Health Committee on Oct. 20th, 2016

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

A role for centres such as harm reduction sites and supervised consumption sites, as one of the aspects, as a short-term treatment while you invest further in this.

[Dr. Mark Ujjainwalla]

It's such a small, minuscule part of what we do; I agree with my colleague. For example, in Ottawa probably only 20 to 40 homeless people would come from the shelter on Nelson Street over there. That's about it. I deal with people all across Ottawa. Nobody's going to get on a bus in February from Orleans and drive down there to inject.

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

I agree with you on that. That's what I'm saying; I agree that it's a small part of it a huge problem.

[Dr. Mark Ujjainwalla]

To your point, I was an emergency physician in a small community for 10 years, and we had no specialists. When somebody had a fractured femur, I'd put an IV in, splint them, and then I'd call the orthopedic guy in North Bay. The difference here is that you guys aren't calling Dr. Wood and Dr. Ujjainwalla. It would be so easy to implement a program where emergency doctors would call the addiction guy, they'd put them on suboxone, they'd send them to my clinic the next day, and then we'd get them into treatment with some counsellors whom the government pays for. That's it. It would happen so fast. What we're missing is that piece. The emergency doctors aren't doing that. They're missing a unique opportunity. They see them as drug seekers.

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

Well, I can say, at least from our experience in Manitoba, that we want to do that.

[Dr. Mark Ujjainwalla]

Okay.

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

In Manitoba we don't have anything like that. I do not have anyone I can call who can see them in the next few days and put them on suboxone.

[Dr. Mark Ujjainwalla]

Are you sure?

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

I am positive. I spent the last eight years in a hospital that everyone comes to.

[Dr. Mark Ujjainwalla]

Well, we need to develop that.

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

I agree completely. What I can do is put them on things like...well, suboxone is fairly new. We've been using clonidine with reasonable effect. We call these people, and they say, “Yes, put them on our list; we'll get back to them”, and it might be a week. There isn't someone like you, who I can send them to right away. I would love to have that. We want that. We've been advocating for it. I'm glad you're here today to tell us how badly we need that.

[Dr. Mark Ujjainwalla]

To your point, if you google “suboxone New York” or “suboxone California”, you're not going to believe what you see. There are thousands of physicians who do this. To the point of developing these guys, it wouldn't be hard. The buy-in on suboxone just hasn't been here in Canada for some reason, unlike Chicago, where every emergency guy is doing it.

Actually, it would be pretty simple to do, and it would save all the emergency guys dealing with all that: you want to put them on suboxone, you send them to me the next day, and it's good to go. It would be really easy to do.

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

I would love to be able to do that.

[The Chair, Liberal, Bill Casey]

Time's up.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair.

I want to ask an opinion question. Please don't take this as one being pitted against another.

Dr. Wood, we've looked at the stats for the Insite website itself, and it does seem to be a positive slant. We have the stats from 2007. There have been about 3.5 million visits since it opened its doors, with about 18,000 registrants over that time period. How do you define success and how do you define good value for dollars and resources? I think everybody's in agreement that you need to have a comprehensive approach, but on the website they're saying out of those number of visits, 1,200 have gone to transitional housing. It really doesn't say how many people have actually been managed properly through treatment. There's nothing there. So 1,200 out of 18,000, that's 6.6%, if they're calling going into housing as the success measurement. Is that how they're measuring success, and is that any indication of how many people are actually being treated properly?

Also, Dr. Ujjainwalla, perhaps you could give us an opinion. There is a cost for Insite. The police association said 100 police officers get diverted down there. If we multiply approximately $100,000 per officer, that's $10 million. That doesn't include the fire, the paramedics, and things like that. If you were given the resources, those millions of dollars going into treatment, and 18,000 registrants, how would you define a success rate with those numbers?

[Dr. Mark Ujjainwalla]

Sorry, are you asking me or Dr. Wood?

[Colin Carrie, Conservative, Oshawa, ON]

I'll ask both of you, so you can start if you want.

[Dr. Mark Ujjainwalla]

The thing is that the end points are different. From an infectious disease and public health standpoint, that's why these things are getting started. We support a safe injection site in Ottawa. I do, and I'm involved. I started a hepatitis C clinic in Ottawa, so I'm all into public health.

I think everybody is getting confused with what you're saying about success, about what the end point of success is and how you define success. For these people, success might be having their own bed to sleep in and having a meal.

That's the problem. You have to define it properly. Again, in medicine, we take a lot of time to define what success is and what the gold standard treatment is, based on evidence. If the success of your daughter is that the best she can do is get off the street and have a clean bed and that's what you want.... I tell my patients that it's like they're on the C team for hockey, but then there's a B team, there's an A team, and there's a AAA team. They all have different expectations. Do you want to be a guy who has a job and a family and pays taxes and enjoys your life? Or do you want to be the guy who has to go and steal and assault people and rob pharmacies in order to use? I don't know which team you want to be on. Also, do you even know what the teams look like?

It's very hard to write out on paper that “this is a success and we save lives”. My position always is that you think you're saving a life, but the people are so unhappy and miserable and they're living in hell. Why do you say that we're saving their lives and therefore we should put this money into it? It should be more about what's important: should you change the whole system so that people have the opportunity to have housing, education, and treatment for their illness?

I agree that this argument.... I've listened to a lot of police. I've been involved with the police chiefs of Ontario. They're frustrated. Of course they are. Think about it. For these injection sites, when you go in, they're not giving you the drugs. You have to bring in your own drugs, so in Ottawa, let's say, you have to go and do all your criminal activity downtown in the market. You have to prostitute, steal, or sell drugs. You get your drugs, you walk over there, and then you inject. You're finally asleep and you feel good, and somebody wakes you up and asks if you're dead yet. You wake up and you have to leave, and then you have to go and get more. You need to get $300 more, so you have to do more crime. It's not really changing anything.

To me, the point is that you're enabling or encouraging a negative existence and at the same time saying, hey, they didn't die today, so that's a good statistic for this funding. I just think everybody's missing the point on it. If that's all you have, if you live in a war-torn zone and it's the best you can do, okay, great, but I think we'd all agree that on every other aspect, whether it's education, or other areas or portfolios that you all have.... In the military, for example, we want the best. We want the best in our military. We want the best in our education. Everybody wants to send their kid to private school.

Why is it different in this area? This is about people's lives. They're sick. They have a treatable illness. If you can treat it, why don't you? If you can't treat it and they're palliative and they're going to die, okay, that's fine, they die, but to Dr. Wood's point, for these hepatitis C guys, I have these guys, and it's almost $100,000 a month for the treatment of hepatitis C. Are you kidding me? They're homeless.

Hey, we didn't really talk about jails yet, but it's $120,000 a year to put one of these guys in jail. That's expensive treatment. Trust me, they look better when they come out of jail, simply because they haven't been exposed to drugs, they've been eating, and they have a safe place to live. That could be an end point, but that's an expensive way to treat somebody.

I don't know if that answers your question.

[Colin Carrie, Conservative, Oshawa, ON]

You have good ideas. I think it is a struggle for all of us.

[The Chair, Liberal, Bill Casey]

Your time is up.

Dr. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I was hoping I could hear Dr. Wood answer his part of the question.

I just wanted to focus on something here. I'm not a member of this committee, but I saw that you're studying the opioid crisis, so I want to go back to the issue. I think I am in full agreement with Dr. Wood that we need to look at this from a public health point of view and then, of course, see what happens when people are in treatment. How do you support them, how do you rehabilitate and house them, and how do you provide all of those kinds of support systems that need to be there to back them up once they've been treated?

I just want to quickly say, because I don't want to use up all my time, that Jenny Kwan and I were ministers who were in charge of the Vancouver agreement, out of which came the safe injection site, and this came out of an evidence base that had happened in Europe that dealt with some of the issues. We were dealing with people who were dying. What are we dealing with now if a thousand people in British Columbia die from an overdose this year? If that happened because of bacteria, a virus, or tainted meat, we would be rushing around trying to stop it.

I want to talk about all of those elements. What do you do immediately to stop those deaths? I think you can't measure deaths on a level unless you think that people who die because of substance abuse are not worth it, that it's okay for them to die. We're talking about deaths. We're talking about stopping deaths. We're talking about preventing disease. That's a public health piece.

I would like Dr. Wood to tell me what he thinks we should be doing immediately, right now. I reiterate the question that Bill C-2 has stopped people from accessing this immediate treatment of stopping overdose deaths, which is what we intended to do, and we were very successful. People's lives were saved.

What other things, Dr. Wood, do we need to do on an immediate basis? You talked about the long term and the medium base, which is the training of doctors and looking at clinical guidelines. What are the immediate things we need to do—now—to stop real people from dying? What can we do now?

[Dr. Evan Wood]

I'll try to answer that as well as the earlier question in terms of success and where we should be investing. First, these programs are not clinical trials, so we have to look at data on deaths and things like that.

To give people context, when Insite opened, it was in the midst of a public health emergency, as was mentioned, and we had the highest rate of HIV infection in the developed world. Because of the comprehensive approach, which included Insite, we have seen a greater than 90% reduction in new HIV infections. Insite is a public health program. It's not a housing program. It's not a treatment program. So having those types of expectations makes no sense.

Because people are dying, and British Columbia is on track to have over a thousand people die this year, young people in the prime of their lives, we need public health interventions and we need them now. We need the things that were mentioned like take-home naloxone, absolutely, and public health strategies to address overdose, including supervised consumption. I think the band-aid point is a good one in that when people are bleeding, you need band-aids. But you also need more comprehensive approaches to prevent bleeding in the first place.

We don't want to have a system that just pulls people out of the river without going upstream to figure out why they're in the river in the first place. These are just structural issues. We need a national approach to the treatment of opioid addiction, and the Canadian research initiative funded by the federal government through CIHR intends to do that.

The other is training health care providers. To use the example of Winnipeg and the emergency room, at Vancouver Coastal Health, which has been dealing with this for a long time, there still have not been the dedicated resources so that emergency room physicians can just pick up the phone and say, “I'm sending someone over to be initiated on Suboxone”, or “I've started it tonight, and they're going to have an appointment tomorrow morning.”

I'll go back to my point about mental health and substance use. We need strategies focused on substance use and on shifting money to mental health and substance use or it just will not trickle down to the needed substance use interventions. Focus on guidelines, focus on practitioners, and don't divide these types of interventions as in opposition.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thanks.

Do I have a minute?

[The Chair, Liberal, Bill Casey]

You do, and 10 seconds.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thanks very much.

I just want to quickly ask one question. You've talked about the immediate things we need to do, which is what I'm concerned about right now. I agree with you on the long term and the comprehensive. There is a big question that I want to ask you. What is the role of heroin as a treatment in opioid addiction? Is there a role for people to go on heroin or heroin substitutes?