Evidence of meeting #136 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was opioids.
A recording is available from Parliament.
Liberal
Sonia Sidhu Liberal Brampton South, ON
You said you have a mobile ACT team, mental health teams, and you need psychiatric help. What kind of psychiatric help do you need and how can other jurisdictions help you? Can you elaborate a little bit on that?
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
Yes, I think some of it is attitudinal. If we categorize people's psychiatric illnesses as schizophrenia, you're born with it, or you have bipolar illness, etc., when you put the element of drug use and these particular substances together with that, the effects are actually exactly the same on the brain and the behaviours. Therefore, the treatment needs to be the same.
Some of our psychiatric colleagues do not share that urgency, unfortunately, and our systems are really not robust enough to keep people safe. A lot of these people, when they become very impaired, such as the patient I'm going to be tracking as soon as I leave here, actually need to be certified and be admitted to the hospital for a long time, to be stabilized and have a constant psychiatric team and treatment around them. They can't just sleep it off and go back to the same circumstance, because they've actually had chronic or permanent impairment of their brain. It's not just as case of, WI used this drug and I have this effect and behaviour”. People are now permanently psychotic. They are permanently dementing. They are losing their ability to speak. They have movement disorders. They are hoarding. They are fixated on their little bicycle parts, etc.
When they are in this state, which is now becoming permanent, it is very difficult for them to accept any sort of health care, let alone addiction care, because they have been permanently damaged. They are psychiatrically unwell and I need more of what we need.
February 26th, 2019 / 4:30 p.m.
Liberal
Liberal
The Acting Chair Liberal Doug Eyolfson
I'm afraid your time is up. Thank you.
Next, we're going to go into our five-minute rounds of questions.
We're going to start with Mr. Lobb for five minutes.
Conservative
Ben Lobb Conservative Huron—Bruce, ON
I'd like to first ask Katrina Hedberg from the Oregon Health Authority something.
We've had a few discussions during this study on injection sites, border security, policing and trafficking, etc. I just wanted to get your opinion.
I understand you're with the health authority, but in terms of the penalties and so forth for people—I'm not talking about the person who's caught with one or two grams and is using, but the people who are middle level and trying to sell it—would any stiffer penalties work for them if they're caught with 20 grams? Or is it the case that you get one and the next one's up and running a few minutes later?
State Health Officer, Oregon Health Authority
I'm not sure I'm the right person to answer your question because you're right, I am with the health authority.
What I would say with regard to the idea of not criminalizing the end-users is that substance use disorder is certainly a chronic disease and, as we've talked about, needs treatment.
I really do think that one of the things we're trying to focus on is the upstream. Who are those people who are both importing and dealing, if you will, with these drugs and getting it to the end-user? That said, we do work closely with our high-intensity drug trafficking partners—they're federal, as well as local law enforcement—to try to help identify how the drugs are getting into the state. But when it comes to whether stiffer sentences would make a difference, I can't answer that because that's outside my area of expertise.
Conservative
Ben Lobb Conservative Huron—Bruce, ON
Again, I know you're not in the legal business or the policing business, but for the end-user who is addicted and in a terrible spiral, is decriminalization or legalization something you discuss with your colleagues?
State Health Officer, Oregon Health Authority
The Oregon legislature is meeting right now and there's a bill that has been put forth by our governor that is specifically related to opioids. One of the primary points in this bill is to treat substance use disorder as a chronic disease. This means that even if people get in and get rescued with naloxone, and even if they're in rehab or substance use disorder treatment for awhile—people do relapse—rather than saying, “You're off the bandwagon, you now need to start at square one,” we're saying it's much like blood pressure or diabetes or even smoking. People who want to stop smoking need to do so several times.
I think viewing the end-user, if you will, as somebody who has a chronic physical disease.... This is not a moral failing, but how do you get them into treatment? Even if something happens with that—like I said, they fall off the bandwagon or start using—it may take them several tries before they get there. That's the piece we're focusing on with the end-user, to really decriminalize the behaviour and treat it as a medical condition.
Conservative
Ben Lobb Conservative Huron—Bruce, ON
I'm from a rural area and methamphetamine abuse has certainly been present in the rural areas of southwestern Ontario for many years. I don't want to use the word “epidemic”, but it maybe 20 years ago, cocaine and marijuana and other things might have been the drugs of choice for users. Certainly now, I think everybody ends up, after awhile, with crystal meth. It is unlike any other in that it will, as a police officer once told me, steal your soul. Unlike others, you can't come back from it.
I know we're doing our best to figure out what to do for the country and I don't want to say it's impossible, but it's almost a dire situation, I would say.
I don't know if anybody else wants to add anything.
Chief Coroner, Office of the Chief Coroner, British Columbia Coroners Service
I might just add one thing.
Certainly, we have heard police officers here in B.C. say, “We can't arrest ourselves out of this situation.” Our public health folks here in B.C. certainly have the same perspective: As my Oregon colleague mentioned, substance use disorder is a chronic, relapsing disease and a medical approach will make a difference.
From my chair—having been in this type of work for the last 25 years—it's almost impossible to remove the traffickers because it so profitable. You take one off, and because it's so profitable, one, two, three or four more will pop up.
If we can focus on the users, if we can focus on the poor folks who are experiencing this chaotic existence, if we can support them where they are and provide evidence-based treatment when they need it.... Some folks are asking for it and it's just not there. It's certainly not there in any way that they can afford or access. If we can focus on the users instead of the suppliers, it just seems to me that we can be much more effective. We know who they are for the most part. They're in our communities. We're already spending lots of money putting them through courts and jail. If we just repurpose that money, it strikes me that it would, in the long run, be a much better solution.
Liberal
The Acting Chair Liberal Doug Eyolfson
All right. thank you very much.
Now we'll go on to Mr. Falcon-Ouellette for five minutes.
Robert-Falcon Ouellette Winnipeg Centre, Lib.
Thank you very much, everyone, for coming. I really appreciate it.
Dr. Burgess, you mentioned that people had been ejected from an HIV program. Could you explain why they were ejected from that program?
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
It wasn't an HIV program. Nobody gets ejected from that, luckily. It's from the Crosstown Clinic, from early on, when they were doing NAOMI and SALOME studies of injectable heroin and hydromorphone to try to stabilize patients.
Various behaviours led to their being ejected; usually it was for trying to steal the substance that was being provided to them freely or for behaving violently. The majority of those people also happen to be HIV-positive, so given my role, those are people I inherited.
Winnipeg Centre, Lib.
That obviously causes some major issues in health care treatment, if they're ejected from one health care program—
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
Yes, if you so-called “fail” injected heroine—free heroine—that makes you pretty complicated for me to look after and to try to get HIV meds into you every day.
I don't have the same experience of a lot of our potential programs being effective for everyone. I have patients now who were given a whole lot of hydromorphone from some prescriber, and who have just gone on opioid substitution and are now way more interested in going to the free hydromorphone provision site.
At the individual level, everything has an effect that we can't always predict. I have experience with people who are very committed drug users and have very difficult health issues that need to be supported lifelong or until death, and others who are very committed drug users and are thrilled that we may be providing no opioid replacement, but really their drugs of choice. We should, perhaps, but there are effects on stabilizing.
Winnipeg Centre, Lib.
In Manitoba we often have issues concerning safe injection sites or safe consumption sites. Does it make the community safer to use safe injection sites or providing things like this for other citizens—citizens who don't use drugs, but who end up...? Obviously someone in the streets might cause issues.
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
We know clearly from research that safe injection sites save lives. People can overdose there and be resuscitated. They can also receive health care at a certain level there and possibly, when they're ready, get some help in trajecting out of drug use life.
However, other people, because they're so damaged, actually require something like drug court for them to get a time out to rebuild their health and to engage in some low-level treatment instead of ongoing drug use. That's particularly the case for and will benefit people with HIV, hep C and other chronic illnesses that can't be managed just by provision of the drug of choice. They actually need to be kind of removed from the setting.
The experience of the individuals I see is complicated. We definitely need to offer all sorts of options for people, but they have to be connected to a benefit in their health needs as well—not just their addiction. Their addiction prevents them from actually living in a more healthy way. How do we connect the treatment of them as an addict or provision of substances with something more, which is robust?
Winnipeg Centre, Lib.
That's a question I have for you. What would be the ideal treatment plan for someone who presents obvious polysubstance abuse issues and who might have trauma? If you're dealing with them on the front lines and they're causing chaos not only within the health care system, but also in the streets, how would you go about it? What would be the ideal treatment plan that you could see, or that you would recommend to the government at the provincial, federal and municipal levels?
Liberal
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
Thanks for that question.
I think the individual needs options for care, of which we don't have enough.
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
Going off to a wonderful treatment place that is culturally appropriate might be an option.
Liberal
The Acting Chair Liberal Doug Eyolfson
Thank you very much.
We're going to go on to Mr. Lukiwski for five minutes.
Conservative
Tom Lukiwski Conservative Moose Jaw—Lake Centre—Lanigan, SK
Thank you very much. I've always been told you never start a presentation or an intervention with an apology, but I do apologize to my colleagues around the table, because I'm subbing in for someone else on this committee, so if I ask any questions that are somewhat redundant and you've covered this ground before, I do apologize for that.
There's a saying, ladies, in politics, that all politics is local. In my case, local means my home riding. As Mr. Lobb indicated with his riding in Ontario, mine is primarily a rural riding. The community of Moose Jaw is the largest city in the riding, with a population of about 38,000 people. I think by anyone's definition, it would not be considered a cosmopolitan centre at the scale of Montreal or Toronto. Nonetheless, according to our mayor, there is a serious meth problem in Moose Jaw.
I'll address my primary question to Dr. Burgess, since you have collected a lot of data. Whether it's meth or a combination of meth and fentanyl, I'm not really sure which, but do you see any commonality in the demographics of drug problems and drug usage across Canada, whether it be age, income, gender or ethnicity? Are there some determinants that we can get some data on to try to make some conclusions that would, we hope, assist the government in finding solutions for this widespread epidemic? I really do think it is an epidemic.
What can we do to try to collect more information than we currently have? I have not heard anyone yet in discussions talk about drug-use problems in small towns with populations of under 5,000 people, for example. What do we need to do to collect the data to assist us and any future government in trying to address this most serious problem?
Clinical Associate Professor, University of British Columbia, Vancouver Coastal Health
Thank you for that. I think my colleagues on the panel here are well aware of our need for more data collection in real time, so that we will know exactly what's happening and what the appropriate, if possible, response is to that local condition. I have experience only with Vancouver, as well as the Northwest Territories. One of the issues that may be relevant for us across Canada is what I saw when large numbers of people with mental illnesses were released from large psychiatric hospitals into the community—but not to a lovely community. What were they released into? They were released into the inner city in Vancouver.
These vulnerable people were released into SROs. They were released into drug use. They were introduced to drug use, which, as I described, actually has some psychometric effects on the patients that they enjoyed. Within a month of being released, they were using injection drugs. Within three months, they were HIV-positive.
That was a policy decision. That was not something that those patients sought. How we care for people with vulnerabilities, whether they are psychiatric, trauma or culturally destroyed backgrounds, is really important. I think we need to think about those policies, and their potential effects on vulnerable people, before we make them willy-nilly.
The latest is, “Let's close all the institutions.” Very good point, but what do we replace them with? Currently, in Vancouver, what do we replace our psychiatric care with? It changes monthly. If I'm on the psychiatric ward in St. Paul's Hospital, the psychiatrist will say, “I actually don't know where I'm sending this vulnerable patient now.” They need psychiatric housing. It's changed so much. We need a robust system everywhere, but we need to be careful, and think thoroughly about what our policies are going to do to these vulnerable people.