Health Committee on Oct. 1st, 2024

[The Chair, Liberal, Sean Casey]

I call this meeting to order.

Welcome to meeting number 129 of the House of Commons Standing Committee on Health.

Before we begin, I would like to ask all in-person participants to read the guidelines written on the cards on the table. These measures are in place to prevent audio and feedback incidents and to protect the health and safety of all participants, including the interpreters.

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'd like to welcome our panel of witnesses. Online, appearing as an individual all the way from Somalia, we have Dr. Sumantra Monty Ghosh. In person, we have with us Dr. Rakesh Patel, associate professor and medical director.

Thank you both for being with us. We normally have a larger panel, but this is to our benefit and to yours because we'll have more time for a conversation with each of you.

We're going to begin with you, Dr. Ghosh. Welcome to the committee. Thanks for making the effort to be hooked up from so far away. We have five minutes for opening statements.

You now have the floor, Doctor.

[Dr. Sumantra Monty Ghosh, Assistant Professor, As an Individual]

Thank you so much.

For introductory purposes, my name is Sumantra Monty Ghosh, but I go by Monty. I'm an assistant professor at both the University of Calgary and the University of Alberta, as well as a frontline physician who works with people who use substances.

I have a strong area of focus around research. Specifically, my research areas include the national overdose response service, which is a phone line that people can call after using substances alone. Seventy per cent of individuals using drugs and dying of overdoses are dying alone. This line helps provide them with support. They just call the line if they're using drugs alone, and they're paired up with a person with lived experience who monitors them. If they have an overdose event or drug poisoning event, EMS will be dispatched to their place.

I also do studies on waste-water testing, specifically in Calgary and the surrounding regions. With waste water in particular, we're looking at monitoring and quantifying substances within waste water, over 48 substances, including carfentanil, fentanyl and methamphetamines. We're also looking qualitatively to see if there are new compounds entering the drug supply. We've had a lot of success with monitoring this. Using this data, we've had an early detection warning system put in place to tell other practitioners that there could be concerns with the waste water. This has also helped us predict and determine why potential spikes and overdoses might happen. As an example of this, back in July 2023, we had a large spike in overdoses in Calgary, and we noticed at the same time that there was a large spike in carfentanil and xylazine within the waste water itself.

Last but not least, a large study was done that we just completed—although not published as of yet—looking at the community's perceptions around supervised consumption services. It included over 2,500 individuals who live in communities across Canada and are not health care providers or people with lived experience to see what their perceptions of supervised consumption services are and what the impacts of them are on their communities. This data is not published as of yet, but we're moving towards publishing it reasonably soon.

I'm glad to talk about any of these topics with the committee. I'm glad to talk about decriminalization as well, which is another area that I'm very much focused on. Last but not least, because I work within the recovery systems of care in Alberta and have a lot of experience with that, I can also share some of those experiences, how things are going within Alberta and the successes that Alberta has been demonstrating.

I'll leave it at that. Thank you so much.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Ghosh.

Next we have Dr. Patel.

Thank you for agreeing to appear. I understand that happened fairly recently. We appreciate your being here.

You have the floor, Doctor. Please go ahead.

[Dr. Rakesh Patel, Ottawa Inner City Health]

Thank you, Mr. Chair and ladies and gentlemen of the committee.

I'll be honest. I'm not quite sure what exactly my role is, or what you'd like from me. Things unravelled very quickly yesterday afternoon. I apologize for being late. There's absolutely no parking in downtown Ottawa, apparently.

I'll tell you what I do. Maybe that will help guide the questions you may have for me.

I am predominantly an ICU doctor. I work here in the city at the Ottawa Hospital. I'm also a general internist. In 2018, I started volunteering at what is known as Ottawa Inner City Health, predominantly because I had a lot of experience in a previous life when I was a pharmacist—before I joined the dark side. I used to work in downtown, inner-city Detroit. I saw the problems that different social systems and a lack of health care can cause. The emergency department was essentially the primary deliverer of health care for the population of inner-city Detroit.

When I wrote my medical school essay, I foolishly said that one day I was going to open up a downtown clinic and look after people who don't have equitable access to health care. When I came to Ottawa, one of my colleagues, Dr. Jeff Turnbull, had already started this. I called Jeff up one day and said that I had to start walking the walk and not living a lie, because I said this is what I was going to do when I applied to med school. It was about time I got off my butt and started walking the walk. That's how I joined Ottawa Inner City Health. I took over from Jeff as the medical director of Ottawa Inner City Health in 2022, just as we were nearing the end of the pandemic.

I work downtown as a frontline physician looking after the homeless and the vulnerably housed in Lowertown and across a variety of different supportive housing and community shelters across the city. I'm responsible for the programs we develop, implement and monitor. Predominantly, those programs are run by frontline nurses, which demonstrates that you don't need a physician at the front line to provide health care. This can be done by people who are kind, compassionate and interested in delivering the care they currently do.

I'll stop there.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Patel.

We'll now begin with rounds of questions, starting with the Conservatives.

Mrs. Goodridge, go ahead, please, for six minutes.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

Thank you, Mr. Chair.

I want to thank both witnesses for being here today. It's always a great day when we have more people from Alberta around this table.

Dr. Ghosh, I'm going to start off with some questions for you.

I find the conversation on waste water quite interesting. You talked about how in July 2023, there was a spike in overdose deaths, and the waste water also had spikes.

How are you and the Province of Alberta working to analyze waste water in ways we could potentially catch this before it results in overdose deaths?

[Dr. Sumantra Monty Ghosh]

Thank you so much, honourable member Goodridge.

That was one of many examples in which we were able to utilize waste water for benefits on a population level. While I share this information with the government as necessary, we're not necessarily working with each other. This is more a research project within the University of Calgary.

Essentially, we're just keeping track of what's going on in the waste water, both from a qualitative perspective, meaning if there's anything new coming in, and from a quantitative perspective, sharing if there are spikes. As mentioned, in 2023 we saw a spike in both carfentanil and xylazine—much higher than we've ever seen before—that coincided with this.

The way this translated was that we alerted the government to it. We alerted our frontline colleagues to the situation as well. In fact, the chief of staff for Premier Smith called us in to talk about the data. Again, one of the things we were able to do was alert the community at large about the situation and people who were using substances.

There were a couple of other instances in which this was beneficial. We were testing drugs at the same time as we were testing waste water, and what we noticed is that for a time, there was a lack of fentanyl in the drug supply, which is very dangerous. The police service in Calgary does their own direct testing and noticed that there were some concerns with the drug supply and there was missing fentanyl. They asked me if I had noticed the same thing. We did some tests and noticed it as well. The reason this is so concerning is that if all of a sudden within the drug supply there are missing drugs, people lose their tolerance towards opioids, and if they use opioids again, they might overdose.

This was a concern. We were able to triangulate the data with the police service and other services. For example, we have colleagues in Atlantic Canada from both the police force and the provider community. We shared this information with them, and they noticed a similar trend. However, what we couldn't figure out was why these two trends were isolated to Atlantic Canada and Alberta. The common thought was that maybe there was some sort of link between the organizational drug crime rings that operate in both areas.

I can share more examples of why it's useful, but I'll leave it at that.

[Laila Goodridge, Conservative, Fort McMurray—Cold Lake, AB]

That's incredible.

I know you are part of the VODP and some virtual RAAM programs. I was just wondering if you could explain to us why the virtual programs that Alberta has been using are so successful and how you think we could possibly move them to a more national scale.

[Dr. Sumantra Monty Ghosh]

Just for clarification, I don't work at the VODP, although I did do some virtual stuff for a while with Grande Prairie. It's using a similar platform.

The VODP has been a phenomenal program. They're currently in the process of launching the virtual RAAM—rapid access addiction medicine—program. The difference between the two is that the VODP focuses just on opioids, whereas the RAAM program will focus on everything but opioids. This includes alcohol, methamphetamines, GHB and other substances.

What's remarkable about the program is that it's open almost 24-7. It's open seven days a week from nine to nine. I know they're thinking of expanding to 24-7.

The benefit of this program is that it's what we call a “low-threshold intervention”, meaning that anybody who has a substance use concern or anybody who works with someone who has a substance use concern can call their number and seek help. For example, people in rural communities can call the VODP number and seek help right away to get off their illicit substances and onto buprenorphine or methadone. If you are someone experiencing homelessness and don't have a phone, you can get someone to call the number for you, whether it's a social worker, a peer or a police officer.

The VODP has permeated multiple different systems and services. They include the homelessness sector—shelters specifically—and our corrections systems to a certain extent. They include our arrest processing units across the province as well. The reason the arrest processing units are particularly important, in my view, is that I've seen first-hand how some people can go through bad withdrawal within these facilities. From a humane perspective, the most appropriate thing to do is provide them with buprenorphine, which will take away the withdrawal symptoms so they're not in agony.

These are all benefits that we've seen with the VODP.

The virtual RAAM program has not yet launched, but it is going to be launching soon, hopefully. It was supposed to launch on October 1, so we'll see if it launches today.

This whole concept of low-threshold intervention is key. In terms of how this can be expanded across Canada, I there's a place for this in every jurisdiction. I know that Ontario has some programs. I know that B.C. is looking at expanding their programs as well. It has been a hugely successful program, and again, it's because anybody can access it provided they have a phone. If they don't have a phone, they just need to get someone to help and call the number. It's been incredibly helpful in that regard.

I'll leave it at that.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Ghosh.

Next we're going to Dr. Powlowski for six minutes, please.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Dr. Patel, I thought I would ask you a few questions.

It seems we're on a similar life trajectory. I was a long-time emergency room doctor, and now I have taken a job where I'm forced to look at the bigger picture. It sounds like when you're working at Ottawa Inner City Health, you have the same kind of perspective: You're seeing a lot of people with homelessness, mental health problems and poverty.

I've been in Ottawa for only five years, but it seems to me that in the five years that I've been here, things in the downtown core have gotten worse. There seems to be a lot more homelessness. There are a lot more people openly using drugs. There are people overdosing on the street. There seems to be a lot of people with mental health issues. For us to walk into the core to the mall, our chance of being accosted by somebody who's either high or has mental health problems is about 50%.

Maybe I'm wrong, but do you think things have gotten worse among people in the downtown core with addictions and mental health-related problems? Is that the case? If that's the case and you agree, what are we doing wrong, or what do we have to do differently to better address this issue?

[Dr. Rakesh Patel]

To answer the question directly, before I try to come up with some solutions, yes, the situation on the streets has definitely gotten worse. There's no doubt about it. If you've driven across Ottawa, whether it's the downtown core or outside the downtown core, you will have noticed there are a lot more people panning. I recognize many of the people on the streets who are panning because they are patients of mine. The reason for it is fundamentally because of the drugs that are non-regulated and non-prescribed and available on the street.

I think at least some of the people around this room are old enough to remember The French Connection, the movie with Gene Hackman. The drug was heroin. That's how it all started. The problem with heroin is that you can only inject it, and it comes in big quantities. As the drug trade has evolved because of a variety of different policies, both social and medical, what you find is that people become a lot more inventive, and they make a lot more varied and potent products.

Fentanyl, crystal meth, xylazine and things like them that you have heard about are all very potent. A milligram of heroin is equivalent to about a microgram of fentanyl. It's one one-thousandth of the quality to give you the same euphoria, the same tranquility or the same peace that you might have felt with the heroin.

As those policies have been promulgated across the years, essentially they are prohibitionist policies. The fundamental conceit about it is that we can stop human desire, which is clearly wrong. Humans have desires, and we are risk-takers, which is why we got to where we are.

You can't legislate away or policy away human desire, so the approach of using supply-side economics has led to far more potent drugs that are manufacturable in much smaller quantities. They are therefore a lot more concealable and are easily transported onto the street. That supply is now fundamentally on the street.

The issue with the drugs on the street is their pharmacokinetics. It's a fancy medical word that says if you take a Tylenol for your headache, how does your body get rid of it? Why don't you have Tylenol in your bloodstream for the rest of your life? The reason is that it's considered a foreign substance, so your liver and your kidneys do everything they can to get rid of it. The problem with crystal meth and fentanyl is that they have such a rapid onset, even faster in some cases than the nicotine that people who smoke cigarettes take in. The onset time is about 30 seconds to a minute or so. It's a rapid rush. It's a rapid hit, but unfortunately, it doesn't last very long, and because of that, we now see people on the streets who are panning for money.

There's an increased number of people on the streets and more people using drugs on the streets, and I will tell you why that is. You're seeing that because they no longer have time to engage with us to help them get to the social determinants of their health: the lack of housing, the lack of food security, poverty and the lack of life skills. They are so busy trying to get the next hit that they don't have time for anything else.

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

I'm sorry, Dr. Patel, but can I interrupt you? There are only two witnesses, so you'd think I have a lot of time, but I probably have only one chance to ask questions.

You seem like a supporter of safe supply. I know the Swiss model of safe supply is heroin-assisted treatment. There's a lot of evidence on that and directly observed treatment, which I have no problem with. However, someone have described safe supply in most of Canada as the poor man's version of that—giving people a bunch of pills because it's easier to give them a bunch of Dilaudid than it is to observe them injecting it.

The concern is diversion. One psychiatrist in Vancouver told me that he has a lot of kids on Dilaudid and a lot of them move on to fentanyl. I asked him why, and he said that when he asked his kids why, they said you can now buy one dilly on the street for a dollar in places. It used to cost $20, but because of diversion, the price has come down. A dilly costs one dollar. A joint costs five dollars. It's just simple economics. Do you want a buzz? Try—

[The Chair, Liberal, Sean Casey]

Dr. Powlowski....

[Marcus Powlowski, Liberal, Thunder Bay—Rainy River, ON]

Do you not see that as a problem, the Dilaudid safe supply model or the Canadian way of doing that?

[The Chair, Liberal, Sean Casey]

Dr. Powlowski, you talked right through the time.

Dr. Patel, give a very brief answer, please. Dr. Powlowski took all of the time.

[Dr. Rakesh Patel]

Yes, I'm concerned about diversion, but the majority of diversion doesn't happen in the way you described it. Much of the diversion happens from regulated prescription medication that you find in your medical cabinet.

[The Chair, Liberal, Sean Casey]

Mr. Thériault, you have the floor for six minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Mr. Chair.

I'd like to pick up on that. People often tell us that it's easy to circumvent safe supply in places like schoolyards. Some people have pointed out that the safe supply program requires people to go somewhere to see a doctor. In Quebec, these substances are available with a prescription. It's much more controlled than people who are in favour of abolishing safe supply would have us believe.

What are your thoughts on that? We're in the middle of a toxic drug crisis. The black market is pumping out massive quantities of products and substances. Anarchy reigns. We have a deadly drug problem on the streets. What other solution is there if safe supply is abolished?

Without safe supply, how are we going to achieve our objectives?

[Dr. Rakesh Patel]

Thank you for the question. I appreciate it.

The fundamental concern that people have about safe supply is what you guys have all alluded to, which is diversion, but the reality is that kids at school—high school students and university students—do not buy dillies from the people I look after downtown. Those people are scary. They look unkempt. They look threatening. Those are not the people the school kids are buying their dillies from. Their dillies are coming from the drug dealers who know how to manufacture them very cheaply and can get them to someone who looks like them and will act as their proxy. That's where the predominant number of drugs that are so-called diverted from safe supply are going.

Safe supply prescriptions are actually well regulated. I write those prescriptions. There are many times when we observe patients take those medications because we don't trust them enough to take them away. We trust some people. That maintains their autonomy. It helps build trust and allows us to engage with the other physical and mental health care disorders they have.

The number of people we have at Ottawa Inner City Health on safe supply is 50. There are far more prescriptions written for morphine and hydromorphone in an acute care hospital on any given day than those 50 people are getting.

Yes, there's an observation that school kids are using dillies. The inference that they're from safe supply is incorrect. You cannot connect those dots easily, reliably or consistently.

[Luc Thériault, Bloc, Montcalm, QC]

You said earlier that, if there's no way to reach these people, that means work at the community level needs to be done. For example, people on the front lines who are dedicated to harm reduction seek out contact with addicts to address their social determinants.

When we did a tour, we noticed that the good stories, the ones with happy endings, always started with supervised housing, among other things. Individuals are given a roof over their head and the right to supervised consumption. Gradually, these individuals were able to control their addiction. Having a fixed address enabled them to find a job and, over time, break the addiction.

That path seems much more difficult, and it can take a long time. Do you think it's better than something like forced detox?

[Dr. Rakesh Patel]

Yes. The problem with forced treatment.... First of all, we don't do it for diabetes, hypertension, rheumatoid arthritis or pneumonia. That's because we want to preserve your autonomy over health care. The underlying hypothesis of forced treatment is that it's one and done. I treat you, you're better and you go home. That's not the case.

When you're working on the sharp end of the stick like I am, you recognize that addiction or substance use disorders are a complex and wicked problem that involve not only health care but the social determinants of health. A simple, single approach for all patients is never going to work. It's a chronic disorder; it's not an acute disorder.

It's no different from managing diabetes. We know what the problem in diabetes is, for example, which is insulin. We still can't cure diabetes, and we've known about insulin since 1922. If we can't cure diabetes, how can we hope that a single addiction treatment is going to solve a complex and wicked problem like addiction?

You have to start somewhere. As an ICU doctor, my fundamental job is to keep you alive. It's to buy you time and, in the meantime, figure out what is actually going on and come up with a comprehensive plan to look after you. It's no different on Murray Street and King Edward Avenue. When somebody is addicted, my job is to keep them alive using a harm reduction approach.

We use harm reduction in all aspects of our life. This committee just used a harm reduction approach when it made me go through security. You don't know who I am. You might be afraid that I might hurt you, so you have a harm reduction process that prevents me from doing that. Most of you probably drove here today, or you had somebody drive you. Your car has harm reductions: seat belts, anti-lock brakes and airbags. You put your seat belt on. Why did you do that? There are traffic signs and traffic laws we all have to follow, yet people still die from traffic accidents. I know this because I look after them in the ICU, but we don't ban driving.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Patel.

That's our time for Monsieur Thériault.

Next we have Mr. Johns online for six minutes.

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

Thank you, Mr. Chair.

It's an honour to be joining you on the unceded lands of the Tseshaht and Hupacasath nations.

I'm sorry I can't be joining you in person. I was home for the National Day for Truth and Reconciliation and I couldn't get back to Ottawa in time.

Dr. Patel, in December 2023, you signed a letter, along with more than 130 experts in substance use, calling on the federal government to continue to support and scale up safer supply programs. The beginning of the letter reads:

As researchers and clinicians across Canada, we are writing out of concern regarding the increased politicization surrounding the response to the drug toxicity overdose crisis that is taking the lives of 21 Canadians every day. We are particularly concerned about the spread of misinformation and the denial of the evidence-base on harm reduction interventions, such as prescribed safer supply programs.

Can you please share with this committee your knowledge regarding the outcomes of prescribed safer supply programs?

[Dr. Rakesh Patel]

Are you asking me or Dr. Ghosh?