Evidence of meeting #105 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was drugs.
A recording is available from Parliament.
11:55 a.m.
Bloc
The Vice-Chair Bloc Luc Thériault
That's perfect.
Are the witnesses also available for questions until 1:30 p.m.?
Okay, I see that the witnesses are.
I have a third request. If the first vice-chair does not arrive, would you allow me to ask my questions?
11:55 a.m.
Bloc
February 29th, 2024 / 11:55 a.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you very much, Mr. Chair.
I'd also like to thank the witnesses for being with us.
Thank you to our witnesses.
It's a really important subject, as you guys all know. I have a few questions. At the end of this, we're hopefully going to have a report, and in the report we'll have a series of recommendations. I truly think it's important to make sure that we're looking at actions as we're moving forward through this.
I will start with Dr. Kahan. You talked about the importance of OAT therapies in addiction treatment. I was wondering if you could expand a little bit on Alberta's model when it comes to the virtual opioid dependency program, how that works and how you think that could possibly be spread across the country.
11:55 a.m.
Associate Professor, Department of Family Medicine, University of Toronto, As an Individual
Yes. I think the Alberta model has been highly successful. They are starting thousands of people in the same day on opioid agonist treatment, and that includes people in remote communities, people who have attended emergency departments or hospitals, and this is the way to do it.
Canada has such dispersed, geographically distant communities and we need to get OAT to where people are in their communities—in the hospital, in the emergency departments—and virtual care is an efficient way to do it. They have 24-7 services. I understand it's not just virtual care; they have connections to prescribers, nurse practitioners and physicians as well as to pharmacies, so I think it's a very good model to make sure that people in remote communities and people who lack transportation, and who are in hospitals and emergency departments, have access to care.
11:55 a.m.
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you for that.
I recently toured the arrest processing centre of the Calgary city police. They actually have the ability to offer people who were recently arrested access to the VOPD program right from the arrest processing centre, and they were telling me of some of the successes they had with this really cool build-out.
Dr. Goyer, you also talked about opioid agonist treatment, or OAT.
I was wondering if you could possibly talk about what you see as some of the shortfalls in accessing OATs across the country and how you would increase people's access to OAT therapy.
11:55 a.m.
Physician, Clinical and organizational support team in addiction and homelessness, CIUSSS Centre-Sud-de-l'Île-de-Montréal
Thank you for the question.
As I said, we need to make this a priority and build a bit on the models we use to treat chronic diseases. Opioid dependence is obviously much more complex, but the models for organizing services and training professionals to treat chronic diseases, such as diabetes and cardiovascular disease, are very pertinent, in my opinion.
As I said in my presentation, we're starting from a long way off. Among the easiest measures to put in place, first of all, we could make addiction training compulsory in all medical faculties, not only for doctors, but also for pharmacists, nurses and people who accompany patients on a psychosocial level. So training health care professionals is the first thing to do.
The second thing to do concerns ethical responsibility. If I take you into the emergency room when you're having a heart attack and all I do is give you an electric shock and send you home without medication, without management and without follow-up, I'm going to lose my licence to practice. We know what works for opioid addiction. When a patient presents to the emergency department because of an overdose, we can no longer simply give him naloxone and discharge him. Patients must be offered treatment immediately. There must be addiction specialists in hospitals who can advise doctors, teams, even patients, and then ensure proper follow-up—
Noon
Conservative
Laila Goodridge Conservative Fort McMurray—Cold Lake, AB
Thank you.
Unfortunately, I have to interrupt you as I have very little speaking time and want to ask more questions.
Dr. Nosyk, what are the barriers to getting OAT in Ontario?
In anecdotal conversations I've had, people talk about the issue with the actual payment and how expensive OAT therapies are. Is that an issue in Ontario?
Noon
Professor and St. Paul's Hospital CANFAR Chair in HIV/AIDS Research, Faculty of Health Sciences, Simon Fraser University, As an Individual
Well, I'm from B.C.
Noon
Professor and St. Paul's Hospital CANFAR Chair in HIV/AIDS Research, Faculty of Health Sciences, Simon Fraser University, As an Individual
We've expanded access to OAT enormously over the past 10 or 15 years. That has been getting more doctors on board by reducing the restrictions and the requirements for licensing to get doctors to be able to prescribe OAT, and more and more patients have accessed it. We hear of constraints to access still in rural regions. I think it's a symptom of constraints in primary care provision. We have a shortage in primary care, and I think this population is severely affected.
Much of the payment that goes into OAT goes into the pharmacies, direct witnessed ingestion fees and dispensing fees.
Noon
Bloc
The Vice-Chair Bloc Luc Thériault
Thank you.
Mr. Nosyk, you may finish your sentence, but there is no more time left.
Noon
Professor and St. Paul's Hospital CANFAR Chair in HIV/AIDS Research, Faculty of Health Sciences, Simon Fraser University, As an Individual
Okay.
Noon
Conservative
Noon
Professor and St. Paul's Hospital CANFAR Chair in HIV/AIDS Research, Faculty of Health Sciences, Simon Fraser University, As an Individual
That was it. I finished it.
Noon
Liberal
Majid Jowhari Liberal Richmond Hill, ON
Thank you, Mr. Chair.
I'd like to welcome all our witnesses.
I'm going to start with Dr. Elaine Hyshka. In your opening remarks, you talked about the shift in drug supply. I just wanted to get clarification from you, and probably a bit of expansion.
Is the shift in the drug supply an independent phenomenon? Is it a phenomenon as a result of, let's say, access to safe supply and how it might not be as readily available? Is the shift unique only to Alberta, or have you seen it across Canada?
Noon
Associate Professor and Canada Research Chair in Health Systems Innovation, School of Public Health, University of Alberta, As an Individual
Thank you for the question.
In my opening remarks, I referred to the staggering difference we see between 2011 and 2023. In 2011, at the height of the prescription opioid crisis—when as many as one in five Canadians reported using a medical-grade opioid, according to some surveys—we had 91 Albertans die of drug poisoning deaths, and those drugs were primarily opioids. Now, obviously, the numbers are astronomically higher than that.
What we started to see around 2012, when there was a series of very well-intended measures to limit access to prescription opioids at a population level, we saw a very dramatic decline in the population flow of prescription opioids that were either being prescribed to patients or being diverted and sold in the illegal markets.
In Edmonton, where I'm from, when I was doing my Ph.D. research in epidemiological surveys back in 2012, everyone I talked to who was using opioids was using hydromorphone pills that had either been purchased or been prescribed to them. Now that's virtually unheard of. We see so few people using those medications now. Everybody is using fentanyl.
What we believe has happened, according to the evidence we can piece together, is the decline in the prescribing of opioids corresponded with a fundamental shift in the illegal market toward novel synthetic opioids. Basically, we cracked down on prescribing, but we did not address demand. As a result, the illegal market innovated and now we have fentanyl, fentanyl's analogues, carfentanil, nitazene class opioids, fake benzodiazepines and a whole host of other very dangerous drugs that are the primary drugs circulating in the opioid supply, and it's contributing to a staggering amount of death that we have not seen before.
This trend is something we're seeing across Canada, particularly in B.C. and, later but now quite clearly, in Ontario and other parts of the country.
12:05 p.m.
Liberal
Majid Jowhari Liberal Richmond Hill, ON
This phenomenon is growing across Canada. Thank you for that.
I understand that current available treatment options and a safer supply are areas you've been looking into and doing some research on. Can you shed some light on how these available treatment options, along with a safer supply, would be able to help present an alternative to the dilemma we are faced with?
12:05 p.m.
Associate Professor and Canada Research Chair in Health Systems Innovation, School of Public Health, University of Alberta, As an Individual
I echo everybody on the panel who has said that it is critical that we respond with a wide variety of different opioid agonist medications and options for people. We need to dramatically expand access to those medications as first-line treatments for opioid use disorder.
We also know there are some patients for whom those medications are either not an option or something they've tried and that has not been successful for them. I don't think it's okay to just say, “well, I'm sorry, but that's all we have for you.” I think it is reasonable to prescribe people prescription opioid medications in an attempt to stabilize them, support them and reduce their extreme risk of overdose death from consuming fentanyl and other toxic street drugs.
I don't think these are opposing things. I think we absolutely need on-demand, high-quality evidence-based treatment, using the full range of modalities—including injectable opioid agonist treatment, which really has not been expanded at all in our country.
That being said, there will be people for whom, for whatever reason, those medications are not an option or have not worked. We can't abandon that population. We really need to support everybody possible staying alive. It's just not acceptable to have this level of death in our country from something that is ultimately preventable.
12:05 p.m.
Liberal
Majid Jowhari Liberal Richmond Hill, ON
Thank you.
My last question is for you.
In your opening remarks, you talked about the societal response we need to present. You also talked about some of the wraparound services. You have about a minute. Can you clearly expand on those things?
I know you went into a number of action items. What would be the top three societal responses to help address the issue we're facing?
Thank you.
12:05 p.m.
Associate Professor and Canada Research Chair in Health Systems Innovation, School of Public Health, University of Alberta, As an Individual
We need to treat this like an actual public health emergency. We need to invest at a scale to ensure that the effective treatments we have—like opioid agonist treatments, supervised consumption services and naloxone—are actually meeting population need. I would say there's a lack of investment in these interventions to the point where they're not scaled to meet the need in the population.
Beyond that, I think we need to look at the factors that drive drug poisoning deaths, which are increasingly housing, poverty and comorbid mental health conditions. For example, in my home province right now just under 40% of drug poisoning deaths are occurring in public places. That implies that there are a lot of people who are unstably housed or homeless. They are currently dying as a result of drugs, obviously, but also due to the fact that they're rendered so precarious in these situations by being unhoused and having no support.
I think primarily the federal government really needs to step up the level of investment and services across the country in partnership with provinces. We have just not scaled our response to anywhere what it needs to be to bring down and achieve sustained reductions in morbidity and mortality across the country.
12:05 p.m.
Conservative
The Vice-Chair Conservative Stephen Ellis
Thank you very much, Mr. Jowhari.
Mr. Thériault, you have the floor for six minutes.
12:05 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Mr. Chair.
I thank the witnesses for their testimony.
I'll address Dr. Goyer first.
Dr. Goyer, you mentioned at the outset that the crisis was linked to contamination of the illicit drug market.
Could you elaborate? Why did you insist on pointing to this reality first?
12:05 p.m.
Physician, Clinical and organizational support team in addiction and homelessness, CIUSSS Centre-Sud-de-l'Île-de-Montréal
If we really want to have an adequate public health response to the data circulating all over the place, we have to agree on the problem. I have a very good understanding of the history of overprescription in Canada and North America. Ms. Hyshka has just illustrated it very clearly.
Today, the majority of deaths are caused by non-prescribed substances produced by the illicit market. Given this situation, we have to ask ourselves what we can do. But I want to warn people about something. As a doctor, I fully agree with what my colleagues have just said. We really need to increase the interventions that work, such as treatments. However, we can't carry the crisis of contaminated drugs from the illicit market on our shoulders. A large number of people will never have access to treatment, either because they don't need it, or because they don't suffer from opioid dependence, or because they don't want it or haven't reached that point in their lives, or because they use recreationally, or because there are very few doctors in Canada.
As we said, access to a primary care physician is complicated for everyone. Access to a primary care physician who is trained in opioids and opioid prescription is even more complicated. Of course, we need to provide more good interventions like these, but we seem to be forgetting what's under the iceberg.
We need to question ourselves and try to find out what's going on. Why are so many people suffering from addiction? As Ms. Hyshka was saying, what are we going to do about poverty? What are we going to do about problems related to childhood trauma, mental health issues and access to housing?
Next, how are we going to deal with the illicit market? How are we going to thwart and fight the illicit market? How are we going to build on the science and experience we've gained with alcohol, tobacco and, more recently, cannabis, to go further and make the fight against the illicit market a priority? How are we going to do this in the current context for these substances?