Health Committee on Feb. 29th, 2024

[The Vice-Chair, Conservative, Stephen Ellis]

Colleagues, I think you heard Dr. Kitchen's amendment. The problem, of course, is that I had moved the motion originally, and if there's unanimous consent we can obviously be the masters of our own destiny, and if there is.... I see heads nodding yes. There is unanimous consent.

Thank you, Dr. Kitchen.

Ms. Brière, you have the floor for five minutes.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you, Mr. Chair.

[The Vice-Chair, Conservative, Stephen Ellis]

I am a very bad chair, obviously, and I apologize for that because we didn't vote on it. We moved it and then didn't vote on it. There's a lot of machinery on the go.

The clerk has an excellent suggestion.

Dr. Kitchen, if you could reread the motion that would be very helpful.

[Robert Gordon Kitchen, Conservative, Souris—Moose Mountain, SK]

Thank you. It reads:

That the committee invite the Minister of Health and the Minister of Mental Health and Addictions to each appear for a one-hour meeting on Supplementary Estimates (C), 2023-24, and that the Ministers appear before the end of the supply period ending March 26, 2024.

[The Vice-Chair, Conservative, Stephen Ellis]

We've all heard the text of the motion. It appears to be in order. We've had unanimous consent to move that. Do we have consent around the table that this is appropriate at the current time?

[Some hon. members]

Agreed.

[The Vice-Chair, Conservative, Stephen Ellis]

(Motion agreed to)

The motion is adopted. Thank you very much.

Now that I finally have all of that out of the way, we can move back to the original business.

For the third time, Ms. Brière, I yield the floor to you for five minutes.

Thank you very much for your patience.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you. I hope it will be good.

Thank you so much to all the witnesses for being with us.

Dr. Goyer, since we began this study, we've heard from various witnesses that the diversion of controlled substances was due to unmet needs.

I'd like you to tell me about the reasons for this diversion. Does this have any implications for the list of drugs that are insured or reimbursed by the public system?

[Dr. Marie-Ève Goyer]

I'll try to go back over the drug diversion cognitive equation so we can all agree on the diagnosis and treatment plan.

The first thing I hear people say is that if you prescribe safe supply, there's necessarily going to be diversion. May I remind everyone that there are very few safe supply programs and very few doctors who prescribe this. If there were diversion, it would occur on a very limited basis.

In my opinion, this also contributes to the stigmatization of those who turn to this treatment. People are targeting safe supply, while doctors are prescribing a lot of drugs to patients. Some patients receive prescriptions for a month's worth of painkillers, for example. Why are we targeting the safer supply? It's not clear to me, apart from perhaps the fact that we associate drug addiction with drug diversion. Certain prejudices are tenacious: A drug addict is bound to divert. It's a connection I don't agree with.

Secondly, as Dr. Sereda has already said, among people who use, if there is diversion, it's often because there aren't enough treatments available. People try to help each other when they're going through withdrawal, when drugs are out of stock or when their pharmacy is closed on weekends. I would remind you that many pharmacies refuse to give out the medications. To me, it's not clear that this diversion is taking place.

It is assumed that the diversion of substances will target children. Again, this is based on fear. I find it dangerous to base political decisions on fear instead of relying on science and facts.

Suppose there is diversion to children. Who are these children and what are we afraid of? We're afraid they'll use and die, or we're afraid they'll end up suffering from addiction.

What do we know about children who are currently using opioids and dying from them? These children have consumed contaminated opioids from illicit markets. The British Columbia coroner's data show it. Just recently in Quebec—and this was covered in the media—a child died after consuming what he thought was a random tablet. In fact, the tablet contained isotonitazene. So, currently, it's not prescription drugs that are ending up in children's hands.

You might also wonder who the people are who are selling these substances to children. If these aren't doctor-prescribed pills, what are they selling our children? What's being sold and consumed right now are illicit tablets. These are facts.

So we keep coming back to the same two questions. First, what are we going to do about the illicit markets? That's the problem. That's what's causing deaths right now.

Secondly, if there were diversion of illicit substances to children, which remains to be demonstrated, how do we ensure that these children don't end up suffering from addiction?

Who ends up suffering from opioid addiction? It's not recreational opioid users. Opioid use falls into fertile ground when it involves people suffering from trauma or mental health disorders, people who live on the margins and who have problems related to poverty and access to housing.

We keep coming back to the same two facts. So let's aim for a treatment plan that targets the real problems: illicit markets and the social determinants of health. That's what I'm proposing.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Thank you very much.

My other question concerns the recreational use of fentanyl. We heard about this from opposition MPs at our meeting last Monday.

Dr. Goyer, you've studied the concept of safe supply, and you use this treatment. Do you think there are doctors who would prescribe fentanyl to someone who isn't already addicted to contaminated drugs, or to drugs whose content is unpredictable because of the way they obtain them?

[The Vice-Chair, Conservative, Stephen Ellis]

I apologize, Dr. Goyer, but time is up. I invite you to send your response to the committee in writing, if possible.

[Élisabeth Brière, Liberal, Sherbrooke, QC]

Could you send your response to the committee in writing, Dr. Goyer?

[Dr. Marie-Ève Goyer]

Yes, I can do that, of course.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much.

Colleagues, I obviously wasn't here during the last vote. My question to you now is.... There is 15 minutes before the time to vote. I understand that, last time, you left here with 10 minutes left.

Is that still what people want to do?

[Some hon. members]

Agreed.

[The Vice-Chair, Conservative, Stephen Ellis]

I see general agreement. That will give us two and a half minutes each for Mr. Thériault and Mr. Johns.

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

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

In summary, there is an unprecedented crisis which is linked to contaminated illicit drugs. These give rise to overdoses and mortality, as we've seen recently.

Dr. Goyer, you said we had to realize that those who die are the most vulnerable. You mentioned that we needed to work on the social determinants of health, because these are structural vulnerabilities. That struck me. We also need to fight against illicit markets. Personally, I don't think we're doing enough on that front.

According to the current model, we seem to want the individual to go to the resource. However, if there is indeed an unprecedented public health crisis and people are dying, to intervene on the social front, we need to go to the front, where the people are, and multiply comprehensive interventions on the ground. Multidisciplinary teams need to go where the problems are. We can't wait for people to show up at a doctor's office for treatment.

What do you think?

[Dr. Marie-Ève Goyer]

I completely agree with you.

What you're saying is somewhat in line with the main principles of the low-threshold approach. It's about knowing who the population you want to serve is, where they are, what their needs are, and how you can reduce the barriers that prevent them from getting to the health care network. This can mean going to the people, as you said, or using community organizations, who know the terrain very well, or virtual care.

There are all kinds of barriers, and they can be geographical or financial. There are services that are covered and others that aren't, for example. However, there are also moral barriers and others related to stigmatization. We want people to feel welcome in health services, and we want to take care of them where they are, here and now. This includes people who aren't ready right away to stop using substances, and who may never be.

I can also tell you that some of my patients wouldn't be here today if they hadn't used substances to ease the terrible suffering they've experienced repeatedly over the years.

So we must also recognize that not all people are ready now to stop using substances altogether. We need to offer them a full spectrum of services, from abstinence, of course, to reducing consumption. We also need to offer them a safer supply. All these modalities must coexist. We want to reach out to everyone.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you very much, Dr. Goyer.

Thank you, Mr. Thériault.

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

Dr. Nosyk, we've heard many anecdotes about diversion, particularly to children. We haven't heard that from law enforcement.

Can you comment on this as someone conducting research on B.C.'s prescribed safer supply?

[Dr. Bohdan Nosyk]

Sure. Thank you.

We've heard statements and anecdotes about diversion. However, in British Columbia, opioid use disorder incidents have remained constant since 2020, when the safer supply program was implemented. That is true for those under 19 and overall.

Moreover—I want to stress this again—hydromorphone was detected in just 3% of all overdose-related deaths in 2022, albeit as one component among a number of substances implicated in toxicology, rather than the primary drug implicated in the overdose.

However, fentanyl was implicated in over 80% of all overdose deaths and was most commonly the primary substance indicated in toxicology reports. Make no mistake: The overdose crisis in B.C. is driven by fentanyl and its increasingly potent analogues.

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

How widely has safer supply been implemented in British Columbia? It often seems, from the media on this, that it's a huge problem, but is it really? Has there been enough capacity?

You're going to have about a minute left of this whole meeting to respond.

[Dr. Bohdan Nosyk]

No, the implementation was very limited. A lot of prescribers chose to not prescribe, and many of those who did chose to add it on to OAT, as opposed to offering it as a distinct option. It was primarily prescribers located in Vancouver and Victoria who prescribed these RMG medications, at least in the first 18 months. These prescribers served larger and more severe caseloads of people with substance-use disorders. Nurse prescribers participated as well. Prescribers with a background in psychiatry were less likely to participate. Already, by the end of our study period, by August 2021, we saw prescriptions start to dissipate.

With respect to our qualitative research, I'll highlight that I work with a range of investigators from UVic and the BC Centre for Disease Control. A qualitative study from our team highlighted barriers to access in rural regions, criminalization and indication that the substances prescribed were, in many cases, insufficient and didn't entirely eliminate reliance on the drug supply.

[The Vice-Chair, Conservative, Stephen Ellis]

Thank you.

Thank you, Mr. Johns.

Colleagues, we are at the time when, as I suggested, if we went and voted and came back, we would probably run out of time. Is it the will of the room to adjourn the meeting? If that would be the will, then that's great. If it's not, please let me know.

Is there a motion there?

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

I think that you know my preference, Mr. Chair, that we—