Health Committee on Nov. 29th, 2018

[C/Supt Paul Beauchesne]

Thank you for your questions. I will answer in English, if that's okay with you.

I think it's a very interesting question.

Organized crime groups are profit-driven, and they don't care about anything else but the profit. Then you have to look at domestic production, those clandestine laboratories. Although I'm not saying it is, the closer they are to specific areas may have an impact on the availability of the product, which may be a contributing factor to why different areas have access to, maybe, meth, and then are seeing the results.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

You seem to be saying that the majority of the production is local, contrary to opioids, which mainly come from outside Canada and enter the country in a variety of ways. You seem to be saying that these are local labs, close to users. So there would be more of them in Manitoba and the west. However, unlike Winnipeg, Vancouver seems to be dealing more with an opioid crisis than a methamphetamine crisis.

[C/Supt Paul Beauchesne]

I was talking more about a combination of the two: domestic production, but also entry into the country of precursor chemicals as well as the finished product, which is called “meth”. So there are actually three different aspects to that issue.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

I will come back to the observatory, which may be a good idea. How far along are you in that file, both in terms of the federal government and the provinces? Some public health issues come under provincial jurisdiction, but others are the responsibility of Health Canada.

[Suzy McDonald]

Absolutely.

We have been working on implementing that observatory for about two years. We have consulted data-gathering organizations. Our minister also held discussions with provinces and territories in the fall. Everyone has agreed to move forward with the initiative, and our partnership has enabled us to have a good national overview of the opioid crisis. However, we must take things even further.

Currently, provinces and territories provide us with their data on opioid-related deaths and hospitalizations. However, that data should be cross-referenced with other information we provide to our partners in order to have a more complete picture.

The observatory's goal is really to ensure that every organization currently gathering data continue to do so, but that another organization compile all that data to provide the overview we need. We are working with Statistics Canada to implement that process.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

Thanks. That's it.

[The Chair, Liberal, Bill Casey]

Thanks very much. Your time is up.

Now we'll go to Ms. Mathyssen for a short round of three minutes.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you very much, Mr. Chair.

I wanted to follow up on what Mr. Lobb was talking about with regard to the drugs that are so readily available on the counters in the pharmacies, and talk about what happened in Ontario in 1992.

The government at the time said no to sales of tobacco in pharmacies because they were also selling drugs to address cancer. Big pharma pushed back and created a fund to get rid of this. Now tobacco is no longer available in pharmacies, but that government is no longer in power.

Given the reality of big pharma, have there been discussions with them about this situation and an ability to push back against what will be a very powerful lobby?

[Michelle Boudreau]

I know others may want to add, but I'll start just for a little clarity.

There has been a focus on products available in the pharmacy, but I think you've also heard my colleagues say that precursors are being imported. While there are products available in the pharmacy, they are there for legitimate purposes and we do have to keep that in mind as well.

For the most part, many of those products may not even fall within the regulatory scheme because of the quantity in the package. When we are putting a precursor on the list for control, we look at the legitimate purpose as well. Some of those packages that you may see in pharmacies technically may not even be on the precursor control list because of the amount in that package.

I think my colleagues were saying that when it comes to precursors larger volumes are being used that are coming in through other sources.

I'll let my colleagues with enforcement add if they wish.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Actually I have another question. I thank you for that.

In Manitoba, monthly emergency room visits by patients using methamphetamines have apparently increased by 1,200%. This has an impact on health care providers. My previous concern about the impact on police forces now extends to those health care providers.

The Manitoba Nurses Union is calling for heightened security in emergency rooms to manage the increase in violence that they say is related to the increase in meth. Are other provinces also witnessing an increase in violence to health care workers due to meth consumption? Has there been any discussion about how to address that? What kinds of safety mechanisms can be put in place for those health care workers?

[Suzy McDonald]

Certainly the safety of health care workers is a concern.

With regard to provinces and territories, the way we work with them is through a series of committees, so we do have a problematic substance use and harms committee that is made up of officials across governments. The issue of methamphetamine use has come up and is being discussed actively within that committee, including finding solutions for prevention and treatment with regard to it.

The issue specifically with regard to the protection of health care workers has not been discussed at that committee. No one has raised it specifically with me. That being said, as we noted earlier, the possibility of psychosis and violence associated with methamphetamine use could be a concern, and we could certainly talk to provinces and territories about the concerns they have about that.

[The Chair, Liberal, Bill Casey]

Thanks very much. The time is up.

[Irene Mathyssen, NDP, London—Fanshawe, ON]

Thank you.

[The Chair, Liberal, Bill Casey]

We haven't got time. We're going to go to another panel.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

I'd like them to submit the emergency treatment fund bilateral agreements that have been signed.

[Suzy McDonald]

It's no problem. They're publicly available online. We'll get them to you.

[The Chair, Liberal, Bill Casey]

I want to thank all of you for doing what you do, because you're talking about people's lives and their health. It's a big responsibility you have, all of you. I want to thank you on behalf of the committee for what you do, and thank you for providing this information.

Now we're going to switch panels very quickly, as fast as we can. We'll just suspend for a moment and then hook up again. We have a video conference next.

[The Chair, Liberal, Bill Casey]

We're going to reconvene.

My message to the members is to try to keep your questions succinct. We're behind schedule. Every time we have five panellists, the answers are quite long and we run over. Almost every question answered today, I think, has gone over the time. I ask the members to keep your questions succinct, and I also ask our presenters to keep your answers succinct, as much as you can. We want to hear what you have to say, but try to focus on exactly what the questions are and give us those answers.

In our second panel, we have Addictions Foundation of Manitoba, Damon Johnston, chair, board of governors, and Dr. Ginette Poulin, medical director. From the Canadian Centre on Substance Use and Addiction, we have Dr. Matthew Young, senior research and policy analyst. By video conference from the Canadian Community Epidemiology Network on Drug Use, we have Dr. Sheri Fandrey, knowledge exchange lead, Addictions Foundation of Manitoba.

We are going to invite Addictions Foundation of Manitoba to make a 10-minute opening statement, then we'll go to the Canadian Centre on Substance Use and Addiction.

[Damon Johnston, Chair, Board of Governors, Addictions Foundation of Manitoba]

Good morning, Mr. Chair and honourable members of the committee. Thank you for inviting us here today.

I'm Damon Johnston. I am the current chair of the board of governors of the Addictions Foundation of Manitoba.

I will now let Ginette introduce herself.

[Dr. Ginette Poulin, Medical Director, Addictions Foundation of Manitoba]

Good morning.

My name is Ginette Poulin. I am the medical director of the Addictions Foundation of Manitoba.

It is a great honour for me to be here to discuss this issue we are currently facing in Manitoba.

While we do understand that there are issues with methamphetamine across the nation, certainly in Manitoba we've been seeing significant impacts that have been stressing not only our health care system but our social system and our justice system. We want to share a few reasons why we are seeing these particular impacts.

I will note that we prepared some packages for you. Although some of the information has been translated and is in both French and English, our apologies, not all of the material is in both languages. We will distribute those for those who wish.

In terms of some of our numbers, certainly from the Addictions Foundation of Manitoba, which services most of the addictions services within the province, we are seeing growing numbers of concern. For instance, 48% of persons seeking help for addictions are reporting methamphetamine as their number one substance of use within the past year. That is in our youth population. We've also seen an increase of about 104% in our adult population reporting methamphetamine use. We've had a threefold to fourfold increase in deaths either contributed to or caused by methamphetamines.

We're seeing a product that is certainly more toxic and more potent. It certainly has longer devastating effects in terms of aggressivity and psychosis, leaving a lot of concern. We've had a reported 1,700% increase in presentations to emergency visits in the Winnipeg Regional Health Authority. From AFM's perspective, across the province there's been an increase in the proportion of use of methamphetamine in the southern region.

Certainly, when it comes to treatment, we are under-resourced. Many of you might be familiar with our Peachey report. That report came out about three years ago on our health system transformation. That's another particularity that's happening in Manitoba. We're undergoing new strategies, in the global health system as well our mental health and addictions, with the Virgo report that was released in the spring, looking at providing a less siloed effect, which is currently the case. The geography of Manitoba is very much concentrated. Over half of our population is within Winnipeg and the southern area.

What came out of both of those reports is that we need more funding. We need more services. Of our health budget, only 5.2% is allocated to mental health and addictions. The national average is about 7.2%. The recommendation from the Virgo report was to increase it to 9.2% to meet some of the gap that has been there. Damon will speak a little bit further about some of the funding. We have been experiencing cutbacks in terms of our climate currently, too, which is a challenge.

When it comes to crystal meth, for withdrawal management services and ongoing care we do have limited resources within the province. We're advocating for withdrawal management services for a longer period of time, given that the detox period for crystal meth requires a longer phase of that safe environment.

Certainly, we're seeing the impacts from the female and family perspective. Manitoba, as you may know, has some of the highest rates of children in care, secondary to apprehension. Again, when we look at our data, we're certainly seeing that women are more affected in both our youth and adult population. This is something that is of great concern for us as well.

I know that safety was brought up earlier. This is certainly a concern on the front of individuals, health care providers, and our judicial and legal services. Winnipeg Police Service is facing significant challenges on the street, facing a lot of aggressivity. You might have heard of claims of machetes tied to the hands, and of the health care provider stabbed with a pencil. When we're looking at safety concerns, that is a real risk. It's certainly something we are facing.

Again, for individuals, many who are under the influence are experiencing harm. We're seeing an increase in IV injection rates. This has gone up at least double in the last few years. There are also the rates of hepatitis C and other infections, such as infective endocarditis, that are secondary to use. Again, the longer this goes on, the more impacts we'll see in terms of that.

I think I'll pass it over to Damon.

[Damon Johnston]

Thank you, Ginette.

Very quickly, in 2018 we know that Canada and Manitoba announced a new health transfer agreement. Within the agreement, there was an allocation to the province of approximately $181 million over 10 years for improving mental health and addictions services. At this time, AFM and our RHAs have been directed to reduce annual budgets by 1% to 4%. This raises the question of where the federal money in the new agreement is being directed.

The City of Winnipeg—so our mayor and council—in September of this year unanimously passed a motion calling for an intergovernmental task force on methamphetamine use, with a mandate to identify treatment and prevention strategies. Council pledged to create its own task force if the province or Ottawa did not step up by November 19, 2018, which has already passed. At this point in time, we're not sure where all of that is, but we remain hopeful that something will be done. The recent throne speech in Manitoba did not make any commitment to a task force, but it did say that there would be some future announcements relative to that.

Just to close, I wear another hat in Winnipeg. I'm president of the Aboriginal Council of Winnipeg. In that role, I'm very aware of the impact of these powerful drugs on members of our community and other vulnerable communities, such as the homeless population and people in poverty. They are the least equipped to meet these challenges—and they're very real. In my job, my role, I interact with families in our community in many different ways. I've had direct experience with some of the nasty outcomes, effects, directly on families, particularly on mothers and children. It's a serious issue. We have a collective table of leaders in Winnipeg, and we will be advocating strongly for more attention to this situation.

Thank you.

[Dr. Ginette Poulin]

Perhaps I will add something to that. There's something important that we see in Manitoba, and I always like to reiterate this point when we talk about substance use and issues related to that. It's always important to take it to the deeper level and look at underlying causes, such as trauma. We know that in our population in Manitoba, we have a lot of people who have experienced trauma, particularly in their childhood and throughout their lifetime.

If you look at the ACE study, which is the adverse childhood events study, they are certainly more at risk for mental health, addictions and other chronic diseases. Sometimes as we view these trends where, in Manitoba.... I know that in the previous session, you were talking about how opioids are hitting other provinces. Right now, why are we seeing crystal meth? There are certainly impacts because of our population, the accessibility and costs. Many factors play into that.

Again, when we look at those underlying reasons, no matter the substance, if we're not addressing those deeper issues, we're just providing band-aid solutions. I think that's a big challenge that lies ahead of us as a nation, and not just for Manitoba.

[The Chair, Liberal, Bill Casey]

Thanks very much.

Now we'll go to the Canadian Centre on Substance Use and Addiction and Dr. Young.

I understand you're going to share your time with Dr. Fandrey. Is that correct?

[Dr. Matthew Young, Senior Research and Policy Analyst, Canadian Centre on Substance Use and Addiction]

That's correct, yes.

Thank you.

Good afternoon, Mr. Chair and members of the committee.

My name is Matthew Young. I'm a senior research and policy analyst at the Canadian Centre on Substance Use and Addiction, and an adjunct research professor of psychology at Carleton University.

CCSA was created in 1988, and we are Canada's only agency with a legislated national mandate to reduce the harms of alcohol and other drugs on Canadian society.

With me today via video conference is Dr. Sheri Fandrey, knowledge exchange lead at the Addictions Foundation of Manitoba and member of the Canadian Community Epidemiology Network on Drug Use. We welcome the opportunity to speak with you today and to assist you in your study of the impacts of methamphetamine use on Canadians.

To respect your time constraints, my presentation today will be brief. Many of the statistics I refer to are included in the methamphetamine summary that was released earlier this month. It was provided to the committee in advance of today's meeting.

Methamphetamine is a synthetic drug classified as a central nervous system stimulant. The immediate effects of methamphetamine include alertness, energy and self-confidence. It is important to note these effects differ from the sedation and respiratory depression produced by opiates.

Since 2015, approximately 0.2% of Canadians report in self-report surveys using methamphetamine in the past year; however, national survey data tells only a very small part of the story. There is considerable variation across jurisdictions in rates of methamphetamine use and problematic use tends to be concentrated among populations that are unrepresented in national surveys.

Although there are gaps in the data, what data we have suggests that since about 2010 there's been an increase in the availability, use and harms associated with methamphetamine in most provinces in Canada, but mainly in the western provinces. Specifically, between 2010 and 2015, the rate per 100,000 people seeking treatment for stimulants in hospital settings increased over 600% in Manitoba, almost 800% in Alberta and almost 500% in British Columbia. During the same time frame rates of those hospitalized for poisonings in Saskatchewan, Alberta and British Columbia doubled. Though these hospitalizations include other stimulants besides methamphetamines, data from other sources lead us to believe they are largely driven by increased harms associated with methamphetamine use.

We feel some unique considerations about methamphetamine are important to mention to the committee. In contrast to people under the influence of opioids or other depressive or sedative drugs, individuals using methamphetamine can be animated and energetic early on and feel increasingly lethargic, dysphoric, depressed and hopeless with intense craving as the drug wears off. This means that people who use methamphetamine can be challenging to treat, and when in public spaces can attract attention from the public or authorities.

In addition to public health concerns about dependence and other harms directly arising from youth, methamphetamine is sold and bought in an unregulated market. Therefore, methamphetamine can contain adulterants and contaminants that can cause health harms. There is evidence from drug-checking programs across the country that there have been samples of methamphetamine testing positive for opioids. This fact is a significant concern as overdoses are more likely among people who do not and are not expecting to use an opioid. It is challenging, however, to know how common this is or why this may be occurring. Many suspect inadvertent cross-contamination.

However, as noted, the data we have at the national level is poor and the data we have at the provincial level is often very different from province to province. As a result, not only is it difficult to accurately assess the harms associated with methamphetamine use in Canada, but it is challenging to know where to target our efforts aimed at reducing these harms.

Finally, it is important to note that methamphetamine use is a very stigmatized behaviour, not only among the general population but among service providers and people who use drugs. This stigma further increases the marginalization experienced by people who use methamphetamine and places additional barriers to those seeking and accessing help.

I'll now turn to Dr. Fandrey to speak about the impact of methamphetamine use at the community level. Sheri is a member of the Canadian Community Epidemiology Network on Drug Use, or CCENDU, led by the CCSA. CCENDU is a nationwide network of community-level partners who share information about local trends and emerging issues in substance use, and exchange knowledge and tools to support more effective interventions in data collection.

[Dr. Sheri Fandrey, Knowledge Exchange Lead, Addictions Foundation of Manitoba, Canadian Community Epidemiology Network on Drug Use]

One consequence of there being abundant, high-potency and inexpensive methamphetamine widely available in Manitoba is the increased likelihood of those individuals injecting methamphetamine using very large doses. This likelihood increases the potential for challenging behaviours and serious overdose.

Further, powdered cocaine is frequently adulterated with or substituted with powdered methamphetamine. This substitution can lead those who purchase a product, thinking it is cocaine, to use too much, with an increased potential for adverse physical and psychological effects.

Manitoba systems and services struggle to address the harms of methamphetamine on several fronts. Emergency room visits related to methamphetamine have increased in Winnipeg from an average of 10 per month in 2013 to 240 per month by the end of July 2018. Presentation at the emergency room is frequently related to psychiatric symptoms, including paranoia, delusions and aggressive behaviour. These psychiatric symptoms generally result from high doses of methamphetamine and can distract from critical and potentially life-threatening effects on the heart and brain. This complex presentation requires a coordinated response from medical, mental health and social services.

For people who use methamphetamine at a high intensity, intravenous injection is the preferred route of administration, further stressing both medical and harm reduction services. Injection poses risks related to sexually transmitted and blood-borne infections such as hepatitis C, HIV, and bacterial endocarditis.

People who use methamphetamine at a high intensity and who are street involved can be reluctant to engage with medical services due to stigma and the requirement to be abstinent. Not completing the course of treatment reduces its effectiveness and can increase the possibility of treatment resistance with corresponding increases in intensity and the cost of the treatment. Enhancing supportive harm reduction services is critical to increase awareness of risk, reduce harmful practices and engage a reluctant, transient population in accessing further services, including treatment for addiction.

The first two to three weeks after stopping methamphetamine use present a range of challenges including volatile mood, profound depression and excessive need for sleep as well as cognitive and memory deficits. The window of opportunity for someone using methamphetamine to access detox or addiction treatment can be short. Ready access to non-medical detox can be a critical step in the process of recovery, as it allows an individual to withdraw from methamphetamine in a supportive environment, which increases the potential for success.

Increasing the length of detox to provide support to an individual throughout this vulnerable period would enhance the potential success of the next steps in addiction treatment and recovery. Ensuring smooth transitions from detox to treatment or supportive housing is key to success.

Prior or ongoing trauma is common in people who use methamphetamine at a high intensity. In many cases, methamphetamine use is a direct response to experiences of physical and sexual abuse and trauma. Restricting services and resources to those requiring abstinence ignores this reality. All services for this population need to be trauma-informed and must include resources for those who cannot or will not stop using.

Methamphetamine use occurs across a spectrum, from occasional use of snorted powder to daily intravenous injection. While attention and resources must be allocated to those experiencing the greatest harms, effective prevention and early intervention are key to limiting the scope of use and ensuring lower intensity use does not escalate.