Health Committee on Oct. 20th, 2016

[The Chair, Liberal, Bill Casey]

I call the meeting to order. We have quorum.

Welcome to our guests.

This morning we have our ongoing study on the opioid crisis. From British Columbia we have Dr. Evan Wood.

I understand it's 5:45 a.m. there, approximately, so thank you for being with us.

From Méta d'Âme, we have Mr. Guy-Pierre Lévesque, the director and founder of the community centre.

From Recovery Ottawa we have Dr. Ujjainwalla. Thank you very much for coming and making a presentation.

I understand, Mr. Lévesque, that you have to leave a little early, so we'll ask you to start off with your presentation. You have 10 minutes.

[Guy-Pierre Lévesque, Director and Founder, Méta d'Âme]

As I was presented, my name is Mr. Guy-Pierre Lévesque. I am the founder of the organization Méta d'Âme, which is a peer-led organization. At our facility we are all peers, people who did or are still using opioids.

We initiated a program, starting in 2013, called PROFAN.

We call it Aller plus loin, or going further. The program focuses on prevention, reducing overdoses, peer training and access to naloxone.

Méta d'Âme is a users' association based on the principles of empowerment. We work to improve the quality of life those who use opioids—such as heroin, morphine and other drugs—through our day centre and our 22 housing units, with community support provided by peers, of course.

PROFAN is a response to a recommendation made by United Nations Commission on Narcotic Drugs in 2011. According to this recommendation, the continuum of care offered to opioid users must include greater access to naloxone and be rounded out with training and education programs. That was resolution 55/7. It referred to

promoting measures to prevent drug overdose, in particular opioid overdose.

PROFAN is a French acronym for prevention, reduction, overdose, training, access and naloxone. So it is really a prevention program.

It is designed to empower users to recognize the signs and symptoms and to differentiate among overdoses of various drugs. Unfortunately, there is an epidemic of opioid overdoses, but there are also stimulant overdoses. We train people to recognize these things.

We also train users to do cardiopulmonary resuscitation or CPR. We also teach them how to react to an overdose so they can call 911. For users, there are several things preventing them from doing this. We train them to react the right way. Reducing the number of overdose deaths is of course our ultimate objective.

As to the community, the objectives are as follows: develop a strategy for one or more physicians to become partners in the initiative and to prescribe naloxone to participants who have completed the training; demonstrate the feasibility and accessibility of the overdose prevention and naloxone access project as part of peer training, which is the unique characteristic of this program; document and evaluate the steps taken in the pilot project and establish a data gathering system, which has already been done; give the community tools to deal with overdoses, that is, first responders, ambulance attendants, police officers, and any other person who can respond to an emergency.

The program consists of two training sessions: a shorter one lasting two and a half hours and a longer one lasting five and half hours. The shorter training does not include CPR. The workshops are divided up as follows. The first one pertains to overdose prevention and education. The second workshop shows how to respond in the event of an overdose, that is, what are the signs and symptoms of an overdose of opioids or other drugs, CPR techniques, and administering naloxone.

All the trainers are peers. We called upon members of our association who are users and took the time to train them properly so they can give the training themselves. They are people who use or have used opioids or other drugs, as well as staff who work for agencies whose services are used by persons who use or have used opioids or other drugs. At the community level, this creates a safety net that is very close to the street, which is an asset.

I would like to highlight an important aspect. Depending on the resources, the staff working in the field may or may not be users or former users of opioids or other drugs. Why? Because drug users are often part of community groups. They work in certain areas and become part of work teams. They are users but they are part of a community group and are employees of that group.

The participants who are trained receive a certificate that enables them to respond to overdoses and to use naloxone appropriately in opioid overdose cases.

In conclusion, PROFAN is a community response to the problem. Peers began developing PROFAN in 2013. Why? Because at the various conferences I have attended, whether in Canada or in Europe, I heard that overdoses are on the rise. This helped me understand that a phenomenon was developing. In the organization's action plan, I included the objective of creating a training program. That is what I have just presented.

The partners who joined the initiative in 2014 were the Centre de recherche et d'aide pour narcomanes, or CRAN, the Douglas Institute, Montreal's public health department, and Quebec's ministry of health and social services.

From the start, peers, community organizations, and network pharmacists have been part of PROFAN. We got all these stakeholders to sit down around a table to evaluate the project and to establish a plan for its first year. We are now planning our third year of operations.

Since the program was established 18 months go, 378 people have been trained and 21 lives have been saved. We are seeing changes in the behaviour of the users who have been trained, but this must still be proven empirically. The researcher, Michel Perreault, who is affiliated with the Douglas Institute, is currently evaluating these changes, so our project is being evaluated.

We are also trying to understand how to retain people who have taken the training, how far peers can go in the training, and their ability to do it.

We found that when peers train people, they saw themselves as lifeguards and felt much more responsible in the community. That is where their behaviour starts to change, and that is very important. These people feel they are playing an important role and it means a lot to them. We had thought that this program would be disparate but it has turned out to be very specific and there is a high level of participation.

We recommend that programs similar to PROFAN be created for drug users wherever possible. Training must also be given to everyone who is in substitution treatment programs and who frequently relapses. These people are the most likely to overdose. They should be trained while they are receiving methadone, for example. These people often associate with other users and they will be able to save someone.

For those receiving pain treatment, it should be recommended that they keep a naloxone kit with them. There are a lot of accidents and non-prescribed drugs that are taken. They can be taken from their mother's or father's medicine cabinet. In our opinion, people with such prescriptions should be given a short awareness training before they receive their kit. That might save lives. If they are trained to prevent overdoses, they will recognize when there is a problem. Drugs that are kept at home must be locked up. Of course, a kit should be on hand should an adolescent, for instance, take pain medication that was prescribed for their father or mother. This has to be done.

Peer outreach workers must be able to train drug users right in the field, giving them brief and specific training. For example, we have outreach workers in downtown Montreal. They come into contact with many opioid users, both sellers or users. These people should be given brief training in the field along with a permit to get naloxone.

There is a legislative void in Quebec because no rules have yet been established surrounding naloxone management. In Montreal, we use a collective prescription for the time being.

That only covers the Montreal area, the users and their entourage. They could be parents, roommates, friends or even community workers who work for an organization such as ours or Cactus. All kinds of non-governmental agencies can play a role.

That is essentially what we do. We drafted the documentation in 2013 and, in 2014, we joined CRAN, as I mentioned before. There was a spike in overdoses in Montreal in spring of 2014, and we were of course encouraged to launch our project.

The use of fentanyl and other contraband drugs made in labs is not as much of a problem right now in Montreal. There was, however, a seizure at a fentanyl lab in the north of Montreal a year and a half ago. Fortunately, we have not yet seen an increase in overdoses, although there are still too many. In our opinion, this problem will eventually spread across the Quebec, so we have to be ready.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we'll go to Dr. Evan Wood, professor of medicine at UBC.

Good morning, Dr. Wood. If you'd like to make your 10-minute presentation, we'd be pleased to hear it.

[Dr. Evan Wood, Professor of Medicine, University of British Columbia, Interim Director, British Columbia Centre for Excellence in HIV/AIDS, British Columbia Centre on Substance Use]

Good morning. Thank you for the opportunity to speak.

My name is Evan Wood. I'm a professor of medicine at the University of British Columbia, where I hold a tier 1 Canada research chair. I'm also an addiction medicine physician and medical director for addiction services at Vancouver Coastal Health.

As you are aware, the costs of substance use in Canada are substantial, estimated to be over $40 billion annually. This is, of course, before the opioid crisis emerged. I think you'll be very familiar with some of the interventions required to address the opioid crisis, but I thought I would take a moment to share with you some of the structural reasons this problem has emerged and some of the structural barriers to fully and effectively addressing it.

The first issue I think Canada can really pursue, to the betterment of public health and public safety and exploring this challenge, is the fact that we have not traditionally, in Canada, as in other jurisdictions, trained health care providers in addiction care. I'll just ask you to imagine a scenario of somebody having an acute medical condition like a heart attack. They would be taken into an acute care environment. They would be seen by a medical team with expertise in cardiology. The cardiovascular team would then look to guidelines and standards to diagnose the condition and to effectively treat it. Unfortunately, in Canada, because we haven't traditionally trained health care providers in addiction medicine, we have health care providers who don't know what to do and routinely do things that actually put patients at risk. With respect to the origins of the opioid epidemic in Canada, when it comes to prescription opioids like OxyContin, clearly there has been the exploitation of a knowledge gap, leading to unsafe prescribing. Of course, the failure to employ evidence-based treatments for alcohol and drug addiction suffers from this concern as well.

In addition to the lack of training for health care providers, the overall lack of investments in this area has meant that there aren't standards and guidelines for the treatment of addiction. In British Columbia the long-standing approach to treatment of opioid addiction has been the use of methadone maintenance therapy. That approach has been disconnected from recovery-oriented systems of care and has overlooked a much safer medication in the form of buprenorphine or naloxone.

In British Columbia, within Vancouver Coastal Health, we have recently developed a guideline for the treatment of opioid addiction, using an evidence-based medicine approach to look at what treatment should be first-line, second-line, or third-line as best ways to help people recover from opioid addiction. This is something we're looking to pursue nationally through the Canadian research initiative in substance misuse, which I'm happy to talk about.

Another structural barrier I want to flag for you is that in Canada we have increasingly lumped together the concepts of mental health and addiction. While we have large mental health challenges in this country, and I certainly support approaches to strengthen a system of care for people struggling with mental illness, when we look at addiction through the lens of mental health it results in a number of concerns. The first is that funding for mental health and substance use, when it's directed in that way, overwhelmingly goes towards other mental health conditions besides substance use.

Addiction really is one of Canada's most seriously neglected diseases, and I strongly encourage you to think about funding and support that's aimed at addressing substance use being clearly earmarked for that. Otherwise, it regularly goes into this sort of mental-health-and-substance-use black hole, and addiction is overlooked. There are tangible ways of focusing energy here, which I can talk about shortly, but certainly focusing on mental health and substance use has unintended consequences.

Of course there are individuals who struggle with both mental health and substance use, but your average person who becomes addicted, whether it be to tobacco or alcohol or opioids, shouldn't be thought of as a mentally ill person. The interventions they commonly receive are more tailored toward people with serious mental illness and can actually worsen an overdose crisis. For example, there are the benzodiazepine medications that people with anxiety traditionally have been prescribed. Individuals with addiction regularly are prescribed these medications, again due to a lack of physician training. These medications themselves are associated with increased risk of fatal overdose.

I anticipate that you saw the report released earlier this week on the need for prescription monitoring programs. British Columbia actually has one of the nation's leading monitoring programs to look at prescriptions being provided by physicians. It enables us to look at the patient in front of us, see what prescriptions have been filled, and address such issues as people getting multiple prescriptions and selling medications on the street. Even in British Columbia, however, it's a reactive approach. There is the ability to establish monitoring programs where colleges of physicians and surgeons could actually look for unsafe prescribing and routinely address that concern. It's certainly something that needs to be done in Canada.

A point that I think needs to be made is that we continue to overwhelmingly treat substance use and addiction as a criminal justice issue. Ultimately that worsens public health and safety. Of course we need to support law enforcement due to the intersection between drug use and crime, but we really need to look at solutions that are evidence-based, that support addiction treatment, and that can support people in their recovery rather than take an approach that reinforces stigma and ultimately worsens community health and safety.

I'll leave a couple of take-away points with you. Then I'll be happy to take any questions.

The first point is with regard to the training of health care providers. The college of physicians and surgeons and the college of family physicians are currently pursuing these strategies. I certainly encourage you to support this. A point I didn't make earlier, which I think I'll leave with you, is that addiction is much too common a disease to be left with specialist physicians. We should really be looking to family practitioners being adequately trained in the prevention and treatment of addiction.

My next point is with regard to a focus on addiction as a disease that's both preventable and treatable, and not getting lost in this muddy mix of mental health and addiction. I would use as an example something that could be done by the Canadian Institutes of Health Research, for instance, in terms of dedicated resources toward substance use. In the United States there is a dedicated institute focused on drug use, and that's the National Institute on Drug Abuse. CIHR has no such institute. It means that Canada is kind of punching in the dark when it comes to approaches to substance use. Certainly through the Canadian research initiative on substance misuse, which is CIHR funded, there are positive things happening, but certainly we could do much more with focused intervention.

As I alluded earlier, prescription monitoring programs provide a huge opportunity to reduce unsafe prescribing and to ensure that the issues that emerged with oxycontin don't happen again. We obviously need strategies for the safe treatment of pain. We are increasingly learning that in the context of chronic pain, opioids can be very dangerous for conditions that could be addressed with non-opioid medications.

I think I'll leave it there. I'll just reinforce the point that we improve community safety and public health by treating this as a health issue. That certainly requires dedicated focus and energy, and that obviously is the point of your meeting today, so I'll stop there and thank you for the work you do.

[The Chair, Liberal, Bill Casey]

Thank you for the work you do and for your contribution today.

We'll be asking questions shortly, but first we'll hear from Dr. Mark Ujjainwalla from Recovery Ottawa.

You have 10 minutes for your opening statement, please.

[Dr. Mark Ujjainwalla, Medical Director, Recovery Ottawa]

Thank you very much for having me here and for taking the time to be interested in this most important issue.

I'm a physician and an addiction medicine specialist. I'm ASAM-certified as of 1988. I've been in the addiction world for over 30 years, in the assessment, intervention, and treatment of addiction.

I developed the Ontario Medical Association physician health program in 1995. I've spent most of my career helping professionals and sending them primarily to the United States for treatment, primarily physicians and people who had a lot to lose. That was in the eighties and nineties. I can tell you that in the eighties and nineties we had the gold standard treatment for addiction, certainly in North America, and that's because we hooked into the United States.

In Ontario—and I can only speak for Ontario—in the seventies, eighties, and nineties, we could send people to the United States for comprehensive treatment at the Betty Ford Center at Hazelden or at the Talbott Center. It didn't really matter. They went there, OHIP paid for that, and when they came back, they had aftercare. We had an amazing program that helped many Canadians.

In the nineties, the government decided that they were going to stop this practice. They were going to take the money and develop treatment centres here in Ontario. Unfortunately, that didn't happen. In fact, in my observation, the only thing that happened was that they started closing psychiatric facilities and throwing those types of patients under the bus, unfortunately. They did not develop comprehensive treatment programs as they promised. That was the start of the downfall, of our crisis.

I agree wholeheartedly with many of the comments that Dr. Wood made. The problem we face here is that the real issue with addiction is not opiates. The real issue is the inability of the present health care system to treat the disease of addiction. An addiction is a biopsychosocial illness that affects 10% of society, probably more if you include families, and it is the most underfunded medical illness in our society.

The problem also is that it's a highly preventable and very highly treatable illness. It's very unfortunate that people don't see that. When it affects your family or you, you can feel the pain and suffering, and you watch the tragedy unfold in front of you.

Dr. Wood commented about cardiology and on what would happen if you had chest pain. I submit to you that if one of you were going blind in here right now and I asked you if you would rather that I give you a white cane or take you to the eye institute to see a retinal surgeon, I'm guessing you would go to the retinal surgeon.

The problem we face is the lack of knowledge and understanding on the part of everybody—society, physicians, people in general, and the government especially—in terms of understanding what this disease is and how to treat it.

I've run the addiction curriculum at the medical school here in Ottawa for the last 25 years. We've been decreased from 25 hours of curriculum time to three hours. Seemingly, people don't want to take this seriously, but at the same time, they want to talk about and sensationalize fentanyl and all of these other drugs. It doesn't matter what you die from; if you die from a Glock or from a rocket launcher, you're still dying from a gun. It doesn't really matter. The problem is that we have an issue here that's poorly understood, and I think it's people like you, who are taking the time to listen to this, who could maybe change this. That would be my hope.

I started an opiate withdrawal management centre here in Ottawa. We are self-funded. There's no government funding whatsoever for this. We started with no patients and now we have a thousand patients on Suboxone and methadone, in Vanier. We have seven doctors. My observation is that these people desperately want help. They're victimized, they're marginalized, and they're diminished. They're the people who really are the lost souls of the world and who we desperately need to help.

I got a card the other day, and I'll share it with you. It's a thank you card from one of my patients. They told me: I just wanted you to know how much my life has changed because of you and your staff. I will be forever grateful for your services. Thank you so much for helping me become who I am today.

I think that's what keeps me going, despite the fact that there is no funding and no treatment.

Some of you live in Ottawa. I sent somebody to a psychiatrist, and this is the message I got back from the psychiatrist the other day, after waiting six months: Dear physician, due to the high number of referrals received, there is currently a two-year wait to be seen. We are unable to accept your referral. Why don't you call the Royal Ottawa hospital?

I called the Royal Ottawa hospital, which is our CAMH here in Ottawa. Number one, if you don't have an OHIP card, you can't go in there. You can go to jail without an OHIP card, I can tell you that, but you can't go into a hospital without an OHIP card. They will not see you. It doesn't matter if you have a needle coming out of your neck, they won't see you. It's a one- to three-month wait to see a doctor for an assessment, and after that it's upwards of nine months before you can even get into any type of program. You're looking at a year, and these people are desperate. They are injecting drugs. It's a $600- to $1,000-a-day habit, and they don't have a job. Of course, they have to get money every day. They have to prostitute, sell drugs, or steal. The crime is unconscionable, and we are all part of that.

Then I said, okay, I will call our detox centre here in Ottawa, which is heavily funded. Guess what? It's not a medical detox. If you call there and ask what to do if you're in withdrawal from benzos, alcohol, or opiates, they'll tell you there's no doctor or nurse there and you have to go to the hospital. But when you call the hospital, they tell you that they can't help you.

You can't go to the Royal. There is no emergency department in our psychiatric hospital, so you go to the emergency department at the General hospital, our teaching hospital, and ask where the department of addiction is. You're told there isn't one. When you ask them what you should do, they tell you to wait, which you do for 13 to 20 hours while you are in serious withdrawal. Then you see a first-year medical student or a resident who, as Dr. Wood says, has no training in addiction whatsoever.

This is a case I had here, where someone went to the hospital by ambulance. They were unconscious. I can't really read this—it's all scribbled, as doctors will do—but it says the patient was found unconscious at a bus station. They woke him up and the diagnosis was “intoxication”. The disposition was to follow up with his GP, which he doesn't have, for a refill on his pills. And that's it. That's at a teaching hospital in our country. That is poor. I do a lot of teaching at the university, and I am a Royal College examiner. If that's what you did on an exam, you would fail. You can't let people who are dying leave a hospital. It's ridiculous. But that's what we do all the time—constantly, all day long.

The smokescreen answer of the government appears to be, “Let's put up injection sites; that will solve our problem. Oh, and give them a pamphlet, by the way.” Here is the pamphlet they give you. I had several media sit with me for four hours. I said, “Let's go through this pamphlet. We'll call everybody and see whether we can get help.” After four hours, they went, “Oh my God, there's no help.”

Nobody will help you. You can't be at any treatment centre on methadone or Suboxone. There is no medically assisted treatment. There are no physicians involved. There is nothing. You have to fill out forms with a thing called OAARS, a 12-page report. How does that help you? You're dying of a disease, and you are filling out reports. Imagine if you had crushing chest pain and they told you to fill out a 12-page report first and then go stand over there for 13 hours. It wouldn't happen.

I feel ashamed, as a physician and as an addiction physician in this province, that this is what it has come to. You can tell by my voice and by my enthusiasm. I have a thousand patients right now: a thousand. I deal with it every day. We try to help these people as best we can. We are integrating with the CAS, the parole boards, and the jails.

It's a bureaucratic nightmare. This is a health problem that's highly treatable, and we are doing nothing about it except say let's talk about care fentanyl, this fentanyl, that fentanyl. It's like a group of people who don't know what they are talking about, or sensationalists followed by the media, rather than saying we have a treatable illness that's called “addiction” and we should take the time to go back to the 1980s and see what we were doing back then, when we didn't have this problem. We had a lot. We still had 10% to 20% of the people with the issues, but we were treating them.

Now, though, if they can't get a psychiatrist, they can't get an addiction doctor, they can't get treatment, what do we expect these people to do? Of course they're going to go around in the market area. Every person you've seen in the news lately has been one of our patients. The girl who got stabbed the other day didn't get stabbed because of fentanyl. She got stabbed because she cheated a guy on cocaine for $15. The guy came back, he was so high, and he stabbed and killed her right in front of the shelter. Another guy got shot the other day. It was another drug-related thing. He was also our patient.

These people need help. They're desperate. They're living in a war zone here. You can just go downtown and look. You can come with me; I'll show it to you. It's right here in Canada's capital, and it's shameful. We as a group should take this opportunity to say that we're all going to leave here and do something meaningful about this. We're not going to let these people die.

Thank you.

[The Chair, Liberal, Bill Casey]

To all of you, thank you very, very much for your passion. We're certainly getting the message.

We'll start the questions now with Mr. Oliver.

[John Oliver, Liberal, Oakville, ON]

Thank you very much to all three of you for your excellent testimony and for presenting your recommendations and thoughts to us.

I just want to step back a bit and review where we're at. Certainly the government and this committee are highly concerned about the number of overdoses and deaths, particularly from opioids. We've heard from many witnesses that this is a public health crisis, not a criminal justice issue. I've heard you echo that.

The Minister of Health has laid out a comprehensive federal strategy: better information for Canadians about the risk of opioids; supporting better prescribing practices; reducing easy access to unnecessary opioids; supporting better treatment options for patients and a better evidence base around this; allowing naloxone to be used, and bringing naloxone nasal spray in from the U.S.; and making some of the drugs that are used to produce fentanyl, some of the chemicals, illegal.

There will be a summit in November to deal with the opioid crisis, which I think the Minister of Health is convening. We're trying to figure out what recommendations we could add to that discussion from witnesses such as you.

From Dr. Wood I heard pretty clearly about training primary health care providers in addiction care and treatment strategies, establishing guidelines and practice standards so that there's a methodology to it, directed funding to addictions versus mental health and addictions, and the online prescription database.

I'm trying to figure out, Dr. Ujjainwalla, what the advice is; I heard about the gap. Is it that we don't have a proper diagnostic category for this? For the person who was left at the emergency department, there was no diagnosis. Do we need a DRG group—

[Dr. Mark Ujjainwalla]

It was “intoxication”. It's as Dr. Wood and I are saying. You wouldn't want me being a retinal surgeon right now, because I have no training for it.

[John Oliver, Liberal, Oakville, ON]

Exactly.

[Dr. Mark Ujjainwalla]

You'll die if you put me in charge. If you want your appendix out right now, I'm not the guy to do it. But if you want to get recovery, if you want to get your son, who's addicted to fentanyl, off and back to normal, then okay, I'm your guy.

Where are all the addiction physicians? Where are Dr. Wood and I on all these committees that are trying to explain to hospital boards and the LHIN and all these people that give them money?

You're talking about naloxone, just as an example. There's no limit—

[John Oliver, Liberal, Oakville, ON]

I get the gap, but what's required here? If there was a diagnosis that said “addiction” or—

[Dr. Mark Ujjainwalla]

It wouldn't matter.

[John Oliver, Liberal, Oakville, ON]

It wouldn't change? How do we get a focus on—

[Dr. Mark Ujjainwalla]

It's action: action. You need to develop a comprehensive treatment program for the treatment of addiction.

Just go on the Internet and google “Hazelden Betty Ford”. It's the gold standard of treatment.

You know, when people ask me, “In 15 seconds, tell me how you'd solve this problem”, it's ridiculous. One needs time to explain to you guys what this means. If you go on that website, I can show you what it—

[John Oliver, Liberal, Oakville, ON]

So it's about federal leadership to say there needs to be....

Dr. Wood, would you add anything to this conversation around some specific recommendations we could make as a committee to Parliament around initiating these kinds of practices?

[Dr. Evan Wood]

I think there is a lot of consensus in the room. Through the college of family physicians federally, really ensure that part of the curriculum includes the prevention and treatment of addiction.

I don't want to bash specialists—I'm a specialist myself—but this disease is so common. It's not something rare like rheumatoid arthritis or something that's relatively uncommon. As you've heard, this is 10% of the population. So we need a primary-care-based strategy to train physicians. In the example that was given with the emergency room, they're saying it's intoxication, but they know exactly what's going on. It's just that the health care system is a deer in the headlights; it does not know what to do. So it's about training health care providers and developing evidence-based guidelines and standards.

Just to give you an example, at St. Paul's Hospital in Vancouver, between January and August there were 2,700 non-fatal overdoses that presented to the emergency room. The literature clearly shows that people who have had a non-fatal overdose are at a heightened risk of a subsequent fatal overdose. So there's a very captive audience. You want to do something about it. There is no system. It's not a broken system: there is no system in place.

I don't want to make it seem so daunting that no one knows what to do. There should be standards in the emergency room and evidence-based pathways and referrals to programs, because I tell you, the Canadian taxpayer is hemorrhaging money to send ambulances, to send police, to treat the infections, to treat the lung disease or the liver disease—all the things that go along with untreated addiction. So there's money to be saved, but what's required is to train health care practitioners and establish guidelines.

[John Oliver, Liberal, Oakville, ON]

Thank you very much.

I have one other line of questioning I want to get in before my time runs out.

We haven't heard any advice or comment around pharma: the introduction of OxyContin, the introduction of opioids, the initial encouragement to prescribe these or the recommendation to physicians to prescribe. Do any of you have any comment about the role of pharma in this, and do you have any advice there?

[Dr. Evan Wood]

I'm happy to speak to that.

It has been well documented, and there are lawsuits for hundreds of millions of dollars in the United States because of the shenanigans of the makers of OxyContin. As I alluded to, there was a void in physician knowledge. This promotion of pain as a fifth vital sign and implying that OxyContin was safe and non-addictive was clearly not true. The influence in the pharmaceutical industry on physicians had a hugely negative impact. So there's regulatory opportunity there, too.

[Dr. Mark Ujjainwalla]

If I could add to that, I think one of the reasons I can't give you a specific recommendation is that it's so broken. Where do we start? As I said, you could go on the Hazelden Betty Ford website, present that to the federal government, and say this is what we had in the seventies, eighties, and nineties. We need to open those doors up.

To Dr. Wood's point about the 2,700 people who came in with non-fatal overdoses, what a unique time to put them on Suboxone. Why would you not just put that guy on suboxone, send him to my clinic, and then get treatment? It's simple: bang, bang, bang, done. Instead, they don't know what they're doing. They're irritated by these people. They spend, as he said, lots of the resources and they dump them back on the street. They get picked up by the police and are back in jail. That's the issue.

Really the message is that you have to open the doors again. You can't have a two-year waiting time for a psychiatrist. It's ridiculous. You can't have no treatment centres. It's ridiculous. You can't have no non-medical detox. It's ridiculous. This is 2016.

[The Chair, Liberal, Bill Casey]

Time's up.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much, Mr. Chair.

I truly want to thank the witnesses here today, because one of the things I think we've been lacking in this study is, really, the front line.

I want to start off with you, Dr. Ujjainwalla. I think you're actually the first medical professional we've had in front of the committee here who actually works every day with opioid-dependent individuals. I think you're the first one to appear at our committee, so thank you for your insight. I want to thank you as well for your passion. I think everybody around the table sees how committed you are and how discouraged you are that all levels of government are not really taking the bull by the horns to deal with this. I do want to thank you for your work, and I have a few questions for you.

I see you as actually doing it. Nobody else who has come here is on the ground actually treating people. I wonder if you could elaborate on the kind of appropriate care that you would provide an opioid-dependent individual in contrast to what has been brought up a lot here, these supervised or safe injection sites. You made a comment just now about dumping them back on the street, so they're in and are just dumped back, dumped back, and dumped back. Could you give us some advice on appropriate care? You're giving them care today. You're helping people today. Could you elaborate on that?

[Dr. Mark Ujjainwalla]

It's similar to Mr. Oliver's question about what you would present to the provincial-federal governments on how you treat the disease of addiction. As physicians, we're evidence-based, so what we're saying is that we have to utilize resources or processes that help people. As a doctor of 30 years, I'm trained to help people. I'm trained to treat treatable illnesses.

Let's say you have a palliative care patient and they're going to die. My father died in a palliative care unit, so I know what that's like. He wasn't coming back, so yes, he had lots of opiates. That was fine, because he had bone pain and he was going to die. But when you have a 26-year-old who two years ago was on the McGill soccer team and now is homeless and injecting heroin and smoking crack, and two years ago lived in Westmount, that's a different story. This is a person we can help.

How do you help them? You have to deal with it from a medical detox point of view, depending on whether it's alcohol, benzodiazepines, opiates, or amphetamines; it doesn't really matter. You have to develop a comprehensive plan to say we're going to deal with each of these issues, and you have to do that properly. Unfortunately, you can't do that in 10 minutes. It requires hospitalization, often, to be able to take the time to investigate it, to understand the biopsychosocial element of this woman to treat her withdrawal properly.

For us in the opiate world, Suboxone and methadone have been godsends. Think about it; if you're stealing up to $1,000 a day to get your fentanyl patch, think about the crime. You're 26 years old, and you have to get $800 today. It's eight o'clock in the morning, and you're in horrible withdrawal. The withdrawal of opiates is like the Norwalk virus and a panic attack at the same time. It's just horrible. They'll do anything. So we have to deal with that withdrawal, and Suboxone and methadone work very well for that.

It's not the treatment; it's the transitioning away from that horrible existence that you've developed of acquiring pharmaceuticals or heroin to a place where you're now stable enough to deal with your life. And then, that's the next part of it. If you go into an actual treatment centre, whether it's Bellwood, Homewood, or any of these places, then they start dealing with life. It is the thinking process that's the problem. We get focused on the behaviour, i.e., using the drug. They're using that to deal with all their problems. They like to use that because it makes them feel normal. The problem is that the consequences of using are the issue. What we need to do, then, is look at the person's physical problems, the person's emotional problems, the person's psychological problems, career, money, family, and all that stuff.

Again, for 25 years I sent professionals, physicians, and lots of politicians to treatment in the U.S. They stayed down there for three months, and when they came back, they were really in an excellent position and maintained sobriety. If I could try to help you guys understand what a comprehensive treatment program looks like, then you could explain that to the rest of the world.

[Colin Carrie, Conservative, Oshawa, ON]

I can see a holistic approach working. We've had a lot of witnesses say these safe injection sites are the solution. I see that as kind of giving up on people, just throwing them back into what they've been doing day in and day out. I'm wondering if you could share the success of the recovery centre you have. Do you do safe injections at your...?

[Dr. Mark Ujjainwalla]

First off, I'm sure you've heard a lot about this injection site thing. The word “safe” is a marketing thing. If I had a needle right now full of fentanyl, would anybody volunteer to let me stick it in their neck? I doubt it, because it's not a safe thing to put a needle full of fentanyl into your neck

On the word “supervise”, the idea I think came out of their issue—Dr. Wood, I'm sure, can speak to this—in the upper east side of Vancouver. Fair enough, it's a public health HIV and hepatitis C issue. It's not really an addiction issue, in my opinion. It's almost like a government smokescreen to say that if we do this, then we don't have to do a comprehensive program that would cost billions versus maybe half a million for the injection site.

My experience is this. If I had an opportunity to get better, why wouldn't I take it? This is one of the analogies I use. Let's say I'm a lifeguard and somebody is drowning. I finally get them out. I do CPR. They're alive again. Then I just throw them back in the water. Why would I do that? I've got them here now, so let's treat them, because it's a treatable illness.

The problem, I think, is that the door is closed everywhere. It's like this has become a quote-unquote treatment option when instead it's just an idea that homeless people could go to this place and I guess somebody would wake them up if they stopped breathing. The thing is that we have in Ottawa alone probably 3,000 to 4,000 people injecting at home every day, and they inject five to eight times a day. That's about 30,000 injections a day. You don't see everybody dying from it.

My main point with the treatment aspect is that if you're this woman who is homeless, who is hepatitis C positive, who hasn't eaten, who is just ravaged with illness, addiction, depression, and who has to wake every morning to turn a trick to get money, do you really think she wants to wake up in the morning? That is no life. That is a living hell. I have some pictures I could show you. If I showed you their faces, then you'd see that it is a living hell. They don't want to do this. If I gave them an option, if there were another door....

But there isn't another door. That's the problem. That's my whole point of telling you all this stuff. There isn't another door.

I opened that door because I saw a need. We had a thousand people within three years. We have had seven physicians within three years working flat-out, all day long, trying to keep people out of withdrawal. Our problem is that we don't have the next step. We don't have any funding for any kind of psychological help or any kind of treatment programs. There are just roadblocks and barriers everywhere.

It almost seems like there's this conspiracy not to treat addiction, but to say, listen, this is the answer; you can come into our little basement thing, inject, we'll give you a pamphlet, and bye-bye. That will be the answer for the treatment of addiction. I don't think, as Canadians, we believe that. I know a lot of really wonderful people who are supportive of a foundation I'm going to try to start, to privatize this, to develop our own centres. If the government's not going to do it, I think we're going to have to do it. I just can't stand here and watch these people die every day, and suffer.