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—