Evidence of meeting #114 for Health in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was safe.
A recording is available from Parliament.
Scientist, Canadian Institute for Substance Use Research, and Professor, School of Nursing, University of Victoria, As an Individual
Okay. Thank you.
Our study came out after the provincial health officer's report, as did a number of other studies. On the control group, multiple linked databases were used to generate, through two different methods, the control group, matching on multiple variables. I'd be happy to refer you to Dr. Nosyk's seminar, which explains extremely well how the matching occurred and the similarity between the two groups.
Liberal
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you, Mr. Chair.
In a previous meeting, we heard from Dr. Morin, who told us that addictions are complex chronic diseases. This complicates matters because multi‑pronged action is required. Furthermore, we're told that relapse is part of the process. British Columbia is trying to correct course, in a manner of speaking.
My question is for Ms. Hopkins, but Ms. Pauly can also weigh in if there is time.
How do you see the situation in British Columbia, and what do you think about the government's desire to correct course? In your opinion, must this lead to “recriminalization”?
Chief Executive Officer, Thunderbird Partnership Foundation
Absolutely not. Thank you for the question.
The expert task force on substance use and mental health recommended safer supply and decriminalization, but they also said that it should be within a full spectrum of supports for people who use drugs or substances, or who wish to enter into a recovery journey.
The task force clearly recommended a more comprehensive and responsive system. When you provide people with the medication they need to live life every single day but they don't have a home, they don't have income security or food security, and they don't have people they can rely on to support them.... Every person needs another person to support them and to be a champion for their belief in their ability to succeed in life, whatever that means from their perspective. Those comprehensive supports are absolutely necessary as an addition.
As I said, there's no silver bullet. There are many instruments that will support change and will keep people alive. Safer supply and decriminalization are not a silver bullet. They're not meant to end the opioid crisis and the toxic drug supply, but they will keep people alive. They will ensure that human beings have the right to live life. That should be our goal: to make sure that human beings can continue to live life. There are many tools. There have to be many tools.
This is not an easy answer, and it's not an easy solution, but what we're seeing is a focus on one technique, one answer, and on criticizing it without considering the other resources that are necessary. When those other resources are in place, we've seen positive changes that have impacted families, their children and their communities. They increase safety, decrease the number of kids in child welfare, increase the number of kids going to school and increase safety in the community. I can't stress enough that a comprehensive approach is necessary.
Liberal
NDP
Gord Johns NDP Courtenay—Alberni, BC
Dr. Pauly, you talked about the effectiveness of safer supply, and you cited some really important information. Can you also talk about why safer supply hasn't been scaled up? What are the barriers you're seeing?
Scientist, Canadian Institute for Substance Use Research, and Professor, School of Nursing, University of Victoria, As an Individual
This is a really important question. Without a doubt, part of the barrier is the politicization of safer supply and blaming it for what is a problem of the toxic and unregulated drug market. Safer supply is part of a comprehensive solution.
Some of the challenges related to increasing access—
Liberal
Scientist, Canadian Institute for Substance Use Research, and Professor, School of Nursing, University of Victoria, As an Individual
I'm sorry. Is that any better?
Scientist, Canadian Institute for Substance Use Research, and Professor, School of Nursing, University of Victoria, As an Individual
What I was saying is that part of the reason that safer supply hasn't been scaled up is it's been highly politicized. That's a harmful narrative when the real problem is a toxic and unregulated drug supply.
In terms of scaling up, we've had quite a lot of insight from the research we've done around prescribers, and particularly the idea of prescribers not being attacked or feeling criticized by their colleagues and recognizing the importance of the intervention and the support of regulatory colleges. One interesting finding is that nurse practitioners are three times more likely to prescribe safer supply. In that finding, there are opportunities to remove barriers, particularly in rural and remote communities. I'd also mention that in British Columbia, the First Nations Health Authority has a virtual substance use and addiction program, which was found to facilitate access for people in rural and remote communities.
We haven't talked much about non-prescriber-based models, but I wanted to highlight that in British Columbia, only a portion of the people who died of an overdose actually had an opioid or substance use disorder. We have to remember to consider alternatives that provide access and that are appropriate and well regulated for people who are accessing the toxic drug market and don't necessarily meet that criteria.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Pauly.
Thank you, Mr. Johns.
Next we will go back to Dr. Ellis for five minutes.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
Thank you very much, Chair.
I know it's been a bit of an up-and-down meeting for the witnesses. I appreciate your patience with all of us.
Dr. Koivu, I'd like to go back to the concept of safe supply. Maybe you could, for the benefit of Canadians out there, talk a bit about the specific difference between opioid agonist therapy and safe supply. Of course, we know that opioid agonist therapy has a significant amount of scientific literature supporting it. Could you explain the difference? I think that would be important to Canadians.
Addiction Physician, As an Individual
Thank you for that question.
Opioid agonist therapy is about having people on a treatment that can stabilize them neurochemically, having them not chase what we talked about earlier with withdrawal and really allowing for recovery. The two main types of opioid agonist therapy are methadone, which has been around for years, and buprenorphine. Buprenorphine was not available at the time the study in London was started.
Buprenorphine is a chemical, an opioid. As to how it works, as you increase the dose, you don't get an increase in negative effect. It is the drug most proven to decrease the risk of overdose. When people are on it, they have a decreased risk of overdose from taking it and from taking other substances.
Buprenorphine now comes in a daily sublingual formulation. It also comes in an injectable formulation that is usually referred to as Sublocade, which is given every four weeks. This is a game-changer because it allows people to get their lives back and get back to the community. Not having to worry about accessing a pharmacy daily is certainly helpful in remote communities as well. It provides a healing of the brain to allow people to have recovery and function normally.
Safer supply programs are about continuing to give opioids at doses that aren't witnessed. I think it's important to recognize that when people are started on methadone and Suboxone, we check what they're able to take. We understand their tolerance. We work with them as we're witnessing what they're taking and we know what they're taking. When people are started on safe supply, that is not the case.
I'm going to be a bit more specific about my own community. A dose can continue to go up without reflection on whether it's a safe dose for a person or a safe dose for the community. It's generally given to them on a daily basis. Sometimes it's every few days. Then the dose is escalated. In my community, generally that's at request, without any evidence that it's what they need. Even when there is evidence that they don't tolerate their dose, it isn't necessarily decreased.
People will continue to have to go to a pharmacy, usually on a daily basis. It means that they're continuing to, from a neurochemical perspective, chase withdrawal. It is about continuing somebody in an addiction. They're maintaining their addiction. They're being maintained in a state where they are addicted to the medication.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
Thank you very much for that, Dr. Koivu.
I have a final question. I'm not sure if you know the answer to this or not, Dr. Koivu.
Our understanding from other testimony is that the street price of Dilaudid at eight milligrams has dropped significantly, which is evidence—perhaps not scientific—of diversion. Is that the experience in your community as well? Maybe you could talk about the price.
Addiction Physician, As an Individual
Absolutely.
It's a market-driven economy. As there has been more diversion and more available.... My understanding from patients and from living in the area is that in 2016, a D8 was about $20. If you're close to the supply—close to where more diversion takes place or the core of London—then it varies, but it's usually about one to two dollars. As you get farther away, it's more expensive.
It really is about supply and demand. As the supply has gone up and there's more and more Dilaudid available in London, and from the amount of tolerance people have compared to what they're prescribed, certainly the amount I'm hearing about.... The numbers are certainly over a million D8s in a year, and as that number has gone up, the price has definitely gone down.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Koivu.
We will now move on to the last speaker.
Ms. Brière, you have the floor for five minutes.
Liberal
Élisabeth Brière Liberal Sherbrooke, QC
Thank you, Mr. Chair, and thank you to all of our witnesses.
Dr. Hopkins, I have one question for you. What does supporting the voice of people who use drugs mean to you?
Chief Executive Officer, Thunderbird Partnership Foundation
Many people who are experts in their field have expertise and know the science behind their expertise. They publish. They know their work very well. We rely on them often for evidence so that we make informed decisions. We don't typically understand or give credit to the experience of living life every day with the types of conditions we're talking about: living with a dependency on opioids, having to survive the processes of coming to the right dosage for them and how people feel about that. Every person's being, their physical being, is different from every other person's. The type of medication needed, the amount of medication needed to address the issues of dependency, and the neurotransmitters that are significantly changed because of the types of drugs being used are all in the story of lived and living experience. It's a credible source of evidence.
If you listen to people who use drugs, you will find similarities. Whether you're talking to somebody in Vancouver's Downtown Eastside or somebody from a first nations community in northern Ontario, they've never met each other, but they will describe the same experiences of withdrawal. They'll talk about their tolerance of incremental increases to their addictions medicine. That's credible evidence.
Listening to their voices means that we give credit to people, not because of their status in life because they're using and not because we're judging them or discriminating against them. We're listening to them because they can tell us a real story that is mimicked across the country. That's important evidence. Listening to those voices is just as important, if not more substantial, to the decisions that need to be made about the health care system and the wraparound services that are provided to any population of people to ensure they can continue living life without the mental anguish and physical anguish that go with withdrawal.
People don't wake up every morning wanting to die. They get to those hopeless stages when we have opinions that form decisions and when we make decisions without looking at all the variables that impact something like we are talking about: safer supply and the toxic drug crisis. We can look at any one perspective and say that one perspective is credible evidence, and it may be, but if we don't look at it in the context of the determinants of health, for example, and how people learn to survive every day, then we're short-sighted and we end up making decisions as though we're God. Not one of us has the right to decide who gets to live, who is expendable and who should die.
Liberal
Élisabeth Brière Liberal Sherbrooke, QC
Thank you.
You say that every individual is different and needs to follow their own path.
Do you think that a more holistic approach, which includes the four pillars, is the best option for responding to the current overdose crisis?
Chief Executive Officer, Thunderbird Partnership Foundation
Absolutely. We need every tool and every strategy that is instrumental for ensuring life. Not one individual can live on this earth all by themselves. We live in relationship to others. We live in relationship to the land and the environment. We have to consider those elements and those four pillars.
We have a substance use strategy in Canada that includes harm reduction. Now we have to figure out what that means. We have to ensure harm reduction, but not only for individuals. We have to ensure we make decisions, policies, resources and programs that reduce harms to families and communities. That does not mean erasing the right to medicine, the right to mental wellness, the right to live and the right to the sacred breath of life. We have to provide and look at life from a holistic perspective. We can't afford to say, “You as a population don't have the right to life” or “You as a population, because you use drugs, don't have the right to health.”
The outcome of the UN declaration on the world drug problem—which Canada supported—was that, instead of a war on people, we had to ensure the right to prevention and treatment. Unfortunately, we couldn't get harm reduction in the declaration at that point. However, this year, the UN Commission on Narcotic Drugs had a vote that passed, putting harm reduction in international drug treaties. Now it matches what Canada has said, and we have to invest.
Liberal
The Chair Liberal Sean Casey
Thank you, Dr. Hopkins, Dr. Pauly and Dr. Koivu.
When we invited you, we told you that we would have you out by 5:30. You've been very generous and patient with your time and very thoughtful in your presentations. Our study will be better because of your contributions. Thank you so much for being with us here today.
Is it the will of the committee to adjourn the meeting?