Health Committee on Oct. 18th, 2016

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

That's fine.

We are currently dealing with the action taken by the federal government concerning health care. Budget issues always come up. Yves Robert, who is the secretary of the Collège des médecins du Québec, says that we always end up with some kind of budget and action being taken.

Given the differences that exist between various regions in terms of preparation and planning, whether within Quebec or in Canada, what action is the federal government going to take this time, Canada-wide, to ensure that there is monitoring and some degree of uniformity across Canada when it comes to care?

[Réjean Leclerc]

Even though it is less current, I will take the example of the apprehension generated by the Ebola virus disease. Within the border services, everyone was involved. The directives and recommendations were clear. In addition, monitoring afterward was requested.

In this case, the unique factor is that the crisis did not break out in the same way from one region to another. It has become national, but in the beginning, for several months, it was happening only in the Vancouver area.

I think we have to go about it somewhat in the same way. The directives have to be clear and there has to be monitoring so that resources are allocated to the right places. People have to be able to adapt so that they can incorporate this kind of emergency into their plans. In any case, the directives have to be clear.

At present, we are talking about it, but I have the feeling that neither the employer nor the department believes that this crisis needs to be addressed the way the Ebola crisis was at the time.

[Ramez Ayoub, Liberal, Thérèse-De Blainville, QC]

So you support the government making regulations and giving directives to ensure uniformity in the action taken Canada-wide.

[Réjean Leclerc]

I would make a distinction between regulations and directives. I am talking here about giving directives and explaining clearly that it is important to tackle the situation, given that it is a public health problem. In terms of regulations, which I prefer not to address today, that is another matter. It is up to the government to decide how it is going to proceed. In any case, the directives have to be clear.

[The Chair, Liberal, Bill Casey]

Your time is up.

Go ahead, Mr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you, Mr. Chair, and it's good to see you back. I hope you're feeling much better.

I want to take this opportunity to thank all the panellists and witnesses here today. This is a huge issue and we really appreciate your input. I really like what the pharmacist said. Mr. Bursey, you said that we really have to take a big picture approach to this; it's about prevention. The solutions are about prevention and treatment.

It seems that governments of all levels want to focus on these short-term interventions, so I appreciate your input on that.

I did want to start with the firefighters though. I read an article recently about one of your members, Ryan McConnell, a Vancouver firefighter from fire hall 2, who recently said, “Welcome to Welfare Wednesday in Vancouver” . He was referring to the busiest day for firefighters because it's the day that people line up to get their monthly welfare cheques. Jason Lynch , another Vancouver firefighter said that he had to revive a 24-year-old girl twice in one month. I think all of us realize that each person has such great potential in this great country of ours, but to hear stories like this—reviving a 24-year-old twice in one month—I think we have to say that we need to do more.

I do understand the importance of naloxone on the ground. Is naloxone really the solution or as Mr. Lynch stated, is it just a small band-aid on a big cut?

[Chris Coleman]

Thank you for the question.

I'll introduce my colleague Lee Lax as well.

It's a great point. Naloxone doesn't prevent overdoses. It doesn't fix the problem. Tomorrow our chief could put a hundred more firefighters in the Downtown Eastside, but it doesn't change a thing.

[Colin Carrie, Conservative, Oshawa, ON]

That's the thing. We can make naloxone available and it may be a temporary solution, but in my opinion, it's not the solution. A concern out there too is now that addicts know that this is more available, do you think that they may start to feel invincible, especially for young people who might be out there trying this for the first time? Is that a problem we have to be aware of?

[Chris Coleman]

I feel that the problem is a health one.

With or without the naloxone, somebody is going to get high. They're addicts, and I think with or without naloxone....just living there and watching it and working there, no, I don't think so.

Addicts will continue to use because they have to use. I don't believe naloxone has made anyone more of a superman. There was enormous risk before the stronger drugs.

[Colin Carrie, Conservative, Oshawa, ON]

They seem to be getting stronger and stronger. My colleague just mentioned that there is a new one out there that is 100 times more potent, a super fentanyl. I think we really have to focus on prevention.

We had Dr. David Juurlink from the division of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre here last week or the week before, and he put a lot of blame on physicians. He was pretty hard on physicians, about lack of education with regard to prescribing, and more specifically the over-prescribing of opioids in Canada. As I see it, though, physicians can only do so much.

Dr. Emberley, you're aware that the U.S. FDA has now approved over seven abuse-deterrent, tamper-resistant opioid formulations of prescription opioids from four different manufacturers, while our current Canadian government has abandoned this regulatory pathway that was being pursued by the previous government. It was supported by our own provinces and territories and health ministers.

I was wondering, does the Canadian Pharmacists Association support the use of abuse-deterrent, tamper-resistant opioids as one tactic, part of a broader national opioid strategy? If so, why?

Second, would you support a regulatory move to convert the entire class of controlled-release or all opioids to the ADF or tamper-resistant formulations over a short transition period?

[Dr. Philip Emberley, Director, Professional Affairs, Canadian Pharmacists Association]

We spoke out in favour of tamper-resistant formulations a few years ago. One of the reasons was that we had a very problematic drug, namely OxyContin, that was introduced in Canada, which we all know created huge problems. As a result of that, there was a tamper-resistant formulation, OxyNEO, that was developed, and we saw this as a move forward. It was not the only solution, but it was one solution.

We got some signals from the U.S. that this was going to become a pattern for all new, long-acting opioids to be introduced in this format, and we saw it as a good thing. We are still positive about this technological innovation.

However, the other side is that we've seen an unintended consequence. People have seemingly turned to illegal sources of narcotics and opiates. They've gone to the illicit market. We spoke about the fentanyl prices, with illicit forms of fentanyl being introduced. It creates this whole concept of a balloon effect. If you reduce the attractiveness of one type of medication or formulation, and in fact make all narcotics tamper-resistant, it causes certain elements of our society to move to the illicit form. We have to be very careful.

The short answer is yes, we still see tamper-resistance as one solution, not the only solution, but as one solution; there are some numbers out of the U.S. that say it has had some effect. However, we have to be very cautious of the unintended consequences, which may end up being even worse than what we were trying to prevent in the first place.

[Colin Carrie, Conservative, Oshawa, ON]

Now it appears that there is a certain percentage of it which is prescribing, but a larger part of it seems to be this illegal fentanyl. You mentioned the pill presses and stuff like that.

I was going to ask Mr. Blackmer about it. Your organization has known about and has been working on this issue for the past decade. What have you done to work with colleges to educate and help improve the knowledge of physicians on the ground?

I see tamper-resistance as a tool. However, for a 24-year old who maybe gets a broken bone playing sports and before you know it in 30 days is an addict, what have you been doing to help educate physicians on proper prescribing, but also maybe on de-prescribing these substances?

[Dr. Jeff Blackmer]

Those are extremely important issues for a physician.

We've been working very closely with the regulatory colleges and with our educational colleges as well. As you know, there are a number of medical bodies in Canada that have different responsibilities for different areas. We work primarily on the production and dissemination of educational tools online and in person, across the continuum of medical education.

We need to do a better job of educating medical students when they take their pharmacology courses, at that foundational level, to understand the potential of opioid addiction, the different types of pain medications that can be used, and other approaches to pain management, as well as things like addiction management. However, right now there is a lot of focus on practising physicians, because of the new formulations of medications, the new types, and getting that information out to them to address exactly the types of issues you're talking about, which are alternatives to opioid medication in certain circumstances. They can be appropriate in some circumstances but not others, then also that de-escalation of dosage, as well, to get them off the medication.

We've been working hand in glove with these other partners to disseminate those educational products.

[Colin Carrie, Conservative, Oshawa, ON]

I've heard that prescriptions for opioids are still up by 29% this year. Is the message actually getting out there? Part of the strategy is on the criminal element, because it seems that most of it is coming from the criminal element. There need to be substantial resources there, but for on-the-ground prevention, is it getting out there if there's a 29% increase in opioids in the last year? What more can we do? What advice can you give us?

[Dr. Jeff Blackmer]

Clearly, there's more to be done, right? We as a profession have to own that, and we are owning that. We're saying that we need to do a better job.

As in all of these discussions, it's much more complex on the front lines if you have a health care practitioner or a primary care doctor who has only five or 10 minutes with a patient. It would be much better if they had a long time to sit down and talk through all the different alternatives for pain management. They often have a very compressed period of time and they feel very pressured to provide or renew a prescription instead of talking about the other types of alternatives that are available.

As well, these front-line physicians feel that they're under a lot of pressure to provide these prescriptions. You have people coming in demanding access to medication and saying they need it and that if they don't get it, they'll go into withdrawal. The physicians are feeling stuck between a rock and a hard place.

What we're seeing sometimes—and I see this in my practice—is that family doctors are saying that this takes too much of their time, it's too difficult, and they feel under pressure from the regulatory authorities on one hand and the patients and their families on the other hand, so they're just not going to prescribe narcotics anymore. That will be their solution. From their standpoint, they've handled things with their patient population, but those patients just go elsewhere. We need to do a better job of equipping that group of physicians with the tools they need to make the proper decisions, as well as the prescribers, who need more help and guidance in terms of the proper dosing and de-escalation.

There's no question that there's a lot more work to be done.

[The Chair, Liberal, Bill Casey]

Your time is up. I'm sorry.

Ms. Kwan, we have it on our list here that Ms. Malcolmson is the replacement. Are you going to ask questions?

[Jenny Kwan, NDP, Vancouver East, BC]

Yes, I am. I will do the first set and Ms. Malcolmson will do the second set.

[The Chair, Liberal, Bill Casey]

Thank you.

Go ahead. You have seven minutes.

[Jenny Kwan, NDP, Vancouver East, BC]

Thank you very much.

First off, let me say thank you to all the witnesses for your presentations, and in particular, in recognition of the first responders and the hard work you do in our community.

By way of background, I'm the MP for Vancouver East, in which the Downtown Eastside is located. I have a special appreciation for the first responders there and for the community, which is hard at work in trying to deal with this ongoing crisis.

Back in the 1990s, there was a declaration of a health emergency. That's when we pushed for the first supervised injection facility. Since that time, we now have a second round with a health emergency, with fentanyl and the stats that you presented to us, Mr. Coleman. It is indeed shocking, even for someone who has known the community for a very long time. To that end, I want to say first off on the question around harm reduction that the work you do is extremely important because, as we know, dead people don't detox. That's what we need to get to, and it is a medical health crisis.

On that issue in terms of going forward, knowing the crisis that's before us and that is going through the entire country, what can the federal government do to address this issue? What action do we need to ensure that the federal government undertakes to work in collaboration with the provincial and municipal levels of government, the NGOs, and the community on the ground?

[Lee Lax, Representative, International Association of Fire Fighters Local 18 and Vancouver Fire Fighters' Union - Local 18]

I think, first off, we should encourage the federal government to really look at this crisis like they would any other national disaster, and they should support the municipalities.

The move to making naloxone available to first responders, and primarily to firefighters in B.C., has been a great first step. Our death rates from overdoses have stabilized in the short term in Vancouver. Unfortunately, those overdose numbers continue to increase.

It should be noted though that naloxone helps, but it's first responders on the ground who are saving lives. For a person who's addicted to an opioid, or has an overdose, to walk you through it, the person overdoses on the opioid, and respiration slows to a point where breathing stops. That then leads to cardiac arrest and then to eventually to death. It's all about the support of first responders on the ground. Without the boots on the ground dealing with these overdoses, we're not going to be able to save lives. Municipalities at this point are pretty well taxed on that issue.

I think we need to realize that this is as much a mental health emergency as it is a drug emergency. In the Downtown Eastside, almost all of the patients that our members see on a daily basis are dealing with mental health issues. They turn to opioids to relieve them from the stress of their mental illness. Opioids provide them that relief and that temporary reduction in pain. Many of these people don't have access to proper mental health assistance. Mental health is a very strong point to this.

We also have to look toward providing mental health strengthening for first responders. It's the first responders who day in, day out are dealing with these types of emergencies. As Chris alluded to, there's a lot of pain and suffering that our members feel from having to see this every day. We appreciate the work that the federal government has done so far in identifying occupational stress injuries. Post-traumatic stress disorder is certainly a hot topic issue for first responders that we need a national approach from the federal government to deal with.

[Jenny Kwan, NDP, Vancouver East, BC]

Thank you very much.

Would it be fair to say there's a need to move away from, for example, doing pilot projects, which has been a historical practice of federal governments? They come in to do a project on mental health supports with housing that has been developed in the community, but when the pilot ends, the program ends and there's no funding anywhere. Then you're closing the facility that's been proven to be effective. Do we need ongoing support to do these programs, so that we can have effective long-term results? When people talk about treatment and prevention, you need to have stabilized housing, and you need to have ongoing mental health support for individuals who are faced with those challenges in our community, for example.

[Lee Lax]

It's pretty evident, you know, just walking the streets of the Downtown Eastside that there are members of society crying out for help. They don't have the supports that they need, and they're just looking to survive on a day-to-day basis. Being able to provide them with long-term assistance with their addictions, or with their challenges with housing, or with their mental wellness will go a long way in helping their lives.

[Jenny Kwan, NDP, Vancouver East, BC]

I want to turn to you for a minute, Mr. Coleman. You mentioned the impact for first responders or firefighters on the ground. I think it's quite striking. I think the words you used were “hopeless” and “helpless” for the first responders and the impact for you when you deal with this crisis.

I wonder, on that question, what action can be taken to take care of the first responders and the people who are on the ground and in the front lines doing this incredible work to save the lives of others? What can we do to ensure that you have the tools you need to do your job effectively and to also support you in this incredibly challenging situation?

[Chris Coleman]

As Lee said, it would be recognizing that it's a national problem and helping with the limited municipal resources. As was noted, we're quite active on the local scene trying to work with the council and the chief for more staffing, which they get a lot of push-back about. Since this is a national problem, help from the federal government would certainly help.

In the short term, there's nothing this committee can do, but I have to say my men and women down there do feel hopeless and abandoned. They're abandoned by their own leadership. They're abandoned by their own management team. The brothers and sisters don't feel they're supported.

When our chief spoke at a fentanyl crisis meeting two weeks ago in Vancouver, he assured council that everything is okay as far as mental health goes and not to worry because we have a great critical incident stress management team. Well, everything's not okay. It would be nice if they had somebody from the management team come to the hall not to say “suck it up”, which is a quote from a deputy, but to be there and to help and listen to these brothers and sisters and to listen to their stories.

[The Chair, Liberal, Bill Casey]

I'm sorry, but time's up.

Go ahead, Dr. Eyolfson.