Health Committee on Feb. 26th, 2024

[The Vice-Chair, Conservative, Stephen Ellis]

I call this meeting to order.

Welcome to meeting number 104 of the House of Commons Standing Committee on Health. Today’s meeting is taking place in a hybrid format, pursuant to the Standing Orders.

I would like to make a few comments for the benefit of members. Please wait until I recognize you by name before speaking. For those participating by video conference, click on the microphone icon to activate your mic, and please mute yourself when you are not speaking. For interpretation for those on Zoom, you have the choice, at the bottom of your screen, of floor, English or French. For those in the room, you can use the earpiece and select the desired channel. As a reminder, all comments should be addressed through the chair. Additionally, taking screenshots or photos of your screen is not permitted.

In accordance with our routine motion, I am informing the committee that all remote participants have completed the required connection tests in advance of the meeting.

Today's meeting is on the opioid epidemic and toxic drug crisis in Canada. Pursuant to Standing Order 108(2) and the motion adopted on November 8, 2023, the committee is resuming this study.

I would like to welcome our first panel of witnesses. Appearing as an individual, we have Dr. Rob Tanguay, addiction psychiatrist, by video conference. Representing the Association des intervenants en dépendance du Québec, we have Louis Letellier de St-Just, chairman of the board. Representing the London InterCommunity Health Centre, we have Dr. Andrea Sereda, lead physician, safer opioid supply program. Representing Pain BC, we have Maria Hudspith, executive director, by video conference.

Thank you for taking the time to appear today. You will each have up to five minutes for an opening statement. I will hold this sign up when you have one minute left. We're looking for good order and discipline here today.

That being said, Dr. Tanguay, you have the floor for five minutes, please.

[Dr. Rob Tanguay, Addiction Psychiatrist, As an Individual]

Thank you. I'll try to keep it to five minutes, since you'll make me, anyway.

I want to acknowledge that I come from the traditional territories of the peoples of the Treaty No. 7 region here in Calgary, in the Métis Nation of Alberta Region 3.

I'd also like to acknowledge that I'm a person with lived experience as well as a physician. On April 10, 2023, I lost my brother to addiction. He was found in his bathroom, dead on the floor. On September 2, 2021, I lost my best friend Tom to addiction. He was found in his kitchen, alone. On April 3, 2021, I lost one of my best childhood friends, Brent, to addiction. He was found in the basement of a house after a party.

That's why I'm here. I think we all know why we're here. It's because we're losing people every day; the last count was in the twenties. These are preventable losses of life. We are all here to try to figure something out, together.

I want to make sure we distinguish addiction from people who use drugs. We all use drugs. I'm currently drinking a coffee. Human civilization has been well known to use drugs. I am here because I'm a specialist in addiction, not a specialist in people who use drugs. Addiction is a disease. Nora Volkow and so many of us have been advocating for this model for many years. It is a disease of the brain, no different from Parkinson's disease, schizophrenia, depression and anxiety. It is a disease and should be treated as such, with appropriate health measures.

Many of our most vulnerable are affected more by this disease. Right now, we're seeing a shift in Alberta where, as we ramp up treatment, we see more and more loss among those who are living without a home. Now the majority of deaths are occurring on the street, rather than in private residences and other areas. We have to acknowledge that our most vulnerable are often people living without shelter. This represents thousands and thousands of people across our country.

When we start looking at those individuals, we understand that about half have a lifetime prevalence of traumatic brain injury, and about one in four or one in five has a moderate to severe brain injury that would normally require someone living in a home with additional supports. These individuals are resilient enough to be surviving on our streets. There's a massive increase in substance use disorders, chronic pain and mental illness among individuals living without a home, especially those who are unsheltered and not able to get into shelters. In recent B.C. data, two out of every three report significant and severe mental health concerns.

We know these individuals need our support. We know they need help. As with any health disorder, the fact that anybody is debating whether or not we should treat it is not only shocking but also discriminatory, racist and stigmatizing. We would never debate whether or not we'll treat someone's cancer or heart disease, but we will debate whether or not we'll treat somebody's addiction.

When we look at the best evidence for reducing death among those with an opioid use disorder, the data is pretty clear: It's medications for opioid use disorder. Those medications include buprenorphine and methadone. In a study done in 2020 out of Boston—one of the meccas—we saw a 90% reduction in death by adding medication for opioid use disorder in treatment. We know we can reduce overdoses by over 90% with molecules such as buprenorphine. We know we can reduce hospitalizations even more.

If there is one thing I can bring to you today, it is that we need access to treatment for all Canadians, rather than stigmatizing and believing these individuals don't deserve it. Like all of us, they deserve the best health care we can possibly provide.

I could go on for hours, but I will pause there to keep within my five minutes and pass it on.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Dr. Tanguay.

Mr. Letellier de St‑Just, you may go ahead. You have five minutes.

[Louis Letellier de St-Just, Chairman of the Board, Association des intervenants en dépendance du Québec]

Thank you, Mr. Chair.

Members of the committee, thank you for inviting me to take part in your study. It's an issue that deserves your full attention, as well as ours.

I am here today as chairman of the board of the Association des intervenants en dépendance du Québec, or AIDQ. We have expertise in addiction, prevention, treatment, rehabilitation in the community and harm reduction, of course. For a number of years, we have also been keeping a close eye on the changing drug policy landscape.

As a lawyer, I have been practising health law for more than 40 years. In 1989, I co-founded CACTUS Montréal, North America's first needle exchange program. I also teach a course for addictions counsellors on drug addiction, public policy and intervention, in the faculty of medicine and health sciences at Université de Sherbrooke.

My remarks today are not without bias, but that bias is in favour of preserving and improving drug policies that revolve around public health and respect for human rights, especially drug users' right to dignity, and the right to health services. I believe in the importance of evidence because it leads to more objective attitudes and discussions. Evidence also helps us consider some of the measures that are taken through a critical lens.

Now I will turn to the measures that have been taken since 2015‑16. I want to say one thing first: the current crisis existed well before 2015. It is no secret that drug policy is a highly political issue. For the last 50 years, governments have chosen the approach of cracking down on drug use and criminalizing it. There is no doubt that repressive policies introduced in Canada between 2005 and 2015 paved the way for the crisis we face today. Of course, no approach is perfect. However, it takes hard work to undo decades of stigmatization, disregard for evidence and discrimination. It takes time.

The AIDQ's assessment of all the measures taken to date is very positive. I will list a few. During the review of the Canadian drugs and substances strategy, the government reintroduced harm reduction, which had unfortunately been set aside in 2005‑06—with disastrous results. A review of the strategy's four pillars led to a modern approach, one much more suited to the current landscape. Under the strategy, access to naloxone was expanded. Well done. It was the right thing to do. The government passed the Good Samaritan Drug Overdose Act, which provides legal protection from criminal charges to individuals who seek emergency help in an overdose situation. There may be a slight problem, though: Do police services across the country all have a clear understanding of how the good Samaritan legislation is to be applied?

Reviewing the criteria to extend exemptions to supervised consumption sites, overdose prevention sites, was the right thing to do. Today, we have more than 40 such sites. As mentioned earlier, and as you are all very aware, these services save lives. I encourage all of you to tour a supervised consumption site in your riding or elsewhere. Ottawa has a number of sites. I encourage you to visit one so you can see it in action.

With the passage of Bill C-5, the government established diversion measures. What a great step. However, British Columbia's move to decriminalize illicit drugs in January 2023 has created confusion around which system applies and Canada's bipolar approach, if you will. Let's at least make sure that both systems are successful, the pilot in British Columbia and the diversion measures regime across the country.

I want to make an important point about legislative measures going forward. On one hand, I am asking you to provide greater access to safe supply and drug-checking services. On the other, I urge you not to succumb to the criticism that has been voiced in recent years, especially recently, with respect to British Columbia's decriminalization pilot. It's only a year old.

Let's take the time necessary to see through these essential initiatives. Above all, let's tackle criminal groups and their hold over the illegal market. There you have the recipe. What's more, I encourage you to give thoughtful consideration to the issue of legalization.

Thank you.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much.

Dr. Sereda, you have the floor for five minutes, please.

[Dr. Andrea Sereda, Lead Physician, Safer Opioid Supply Program, London InterCommunity Health Centre]

Thank you and good afternoon.

I am Dr. Andrea Sereda and I am a physician working at the London InterCommunity Health Centre. I have 14 years of frontline experience providing primary health care to about 2,000 people living in homelessness and people who use drugs.

As an emergency room doctor, I have resuscitated patients who have died due to overdose and I have treated debilitating infections related to the toxic drug supply.

I am also the lead physician for Canada's longest-running safe supply program, which has been in operation in London since 2016.

There are many different models of safe supply, but today I am going to speak about medicalized, prescribed safe supply. The goal of prescribed safe supply is to convert people who are using an unregulated, illegal, street-based supply of fentanyl to a regulated, legal, prescribed alternative opioid of known dose and known purity.

This goal is really important to understand in our discussions, because the reason unregulated fentanyl is so deadly is not just that the fentanyl molecule is so potent. We use highly potent pharmaceutical fentanyl safely in emergency rooms, ICUs and ORs across the country every single day. Illicit fentanyl is so deadly because its composition and potency are so unpredictable. People who use drugs don't know if the piece of fentanyl they have is 5% fentanyl or 70% fentanyl. It's this unpredictable variability in illicit fentanyl that is causing the devastating overdose crisis we see in Canada.

I explain the problem of fentanyl variability to my patients by using a metaphor that compares fentanyl batches to a batch of chocolate chip cookie dough. If you don't mix the cookie dough well enough, you can end up with a cookie that has two chocolate chips or a cookie that has 20 chocolate chips. These metaphorical cookies are from the same batch, but they have wildly different chocolate potencies when you bite into them. The problem with illicit fentanyl is not knowing whether you have two fentanyl chocolate chips or 20 fentanyl chocolate chips.

By providing people with a prescribed safer supply of an opioid of known dose and known purity, they always get the same standard, safe supply cookie of 10 chocolate chips. People know exactly what dose of opioids they are getting. Therefore, they can be much safer when using them.

Safe supply doctors like myself see safe supply as one part of a spectrum of solutions to the fentanyl crisis. Safe supply clinicians support their patients along the entire continuum of treatment, from abstinence to the prescription of medications like buprenorphine and sublocade, to residential treatment, if that is the person's goal. Within prescribed safe supply programs, we provide the full spectrum of treatment for people with opioid use disorder.

Safe supply is not a wild west of overprescribing, as some have described it. We prescribe safe supply very carefully to a group of people with highly complex medical and social needs that have not been met in other addiction treatment models.

To be eligible for prescribed safe supply in the first place, people need to have experienced—

[The Vice-Chair, Conservative, Stephen Ellis]

Excuse me, Dr. Sereda. I just have to stop you there. I think there is a problem with the translation.

Okay. It's fine.

I'm sorry, Dr. Sereda. Please continue.

[Dr. Andrea Sereda]

As I was saying, safe supply is not a Wild West of overprescribing, as some have described it in the media. We prescribe safe supply very carefully to a group of people with highly complex medical and social needs that have not been met in other addiction treatment models. To be eligible for prescribed safe supply in the first place, people need to have experienced very severe health conditions due to their drug use, like untreated HIV or AIDS, frequent overdoses or history of severe infections.

Safe supply patients have tried multiple previous treatment options, like methadone, AA and residential treatment, often dozens of times, and they simply have not worked for them. Prescribed safe supply is another tool in the tool box for these people, and it has helped to stabilize a group of people with enormous health care needs.

Despite the efforts of safe supply critics who say we have no evidence, there is a strong and growing scientific research base of high-quality research on safe supply. Our team has published a comprehensive program evaluation, which found that safe supply patients experience significant decrease in their number of overdoses and their use of fentanyl. This rapid decrease in overdoses experienced by Ontario safe supply patients is not unique. A recent study published in the British Medical Journal found that people in B.C. who were prescribed just one day of safe supply medications had a 61% decreased chance of dying the following week. If people received four days of safe supply medications, they had a 91% decreased chance of dying.

Our team published in the Canadian Medical Association Journal in 2022. We used Ontario health administration data to compare people's emergency department hospital admissions and the number of infections in the year before they were on safe supply with the year after they were on safe supply. This data showed a 50% decrease in emergency visits and hospitalizations among safe supply patients, translating to a 50% reduction in health care costs among people prescribed safe supply.

To this committee, my job is to keep my patients safe, and the evidence shows that safer supply is helping to do that.

I'll end my remarks here, and I look forward to answering your questions.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Dr. Sereda.

Ms. Hudspith, you have the floor for five minutes, please.

[Maria Hudspith, Executive Director, Pain BC]

Thank you for inviting me to speak to you today.

My name is Maria Hudspith. I'm the executive director of Pain BC, a collaborative charitable organization whose vision is a future where no one is alone with pain.

I'm joining you today from the traditional ancestral and unceded territories of the Musqueam, Squamish and Tsleil-Waututh nations.

In addition to my role with Pain BC, I was the co-chair of the Canadian pain task force, convened by former health minister Ginette Petitpas Taylor following the 2018 opioid summit.

I was invited here to speak with you today about the role of chronic pain in the overdose crisis.

What do we know about chronic pain? Very briefly, chronic pain is defined as pain that persists beyond three months. It can be caused by other diseases, injury or surgery, and it can exist without an identified cause. It is a prevalent, costly and often invisible condition. One in five people in Canada lives with it across their lifespan. People who experience marginalization are disproportionately impacted by chronic pain, including indigenous peoples, people who are incarcerated, veterans, people who are unhoused and others. Best practice treatment includes what we call the three Ps: pharmacological treatment, psychological support and physical approaches.

What are the impacts of chronic pain? We know that in 2019 it cost Canada between $38.3 billion and $40.4 billion in direct and indirect costs. We know that people who live with pain are four times as likely to experience depression and anxiety, and twice as likely to die by suicide. We know that untreated pain is a significant driver of substance use and the overdose crisis. Estimates vary but consistently note that between 45% and 65% of people with substance use disorder report living with chronic pain. Chronic pain impacts our ability to work and earn a living, to go to school, to be a caregiver and to participate in our communities. Despite the prevalence, the impacts and the tremendous financial and human toll, Canada has been slow to address pain as a priority across the health system, and approaches to pain have not been integrated into the overdose crisis response.

What is the connection between pain and the overdose crisis? Well, we know that untreated pain is a significant driver of this problem. People who use substances, and their families, point to the lack of pain care as a contributor to substance use and also as an impediment to successful treatment and recovery. One example is a study focused on primary care patients who used illicit substances, which found that 87% experienced chronic pain and 51% reported using illicit drugs for pain relief. In B.C., coroner's data shows that nearly half of all people who died of overdose sought care for pain in the year prior to their deaths.

Starting in 2016, we began to see a pendulum swing away from prescribing opioids for chronic pain. The change was rapid, driven by new evidence, public discourse and various regulatory and policy levers. Unfortunately, these changes have had significant unintended consequences, as access to opioids for pain was reduced without offering accessible, affordable alternatives. Many Canadians who used opioids to manage pain have been weaned or cut off their medications. We know, through both research and the stories of people with lived experience, that this has driven some people towards the toxic drug supply, with devastating and sometimes deadly results. While governments have noted these unintended consequences of the revised prescribing guidelines, we have not seen a shift in practice, nor a reduction in overdoses. Some people who live with pain have called out the irony of safe supply, with de-prescribing opioids for pain on one hand and prescribing opioids for addiction on the other.

As an organization, we care about all people who live with pain, so this distinction between “legitimate” pain patients, as sometimes has been noted—meaning people who don't live with addictions—and people who live with concurrent pain and addictions.... To us, everyone who lives with pain deserves care.

The overdose crisis has continued unabated, despite tremendous investment in prevention, harm reduction and treatment. What has lacked investment is pain management as an essential component of our health system and our overdose response.

The Canadian pain task force was mandated to assess the state of chronic pain in Canada, to advise on best practices and to make specific policy recommendations in the form of a national action plan. This action plan was released by Health Canada in April 2021, and implementation is ongoing through top-down and bottom-up approaches.

The action plan—

[The Vice-Chair, Conservative, Stephen Ellis]

Ms. Hudspith, I'm going to have to stop you there. Your five minutes are up.

[Maria Hudspith]

Okay, thank you.

The Vice-Chair (Mr. Stephen Ellis) Thank you.

So we're all very aware, we have a convention in this committee. If someone asks a question, what we suggest is that the response is the same length as the question, and the member will have the opportunity to interrupt you, should they desire, at that same length. We will stick to that convention per the usual chair.

With that being said, let's get to the first round of questions. We'll begin with Mrs. Goodridge.

You have the floor for six minutes.

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

Thank you, Mr. Chair. It's wonderful to see you in that spot.

Thank you to all the witnesses for making time to be here today as we study this really important topic.

I'm going to start with my first question for you, Dr. Sereda.

New information has recently been released that corroborates previous reporting that there's mass safe supply diversion happening near the Chapman's Pharmacy close to your clinic. Are you aware of this diversion near Chapman's Pharmacy?

[Dr. Andrea Sereda]

I first have a question for you as well, Mrs. Goodridge.

What evidence has been released showing this?

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

It was in a series of tweets from one of the journalists, Adam Zivo. It was put out today.

[Dr. Andrea Sereda]

As safe supply clinicians, we rely on good research and published evidence and not on anecdotes and tweets on the social media platform Twitter or X, so—

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

Thank you.

Are you aware—

[The Vice-Chair, Conservative, Stephen Ellis]

Excuse me, Mrs. Goodridge. If she has more, we'll give her another 20 seconds, please.

[Dr. Andrea Sereda]

Mr. Zivo is a columnist for the National Post who has dipped his toes into this for the past eight or nine months. Certainly, early in his writing about safe supply, he expressed his desire to burn the whole system down. I'm not sure that he's a terribly credible source of information that we want to rely on in this committee.

In addition, Mr. Zivo visited InterCommunity Health Centre, where he was a very bullying presence to my patients. There is a gate just outside my clinic door, three feet from my clinic door—

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

Thank you.

[Dr. Andrea Sereda]

I'm not finished, Mrs. Goodridge—

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

It doesn't really matter whether you're finished or not.

[Dr. Andrea Sereda]

—and Mr. Zivo blocked access to health care through the only door to my clinic—

[The Vice-Chair, Conservative, Stephen Ellis]

I'm sorry, Dr. Sereda. I think I made you aware very clearly of the convention we have in this committee. I request that you respect that. I've done that with respect to Mrs. Goodridge.

Again, let's be respectful today, everyone. Thank you.

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

Does diversion of safe supply worry you?