Health Committee on Oct. 4th, 2016

[A/Commr Todd G. Shean]

I think we can always look at other areas and say that they have this or that. My approach to this has always been that there are bodies within Canada that decide what the laws within Canada will be, and we are there to enforce those laws. If laws are being considered and our opinion is asked, we will certainly inform those discussions, but at present we work within what the Criminal Code of Canada provides us today.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Thank you.

This question is for the Canadian Centre on Substance Abuse.

As you may well know, Surrey, along with other areas in British Columbia and Alberta, has been hit hard by the opioid crisis, particularly by fentanyl-laced recreational drugs. My colleague Sukh Dhaliwal held an emergency summit with health professionals who work with individuals on the street who have substance abuse issues.

Through these dialogues, I've heard conflicting conclusions as to whether or not opioid prescriptions should be reduced. I'm curious. Could you disclose what your research indicates on this matter? Some have stated that the prescriptions should not stop and that some of the opioid-based prescriptions are helpful in reducing addictions; otherwise, the alternative is fentanyl-laced drugs. Others have said that prescription-based opioid use is very high. What's your opinion on that?

[Rita Notarandrea]

I do want to stress one thing. When we first did our “First Do No Harm” report, there was an impression that there was one solution to the issue. As all of us have said, I think, there is no one magic bullet, no one solution.

I think we do need to address prescriber education. I think we need to look at ensuring that clinical practice guidelines are being utilized in the physicians' offices by primary care professionals. At the same time, we also need to look at diversion.

We need to ensure first of all that the physicians are complying with those guidelines, and we do have that evidence that indicates what those guidelines ought to be. We then need to look at what physicians are prescribing that is higher than those guidelines. When I mentioned prescription monitoring programs, I was referring to that.

As to the diversion, there is a lot of diversion right now. I think that was mentioned, and we're seeing that.

There isn't one answer to the problem. We have to look at both.

[Randeep Sarai, Liberal, Surrey Centre, BC]

Thank you.

I'll give the rest of my time to MP Sonia Sidhu.

[The Vice-Chair, Conservative, Len Webber]

You have one minute, Ms. Sidhu.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thanks to all the witnesses for sharing that valuable information with us.

I would like to start by discussing safe injection sites. Recently we have seen many media articles about municipalities that are thinking about having safe injection sites to help reduce overdoses and address addiction problems. What does the current evidence say about the positive impacts of safe injection sites?

[Hilary Geller]

Thank you very much for the question.

The evidence is overwhelmingly clear that when a supervised consumption site is properly established and properly maintained, it saves lives without increasing rates of crime in the surrounding area.

There have been numerous studies, both domestic and international, that point to that. There is a relatively long history of experience with supervised consumption sites in Europe upon which to draw, and over a decade now of experience with Insite in Vancouver. It all points to that fact.

[The Vice-Chair, Conservative, Len Webber]

We'll have to move on. Your minute is up now. I'm sorry.

We're moving to Dr. Colin Carrie, for seven minutes.

[Colin Carrie, Conservative, Oshawa, ON]

I want to thank the witnesses for being here today because this is a serious crisis.

Dr. Sharma, I would like to start with you because you are a physician. I think we all realize that addiction is a treatable condition. That's why our government's approach was our anti-drug strategy, which put $500 million out there to keep drugs out of the hands of addicts and looked towards prevention and treatment. At that time, the mandate of Health Canada was that it really wanted to look after the health and safety of Canadians. I think that's still true, isn't it?

I think it's really important in this situation we're facing that Health Canada and the minister's office be open and transparent. There has been some worry about some of the minister's actions and judgments, some of the controversial decisions that she's made. I want to ask you about that.

Because of the seriousness of opioids on the street, if there are reports going back about contaminated or adulterated drugs on the street, I think it's very important. We heard from the media, unfortunately, that Tilray, a company in British Columbia, sent information to Health Canada that, in dispensaries, there is marijuana that was adulterated with carcinogens, fungicides, and pesticides. The minister chose not to let Canadians know about this.

As the senior medical adviser for the health products and food branch, if information came across your desk about an adulterated opioid that was on the street, do you think it would be important to get that information out to Canadians, through a press release or something along those lines, or through the media, so that Canadians who may be using these substances would know about it? Do you think that would help in protecting the health and safety of Canadians?

[Dr. Supriya Sharma, Senior Medical Advisor, Health Products and Food Branch, Department of Health]

In terms of the authorizations in Canada for opioids, they're a marketed product. So if there was a situation where there was an adulteration or contamination, we would embark upon an assessment to see what the risks associated with that would be. Then we would look at whether or not there were compliance and enforcement actions that we would need to take.

There is a whole suite of compliance and enforcement actions that we can take, such as recalling the product, changing labels, etc.

[Colin Carrie, Conservative, Oshawa, ON]

You could get it off the street and you could do something about it, let Canadians know about it, and not wait a year, right? You wouldn't do that would you?

[Dr. Supriya Sharma]

Once we know what the risk is and what the action is, we make a decision about what the most appropriate form of communication is. Again, that could be putting something out on the web. It could be a news release. It really depends, on a case-by-case basis, on what the risks are and on what the assessment is.

[Colin Carrie, Conservative, Oshawa, ON]

All I'm saying is that waiting a year to get that information out, having people find out through the media, is a poor judgment.

Madam Geller, you do know about the SALOME study.

[Hilary Geller]

Yes.

[Colin Carrie, Conservative, Oshawa, ON]

Did that study find that hydromorphone was a valid alternative to actual heroin and had less risk?

[Dr. Supriya Sharma]

Perhaps I could take that.

SALOME was a study to assess long-term medication opioid use. The aim of the study was to compare the use of injectable pharmaceutical grade heroin or diacetylmorphine with the use of hydromorphone, an injectable form of a pain medication that's approved in Canada but not approved for use in opioid addiction at this point in time. The results of that study did show that, in the study population, hydromorphone was equally as effective as pharmaceutical grade heroin, and it did show some advantages in terms of adverse events.

However, that's one study and, obviously, that has to be taken into the context of the body of scientific and medical literature that is there.

[Colin Carrie, Conservative, Oshawa, ON]

I think it's promising. Madam Geller mentioned that the special access program—developed for patients with serious or life-threatening conditions when conventional therapies have failed, are unsuitable, or are unavailable—is being used to get the pharmaceutical heroin out there. It was never really intended for that. If you have a legal alternative to it—even in the access statement here on your website—don't you think we should be trying to substitute a legal, safer alternative rather than get more heroin out on the streets?

[Dr. Supriya Sharma]

The special access program, as you've said, is intended for emergency and life-threatening conditions. An individual physician comes in and makes a request for an individual patient and it's assessed as such. When requests come in, we do look at the information that the physician has provided and there are assurances that the physician has spoken to the patient about the potential risks and benefits, and then they're assessed on a case-by-case basis.

Comparing the two products, hydromorphone is a marketed product, but it is not marketed for that use, and diacetylmorphine has also a body of evidence that supports its use in terms of chronic relapsing opioid dependence and it has been used in a number of different countries.

As with any request to the special access program, we would look at that individual's information and the request that's being made, to make sure that it fulfills the criteria of the special access program and that it's reasonable. In some cases, you're right, in that we have authorized the use of diacetylmorphine. It has to be when all other treatments that could be applied have unfortunately failed, so it's a very small percentage of patients.

[Colin Carrie, Conservative, Oshawa, ON]

Hopefully it stays small. I know that program. I've actually advocated and tried to help patients who have life-threatening cancers. I know that program has a limited amount of funds, and to see that those resources go towards access to heroin when there is a legal, safe alternative out there that may be available in another way, I just feel that maybe we need to keep a close eye on that.

Dr. Young, the CCENDU reports that you have are extremely valuable to us and I want to thank you for that. A few years ago in Ontario, Deb Matthews, who was the health minister, basically demanded and begged that the federal government move towards tamper-resistant opioids.

[The Vice-Chair, Conservative, Len Webber]

Dr. Carrie, I'm sorry but your time is up. Perhaps next time around you can continue on with that. I have to move on now.

Mr. Davies, you have seven minutes.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you all for being here today.

By the end of the year, 800 British Columbians are expected to die from opioid overdoses. That's one by noon today, and one by midnight. Dr. Perry Kendall, the provincial health officer for British Columbia, has declared a public health emergency in British Columbia. Hundreds more will die in Alberta, and about the same number are expected to die in Ontario as in British Columbia by the end of this year. Across our country this year, 2,000 Canadians are expected to die from overdoses. That's a Canadian dying about every four hours.

The RCMP reports that the fentanyl market is expected to grow in the next 18 months, which means that even more Canadians will die. Two grains of fentanyl the size of a salt crystal, or one grain in the case of carfentanil, are capable of killing drug users, including young people who don't even know they're ingesting it. This puts our first responders and our police at risk. These are our neighbours, our friends, our families dying; as Ms. Geller said, no one is immune.

Ms. Geller, my question for you is this: Is the national opioid overdose crisis a national public health emergency?

[Hilary Geller]

Certainly B.C. has declared it a public health emergency in B.C. If you look at the definition of an epidemic as set out by the World Health Organization, it has to do with levels of death or disease above an average level. By that definition, certainly in British Columbia, as declared by the government, it is indeed an emergency. If you go with that strict definition, I can honestly say, because of some of the data limitations unfortunately, it's impossible to tell you if that definition would be met in every other province, but certainly we see growth in Alberta as you said and signs that it is moving eastward. We've heard from police in Ontario indicating that.

I think from our point of view we are treating it as an emergency to help jurisdictions across the country have what they need in order to be able to respond. We as the federal health department are putting everything in place within our areas of authority and encouraging others to do the same, so that not only can we respond in B.C., but we're ready for when it emerges elsewhere.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay. I don't mean to interrupt, but I have limited time.

Doesn't the Public Health Agency of Canada have the ability to actually declare a national public health emergency?

[Hilary Geller]

I apologize. I'm not familiar with their legislation.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay, thank you.

We've talked about Bill C-2. Ms. Geller, you've crisply described the evidence. We know that safe consumption sites save lives. We also know, from every stakeholder in the country, that Bill C-2, which was passed by the previous government, establishes 26 separate, discrete requirements that every group I've talked to in the country says establishes unnecessary barriers to establishing safe consumption sites. It takes months. It takes hundreds of hours.

I've talked to Toronto's Board of Health. I've talked to the City of Montreal. I've talked to the City of Victoria. These are not fly-by-night operators that want to open safe consumption sites. These are municipalities and boards of health in our provinces telling us that safe consumption sites save lives and that this legislation puts up unnecessary barriers.

Ms. Geller, you said that your strategy is to explain the barriers to the groups, but these groups aren't telling me that they need the barriers explained to them. They're telling me that they need the barriers removed.

My question is actually for Ms. Notarandrea. Does your group support the repeal or the streamlining of Bill C-2 so we can get more safe consumption sites up and running and save lives?