Health Committee on May 6th, 2024

[The Chair, Liberal, Sean Casey]

Welcome to meeting number 114 of the House of Commons Standing Committee on Health.

Before we begin, I would like to remind all members and other meeting participants in the room of the following important preventative measures.

To prevent disruptive and potentially harmful audio feedback incidents that cause injuries, all in-person participants are reminded to keep their earpieces away from all microphones at all times. As indicated in the communiqué from the Speaker to all members on Monday, April 29, the following measures have been taken to prevent audio feedback incidents.

All earpieces have been replaced by a model that greatly reduces the probability of audio feedback. The new earpieces are black in colour, whereas the former earpieces were grey. Please use only an approved black earpiece. By default, all unused earpieces will be unplugged at the start of the meeting. When you are not using your earpiece, please place it face down on the middle of the sticker for this purpose, which you will find on the table, as indicated. Please consult the cards on the table for guidelines to prevent audio feedback incidents.

Also, the room layout has been adjusted to increase the distance between microphones and reduce any chance of feedback from an ambient earpiece.

These measures are in place so that we can conduct our business without any interruptions and to protect the health and safety of all participants, including the interpreters. Thank you for your co-operation.

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

I would like to welcome our panel of witnesses.

We have with us here in the room Dr. Sharon Koivu, addiction physician. Online is Dr. Bernadette Pauly, scientist with the Canadian Institute for Substance Use Research and professor at the School of Nursing, University of Victoria. By video conference, representing the Thunderbird Partnership Foundation, we have Dr. Carol Hopkins, chief executive officer. Finally, also by video conference, representing the Vuntut Gwitchin First Nation, is Chief Pauline Frost.

To all of our witnesses, thank you for being with us.

Parliament Hill is a place where rumours are a constant. I heard a rumour today that there's going to be a vote in roughly 45 minutes. If that happens, the meeting is likely to be interrupted, and we will be asking you to stay a little later than you might have anticipated. If you are able to stay with us to ensure that everyone gets a chance to fully converse on these matters, it will probably result in your time with us being extended from 5:30 until 6 o'clock or a little later. I'll give you a heads-up for that.

We can now go ahead with our opening statements, beginning with Dr. Koivu.

You have the floor for the next five minutes. Welcome to the committee.

[Dr. Sharon Koivu, Addiction Physician, As an Individual]

Thank you, Mr. Chair and members of the committee.

I have been a physician for 39 years. I have my certificate of added competence in palliative care and addiction medicine from the College of Family Physicians of Canada. I began working in addiction medicine in 2012. Until 2021, I was the sole health care provider offering comprehensive consultations in addiction medicine at the London Health Sciences Centre, where, in 2023, an interprofessional addiction team was established. I also provide addiction consultations in St. Thomas.

I have decided to speak out to bring a voice to the horrific suffering I have witnessed from safe supply.

Early in my addiction career, I identified a link between injecting long-acting hydromorphone capsules and developing a heart valve infection. An infectious disease specialist I worked with found a link between injecting these capsules and getting HIV. When this specialist and the department chair took our findings to the community agencies, we were initially criticized and called fearmongers.

Fortunately, we established community engagement and developed an integrated response. As part of the response, in 2016, the London InterCommunity Health Centre developed a program that provided high-risk sex workers using hydromorphone capsules with short-acting hydromorphone tablets, also called Dilaudid. This was the inception of the safe supply program in London. I initially supported the program. It is important to note that we did not have a problem with illicit fentanyl at this time.

Prior to the safe supply program, I rarely saw people with spine infections. In the following summer, I saw five patients in one month. The numbers continued to climb. The common thread among patients was that they were injecting Dilaudid tablets. Many told me they were buying Dilaudid diverted from the safe supply program.

Some patients were in the program. I had patients who were housed, using clean equipment and only injecting Dilaudid developing horrific infections. Spine infections cause perhaps the worst suffering I have ever seen. Not only are they unbearably painful, but they can also cause paraplegia or quadriplegia.

In June 2018, I had my first patient tell me that he left his apartment to live in a tent near the pharmacy, close to the safe supply clinic where much diversion takes place, because the safe supply pills were cheaper and more abundant near the source. I lived in the neighbourhood and watched this encampment grow.

Since safe supply began, I have been involved in about 100 hospitalizations of patients with spine infections. That's currently about one per month. However, spine infections are only a small part of the suffering we see. About 30 patients per month are admitted with another severe infection. Of patients admitted with opioid use disorder, 25% were receiving a safe supply prescription and 25% reported using diverted Dilaudid. Only 4% of the consultations we did were for unintentional overdose.

Generally, in hospital, we start patients on home medications. If we did this for safe supply patients, the results could be fatal. This is dangerous for patients and very stressful for health care providers.

For example, patient one was prescribed eight milligrams of Dilaudid, D8s, which was 40 tablets per day, along with 100 milligrams of long-acting morphine in nine capsules per day. When they were given less than half of their prescribed dose, they had a severe respiratory depression—that is, toxicity. Patient two has frequent admissions requiring intubation. They were prescribed 28 D8s per day. They tolerated about six to eight and said they never took more than 12 in a day.

The patient population has changed. I see more young patients and many more men. Now, most start opioids recreationally and not with a prescription for pain, as was the case in 2012. I am also repeatedly hearing disturbing stories that people with prescriptions are vulnerable to violence.

Importantly, as I mentioned previously, when safe supply started in 2016, we did not have a problem with illicit fentanyl. We do now. Many patients have told me that they sell or trade much of their prescribed safe supply to buy fentanyl. Others not in the program have told me that their dealer has claimed to be out of Dilaudid and has sold them fentanyl, starting them down this path.

Safe supply appears to be contributing to the illicit fentanyl crisis. Safe supply is not reducing illicit fentanyl or its harms within a community. Our hospital experience also shows that safe supply is preventing patients from choosing opioid agonist therapy and the opportunity for recovery.

I would like to mention a program that is showing significant benefits. The Central Community Health Centre in St. Thomas has a low-barrier approach using subcutaneous buprenorphine, also called Sublocade. They are having success serving a very similar population to that of the London InterCommunity Health Centre, without the unintended side effects. It should be a model that we are discussing.

Of note, while I have broad shoulders, I found some of the comments made by Dr. Sereda on February 26 about me and cardiac surgeons to be misleading, and I look forward to an opportunity to address this.

Thank you for your work and your time. Meegwetch.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Koivu.

Next is Dr. Pauly for five minutes.

[Dr. Bernadette Pauly, Scientist, Canadian Institute for Substance Use Research, and Professor, School of Nursing, University of Victoria, As an Individual]

Good afternoon. Thank you for the opportunity to be here.

I am Dr. Bernadette Pauly. I'm a professor in nursing at the University of Victoria and a scientist at the Canadian Institute for Substance Use Research. I'm a member of the research team conducting the B.C. provincial evaluation of prescribed safer supply.

Prior to the introduction of the prescribed safer supply policy, evidence of the need for that intervention was well demonstrated by the overdose deaths caused by the unregulated drug market. However, it's critical to generate evidence of ethically justified interventions and determine whether or not prescribed safer supply reduces overdose risk. To answer that question, our team designed a rigorous mixed methods study using state-of-the-art approaches combining administrative and primary data.

In January 2024, the team led by Dr. Slaunwhite and senior scientist Dr. Nosyk published the first-ever population-level study in the British Medical Journal, a high-impact journal. Everyone receiving risk mitigation safer supply prescriptions was included in the study and was carefully matched with people not receiving them on multiple variables, including receipt of opioid agonist treatment. For those receiving opioids through this program, the risk of dying from any cause was reduced by 61% and the risk of dying of an overdose was cut in half. If they received four days or more, their overdose risk was further reduced to 89%. This is known as a dose-response relationship, and the finding was independent of opioid agonist treatment. A similar pattern was found for stimulants, but the sample size was smaller so there was less certainty. This protective effect continues week after week as long as they're able to access a prescription.

However, only 7.6% of those with an opioid use disorder and less than 3% of those with a stimulant disorder received the intervention during the period of study. There was limited implementation, with implementation occurring mainly in urban areas like Vancouver and Victoria and among prescribers who had larger caseloads of people with substance use disorders and more complex problems. While the intervention did not fix all their issues, nor was it expected to, it was protective for reducing risk of overdose death and all causes of death.

In a qualitative analysis, we found that prescribers were hesitant to take up the intervention out of fear of audit from regulatory colleges, as well as criticism and censure from colleagues. Where there were networks of prescribers who had support, there was increased continuity of prescribing. However, prescribing alone is an inadequate response to a systems issue, namely prohibition and an unregulated, unsafe supply of drugs.

The intervention was often difficult to access. Participants in the qualitative arm of the study reported the need to climb a steep staircase with many steps. Often, potential participants did not know about the risk mitigation guidance or safer supply. When they got their hopes up, they had to find a prescriber and navigate highly medicalized systems to get an appropriate prescription, and then pick it up daily to keep it. This required self-advocacy and fortitude. In a primary survey of 197 people, less than half of participants received a prescription sufficient to reduce withdrawal. Reducing withdrawal is a minimum requirement, so there's room for improvement.

Prescribed safer supply is a not a competitor to OAT or any form of treatment. It provides a pathway for people to access a life-saving intervention as part of individual recovery journeys. It does not replace or threaten the need for treatment. In fact, as part of a system of care, treatment options must be available for people if and when they are ready. In spite of this, the number of people dispensed a prescription in B.C. is decreasing.

Fears of diversion causing death are unfounded. Hydromorphone was detected in 3% of overdose deaths in 2023. It's unregulated fentanyl that's responsible for 85% of the toxic drug deaths. The root problem driving this emergency is toxic drugs, which is a consequence of prohibition. The unregulated market is accessed by those with substance use disorders and those without.

We need to expand access to alternatives beyond the health care system to ensure safe and regulated access to substances of known safety, quality and composition. We should be scaling up, not scaling back, safer alternatives to the unregulated drug market and looking to end prohibition.

Thank you. I look forward to the questions and comments.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Pauly.

Next, on behalf of the Thunderbird Partnership Foundation, we have Dr. Carol Hopkins.

Welcome to the committee. You have the floor.

[Dr. Carol Hopkins, Chief Executive Officer, Thunderbird Partnership Foundation]

[Witness spoke in Lunaape]

[English]

I'm Carol Hopkins of the Lenape nation in southwestern Ontario. I'd like to acknowledge the lands that you are joining us from and that we're all coming together on today.

In 2023, the number of first nations deaths due to drug poisoning was 36 times those in the general population in Ontario. In eight short years, from 2016 to 2023, first nations deaths due to the toxic drug supply grew at a rate of 33 times those seen in the Ontario population.

During the pandemic, from 2019 to 2022, 28% of first nations people used opioids in a harmful way, and 18% used methamphetamines to survive in an environment where there were no resources for housing, food security or income security. Those who reported food insecurity were two times more likely to use methamphetamine, according to a survey that Thunderbird ran. Forty per cent of first nations people reporting methamphetamine use felt hopeless to change their lives. It was this hopelessness that increased their risk for using opioids in a harmful way.

This population also reports a high rate of trauma, grief and loss, with a lack of resources close to home to support their mental wellness. The use of fentanyl, benzodiazepines and xylazine has been increasing across all regions of Canada, including in first nations. They are core to the opioid and toxic drug crisis that we are talking about today. The impact of these drugs requires community-based health resources that often first nations communities lack. First nations communities that declare a state of emergency report no capacity for preventing deaths due to the toxic drug supply. They also report their vulnerability to gangs, gun violence and murders, as well as human trafficking, which is now present in many first nations communities for the first time.

The war on drugs, including the criminalization of people for their health and social needs, has been a long-standing experience of first nations people in Canada, who are only 5% of the population yet represent 32% of those incarcerated. Indigenous women represent 50% of the incarcerated population. The war on drugs and incarceration have not increased safety from the toxic drug supply, have not reduced crimes of survival for people who live with opioid dependency and have not eliminated the illicit and toxic supply.

Indigenous Services Canada does not provide for physician or pharmacy services in first nations communities. We know those things are the responsibility of the provinces and territories. In this context, the opioid crisis and toxic drug crisis do not depend on geography. Rural and remote first nations communities are not exempt from the toxic drug supply or opioid crisis. The crisis is about a lack of equitable, available and accessible health care for first nations, with access to primary health care, physician services, pharmacies and public health resources. These are all necessary components of a response to the toxic drug crisis. Live-in drug treatment aimed at abstinence is not the evidence base for addressing opioids, and it is not the first line of evidence-based intervention. Abstinence-based programs will not change drug dependency or address physical withdrawal from opioids.

Where live-in treatment programs have additional resources—for example through provincial health authorities, harm reduction networks and first nations-governed culture-based and land-based services—and have options for readmitting or keeping first nations people on a continuous basis, clients have gone on to gain employment, obtain housing and maintain their own wellness.

Buprenorphine treatment is initiated by the community's primary care physician, when they are lucky enough to obtain a partnership; by addictions physicians through telemedicine; or by fly-in locums, who dispense daily under supervision. It has proven to be effective, along with a recovery program involving community mental health workers who provide both conventional counselling and culturally relevant healing practice. This comprehensive approach has enabled many patients or first nations people to stop or manage their opioid use and return to work, school and family. A year after such programs have been initiated, criminal charges and medevac transfers decreased, the needle distribution program dispensed less than half its previous volume and rates of school attendance increased.

Addressing the opioid crisis has been challenging for first nations communities, most significantly because of inconsistent support and resources to community-governed and culturally relevant treatment. One study of community-based opioid misuse reported that among adults aged 20 to 50, 28% were on buprenorphine or naloxone, double the rate of adults in the community living with type 2 diabetes.

First nations people have the right to live—to live life. They have the right to the sacred breath of life, and that has to be our focus in any drug policies that are humane and sensible for first nations communities.

First nations communities require increased capacity for reducing harms related to opioids, opioid analogs, methamphetamines and xylazine, such as consistent support; access to prescribers, pharmacies, safe housing, food security and medication to address withdrawal; and a choice to continue to use drugs safely. Harm reduction kits and resources are needed. Human resources are also needed—

[The Chair, Liberal, Sean Casey]

Dr. Hopkins, I'm sorry to interrupt. If I could get you to wrap up, you will get a chance to expand on your presentation in questions and answers.

[Dr. Carol Hopkins]

Human resources are needed in community. The existing resources of treatment centres can also play a role, but they need additional resources and capacity.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you.

Last but not least, from the Vuntut Gwitchin First Nation, we have Chief Pauline Frost.

Thank you for being with us. You have the floor.

[Chief Pauline Frost, Vuntut Gwitchin First Nation]

Thank you. I appreciate the opportunity today.

I am the chief of a very small community—

[The Chair, Liberal, Sean Casey]

Excuse me, Chief Frost. I'm sorry. The bells are ringing, and that means we're obligated to vote unless we have unanimous consent to continue.

Do we have unanimous consent to allow Chief Frost to finish her opening statement before we head off to vote?

[Some hon. members]

Agreed.

[Luc Thériault, Bloc, Montcalm, QC]

Mr. Chair, while we're at it, to avoid interruptions, could the volume in the room be lowered a bit so that I can hear the interpretation better without having to turn up the sound? It's too loud in the room.

We should be doing tests at the beginning of every meeting to solve the problem. This isn't the first time I've had to intervene. I haven't interrupted the witnesses more often out of courtesy. However, the discussion is becoming difficult to follow.

[The Chair, Liberal, Sean Casey]

Okay.

Chief Frost, I'm sorry for the interruption. Go ahead and finish your opening statement. We'll likely suspend once you're done.

You have five minutes.

[Chief Pauline Frost]

Okay. Thank you.

As the former minister of health and social services for the government of the Yukon, I was responsible for identifying the opioid crisis, as well as the COVID pandemic. At the same time, I worked as a lead negotiator for my first nation, a small, isolated aboriginal community in north Yukon. We signed our self-government agreement 30-some years ago. We exercise our inherent right to self-determination. We have responsibilities for the general welfare of all citizens, our community, the land and the resources. As an isolated community, we're a resilient people, resilient in that we are connected to our roots, our traditions. At the same time, we are deeply affected by the opioid crisis and the toxic drug overdoses in the Yukon and across this country.

The serious challenges that we face and the high cost of living.... Food security is huge. Fiscal capacity is limited in our communities, causing significant challenges in addressing mental health. Substance use challenges have arisen in our history due to colonialism, racism and intergenerational trauma. All of this is a priority for my community.

In April 2020 and 2023, we declared a state of emergency and substance use crisis in my community. The reason is that we've suffered significant loss due to opioid, alcohol and drug use and abuse. Over the last five years, we've lost 15 Vuntut Gwitchin citizens linked to substance use.

Because of the small community, this is very complex, and it affects everybody, with compound impacts and effects. Every person in my community has been affected in one way, shape or form. Because we're an isolated community, our citizens are required to travel out of the community for amenities and medical supports. Therefore, we tend to see impacts and effects when they get to the city. There's an urban centre effect on average on northern isolated people.

We have worked tirelessly to support our citizens the best we can with healing and wellness. Our approach has been comprehensive and non-judgmental. We commit to facilitating easier access to treatment services. We set aside, last year, almost a million dollars for supporting our citizens to access treatment programs. That comes out of our FTA base funding that we get for programs and services.

Ensuring consistent availability of counsellors both locally and remotely is a priority for me as a chief. We are developing aftercare programs that provide supports to our community.

What I'm saying here is that we are working hard to combat substance use in our communities. We are utilizing the Yukon's Safer Communities and Neighbourhoods Act to address and combat drug trafficking and bootlegging. We've asked for changes to the security designation for our northern airports so they can implement passenger baggage and freight screening for northbound routes, equivalent to what's seen southbound. In other words, the drug traffickers can come into our community without restrictions whatsoever because we're remote fly-in.

Our tools are limited, but we are making significant headway, and we have sent over 70 people to a treatment facility in the southern parts of B.C. because the Yukon is not equipped. Treatment options are not available to us in the Yukon; we have limited availability. We need more. My first nation needs support to implement programs and improve the wellness of my people.

As we are on the ground, we know what's happening. We have the flexibility, but we are also trying to address the crisis. Adequate and secure funding for life-saving interventions is not going to save us. It's not going to help us. We need more supports in addressing the illicit drug overdoses and for program services.

We looked at a piecemeal funding program available to us through the federal government and the territorial government, which is not sufficient. We just asked last year, at the Prime Minister's forum, for direct access to funding and support. Put it in our base, and let us provide services. We don't have that flexibility. There needs to be consideration of the political, social, economic and cultural pressures that we're facing.

I want to quickly say that we've just finished a coroner's inquest in the city of Whitehorse, Yukon, for four overdose deaths at the emergency shelter facility. Two of those individuals were residents of my community.

We are proud of our community, because we are resilient. We've done amazingly. We own an airline. We don't have a housing crisis. However, our people are directly affected. We have to make a meaningful difference in the services that are provided, and the only way forward is by working together and jointly addressing this. We have looked at options, like a safe exchange in our community. We've educated our citizens. We have looked at alternative options. We are looking at recovery withdrawal supports in our community. We also have to look at a distribution program.

Everything we need to do is about building on healthier families and healthier communities. For the first time, we are actually focusing on our young people now, and we have a youth wellness program. We're bringing our youth together, and facilitators are coming in—

[The Chair, Liberal, Sean Casey]

Thank you.

[Chief Pauline Frost]

Marsi. I appreciate this time.

[The Chair, Liberal, Sean Casey]

Thank you, Chief Frost. We're going to suspend now to allow members to vote.

You can expect the suspension to last for about half an hour. Then there will be probably about an hour of questions, more or less. Stretch your legs. We'll be back once we've voted.

The meeting is now suspended.

[The Chair, Liberal, Sean Casey]

I call the meeting back to order.

We've finished the opening statements and are now ready to move to rounds of questions.

We're going to begin with the Conservatives for six minutes.

Dr. Ellis.

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

Thank you very much, Chair.

Thank you to the witnesses for their patience.

Dr. Koivu, I listened carefully to your opening statement. When we look at patients—you described a couple of them—we're really not offering them any therapy other than opioid therapy. Perhaps there are other things in addition to that.

For the sake of those listening at home, we all know that people who take opioids will eventually get habituated or used to the dose they're on and will require escalating doses. If that's the kind of medicine we're going to provide, is it not fair to say that we're providing these folks with palliative care?

[Dr. Sharon Koivu]

Absolutely. That is one of the significant problems with opioids. As you take them, your brain has changes in neurochemicals. What you're taking, your brain becomes used to. That becomes your normal. To get the same effect, you have to increase the dose you're taking. To get the same euphoria, you have to continue to increase the dose.

Perhaps even more importantly, when your brain readapts to this new level of normal, you have to take opioids. If you miss them, your brain will miss them and you'll go into what's called withdrawal, which is a horrific experience. You get severe pain, anxiety, nausea, vomiting and diarrhea. You can feel like you're literally going to die. You keep thinking you need more and you need a higher dose. Whenever you're in a scenario where you're taking an opioid regularly, you're always chasing the high, your dose continues to escalate and you're always trying to medicate away from the withdrawal.

An important thing that isn't always mentioned, which I want to add, is that as your brain regulates and gets used to a certain amount of opioids, you can generally tolerate it if you're well. If you develop pneumonia, endocarditis or any other illness that affects your cardiorespiratory system, that same dose can be toxic or fatal. When you're taking an opioid, it could be that you're always taking the same dose of your Dilaudid or fentanyl, but if you develop pneumonia or sepsis, that dose could become toxic because your brain wants more than what your body can tolerate.

When you are in a position of getting a treatment that's given to you daily to keep you going from one withdrawal to another, it's not allowing your brain an opportunity for recovery. You're staying in a cycle in which you are absolutely dependent on the medication, and you can be at risk of developing tolerance, needing a higher dose and needing a dose that will eventually be more than you can handle. From the cases that I mentioned in hospital, patients were being prescribed substantially more than they could tolerate when we had them in a position where we could see what they were taking. Had we given them the amount they were prescribed, it would have been fatal for them.

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

Thank you very much for that, Dr. Koivu.

It's interesting that you started talking about dosages. When we looked at patient 1—I wrote this down—they had 900 milligrams of morphine and 320 milligrams of hydromorphone. Using an opioid calculator to look at the overall dose of milligrams of morphine, that would be equivalent to about 2,500 milligrams of morphine. Is that correct?

[Dr. Sharon Koivu]

That is correct.

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

Looking at that for the average Canadian and again doing the math, that's about 640 Tylenol 3s. You don't have to trust me on that, but I used the same calculator to do it.

The reason I talk about this is people often think it's just one tablet of eight milligrams of Dilaudid. It's a bit concerning that for those who don't use opioids on a regular basis, even though it's one tablet, it's still a significant amount of opioid.

Maybe, Dr. Koivu, you can talk a bit about that.

[Dr. Sharon Koivu]

Absolutely.

One tablet is also equivalent to four Percocet or 20 milligrams of OxyContin. Those are doses we consider fairly high during the opioid crisis. Taking two of them would essentially be considered relatively safe for most people. Even one can be considered toxic if someone is not used to taking it.

The numbers we're seeing are substantially higher than the milligram equivalent of morphine that I was seeing during the time when people were prescribing heavily for chronic pain. These are the highest doses I've ever seen.