enticed into treatment, for whatever treatment can work for them.

The point that I'm going to end with is a nod to good clinical practice. It's a very general, non-specific statement but it has to be said.

There is an enormous knowledge gap between what we know about the disease of addiction and how it is managed in medicine generally—the present company excepted, naturally. Anything you can do to support good clinical practice would be appreciated. I'm sad to say that in my experience—perhaps it's a self-selection process, because the people whom I see are the people who, by definition, are in trouble with opioids—all I see are the failures. But I find there are cases where medicine still does poorly and unloads much of society's stigma and true ignorance onto opiate addiction patients.

In terms of good clinical practice, I'd ask you to consider this question—

[The Chair, Conservative, Ben Lobb]

Dr. Bromley, are you close to concluding there?

[Dr. Lisa Bromley]

Yes, sir.

I failed to come in under 10 minutes. Thank you for your patience.

[The Chair, Conservative, Ben Lobb]

You were almost on your way to winning the award for closest to 10 minutes there. The little bit at the end put you over. Sorry about that.

Okay, this is our first round of questions. There are four of these for seven minutes.

Dr. Morin, for seven minutes, please, sir.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much, Mr. Chair. I will also try not to exceed my seven minutes.

My first question is for Ms. DeGroote.

Thank you very much for your testimony. I especially liked the part where you talked about your work in the two clinics—in Burlington and in Hamilton. You saw that Canadians were reluctant with regard to those types of clinics.

When I heard that, it made me think of a Conservative campaign titled “Keep heroin out of our backyards”, which can be found on their website. The campaign is clearly targeting supervised injection sites. The Conservatives are trying to provoke fear in people and make them not want those clinics close to them or close to their family. So it is clear that the government is trying to frighten people, even though those clinics are ultimately supervised, regardless of how they operate.

Do you think it is okay for the Canadian government to spread fear among people, and try to convince them that those clinics have no place in their neighbourhoods and that they pose a danger to their family?

What do you think about that, Ms. DeGroote?