Health Committee on Oct. 1st, 2024

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

I'm asking you, Dr. Patel.

[Dr. Rakesh Patel]

The entire goal of safer supply is to have a harm reduction framework to try to get you into health care, which includes mental health care and the social determinants of health. There's not one outcome. It depends on what outcome you want to look at and in what way safer supply is helping.

If you want to look at mortality, there's a lot of evidence that safer supply reduces mortality. If you want to look at housing, do people who get safer supply get housed? Yes, they do. Do they get housed as much as we'd like? No, they don't. Do people who get into safer supply ever come off their drugs? Some people do—just like some people quit caffeine, some people quit cigarettes and some people quit alcohol. Do the majority stop? No. It's because they don't want to stop. Why don't they want to stop? The trauma and all the other things they've experienced in their life journey have not been dealt with, so it remains a coping skill for them. The tranquility, euphoria and peace they get from that override everything they're not getting to help them manage the influences that lead them to continue taking that drug.

If you're asking me, as I think you are, whether safer supply is a perfect program, of course it isn't. Is it a program that actually works? Yes. Does it work all the time for all people in every circumstance? No. Neither does insulin, but that doesn't mean we stop giving you insulin.

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

I appreciate your response, Dr. Patel.

Do you remain concerned about the politicization of this crisis? You're saying that a multi-faceted approach needs to be applied. I think I'm hearing that from you. It's not one size fits all, but prescribed safer supply is one of the tools a physician can use to help support their patient. Are you concerned about the politicization of it?

You don't see politicians getting involved in heart disease or diabetes. Every party is saying that this is a health issue. Do you see that being applied given what you're hearing from politicians?

[Dr. Rakesh Patel]

Yes, I do. It's unfortunate, because substance use disorders, as you've alluded to, transcend political ideology and partisanship. The patients don't ask me what my political affiliation is before they let me examine them on the street. I don't ask them.

It very definitely has become a political issue. Can I share why I think it's become more of a political issue? It's because you are now seeing more people on the street using drugs, whereas before they were in safe consumption sites. That's because the way drugs are used, the availability of drugs and the types of drugs that are available mean that they can no longer take one injection of heroin, get on with their day, get a health card, find a house and get money from the bank like the rest of us do on a day-to-day basis. They now have to spend all their time doing that every hour, and because of that, it's become a visible problem.

That's the issue. That's what is driving politicians to make it a political issue. Just as you very clearly said, I've yet to hear a politician come down to the ICU and tell me how to manage a critically ill patient, yet all politicians, from a variety of different partisanships, have no issue telling me how to do my job at the corner of Murray Street and King Edward Avenue. It's visible. The reason it's visible is that the types of drugs people use have fundamentally changed. They are so rapid-onset and short-acting that patients have to get the next hit.

Let me explain it to you in a very quick way. Patients who inject drugs or smoke drugs, however they choose to do it, know that what they bought on the street they have no idea about. They have no idea, really, what they bought on the street. They may have bought fentanyl, or at least have been told that there's fentanyl in there. You heard from the other physician that there are a lot of contaminants. They know that when they smoke or inject that drug, they may very well die. However, they've experienced withdrawal, and withdrawal for them is a fate worse than death. Basically, they're taking a handgun with a single bullet and spinning the chamber. They're doing whatever they need to do to avoid withdrawal. They would rather die than go through withdrawal.

That is part of the problem. That's how potent and sinister the drugs on the street are. Therefore, one single approach will not solve this problem for us. It just can't.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Patel and Mr. Johns.

Dr. Ellis, you have five minutes, please.

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

Thanks very much, Chair.

Thanks, Dr. Patel, for being here.

One thing that I object to and find difficult is.... When you talk about treating diabetics, as a physician you're talking about treating one patient. What we're talking about here is how a population responded to some measures put in place by this coalition government that have allowed more and more people to access the short-acting narcotics that you find so objectionable and, I believe, should.

Maybe you could comment on that. Our job here is not to look after one patient at a time, as yours is. Our job is to try to help an entire country, which is in a terrible crisis.

[Dr. Rakesh Patel]

I take objection to the idea that I only look after one patient. It's true that I look after one patient at a time, but there is a cohort of patients I manage collectively at Inner City Health. It's not just one patient, and all of their well-being is important to me.

The treatment approach that I use is really not that different from the infrastructure of diabetes. There is a community of patients who have diabetes, have home care, have foot care and have regular clinic visits. There's an entire infrastructure that we as a society have collectively put in place to help manage them, because we view that as an important problem.

I think we should take the same approach to substance and drug use, because it is not a single patient issue, it's not a single entity and it's not an acute problem. It's a chronic problem.

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

Thanks for that, Dr. Patel.

On this side, that's not something we're arguing. Realistically, if all we're going to do is give you the substance you're seeking, we're talking about palliative care, because there's no other treatment for you as someone who uses drugs.

Over here, what we suggest is that people absolutely do need comprehensive care—housing, withdrawal management, all those things. However, we're also talking about supporting them while they're doing it. I guess the question is this: Why would we use the so-called safer supply method when we have other alternatives like Suboxone? How could you argue against using it? I don't know if you are arguing against it, but that's my question.

[Dr. Rakesh Patel]

I do use Suboxone for some of the patients I look after downtown, but that's a patient autonomy issue. Lots of people don't want to be on Suboxone because they don't necessarily want to stop their drug use entirely. I don't want to stop taking a single shot of whisky on a Saturday night, but I want to use it responsibly. As long as they have capacity and turn down Suboxone, I can't force that treatment on them.

I understand the value of Suboxone because there are some patients who take it and do well on it. If the goal is to get them completely off any opioid, whatever substance they're using, and the patient wants to do that, then I agree with you that we should look at alternatives other than safe supply. However, often the only way to get the patients to trust us, as an infrastructure of people at the front lines looking after patients, is to start them off on Dilaudid and get them into the fold. You have to remember—and as a physician, you know that building trust is crucial—that lots of the patients who end up on the street have substance use disorders and have gone through horrible life journeys where the people they wanted to trust let them down, so for us to develop trust takes time.

I wish I could start everybody on Suboxone and see how they do, but the reality is I can't because of an individual's situation.

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

The only other argument, Dr. Patel, is related to the fact that, as you and I both know, the opioid crisis was largely fuelled by OxyContin prescribed by physicians. Just for the record, you nodded in the affirmative to that statement. How can we suggest that flooding the market with more and more opioids for people to use at their will is going to be of benefit? To me, that's counterintuitive. It really becomes nonsensical to say that we got into this problem—which we agree on—based on an oversupply of readily available, highly potent short- and long-acting opioids, and now we're going to get out of it by giving people more and more opioids. That seems counterintuitive to me.

I agree with you that we need to create spaces where we have relationships with people, but just saying, “Take whatever you want” doesn't seem sensible to me.

[Dr. Rakesh Patel]

I would disagree with the statement you're making—“Take whatever you want.” That's not the case; that's a gross oversimplification. I think you know that.

The reason to have safer supply is to try to build trust while keeping a patient alive. If they're dead, who cares? Why use Suboxone? Why worry about Billy? He's dead. The problem is gone.

However, we're human. We try not to kill people if we can actually avoid it through a variety of different societal policies. This is no different than that policy. The goal of safer supply—I'll say it again—is to keep people alive so that we can get them the help they actually need. There's no other way around it. If we take away safer supply, people will die. You're going to have a bigger problem on your hands, and that's the issue.

[The Chair, Liberal, Sean Casey]

Thank you, Doctor.

Ms. Sidhu, go ahead, please, for five minutes.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you, Dr. Ghosh and Dr. Patel, for the work you are doing on the ground.

My first question is for Dr. Ghosh.

Dr. Ghosh, you talked about waste-water testing, and you also talked about two programs that are working very successfully. You're co-chair of the Canadian Network for the Health and Housing of People Experiencing Homelessness. Can you talk about the link between homelessness and substance use? Can you elaborate on that first?

[Dr. Sumantra Monty Ghosh]

Thank you so much, honourable member Sidhu. I can definitely talk about the link there.

First and foremost, in homelessness, the population itself is not ubiquitous; they're very diverse in who they are. As Dr. Patel mentioned, while one treatment might work for one population in one group, it might not work for another.

It's a difficult thing to manage because you have different levels of acuity in that circumstance as well. What I mean by this is that you have new people entering homelessness who are not chronically homeless yet. They are traditionally easier to get back into the housing system than others. These are people escaping domestic violence issues or who had their house burn down, for instance—situations like that. There are also youth experiencing homelessness, which is a different category or group.

In terms of chronic homelessness, one of the big things we see within this particular population is a large number of mental health concerns and a large amount of substance use, as Dr. Patel mentioned. However, there's also a large amount of brain injury. For that population in particular, this is one of the main concerns we have. We see this within various downtown cores throughout the country.

I'm an internist as well. At the University of Alberta Hospital, for instance, I often manage individuals who have a traumatic brain injury from a motor vehicle accident. I sometimes have patients with frontal temporal lobe dementia, and the behaviours they enact are no different from those of individuals I saw and took care of in the shelter at the Calgary Drop-In Centre when I was working there, or in our opioid dependency program, which is above our supervised consumption site. It's a very similar population. The only difference is that within the acute hospital setting, people with frontal temporal lobe dementia have families that are very supportive of them. We get them into long-term care facilities or housing, whereas with this particular population, we don't.

I want to highlight that systematic reviews have been done demonstrating that among the population experiencing homelessness, nearly 50% have moderate to severe brain injuries or moderate to severe cognition concerns. That is huge, yet we don't provide proper support for them.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you.

My next question is for Dr. Patel.

Dr. Patel, you're running an Ottawa Inner City Health pilot project. In terms of the patients who received help and changed their lives for the better through your work with that pilot project, what recommendation can you give this committee for what led to their recovery?

[Dr. Rakesh Patel]

Thank you for the question. I appreciate it.

The fundamental thing that I would request the committee remember is that substance use disorder is a complex, chronic and wicked problem. Lots of different things have to be in place for us to manage it. You had a question about homelessness, which is a crucially important thing, along with the other social determinants of health. The medical and mental health we provide at Ottawa Inner City Health is one very small piece of the puzzle. All of the other things are crucially important.

If you have a home, the reason you benefit from it, whether it's a small apartment or a house, is that you have personhood. When you have personhood, you have a purpose. When you have a purpose, you're motivated to change. I don't know how my patients feel. I can only imagine how they feel. However, if I were living on the street, I would feel like I don't count and that nobody cares. If they did, why would they let me live on the street?

The social determinants of health, I would argue, are going to be far more important in how we manage this problem going forward than safer supply, Suboxone or whatever you want to put out there as a medical treatment. It is going to pale in comparison to what we do about the social determinants of health.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Patel.

Mr. Thériault, you have the floor for two and a half minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Since I only have two and a half minutes, I'll try to be brief so you have time to answer my question, Dr. Patel.

Earlier, you talked about how people are politicizing the fact that this problem has become visible. There are problems with coexistence in cities. I'm sure you're seeing that downtown. Can you speak to that?

Do you think something can be done to address this issue?

[Dr. Rakesh Patel]

I'm not quite sure I understand the question about cohabitation. Are you referring to—

[Luc Thériault, Bloc, Montcalm, QC]

There are the people who live downtown and walk around there, and then there are the addicts who live on the street. You said earlier that this problem had become visible, so people are making it an issue, but that's a red herring.

How can we solve the fundamental problem? That's what you've been trying to tell us this whole time. If not for that red herring, we might not be having this discussion. Still, we need to take action. That's why I want you to tell us what else needs to be done, in your opinion. What are your thoughts on people who complain about the very real problems associated with coexistence?

[Dr. Rakesh Patel]

I'll start with the end of the question, which is about visibility. That problem is an issue for folks who live around it.

In the market here in Ottawa, for example, there are lots of new condos going up. It's a big issue for people who live there. It's not that the people living in those condos in the market are inhumane; it's that they're worried about their physical safety. That's what it really comes down to.

One way to get that visibility problem off the street is not to shut down safe consumption sites. It's to help support safe injection sites so that people can come out of the cold and into a site where not only are they allowed to use their drugs safely, but we can provide them with food, clothing and water. We can get them to trust us so they come to us when they want to use their drugs, not doing them on the street corner. The street corner, as everybody in this room knows, is going to be a very unsafe place, not only for them, but also for the people who live in the buildings around where that's happening.

There are a lot of different projects that people are doing. One example here in Ottawa is the block leaders program. People who use drugs and have lived experience are looking after those who are new to the problem. They're trying to show them the ropes, basically, as we would do in any other profession, so that they are safe.

My argument is that taking away centres like that—safe consumption sites and the clinic space I have downtown—is not the way, because you're going to push people outside. Part of that is based on the fact that the drug supply is not the same. It's not heroin anymore. Because it's so quick on and so quick off, they spend so much time with it that they don't even have time to come into the safe injection site. They have to do it outside because they don't want to be dope sick. In other words, they don't want to go into withdrawal because that to them, as I said, is a fate worse than death.

If you close down the places where they were going before, where else are they going to go? They have to go to the streets. The dealers aren't going away. They make money. The dealers are always going to be around. If you think pushing away all of the infrastructure we have now, either because you don't understand it or because you're ideologically opposed to it, I would just ask you to step back and think about the alternative.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Patel.

Next is Mr. Johns, please, for two and a half minutes.

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

Thank you both for your incredible insight.

Dr. Ghosh, I have a couple of questions. Do you believe there's an urgent need for national standards on substance use treatment programs? Also, can you please share any thoughts or concerns you have about the role of for-profit treatment facilities in responding to the toxic drug crisis? For example, are standards of care consistent between facilities?

[Dr. Sumantra Monty Ghosh]

Thank you, Mr. Johns.

One concern I have is that there is no standardization around treatment programs across our country, let alone across our province or our own jurisdictions. Some of them are medically supported and medically assisted. This includes sites that provide buprenorphine and methadone, which are evidence-based medicines. There are others that do not provide this and sometimes do forced detox, for example, for opioid use disorder and don't provide opioid agonist treatments. This can lead to a loss of tolerance and risk of relapse once they get discharged from these facilities.

I think there is a need to standardize this across the country. We need to make sure it's evidence-based and evidence-focused. It needs to have a combination of medically assisted treatments, which includes medications such as buprenorphine and methadone. For alcohol, there's naltrexone, for instance, or acamprosate.

There's also a need for an evidence-based system around mental health supports, as well as cognitive behavioural therapy, for example. These are other added layers that we need to have to support this.

It doesn't just end there. We need to also address the social determinants of health, as Dr. Patel alluded to.

Again, there are no standards around this. There's a lack of competency at times with some of these facilities. They vary. Some of them are excellent and some of them are not so great. Some of them are private for-profit and some of them are public. I've seen great private for-profit ones and poor private for-profit ones and vice versa for the public system.

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

We're hearing about for-profit mental health in the United States and that it's skyrocketing.

Can you talk about the dangers that we could be heading towards when we go to for-profit care?