Health Committee on Oct. 25th, 2016

[Dr. Claudette Chase]

I'll speak first to the tamper-resistant things. They don't work. People who are addicted are in tremendous physical, emotional, and mental pain, and that motivates them to get around all those tamper-resistant things. While that may slow some things down in being injected, it doesn't stop them from being abused.

I'll let the others speak to the actual amount that's allotted, but I can say at the community level in Eabametoong, the community has taken money from other projects so that they can pay someone with a master's degree in social work to come in and offer counselling. There is one drug and addictions worker in a community where a survey five years ago found 400 people openly admitting that they had an opioid addiction—one worker. Then there are three mental health workers with various levels of training and ability who are from the community and who work with people in the program.

The program gets funding from Health Canada, and this is at the higher end of the spectrum of them being helpful. The program was on an annual basis, so the people in the program were using their energy every year to write a new proposal. I heard from a mole within Health Canada that the advice was to fund these programs at approximately 60%. I can't swear by that, but I think that was accurate information, so here you have a program that's underfunded and understaffed. We have people on the waiting list who want to join our program. We don't have enough staff to do the direct administration of the Suboxone, so whatever the funding's at, it's not adequate to truly fund a community-based treatment program.

There's the trickle-down thing. Pikangikum, which I'm sure is a first nation most of you have heard about, has a huge housing crisis. I don't know how many new houses they get a year, but there's never been someone who has came in and said that “this is how many houses you need and we're going to build them this year because we know this is why you still have tuberculosis, rheumatic fever, and all these things.”

I think it's the same thing with the addictions treatment. We know how many people are addicted. The communities are aware. They know what they need. Let's fund it adequately. Let's admit that it has to be five-year funding, at the very least, and let's start saving some lives.

[Colin Carrie, Conservative, Oshawa, ON]

I think we've heard that prevention is one of the best ways. I believe it may have been that chief—I don't remember who the quote was attributed to—who said, “The drug pushers in my community wear white jackets.” We've had witnesses say that physicians have a role here, and Chief Day mentioned the program. It seems that the simple thing is to give out the opioid instead of looking at these long-term treatments.

I was wondering about the whole idea of proper prescribing. Again, we're looking for your advice. If you had to lay out a solution and give us some concrete recommendations on what the federal government needs to do differently in regard to opioid abuse, what would that be?

[Dr. Claudette Chase]

I can only speak to my practice, which includes the physicians who serve the Sioux Lookout zone. Our practice of prescribing is very cautious. When we do prescribe opioids, it's often because there is very little funding for physiotherapy and occupational therapy. People get injured at work and we have no access to those services. The basic service that would prevent acute pain from becoming chronic doesn't happen.

We do have some challenges, but increasingly, in Thunder Bay and Winnipeg, specialists are no longer sending home orthopedic patients with 200 Percocets for a procedure where it might be required that they take them for a week. We are very cautious in our prescribing practices. I appreciate your bringing that up. I absolutely own that it was physicians who started this. Our prescribing practices in Ontario started this, but often it's because we don't have other services. Getting physio, OT, massage therapy, and chiropractors into these communities would decrease the need for many of my arthritic patients, whom I'm obligated to provide—

[Colin Carrie, Conservative, Oshawa, ON]

I was wondering if I could get some comments from the others too.

[Dr. Claudette Chase]

Certainly.

[Colin Carrie, Conservative, Oshawa, ON]

I'm a chiropractor. Seventy per cent of these opioids are given for back pain because there are no other services out there.

I think everybody would like to comment.

[Dr. Nady el-Guebaly]

Just very briefly, I want to make sure that we don't go to a knee-jerk reaction of suddenly moving on and saying, okay, no more opioids. Unfortunately, I have an impression that part of the fentanyl crisis that has occurred has been because of people getting desperate because suddenly their medication was cut down.

We're talking about a progressive reduction with the emphasis on “progressive” reduction and also the progressive reduction with the substitution of alternate methods. I sympathize with Dr. Chase. If you have nothing else to play with, then it's kind of difficult to look for alternatives. We really need to have a systematic approach to funding those alternatives and making them available too.

[Chief Isadore Day]

I'll be very quick.

Let me talk about the 30,000-foot solution. It really is about health transformation and looking at first nation jurisdiction on health. That's where we need to be, because essentially jurisdiction means authority, and authority means responsibility. We've not had a history of having our ability to respond to our own issues being respected.

For an example, look at the Indian Act system. The Indian Act system is really at the root of much of the oppression and the outside impositions that have affected the daily lives of first nations people: on land, on the people, and on our economy. That's the first piece.

If you think for a second about what has transpired here in the last two decades, you'll see that two significant studies have taken place. One was the Truth and Reconciliation Commission. The other one was the Royal Commission on Aboriginal Peoples. Those two provide the guideposts that are needed. One is on an institutional self-determination level, which really talks about the imposition of the Indian Act. Those are things that talked about nationhood and the overall community. The other one is the TRC, with the 94 calls for action. All the solutions are in there. That's the 30,000-foot solution.

The issue here was looked at by the first nations of Ontario. A few years back, we took the approach of studying this. We did a “take a stand” approach in our report, and it looked at four strategy areas that address prescription drug addiction.

The first one is obviously looking at prevention and health promotion. The second is looking at healthy relationships at all levels to address complex issues, because this is a very complex issue. It involves everybody in being part of the solution.

The third is reducing the supply, and I think this incremental approach to disentrenchment of this insidious addiction is really where we need to go. The fourth is the need for a continuum of care, that continuum of care being here, again, with first nations being responsible, responsive, and respected within that process.

Overall, this is going to require the investment needed to address the issue. The problem we're looking at right now with respect to the joint review on non-insured health benefits in Canada for first nations is the fact that historically the program is not a needs-based program. It's based on funding levels, with the allocation that comes down from Treasury Board not so much looking at the cost to deal with the solution. Again, it's throwing good money after bad and not really addressing the root of it and eradicating terrible issues like the opiate addiction.

To the committee, we do need investment spending. This is the only way.

[The Chair, Liberal, Bill Casey]

Mr. Davies.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you, Mr. Chairman.

Thanks to all of you for being here today. It's very compelling and helpful testimony.

The first thing I want to establish is a benchmark.

Dr. el-Guebaly, I think you made the excellent point that in many ways these issues have been with us for a long time. The substances change, but the causes, challenges, and lack of activity and action remain the same.

I want to briefly get each of you to tell me whether, in your experience, the rates of addiction are going up, down, or staying about the same.

Ms. Hopkins.

[Carol Hopkins]

Addictions continue to be one of the number one issues noted by first nations people. In the first nations regional longitudinal health survey, first nations people—82% across this country—said that substance use is the number one barrier to wellness in first nations communities. That might not seem surprising, but it is surprising when it's 82% saying that addiction is the number one issue, before housing and before employment.

First nations communities have been struggling with addressing substance use issues in their communities for a long time, but again, on outdated formulas, not based on needs. Some communities receive funding based on per capita, which doesn't even—

[Don Davies, NDP, Vancouver Kingsway, BC]

[Inaudible—Editor] I have a number of questions.

[Carol Hopkins]

Okay.

[Don Davies, NDP, Vancouver Kingsway, BC]

I'm just trying to find out if it's getting worse or better. I know it's profoundly important.

[Carol Hopkins]

We are seeing success with programs that are currently available, but is it meeting the need? No.

[Don Davies, NDP, Vancouver Kingsway, BC]

Okay.

Chief Day, is addiction becoming a greater problem, a lesser problem, or is it as bad as it always has been?

[Chief Isadore Day]

I think you have to look at addictions as a systems issue. I think we can look at the numbers and certainly generate the stats, but this is a very complex issue. For example, the cost impacts of alcoholism or marijuana misuse is, in some cases.... I don't like to use the comparison, because it's all bad, but when you talk about fentanyl and the types of opiates that are wreaking havoc on our communities, the cost is enormous.

I would also suggest there may be a need to start drawing some correlations among poverty, nutrition, diabetes, and addiction. If we have elevating rates of diabetes, chances are we're going to have elevated rates of addiction as well. That's just my comment.

[Don Davies, NDP, Vancouver Kingsway, BC]

Dr. Chase, is addiction getting more prevalent or less?

[Dr. Claudette Chase]

I've been in the area of Sioux Lookout since 1982, when I first went as an outpost nurse. When I first arrived, alcoholism was a bigger problem. The introduction and use of OxyContin, many of my patients said, was the first time in their lives that they remembered feeling relaxed and not anxious. You all know the story. It was engineered to have that impact.

I would say that there are more people involved than there ever were with alcohol, and I would say the rates are going up and the users are getting younger. We have seen 12-year-olds and 14-year-olds injecting in some of the communities.

The numbers appear higher to me, but part of the challenge is that the numbers aren't there. I would reiterate the point that this is a complex systems issue and we need data.

[Dr. Nady el-Guebaly]

I'm going to talk about general population surveys, where sometimes the figures come from the States. At this point in time, looking at the last 20 years, the rates for alcohol are—the answer for you is to go drug by drug—more or less steady, maybe slightly increased, but really steady.

There's an interesting phenomenon among the final grades of school. While we are very proud of the fact that we have reduced the rates of tobacco use, which have really come down, well, marijuana use has gone up. That's really what it is today.

Opioids, I think, are a more episodic phenomenon. I don't think we have 20-year studies on that. At this point in time, they've been on a high, particularly for overdoses and so forth.

[Don Davies, NDP, Vancouver Kingsway, BC]

Thank you.

The reason I asked is that in some ways when we look at a study like this I think we're talking about water being wet. We know it's complex. We know there are incredible social determinants involved, including poverty, lack of housing, lack of employment, the impact of colonization if we're talking about first nations, trauma, lack of treatment facilities, regional differences, and the fact that our health care system does not pay for physiotherapy, chiropractic, or counselling. You can go to a doctor if you're sick and get a prescription for a pill and go get that paid for, but if you are directed to a psychologist, you can't get three or four sessions, which may be more a appropriate angle of good care.

By the way, I noted that at the AFN assembly in Ottawa in 2011 a resolution was passed to support the Mohawk Council of Akwesasne's declaration of a state of crisis due to the community's alarming rate of substance abuse. Five years ago, it urged the federal and provincial governments to identify funds and resources for community-based programming and services. In 2012, the AFN Special Chiefs Assembly directed the National Chief and executive committee to urge the federal government to develop and fund a first nations opiate recovery and prevention strategy. That was four years ago. We have been calling for these programs and responses for years. It just doesn't happen.

My last question to you is going to give each of you an opportunity to follow up on Dr. Carrie's question. To get a resolution, what is a suggestion you have that the federal government should take? If you were the Minister of Health, the Minister of Indigenous and Northern Affairs, or the Prime Minister, what would you be directing right now to help us deal with addictions to opioids and other drugs in this country, in first nations communities and otherwise?

[Carol Hopkins]

I would suggest that the federal government seriously look at the resources to fully implement the first nations mental wellness continuum framework. It addresses the lifespan. It has a core basket of services that are required.

Neonatal abstinence syndrome has grown at four times the rate. First nations schools have now classrooms full of children who were born on methadone. We don't know the long-term impacts of methadone. With in utero, infant, toddler, and early childhood development, we don't know what those long-term impacts are, but we have classrooms full of kids who are struggling with that. We also have a senior population with chronic health issues and substance use issues.

This mental wellness continuum framework is a model that is intended to address that, and it relies on indigenous culture and indigenous governance over those services, and we need the resources to implement this. We keep developing these frameworks, but we don't have resources to implement them.

[Don Davies, NDP, Vancouver Kingsway, BC]

Chief Day.

[The Chair, Liberal, Bill Casey]

Your time is up, Mr. Davies.

[Chief Isadore Day]

I think this is going to require that we don't just do a committee report. I think there needs to be the commissioning of an opiate crisis response strategy for Canada. That would include the engineering of a meaningful, shared, and effective national response to opiate addiction and the crisis. In Ontario, for example, we do have the taking-a-stand strategy, but it doesn't have all the jurisdictions around the table investing in a shared solution and response, and that would include the individual. That would also include the families, and it would certainly include first nations jurisdictions.

I think we need to step it up. It needs to be commissioned, and it needs to be funded appropriately.