Evidence of meeting #135 for Health in the 42nd Parliament, 1st session. (The original version is on Parliament’s site, as are the minutes.) The winning word was methamphetamine.
A recording is available from Parliament.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
That's exactly what I wanted to hear, because it shows that, without recovery in place, you're not going to solve this issue.
I'd like to ask Dr. Peter Butt this as well. You mentioned that we need therapeutic supportive housing, and I'd like you to comment on this same thing. What are you missing in terms of recovery? How many beds would you need? How long is it to get treatment? What's the situation in the Prairies?
Associate Professor, College of Medicine, University of Saskatchwan, As an Individual
It's very similar to what we've heard elsewhere, where there isn't adequate capacity with regard to accessing detox.
Keep in mind that detox is not treatment; detox is simply the first step. Locally, people have to keep phoning until there's a detox bed available, so they need access to a telephone, and they need to have the persistence and the perseverance to keep on calling until a bed becomes available. For somebody who's struggling with a substance use disorder, if they're craving or they're in withdrawal, they're only going to be doing that for a certain period of time before they go back out and self-medicate, if you will. They'll continue to use to avoid withdrawal.
I think that we set people up by not having a system of care that's evidence based and has continuity from outreach and engagement through various harm reduction strategies when they're prepared, when they want to move on to detox and have a transition there. The gap between detox and different treatment models is variable. In some instances, if people have stable housing, they might be able to go to a day program, and they don't have to go into residential treatment. But by and large with the folks we're talking about today, the psychosocial instability is such that residential treatment is usually preferred. Until their minds are more settled, it's very hard for them to engage in counselling, in the psycho-educational groups, and the intensity of just being present, not to mention some challenges with perhaps literacy skills and the pedagogy of how these things are taught within treatment centres, the ideology.
A host of things may not speak to a person. If the treatment centre is modelled on alcohol, that's not going to resonate with people who are smoking or injecting. They don't see the commonality to it. We need to be very mindful of this and be culturally appropriate, gender appropriate and so on. That sometimes is where supportive housing between detox and treatment can be helpful to help them to further stabilize so that they can engage when they go to a treatment centre. Following treatment, what's a 28-day period for brain rehab? Nowhere near long enough, and some treatment centres will go three months or six months.
I think it has to be client specific, particularly if there's a concurrent mental health problem, trauma or just layers of other issues that need to be addressed until people can get stable enough to get back out into the community and function on a day-by-day basis. This takes time, and that's not how we have provided services. As I mentioned, it's episodic acute care, nowhere near what we need.
In the DSM-5, the psychiatric manual, three months of non-use is early remission. Twelve months of non-use is sustained remission. We don't stop cancer treatment before they even get into early remission, and yet that's all we offer people with addiction. We're not offering them enough, long enough, appropriately client-centred treatment in order to achieve the success we could achieve if we did, and we blame these individuals because they're not able to get better. We don't provide them with a coherent, evidence-based system of care.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you, Mr. Chair.
Thank you, all, for coming. That was all very interesting testimony.
This is directed to two of our witnesses, Dr. de Villa and Dr. Thomas. You both talked about harm reduction, particularly for injected drugs, and the use of safe consumption sites as part of health reduction, by no means as a long-term strategy, but as a short-term strategy.
Would either of you be able to give us an estimate on the yearly budget? How much does it cost at a harm reduction site, just the component that is for the safe injection site? Is there any estimate as to what that component of it costs in a year?
Medical Officer of Health, City of Toronto
It all depends on the model you've got. There are many different varieties of supervised consumption service that are available, and it depends on the nature of the staffing.
At Toronto Public Health, ours is a nurse-led model. We do have peer workers, as well, as part of the service. It's not just a supervised consumption service. It does also offer a variety of other services. We have a methadone clinic, for example, and we offer supplies for safer use. We also make referrals to necessary health care services.
Because of the nature of the staff we have and the nature of the contract we have with our staff, we tend to be a more expensive model than other community-based models doing similar things.
Also, it all depends on how many booths you have. Right now, we're able to accommodate six people at any one given time for supervised consumption service, per se.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Okay, thank you.
The reason I'm asking this is that one of the things that safe consumption sites will prevent, of course, is the transmission of blood-borne illnesses. You prevent HIV transmission and hepatitis C transmission.
From what I understand—and I haven't practised medicine in three years now—a single case of HIV can cost close to a million dollars in treatment over the life of the patient and a single case of hepatitis C might cost about a third of a million dollars per year. Do these sound right to you, as well, these figures? I see you're nodding.
Would you not agree that, given just these cost savings, these centres are a cost-effective public health initiative and not a complete waste of money, as some detractors say?
Medical Officer of Health, City of Toronto
I would characterize them as life-saving, cost-effective and very beneficial in terms of actually establishing that relationship that you've heard the other experts around the video conference speak about as necessary to address the challenges. Harm reduction workers are a crucial part of the response, and they actually provide access to the populations, to the clients, in a way in which you and I would not be able to get access.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Okay, good. Thank you.
I'll address Dr. de Villa again. You were talking about crack, that it is still an issue there. One of the things this reminded me of, as I've been watching the history of methamphetamine and this recent history, is that it sounds parallel with what happened with crack in the 1980s. Cocaine was a very expensive drug in the 1970s before crack was invented, and in the 1980s, crack was invented. I think it first surfaced in New York in 1980, and that's when it started to flood the streets and become a drug of those with low incomes and those living on the street.
You said actually that there's more cocaine around in your centre. What are the trends over the years? Would you say the use of crack is levelling off? Is it going up? Is it going down?
Medical Officer of Health, City of Toronto
I think it depends on particular populations. We have seen a little bit of an increase. I think I addressed that in my remarks, but in respect of methamphetamine use, there have been particular subpopulations where its use has been more prevalent relative to the general population.
As I mentioned in my remarks, in the general population, methamphetamine isn't reported to be particularly widely used, and it's not the most prevalent drug that is used here. However, there are particular subpopulations where we are seeing quite a bit of use.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
I'd like to go back and get input from you and Sergeant Pearce. Getting back to harm reduction and particularly needle exchange programs, which were the very first of the harm reduction modalities—I think they started in San Francisco in the 1980s—there are detractors who claim that needle exchange programs facilitate or encourage drug use. Is that true?
Medical Officer of Health, City of Toronto
I would suggest to you that needle exchange programs are also, as I mentioned with harm reduction, a critical, life-saving component as part of a response to drug use in our community. They are not encouraging drug use. I think they encourage safer drug use. They allow for the healthier choice for drug use to be more amenable.
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
Thank you.
Sergeant Pearce, you are in law enforcement. We've been getting push-back from staff having Corrections Canada starting to introduce needle exchange programs in prisons. We've been receiving literature saying we're here to keep the public safe; we are not here to facilitate drug use by inmates.
What would you say to the staff in Corrections who are pushing back on this, given what we know about needle exchange programs?
Det Sgt John Pearce
It's a very awkward situation. My opinion is somewhat biased. I support what they're saying, because ultimately you're not incarcerating to promote or facilitate that type of drug use.... In theory, they're being incarcerated to pay their debt to society and—
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
I don't want to cut you off, but all the medical experts have agreed, this does not facilitate or encourage drug use. It's clear on that.
Det Sgt John Pearce
Right, but that's what I'm saying. If you're having needle issues while they're incarcerated, how is it coming to be? Is it their job or responsibility to get involved in that because now we have another health and safety issue as well?
Liberal
Doug Eyolfson Liberal Charleswood—St. James—Assiniboia—Headingley, MB
But you already have a subset—
Liberal
Fin Donnelly NDP Port Moody—Coquitlam, BC
Thank you, Mr. Chair.
Thank you to all our witnesses for being here.
I want to return to my colleagues' earlier line of questions to Dr. Butt, talking about the need for therapeutic housing.
I'm wondering, Dr. Butt, if you could give us an idea of the state of the current supply of this housing.
Associate Professor, College of Medicine, University of Saskatchwan, As an Individual
It's inadequate. Typically it relies on faith-based or community-based organizations to fill that need. It comes from people in recovery or from a particular religious or philosophical point of view who see this as an important service to the community and that indeed these individuals are worth investing in.
I think the recovery community is probably one of the stronger proponents, but it's hard for them to raise funding to provide these services. That's where working with developers, people who have housing stock who can be convinced that this is a good investment...if you're providing support to people who are transitioning into recovery or support for people in need, they're less likely to damage the property. They have income support from social services. There's a way of making this more of a wraparound approach using existing resources in the community if people can be brought together at the same table. I appreciate that Health doesn't want to buy houses, but they can provide programming to some of these residences.
We're seeing this very successfully with people who have HIV, with people struggling with mental health and addiction problems. There are mental health group homes in many communities, but we don't see a lot of addiction group homes that are effectively recovery homes. We tend to leave that to the community-based organizations rather than having them facilitated through our health care system.
NDP
Fin Donnelly NDP Port Moody—Coquitlam, BC
You mentioned municipalities, municipal services, developers.
How do the senior agencies fit in there, the province, the feds, the health authorities? How is this instigated? You talked about communities where this wraparound service is happening, and happening effectively. Can the federal government play a role in instigating that or is this more the municipal agencies?
Associate Professor, College of Medicine, University of Saskatchwan, As an Individual
I think that every level of government potentially has a role. The question is what role they would have depends upon what enablers they have at hand. For instance, in terms of tax models that would be more federal or provincial, I would think.
In terms of recognizing social impact from people who are making donations or philanthropic organizations that are getting heavily involved in this, if they're working with the health care sector and we're providing what's essentially an expansion of a health care need, does that social impact merit a higher level of a charitable tax credit than what they would get? Or is there a way of returning some of the money they've invested in achieving a health care end back to them, that can then be recycled into the organization that's providing that care?
If there's a million-dollar donation, yes, there are certain tax credits. Can some of that be recycled back once they achieve certain health care metrics with regard to people being stabilized and people avoiding the vertical transmission of HIV? If we're providing housing and services to women who are pregnant and HIV positive.... In chaos, they may very well transmit that to their fetus. We can prevent a lifetime of HIV care if we can provide stabilization to high-risk women and prevent that vertical transmission. Is there a way of recognizing that, in terms of some of the funding models, in order to keep that money recycling and supporting these very marginalized, vulnerable people and programs that are just grossly underfunded?
The other thing I mentioned—and I don't want to be in competition with the police—is recognizing that proceeds of crime related to trafficking and drugs perhaps could be a source of revenue as well, to address the demand side of this.
NDP
Fin Donnelly NDP Port Moody—Coquitlam, BC
Okay. Interesting.
Moving to addiction substance use disorder, can you describe the impact of criminalization on patients suffering from addiction substance use disorder?
Associate Professor, College of Medicine, University of Saskatchwan, As an Individual
The challenge, of course, is that particularly with these more potent drugs we have, with methamphetamine and the more potent opioids but also even with alcohol, the disruption in people's lives is such that it's difficult for them to hold jobs. They don't have the income. They go in and out of withdrawal. The positive reinforcement of getting high diminishes over time as they develop tolerance. What takes over is the negative reinforcement, which is to avoid withdrawal. Typically, when I see them, they're sick and tired of being sick and tired. They're just trying to get through a day, trying to feel normal, typically by going out, getting the money, getting the drugs, using, and then the cycle continues 365 days of the year. It's not surprising that it will reach a point where they're going to commit property crimes, where there are going to be break and enters, where this sort of activity increases.
Once people transition, typically through the outreach and engagement that we see with people who can work in harm reduction programs and in detox and treatment, with stabilization that crime goes down. Statistically it diminishes very rapidly, because they're not inherently criminal by nature. It's circumstance. If we can treat, we can keep them from going back, in and out of the correctional system, in and out of police contact, and hopefully to a place where they're not only not drawing on community resources but perhaps potentially contributing to them.
NDP
Fin Donnelly NDP Port Moody—Coquitlam, BC
Would you agree that it's better to look at this as a health issue as opposed to a criminal issue, and it's even more cost effective to do it as a health issue?
Associate Professor, College of Medicine, University of Saskatchwan, As an Individual
No question, there's absolutely no question at all. This is fundamentally a health issue. This doesn't mean that if they're committing crimes and are potentially a danger to public safety, there isn't a role for policing in this. Sometimes I've had patients whose lives were saved by a period of incarceration because the chaos was so severe. But having said that, if we could combine the two, then I think it would be much more effective. It would reduce correction and policing and justice cost, ultimately reduce health care cost, and improve the safety and well-being of our communities and our families. Families are terribly devastated by this.
