Health Committee on Feb. 26th, 2024

[Dr. Andrea Sereda]

Absolutely, yes.

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

One thing that really scares me as a mom and as someone who lives in a community that is impacted by addiction—like so many of us—is that when people hear “safe supply”, they think that this is now somehow safe, just like Dr. Powlowski mentioned about the fact that much of this was born out of the over-prescription of opioids. This is now a marketing tool, a marketing term, to call it “safe supply”. Would you consider using a different word?

[Dr. Andrea Sereda]

The term “safe supply” actually comes from the community of people who use drugs, so we honour their participation in this and we use the language that they would like us to use.

In terms of calling it “safe”, “safer supply” or “managed opioids”, whatever you choose to call it, all people who receive a prescribed safe supply are counselled extensively on the benefits and potential harms and potential risks. That's part of a normal consent procedure, so we do—

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

I'm sorry. We just have very little time.

The studies that purport all the benefits of safe supply are based on questionnaires to patients who are prescribed safe supply. Is that not anecdotal?

[Dr. Andrea Sereda]

It's not anecdotal. It's qualitative studies, which are highly prevalent in science and medicine and certainly not unique to safe supply investigations.

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

One thing I find kind of ironic is that after eight years of the Liberals being in power and eight years of your clinic being open, it seems like the only thing in Canada that's cheaper is the price of hydromorphone tablets. In fact, Dr. Sharon Koivu said that hydromorphone dropped from about $20 a tablet in London to $2 a tablet. Does that not show that there is a diversion clearly happening en masse in London?

[Dr. Andrea Sereda]

Maybe, but maybe not. The price of fentanyl has also dropped dramatically.

Back in 2016, when we started, a point of fentanyl was $40 to $50. A point of fentanyl is now maybe $10, often less. You have Costco-sized buys of fentanyl, where people are getting better deals for a larger volume. The prices of all drugs on the street have actually declined.

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

Does that not terrify you?

[Dr. Andrea Sereda]

Of course it does.

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

Why are you not doing more in your clinic to prevent diversion from happening? There are so many.... I get that you're going to say that they're anecdotes, but there are so many stories that I have read specifically of your clinic, with your name on it, of pill bottles going out with hydromorphone that's being sold and that people think is safe.

They might be coming from someone else. They might be coming from some big, bad cartel that's making them and putting them into your pill bottles. It doesn't really matter. They are on the streets in London, and it has your name on it, and they're being sold to kids.

[Dr. Andrea Sereda]

They're not being sold to kids. Our diversion protocols in London are very robust, so every single—

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

Diversion is illegal.

[Dr. Andrea Sereda]

Yes, but I don't cause diversion. It is not my responsibility.

Every single person who is seen in the safe supply clinic receives a urine toxicology at every single visit. We monitor people very closely. Is it a perfect system? No, it's not—just like methadone monitoring through urine toxicology is not a perfect system either—but we intervene whenever there is any objective evidence of diversion. We meet with patients and we move them to observed models when we have objective evidence, and we support people through that.

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

I appreciate that.

In your observed model, if someone does a urine test and it shows a drug other than hydromorphone, what does the conversation look like?

[Dr. Andrea Sereda]

Our patients actually really welcome that feedback, because what we do with people's urine toxicology is that we actually summarize it. When people give urine, they know they're giving information to their community about what's present in the drug supply. It helps us to know what analogs people are from.

If your question is whether they continue to receive safe supply, of course they do. Our intervention is meant to reduce or extinguish.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you, Dr. Sereda. Unfortunately, the time is up in this round as well.

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

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all the witnesses for being here.

Dr. Sereda, can you tell me how we can keep Canadians safe and speak about the importance of research and a data-driven approach so that it's not based on misinformation? Can you elaborate on that?

[Dr. Andrea Sereda]

I think that if I had the answer to that question, we may not be having half of the discussion that we're having today.

How do I interrupt misinformation? I don't know. It's so much easier to spread misinformation and disinformation than it is to actually rebut it with truth. It's very easy to make things up. It's more difficult to actually do the work of showing the truth of what's out there with research.

Certainly, our group and safe supply clinicians across the country are involved in robust and ongoing data generation and research. There are multiple ongoing studies about diversion, because we know it is a concern that is being raised, and we are studying it, but that science takes time. Good-quality research is not something that we can produce in weeks or months, but those studies are ongoing. That's why it's hard to stay ahead of that misinformation campaign.

Again, I can make anything up and I can tweet it out or put it in the media. That takes 10 minutes or half an hour. How long does it take to make something up? However, to actually do the research, to show the truth on the ground, takes time, expertise and commitment, which all safe supply clinicians, including me and my program, are committed to.

[Sonia Sidhu, Liberal, Brampton South, ON]

You talked about the stigma. Stigma is a very real factor. In this debate and in responding to the crisis, what is your opinion on how to combat stigma? Can you give a few examples of how the disclosure around the issue can further stigmatize those already suffering in the communities?

[Dr. Andrea Sereda]

In the two patient stories I discussed near the beginning of this session, I highlighted two women, one with HIV and what was considered palliative AIDS, and another who was declined a heart valve replacement because she was a person who used drugs. That is stigma in action. The medical system assumed those two women were going to die—that this was going to be the outcome. Except, when we provided an intervention that stabilized their substance use, which was safe supply in this case, those women lived. They received their medical surgeries and medication for AIDS and they are thriving and doing well.

In these instances, stigma almost killed these women. Stigma kills many more our team doesn't hear about, isn't able to intervene with and doesn't get wind of. Those stories absolutely break my heart, because we hear them every day from our patients who have friends who went through it but didn't have a team to support them.

We're hearing so much about diversion today. It's a critical issue that we discuss, but the premise behind many of these questions is that people who use drugs can't be trusted—that they're nefarious criminals looking to sell their medication to children and other people, or looking to profit off the medications they are receiving.

Starting that conversation with those assumptions is also stigma in action. The stigma from our assumptions about drug users is limiting our ability to respond to this crisis in a timely manner. It's limiting our ability to respond to this crisis with research-based evidence. To your first question, we're spending so much time responding to the disinformation campaign that it's taking away from our ability to provide that direct clinical care and research we need to do to save lives.

[Sonia Sidhu, Liberal, Brampton South, ON]

Can you expand on the importance of an integrated, wraparound model of care that addresses the social determinants? How specifically does this model engage more people who are ready for recovery?

[Dr. Andrea Sereda]

Absolutely.

I think we've heard references to the CMAJ paper a couple of times. I would like to reiterate that the CMAJ paper showed 50% reduction in poor medical outcomes and 50% reduction in cost only from safe supply prescribing.

Since then, we've been able to add the wraparound care. In my experience, we are seeing people do so much better. There is a glass ceiling on how well I can make people when they are not housed. We help them find housing. There's a glass ceiling when they're on social assistance and can't afford enough food to eat. We provide people with food security. I could go on and on.

We are planning to repeat that study to look at the impacts of wraparound care on people receiving safe supply—not just a prescription, but the entire program—and we have every expectation that it's going to show even better outcomes, because we're seeing this every single day with the people we serve.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Ms. Sidhu and Dr. Sereda.

The next round will go to Mr. Thériault.

Mr. Thériault for two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

All right.

In your presentation, Mr. Letellier de St-Just, you indicated that the period from 2005 up until the implementation of programs paved the way for the current crisis. Could you expand on that?

[Louis Letellier de St-Just]

Indeed, it was quite clear. The then government cannot be accused of lying to the public. Its election platform included cracking down on crime and strengthening the Controlled Drugs and Substances Act to impose mandatory minimums for drug-related crime.

I remember very clearly the 2011 case involving Insite in Vancouver, which went all the way to the Supreme Court of Canada, here in Ottawa. I was one of the lawyers for an international coalition appearing before the Supreme Court. The government refused to renew the exemption for the Insite supervised injection site, which was the only supervised injection site back then. Today, there are 30 such sites.

Such policies exacerbated the crisis by removing harm reduction from the Canadian Drugs and Substances Strategy. That is a major flaw and the main reason why the situation worsened. By focusing first and foremost on enforcement, the government increased prison sentences and filled prisons. Legislation resulting from Bill C-5, which was passed in November 2022, confirms the overrepresentation of indigenous and racialized individuals in our correctional facilities. This is due to the fact that people have been locked up, put in prison and sentenced for minor offences that, for the most part, have had no impact on public safety.

This is an archaic attitude, and it's a misinterpretation of international conventions. When you have the World Health Organization, the UN High Commissioner for Human Rights and the UN Office on Drugs and Crime telling us that we need to move toward decriminalization, adopt a public health approach and respect human rights, it's quite clear. That's the current direction.

It's clear that, by tightening the rules around the strict enforcement of the law between 2005 and 2015, we missed the mark. Should we go back to that? Please, don't go there.