Health Committee on Feb. 26th, 2024

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Mr. Thériault.

Mr. Johns, you have the floor for two and a half minutes.

[Gord Johns, NDP, Courtenay—Alberni, BC]

It's really good to hear everybody at the table say that there's no one-size-fits-all in terms of responding to this. We know it's a complex issue that requires a comprehensive response.

I'm going to go back to the safer supply claims that have been made, because we saw B.C.'s overdose death rate go up 5%. That's not good. In Ontario it was 6.8%. Those are two provinces that have safer supply programs. But we saw in Alberta that death rates went up 23%. Saskatchewan had gone down but jumped up by 32% last year. In 30 U.S. states, according to the numbers we have, the rate doubled from 2019 to 2021. Baltimore's death rate is four times that of Vancouver. In Philadelphia the rate has doubled. In Washington and Milwaukee it is higher. They're all without safe supply.

Dr. Sereda, when you hear people point to safe supply as the cause of this crisis and as driving death rates, and then you hear about the numbers in places that have no safe supply, could you speak to how that isn't factual and how anecdotal comments are causing harm to communities? You have a minute and 20 seconds and you can add whatever you'd like to.

[Dr. Andrea Sereda]

Yes, it sets my brain on fire a bit, to be completely honest, because it is simply not possible for safe supply to be driving these deaths. It's not possible, with the number of people receiving it compared to the number of people who use drugs and the number of people who are dying.

You're absolutely correct that in Canadian provinces that have robust harm reduction programming—not just safe supply but robust harm reduction—we have seen less death, as we have in provinces that embrace an entire spectrum of treatment approaches, as I mentioned in my opening remarks.

When I see what is happening in these other cities, my heart absolutely breaks, because that means there are four times as many families that don't have their loved ones anymore. It means there are four or five or eight times as many kids without their parents or parents without their kids.

[Gord Johns, NDP, Courtenay—Alberni, BC]

What do you believe needs to happen? We hear that 1.8% of those who use substances on a daily basis in British Columbia—225,000 people—are getting access to safer supply. What are the responses necessary in this health crisis?

[Dr. Andrea Sereda]

Just to be clear, 225,000 are not receiving safe supply. It's 4,500 of 225,000 who are receiving it.

As for getting ahead of this crisis, I'd say the horse is not just out of the barn; it's all the way down the country laneway, and we're just chasing it and trying to get it back. We need—

[The Vice-Chair, Conservative, Stephen Ellis]

I'm sorry, Dr. Sereda. I'm going to have to stop you there.

However, the good news, Mr. Johns—because you have a benevolent chair—is that there will be two more rounds on the Conservative side, two more on the Liberal side and one more for each of you. It's good news.

Moving on, Mrs. Goodridge, you have the floor for five minutes.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you, Mr. Chair.

Dr. Sereda, a series of letters came out in the last little while from some of Canada's leading addiction doctors sharing their concern around safer supply. Do you not take their words seriously?

[Dr. Andrea Sereda]

I take them very seriously.

First of all, they are self-described leading addiction physicians. There are 30 people who signed that letter.

There is also a letter that was signed by 130 experts in substance use care supporting safe supply. That letter gets a lot less attention and we need to pay attention to it.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you. I appreciate that.

It's frustrating to me. I also think this information is extremely damaging. The addiction crisis is incredibly troubling. In my home province, there are five addiction deaths a day. This is not something small. This is not something I take lightly.

I don't think giving more drugs is somehow going to solve the problem. If that were the case, we wouldn't have anyone dying from alcoholism, yet we have alcoholism leading in deaths across the country.

My question is going to be for Dr. Rob Tanguay.

You talked in your opening statement about some of the OAT pieces. I am just wondering whether you could explain to the committee in a bit more detail what OAT is and how Alberta goes about getting rapid access to OAT prescriptions for people struggling with addictions.

[Dr. Rob Tanguay]

I think that, when we look at OAT, which is opioid agonist therapy—another term for it is medication for opioid use disorder—we have guidelines based on massive studies. Guidelines suggest first line A is buprenorphine or naloxone and first line B, the gold standard, is methadone. These are not accessible to many Canadians around the country, which is very unfortunate. Access is everything. Getting access to these medications is key. Again, it's very important that this comes with wraparound services.

A molecule isn't about treatment. It's about stabilization. It's about initiating treatment. That's a very big differentiating feature. When we look at treatment of opioid use disorder, we talk about the use of buprenorphine, methadone, slow-release oral morphine or whatever molecule we have. It's about stabilizing that individual so we can work through some of the reasons they're suffering with addiction. That may include mental illness or trauma. There are a variety of reasons. It may include chronic pain.

I am lucky to work with Maria on a lot of things as the co-chair for the Alberta pain strategy. One thing is that our virtual pain program works directly with our virtual opioid program to deal with these issues.

Again, this is about medicalizing addiction as a health disorder, not about activism and other aspects. The reality is that following the evidence is something that doesn't seem to be the focus here.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

I appreciate that.

Frankly, I am a politician. I don't think I should be the one setting the policy when it comes to these pieces. I believe we need to be listening to medical evidence and peer-reviewed evidence.

At the end of this, we will have a report going back to Parliament. What would your recommendation be when it comes to opioid agonist therapies and perhaps having more access to them?

[Dr. Rob Tanguay]

Yes, well, there it is: There should be more access.

We talked about the opioid crisis and how we got here. The reason we got here was the diversion of prescribed opioids. It was the over-prescribing. The people who were being prescribed and taking the medication were never the problem. It was the fact—and this was mentioned—that it was family members and friends, or other reasons people were diverting them. That, then, led to the issues.

We heard about correlation versus causation. The correlation coefficient—which has been published—on the amount of prescribed opioids and death is 0.99. A perfect correlation that can cause causation is 1. We know that the more we prescribe, or the more access there is to a substance that can cause harm, the more danger there is from that substance. This is simple public health knowledge. Anybody who works in this area knows this. That is why a lot of my colleagues are up in arms. It's not about the molecule. It's about the fact that we're not taking the time to prevent that molecule from being diverted and being harmful.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you, Dr. Tanguay. I appreciate that.

Mrs. Goodridge, thank you.

Just so we're clear, it will be Mr. Jowhari, Monsieur Thériault, Mr. Johns, then back to the Conservatives, and we'll finish off with the Liberals, just so we're fair.

Mr. Jowhari, you have the floor for five minutes. Go ahead, please.

[Majid Jowhari, Liberal, Richmond Hill, ON]

Thank you, Mr. Chair.

I'd like to thank all the witnesses for being so prepared and for the work they do out there.

Dr. Sereda, I would like to start with you.

You made a comment, which I hope I wrote down properly, and I'd like you to expand on it. You said diversion is a symptom of unmet needs in the community. Then in another response you talked about that and how you'd really like to have the opportunity to talk about some of the diversion protocols that you have in your practice.

Can you expand on what you mean by “unmet needs in the community”, if I actually understood that correctly?

[Dr. Andrea Sereda]

Yes. There is an unmet need. Because safe supply programs have a limited capacity in terms of the number of people they can take in, the number of those who benefit compared to the number of those who are not able to access it results in a lot of translation between those two patient groups, if we can say that. We know from the literature on methadone that methadone is widely diverted because of that unmet need as well. When we read that research on methadone, we know that people are distributing methadone to their friends and their family members who are in withdrawal, who may have just had an overdose or who are trying to get away from fentanyl. We know that clearly from that research.

That's what we see at the street level with people using safe supply as well. People will “divert”—and I would like to put air quotes around that—to their spouse who is in profound withdrawal. They may divert to their roommate who just had an overdose. This is being done out of caring and compassion, so I think it's really important that we be careful with the morality that we're overlaying on the word “diversion”. When I say “morality”, does that mean people don't sell it? I'm not sitting here and saying that. I am saying that we are actually not looking at it in its entire context, because we stigmatize people who use drugs. We always assume that they're doing a bad thing, when the research shows that they are doing loving things for the people around them.

You asked me to expand on the diversion protocols, and I did mention these to Mrs. Goodridge. As I said, every single person on my program submits a urine toxicology test every single time they come in to see me, which for most of my patients is once per week. We monitor those urine toxicology tests and we always do them sequentially, because we know there is a false negative rate in those. If we see people who do not have hydromorphone in their urine, our first step is actually to have a conversation with this patient, because we have a long-term relationship. Within this, we say, “Do you have enough food to eat? Do you have a partner who is taking these medications? Are you at risk for violence?”—outside a pharmacy, as the Conservative MPs have alluded to here. We talk to them about the problems they're experiencing and we seek to fix those.

As I said, we provide food security, and we can provide safety planning. We help women leave partners when that is necessary. The vast majority of the time, that solves the issue of what we're calling “diversion”. When it doesn't—

[Majid Jowhari, Liberal, Richmond Hill, ON]

Thank you.

I want to go quickly to Dr. Tanguay.

I also want to extend my condolences. Losing so many loved ones—close friends and family members—must be very hard on you, so thank you for the continued advocacy you do.

Dr. Tanguay, do I understand correctly that you say the prescription of safe supply should be used in the context of stabilizing the patient to a point where their other needs could be addressed through treatment? Am I right in my understanding here?

[Dr. Rob Tanguay]

You are correct. All prescribing that we do in addiction is about stabilization of that individual so we can move forward with treatment.

As physicians, we also make sure there are no harms to the community or others when we prescribe. For instance, when we do a urine test with respect to methadone treatment, this is something we do all the time, but we don't check for methadone. We check to see if they're using illicit substances. If they're not, then they get to start taking methadone home and not just picking it up at the pharmacy—not the opposite way of trusting that everybody is perfect.

[Majid Jowhari, Liberal, Richmond Hill, ON]

I have just 30 seconds, so thank you.

I want to come back to you again. What would that treatment look like? At the end of the day, we're trying to come up with recommendations as to how safe supply could be managed and how it could be complemented. In the short time you have, could you talk about the treatment and what it would look like?

[Dr. Rob Tanguay]

It's a staged approach. I could do this all day long.

It would start with stabilization biologically and then move into the psychosocial treatment aspect. It would include treating the underlying mental health conditions and treating the trauma, but it would also be looking at workplace training and how to help someone look at returning to the workplace, or looking at a house and what that looks like. So many of our people have never lived in a home that's been stable and have never really appreciated that they can have it.

What treatment is all about is simple: hope. Our job is to create—

[The Vice-Chair, Conservative, Stephen Ellis]

I'm sorry, Dr. Tanguay. I'm going to stop you there. I apologize. As you said, maybe you could go on for days, but we don't have days.

Mr. Thériault, you have two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Tanguay, I'll continue along those lines.

I was struck by something you said earlier in your presentation. You talked about providing care for people who are suffering and struggling with addiction. On a practical level, how do you provide that care? It's not simply a matter of being admitted to a drug treatment program; people have to be very determined. We can't just lock them up. I'd like you to tell us about your experience and your successes.

[Dr. Rob Tanguay]

I can give many success stories about patients. I didn't really want to go down that road.

I think the concept.... I have patients who have gotten their jobs back, gotten their spouses back. Most important is when you help people get their children back. That's the biggest home run in my work—seeing someone come in and introduce their children to you because you helped them in their path to recovery.

We talk about calling people. I've made many of those horrible calls. I've had tears on the phone with moms and dads, brothers and sisters. At the same time, I've had tears of joy and hugs when we're discharging people and they're successful, when they've been with us for years and they're showing us that they can and do recover.

It's about building hope. It's about believing that you can—if you want to—move down the path to remitting your addiction or your mental health disorder and get your life back, and that you deserve it.

[Luc Thériault, Bloc, Montcalm, QC]

Do you agree that relapse is part of the drug treatment and healing process?

[Dr. Rob Tanguay]

Part of that is acceptance, accepting that some of the decisions and aspects of being in a health disorder such as addiction have also led to issues and that you have to deal with those issues.

I also believe that people do remit and relapse because it's a chronic, complex illness. With that, we need access to supports, and we need communities of care and health and wellness. That takes time. There's no easy answer to that.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Mr. Thériault.

Thank you, Dr. Tanguay.

Mr. Johns, you have the floor for two and a half minutes.