Health Committee on Oct. 25th, 2016

[The Chair, Liberal, Bill Casey]

I call the meeting to order.

I welcome our presenters. We have a little challenge this morning in that we think there's going to be a vote around 10:30 or 10:40 and members will have to leave to vote. Depending on the time, we'll either come back or not come back, but we'll do the best we can to make sure we hear from you. I know that we've asked you to make 10-minute opening presentations, but if it's possible to tighten that up a bit because of the restricted timeline we have today, it gives us more chances to ask questions.

Anyway, I certainly welcome all the presenters. I know we're going to hear some interesting testimony. We're going start this morning with Chief Isadore Day, the Ontario Regional Chief.

Chief Day, please proceed and give your opening presentation.

[Chief Isadore Day, Ontario Regional Chief, Assembly of First Nations]

Thank you, sir.

First of all, I would like to acknowledge that we are on the unceded territory of the Algonquin people, and I'd like to acknowledge the Creator, creation, the prayers, and the protocols.

Today I will accommodate the time pressures. However, Mr. Chair, I do want to make an initial note that these are long-standing issues in our first nation communities throughout all regions across this country. Those who are suffering from this affliction of opioid addiction are living within a prison of physical and psychological torture from this addiction, and I think we need to ensure that we afford the time necessary. I will, however, accommodate the time pressures within this House today. I will ensure that I afford time for my colleagues, who are also presenting.

I'm presenting here as the Ontario Regional Chief, as a member of the AFN executive who holds the portfolio for health, and as the chair of the Chiefs Committee on Health at the Assembly of First Nations. In fact, I represent health issues for 633 first nations across the country.

I'm here because the opioid crisis occurring in Canada is also a crisis that is occurring in many of our first nation communities. Prescription drug abuse is increasing exponentially, and communities are overwhelmed with incidents of illicit drug abuse.

The use and abuse of substances has consistently been a top priority for first nations people as well as their leadership. In fact, a national survey of first nations communities completed between 2008 and 2010 reported that alcohol and drug use and abuse were considered to be the number one challenge to community wellness faced by on-reserve communities, at 82%, followed by housing at 70% and employment at 65%.

Prescription drug abuse is exacerbated by widespread violence, endemic poverty, emotional abuse, and the lasting intergenerational traumas of colonization. The psychological and social effects of residential schools have also contributed enormously to the level of addiction in first nations communities, impacting people of all ages. First nations youth are especially vulnerable to the effects of substance abuse.

The question then becomes, what can be done? More action is needed, and that's what we're here to address today.

In order to reduce prescription drug abuse in first nations communities, the decolonization of the health care system is essential. It is imperative to fully implement the “First Nations Mental Wellness Continuum Framework”. The framework outlines opportunities to build on community strengths and control of resources in order to improve existing mental wellness programming for first nations communities. This includes: community development, ownership, and capacity building; a quality care system and competent service delivery; collaboration with partners; enhanced flexible funding; and, ensuring culture is at the centre of mental wellness and must be understood as an important social determinant of health.

Again, we do have the work. The continuum has been a culmination of several years' work, and we have a document here that we can leave for the committee members.

Full implementation means increasing the amount and flexibility of resources in order to increase capacity, ensure quality care systems, and competent delivery so that all first nations have access to the essential basket of services that make up the continuum of care. A full and adequately funded continuum of services also includes long-term funding for community-based prescription drug abuse programs, such as opioid substitution therapy with buprenorphine, along with land-based treatment and other cultural treatments.

I want to note, Mr. Chair and committee members, that we are probably experts in the experience of alternative use to opiates in our communities. One thing I must underscore, however, is that we're finding that a lot of our remote communities don't have the amount of services that other regions do. In remote and rural territories in other parts of Canada, there simply are not enough resources.

What's happening is that you're almost getting to the point of a solution with the alternatives to opiates, but there's no follow-up. There are no investments being made, and that is really throwing good money after bad. It's actually perpetuating the ongoing and torturous cycle of addiction. What happens is that if there's no aftercare, no completion of that continuum of aftercare, then you're not getting the results you need, and it's complicating the issues.

One of the things we're looking at, Mr. Chair, is that we definitely need to look at the opiate addiction from a.... If you think about what is done in a crisis situation from a medical perspective, they triage that situation and look at all aspects. They look at the environment, the situation, and the injury, and, in this case, addiction being the injury, they are having to fully address in a very specific way that is meaningful at that community level. In the north, there's a very different situation. We do need results-based investments. That investment spending has to include land-based programming. It has to include aftercare for those communities in the north.

With regard to the mental wellness continuum framework, the creation of a community-centred and culturally driven health promotion framework is essential for building effective alternatives to the current treatment system. Ideally, a new system would enable first nations to integrate their values, beliefs, and ways of knowing into programming, making culture a foundation of health care and promotion. It is a plan that provides a broad framework and allows communities to build programs and services based on their unique needs that are responsive to service gaps that exist.

I generally like to complete my presentations, Mr. Chair, but I do have with me Carol Hopkins from the Thunderbird Partnership Foundation, who is an expert in the field. She's somebody we rely on in first nations across the country. I'd like to afford her a few minutes of my time to provide some remarks.

Thank you.

[The Chair, Liberal, Bill Casey]

Go ahead. You have minutes.

[Carol Hopkins, Executive Director, Thunderbird Partnership Foundation, Assembly of First Nations]

Thank you so much, Chief.

[The Chair, Liberal, Bill Casey]

Welcome.

[Carol Hopkins]

Good morning. I'm Carol Hopkins, executive director of the Thunderbird Partnership Foundation. Our mandate is to implement the mental wellness continuum framework and the “Honouring our Strengths” renewal framework. Our focus is on mental wellness, meaning addictions and mental health.

I want to also begin by acknowledging the invitation and saying thank you for that and for sharing time with the Assembly of First Nations. I also want to recognize the Algonquin people on whose land we are meeting today.

I'd like to start by taking us back to 2004, when the third report from the Auditor General criticized the first nations and Inuit health branch of Health Canada for the third time for not doing enough to mitigate the issues related to prescription drug abuse in first nations and Inuit communities. First Nations and Inuit Health then established a drug utilization prevention and promotion working group.

That working group had a mandate to do three things. One was to make data more available from the non-insured health benefits. The second was to engage first nations communities in developing and implementing a community-driven response to prescription drug abuse. The third one was to work with prescribers to address practices and situations of over-prescribing.

That was in 2004. It's 12 years later and one of those issues is still outstanding, that is, the pilot- and proposal-driven nature of funding to first nations communities to address prescription drug use issues. The most critical issue when we talk about the opiate crisis amongst first nations people is that there is annual funding based on proposals, and those proposals are not always fulfilled. It's year-to-year funding somehow expecting that within a year we're going to be able to take care of the opiate crisis that exists in first nations communities.

Addressing the opiate crisis has been a challenge, then, most significantly because of the inconsistent support to community-governed and culturally based treatment. One community-based opioid misuse study reported that among adults ages 20 to 30 years old, 28% of the community was engaged in a buprenorphine/naloxone program. Now, 28% of the community is double the rate of diabetes in that same community. We have dedicated funding, thankfully, to address the issues related to diabetes in our communities, but we don't have the same type of resources when it comes to dealing with the opiate crisis.

The drug utilization prevention and promotion program was successful in demonstrating and piloting a number of community-based programs. We also have a Lakehead study that demonstrated the success of community-governed programs to address opiate addictions. We have other programs in northern Ontario that you'll hear more about and that also demonstrate the importance and significance of this success, unfounded in urban environments and other communities, simply because of the team-based, community-driven, culturally based programs that are offered. Yet they do not have annually committed core funding within their health envelopes.

[The Chair, Liberal, Bill Casey]

Ms. Hopkins, I have to call it. It's time.

[Carol Hopkins]

That was the main point I wanted to make. Thank you very much, Chair.

[The Chair, Liberal, Bill Casey]

I'm glad. Thanks very much.

Dr. Chase.

[Dr. Claudette Chase, Family Physician, Sioux Lookout First Nations Health Authority]

Thank you for this opportunity. I'm very much hoping this will be a meaningful consultation and not further history made with consultation that doesn't lead to action, because it is not extreme to say there are lives at risk on a daily basis because of the opioid crisis.

I am speaking to you today about what I'm most familiar with, which is how the crisis has impacted northwestern Ontario first nations. I work with a practice that serves remote first nations, and we were the first in the country, I believe, to start community-based treatment programs in partnership with the first nations who wanted help.

I want to make three key points today.

The first is that the communities have worked with their primary care providers to build locally run and community-based treatment programs. These are grassroots, they're innovative, and they are effective, effective if you measure them in terms of children coming back to their parents, people being able to return to work, and education. They provide a model that could be offered to indigenous people across Canada, and I say “offered”, not imposed upon. There are ongoing challenges, and I'll get to those, but I want to go through the key points first to make sure I have time for them.

Health Canada's response to this crisis can be measured along a continuum, with the low point being obstructionist and the high point being woefully inadequate. The nurses have been forbidden to work with clients in the addiction program for more than 30 days. If any of you know anything about chronic illnesses, we don't fix diabetes in 30 days and we don't fix addiction in 30 days, and there's abundant scientific evidence to prove that this is a chronic illness. Again, later, I'll speak to why this is problematic.

Number three, I think a key point is disrupting. Our Prime Minister has used the theory of disruption as a positive force, and I believe that. Disrupting the status quo of archaic colonial policies and embracing self-determination for first nations is key to ending intergenerational trauma. I think what this could look like is supporting people to develop the community healing strategies that they believe will work, and that means long-term support. It may also mean funding evaluation so that there is accountability, but I believe this is key.

I want to go back to the first point about the treatment programs and what the challenges are. The ongoing challenges include the lack of stable or adequate funding and little access to land-based treatment. The fuel prices are insane on reserve. We've seen over and over that when communities can commit to these programs, clients get better, but when they come back, especially because they're only on the land short-term, the relapse rate is high. I think that's something very concrete that you could offer to support, and it is something that the communities have asked for—for a long time.

There is no real addiction training or treatment of vicarious trauma for front-line staff. I tear up every time I think about this, because our workers are putting themselves on the line to hear the stories of incredible trauma. We have little funding to train them. These are community members who, because Health Canada has refused to step up, have stepped up themselves. They do this and they get traumatized daily, and I have little or no means to support them other than being their family doctor. It's not acceptable.

My sister worked at an Ottawa clinic for street-involved people. The training she received to work at Oasis was unbelievable. The debriefing was phenomenal. She was able to do it for 16 years. I don't think our workers are going to last 16 years.

I can elaborate more on Health Canada. I've told you that there is an actual policy. You can check with the FNIHB nursing branch about what they have directed nurses to do. I'm sorry that I didn't bring that document, but it has been circulated.

Nurses can help no more than 21 patients and for no more than 30 days, so what has happened is.... I hesitate to even bring this up, but lay people are now storing, administering, and counting buprenorphine/naloxone, which is a very powerful opiate that we use to treat narcotic addiction, and they're doing a fantastic job.

But it's not acceptable. I was a nurse before I was a doctor. We had so much training on how to be accountable around narcotics, and yet.... These community members are doing it and I don't want to undermine them, but it's not fair. It's not a service that would be provided down here—or a lack of a service, I guess. It's creating a divide between the communities and the nursing station. The communities say that this is their most urgent concern, and the nurses are being told by the FNIHB that they are not to be involved in this. It creates an artificial.... It creates conflict at the local level.

For the last point, about embracing self-determination, I've included the article by Chandler and his colleagues. I'm sorry, but it will be translated; it hasn't been yet. He speaks very strongly to what was a protective factor against suicide in aboriginal communities in British Columbia. He said that the in terms of the protective factors for the communities that had lower suicide rates than the dominant culture, they weren't based on economics. They were based on self-determination and attachment to their culture. Those are concrete things that you have the opportunity to support to save lives.

I have a story—it's an all too familiar story for us—of a woman who started snorting Percocets because she had been sexually abused as a child and also as an adult. Her marriage fell apart. She went from Percocets to Oxy, and from snorting to injecting. Luckily, she escaped hepatitis C, which many of the people in the community I serve have contracted. Three of her five kids went into care.

She joined our program in 2011. Her husband joined six months later. To be honest, I thought she would never make it, from what I had seen. Then one day her husband said to me that he was getting better and was back with his wife. He said that she was really strong. I asked who his wife was and he mentioned this woman who I had presumed would not make it. She has proven her strength. She has all her children back. Her marriage is back together.

She and her husband are working, but her children have multiple needs, including for the trauma they suffered when they were apart from their parents. I have no access to family therapy for them. The children need testing. I have no access to get them tested. This is not acceptable care. My colleague, Dr. Mike Kirlew, presented on the lack of services to children in isolated reserves.

These are concrete things you can change.

Thank you very much for your attention.

[The Chair, Liberal, Bill Casey]

Thank you very much for your first-hand testimony of your experiences.

Our next guest is Dr. el-Guebaly, who is a professor in the Department of Psychiatry at the University of Calgary.

[Dr. Nady el-Guebaly, Professor, Department of Psychiatry, University of Calgary, As an Individual]

Thank you very much for the invitation and the experience. It's my first time to stand in front of one of your committees.

First of all, I support all the statements that have been made. I was thinking as I was listening to my colleagues here that there's actually a fair amount of consensus around what we're talking about, as in the issues and so forth, and I'm thinking if there's so much consensus, how come we're still having so much difficulty delivering the services we need?

To put things in perspective, I've been in the field for 48 years—too long—as an addiction physician and an addiction psychiatrist, and I want to put this in perspective: when we talk about drugs, we should never forget about alcohol and tobacco first, followed by the other drugs.

I think we all agree that the problem we are facing is a bio/psycho/social/spiritual problem. I think there is a lot of agreement on that. Certainly among the physicians who specialize in the field, this a common agreement. This is not a matter of having one or the other. It's all together. This is the package.

I couldn't help but also think that probably 10 years ago I would have been here talking about methamphetamines. Before that, I would have been talking about stimulants. Before that, I would have been talking about heroin. The field has a way of bringing us continuous crises, one after the other after the other.

I would assume that one of the reasons that we're meeting here is that at this point in time hundreds of our patients in western Canada are dying from the fentanyl crisis as well as the overdoses from prescription drugs. I like to tell people that unfortunately we should also plan for the next crisis, and we already have it. The next crisis is not fentanyl. The next crisis is carfentanil, which is 100 times more potent than fentanyl. What else is coming up?

What is the major difference occurring right now? The major difference is that in the past our addictive drugs came from plants. This is now a thing of the past. Our major drugs will now come from labs. Therefore, the frequency, the potency, and all those qualities are going to change much more rapidly than they used to before. That, I think, is a new phenomenon that we should be careful of.

I'm a strong believer that a crisis is also an opportunity, and when I look at what has been happening over the last while, I just want to point out some topics that I think may give us some hope.

The crisis at the moment has three components to it.

Number one is the component of overdoses. This is what makes people die. Hundreds of people have died. In terms of lethality, it's probably been many years since I've seen such an amount of people dying so fast. They're not all addicted; they could be my son or my daughter going to a rock concert and taking those blue pills. Sometimes they don't even know what they're taking. Before you know it, respiratory depression occurs, it's an emergency, and you're lucky if you only pass out. These are not addicts. These are experimenters. In terms of overdoses, what we are now providing more and more across the population naloxone injections. I want to congratulate Health Canada. It's not very often that I congratulate Health Canada, so let's congratulate Health Canada when it's due. Naloxone spray is a tool that we didn't have two years ago and is now available to the population for opioids.

The second issue we have is a major issue around what to do with chronic pain. We have more and more older people. We have an aging population and we have all kinds of disabilities, all kinds of things. As a physician, I was the recipient of lectures that were given to us in the 1980s and how we were opio-phobic. Physicians were afraid to prescribe opioids, and it was “what's going on, we're not treating chronic pain properly, we don't know what we're doing”, and opioids would be the solution. As usual, the pendulum swung from A to B, and now we have this epidemic going on with prescriptions.

There are two things. First of all, there's a major effort going on at the moment with educating the physicians. It takes some time to reverse the pendulum, but I think there are some signs that the pendulum will reverse. The other thing is that the treatment of chronic pain is not only about opioids, about giving someone OxyContin. The treatment of chronic pain is a comprehensive program involving a number of alternative methods, one of which is opioids.

By the way, opioids are now increasingly coming up as being not that effective, in fact, in the treatment of chronic pain. The nature of the medication is such that when you use it, it will make you dependent after three to six months.

The third component, then, is addiction—and I agree with my colleagues—but it's not the only one. In addiction at the moment there are new methods of delivery going on. One of the things that has been a problem for us is the non-compliance from people. People are given medication and don't take it. The same thing applies, actually, to schizophrenic patients, so learning from schizophrenia, increasingly the medication that will be provided would be in an injectable form.

We see a number of medications in the United States that are not yet here in Canada. I really would like the committee to make a recommendation about that. There's a medication called Vivitrol. Some of the medications are implants. In the future, there are probably going to be vaccines. A number of future things are coming up. For some reason, we seem to be delaying its introduction in Canada, and I would recommend that we do something about that.

Unfortunately, as the methods of delivery of our medication change, so does the method of delivery of drugs. One of the things that is being singled out at the moment is the famous electronic cigarette. The cartridge for the electronic cigarette, which was supposed to be no problem and all that kind of stuff, can actually be used for a number of things, including the delivery of opiates, including the delivery of your favourite drug and including a number of things. We are really worried about that as, again, a new method of delivery.

In thanking the committee, I will say to please put the crisis in perspective. There are a number of components to it, and think there are some possibilities. I wouldn't talk about solutions, because humanity has experienced addiction since its beginning, but certainly, to reduce the harms of the present day with them is a possibility. It is opening up opportunities too.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

We're going to our seven-minute round of questions. I usually leave a little flexibility, but I'm going to keep it right at seven minutes because we will be restricted with the vote coming up.

We're going to start this morning with Mr. Kang.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

First of all, I would like to thank all the witnesses for their insight on the crisis we are all facing today.

My question is for Isadore Day or Carol Hopkins. In Alberta, three bands of the Stoney Nakoda reported in July of this year that nearly 60% of their adult population was struggling with opioid addiction. In 2015, the Blood Tribe also declared a state of emergency on this issue. What factors do indigenous Canadians face that increase their likelihood of suffering from opioid addiction?

[Chief Isadore Day]

I'll answer part of that and then turn it over to Carol.

It is really an issue of access. You have to look at the history of opioid addiction in our first nation communities. Look at the first nations and Inuit health branch of Health Canada and the drug program.

I was a chief of Serpent River First Nation for 10 years. We used to get the drug reports. The two main drugs that were actually administered in our community, the drugs with the highest rates, were methadone and opiates. This is really a systemic issue. The roots of it are that this is how the medical profession was dealing with the health issues in our communities. They would give opiates as a way to deal with the health issues and concerns of our people. This would then establish not only the culture but a really deep dependence on opiates.

I'm going to suggest here very quickly that we have to analyze this problem from a systems and systemic perspective in that this is a shared responsibility. It's not only the individual. The federal government needs to really examine where they are at fault here. The federal government is to blame for a large portion of the problems we're faced with. Our people will have to deal with this as individuals, as families, and as communities, but this is a real systemic and chronic issue, and the genesis is found in the programs that are governed by the federal government.

Carol.

[Carol Hopkins]

Yes, I'd like to—

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

You're—

[Carol Hopkins]

Go ahead.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

You're pointing fingers at the federal government. What are these faults that we should be looking at? You don't say what those things.... It's a shared responsibility. We would like to know what are those faults on the federal government side.

[Chief Isadore Day]

Basically, there are no alternatives. Many of our people don't have those types of psychosocial programming or the access to ways to deal with the historical trauma or physical pain. The reality is that this is an investment spending opportunity. As my colleague indicated, this is a crisis, but it's also an opportunity. What it all boils down to is that there is a two-tiered health system in this country. First nations do not have the level of health that mainstream Canada has. The stats are there. We know that a gap exists.

I think it's levelling the playing field. When our first nations have access to appropriate health programs and services, when we actually achieve health equity in this country, first nations will be able to deal with this issue.

[Carol Hopkins]

Yes, as I said earlier and as you heard from my friend Dr. Claudette Chase, the primary health care system we have in first nations communities is at the nursing station. Nurses employed by Health Canada do not have the scope of practice to engage in supporting first nations people in their own community in addressing opiate issues beyond 30 days. That's one point.

The second point is that we don't have access to treatment for opiate addiction, and when there is access, it's short-term access. Without access to treatment, many people are suffering in their communities, which leads to illicit drug use, and the problem continues.

I'm thankful that you mentioned southern Alberta, because I also want to say that the research on addiction says that it's permanent brain damage and it can't be undone. I think that's a racist way of keeping people on methadone, because people in indigenous communities have had to leave their communities to access treatment, and the primary course of treatment has been with methadone by physicians who say it's a course of treatment for the rest of your life.

[Darshan Singh Kang, Liberal, Calgary Skyview, AB]

Thank you.

You touched a little bit on naloxone. To your knowledge, do all first nations communities have access to naloxone to treat opioid overdose?

I also have another question. Have there been any differences in the ways this crisis has been felt by the urban population as compared with the rural, and what are the differences or similarities when facing this crisis?

Those are two questions.

[Carol Hopkins]

Access to buprenorphine and naloxone has been a challenge for first nations communities. We have been successful in getting some greater access to buprenorphine and naloxone—it's by exception on the non-insured health benefits—and then in Ontario the Minister of Health has just announced greater access.

The program that Dr. Chase is talking about is successful because it uses buprenorphine and naloxone. I would encourage that buprenorphine and naloxone be the first line of treatment for indigenous populations with an opiate addiction, because it allows them to stay in their community and it allows for a team-based approach. Health Canada has to change its policies around nursing in communities so that it's a strength-based primary care program and not a “nurse” program, so that they can work with others in communities.

The other question you had.... I'm not sure that I answered it.

No, naloxone kits aren't widely available. That's true. We need greater access to naloxone, and we need support for broader distribution to high-risk populations for naloxone.

[The Chair, Liberal, Bill Casey]

Your time is up.

Dr. Carrie.

[Colin Carrie, Conservative, Oshawa, ON]

Thank you very much to the witnesses for being here today. I think we could probably spend a lot more time on getting your input, and maybe that's something we can look at.

I want to ask for a couple of specifics. We're all looking for solutions. You may know Alvin Fiddler, who a few years ago was the deputy grand chief of the Nishnawbe Aski Nation. With Deb Matthews, the minister in Ontario, he was pushing to make the entire class of opioids tamper-resistant, because one of the things that was problematic, I guess in first nations.... Ms. Matthews even said that in one community in northern Ontario 85% of the community was addicted to opioids.

Dr. Chase, you were saying that they get generic OxyContin, they crush it, they snort it, they inject it, and it's very problematic. I am wondering whether you still support the idea of making that entire class of drugs tamper-resistant.

Also, how much money is allocated to mental health and addiction in first nations, and what services are offered with that money? I wondering whether you could answer that.