Health Committee on Dec. 11th, 2023

[The Chair, Liberal, Sean Casey]

I call the meeting to order.

Welcome to meeting number 95 of the House of Commons Standing Committee on Health.

Today's meeting is taking place in a hybrid format, pursuant to the Standing Orders.

I just have a couple of comments for you, Dr. Humphreys, in participating remotely. You have, on your screen, the ability to use interpretation. You'll see on the bottom of your screen a choice of either floor, English or French. Please mute yourself when you're not speaking. Most of the time that will happen automatically, but if it doesn't, please tend to it, and refrain from taking any photos of your screen or any screenshots.

In accordance with the routine motion, I'm 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 the toxic drug crisis in Canada.

I would like to welcome our witnesses. We are joined by Dr. Keith Humphreys, professor of psychiatry, participating by video conference. We are also joined by Dr. Dan Werb, who is representing St. Michael's Hospital in Unity Health Toronto and is director of the Centre on Drug Policy Evaluation.

Thank you both for being here today.

We'll begin with opening statements of five minutes, starting with you, Dr. Humphreys.

Welcome to the committee. You have the floor.

[Dr. Keith Humphreys, Professor of Psychiatry, As an Individual]

Thank you, Chair.

Thank you for the opportunity to speak to your distinguished committee today.

My name is Keith Humphreys, and I am the Esther Ting memorial professor of psychiatry at Stanford University School of Medicine and a former White House drug policy adviser to U.S. presidents Bush and Obama.

Today I will briefly summarize some of the key conclusions of the Stanford-Lancet commission on the North American opioid crisis, which I chaired and which published its main conclusions in The Lancet medical journal last year.

The commission comprised North American clinicians, scholars and policy-makers who carefully studied the opioid crisis in the U.S. and Canada and made recommendations for how to resolve it.

In both of our countries, the opioid crisis originated in the health care system when insufficiently regulated pharmaceutical companies and health care providers increased per capita opioid prescribing by over 400% in a little over a decade. The fact that these drugs were legally made and of consistent, known quality did not stop them from addicting millions and killing hundreds of thousands of people across North America.

Some of those who suffered were patients. Others were individuals who gained access to medication prescribed for others that was given or sold to them through diversion. When prescription opioids are distributed in the community with little oversight, it is easy for each person who receives them not only to become addicted but also to initiate addiction in others.

To their credit, both the U.S. and Canada have subsequently taken significant steps to make opioid prescribing more judicious and safe. However, the expansion in the illicit drug markets of first heroin and later fentanyl has continued to cause great suffering, as you all well know.

The commission recommended the expansion of robust evidence-based prevention programs, targeting individuals not yet using opioids, coupled with treatment and harm reduction strategies for those who are already addicted. Many of these strategies are in place in multiple locations across Canada, including methadone maintenance clinics, syringe exchange services, drug courts, residential rehabilitation programs and initiatives that distribute the overdose rescue drug naloxone. The commission saw no reason that harm reduction and treatment programs could not be offered side by side. Promoting public health should be a shared journey and not a competition.

The commission also endorsed the goal of recovery from addiction for all services, meaning that while it was clearly valuable and moral to save someone's life today—for example, from an opioid overdose—it is important to not yield to the soft bigotry of low expectations by assuming that surviving from day to day is all an addicted person can be helped to achieve.

Tens of millions of people in North America have recovered from addiction, restoring their health and humanity and simultaneously benefiting their families and communities. Increasing the number of people who leave active addiction and enter recovery is a worthy goal to which all service providers and policy-makers should aspire. This is the animating spirit of the recovery-oriented system of care currently being built in Alberta, a destigmatizing and optimistic vision that I believe should be spread nationally.

The commission recognized that safe supply programs that distribute pharmaceutical opioids and other drugs in the community are a subject of significant discussion in Canada. I'll close by mentioning that commissioners were skeptical of such programs. The reason is simple: We have seen this movie before.

If handing out prescription opioids with minimal supervision was good for community health, neither the U.S. nor Canada would ever have had an opioid epidemic. The first decade of the crisis should have taught us that the fact that a drug is legally produced and of known quality is no barrier to it causing addiction and death.

Further, as the early years of the opioid crisis showed, it only takes a small amount of diversion to new users for an opioid distribution program to increase the prevalence of addiction. Even if we assume optimistically that 90% of people on the safe supply program take all provided drugs exactly as prescribed and that the other 10% divert only enough to each generate one or two new cases each of addiction each year, the number of addicted people doubles every five years.

The commission therefore recommended keeping faith with the prevention, treatment and harm reduction strategies I have just described, which have evidence of making our shared addiction crisis better rather than worse.

Thank you again for the opportunity to testify today. I look forward to your questions.

[The Chair, Liberal, Sean Casey]

Thank you very much, Dr. Humphreys.

Next we're going to hear from Dr. Dan Werb from St. Michael's Unity Health Toronto.

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

[Dr. Dan Werb, Director, Centre on Drug Policy Evaluation, St-Michael's Unity Health Toronto]

Thank you for the opportunity to present today.

I am a social epidemiologist and the director of the Centre on Drug Policy Evaluation at St. Michael's Hospital in Toronto.

Canada's overdose epidemic is getting worse. This has understandably led to a questioning of the current response and a reflection on what must change for Canada to overcome this all-of-society crisis.

In that context, it's important to recognize where scientific consensus exists and where questions remain. I want to focus my comments on two contested areas: opioid agonist treatment and supervised consumption services.

There is scientific consensus that opioid agonist treatments like methadone, buprenorphine and others are the most effective approach we have for managing opioid use disorders and helping to stabilize people at risk of overdose.

Over three decades, there have been multiple Cochrane systematic reviews and meta-analyses, which are the gold standard for evidence-based medicine. They have demonstrated that this class of treatments, which includes providing opioids such as methadone, buprenorphine as well as diacetylmorphine and others, is effective at retaining people on treatment, reducing their use of non-medical opioids and reducing their risk of overdose.

Work that I led on a study funded by U.S. National Institute on Drug Abuse and the Canadian Institutes of Health Research across four countries also found that enrolment in opioid agonist treatment was associated with a reduced likelihood that people who injected drugs would assist others in initiating injection drug use, thereby potentially preventing people from becoming at risk of overdose.

However, questions remain regarding opioid agonist treatment. For example, how do we best reduce the barriers facing people at risk of overdose who could benefit from treatment? How do we scale up treatment to those who need it? What types of medications are most effective, given the extremely high potency of synthetic opioids like fentanyl, carfentanil and nitazene-class opioids? What kind of monitoring is required to ensure that patient needs are being met and medications are not diverted? Finally, how do we ensure that those who lose access to treatment don't end up reliant on the toxic drug supply and thereby at greater risk of overdose?

These questions are important to investigate, but they do not change the fact that opioid agonist treatment is our best clinical tool for managing opioid dependence and that recovery-based approaches have not demonstrated similar effectiveness. We should continue to focus our efforts on scaling up coverage to meet the needs of those who could benefit from this treatment while also ensuring that we evolve the design of programs to respond to these important questions.

Similarly, there is scientific consensus that supervised consumption services are effective at preventing people from dying of overdose. They are, in fact, the most effective structural intervention that we have. These services have generated evidence over four decades of operation and are now present in over one-third of all countries in the world. They have been shown to not only provide immediate life-saving responses to clients on site, but can also serve as pathways into the broader continuum of care for people who are at risk of overdose. This includes referring their clients to treatment, social services and clinical care.

However, questions have been raised about the limits of their impact. For example, some observers have questioned their cost-effectiveness, on the assumption that their impact is restricted only to the clients within the four walls of the sites themselves.

On that, I would note a study from my centre, led by Indhu Rammohan and currently in press at The Lancet Public Health, the world's leading peer-reviewed public health journal. It recently found that the implementation of nine supervised consumption sites in Toronto, starting in 2017, led to a 67% reduction in overdose mortality in surrounding areas—as far as five kilometres away—with significant positive rate reductions increasing year over year.

This study adds to data from Vancouver, as well as Sydney, Australia, which collectively demonstrates positive spillover effects of these sites across neighbourhoods.

If we're serious about ending the overdose epidemic, the chief question is how we best resource these services to fully integrate with the broader continuum of care, such as social services, including housing, clinical care and substance use treatment, so that they are as effective as possible in preventing overdose as well as in helping to connect individuals with services that they need.

Also, how do we best design and manage these sites to minimize potential public safety concerns for surrounding communities? Rather than seek to reduce the number or the funding of these sites, we need to resource and design them to meet the needs of those at greatest risk of death as well as those of the communities in which they are located.

This is why I am so troubled that supervised consumption sites are slated for closure in both Sudbury and Timmins, Ontario, and are under threat elsewhere. Given that northern Ontario's per capita overdose mortality rate is roughly three times the provincial average, we simply cannot afford to backslide, or more people will die.

The overdose epidemic will soon claim more Canadian lives than COVID-19, and mostly young lives. Let us recognize our collective national grief and transform it into a comprehensive evidence-based road map to end overdose based on the evidence of what works and what must be adapted. The only other option is more death.

Thank you.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Werb.

We're now going to begin with rounds of questions. We're going to start with the Conservatives and Ms. Goodridge.

Ms. Goodridge, welcome back. It's good to see you. You have the floor for the next six minutes.

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

Thank you. That's wonderful. I appreciate it.

I want to thank both witnesses for providing testimony here today.

I'm going to start with you, Dr. Humphreys. I really appreciated your entire report in the Stanford-Lancet commission.

I'm going to pull one quote:

At the same time, evidence clearly shows the folly of assuming that population health inherently improves when health-care systems provide as many opioids as possible with as few possible regulatory constraints as possible. Policies that should attract skepticism include dispensing of hydromorphone from vending machines and prescribing a range of potent opioids and other drugs, ([i.e.] benzodiazepines [and] stimulants) to individuals with OUD in hopes of creating a safe addictive-drug supply and eliminating the supervision of methadone patients—i.e., converting the system to unmonitored, long-term prescriptions on a take-home basis.

I was wondering if you could expand on that a bit, because I think this is so much the crux of the issue we're in.

[Dr. Keith Humphreys]

The commission is very positive about medication-focused treatments in which people are monitored and supported. I mentioned methadone maintenance clinics and other opioid agonist therapies.

At the same time, the commission looked at the history of what happened in both of our countries around widespread prescription of opioids given with very little supervision in the community. We were assured by the companies and by the doctors that no harm would result. Prescriptions went up dramatically, and that is how this whole crisis started, so to say that now, for some reason, if we now distribute opioids without any supervision, the same thing won't happen again beggars belief. That contradicts our very recent historical experience, both in Canada and in the United States. We didn't recommend doing the same thing as before and expecting a different result.

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

I think that's an important piece to say. The entire idea.... Where so much of this opioid epidemic started was in fact from the OxyContin in the 1990s and 2000s, and the whole piece around diversion and the 400% increase in prescription opioids.

What do you think we could do better or differently? You touched on the Alberta model. I'm wondering if you could explain why you think Alberta is doing it right. I agree with you; I think Alberta is doing it wonderfully. I'm very proud of my province for taking this leadership. I'm just wondering if you could give some descriptions from a medical perspective as to why Alberta is leading in this.

[Dr. Keith Humphreys]

Alberta has made a major fiscal commitment to treatments of all sorts. They have expensive opioid agonist therapy. They have residential rehabilitation. They also have, by the way, very strong investments in harm reduction. What they are doing that is different from a lot of other places around the country—my country too—is that, first off, it is a system. All the parts are integrated together. There's a province-wide plan. There are steps of care that people go through so they can go on a pathway to come out at the end much better off then when they went in.

The second thing, as I mentioned, is this optimistic idea of recovery. You know, because addiction is a stigmatized condition, there are a number of people who would believe colloquially and say, in a cold way, “Well, once an addict, always an addict. They will never change. They can't get better.” The Albertan model believes that, no, that is not true, that in fact people can recover. We have millions of people who have recovered, who are productive citizens, who are connected to their families and who are people we prize and cherish in the community.

Setting that as the goal, as the aspiration, is extremely important, rather than saying that we're just going to manage this population, that we don't really expect much out of them and that at most we might be able to help them live until tomorrow, and that's all they can ever achieve. That becomes a self-fulfilling prophecy.

I admire that fact when I've gone up to Alberta and visited and have seen what they're doing, seen that vision that every single person is capable of having a much better life through recovery than they have right now.

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

You touched very briefly in your opening statement on how you were one of the policy drug advisers for both President Bush and President Obama, so you've crossed party lines when it comes to the policy piece.

What did you learn in those roles that you think Canada could and should adopt?

[Dr. Keith Humphreys]

Yes, I did that. I'm not a politician. I'm a policy adviser. Since the science stays the science, anyone who wants to adapt it to.... You can work with a broad range of people, and that's what I've tried to do.

What I saw in both of those administrations was that the commitment to treating addiction as a health problem was profound and important for both of those presidents. Although they differed in many ways, obviously, they both believed the health care system is something we can handle addiction through. Yes, we need law enforcement when someone does something violent because of their addiction, but, for the most part, we want people to be able to talk to their doctors about their addiction as they would talk to them about cancer or a heart problem. They both moved our system that way.

Canada, by the way, does better than the U.S. It gives health insurance to everyone, and I think that's great. We've made some progress towards this. We like to copy you.

I think the concept of trying to manage addiction as much as possible in health care.... You don't need public safety, unless a person does something that threatens another human being.

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

Well, thank you. We agree completely. From our perspective, at least on the Conservative benches, addiction is a health care issue. It needs to be treated as health care in order to move forward in destigmatizing those conversations so that people can have those conversations with their doctor and get the treatments they need in an appropriate manner. It's absolutely required.

I want to thank you for your leadership on this issue and for being part of this committee.

If you have anything further you'd like to add....

I was reading quite a bit about your 24-7 recovery model. I didn't, unfortunately, get an opportunity to ask you any questions about that. If you could perhaps send a brief to the committee on that, it would be much appreciated. Everyone else on the committee could learn a bit about that model as well.

[Dr. Keith Humphreys]

Thank you. I would be happy to do that.

[The Chair, Liberal, Sean Casey]

Thank you, Mrs. Goodridge. Thank you, Dr. Humphreys.

Dr. Hanley, go ahead, please, for six minutes.

[Brendan Hanley, Liberal, Yukon, YT]

Thanks very much to both of you for your thoughtful presentations.

Dr. Humphreys, I want to briefly go back to you.

You have written a lot about prevention. You haven't focused on it in this talk, but I think you talk about prevention with some sense of urgency, including that you can't solve epidemics by concentrating on people at the extreme end.

Knowing there's a strong relationship between adverse childhood experiences or childhood trauma and addiction later in life, can you very briefly comment on the importance of upstream investments with that same sense of urgency we're thinking about at the other extreme?

[Dr. Keith Humphreys]

Thank you so much for raising that, Doctor.

You're absolutely right. Look at how HIV/AIDS and COVID were brought under control. It was through reducing new cases. We are not doing enough of that with addiction.

The commission recommended focusing particularly on kids in low-income environments and on generic investments in their well-being. These would be things like early education programs, nurse-family partnerships that help low-income parents-to-be with their first experience of birth and early child raising, and Communities That Care, which is a very well-studied program for kids a bit older, usually around 11, 12 or 13. It teaches them things like how to recognize and manage their own emotions, connect positively to other kids and connect to positive community organizations, whatever they may be—cultural, religious, artistic or athletic—which provide them with alternatives to substance use.

The evidence in those studies, which is very strong, shows that kids who get those investments not only have lower rates of drug, alcohol and tobacco use but are also more likely to stay in school. They're more likely to go to university someday. They're less likely to get involved in crime. They're less likely to be depressed. Making those investments—again, particularly for children who are growing up in adverse environments—is very critical, unless we all want to be having the same conversation 10 years from now, which I'm sure we don't.

The way we get out of that is through those preventive investments.

[Brendan Hanley, Liberal, Yukon, YT]

Thank you very much.

I'll go to Dr. Werb on the prevention theme.

You've written about treatment as prevention. You've written a paper on this, and probably several. I wonder if you could briefly comment on what you mean by “treatment as prevention”.

[Dr. Dan Werb]

This is an adaptation of an approach that was used really successfully in the HIV space. Basically, you meet somebody's needs in terms of treatment, and you have positive knock-on effects in terms of the spread. In the case of HIV, you actually reduce the transmission of HIV among people if you provide them with medications like highly active antiretroviral therapies.

This is a slight adaptation of that approach, but of course drug use is a very, very different phenomenon. Essentially, we found in the work that I referred to in my opening remarks, funded by both NIDA in the United States and CIHR here in Canada, that people who were provided with opioid agonist treatments and who were injecting drugs were less likely to report that they had assisted in the initiation of other people into injection drug use. We know that injection drug use is often implicated in an increasing severity of opioid use disorder or other substance use disorders. We also found, for instance, that increasing the intensity of policing actually had the reverse effect. People who were encountering police more often were more likely to assist people in their initiation of injection drug use.

Let me just say that this is not to cast people who engage in this behaviour as predators or anything like that. There are many rational reasons that people engage in this kind of behaviour, but if we're looking to prevent the expansion of substance use behaviours that we think could potentially put people at higher risk of overdose and we rely on the evidence of interventions that can help meet people's needs themselves, we find that there may be this potential knock-on effect on other people being at risk.

On that I'll say that we have not seen the same evidence of the effectiveness of recovery-based treatment as opposed to opioid agonist treatment and pharmacotherapy treatment. I would point to a recent study—it will be coming out in Drug and Alcohol Dependence in January, but it's available online now—that compared overdose mortality among people who had been enrolled in methadone and buprenorphine with recovery-based non-pharmacotherapy treatments. It found that there was a reduced risk of overdose mortality among people who were enrolled in buprenorphine. However, when the authors looked at non-pharmacotherapy recovery-based treatment, there was an increased risk, compared with the placebo, of overdose mortality.

On that note, I would say that the adoption of the Alberta model, while it is of course aspirational.... I think everybody in this field who devotes their time to it is aspirational and optimistic about the possibilities of people becoming well, managing their lives, being healthy and having social well-being. In Alberta, after the adoption of the Alberta model in mid-2019, there was actually a more than doubling of the overdose mortality rate in that province. There was an increase in overdose mortality basically everywhere in Canada, but the rate of increase in Alberta actually outpaced a lot of other places in Canada, so I would just offer a little bit of caution on that.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Werb.

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

[Luc Thériault, Bloc, Montcalm, QC]

Since I am particularly interested in the topic, I would like to continue with it.

Mr. Werb, the people to my right believe that the implementation of the program to reduce harm and ensure a safer supply has had a negative effect. This morning, you are saying that, when urgent action is needed to prevent overdose deaths, this is the best approach possible. Yet you are critical of the model recommended by Dr. Humphreys.

Aside from the data you mentioned, in what way is that model problematic?

[Dr. Dan Werb]

I think it's just a matter of the evidence that is out there. The evidence on recovery-based non-pharmacotherapy treatments is just not as strong as the evidence on pharmacotherapy-based treatments. There's a reason that methadone and buprenorphine are on the WHO's list of essential medicines. It's because they are the most effective approaches we have to managing people who have opioid use disorders.

I share Dr. Humphreys' aspirational and optimistic sense of people's capacity and of helping people return to full lives after experiencing opioid use disorders. The fact is that these methadone and buprenorphine programs seem messy because people often will begin a program and will be enrolled in methadone and buprenorphine or another medication for opioid use disorder, and then they will stop the program. They will go back on. However, over time we don't see the scientific evidence out there suggesting that recovery is an effective approach. I think it can certainly be part of a comprehensive approach, but not at the expense of evidence-based pharmacotherapy clinical treatment.

I will say that one of the issues in Alberta is that the proportion of the population that actually has coverage for these types of medications—opioid agonist treatments or medications for opioid use disorder, or whatever term you want to call it—is actually quite a lot lower than in places such as B.C. and Ontario. When we're thinking about ways to prevent the overdose epidemic, I think we need to start with where the scientific evidence is and where the scientific consensus exists. That's not to say that recovery is not appropriate for some people; it's just to say that the scientific evidence—and that's what I follow—is much stronger with respect to these types of treatments versus recovery-based treatments.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Marie‑Ève Goyer is the deputy medical head of specific homelessness services, dependency and mental health at CIUSS, the Centre intégré universitaire de santé et de services sociaux, Centre‑Sud‑de‑l’Île‑de‑Montréal, Quebec. With regard to the diversion of drugs in her practices, she said that those who sell their doses often do so to buy food and clothing. She said it is troubling for her as a physician to see that her prescriptions are being used to fight poverty, but insists on calling things what they are.

What do you think of that statement?

[Dr. Dan Werb]

Absolutely. This is what we've seen over and over again. I run a cohort study of people who use drugs in Toronto. We followed them for about five years. There is evidence from cohort studies of people who use drugs in Vancouver and Montreal as well, and housing is one of the key factors that is placing people at risk of overdose.

It's interesting, because we see housing in the news every day, but rarely do people put the links together between the housing crisis that is affecting all of Canada and the fact that this is also really contributing to the overdose epidemic that we're experiencing as well. It's very difficult for people to engage in treatment if they are unhoused.

There is often a requirement that people—often an informal or an implicit requirement—be housed prior to receiving standard treatment because their clinicians believe that they may be too chaotic to actually be able to undertake or be retained in a treatment program. I think you really hit the nail on the head that housing goes hand in hand, and unfortunately when resources are being allocated towards ending the overdose epidemic, this issue of housing really does not come up.

We have a shelter system across Canada that is generally abstinence-based. This means that if somebody is managing their substance use through a methadone or buprenorphine program or some other program, but they're still potentially using a little bit of unregulated opioids, they're unable to stay in that shelter. There are some restrictions around even accessing low-barrier housing that are causing people to have to make a choice between remaining on treatment or being housed.

[The Chair, Liberal, Sean Casey]

Thank you, Dr. Werb.

Next is Mr. Johns. Go ahead, please, for six minutes.

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

Thank you both for being here. I really appreciate it.

I'm going to start with you, Dr. Humphreys.

You cited that prescribing for pain does have many ethical problems. I think that's not really what's happening with safe supply. Safe supply is prescribed to people who are already consuming large amounts of fentanyl. It's monitored very closely.

Dr. Humphreys, maybe you can explain what your experience is with safe supply programs. Have you spoken with any safe supply clinicians to understand their protocols, or are you basing your statements on others' anecdotal statements?