Health Committee on Oct. 4th, 2016

[The Vice-Chair, Conservative, Len Webber]

Hello, everyone, colleagues and witnesses. We are going to start the meeting, even though we have a few members missing. They'll come trickling in here eventually.

I would like to thank you all for joining us here today for this very important meeting. On September 22, 2016, just about a week and a half ago, the House of Commons Standing Committee on Health adopted the following motion from MP Don Davies:

That, pursuant to Standing Order 108(2), the Committee undertake an emergency study of the opioid crisis in Canada.

Today, we will begin that study. We will continue on this study for several meetings. It is my hope that the witnesses, in their testimony, focus on solutions, specifically solutions the federal government can participate in. There is a problem here in Canada, and it is well known. There is one fentanyl overdose death every 14 hours in Canada, and the problem is getting worse. We need to act very urgently.

We have a variety of witnesses lined up who will offer their own unique perspectives and suggestions. We know that there is no silver bullet solution, so this study will be important in providing us with a tool box of solutions that we can consider. I appreciate that we are all concerned about this issue.

With that, let's hear from our witnesses. To start, I'd like to introduce some witnesses from Health Canada.

We have Hilary Geller, who is the assistant deputy minister for the healthy environments and consumer safety branch at Health Canada. She holds a degree in business administration from York in Toronto, and she has been with Health Canada since 2007. Welcome, Hilary.

We have Supriya Sharma, who is a senior medical adviser to Ms. Geller. She is a medical doctor and has a master's in public health from Harvard University. She has been with Health Canada for almost 12 years in various roles.

We also have Rita Notarandrea, CEO of the Canadian Centre on Substance Abuse, and she has been with the CCSA for 10 years. Previously, she spent 21 years with the Royal Ottawa hospital, a large psychiatric institution, including 13 years as a CEO there. Welcome, Rita.

Also from the Canadian Centre on Substance Abuse, we have Matthew Young. Sorry, I don't have any biography for you, Matthew. Maybe you could tell us all about yourself when you're up.

From the Royal Canadian Mounted Police, we have Todd Shean, assistant commissioner for federal policing special services. This division has responsibility for border integrity and national intelligence coordination, among other things. Mr. Shean has been a police officer for 30 years. While in the rank of chief superintendent, he was responsible for drug and organized crime national operations.

We also have Luc Chicoine. Luc, I just have your business card here, so I'll just read that. Luc is a national drug program coordinator with the RCMP, at the federal coordination centre here in Ottawa.

We also have Caroline Xavier, vice-president of operations at Canada Border Services Agency. Caroline has a master's degree from Dalhousie, and an executive diploma from Harvard. She has been with the CBSA for about six years. As we all know, CBSA has responsibility for securing Canada's land and maritime borders.

We also have Mr. Brent Diverty, vice-president of programs at the Canadian Institute for Health Information. He has a master's degree in economics and has previously worked for Stats Canada. He recently spent two years working with the equivalent agency in Australia.

Welcome, everyone.

I would like to just quickly go around our table here to introduce my colleagues to you. We can start with Darshan.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

I'm Darshan Kang, member of Parliament for Calgary Skyview.

Good morning, everybody.

[John Oliver, Liberal, Oakville, ON]

I'm John Oliver, member of Parliament for Oakville.

Good morning.

[Randeep Sarai, Liberal, Surrey Centre, BC]

I'm Randeep Sarai, member of Parliament for Surrey Centre.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

I'm Doug Eyolfson, member of Parliament for Charleswood—St. James—Assiniboia—Headingley in Winnipeg.

[Sonia Sidhu, Liberal, Brampton South, ON]

Good morning.

I'm Sonia Sidhu, member of Parliament for Brampton South.

[Ron McKinnon, Liberal, Coquitlam—Port Coquitlam, BC]

Good morning.

I'm Ron McKinnon, member of Parliament for Coquitlam—Port Coquitlam.

[Colin Carrie, Conservative, Oshawa, ON]

I'm Colin Carrie, MP for Oshawa.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm Don Davies, member of Parliament for Vancouver Kingsway.

Thank you for being with us.

[The Vice-Chair, Conservative, Len Webber]

Rachael, do you want to quickly introduce yourself?

[Rachael Thomas, Conservative, Lethbridge, AB]

I'm Rachael Harder, member of Parliament for Lethbridge in Alberta.

[The Vice-Chair, Conservative, Len Webber]

All right. We'll get started with the presentations now. We have round one. We will start with the Department of Health, Hilary and Supriya.

[Hilary Geller, Assistant Deputy Minister, Healthy Environments and Consumer Safety Branch, Department of Health]

Thank you, Mr. Chair.

Good morning. On behalf of Dr. Sharma and Brent Diverty, I'd like to thank you very much for the opportunity to appear today.

As you know, British Columbia is at the epicentre of the current crisis of drug overdose and deaths, with the B.C. Coroners Service reporting that there was a 62% increase in illicit drug overdoses from January to August of this year compared to the same period of last year. According to the B.C. Centre for Disease Control, if this trend continues, B.C. could see 800 illicit drug overdose deaths by the end of the year, with nearly half of those expected to involve fentanyl. Yet, the most recently available national data from the Canadian tobacco, alcohol and drugs survey did not show increases in the use of the most common illicit drugs.

What has changed?

What seems to be accounting for the unprecedented rise in deaths is the increased presence of fentanyl on the illicit market, an opioid that is significantly stronger than morphine. According to the B.C. coroner, there were 264 illicit drug overdose deaths where fentanyl was detected from January through July, a 222% increase from the same period in 2015. lnsite, one of two supervised consumption sites in Canada, recently began providing test strips as a pilot project at their site so that users of their services could test their drugs. They report that 86% of those samples tested positive for fentanyl.

As you'll no doubt hear from the CEO of the Canadian Centre on Substance Abuse, the Canadian Community Epidemiology Network on Drug Use flagged that deaths linked to fentanyl have increased markedly across the country. As you will no doubt hear from our colleagues from the RCMP, this also reflects what law enforcement is seeing.

While illicit drug use has always been a high-risk behaviour, with the exact composition and strength of the substance being unknown, fentanyl has increased those risks immeasurably. As British Columbia's provincial health officer, Dr. Perry Kendall, has said, no one is immune. People with long histories of drug use are overdosing, as are people trying drugs for the very first time.

In terms of critical actions to deal with the immediate crisis of overdose and deaths, many experts are calling for three things: increased availability of naloxone, increased availability of supervised consumption sites, and increased availability of treatment, including medication-assisted therapies.

Health Canada is responding to each of these three calls to action. We have made naloxone more widely available by removing the requirement to have a prescription. This was the first time that Health Canada initiated the removal of the prescription requirement for a drug to respond to a public health need. In addition, the Minister of Health issued an emergency order on July 5 to allow immediate access to the more user-friendly nasal spray form of this medication. I'm pleased to note that yesterday it was announced that the department has completed its expedited review of this nasal spray form of naloxone, thereby regularizing its availability in Canada.

In the case of supervised consumption sites, evidence has shown that, when properly established and maintained, they can save lives, all without increasing drug use and crime in the surrounding area. These supervised consumption sites decrease the number of deaths by overdose, and they can redirect injection drug users to health and social services. In addition, they reduce public drug use, rates of infection, and unsafe syringe disposal.

I would like to note that Health Canada has heard concerns with regard to the legislative requirements contained in the Controlled Drugs and Substances Act related to the establishment of supervised consumption sites. Further to direction from our minister, we are working closely with potential applicants to explain the legislative requirements in order to ensure there are no unnecessary barriers for communities that wish to open such a site. In addition, we are looking at the legislation to assess whether amendments may be advisable.

In this context, it is important to recognize that the application review and authorization process seeks to ensure that supervised consumption sites are established based on evidence and with sufficient support so that these sites will be properly maintained. These rigorous criteria protect the health and safety of both the clients and staff and give confidence to the community that there is a process in place to ensure that these facilities are operating responsibly.

Health Canada is also supporting access to medication-assisted treatment options. For example, a regulatory amendment was recently published to allow for the consideration of applications for medical-grade diacetylmorphine under Health Canada's special access program, as scientific evidence supports the use of heroin in select cases for the treatment of chronic relapsing opioid dependence. This same type of medical treatment with heroin has also been used in several European countries under very specific circumstances and provides a treatment option for the very small percentage of patients who have not responded to other treatments.

This winter, we also intend to consult stakeholders on the regulatory requirements for physicians to obtain an exemption to prescribe methadone in order to determine whether that requirement is an unnecessary barrier to treatment.

Health Canada also recognizes the importance of research to assist us in making evidence-based decisions, including as it relates to medication-assisted treatment.

Through the Canadian Institutes of Health Research, we are making important investments in research to help build the evidence on which key policy decisions are made. The OPTIMA study is just one project the CIHR is supporting. It will compare and evaluate the effectiveness of two treatments for prescription opioid dependence—methadone and the combination of buprenorphine and naloxone—with the goal of generating practice-based evidence that will inform patient care and improve health outcomes in Canada.

Beyond the harm reduction measures described above, I anticipate that others, including the RCMP, will highlight the importance of addressing the supply side of the opioid crisis.

Within the purview of Health Canada, the intention to put forward regulatory amendments to control six chemicals that are used in the illicit production of fentanyl was announced last month. The comment period for this regulatory proposal closed yesterday, and we will be moving forward expeditiously to control these precursor chemicals. The Minister of Health has also stated that she intends to bring forward legislative options for consideration on the issue of pill presses.

Stepping back from the immediate crisis of overdose and death, it's important that the numerous individuals and organizations with a role to play in addressing various aspects related to the root cause of the opioid crisis come together. It's only by taking a collaborative, comprehensive, evidence-based, and sustained approach that we can make a difference in the long term.

Important foundational work is well under way. Following the 2014 HESA report on the government's role in addressing prescription drug abuse, the report of the Canadian Centre on Substance Abuse, “First Do No Harm”, and the input of many stakeholders, budget 2014 funding of $44 million over five years has allowed many of the initiatives identified in these studies to move forward.

I will give just a few examples. Updated opioid prescribing guidelines will be available early in the new year. Nineteen new inspectors have been hired and are on track for over 1,000 inspections of community pharmacies. Public awareness campaigns have been run. The Canadian Institute for Health Information is using $4 million in funding to strengthen surveillance and data collection. The first nations and Inuit health branch of Health Canada is investing $13 million over five years to increase support for improved training for community-based addictions workers and to establish crisis response teams.

Building on this, Minister Philpott called on the department in April to look at all possible options to take action in addressing this crisis. That work led to Minister Philpott's announcement in June of a five-point action plan that aims to influence the root causes and reduce the potential for harm, both in its most extreme manifestations as an overdose death but also for so many other Canadians who experience harm from problematic opioid use.

Given the challenges and complexities of this public health emergency, it's clear that our response to the crisis requires leadership among many different players, as well as a coordinated approach. To quote the Canadian Medical Association in a statement they made last year, “The unfortunate reality is that no single level of government, no single health provider group and no single sector of our society can resolve this complex crisis on its own.”

For this reason, the Minister of Health and the Honourable Eric Hoskins, Ontario's Minister of Health, as co-chairs of the conference of federal, provincial and territorial ministers of health, will be co-hosting a conference and summit in the middle of next month to discuss the current problem of opioid misuse in Canada and to identify further potential ways forward. The smaller summit following the conference will bring together individuals and organizations who have both the authorities and the commitment to take concrete action in combatting the opioid crisis.

I'd like to thank the committee for the opportunity to speak to you today.

My colleagues and I will be pleased to answer all your questions

Thank you.

[The Vice-Chair, Conservative, Len Webber]

Thank you, Ms. Geller.

We'll move to our next presenter, Brent Diverty, from the Canadian Institute for Health Information.

Brent, go ahead with your presentation.

[Brent Diverty, Vice-President, Programs, Canadian Institute for Health Information]

I'm actually not here with a planned presentation. I'm here supporting Hilary and to answer any questions you have about some of the data we have available to look at this issue.

[The Vice-Chair, Conservative, Len Webber]

Thanks, Brent.

Then we'll move to the Royal Canadian Mounted Police, and we'll start with Todd Shean.

[A/Commr Todd G. Shean, Assistant Commissioner, Federal Policing Special Services, Royal Canadian Mounted Police]

Good morning, Mr. Chair, and thank you for the opportunity to speak to the committee this morning.

As we are well aware, there has been a staggering increase in opioid overdoses in Canada, both lethal and non-lethal, which is the reason that this issue must be treated as a crisis. Canada and the U.S. have been facing a similar crisis related to the abuse of opioids causing a large incidence of overdoses. As such, the U.S. has had the most fatal overdoses from opioids in the world while Canada follows in second place.

The increase in overdoses and fatalities linked to opioid abuse can be associated with the diversion of licit pharmaceutical opioids as well as with the increased availability and access to illicit opioids such as the fentanyls. The highly potent nature of synthetic opioids is well documented; in particular, fentanyl is estimated to be up to 100 times more potent than morphine. The mere exposure to it, whether it is via inhalation of air-borne powder or absorption through the skin, can result in serious and life-threatening consequences.

Since 2010, seizures of illicit fentanyl have been made all across the country, and this continues to increase. Important seizures continue to be made on a regular basis in areas of the country, such as British Columbia, Alberta, Saskatchewan, and Ontario, where high numbers of overdoses are also being reported regularly.

The current upsurge in illicit fentanyl is expanding geographically, facilitated by known organized crime groups and local drug trafficking networks. The constant demand has promoted the illicit importation of several analogues to fentanyl. For decades, Canada-based organized crime networks and drug traffickers have produced illicit synthetic drugs in both powder and tablet forms. Illicit fentanyl has been accessed as a replacement to conventional drugs of abuse, as well as used as an additive to other drugs, often without the user's knowledge.

Fentanyl is a significant concern, but the illicit opioid market is evolving at an alarming rate. As a primary example, in December 2015, a substance known as W-18 emerged in Canada, in what was thought to be a fentanyl seizure. Also imported from abroad, it was reported that W-18 is 100 times stronger than fentanyl and known to be fatal in very small doses.

Investigations and intelligence reports indicate that British Columbia is the main distribution point for fentanyl tablets and is the most affected province. This may be due to its geographical situation in relation to the main producer of fentanyl in the world, China.

Domestic production of fentanyl has also been identified, but in low numbers.Our federal investigators are currently working on a variety of investigations involving fentanyl importations. Shipments are coming into Canada disguised or labelled in a variety of ways such as printer ink, toys and DVDs.

Once in Canada, pure fentanyl is diluted using cutting agents. It is then manufactured in the final product, which can be in tablet form or powder form, in clandestine labs before being distributed throughout Canada and to a lesser extent the U.S. Illicit fentanyl trafficking offers a significant profit margin. By way of example, it is reported that the raw material cost to produce one million fentanyl pills is under $100,000, but once sold, these tablets can yield profits of upwards to $20 million. These profits, coupled with easy access to supply markets and a growing demand, are likely to mean that the situation will not abate any time soon.

Recognizing the potency of synthetic opioids has highlighted the immediate urgency to ensure the protection and safety of front-line police officers, border officers, postal workers, and the public writ large. As a result, the RCMP has engaged in a number of safety awareness initiatives for front-line officers and the general public.

In the past year and more recently, officer safety bulletins were distributed throughout the RCMP, addressing the safe handling of unknown substances, including fentanyl, and outlining the risks, hazards, and necessary precautions that must be taken.

We have made presentations to the provincial law enforcement community and other government departments as well as publicly releasing a video via social media which highlights some of the dangers that synthetic opioids pose to first responders and the public, and steps to protect themselves if there is a suspicion of possible exposure.

The RCMP has purchased 13,700 naloxone nasal spray kits which were distributed across the Force. Naloxone is an antidote to fentanyl that quickly reverses the symptoms of exposure to fentanyl and other opioids.

The kits are being carried by on-duty operational police officers and employees who are at risk of accidental exposure and who may be required to provide first-aid treatment to citizens in an emergency situation if an opiate overdose is suspected.

The RCMP has developed mandatory training for officers, as well as operational policies that address fentanyl and other opiate overdoses. With respect to collaborative efforts, the RCMP continues to consult with various stakeholders on outreach materials, and we are currently working to produce additional awareness of products to help police, youth, and parents to understand the impact of fentanyl.

Where are these illicit synthetic opioids coming from? According to RCMP criminal intelligence reports and investigations, it is apparent that China is the main source country for these drugs entering Canada, particularly fentanyl.

The growing threat from fentanyl, related precursors, and other novel synthetic opioids is directly correlated with a huge industry producing these substances within China.

Anchored between domestic criminal entities and those based in China is the Internet. The surface web and the dark web enable criminals to anonymously create global supply chains for a range of illegal goods and services, and acts as a platform for criminal expert forums. The RCMP has been building relations with our law enforcement counterparts in China in an effort to strengthen collaboration wherever possible to combat criminal activities with the goal of disrupting international drug trafficking networks.

In October 2015, the Chinese government completed regulatory amendments controlling 116 new substances, including some fentanyl analogues, but the drugs that made it to Canada are not controlled in China. In addition, there's a disparity between what Canada and China consider a public health crisis simply based on population numbers. Fentanyl abuse has not been identified in China. The Chinese government's focus is on other synthetic drugs of abuse like methamphetamine and ketamine.

As mentioned earlier, our U.S. counterparts have also been faced with the illicit synthetic opioid epidemic and have identified Mexico as their main source of distribution. However, it must be noted that the drugs that are entering Canada from China are also evident in the U.S.

The RCMP is working at home here in Canada with other government departments to raise awareness about the challenge, gather data on the scope of the problem, and collaborate with communities to stem the flow of illicit synthetic opioids that are having such a destructive impact. Alerts were put out as early as June 2013 by the Canadian Centre on Substance Abuse. Internationally, the RCMP has liaison officers and analysts who are deployed all around the world. They are tasked with providing direction, support and assistance to Canadian law enforcement agencies in the prevention and detection of offences relating to Canadian laws. As such, they liaise with foreign agencies and develop partnerships to address issues of concern to the RCMP and Canadian government.

The RCMP actively participates in the international narcotics control task force, which is a forum of countries that discuss both domestic issues as well as investigations with international dimensions. Over 30 countries, including China, participate in the task force. We have used this focus group to share information in relation to the Canadian opioid crisis. Discussions at these meetings can strengthen international co-operation by assisting respective countries in considering amendments to the regulatory framework.

In addition, initiatives are being proposed in international forums, such as the G7 law enforcement project groups, to address issues around equipment and new technologies that facilitate the ability to manufacture pills made from bulk active ingredients. Criminals are profiting from new psychoactive substances that haven't yet been regulated by importing these powdered bulk ingredients. As such, law enforcement must think of novel ways to mitigate the presence of these threatening substances within our country.

Let me be clear - as long as criminal entities in Canada maintain vested interests in the opioid market, its expansion will likely continue to accelerate. Continued collaboration and support from Canadian agencies, government departments and our international partners will be necessary to combat this issue.

With that said, I believe that measures taken, under way, or under consideration across Canada will significantly assist in the prevention of fatal overdoses, advancing deterrent strategies and developing early warning systems to rapidly identify and respond to high-threat opioid substances circulating on the illicit market.

Thank you for this opportunity to speak with you today. I look forward to your questions.

[The Vice-Chair, Conservative, Len Webber]

Thank you very much, Todd.

I will move to Caroline Xavier from the Canada Border Services Agency.

Thanks, Caroline.

[Caroline Xavier, Vice-President, Operations Branch, Canada Border Services Agency]

Good morning, Mr. Chair and honourable members.

My name is Caroline Xavier. I appear today on behalf of the Canada Border Services Agency, the CBSA, in my capacity as Vice-President, Operations Branch. I would like to thank the committee for the invitation to speak today.

The opiate situation in Canada is a subject that is of immediate and ongoing concern to the CBSA. Our mandate to keep Canadians safe encompasses a wide range of enforcement and facilitative activities, not least of which is the seizure of harmful drugs at the border. Part of our job is to interrupt the flow of drugs through our borders. This is a job that requires a combination of partnership, technology, and constant vigilance.

Today, I will divide my remarks into three sections.

To begin, I will summarize the operational mandate and role of the CBSA in interdicting drugs at the border, including the importance of partnerships. Next, I will describe some of the technology we are using in identifying and seizing drugs. Finally, I will speak directly to how we are dealing with the fentanyl issue.

Mr. Chair, our operational mandate covers a range of pre, post, and at-border activities. We ensure public safety and national security through risk assessment and intelligence, and through coordinated responses to emergencies, threats, and emerging issues.

Clearly, fentanyl and similar opioids fall in this category. These are the newest and latest substances appearing in increasing volumes, most often found in our postal and courier stream. The most effective approach is to develop awareness of the threat and to mobilize a commanding response.

Our national targeting centre, which is a 24/7 facility, works to identify suspected high-risk people, goods, and conveyances through an integrated, comprehensive risk assessment program. Likewise, we deploy officers around the globe, pushing the border out to manage threats before they arrive at our doorstep. These measures demonstrate our capacity to look beyond the border, to the point of origin, for contraband and other threats.

In addition to our in-house capacities, we are deeply integrated with our law enforcement partners across the spectrum, including the local police services, provincial law enforcement, the RCMP, and our counterparts in the U.S. and other like-minded countries.

The border is an obvious nexus for cooperative enforcement against drug trafficking and major crime.

We are also constantly developing and researching innovative detection technology to assist our officers. There are a number of tools and systems in use at the moment. At the border, digital fingerprint machines allow us to quickly and securely transmit electronic fingerprint data to our partners in the RCMP.

Density meters at major border and marine ports can determine the density of a surface or an object. These meters can discover hidden walls and help us detect contraband.

We also use flexible video probes and X-rays to locate undeclared currency and contraband and fibre scopes to view areas of vehicles and cargo that are not visible to the naked eye. Various tools help us inspect the undercarriage of vehicles and other hard-to-reach areas.

Trace detection technology is used to detect trace amounts of narcotics and explosives on sampled goods and conveyances.

Finally, we are supported as well by a team of detector dogs that assist in the detection of illegal narcotics, firearms, and currency, which is further enhanced by the training we are giving our officers to identify threats and risks, and also supported by a world-recognized science and engineering laboratory.

Mr. Chair, with respect to fentanyl in particular, we've seen an increase in the number of seizures since 2014. Fentanyl powder and equivalent substances are most often smuggled into Canada mainly from China, as was stated by our RCMP colleague, through the postal stream in our case. From January 1, 2010, to September 22, 2016, the CBSA recorded over 115 fentanyl seizures.

Due to the increased volume of packages sent through the postal and courier streams, it can be a challenge for the CBSA to identify and intercept all shipments of concern. Postal and courier shipments are often accompanied by false declarations or are intentionally mislabelled.

The CBSA takes its employees' health and safety very seriously. To that end, safe handling procedures and adequate control measures are in place, including personal protective equipment, to prevent accidental exposures. Furthermore, given the pace of evolution with these products, the agency reviews their adequacy on an on-going basis.

Again, this is where partnerships and our intelligence are important. The CBSA's collaborative efforts to address the fentanyl threat to public safety are ongoing, at the regional, national, and international levels. We leverage our intelligence and work with partners to identify and risk assess subjects and businesses that may be involved in fentanyl trafficking.

We have a number of commercial risk assessment projects designed to intercept fentanyl and other controlled substances arriving via air and marine cargo shipments from China and Hong Kong. Our regional operations are participating in policy agency projects, and our international network has been engaged with customs authorities in China on the fentanyl issue.

The opiate crisis is a challenge that requires considerable resources and coordination. We have a responsibility to all Canadians to focus our efforts and strengthen our collaboration wherever possible.

This is a multi-dimensional challenge. There are significant social, public health, and criminal justice impacts, and part of the solution lies in keeping the substance out of Canada to the greatest extent possible. This is where the CBSA's responsibility lies, and we welcome the opportunity to discuss this further today.

Thank you.

[The Vice-Chair, Conservative, Len Webber]

Thank you, Caroline.

Finally, we'll move to the Canadian Centre on Substance Abuse, Rita Notarandrea and Matthew Young.

Go ahead, Rita.

[Rita Notarandrea, Chief Executive Officer, Canadian Centre on Substance Abuse]

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

My name is Rita Notarandrea and I'm CEO of the Canadian Centre on Substance Abuse.

I am joined today by my colleague Matthew Young, a senior research and policy analyst at CCSA. Dr. Young leads our drug use epidemiology research, which includes the Canadian Community Epidemiology Network on Drug Use, or CCENDU; the student drug use surveys; and work on novel psychoactive substances.

I'd like to begin by thanking the committee members for inviting us here today.

For those of you unfamiliar with CCSA, it 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.

Today I will touch briefly on the crisis, given that others have already spoken to the prevalence and the devastation that individuals and families are experiencing in Canada. I will also mention CCSA's contributions to the federal response. Then, based on our experience with this issue as well as with our partners, I will highlight a few areas for action.

In the past decade, the use of opioids and the harms associated with them have increased dramatically. In response, in 2012 CCSA brought together more than 40 dedicated experts and organizations to determine how best to tackle this national health problem. This diverse group, with ownership in both the problem and its solutions, included physicians, nurses, dentists, pharmacists, coroners, medical examiners, first nations, law enforcement, researchers, and governments.

We all recognized that this was a complex and multi-faceted issue that could not be addressed by one level of government or one organization. Everyone was tackling this in silos. In fact, there were at least 70 reports that were being looked at. We also knew that there was no one solution and that many of the intended benefits of these drugs in treating chronic pain also came with unintended harms, like addiction, overdose, and death.

In 2013, 12 months later, the group released an ambitious 10-year national road map entitled, “First Do No Harm”, responding to Canada's prescription drug crisis. This vision was reliant on efforts by everyone at the table and everyone sharing the responsibility of addressing this significant health crisis in our society. Designed to be comprehensive in its approach, the strategy included 58 recommendations for action in areas of prevention, education, treatment, enforcement, legislation, regulation, as well as monitoring and surveillance.

In the past three years, we have made progress, and by “we” I am referring to the collective “we”. My colleagues here today have highlighted some of this work. Other experts at that table also received funding related to recommendations in the report. Again, it's a shared responsibility. I'd be happy to share copies of the initial strategy, the progress report, and an update of current activities by many of those partners.

Under the direction of Dr. Young, CCSA leads the Canadian Community Epidemiology Network on Drug Use, or CCENDU. This nationwide network of community partners serves as an early warning system by investigating reported emerging issues, communicating alerts and bulletins on topics of immediate concern, and informing communities on lessons learned in responding to local drug use issues.

CCENDU first alerted its network to the sale of fentanyl in the illicit drug market in July 2013 and followed up with alerts on fentanyl being disguised as OxyContin pills in February 2014. I mention this as an example of the unintended consequences of addressing the supply of prescription opioids and diversion, where organized crime steps in to produce and sell powdered fentanyl pressed into counterfeit pills or added to powders and sold in the illicit market.

In fact, given increasing concerns about the harms associated with fentanyl, from both illicit and pharmaceutical sources, and the lack of national data on deaths involving fentanyl, in August 2015 the CCENDU network decided to collect and collate the number of deaths involving fentanyl in Canada, spanning 2009 to 2014, to better understand this evolving situation and to plan for appropriate interventions, as needed.

Although the use of any opioid can result in harm, such as overdose or other health complications, illicit fentanyl and other new synthetic opioids pose an even greater health threat for a number of reasons, including the lack of regulation and quality control as well as their potency relative to other opioids. People take these drugs believing them to be other less-toxic substances.

We knew when we released “First Do No Harm” that this is a complex health and social issue, one that is part of a broader issue of substance use in Canada. We knew the strategy would require some refinements to keep it relevant and responsive as new information became available. We knew that priorities might shift.

While the solution continues to be challenging, the positive news is that we don't have to start at square one. “First Do No Harm” provides a road map that speaks to prevention and professional education, treatment, monitoring and surveillance, but it's all based on the evidence. We, and again I mean the collective “we”, recognize the need for interventions aimed at reducing the supply of prescription and illicit opioids, as has been presented. These are important and should continue or be enhanced. We also recognize that we need to address demand and availability of appropriate interventions in a timely way. To that end, we recommend a few areas for attention. These relate to evidence-based interventions, monitoring and surveillance data, public education and awareness, stigma, and collective efforts.

First, the opioid crisis has shed light on the system of care for substance use disorders. We recommend increasing access to effective evidence-informed treatment services along the continuum of care. That includes primary care, treatment services, and supports. We need to ensure that treatment is available. We need to ensure that these services are based on the evidence so that people seeking help get the help they need and the support they need. We need to promote accreditation and licensing of facilities providing treatment and the required qualifications of the health professionals. Every door opened should lead to help in getting the needed treatment and supports from those with the competencies, the current knowledge and skills to provide those supports. Yet sadly, we have heard in the news of facilities, many privately funded, providing health services to those with an addiction problem, lacking in qualified staff, and in fact, giving wrong information to clients.

We have discovered through the opioid crisis what is needed to be added to the health system to properly respond to effectively treat those with an addiction to opioids. We learned that primary care professionals were not well-equipped with competencies in pain management and addiction, that the curricula did not effectively address these areas. Therefore, we need to provide education and resources to help primary care professionals, as an example, to prescribe according to guidelines, to identify and intervene early. As we deal with the crisis, we know that many are looking for evidence-informed services to meet the needs of those with an addiction to opioids. As has been mentioned, there are interventions such as naloxone, overdose education, opioid substitution therapy, supervised consumption sites. Effective medications like Vivitrol are unfortunately not yet available in Canada.

As I continue to refer to the evidence in addressing the opioid crisis and treating those who need support with effective interventions, I would like to draw your attention to a new report by the WHO, the World Health Organization, and the United Nations Office on Drugs and Crime, entitled “International Standards for the Treatment of Drug Use Disorders”. It speaks to the continuum of care, different interventions, along with the strength of the research supporting these interventions.

Mr. Chair, we would be pleased to send copies of this report to the committee clerk.

Second, in order to address what is happening across the country and the impact of our actions, we need a comprehensive national monitoring and surveillance system, the national picture. In many countries this work is undertaken by a national drug observatory, NDO. As was mentioned just yesterday, Health Canada, CCSA, and the Canadian Institutes of Health Research hosted a best brains exchange to examine possible models for establishing a Canadian observatory and to assess how these models could support general and targeted drug surveillance. But this also includes in each province prescription monitoring programs. CCSA will be meeting with Health Canada and other leaders in this area to explore how best to develop this Canadian drug observatory in Canada, and an early warning system. Given the enormous amount of work that is required to develop a Canadian national drug observatory as well as the strength of many national leaders who are working in this area, such as Health Canada, CCSA, CIHI, the key to successful establishment of a Canadian observatory will be a clear vision, an understanding of the roles and responsibilities of leaders in this area as well as the jurisdictions, and a delineation of what is needed over the short and medium terms to identify emerging issues, and respond quickly. We do this well when it comes to physical health and infectious diseases, as an example.

Third, Canadians need access to accurate information to make informed decisions about their health. We need to do a better job of informing and educating Canadians about opioid-related harms and how to share in the decision-making when seeing their health professionals. Canadians also need to know about evidence, form non-pharmacological treatments for pain, and learn about quality-accredited treatment services for their substance use disorders. And they need to know the symptoms of overdose. They need to understand the importance of the safe storage and disposal of their unused medication and the dangers of driving while impaired by opioids.

Finally, one of the biggest challenges we face in addressing this crisis is societal stigma. Many still believe that addiction is a moral weakness. This means that people have to pay to get timely access to treatment, and when they do, this does not guarantee that the facility will provide quality care and treatment. We need to elevate awareness about the science that surrounds these disorders.

Mr. Chair, I look forward to continuing to work with our partners to bring about the needed changes to help address the opioid crisis and the devastation of people's lives. We look forward to collaborating with Health Canada, particularly on the opioid conference and summit that is coming up in November. There will be opportunities to connect with the “First Do No Harm” partners in addressing this issue and in developing concrete actions.

CCSA will continue to coordinate collective efforts, connect partners, gather and share evidence, identify emerging issues, and address stakeholders' needs as per our mandate.

Dr. Young and I would be pleased to answer any questions you may have at this time.

Thank you very much.

[The Vice-Chair, Conservative, Len Webber]

Thank you ver much, Rita.

Yes, if we could get copies of that report, it would be much appreciated. Please bring it to the clerk.

All right, let's move to round one of questioning.

Mr. Randeep Sarai, you have seven minutes.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Thank you to all the panellists. I'm very delighted that all of you have a very comprehensive knowledge of fentanyl.

This question is for the RCMP.

The RCMP division headquarters are in my riding in Surrey Centre. Some of the country's best and brightest law enforcement professionals live right in Surrey and across the Lower Mainland.

I'd like to know what sort of strategy the RCMP has in place to address the crisis, given the negative impact it's had in our community.

[A/Commr Todd G. Shean]

Thank you for your question.

The RCMP has a number of strategies involved. A number of years ago, the RCMP instituted what we called a synthetic drug strategy, which focused on prevention, enforcement, and of course education. Also, within the ranks of the RCMP here in Ottawa, as I said in my opening remarks, we have liaison officers and analysts who are posted around the world, to build those relationships we need around the world because, as we shared with the committee, a lot of the fentanyl that we're looking at is coming into the country. So how do we build those relationships with those particular countries to be able to address it at source and prevent some of those products from entering the Canadian market?

Just last week I spoke at a Canada-U.S. border symposium. It was addressed by the administrator of the DEA, Mr. Rosenberg. The issue that he raised as well was the issue of fentanyl and the emergence of W-18 and carfentanil, which they're seeing in the U.S., and the significance that they're placing on the prevention and education efforts within the U.S. to reach the youth at risk. He stated that what he sees as significant is the partnership and the collaboration between the Royal Canadian Mounted Police and the American authorities in securing our borders as we work along with our border enforcement officers, our CBSA counterparts who are also there.

As I said, through our office with Mr. Chicoine here and our federal coordination centre, we've done a lot of work with our communities. This includes videos and printed products; our front-line officers; adjusted our policies; issuance of naloxone to our front-line officers; and collaboration throughout the spectrum of government departments and consultations to inform, from an enforcement perspective, what the RCMP can bring to the table. As we've heard today from all the counterparts here, it's a collaborative effort among a number of departments.

There's a number of things, from the international to the domestic, to our front-line officers, to being part of the team that's before you here to inform each other to advance a Canadian effort against this crisis.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Along those same lines, is there any support in our Criminal Code or elsewhere that would help you prevent this or enforce this? Is there anything you think that our Criminal Code or perhaps our legal streams are lacking?