Health Committee on Oct. 6th, 2016

[The Vice-Chair, Conservative, Len Webber]

Hello, everyone. I'd like to call the meeting to order here, please. We are continuing today our study of the opioid crisis in Canada. I am going to get right into it quickly, because we have a lot of work to do today.

I'd like to introduce our panel this morning. From the British Columbia Coroners Service, we have Lisa Lapointe, the chief coroner. Thank you, Lisa, for coming.

From the British Columbia Ministry of Health, we have Bonnie Henry, the deputy provincial health officer. Thank you, Bonnie.

We also have David Juurlink from the Sunnybrook Health Sciences Centre in Toronto. David is the head of the division of clinical pharmacology and toxicology at Sunnybrook.

From the Drug Users Advocacy League, we have Sean LeBlanc, the founder and chair. Thanks, Sean. We also have Catherine Hacksel, a community organizer and research assistant. Thanks, Catherine, for coming.

Let's get right down to it here. We'll start with the British Columbia Coroners Service, and Lisa Lapointe. Thank you, Lisa.

[Lisa Lapointe, Chief Coroner, British Columbia Coroners Service]

Good morning. Thank you for having me. It will be a challenge to confine my remarks to 10 minutes, because there's so much to say about this crisis that is happening, but I will do my very best.

I'm going to tell you a little bit about the coroners service's investigation so you have a bit of an understanding of how we gather this information; some highlights from the data; information on the collaborations we've developed in B.C. in an attempt to reduce the number of deaths that are happening; and then some of the strategies we've developed moving forward.

One of the key points is the importance of thorough death investigations. If you're not doing the investigations and gathering the information, of course you don't know that you have a problem. That sounds very much like common sense, and I'll talk about that in a minute.

Then there is strategic surveillance. Again, if you're not doing the surveillance on the deaths, you don't know you have a problem. It's interesting to see across the country the different surveillance and reporting that's happening on these types of deaths.

The B.C. Coroners Service has 90 coroners across the province. The coroners actually respond to all sudden, unexpected deaths, so they go to the scene of death and do a thorough investigation, which includes an examination of the deceased, an examination of the scene, and then a collection of the medical history of the deceased. That information is critical in determining next steps. If you don't have the suspicion that this death may be linked to drug use, then you won't order the appropriate testing and you won't have the appropriate results. That sounds really like common sense, but it's really important to do a thorough scene investigation of each of these sudden, unexpected deaths.

The coroners work 24-7, and that's important. People die all over the province at different times. We have a very clear investigative protocol, which ensures that consistent information is collected on every death. Again, that is critically important if you're looking for patterns.

We also have in B.C. a dedicated research unit. Again, that seems to be a matter of common sense, but unless you make a decision to do surveillance on a type of death, you won't have the data. Across the country this varies, with every province and territory doing something different. In B.C., we decided to do some pretty focused surveillance on our drug deaths, which has resulted in the data that we now have and been able to share publicly. Those strategic decisions really can be made death investigation by death investigation and province by province, and they will vary across the country.

Something I want to talk about is how we have always heard the term “overdose”. In my coroners service we are starting to shift our terminology, because “overdose” suggests that there's a safe dose. It also has a bit of a pejorative tone, implying that perhaps if the user had used the right dose, they wouldn't have died. In fact, that's really misleading, because for many of these drugs, there is no safe dose. “Overdose” suggests that there's a safe dose; there isn't. We really want to move away from that, so our reporting from now on will no longer talk about overdose deaths. All of these illicit drugs, the opiates and the non-opiates, are manufactured in very suspect circumstances, and you never know what's in the substance that you're taking.

I also wanted to make clear that I know that the meeting today is focused on the opioid crisis, but the deaths we've been reporting are related not just to opioids. While B.C.'s reporting on illicit drug deaths includes opioids, such as heroin and fentanyl, for example, it also includes other illicit drugs, such as cocaine, MDMA or ecstasy, and methamphetamines. The high numbers of illicit drugs, which are going up month by month, include all of those substances, not just opioids. They also include prescription medications that have been diverted; there is a small market for people selling their prescription medications, but we're not seeing a lot of that in this crisis.

Again, toxicology testing is critically important. If you haven't identified that illicit drug use or any substance use may be a factor in the death, then you won't order the appropriate testing. That again speaks to the importance of the initial investigation and then the toxicology testing.

We have in British Columbia something called “expedited” toxicology testing, which means our provincial toxicology centre will give us results within 48 to 72 hours. That doesn't happen elsewhere in the country. I've spoken to my colleagues, chief coroners and chief medical examiners across the country, and they don't have that ability. That expedited toxicology, the ability to get information back from the lab very quickly, is really key in getting the messaging out in a timely manner.

As I think you know, British Columbia so far, to the end of August, has had 488 illicit drug-related deaths. That compares with 505 for the whole of last year. Just to give you a bit of context, in the whole of last year British Columbia had 300 motor vehicle incident fatalities. This epidemic of death is much more significant than the deaths we're seeing on our roads, which we have numerous strategies in place to try to resolve. We're seeing approximately 61 deaths a month due to illicit drugs. If that number continues to the end of the year, we'll have 732 deaths in 2016. That's quite a significant increase. The significant rise started in 2012, which is, ironically, when we first saw fentanyl appear on our horizon.

Although we're seeing deaths among all ages, the deaths we're seeing primarily are among males between the ages of 19 and 39. Most of the deaths involve those who use illicit drugs habitually, but we have seen deaths of recreational users, such as people who all use drugs at a party. We've had situations, in fact two or three in the last couple of months, where five or six people at a party “overdosed”, for lack of a better term, became very ill, and were treated. In most of those cases they've all survived. although we've had one or two fatalities. Generally, then, it's the people who use drugs habitually that we're seeing among the deceased, but we are also seeing some recreational users.

As well, a number of people who use drugs quite consistently are what we would call “high-functioning users”. That sounds pejorative, and I don't mean it to be, but it's people who go to work, hold steady jobs in all sorts of occupations, and routinely use illicit drugs. That's a fairly significant population as well.

Most of the deaths we're seeing involve mixed substances. Very few involve just heroin, or just fentanyl, or just cocaine. In fact we looked at 207 results recently, and 96% of those were mixed-drug deaths. Cocaine was involved in 46%, alcohol 36%, methamphetamines 34%, and heroin 30%—and that was with fentanyl.

The proportion of illicit drug deaths where fentanyl has been detected has grown substantially since 2012. We saw 5% of our illicit drug deaths in B.C. involving fentanyl in 2012. That's up to 60% in 2016. That's a significant increase. That's not to say that fentanyl is the cause of all of those deaths, but fentanyl was detected at varying levels in the toxicology results of all of those deaths. If there were no fentanyl, we don't know how many deaths we would see. If we removed all the fentanyl deaths, we would have at least 200, but our numbers for previous years suggest that it would be between 200 and 300. The involvement of fentanyl appears to be doubling the deaths we're seeing.

I won't spend any time talking about what fentanyl is. I think you know that it's a synthetic opioid traditionally used for pain management. It's become increasingly prevalent on the illicit markets, brought in from other countries, primarily Asian countries, but also manufactured in clandestine labs in B.C. When you think of a lab, you tend to think of white coats and sterile circumstances. In fact these labs are people's kitchens and people's basements. They are quite random, in a way. They're trying to measure substances appropriately, but they're blending them in juice blenders and Mixmasters. The compounds are by no means secure or safe. These labs are often, as we can see with the number of deaths, getting their mixtures wrong. The police are well aware of that. They're finding fentanyl in pill form and in liquid form. It's used in a variety of ways.

What we're experiencing in B.C. are deaths due to illicit drugs, including a significant percentage due to fentanyl. We're often seeing unsuspecting use. People think they're purchasing cocaine, for example, and it's laced with fentanyl. They're either becoming very ill and being treated and surviving, or they're dying.

We found a paradox with warnings. We've tried to work closely with our police community on this. The language around this epidemic is very important. We've had our law enforcement partners often wanting to go out and say “There's very strong heroin on the street”, or that fentanyl is “very strong” or “powerful”, but those words can be triggers.

Paradoxically, we now have people actively seeking fentanyl because of the bigger high. It's really important to remember that we should be talking about the risks and the toxic effect, but not necessarily that this is a more powerful drug or a stronger drug.

I'll wrap up. One of the really important things is the messaging. We've gone out with public messaging and talking about what to say and what not to say. In B.C., we've adopted a harm reduction approach. Shaming and blaming does not help. We want to ensure that people, if they're going to use, have medical assistance nearby. That's the biggest message that we're giving: “Don't use alone, but have somebody there who can help you out if get into trouble.”

We have a multi-sectoral partnership. If not for the collaboration of a variety of groups, we wouldn't have been able to approach this crisis the way we have. We have BC Ambulance, the health communities, the corner service, law enforcement, and the labs all working together to try to collaboratively come up with solutions.

One of the changes that BC Ambulance has adopted is a policy not to call police every time they respond to an overdose. Again, the emphasis on encouraging people to ask for help, as opposed to being afraid they're going to be arrested or that somebody is going to be in trouble. It's that the shift toward preventing deaths. Thank you.

[The Vice-Chair, Conservative, Len Webber]

Thank you, Lisa.

We'll move on quickly to Dr. Bonnie Henry from the B.C. Ministry of Health. She's the deputy provincial health minister.

[Dr. Bonnie Henry, Deputy Provincial Health Officer, British Columbia, Office of the Provincial Health Officer, British Columbia]

Thank you. I'm the deputy provincial health officer, not the deputy minister.

[The Vice-Chair, Conservative, Len Webber]

The officer, and not the minister.

[Dr. Bonnie Henry]

Thank you, Mr. Chair.

Thank for your this opportunity to present the work that British Columbia has done to respond to this tragedy.

I have a short presentation that will illustrate some of what Lisa talked about.

This response, as our coroner indicated, has been across the health sector and public safety in B.C. This is the first time that we have used the Public Health Act in B.C. to declare an emergency. The provincial health officer, Dr. Perry Kendall, declared an emergency on April 14 of this year, when we started to see the dramatic increase in the number of people who were dying from these overdoses. What that allowed us to do was to collect information that we couldn't necessarily receive without this order, and it allowed us to get information in a more timely and detailed way. One of the things we needed was to understand a little better who was being affected by this.

The data we collect on people who are surviving overdoses is really important in helping direct our programs and our response to this as well. We have started to receive data from emergency departments, from 911 calls, and from our ambulance service about people who are surviving overdoses. That has helped us look at how we can make naloxone, for example, more available. I'll talk about that in a minute.

In June, we had an overdose action summit, where we had people from public safety, law enforcement, and the health sector, as well as people with lived experience and people who use drugs. We had a lot of brainstorming about the things we can do to address the death crisis we are dealing with, but also, longer-term, to address the whole issue of over-prescribing opioids and the other factors that have led to some of the issues.

We have developed new guidelines for prescribing opioids that came out of the College of Physicians and Surgeons of British Columbia. Those are being looked at across the country.

With the help of the federal government, we've made it easier for doctors to prescribe Suboxone, which is a combination opioid substitution treatment that allows people to get away from the use of illicit drugs and gives them the opportunity to take a different path.

In July, the premier appointed a joint task force with health and law enforcement that is co-chaired by Dr. Perry Kendall and Clayton Pecknold, our chief of police services in B.C.

A couple of things happened after that. As you may be aware, InSite, which is one of the only supervised injection service sites in Vancouver, a stand-alone site in Downtown Eastside, expanded its hours because of the data we were collecting, which showed peaks in overdoses and deaths around certain periods of time.

We launched a public awareness campaign, because, as indicated, it is not just about people who are using drugs on a regular basis. There are many different populations being affected, including people who are prescribed opioids for very valid reasons, but in very high doses, and who overdose on those.

One of the big successes we've had is expanding our take home naloxone program. We started that program in B.C. about three years ago, in 2012. We have now distributed over 13,000 free naloxone kits. These are for people who use drugs to help each other, and many overdoses have been survived because colleagues, friends, or family members have used naloxone. Now, thanks to the delisting and approval of nasal spray naloxone, we have police departments, fire departments, and emergency departments now providing naloxone and using it to help. Just in September, naloxone was deregulated, so now it does not need to be prescribed by a pharmacist, and we can distribute it through many of our public health distribution places across the province.

This slide is the data that the coroner described, from which we've seen a dramatic increase in overdose deaths in the last two or three years. The final column on this page, on the far right, is just until the end of August 2016. As you can see, we are on track to far exceed the number of deaths that we saw last year. This reflects the number of deaths; it does not reflect the fact that we're seeing hundreds of people in emergency departments across the province who are surviving their overdoses. That is a critical period of time when we can intervene, and a place where people at the very least can get naloxone and training on how to use naloxone. It's an opportunity to get connected, where they might be amenable to taking another path away from drugs.

I'm going to show a series of maps that we put together once we started collecting more detailed data on where overdoses are occurring in B.C. This is to give you a sense of why there has been such an across-government and across-province response.

This is rates by population. The darker the red, the higher the rates. This is from the distribution of illicit drug overdose deaths in British Columbia in 2016, from January to March. The comparison is with 2010. In 2010, what we used to see, and what people typically think of, were overdoses in the Downtown Eastside in Vancouver. But we're now seeing it happening across the province in communities everywhere in B.C., in the north, the interior, the Island, not just the Downtown Eastside in Vancouver. In Vancouver, it's not just in the areas that we have seen it in the past, but all around Vancouver. People are dying in public places and in their private homes.

This is some of the information that Lisa presented as well, just in a pictorial form. It shows you the percentage of these illicit drug deaths where fentanyl has been involved. It has dramatically increased from less than 5% in 2012 to over 60%, but as she indicated, these don't happen in isolation. Alcohol is very frequently a factor, and other drugs as well. It has been somewhat alarming in that most people we hear from are community members who are partners in this response, and they say there's very little heroin left in B.C. It's all illicit fentanyl. It's much more easily imported than heroin because you need such a small amount, and drug dealers are looking at maximizing their profits. It's easier for them to manufacture it and bring it in than heroin, so there's very little heroin left.

More disturbing, we are now seeing it being mixed with stimulants like cocaine. People do not necessarily expect to find a depressant, like opioids, like fentanyl, mixed with those drugs. They're not necessarily prepared and that's where we're seeing clusters of overdoses in people who are weekend users of cocaine, for example, where they don't have naloxone or the training about what to look for and how to respond.

As indicated, most of the deaths that we're seeing are of young men, many of whom had been using drugs for some time. It's really a case of roulette, if you will. If you're using on a regular basis, your chances of getting a toxic dose of fentanyl just go up that much higher. Every day that we can keep people alive is a day that they may move on a different path.

This is a description of how we have organized our response. We have a joint task force that reports up to our Minister of Public Safety and Solicitor General, and the Minister of Health. It's chaired by Dr. Kendall and Clayton Pecknold, the director of police services in B.C.

We have a large group in the middle of that pink box of people who are stakeholders in this response, from law enforcement and health to people with lived experience, including families of drug users, the drug-using community, people who use drugs. They give us very valuable advice about the issues that are happening on the street, and also about our response, what makes sense and what doesn't make sense for them. It's been an invaluable group to help us in shaping what we can do.

Then we have a number of task groups, and I'll talk about some of the things the task groups are working on. Our immediate three-month work plan has a number of specific issues.

One of the biggest things we wanted to initiate was to expand the reach of naloxone. Its deregulation at the federal level so that it is now a non-prescription substance has been a huge help for us, because we now have an inter-nasal formulation available. It's particularly useful for law enforcement, who didn't feel comfortable using the injectable form. Most of it is the injectable form, and we have a lot of good evidence that the injectable form works well. People can very easily learn to use it. We have some videos that we've developed for young people in particular that are entitled, “Naloxone Wakes You Up”, which tell them how to use it. We'd be happy to share those with people.

We've done a lot of work around opioid substitution treatment, making it more available and teaching physicians how to use it, particularly Suboxone, which is a much safer form of opioid substitution treatment, delinking it from the methadone programs that we've had in the past. We've also expanded its use to the nursing practice so that nurses can monitor opioid substitution treatment as well.

[The Vice-Chair, Conservative, Len Webber]

Great, Bonnie.

[Dr. Bonnie Henry]

Some of the other areas that—

[The Vice-Chair, Conservative, Len Webber]

Bonnie, excuse me, but I'm going to give you about another minute, if you don't mind.

[Dr. Bonnie Henry]

Yes, I'm on my last one.

Some of the other things we're expanding are around drug checking, the ability for people to check their drugs to see if there's fentanyl in them prior to taking them. There are some legislative barriers to those. We are doing monitoring and surveillance, increasing our access to supervised consumption services around the province—and again, there are some legislative barriers at the federal level, which it would be helpful to us if they were addressed.

Also, we are doing quite an extensive public education and awareness campaign around licit fentanyl and what to do about it.

This is just a graph that shows the number of naloxone kits we've distributed in the province.

To sum up, there are a couple of things that we would like to bring to your attention. The province would like support in expanding our supervised consumption services. In particular, the Respect for Communities Act has a number of barriers that are quite extreme that we would like to see reduced or eliminated. We understand there's a need to make sure that these safe consumption services are developed in a way that is safe and that has community support. We have ways of doing that which we think can meet the spirit of the bill without the extreme barriers that the bill puts in place.

We would like to work with the federal government to ensure granting of exemptions under the Controlled Drugs and Substances Act for the purpose of drug checking, which is something that we think can be an important service in helping people understand what they're taking prior to taking it.

We want to increase the availability of treatments for opioid use disorder, particularly some of the longer-acting, more effective treatments that are available south of the border. We know that some people in B.C. aren't able to access these south of the border.

Again, these are areas that, if we can get your help on, it would be appreciated.

Thank you very much for your time today.

[The Vice-Chair, Conservative, Len Webber]

Excellent. Thank you very much for that, Bonnie.

We'll quickly move on here now to David Juurlink who's with the Sunnybrook Health Sciences Centre.

Thanks, David.

[Dr. David Juurlink, Head, Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre]

Good morning. Thanks for the opportunity to present.

By way of introduction, I'm a physician. I specialize in internal medicine and pharmacology. I'm not a specialist in addiction. I'm not somebody with extensive public health training, but I do a fair bit of research in the field of drug safety, and over the last seven or so years this problem has become a major preoccupation of mine.

I'll just share with you some reflections on the problem as I see it. I apologize if you've heard some of these things before.

In the early 1990s, I was a pharmacist in Nova Scotia. I trained there, and during medical school and my internship I practised as a pharmacist. I worked in about three dozen pharmacies across the province. It was the case then that when patients came to the pharmacy with a prescription for morphine, they had cancer.

By the late 1990s, when I was finishing my internal medicine training, things had changed quite a lot. We saw OxyContin—a drug that is 1.5 to two times more potent than morphine—prescribed very liberally for chronic back pain, hip pain, osteoarthritis, fibromyalgia, and you name it. It was even doled out for minor ankle injuries. This happened because physicians were taught that it was safe and effective to use opioids for chronic pain.

Most physicians had no reluctance to give opioids to patients at end of life or to patients whose femur was sticking out of their leg, but the chronic-pain market was huge, and every day doctors were faced with patients with pain and we had reluctance to use the other drugs at our disposal. Acetaminophen—Tylenol—just doesn't work very well. The other drugs—anti-inflammatories—had all kinds of horrible side effects. We've all been burned by patients who had bowel problems or kidney problems as a result.

So the message that we could use these drugs, and we should use these drugs more liberally, was one we were quite happy to hear. The important thing to realize is that that message came directly and indirectly from the companies that make these drugs, and that have subsequently earned tens of billions of dollars from selling them.

They sent drug representatives to doctors' offices, but there was much more than that. Key opinion leaders in the field of pain all across North America gave talks at CME events, continuing medical education events, at fancy restaurants. I went to them myself and I was told that not only should I use these drugs, but also that if I didn't use them, I was being “opiophobic” and was depriving my patients of a proven therapy. The virtues of these drugs were extolled. The companies made their way in some instances—including at my own medical school—into the curriculum where individuals in the pay of the companies that make these drugs taught medical students for years without disclosing their conflicts and gave them overly rosy views of the utility of these drugs.

As I said before, for many of us, this was a message we were quite happy to hear. We now, however, realize with the benefit of hindsight that we should have known better. I can tell you that there are no good studies showing that opioids used in the long term improve patients' outcomes. The overarching goal when I prescribe a drug to a patient is to give more benefits than harms, and there's never ever been a study that shows that in the long term this happens.

Most of the studies, by the way, go for eight or 12 weeks. They involve very carefully selected patients who have no risk factors or as few risk factors for addiction as you can find. They're not on benzodiazepines. They have no mental health problems. They have no history of having had trauma as a child. They show that over a couple of weeks these drugs lower pain scores. The fact that there are no long-term studies didn't stop Health Canada and the FDA from approving these drugs for long-term use, and we've now seen what amounts to a 20-year experiment on the population. We've seen and we know that the beneficial effects of these drugs very often wear off, and increasing the doses doesn't solve this problem; all it does is add to the toxicity. Virtually everyone who takes these drugs daily is dependent on them, making for a self-perpetuating therapy. You can't stop these drugs. Even if the pain-reducing effects have worn off, stopping the drugs will make you sick and it will lead patients to perceive that the drugs are needed. Patients need the drugs just to feel normal.

Critically, we were taught that addiction was a rare consequence of using these drugs long term. I remember hearing these words: less than 1% of patients will become addicted. That's not true. The best estimate at the moment is somewhere in the order of about 10%. Just imagine that: hundreds of thousands of patients in Canada are on these drugs as a result of well-intentioned prescribing, and 10% of them may be spiralling into addiction.

We also know that high doses kill people. I can't tell you how often I see patients coming under my care who are on hundreds of milligrams of morphine or the equivalent. We did a study in 2015 that made it very clear that people on high doses of opioids were more likely to die from their medication than from almost anything else.

When we talk about addiction and death, there's a lot more to it than that. The death toll in Canada, as I'm sure you've already heard, is not known. It sounds as if B.C., with a population of about 4.7 million, is on track for about 700 deaths. That places it up there with Alabama, the worst state in the U.S. in terms of rates.

You can think about it differently. We published a paper in 2014 that looked at deaths in Ontario, and we found that one out of every eight deaths of people aged 25 to 34 involved an opioid. That's a staggering number. When you total the deaths from opioids in Ontario—remember, these are people dying in their twenties and thirties and forties who should have lived to their seventies and eighties and longer—the total years of life lost is somewhere in the order of one-thirteenth of all years lost from all cancers combined.

There are other harms here as well. People driving under the influence of opioids are at risk of collisions. We've shown that convincingly. There are falls. I see older people all the time who are on opioids for chronic pain—often not benefiting, as far as I can tell—who fall and break hips and necks and have head injuries. There is constipation. It sounds like an annoyance. I have had more than one patient die under my care from constipation caused by these drugs.

It might seem counterintuitive, but these drugs can worsen pain. As the doses go up, the pain gets worse because of the drugs. These drugs disrupt sleep. I am convinced they cause depression in some people and cause them to commit suicide, and those suicides are very often blamed on the pain rather than the drugs themselves.

There are other epidemics here like neonatal abstinence syndrome. In Ontario, from 1992 to 2011, the number of babies born dependent on drugs went up 15-fold. That's just from the prescribing. The proliferation of tablets from our well-intentioned prescribing of drugs has left every medicine cabinet in Ontario with some opioids. It's a bit of an exaggeration, but those drugs are there for people who might want to experiment, 16- or 17-year-olds who are curious and find themselves spiralling into addiction.

The epidemic has transformed over the last couple of years, as you've been told. It's not just about OxyContin and Dilaudid, and so on. It's now about fentanyl and heroin. Those drugs have been used for a long time, but a market has been created in response to our well-intentioned prescribing, a market that did not exist to anywhere near the same degree in the early 1990s.

This was a crisis that was largely created by physicians, and it has to do with the fact that opioids, once started, are hard to stop. It was exacerbated in 2012 by the reformulation of OxyContin. Purdue took off their old product, put on a new product that was tamper resistant, and we found a lot of people going to heroin and fentanyl as a result.

This can't be overstated. You can get a kilogram of fentanyl from China for $10,000 or $20,000. It fits in a shoebox and you can turn it into $20 million of profit. That's not ending up, as you've heard, just in heroin. It's ending up in fake OxyContin tablets, cocaine, meth, in fake Xanax tablets.

The scope of the problem in Canada is completely unknown. We know that in the U.S., the CDC estimates that over the last 20 years, about a quarter of a million people have died from opioids, more than half of them from prescription opioids, and about 2.1 million people in the U.S. suffer from addiction. We have no corresponding numbers in Canada. I speculate that somewhere in the order of 20,000 Canadians have died over the last 20 years from these drugs. The fact that no federal politician can tell you that number is a national embarrassment.

This is the greatest drug safety crisis of our time, and it's not hyperbole to say that every one of you knows somebody with an opioid use disorder. Whether you realize it or not, you do, and it's quite possible that you know someone who's lost a loved one to these drugs. Yet the Public Health Agency of Canada has been largely silent on this issue, despite its mandate “to promote and protect the health of Canadians through leadership, partnership, innovation and action in public health”. Go to their website, search fentanyl, and you'll find almost nothing.

Health Canada seems to have largely handed this file to CCSA, which I think is a good organization and has all kinds of potential, but it's not adequately resourced and it's not focused exclusively on opioids. It has alcohol and other drugs under its consideration. It feels very much as if no one is really in charge of this file and everyone is keen to pass the buck to someone else. Only recently we've begun to see some federal leadership on this issue with the hastening of the move of naloxone to non-prescription status; reducing barriers to safe-injection sites, which are very important; and this upcoming summit in November.

To solve this problem, I think the response needs to be collaborative, proportional to the scale of the problem, and urgent.

If 30 or 40 Canadians were dying every week from the Zika virus, your hair would be on fire with the scope of the problem. I mean, this is actually what's happening now. We need timely surveillance, and not just in B.C., which is the only province that is doing it in a timely fashion. We need it everywhere, and not just on deaths but on non-fatal overdoses as well.

Naloxone saves lives, and it should be everywhere. It should be in corner stores and gas stations for free.

Health Canada has good grounds to revisit its decision, its indications, for these drugs. There has never been a study, as I said, that shows that these drugs are safe and effective for chronic pain. I think that the label, the indication, should be revised, and when doctors choose to prescribe these drugs for chronic pain, they should do so off-label, without an official endorsement from our national regulator.

We can give serious thought to removing market approval for the highest-potency drugs out there: the fentanyl patches of up to 75 and 100 micrograms, OxyNEO 80, and the highest formulations of Dilaudid. The provisions under Vanessa's law give the minister the power to do exactly that.

We need to change how doctors prescribe. Doctors need to start these drugs much less readily, and escalate doses much less readily than they have. A whole generation of doctors has lost respect for these drugs. We do not see this as we did 20 years ago.

The education of physicians is important, but it is not going to solve this problem on its own. It has to be detached completely from industry, and from pain specialists who take money from these drug companies.

You'll see new prescribing guidelines for physicians coming out early next year. I'm on the steering committee for that, and I think that will be helpful. However, the fewer patients who start on these drugs the better. The patients who are on very high doses need to be de-escalated cautiously and closely.

We have a large swath of the population with addiction. I think it is very important that we perceive this as a public health problem and not a criminal one. When somebody steals from a pharmacy or holds up a store, it's not because they're a bad person, but a person who needs help.

Many of these people want out. They need rapid access to opioid substitution therapies, like Suboxone. They need access to supports. We need many more clinicians who know how to treat these people, and ready access to them. We need safe injection sites. I think the point has been made that the Respect for Communities Act poses a major barrier to the construction of these sites.

I will leave you with one last point. This is not your usual epidemic. No one has ever argued for more Ebola, more Zika, or more influenza. There are forces at play that will argue that physicians should not prescribe differently, that we need these drugs for chronic pain, which, I think, is exactly the wrong message. Those sorts of oppositional comments need to be disregarded.

I'll leave my comments there.

[The Vice-Chair, Conservative, Len Webber]

Thank you very much, Doctor. It was very informative, for sure.

We now have, from the Drug Users Advocacy League, Catherine Hacksel and Sean LeBlanc.

You have 10 minutes.

[Sean LeBlanc, Founder and Chairperson, Drug Users Advocacy League]

First of all, thank you very much for inviting me.

I'd like to mention that I'm also a peer support worker in the city of Ottawa. I work pretty well first-hand and front-line with drug users, almost specifically opiate users, on a daily basis.

DUAL is a non-profit that was founded in 2010. It neither condones nor condemns drug use, but sees it as a facet of everyday society. People are going to use drugs, and we just try to best educate them about that. We have several services, some of which Catherine runs, with a couple of drop-ins. It's basically to provide a voice for people who do not have one.

I am someone who has survived an addiction to opiates. I used opiates for about 15 years. It's not a pleasant thing; it certainly isn't. Coming off of these drugs is extremely, extremely hard. I had pretty well a normal childhood and everything. The last thing I thought I would ever be was someone who would inject opiates. Unfortunately, I suffered through a few traumas during my teenage years, and I just wanted to end the pain.

That's one thing that I will give credit to opiates for: they help you to numb the pain, not in any healthy or helpful way, but for someone who's really hurting, opiates do deaden that pain.

My life pretty well spiralled after that. I ended up homeless, with not much self-worth. I guess I have kind of a stubborn streak, and thankfully, around 2010 I started to do some advocacy, and founded DUAL out of that. It was basically the lack of inclusion that really made me want to start DUAL to create a voice for people. I started being on different committees and everything like that. I'd always see some great doctors and police officers and epidemiologists, but there were never people who actually used drugs on those committees. If they were there, it was usually in a really tokenistic way.

This is why I'm so thankful to be invited here today. These offers don't usually come around. I think the best way we can get results in this crisis is by working in conjunction with each other—doctors, coroners, police officers, and, more so than anybody, people who use drugs, because they really are the experts on this.

The Oxy crisis started right around 2010 in Ontario. As my fellow panellists have alluded, it created this whole desire, this need, for fentanyl and heroin. The drugs have gotten so much stronger, and so many younger people are using them now, it's really, really scary.

I think we don't want to get too far into that, though. These drugs do play a really good role in the lives of some people, those who are really suffering from great pain. I've known people who cannot get relief from that pain through an opiate prescription because of the stigma associated with using these drugs. Again, I'm not condoning them or anything, but they do fill a role in our society. Some people need them, and I don't think we want to get too far away from that.

I'll just speak very briefly and very informally, because my fellow panellists have said everything I wanted to say on this. I alluded earlier a little bit to detoxing off the opiates. When I first started to want to get off opiates, there weren't really any substitutes out there for me. There was methadone, but there was no treatment offered. I tried to get into a treatment centre, and that was impossible. To this day it's pretty well a roll of the dice if you can get into treatment or not. We really need to increase all different types of treatment. Right now there's basically one form, and that's detox. That's it. It's not going to work for everybody. Nobody ever wants to grow up to stick a needle in their arm or use opiates, but it's a facet of society and I think we need to deal with it responsibly.

This is a medical issue, as some of my fellow panellists have pointed out, and not a criminal issue. I think we need to continue to deal with it in that way. Almost all my recommendations have already been said by my fellow panellists, but I think we really need to repeal Bill C-2, or at least different parts of it, and have supervised injection sites. The Supreme Court came out unanimously in favour of keeping InSite open in Vancouver, yet we've seen no other supervised injection sites in this country. Frankly, there should be one, if not several, in every major city. They've been shown to reduce overdoses, reduce deaths, and reduce the transmission of diseases.

Another thing that DUAL does is to go into schools a lot, but we're very limited in what we can say, especially in public schools. There's no harm reduction education; it's all abstinence based. And a lot of people who are starting into drugs, specifically opioids, are doing so at that age. Those teenage years are extremely important and we're not allowed to have an honest conversation with them.

I think there can be some really good benefits to getting to people while they're young and showing them that in addiction, addiction to opioids specifically, nothing positive is going to come of that.

I think we need to be educating people who are being released from jail. Right now there are a lot of overdoses among people being released. They'll get out, they'll use, and take the same dose they used before they went in and it is enough to kill them. I'm sorry I'm so emotional, but these are my friends, the people I work with, people I love. I lost my best friend to a fentanyl overdose and it really hits home. In Ottawa we see an overdose on opioids about every 10 days, and that's obviously just not acceptable.

I brought a naloxone kit here today, which has been really great. I've actually used it twice and I've seen it, basically, pull people right out of an overdose. The problem with these kits right now is that the dose of the naloxone is so low and the drugs doses are so high it isn't actually counteracting the overdoses as well as it should. I'd really like to see the dosage of naloxone, a very innocuous and harmless drug, increased so that it can meet the demand that these drugs are putting out.

I'd also like to see and develop other forms of treatment. Right now, even to get somebody into detox is difficult. I've got people approaching me every day wanting to clean up their lives per se and we can't get a bed anywhere. It's basically just the luck of the draw. If you can get somebody in, great, if you can't, then that's a....

What's most important is that we need to continue to include people with lived experience and people who use drugs in these conversations. We have a wealth of knowledge that I think we could share. As I alluded to earlier, in conjunction with scientists, doctors, and politicians, as well, obviously, we can really get to the guts of this problem. There are solutions out there. I believe that Canadians are really nurturing. We really believe in health care. This is a medical issue and I think we need to continue to treat it as such.

A statement that we use at DUAL and other drug-user groups around the country is “nothing for us, without us”. We'd just like to see more inclusion at all levels from the top to the bottom, because there are solutions to these problems. We solved a lot of things with the Oxy crisis and I think we really can do that with the fentanyl crisis. Let's just keep plugging away and I think these problems can be eradicated really quickly.

Again, I apologize for my emotion. My voice was breaking most of the time and I really appreciate the invite here. Thank you very much.

[The Vice-Chair, Conservative, Len Webber]

Thank you, Sean. I'm really happy to see you're doing better and thank you for your presentation.

[Sean LeBlanc]

Thank you.

[The Vice-Chair, Conservative, Len Webber]

Sean, you do have a minute, so may I ask you a very quick question about that naloxone kit. How easy is it for you to get that and to distribute that to your patients, to your clients?

[Sean LeBlanc]

I've now been trained as a trainer to be able to do it, but it took a lot of work to do that. We've only given out 250 kits, or I should say Public Health has only given out 250 kits in Ottawa over five years. That's less than one kit a week. Now there are a lot of pharmacies that are giving it out, which is really great. They're not training people maybe as well as they should, and a lot of pharmacies still don't realize that they're able to get rid of it.

I think someone mentioned there were 13,000 kits given out in B.C. I think we can easily approach that in other provinces too.

[The Vice-Chair, Conservative, Len Webber]

Excellent. Thank you, Sean.

We'll get into our questioning round now and we're going to start with MP John Oliver.

John.

[John Oliver, Liberal, Oakville, ON]

Thank you very much and thank you to all of you for your presentations. You showed a lot of passion.

And Sean, in particular, the sharing of your own personal story is much appreciated.

Dave, I just want to confirm that I heard from you that one out of eight deaths in Ontario involve opioids now and that the years of life lost from opioid deaths are greater than all the cancer years of life lost. Did I hear that right?

[Dr. David Juurlink]

Not quite. We published a paper a few years ago that simply looked at all of the deaths that occurred in Ontario and at the deaths that involved opioids, and we broke those up into age ranges. I think the key finding there, other than the fact that deaths involving opioids have skyrocketed over the years, which is no surprise, is that in 2010 in the age group of 25 to 34 years—

[John Oliver, Liberal, Oakville, ON]

I have seven minutes, so get to the punch.

[Dr. David Juurlink]

—that's the segment of the population where one in eight young people died of an opioid and, collectively, all of the person years of life lost was about one-thirteenth that of all cancers combined.

[John Oliver, Liberal, Oakville, ON]

David, I also appreciated your comment that you've seen some federal leadership coming on this.

The Minister of Health has laid out a comprehensive five-point federal strategy, including better informing Canadians about the risks of opioids, supporting better prescription practices, reducing the access to unnecessary opioids, supporting better treatment options, and improving the gathering of evidence and getting the evidence together. The naloxone capability was made possible, and the nasal sprays are now coming in from the U.S.

I heard a number of recommendations from you and from Bonnie.

From Bonnie I heard about expanding supervised consumption services, and that Bill C-2 is a major problem across Canada; establishing drug checking as a harm reduction service to make sure you can see what you're ingesting, even if it's illegal; and increasing availability of treatments for opioid use disorders.

From David I heard about prescription changes and better education of physicians to make sure that the use of opioids is better managed.

All of you referenced better surveillance, and that we need a national surveillance program for this.

I heard from John that the dosage of naloxone needs to be increased in some of these kits.

Are there any other recommendations beyond these? The minister is convening a workshop in November as a special consultation. Is there any other advice you can give us to better the situation or to give advice to the minister?

[Lisa Lapointe]

We would recommend more regulation of the precursors, the sorts of chemicals that combine to make these drugs, and drug regulation of those. Regulation around commercial pill presses, those—