Health Committee on April 29th, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 112 of the House of Commons Standing Committee on Health.

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I thank you for your co-operation.

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.

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

I would like to welcome our panel of witnesses. Appearing as an individual by video conference, we have Dr. Nickie Mathew, who is a physician. On behalf of the Canadian Centre on Substance Use and Addiction, we have Dr. Alexander Caudarella, the chief executive officer. On behalf of Moms Stop The Harm, we have Petra Schulz, who is a co-founder. On behalf of Projet Caméléon, we have Dr. Marie-Ève Morin, a general practitioner in addiction and mental health, and who is also appearing by video conference.

Welcome to all of our guests here today.

We'll begin with opening statements. We're starting with Dr. Mathew, please, who has five minutes.

[Dr. Nickie Mathew, Physician, As an Individual]

Thank you for allowing me to come here to speak. I'd like to provide a disclaimer that the views and opinions I express are my own and are not attributable to any organization.

I'm an addictions and forensic psychiatrist, and I'd like to talk about the connection between substance use, psychiatric illness, overdose and violence. I want to take a case from forensic psychiatry.

So, this is John Doe. His father left the household when he was young. He experienced racism in school due to his skin colour. He found a sense of belonging in a group of friends who used cannabis. He started using cannabis in elementary school and started to skip school to use with his friends. In high school, he was transferred to an alternative school, but he dropped out shortly after. He started using opioids with hydromorphone that he bought from the street. Due to his drug use and theft at home, he was asked to leave, and he moved to the Downtown Eastside. To stay awake on the streets, he began to use crystal meth. Roughly one year prior to his index offence, he began to experience psychosis with paranoia and visual hallucinations, and he heard voices with auditory hallucinations.

On the day of the index offence, John Doe was using fentanyl and crystal meth. John Doe heard voices that the victim was going to rob him. As a result, John Doe punched the victim. The victim grabbed John Doe, who is now afraid for his life. John Doe then pulled out his knife and stabbed the victim in the neck. John Doe felt remorse after the event when he was no longer intoxicated and psychotic. John Doe did not know the victim before the event.

So, when we look between 2017 and 2022, we see that unregulated drug toxicity has become the number one cause of death among British Columbia youth, and 73% of the youth who died had received services from the Ministry of Children and Family Development. A study called the "Hotel Study" looked at the population of the Downtown Eastside and found that 95% had a substance-use disorder and 84% had a mental illness, with 74% having a current mental illness at the time of their substance-use disorder. There was also a 45% prevalence of a diagnosable neurological disorder on MRI, so there are a lot of folks out there with these disorders who are brain damaged.

Also, with the coroner's report in 2017, what they found was that 52% had a mental disorder. Concurrent disorders—a mental illness and a substance-use disorder—are the rule, not the exception.

There was a study by Kristen Morin out of Ontario, and it looked at adding psychiatric treatment for folks with opioid agonist therapy—so methadone clinics. It looked at northern Ontario and southern Ontario, and what it found was that adding psychiatric treatment decreased ER visits and hospitalizations in both northern and southern Ontario, and all-cause mortality in southern Ontario.

There's a lot of amphetamine use among these folks who overdose in British Columbia. Between 67% and 79% of the people who passed away also had amphetamines in their systems. Now why should we worry about amphetamines? There's been a rise of phenyl-2-propanone in meth, which is more potent and more likely to cause psychosis.

When you look at the folks with an amphetamine-use disorder, you will see that 40% will have experienced psychosis. As an amphetamine-use disorder increases in severity, 100% will have experienced psychosis. Psychosis is a neurotoxic event. Initially, these users won't be psychotic. Then they'll be psychotic when they're intoxicated. Then it will be when they're in withdrawal and then in times of sobriety. There's a kindling effect, and this psychosis is more difficult to treat and more severe as use continues.

What would be the recommendations?

Treating addictions is complicated. The way the opioid crisis has been approached is as if there's an opioid deficiency—so like iron-deficiency anemia, where if you add iron, you'll cure the illness. Almost the entire focus has been on giving people enough and different kinds of opioids, assuming that this will solve the crisis.

Opioid-use disorder is not an opioid deficiency. Any place on earth that has treated an opioid crisis has used multiple approaches where medication was just a small part. We need to look at a wide range of evidence and solutions. It is unlikely that we will find a home-run intervention. With the varied populations, we will need input from public health, from addictions medicine and from addictions psychiatry, among other things. We will need to have clearly defined metrics of failure for interventions and be willing to re-evaluate those interventions if they do not pass the bar.

There is recent Canadian evidence that treating patients' mental health and addictions issues concurrently will keep the population alive. Psychosis increases the risk of violence threefold to fourfold, so treating psychosis is important in treating violence. Early access to treatment for concurrent disorders can help change the trajectory of the illness and the associated risk. Clients, especially high-risk clients, need timely access to treatments.

Along with treatment, there needs to be stable housing with appropriate supports. There needs to be vocational and rehabilitation opportunities. Psychological therapies are not covered. The intervention with the most evidence for amphetamine-use disorders is contingency management, which is psychosocial treatment. There are significant gaps in the criminal justice system, especially on release, and those gaps need to be filled.

Providing concurrent psychiatric care to patients with addictions can reduce violence and save lives.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Mathew.

Next, from the Canadian Centre on Substance Use and Addiction, we have Dr. Caudarella for the next five minutes.

Welcome to the committee, Dr. Caudarella. You have the floor.

[Dr. Alexander Caudarella, Chief Executive Officer, Canadian Centre on Substance Use and Addiction]

Mr. Chair, vice-chairs and committee members, thank you for inviting me and the Canadian Centre on Substance Use and Addiction.

It was the late Brian Mulroney who created CCSA through an act of Parliament 35 years ago as a neutral, arm's length agency to provide leadership on substance use health and to advance evidence-based solutions.

As CCSA's newest CEO, I've spent my first year listening to diverse voices on how we need to act to achieve the most impact. As well, I'm a family doctor who's worked across three provinces and a territory.

My patients have told me that, when someone with an opioid issue goes to an emergency department anywhere in Canada, rarely do they get support. In fact, less than one per cent of people surveyed in a recent study co-led by the Canadian Centre on Substance Use and Addiction, or CCSA, said they would go to their family physician for help with an opioid use issue.

With Ontario youths, the rate of use of opioid agonist therapy has declined over the past 10 years. We need wide access to treatment, but people are facing closed doors across Canada. We have a responsibility to open doors to treatment and make the access way as wide as possible.

No Canadian jurisdiction has resolved these challenges. They are challenges rooted in pain and tragedy, coupled with a deep sense of urgency, that have sent people and organizations off in all directions.

Countries that have successfully tackled past drug crises have done so not within silos, but with humility and collective whole-of-health, whole-of-government and whole-of-community approaches.

A spectrum of care that includes treatment, recovery and harm reduction, but that arcs towards improved health is required. To reduce risk, this spectrum must also include prevention.

In 2011, CCSA published the world's first evidence-based prevention standards. With the emergency declaration first happening eight years ago, we must think of the lives we could have saved if we had invested. It is why CCSA is committed to building community prevention coalitions.

Every community deserves to feel safe and every person deserves access to the care they need, when and where they need it. People want to help each other and we need to create opportunities for them to do so. CCSA has been working with people with lived experience, families, physicians, police and communities to move this forward. The real solutions will come from them and CCSA is committed to using its resources and data to support their collaborations.

We're hosting a series of community-level summits on the ground where the issues are felt on strategies to end substance use crises. One immediate outcome has been the establishment of competencies for prescribers of all levels.

Our failure to collaborate more effectively amongst sectors strains the broader health care system. Harms from substance use cost the country $49 billion or about $1,300 per Canadian.

I'll never forget, when I was working in the ER, watching a man lay in pain waiting for four days with a broken hip. His granddaughter never left his side. He didn't get a hospital bed because we had three people in our ICU with overdoses that they should never have had and two people waiting for heart surgery for drug-related infections that we waited to treat.

There is no turning back. We now live in an era of powerful synthetic drugs that are too cheap to make and too easy to buy, and where data and clinical practice are evolving rapidly.

In 2005, CCSA redirected resources in partnership with the provinces, municipalities, first nations, Métis and Inuit providers, enforcement agencies and key federal departments to drive everything we did towards supporting what our communities needed most. The resulting national framework for action to reduce the harms associated with alcohol and drugs was relevant, real and impactful.

We collaborated across divides then. Now, it is the time for the leaders of our field, myself included, to set the table and work together. The solutions are in the communities and we need to provide the data, the science and the resources to activate them.

Thank you for your time and for your study of these important issues.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Caudarella.

Next, on behalf of Moms Stop the Harm, we have Petra Schulz, co-founder.

Welcome to the committee, Ms. Schulz. You have the floor.

[Petra Schulz, Co-Founder, Moms Stop the Harm]

Thank you for this opportunity.

I am co-founder of Moms Stop the Harm, representing thousands of families across Canada. Most mourn a loved one due to the toxic drug crisis, and many support loved ones with lived or living experience. Our website includes 600 images of loved ones who have died.

Being here today is both meaningful and difficult as tomorrow is the 10th anniversary of the day when our son Danny died. Danny was a brother, a friend and a talented chef.

Danny is a poster child for failed drug policy. He was on methadone for a while, then abstinent, but never stable. In 2014, fentanyl appeared on the market, and he was one of the early victims. There were no warnings, and he did not have access to harm reduction, which could have saved him.

Today, almost everyone knows someone who has lost a loved one. Those who die include people who use them every day, occasionally or just once—like Olivia, a 13-year-old girl from central Alberta, who died after using it with a friend. We do not know what substance the teenagers intended to use or how much, but unregulated fentanyl killed them both.

The increasing death from the toxic drug supply is driven by prohibitionist policy decisions that have failed to keep our loved ones safe. This includes a failure to robustly implement harm reduction across the country.

In Canada, almost all deaths are from unregulated drugs, with over 85% nationally; and for opioids in Alberta, it is a staggering 98%. Yet, we see political leaders create moral panic around the 2%, while ignoring the other 98%. We are told this is an addictions crisis and more beds and more abstinence-based treatment will be the answer. Yet, the example often cited, the Alberta model, has failed to save lives. The year 2023 will be the worst year on record for deaths in my home province.

According to national data, substance use has not gone up in over 10 years, yet deaths have skyrocketed. Why?

This is not a problem of addiction, but of a toxic, unregulated supply. Access to consumption services, drug checking, unregulated alternatives and decriminalization of people who use drugs are what is needed. Sadly, these measures currently in place are insufficient for the magnitude of the crisis and do not reach all communities.

This is a truth and reconciliation issue. The TRC report calls on the government to reduce gaps in health outcomes between indigenous and non-indigenous people, yet indigenous people are disproportionately affected. They are seven times more likely to die in Alberta, and five times more likely in B.C.

Sarah Auger lost her son Lakotah in 2022. He was a doting father, a loving son and proud to be Cree. He used alcohol and other substances, but his use of unregulated substances, including fentanyl that later took his life, escalated only after he was incarcerated. While we know the harm of alcohol surpasses all other substances, one drink will not kill you.

Lakotah's story and the story of Mike also illustrate the danger of forcing abstinence on people despite the well-documented risks. Mike was the son of our board chair, Traci Letts. He was playful, thoughtful and a passionate cook. Both Lakotah and Mike died shortly after incarceration.

Similarly, Angela Welz lost her young daughter Zoe, who was athletic, funny and headstrong, shortly after two failed attempts at getting help through the involuntary detention via the Alberta PChAD act.

What is so upsetting is the fact that the deaths of our loved ones have become politicized with misinformation and outright lies. This is a public health issue and needs to be treated as such. I urge you to stop the angry, harmful, misinformed, polarizing debates. Politics and ideology must be taken out of health care.

Work together and focus on what the evidence tells us. Harm reduction, including the provision of regulated alternatives, saves lives. Evidenced-based, voluntary and accountable treatment saves lives. Prevention and addressing the social determinants of health save lives. This is not a harm reduction versus recovery debate. Our loved ones need and deserve both.

Danny is on my mind every day, and I know he wanted help. The day before he died he asked me to make an appointment with his psychologist. He did not live long enough to see her. More treatment would not have saved him, but harm reduction and access to regulated substances would have.

Where there is life, there is hope. It is your responsibility to ensure that our loved ones live and that we have hope that the needless deaths will end.

Thank you kindly for this opportunity.

[The Chair, Liberal, Sean Casey]

Thank you, Ms. Schulz.

Now we will hear from the Projet Caméléon representative.

Welcome to the committee, Dr. Marie‑Eve Morin.

Please go ahead.

[Dr. Marie-Eve Morin, General Practitioner, Addiction and Mental Health, Projet Caméléon]

Good afternoon to the committee members and the other experts on the panel.

I want to start by thanking the committee for having me today. It's a privilege to be able to share my perspective on addiction and mental health issues among young people.

The committee's study is timely. The World Health Organization just released an alarming study carried out in a number of countries, including Canada. It reveals an increase in the use of cannabis, alcohol and e‑cigarettes by youth. In addition, opioid and substance-related overdoses are the leading cause of death among youth in western Canada.

I have spent 20 years as a family physician working in addiction and mental health in Montreal. I currently practise at La Licorne Medical Clinic. I've worked in a number of settings, all in the area of addiction and mental health. In 2017, I founded Projet Caméléon, a not-for-profit organization focused on harm reduction.

I have a book on drugs and addiction coming out in September. It's geared towards young people between the ages of 12 and 25, as well as parents and teachers. I care deeply about young people. I think we urgently need to educate them, in an honest and non-judgmental way, about how their brains work and how drugs affect their brains. In my experience, education is the most effective way to prevent problems. Repression is an outdated approach.

A new phenomenon since I was a teenager is the exponential growth in the range of drugs on the black market. Thirty years ago, when I was in high school, we didn't have methamphetamines, GHB, MDMA, lean, ketamine, fentanyl, cannabis vape devices—known as wax pens—or ecstasy, and we had even fewer opioid and benzodiazepine-based drugs. Putting profits above all else, drug dealers no longer have any qualms about letting fentanyl and other opioids flood the market. It's a well-known fact that the family medicine cabinet tends to be the first place where teens come into contact with opioids and benzodiazepines.

I've been giving talks in schools since 2005, mainly to audiences in private high schools. Public schools say they don't have the funding to educate students about addiction and prevention. However, if we at least invested the profits from cannabis sales in prevention, education and addiction treatment, we could really make a difference for young people.

Since cannabis was legalized, its use has been overly trivialized by both young people and their parents. Legal equals no big deal. The reality is that THC is actually an extremely potent and unpredictable disruptor, even at low doses. Despite still being illegal, wax pens are readily found in high schools across the country because they have such a high THC content. In fact, even though selling cannabis to minors is prohibited, more and more young people are reportedly going to the emergency department and being hospitalized as a result of THC-induced psychosis. Not only has legalization not come close to eliminating the black market, but it has also brought down the price of cannabis that continues to be sold illegally on the street.

Like many, I have seen the significant impact the pandemic has had on people's mental health and substance abuse, especially among those 25 and under. They were craving emotional connections and human contact. Isolation, the prevalence of screens, cellphones and social media, compulsive gaming and the lack of recreational activities have, in some cases, had devastating consequences for the mental health of young people, whose brains are still developing. What's more, these factors have been a catalyst for the development of alcohol and substance abuse among youth. In many cases, they take substances as a way to self-medicate. Keep in mind that 50% to 70% of people with an addiction also have a primary mental health issue, one that existed long before they began using. That is known as comorbidity. My colleague talked about that earlier. A teen whose attention deficit hyperactivity disorder, or ADHD, goes untreated may very well feel better and more able to function after taking speed or other such stimulant, or even a depressant such as hydromorphone.

If all my patients ended up in prison, psychiatric wards or the morgue, I wouldn't have spent the past 20 years doing this. Many people are able to come out the other side, becoming independent functioning individuals once again. However, that takes time, support and empathy, which are necessary to uncover the person's trauma and treat comorbid conditions as soon as possible. In my experience, that reduces the criminal activity and harms associated with drug and alcohol use, while improving the person's overall health.

My humble recommendation to the committee is that the government take concrete steps to support prevention, treatment and education around alcohol and substance use, for the benefit of all young people, in every school.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you.

We'll now begin with rounds of questions.

We'll start with Dr. Ellis for six minutes, please.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Mr. Chair.

Thanks, everyone, for being here.

Dr. Mathew, you talked a bit about comorbidities. I certainly have a concern with respect to cannabis use and psychosis associated with that.

Could you comment on your experience with how prevalent that is in society these days?

[Dr. Nickie Mathew]

Regarding cannabis use in Canada, we've seen in an increase in cannabis use disorder. We've also seen an increase in ER visits for psychosis related to cannabis. Legalization of cannabis hasn't decreased that.

However, a balance needs to be struck. Has that downside been outweighed by the upside of decreased criminalization of people who are using cannabis? I'd leave it to policy-makers to decide that, but there do seem to be upsides and downsides for legalization.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Dr. Mathew, you talked a bit about psychosis associated with methamphetamine use.

In your experience—and if you don't have experience in this I'm happy to ask someone else—is it the same type of psychosis you would see with schizophrenia or with cannabis use disorder?

[Dr. Nickie Mathew]

That is a large question.

Psychosis is a symptom and a loss of touch with reality. These could be fixed false-beliefs, which are delusions, or it could be hallucinations, which are false sensory perceptions, or you could have disorganized thought.

Whether someone has an intrinsic, organic psychiatric illness like schizophrenia or whether they have a substance-induced psychosis, such as cannabis-induced psychosis or amphetamine-induced psychosis, it's very difficult to tell these apart clinically.

One thing we have found is that people can have psychosis that is substance-induced that lasts a very long time. The textbook that we use in psychiatry, the Diagnostic and Statistical Manual, would describe a substance-induced psychosis as one month long. However, recent research from Shah et al found that 80% of cannabis-induced psychosis will last longer than a month. We know that with amphetamine-induced psychosis, 27% will last longer than a month. It's actually very common for these psychoses to last longer than a month, and clinically it's very difficult to tease these two apart.

It ends up being that the treatment is the same so you would use anti-psychotic medication to treat both.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Dr. Mathew, thank you for that.

Through you, Mr. Chair, to Dr. Mathew again, when we're talking about making the diagnosis of someone who has substance-use disorder and a concomitant mental health illness—let's just put it generically as "psychosis"—is it possible to tell those apart when the person is continuing to use their substance of choice?

[Dr. Nickie Mathew]

There was a study, and the author's name escapes me now, but what they looked at was folks who came into an addiction treatment facility. They used a scale called the "brief severity index" and they looked at different types of psychiatric symptoms such as depression, anxiety, and paranoia, which they called "psychoticism".

They found that of everybody who came into this addiction treatment facility, 39% of them had psychiatric symptoms. However, after one month in sobriety that dropped 13-fold to 3%, and that 3% held steady six months out. This is what's recommended in the DSM, which I mentioned earlier. That is, you should wait a month into sobriety before diagnosing a psychiatric illness.

To answer your question, if someone is currently using substances and they don't have a month of sobriety and you don't have a longitudinal history of clinical records, it's very difficult to make a psychiatric diagnosis before they've had that time in sobriety.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much for that.

Through you, Mr. Chair, if I understood you correctly, Dr. Mathew, you would suggest treating that person with medication for the psychosis even though they continue to actively use their substance of choice?

[Dr. Nickie Mathew]

For anti-psychotic medication, you will find that if someone has a substance-induced psychosis and they have an anti-psychotic medication on board, the anti-psychotic medication won't prevent their from becoming psychotic.

Earlier in my talk I spoke about a kindling effect that occurred with substance use. As I mentioned earlier, what happens is you'll become psychotic during toxication, and that extends into sobriety, which extends into...and it becomes more severe. It actually prevents that progression from happening, and that's the benefit of it.

Also, if someone is acutely psychotic, it will help treat their acute psychotic symptoms.

[Stephen Ellis, Conservative, Cumberland—Colchester, NS]

Thank you very much, Dr. Mathew.

Through you, Chair, I do have a motion that I'd like to move, as follows:

That, given

Prime Minister Justin Trudeau’s dangerous experiment of the decriminalization of drugs, such as cocaine, crack, methamphetamines, fentanyl, and more, in British Columbia has resulted in a significant increase in deadly drug overdoses and compromised the safety of Canadians;

The current drug decriminalization experiment has resulted in carnage and chaos, causing detrimental impacts on public health and community safety;

Last week, British Columbia's Premier David Eby has recognized the failings of this experiment, and called on the federal government to help them backtrack out of this reckless policy decision;

The City of Toronto has made a request to Health Canada asking for drug decriminalization, referring to it as the Toronto Model, drugs would be legal to use everywhere except childcare centers, K-12 schools and airports;

Canadians from coast to coast have been calling for the end of decriminalization, knowing that it is a recovery-oriented system that leads to saving lives, rebuilding families, and eliminating chaos;

The committee report to the House its recommendation that the government immediately dismantle all drug decriminalization programs in Canada.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Ellis.

The motion touches on the subject matter that we are now considering. It is therefore in order, given that we are studying the opioid epidemic and toxic drug crisis.

I rule the motion in order. Therefore, the debate is on the motion.

I'll go to Dr. Hanley first and then Mr. Doherty.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you, Mr. Chair.

This is a really important meeting today. We have four excellent witnesses. We've only just begun to hear the testimony. I think the motion, although in order, is not something that we need to debate right now. What we really need is to hear testimony from the witnesses.

I suggest that this is a frivolous motion, and I hereby move to adjourn debate.

[The Chair, Liberal, Sean Casey]

The motion to adjourn debate is a non-debatable, dilatory motion that must proceed directly to a vote.

By a show of hands, shall the debate be adjourned?

(Motion agreed to)

The motion is adopted and the debate is adjourned.

Dr. Ellis's turn is up.

Next up is Dr. Hanley for six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much, Mr. Chair.

Again, thank you to all of the witnesses for appearing today with some very important testimony.

Dr. Caudarella, I'd like to begin with you. You've written about how responses and solutions may vary by community. You talk about a diversity of approaches that respond to communities' needs, but also what builds a successful approach as a spectrum of care.

Can you talk about a community or an approach that has been successful in integrating the important components in a community-based approach? It could be a real example or perhaps even a hypothetical example of what would actually work.

[Dr. Alexander Caudarella]

When we talk about these approaches, often they are places that have had linkages between sectors that haven't traditionally worked together. They're places where you'll see law enforcement and health working together, or where you'll see cities working with families and different pieces.

A couple come to mind. Iceland, for example, tackled very high rates of alcohol use among its youth. Really, what they were able to do was make it everyone's problem. It wasn't just experts. It wasn't just specialists. It was parents. It was schoolteachers. Everyone felt they had a role, when they woke up in the morning, in contributing to the reductions of the harm. It was very successful.

In France, during a heroin epidemic in the nineties, again, they kind of made it everyone's problem. Every prescriber was taught how to use Suboxone and how to do these different things.

We've actually found, through some of our recent conferences and different pieces, that with the right supports, you can put people with diverse ideas in the same room as long as they're feeling like they're moving forward and as long as they're feeling engaged. I think a lot of the anger and frustration we're hearing from community members is actually a desire to be more involved in the process. People want to be involved in what is happening in their communities, but they also want to be involved in the solutions.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you.

Ms. Schulz, thank you for your testimony. I'm really sorry about Danny and the approaching 10-year anniversary. I am sure you must be rehearsing over and over again, maybe a thousand times or more, what might have happened.

If Danny were here today in that situation, what would be the ideal support to help him survive and even thrive?

[Petra Schulz]

Thank you for the question and your kind words.

With Danny, obviously he was not at a point where he wanted to stop using. Many people who use substances are not at a time or in the right position to stop using, but everybody deserves the right to live.

At that point, if Danny had had access to regulated alternatives, they would have given him a chance to use a substance that would not have killed him, and would also have connected him to a health system and opened doors for him to get other supports.

He also struggled with some mental health issues that could have been addressed at the time, which would have been a key element. At that time, there was no harm reduction available, which has now been expanded. He was always very safety conscious. Even the day before he died, he bought fresh needles. We saw that receipt, and it was very hard.

It would have been better if there had been a safe place to use. He died a short walk from where we later had a consumption site in Alberta, but which was subsequently closed.

To those who feel that recriminalization will end public substance use, I invite them to come to Alberta. There is a lot of public substance use happening because we have closed safe places. As long as we don't have housing and safe places for people to use, we will see public substance use, and we'll also see people like Danny using at home alone.

Another thing that would have helped Danny is decriminalization. He was very aware of his substance use, and he felt shame. He felt it was causing our family shame and stigma. Stigma is a huge issue. We often talk about stigma, but we will not remove stigma until you end the criminalization of substance use.