Evidence of meeting #18 for Health in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was police.
A recording is available from Parliament.
9:15 a.m.
Liberal
The Chair Liberal Bill Casey
Thank you very much. You fit in the time nicely. I appreciate that.
Our next presenter is the Centretown Community Health Centre, and we have Sarah Brown from Ottawa.
September 20th, 2016 / 9:15 a.m.
Sarah Brown Harm Reduction Worker, Centretown Community Health Centre
Good morning and thank you for this opportunity.
I understand that you've received a great deal of evidence on the realities of overdose and the opioid crisis in Canada. I'm here today to offer a front-line perspective and talk about how Bill C-224 would improve community health.
I want to preface my statement by imploring this committee to hear from the community of folks who are most directly affected by overdose and criminalization, and that is the community of people who use drugs. I am here with one member of that community, my colleague, Christine Lalonde. I'm a front-line harm reduction worker at Centretown Community Health Centre, just 10 blocks from Parliament Hill. Every day I provide safer injecting and safer smoking supplies to people who use drugs in this city. In addition to distributing supplies and offering health education and referrals, I also listen, support, and build trust with people who use drugs. At times I am the first and only point of health care contact for folks who use drugs.
Nearly every person I talk to about overdose has had a personal experience with it. Either they have overdosed themselves or they have been present at an overdose. I have worked with people who have overdosed and died in Ottawa's parks, overdosed and been resuscitated in shopping centre washrooms, and folks who have had peers overdose and die in their homes. Community members continue to be apprehensive about calling 911 in overdose situations. Calls occur less than 50% of the time, according to Ottawa Public Health, due to concerns about police presence, fear of arrest, or being implicated in the overdose. Individuals who do call 911 often report being heavily questioned by the police, assumed to be suspicious rather than praised as quick-thinking witnesses.
If you are someone who has regular contact with police and the criminal justice system, you may be reluctant to involve the police in an overdose situation. Past charges and criminal records have a way of influencing police behaviour. One man I work with who has a long history with the police in Ottawa has instructed his partner to never call 911 if he overdoses. He knows he will face charges if that happens. The last time he overdosed, his partner ran to the nearest fire station and asked them to help but not to involve police. Criminalization impacts this community's health. People who use drugs are incredibly stigmatized in our culture. They are frequently judged for their behaviour and perceived as undeserving of care. This stigmatization plays out in health care settings and impacts people's decisions to seek care, be it with their own doctor, or by calling 911 for an overdose. While our law and law enforcement need to adjust their attitudes towards people who use drugs, so too do we as Canadians. Bill C-224 challenges criminalization and stigma by prioritizing public health and safety at overdose scenes.
There are a great many drug policies that you as decision-makers can implement to address the opioid crisis in Canada, which include decriminalizing the use of all drugs, supporting the expansion of supervised consumption services and take-home naloxone programs, increasing access to drug and alcohol treatment, opioid substitution therapy, and medical marijuana. The good Samaritan drug overdose act is just one of a multitude of strategies this country desperately needs to respond to the current public health crisis.
Like some of your previous witnesses and members of this committee, I feel the immunity outlined in this bill needs to be broader than possession. Nevertheless, I support this bill as a first step and I applaud MP McKinnon for proposing it and using his position to support the lives of people who use drugs. Bill C-224 is a harm reduction strategy that this committee has the influence to pass into law. A common definition of harm reduction is “any step towards greater safety is a step in the right direction”. Bill C-224 is a step towards greater safety.
Thank you.
9:20 a.m.
Liberal
The Chair Liberal Bill Casey
Thank you very much.
Next, we have Professor Jane Buxton from the University of British Columbia.
9:20 a.m.
Dr. Jane Buxton Professor, University of British Columbia; Epidemiologist and Harm Reduction Lead BC Centre for Disease Control, As an Individual
Thank you for the opportunity to present today. I'm a public health physician and a professor at the School of Population and Public Health. I'm also the harm reduction lead at the BC Centre for Disease Control.
I wish to provide some evidence about the overdose crisis in B.C., the emergence of fentanyl, and the importance of calling 911.
The BC Drug Overdose and Alert Partnership was developed following an increase in illicit drug overdose deaths in 2011. Members include stakeholders from health enforcement, emergency services, coroners, researchers, and people with lived experience. The goal is to coordinate communication and action to enable timely alerting and responses to illicit drug issues.
The B.C. take-home naloxone program was introduced in 2012 and provides overdose training and naloxone to people in the community. It enables naloxone administration by bystanders while waiting for any emergency health services to arrive. We've had over 2,000 overdose reversals reported.
An opioid overdose crisis is occurring in Canada. A public health emergency was declared in B.C. in April 2016 due to rising opioid overdoses. In 2015, there were 505 illicit drug overdose deaths, which is the highest number ever recorded, and in the first seven months of 2016, there have been 433 deaths. We're on route for 750 deaths in the current year.
The proportion of deaths where fentanyl has been detected increased from 5% in 2012 to 30% in 2015 and to a staggering 62% in 2016 year to date. Fentanyl is also increasingly identified in Alberta and across Canada. Fentanyl is a synthetic opioid often described as 80 times more potent than morphine. In an unregulated market, there is no control of the amount and dose of fentanyl in illegal drugs. The Health Canada laboratory has found pure fentanyl in powder sold as heroin and in varying, and sometimes fatal, concentrations of fentanyl in fake OxyContin tablets.
Although some people may intentionally take or seek out fentanyl, many don't know they have taken it. In a study performed in B.C. last year, we found almost three quarters of those who had fentanyl detected in their urine were unaware that they had taken fentanyl.
In an opioid overdose, the breathing slows and a person becomes unconscious. Lack of oxygen to the brain even for a short period of time can cause brain damage and death. The onset of a fentanyl overdose is much faster than other opioids. As we've heard, the effect of naloxone wears off after 20 minutes, and the high concentration of fentanyl in drugs requires large and often repeat doses of naloxone. It's vitally important to restore breathing as soon as possible and seek professional help for immediate and ongoing assistance.
People who administer naloxone in B.C. complete an administration form. The program emphasizes the importance of calling 911, and although the proportion that call 911 has increased over time, in 2015, 30% of people responding to an overdose did not call 911. It varies by region. Approximately 82% of people in Vancouver call 911, but less than 60% in regions outside of Vancouver do. The differences by region may reflect previous interactions with the police and policing policy, and the influence of other bystanders.
Enforcement members of the Drug Overdose and Alert Partnership have shared that most police would not make an arrest for simple possession of drugs in B.C., but this may vary by province. A good Samaritan act would ensure consistency across the country.
We also found people were more than 10 times more likely to call 911 if the overdose took place on the street rather than in a private residence. That may be because they're concerned about the residence being identified and the ability to flee if police arrive.
To explore reasons why people didn't call 911, we interviewed 20 naloxone program participants. They shared the barriers to contacting emergency services during an overdose, which included concerns about being arrested for illegal activities such as drug possession, breach of probation or parole, and outstanding warrants. Police were noted to be collecting the names of those present at an overdose scene and checking the police database.
We also heard stories about people who had overdosed being dragged down stairs into the street before 911 was called, and people calling 911 and then leaving the scene rather than staying with the person until first responders arrived.
According to a review by the U.S. National Conference of State Legislatures, good Samaritan or 911 drug immunity laws are enacted in 37 states and provide immunity from supervision violations and low-level drug possession and use offences. However, a recent study of young adults in Rhode Island found fewer than half were actually aware of the good Samaritan law.
It's important if Bill C-224 were to be enacted that this would be communicated broadly to the populations at risk of witnessing or having an overdose. Dissemination will require different approaches for youth experimenting with drugs and afraid of arrest and parents being informed compared to those with substance use disorders.
In summary, fentanyl prevalence in illegal drugs is increasing. Fentanyl has a rapid and long duration of action and overdoses may need large and repeat doses of naloxone. Therefore, it is imperative to call 911 and receive rapid and professional help. There is evidence that fear of arrest deters people from calling 911, and that good Samaritan laws can increase the likelihood of calling for medical assistance if people are aware. Expanding immunity in Bill C-224 beyond simple possession to include supervision violations could increase the rate of calling 911 and thus prevent further brain damage and save lives.
Thank you for your attention.
9:25 a.m.
Liberal
The Chair Liberal Bill Casey
Thank you very much.
From the Paramedic Association of Canada we have Mr. Pierre Poirier.
9:25 a.m.
Pierre Poirier Executive Director, Paramedic Association of Canada
Good morning. Thank you for the opportunity to speak today. My name is Pierre Poirier. I'm the executive director of the Paramedic Association of Canada.
There are approximately 40,000 paramedics in this country, and we respond to almost three million calls annually. I want to note that there are different classifications or designations within the term “paramedic” that cover different scopes of practice, and that's an important detail that I'll refer to later.
The Paramedic Association of Canada absolutely supports Bill C-224, although we have concerns about its application or whether it sufficiently meets the intent to save lives in a timely manner.
I've taken some excerpts from other presenters and have parsed some of their words.
Opioid overdose deaths are preventable with timely intervention. Good Samaritan legislation is one component of a comprehensive public health approach to overdose within a harm reduction paradigm. We need to improve the community response of Canada as part of a comprehensive response to overdose deaths. The community response must involve a comprehensive approach.
Let's make naloxone available, absolutely. Let's provide naloxone to the overdose victim in a timely manner, because seconds count. Let's coordinate the health care system on this important issue—and that's an important piece that I want to make reference to—with consideration of the alignment of a federal initiative with the provincial mandate in the health care system and with the way we approach health care.
This is an important piece that I want to spend a couple of seconds on. I have to admit that change has been rapid, but I still don't think our addressing of this issue has been fast enough. Paramedics regularly respond to incidents in which an individual has overdosed. We provide medical care. This is a life-and-death event.
Let me explain how a patient is treated. There is the 911 call, and paramedics are requested. Police are often asked to attend for safety and security reasons. Recognizing the triage system and that for a medical emergency it is the paramedic who is called and not necessarily that police go to attend to every call is, I think, an important point.
The paramedic will assess the patient and determine an overdose. This is the important piece: often the paramedic is required to call a physician for permission to administer naloxone, and oftentimes some paramedics may not have permission to provide this drug in this country. That's an important distinction. We have this law that approaches it in good Samaritan terms and as a public health issue, but we should also recognize that the individual providing care may not be allowed to provide the care that is really intended or that is life-saving. This is important as an issue.
Here is the problem. I noted earlier that seconds matter in this life-and-death situation. In the event I described, paramedics may not have permission to administer naloxone. That could happen in Saskatchewan, Ontario, Nova Scotia, and Newfoundland.
Also, if they do have permission.... They may be required to call for permission to administer. A paramedic who administered without permission would now be subject to discipline by the health care system or by a regulatory agency to which they report. This is a significant issue.
On the one hand, then, we would have legislation that supports an individual's providing it, but by the same token a paramedic on scene may not have that permission. How do we resolve this? There are a few things.
I have to admit that I'm not familiar with all the nuances of the prescription drug list and its relationship to the Controlled Drugs and Substances Act, but if we were to remove naloxone from schedule I of the Controlled Drugs and Substances Act, that might actually help the situation.
One question is whether there is really a need that naloxone continue to exist within schedule I. I think there are important lessons to learn. Paramedics often work under medically delegated acts or things with that description. When we went through the last 40 years of experience with AEDs, automated external defibrillators, we came to a point at which we made them publicly accessible, but we removed the designation of their use being a medically delegated act, which really benefited the community and all health care providers in that situation.
I'm not sure that we can consider Bill C-224 is applicable to all Canadians, and that would be a motivation behind this, because if you look at good Samaritan legislation, if there's remuneration, there is no longer the cover of the good Samaritan legislation. Paramedics in the performance of their duties are deemed to be providing a service and therefore being paid to provide that service, and therefore are not provided the cover of the good Samaritan legislation. That's an issue, and I think it can be resolved.
Last, we should consider other applications of the drug, and look at the provision of naloxone in a similar manner to the development of EpiPens. You don't need to provide it as an injection; it can be provided as a nasal spray or by other methodologies. That wouldn't require it to be a medically delegated act, and it would be a simpler, more accessible, easier way of providing a service to our community.
Thank you for the opportunity to speak today.
9:30 a.m.
Liberal
The Chair Liberal Bill Casey
I want to thank all of you for your presentations. All of you experience a reality that we don't experience, and I compliment you on the job you do and thank you for it. I can only imagine what your day is like for some of you. I appreciate your contribution. You've already taught us a lot.
We're going to start questions with Ms. Sidhu.
9:30 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thank you, witnesses, for coming here today and giving us your expert testimony about this important issue. It is very enlightening. My question is for all the witnesses.
Can you tell us what evidence there is, if any, that bystanders are not seeking emergency assistance in suspected overdose cases because of a fear of being prosecuted?
We can start with Mr. Poirier.
9:30 a.m.
Executive Director, Paramedic Association of Canada
I think it has been noted previously that it's about half the emergency calls, and paramedics respond to probably about three million calls across this country. I don't have the number of overdose calls we attend to. That data isn't available, but as was noted before, half our calls are ones where people do not call for fear of an overdose offence.
9:35 a.m.
Professor, University of British Columbia; Epidemiologist and Harm Reduction Lead BC Centre for Disease Control, As an Individual
As I mentioned, 37 states in the U.S. have good Samaritan or 911 drug immunity laws and they also sometimes are for low-level possession, but often will include supervision violations as well. There is evidence when they did a survey in Washington state, the vast majority—88% of people who used opioids—indicated they would be more likely to call 911 during a future overdose, knowing it was there. But there is the issue of making sure that people are aware of the good Samaritan law, and I think that's where we need to make sure it happens.
9:35 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Sarah Brown, is there any evidence in other places and jurisdictions that having a good Samaritan overdose law in place increases reports of overdoses? Do these laws make a difference?
9:35 a.m.
Harm Reduction Worker, Centretown Community Health Centre
I'm not sure about whether or not they make a difference in other communities. I can speak to the community here. I think they would make a difference in our city. Yes, I think more people would call if they knew they wouldn't be charged for possession.
9:35 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
Thanks.
When we had Donald MacPherson from the Pivot Legal Society come before this committee in June, he talked about how such laws and policies should try to restrict police attendance to overdose calls. He said that police should maybe only show up if there are public safety issues.
Do you agree that restricting police attendance at routine overdose events would do what Bill C-224 is intending to do?
9:35 a.m.
Professor, University of British Columbia; Epidemiologist and Harm Reduction Lead BC Centre for Disease Control, As an Individual
Certainly, for the last 10 or so years, Vancouver police have not routinely attended overdoses. There are obviously certain times where the police will attend whether it's due to a death, whether there's concern around violence, or safety of the responders and the police. As I mentioned, in Vancouver, in the study that we did, 82% of people actually called 911 in an overdose situation compared to 60% or less in other regions. I think it has made a difference.
BC Emergency Health Services introduced a new policy in June such that they will not inform police and enforcement except in certain circumstances which include the ones I've mentioned, but also if there's concern on chemical biological radiological terrorism, anything like that, but also attempted suicide.
9:35 a.m.
Liberal
Sonia Sidhu Liberal Brampton South, ON
The definition of overdose in the bill notes that a reasonable person would believe that the situation requires emergency medical or law enforcement assistance. Given that individuals in the circumstances encompassed by Bill C-224 may be impaired by drugs or alcohol, could the use of the reasonable person standard in the definition of overdose be problematic? Please explain why or why not.
My question is for Dr. Buxton.
9:35 a.m.
Professor, University of British Columbia; Epidemiologist and Harm Reduction Lead BC Centre for Disease Control, As an Individual
I know overdose is when somebody has over and above what the body can tolerate. We do know that, frequently, it's not just a single substance that is causing the overdose, and it may be taken intentionally or unintentionally.
We know that people can respond and if they make a plan, can contact emergency services. People can respond and use the naloxone very effectively as a bystander. We're well aware that people who are in a situation can call 911 and it really does make a difference.
9:40 a.m.
Conservative
Colin Carrie Conservative Oshawa, ON
I want to thank everyone here because this is an extremely important bill. I want to thank the witnesses for being here today because it's vital that we all work together to combat drug overdose and help save the lives of those who have lost their way or, as was mentioned, people who are just experimenting.
I want to thank Mr. Poirier for pointing out a loophole that maybe we have overlooked something in regard to the paramedics who, as you quite correctly pointed out, Mr. Poirier, you guys are the guys on the ground. We do have the parliamentary secretary here who is monitoring the committee, and we also have an emergency care physician which we are very fortunate to have.
If there's some type of a regulatory change that could be made that would make your job on the ground better and not give your members a situation where they could be confronting a risk for actually saving a life, that's something we could all support. Thank you for pointing that out.
I also want to thank you for pointing out that this bill is really important, but it's only part of a comprehensive and coordinated approach to work with our provinces and territories. I thank you for your positive suggestions to improve the bill.
We can't ignore that a major issue when it comes to overdose is that there's currently nothing in the pipe. You mentioned prevention. There doesn't appear to be a lot in the pipe to prevent overdose. We're facing this crisis. We're looking at Canadians, as was pointed out, being number one in the world with opioids. Something needs to be done.
We can enable addiction by providing, whether it's a syringe or heroin, whatever, but it does nothing to treat the problem.
I'd like to read a quote from the International Task Force on Strategic Drug Policy, which stated:
We oppose so-called `harm reduction´ strategies as endpoints that promote the false notion that there are safe or responsible ways to use drugs. That is, strategies in which the primary goal is to enable drug users to maintain addictive, destructive, and compulsive behaviour by misleading users about some drug risks while ignoring others.
We must not forget that addiction is a treatable and, in fact, a curable disease. Putting bills like this one forward is a positive step in the right direction. There's still little being done by governments to actually help treat drug addiction, and we need to address that.
With that statement, I do have some questions for you. Maybe I'll start with Mr. Poirier.
When an overdose happens, who would you say that your members see? Who is more likely to call for help? Is it the avid drug users, individuals battling addiction or familiar with overdosing, or is it just basically somebody who is around there? Who do you see as the major people who are actually calling you in?
9:40 a.m.
Executive Director, Paramedic Association of Canada
For the most part, it is a bystander or somebody who is nearby. There are many scenarios, but oftentimes it is a loved one of that individual. This is the first scenario. In the second scenario, it is a bystander who recognizes somebody is unconscious or unresponsive. This is the terminology we use. Those would be the two designations or categories by which we receive those calls, usually: a bystander or family member or loved one.
9:40 a.m.
Conservative
Colin Carrie Conservative Oshawa, ON
Are you seeing a lot of calls now where people are just at parties and suddenly you get called in?
9:40 a.m.
Conservative
Colin Carrie Conservative Oshawa, ON
If this bill were to become law, I believe the general public would need to be made aware of it in order for it to do its job. How do you think this should be communicated with citizens in order for the bill to be successful?
9:40 a.m.
Executive Director, Paramedic Association of Canada
This is a tough question. I think there is absolutely a requirement that it become part of a communication strategy on a national basis, because this truly is an epidemic. The health community has recognized this, probably going back five years, at least. We are just catching up in terms of legislation and what we do.
Without promoting drug use or drug abuse, I think it is absolutely a requirement that this be communicated broadly and be part of a national strategy on this issue, absolutely.