Proceedings of the Standing Senate Committee on
Legal and Constitutional Affairs

Issue No. 26 - Evidence - April 5, 2017

OTTAWA, Wednesday, April 5, 2017

The Standing Senate Committee on Legal and Constitutional Affairs, to which was referred Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts, met this day at 4:14 p.m. to give consideration to the bill.

Senator Bob Runciman (Chair) in the chair.


The Chair: Good afternoon and welcome, colleagues, invited guests, and members of the general public who are following today's proceedings of the Standing Senate Committee on Legal and Constitutional Affairs. Today, we continue our consideration of Bill C-37, An Act to amend the Controlled Drugs and Substances Act, and to make related amendments to other Acts.

For our first hour we have, from the Canadian Nurses Association, Meaghan Thumath, Senior Public Health Nursing Expert; and Lisa Ashley, Senior Nurse Advisor, Policy, Advocacy and Strategy Branch.

From the City of Vancouver, we have Councillor Kerry Jang.

And from the Province of British Columbia, we have Dr. Perry Kendall, Provincial Health Officer; and Clayton Pecknold, Assistant Deputy Minister and Director of Police Services, who are both joining us via video conference from Victoria.

Thank you all for being with us today.

I'll start with opening statements from our witnesses in the room, beginning with Ms. Ashley, and then we'll move to Mr. Jang and our witnesses from British Columbia.

Ms. Ashley, the floor is yours.

Lisa Ashley, Senior Nurse Advisor, Policy, Advocacy and Strategy, Canadian Nurses Association: Good afternoon, honourable chair and members of the committee. I'm a registered nurse and I work at the Canadian Nurses Association. It's the national professional voice representing more than 139,000 registered nurses and nurse practitioners across the country.

I'm pleased to be here today with Meaghan Thumath, from the B.C. Centre for Disease Control. She will be able to answer questions that are more technical in nature.

At the outset, I'm pleased to inform the committee that the CNA is supportive of this important bill, particularly sections whereby it has removed many of the 26 procedural barriers for opening a supervised consumption site. Registered nurses and nurse practitioners know the impact of problematic substance use. We see it in our communities, in our clinics and in our emergency departments. Public health nurses have been integral in pioneering Canada's supervised consumption sites, evidence-informed programs that improve access to care, improve health outcomes, reduce overdose deaths, without increasing substance use rates, community disorder or crime.

I will now turn to our suggestions, which include straightforward amendments to the bill for the committee's consideration. They are also outlined in our brief, which has been submitted to the committee.

First, there is a need to remove additional procedural barriers to opening supervised consumption sites. While the current version of the bill removes legislative barriers to opening supervised consumption sites, amendments are needed to provide a more immediate response to overdose epidemics. We recognize that the proposed legislation reduces the exemption criteria from 26 to 5, a change that decreases barriers to obtaining an exemption to operate a supervised consumption site. However, the application process will still require significant time and resources on the part of medical officers of health, health care providers, community organizers and individuals whose time and resources are already stretched and better applied to providing services to those who need them.

This added step leaves health service providers with two unreasonable options: either delay the provision of life- saving services while an application is under way, or proceed without the exemption and face possible criminal charges.

The CNA puts forward two recommendations to address these procedural barriers.

Recommendation 1: To be more responsive during developing situations such as the current opioid crisis, the CNA recommends that Bill C-37 be amended to include a provision that would allow provincial or territorial ministers to grant temporary exemptions to supervised consumption sites.

Recommendation 2: Our position is that of the five proposed requirements, the sole criterion that needs to be considered is 56.1(2)(b), "the local conditions indicating a need for the site.'' This proposal aligns with the federal government's recent commitment to treating drug use as a public health issue rather than a criminal justice issue. It also reinforces the role of harm reduction as a key component of Canada's new federal drug strategy.

The CNA believes that if 56.1(2)(b) — "the local conditions indicating a need for a site'' — is met, the minister may then consider whether the regulatory structure, under 56.1(2)(c), and resources, under 56.1(2)(d), are in place to support the site. Still, an absence of regulatory and resource requirements should not invalidate the application. Rather, it should only serve to indicate the community's potential need for support in meeting them and assisting in government planning.

Further, it is CNA's position that 56.1(2)(a), "the impact of the site on crime rates,'' and 56.1(2)(e), "expressions of community support or opposition,'' should also be removed. Such requirements are not supported by evidence and, as such, would be contradictory to the federal government's intention under the New Canadian Drugs and Substances Strategy that drug policy decisions be rooted in a strong evidence base.

The CNA recommends the amendment of existing exemption requirements under section 56.1(2) by offering the following proposed wording:

An application for an exemption under subsection (1) shall include evidence, submitted in the form and manner determined by the Minister, of the local conditions indicating a need for the site.

Before closing, I must emphasize that the CNA is a strong advocate of harm reduction, which we view as an essential part of a comprehensive health care response that complements abstinence, prevention and treatment strategies.

I thank the committee for providing the Canadian Nurses Association with the opportunity to speak on behalf of registered nurses and nurse practitioners. We have a professional responsibility to advocate for improved access to life- saving services that are based on current evidence and research on behalf of all people of Canada.

Thank you.

The Chair: Thank you.

Mr. Jang, the floor is yours.

Kerry Jang, City Councillor, City of Vancouver: Thank you very much. Good afternoon, Mr. Chair and honourable committee members. I'd like to thank the committee for inviting the City of Vancouver to speak about Bill C-37 from the municipal government perspective. My name is Dr. Kerry Jang, and I'm a Vancouver city councillor and a professor of psychiatry at the University of British Columbia.

I'll be blunt. Throughout my long career in municipal government and mental health addictions research, I have never witnessed a public health emergency of the magnitude of what we're seeing in Vancouver today. Just to give you some statistics, so far in 2017, our staff estimate, based on data from the Vancouver Police Department and B.C. coroner reports, have shown that there have been over 100 overdose deaths in the City of Vancouver. It represents an average of more than one death per day in our city alone. If this pace continues, we will see more than 400 deaths in Vancouver by the end of this year.

The financial and human resource costs associated with the current measures are not sustainable. Throughout the first quarter of 2017, Vancouver Fire and Rescue Services have attended 1,716 overdose calls. In 2016, they attended 4,709.

The magnitude of this problem is so huge that we had to actually increase our municipal property tax by 0.5 per cent in order to fund additional resources, and that was not popular.

However, we do know from our colleagues at InSite and other overdose prevention sites that they are absolutely necessary in intervening in this overdose crisis. Without these critical programs in place, we would be in a much worse situation. In fact, our staff is now noting that the number of deaths occurring outside the downtown core, in areas that do not have a supervised injection site, are actually increasing.

Supervised injection sites, or consumption sites, offer the critical opportunity for intervention in the case of overdoses. Rigorous evaluations of InSite, for example, show that the facility has significantly reduced HIV risk behaviour, such as needle sharing. It also is an important point of contact for users to get referrals for treatment and primary care.

I'm very encouraged that Bill C-37 reframes the issue of substance use within a public health framework. However, at the City of Vancouver, we feel that too much emphasis still has been put on enforcement, leaving harm reduction, treatment and prevention grossly under-resourced and neglected in federal and provincial policies. As such, the City of Vancouver is concerned that Bill C-37 places unwarranted concern that new facilities having an impact on local crime.

Quite simply, the research has not borne that out. In fact, supervised injection facilities have been shown to actually benefit community safety. We see, for example, the number of needles around InSite and other overdose prevention sites actually drop. We see from our police data and other empirical research data that it does not increase crime, it actually reduces open drug use and it does not increase break and entering.

I'd like to point out to you how important it is to get these sites open as quickly as possible. By having so many criteria in place, it will take time. I have to repeat that we're on track for 400 deaths this year, and over 100 people have already died in Vancouver, so the time that we all spend debating something small probably means somebody else has died. That's just not acceptable — not from a health care perspective and not from a civil society perspective.

As such, we recommend that the criteria be reduced, as my colleagues from the Canadian Nurses Association pointed out, to require only a demonstration of the needs on the grounds of public health.

We are also concerned that the CDSA does not allow for flexibility for quick implementation of supervised consumption services under exceptional circumstances. For example, despite our having submitted two applications in October 2016, two new sites in the City of Vancouver have yet to receive approval. Without access to these services, the City of Vancouver is on track for 400 deaths this year.

I'm sorry. It's a very emotional issue for us in Vancouver. I'm finding it very difficult to speak, because we see death after death. In my job at UBC, the morgue is full. We simply cannot get any more bodies in, sometimes. It's absolutely terrible.

We also recommend, at the City of Vancouver, giving provincial ministers or their health officers the ability to grant temporary exemptions. This will allow for faster implementation and it does not take away from the federal exemption process, which is still required for any service that wishes to operate on a long-term or non-temporary basis.

Thank you.

The Chair: Thank you.

We'll move on to Dr. Kendall and Mr. Pecknold.

Dr. Perry Kendall, Provincial Health Officer, Province of British Columbia: Thank you, and good afternoon. Beside me is Mr. Clayton Pecknold, Assistant Deputy Minister and Director of Police Services for the B.C. Ministry of Public Safety and the Solicitor General. I thank you for the opportunity to comment on Bill C-37.

Together, Mr. Pecknold and I co-chaired a joint task force on opioid overdose and response in B.C. In April 2016, after watching overdose deaths increase year after year since 2010, I declared, with ministerial support, a public health emergency in British Columbia. The joint task force was formed by Premier Christy Clark in July 2016. This is a partnership between the ministries of Public Safety and Health, with representation from the coroner's office, regional and provincial health services, the RCMP and municipal policing. Our mandate is simply to coordinate responses to mitigate the overdose crisis and to make recommendations on actions that need to be taken.

We thank you for the opportunity to speak to and to support Bill C-37, An Act to amend the Controlled Drugs and Substances Act, and to make related amendments to other Acts.

B.C., as you know, has been seeing an unprecedented epidemic of overdose fatalities from illegal opioids driven, we believe, by synthetics like fentanyl and, more recently, carfentanil, which have flooded our illegal drug markets.

Our response has been multi-faceted: to address stigma, prevent overdose, reverse overdose, offer treatment and enhance interdiction efforts. Despite this, however, 922 individuals died from illegal opioids in 2016.

Significantly, in all the millions of injections at InSite since it opened in 2003, we have never had a fatal overdose at that site, nor have we ever had a fatal overdose at any of the 20 or more overdose fatality prevention sites that opened up in early December under an emergency order from our health minister, the Honourable Terry Lake.

It actually pains me to think that had the conditions of Bill C-37 been in place years ago, we in B.C. would have had more consumption sites and would have been better prepared to respond to this onslaught. As an individual who has advocated for a repeal of the Respect for Communities Act because of the unnecessary barriers it imposed, I respectfully ask this august body to pass this bill.

Supervised consumption sites do save lives, prevent the spread of communicable diseases, reduce public disorder and, perhaps most importantly, they initiate care and refer individuals with mental health and substance use disorders into community-based systems of care.

As co-chairs of B.C.'s joint task force on opioid overdose, we recognize the critical roles that public safety and public health play together in anticipating and responding to a crisis like this.

I'll now hand the microphone over to Mr. Pecknold.

Clayton Pecknold, Assistant Deputy Minister and Director of Police Services, Province of British Columbia: Thank you, Dr. Kendall.

Thank you to this committee for the opportunity to speak on the bill. As my colleague and other speakers have mentioned, we're facing an unprecedented number of deaths in British Columbia related to illicit drug use and, in particular, related to fentanyl, carfentanil and other derivatives.

B.C. has taken measures to enhance its public safety response in the face of this crisis, including rapidly responding access to naloxone across the province to the public and to first responders, including the police and operators of overdose prevention sites.

B.C. recognizes the commendable work undertaken by the Canada Border Services Agency in our region and their cooperation to support and curtail the importation of fentanyl and carfentanil into our country.

However, while enforcement has a role in meeting this crisis by strengthening the public safety response to the production and trafficking of existing and emerging controlled substances, the answer, in my view, requires a coordinated national effort of health, social services and public safety agencies.

B.C.'s joint task force has undertaken 41 actions of its 71-point response. These include a collaborative, multi- agency campaign to raise awareness and provide education about the dangers of fentanyl, being drug smart and how to minimize deaths and injury from this behaviour, purchase of drug equipment such as ion scanners, and training for the federally funded Clandestine Laboratory and Enforcement Response Team as well as our key municipal departments. We've also provided funding for dedicated enforcement to the Royal Canadian Mounted Police, who act as our provincial police force, including our organized crime unit within the province, to target high-level organized crime traffickers. I emphasize that that's the purpose of this funding, to target high-level and organized crime traffickers.

However, there are some actions which are outside the control of the province.

The Chair: Mr. Pecknold, I'm afraid I have to jump in. We have to move to questions. We have a very engaged committee who wish to ask a number of questions. We'll begin with Senator McIntyre.

Senator McIntyre: Thank you all for your presentations. My first question is to the Canadian Nurses Association.

I note that in both your written and oral presentations, you made two recommendations, one of which calls for empowering provincial and territorial ministers to grant temporary exemptions to supervised consumption sites. Have you had an opportunity to discuss this recommendation with either the federal Minister of Health directly or with her provincial counterparts?

Ms. Ashley: No, we have not. However, we have been working with the providers who are working with those federal and provincial ministers in order to ensure this is the direction that would help to ensure that we are responding to public health crises as they occur.

Meaghan Thumath, Senior Public Health Nursing Expert, Canadian Nurses Association: As a registered nurse who has worked at both InSite and some of the overdose prevention sites that Dr. Kendall mentioned, I would add that some of these were scaled up within 24 hours. As someone who works on the front lines of the Downtown Eastside, I can tell you it's critical that we're able to respond and have supervised consumption sites available and targeted in hot spots where we know we've had many deaths. This flexibility in working with our provincial Minister of Health has been absolutely crucial and saved many lives.

Senator McIntyre: Last July, the federal Minister of Health signed an interim order allowing naloxone, which can either stop or reverse the effects of an overdose. I understand it's now available in Canada in a nasal spray form on a temporary basis, and prior to this interim order, it was only allowed by way of injection. Has this new measure been effective in either stopping or reversing the effects of an overdose?

Ms. Thumath: Absolutely. The injectable formulation is critical for non-medical first responders who don't typically have training in terms of giving injections. It's been extremely helpful, although I would say the cost is still quite prohibitive to scale it up everywhere. So at sites where we have folks who are able to give injections, we continue to use the injectable naloxone, but both measures have been absolutely life-saving.

Mr. Jang: It has saved lives. One of the side effects of naloxone is it does precipitate withdrawal in high doses. What we're seeing in Vancouver is the fact that people, as soon as they're revived, are back out on the street looking for the next hit. That's probably because there's a lack of wraparound mental health supports to help people stay in treatment once they get there.

Senator Jaffer: Thank you all for your presentations and the work you do. Coming from B.C., I see first-hand the great work you do.

Councillor Jang, it's always a pleasure to see you. Welcome here.

We see a death a day in Vancouver. I pass by the area, especially East Hastings, near where I live. We see a real crisis. What you just said upset me. I didn't know that in 2016 you applied for two sites and you're still waiting for an answer. Did I understand?

Mr. Jang: That's correct.

Senator Jaffer: In 2016.

Mr. Jang: That's correct. The mayor was told in discussions with the health minister that in December we would have those safe injection sites able to operate. The City of Vancouver helped prepare the sites, did the permitting, fast tracked it, and here we are in April.

Senator Jaffer: And you live at the moment by the 2016 regulations that they wanted in the law?

Mr. Jang: That's correct.

Senator Jaffer: You speak about having that one criterion so that you can get sites open faster. May I ask how soon you think a site can open?

The chair will cut me off because I have many questions.

I go to InSite a lot. I know what InSite offers. First of all, it keeps our neighbourhood clean, with no needles. The other thing that's useful for my colleagues to know is they come for a safe injection on the bottom floor, but there are many other things that are upstairs. It would be effective just to know it's not just a safe injection site; it's other things as well.

Mr. Jang: Yes, that's correct. Some of the sites we're able to open up and put in in 24 hours.

Another sites, as the one you're referencing, that InSite has on site, which is upstairs, is a treatment program that could also be put into buildings. Many of these sites are in city buildings or on city land. We're able to turn those permits around in no time flat because we recognize how important they are to our city.

The Chair: I want to give Dr. Kendall an opportunity. It's tough when you're on video conferencing sometimes. I know you wanted to respond to the previous question from Senator McIntyre.

Dr. Kendall: Thank you, senator. Yes, I was going to say that naloxone has been very beneficial for the RCMP and municipal police forces, because they do not wish to carry needles. We recently had a report where they have used it on numerous occasions on the public and reversed a number of overdoses. They had very little trouble with people coming up and being in withdrawal, and they found it very satisfying. It also greatly increased their interaction with the people on the street with whom they don't normally have such a socially positive role.


Senator Boisvenu: I want to thank you for your very informative testimony and congratulate you on the work you are doing. I recognize that those are not easy environments.

The majority of Canadians — at least those I talk to — are very opposed to the opening of consumption centres in their neighbourhoods. There are two conflicting philosophies involved: detox and continued consumption.

The bill seems very weak to me in terms of consultation with Canadians. The time set aside for studying this bill was very short, and very few people were consulted. As a result, I believe that it will increase Canadians' reluctance toward those centres.

I worked for the Government of Quebec for a long time, in environment, and we had to work on some very contradictory projects. We would organize watchdog committees to inform the people living in the affected neighbourhood with greater transparency.

In this case, people could be told about the crime rate, for example, as well as the type of clients that use those centres, and that may reassure them. Do you think the bill should provide for this kind of a formality?


Mr. Jang: From the perspective of the City of Vancouver, we do that with our social housing units, with safe injections sites. We have community advisory committees and we do find in our experience, if it's well run, that the committee is not interested anymore because it has become part of the neighbourhood.

I will add that when people worry about consultation, these safe injection sites actually serve people in the neighbourhood. These are addicts and users in a particular neighbourhood, so they are serving the local community. There is some opposition, but generally, in Vancouver, we have found people understand the need and we have not had too much difficulty.


Senator Boisvenu: So you would be favourable to us ensuring that this type of official communication structure between Canadians and the centre's management be enshrined in the bill.


Ms. Ashley: From the perspective of the Canadian Nurses Association, our response is that when you're looking at any municipality, they have a number of community consultations that are already set up within bylaws for any new services that go in. If you're looking at it from a public health perspective, this is no different from setting up a diabetes clinic in a community. The community is consulted and there are services in place for that.

Mr. Jang: It is part of our municipal charter.

Dr. Kendall: In B.C. we have already submitted or are in the process of submitting some six or seven exemption requests, each one of which has been done in consultation with a community, business associations and councils. We have that support to move ahead. People are concerned, of course, but the process has moved ahead, and we have those supports from councils, local police, business improvement associations, et cetera. We don't think adding a requirement of that nature is necessary in practice because we are actually doing it.

Senator Boniface: Thank you very much for being here and congratulations on the effort. I can't imagine how difficult it must be, but I appreciate you all taking the time to be here.

I want to talk about the impact of the site on crime rates as one of the criteria. Both Ms. Ashley and Councillor Jang questioned whether this is a valuable criteria. In Dr. Kendall's comments, he said that it actually reduced social disorder. I would like to have feedback on that because, as you can appreciate, that's one of the issues people are most concerned about.

Ms. Ashley: Thank you very much for your question, senator.

Yes, evidence has shown — and we'd be happy to share it with the committee — that crime rates are reduced. People are starting to get the social and health supports they need. There is evidence to show that crime rates do not go up.

Mr. Jang: We see this in the Vancouver Police data. We track this on a weekly, monthly basis, and we have not seen increases. As I pointed out, things like break and enters and those types of crimes have actually been reduced.

Dr. Kendall: I would add that the data from InSite is quite clear. People who become attached to InSite are more likely to enter addictions treatment programs than people who are not attached to InSite. In the longer run, we would anticipate that reducing the pool of people with persistent disorders would reduce the crimes as people move through into treatment.

Senator Batters: Thank you so much for being here today.

To the Canadian Nurses Association, Ms. Ashley, maybe I missed something in what you were saying, but I think you were indicating that you find this safe drug injection site to be no different from a diabetes clinic. I find that comment quite shocking. You stated in your brief that the only criterion that should be required for approval of a drug consumption site is for the applicant to demonstrate the need for an SCS, which is a safe consumption site. Could you explain why you don't think it's necessary to consider the impact of the site on public safety and security when considering the site application? What about the concerns from the local government, police and community?

Ms. Ashley: Thank you for that question. There are two parts to your question so I have two parts to the answer.

We know that crime rates do not increase, so public safety is actually not a concern. This goes down.

I did compare it to a diabetes clinic; you are looking at public health intervention. People are then able to get health and social service referrals and to go to treatment and detox centres. They may move to abstinence. They get housing. From a health perspective, this is the same as offering any other situation. While people may be having supervised injections, they have that support of health providers near them who are able to improve their health and wellness.

Senator Batters: So the second part of my question was that you don't think it is necessary to consider police concerns, public concerns and local government concerns.

Ms. Ashley: Well, no, we do. We said that the municipal bylaws already have those sanctions in place where people can consult.

Senator Batters: That is potentially leaving it. It could alter from place to place. Some places might have strict municipal bylaws and others might have very lenient ones.

In our previous Conservative government's legislation, there were 26 different criteria. You are proposing that it basically be limited to one. Do you think that municipal bylaws alone are sufficient to take all of those into account?

Ms. Ashley: I will answer and then move it over to Meaghan because she can give you a real life experience.

Certainly we know from evidence that that is not the case. You do see a reduction in crime, and there are consultations. I can't speak to the municipalities and what they do.

Ms. Thumath: Thank you very much for the question, senator. I think with respect to the previous Respect for Communities Act, we found that was too restrictive and there were no new supervised consumption facilities opened under that act.

It took binders for our particular program. I think we spent six months preparing an application, and that is policy- makers, registered nurses like myself, physicians' time, lawyers and others. It was an incredible expense to prepare an application while we were having 922 British Columbians — my friends, my colleagues and my patients — die.

We are here before you to say this is an urgent public health crisis. We are here in support of Bill C-37, and we need to trust municipalities and provincial governments. We have asked for local conditions indicating the need for the site, and those include community support and the demonstrated public health need. We are asking for the bill to be something that is simple and easy so that we can create these life-saving public health interventions.


Senator Dupuis: My first question is for Mr. Jang. The opioid crisis is a matter of public health. From your perspective as a medical doctor, can you tell us what in that crisis you feel has to do with public health? Is there consensus among various Canadian provinces on what constitutes a public health issue?

What I'm trying to understand here is the idea of a public health issue. I want to specify that I am not at all against that — I agree that this is a public health issue — but how do you define it as such?


Mr. Jang: Thank you for the question, senator. When people are dying — and we are seeing thousands die — that's a public health crisis. When you know that the problem is that people are taking drugs, they are addicted and they are trying to get into recovery and you have nowhere for them to get help, that constitutes part of what I consider the continuum of care.

The safe injection sites and consumption sites are an integral part of the continuum of care. As you heard earlier, it's the place where people adopt that. Crime rates drop because it's part of their community, and they see it as their hope. Getting them into health care for their referrals is key.

The second part we are talking about in British Columbia is opioid substitute treatments. It's not just methadone and Suboxone, but things like hydromorphone and others, in order to clean up the local drug supply and help to keep these people in treatment. That's part the continuum, but when we have over 1,000 deaths in one province, 300 in Vancouver alone, that is a health crisis.


Senator Dupuis: I have another question. I would like to read a quote from Patricia Daly, Chief Medical Health Officer of Vancouver Coastal Health. She says that public health officials in British Columbia asked for the regulation of illegal psychoactive substances, and I quote:

Most public health physicians believe that the best way to decrease the harms associated with any psychoactive substance — whether it's illegal drugs like heroin, cocaine, marijuana or alcohol, tobacco, or even prescription drugs. . .

The public health issue that should be of concern to us encompasses the entire continuum, as any consumption of psychoactive substances causes a problem, be it because those substances are prescribed by a physician who "overprescribes'', or because they are imported through organized crime and consumed on my street.


Mr. Jang: Thank you for the question. You are absolutely correct. All consumption of psychoactive substances is a public health issue, whether prescribed by a doctor or when somebody picks it up off the street and experiments with it. You are right on.

Part of the response from the province has been not only to look at the immediate problems on our streets with safe injection sites but to create better physician training.

One of my jobs at the University of B.C. is to train medical students, and this is exactly what we're engaged in right now: teaching them how to prescribe, how to follow up, use PharmaNet and do all the things they need to do to make the right choices for their patients and to follow up to make sure there is no abuse.


Senator Dagenais: I would like to say one last thing about Mr. Pecknold's comments. I went to Vancouver a few years ago with Mr. Stamatakis, a Vancouver police officer you may know. I visited the Insite centre. Mr. Stamatakis told me that police officers did not patrol around Insite, as it attracts a lot of drug users and the area is dangerous.

That said, Dr. Kendall — I know that you have more experience in Vancouver than in other Canadian cities — I would like to know how much new funding for health care was dedicated to the Insite centre in your province. Do you think that the money set aside for Insite would have been better invested across British Columbia? Do you think that, by investing across British Columbia, the money may have been distributed better to help drug consumers and thereby obtain better or similar results?


Dr. Kendall: I'll answer that question first, if I might. We would indeed have liked to have seen more supervised consumption sites opened across British Columbia, but up until recently that would have been practically impossible because of the policies of the previous government.

However, the operating costs of InSite are, I think, approximately between $1.5 and $2 million a year. They cost a fraction of the money that is spent in Vancouver Coastal Health on prevention and treatment, and had you spread them across the province, it would not have had a measurable difference as InSite did actually have on the population it is serving.

Mr. Pecknold: To answer your first comment, senator, the response to this crisis has involved a considerable amount of structured conversation and coordination with the police in British Columbia, the RCMP and the Chief Constable of the Vancouver Police Department. I can tell you that there is broad support for supervised consumption sites, properly consulted with local governments in terms of creating them. We have a very coordinated and collaborative approach with the health authorities in terms of addressing all the concerns that may or may not arise in a particular community. I can tell you that from the words of the chief of the Vancouver police, they support the work of InSite and they support the work of supervised consumption sites.


Senator Dagenais: Can you tell me whether police officers patrol the area around Insite or refuse to go there because it is dangerous?


Mr. Pecknold: I can't confirm one way or the other what the Vancouver police are doing day to day, senator, but I certainly respect the views of Mr. Stamatakis and he has been part of our conversations as well.

Mr. Jang: Mr. Stamatakis is head of the Vancouver Police Union. I know him very well, as well as the chief constable.

The reasons why the VPD don't spend time at InSite are, first, because they don't need to because it is well-policed by itself, and secondly, the police presence scares away addicts seeking treatment. That's why they deliberately stay away or take a soft approach in order to encourage people to go into treatment.

Senator Joyal: Dr. Kendall, you mentioned in an answer earlier on that the way to convince or to lead a person who has a drug addiction and is a "customer'' of InSite — if that word can be used in that context — would be to be more open to accepting treatment. It would, in other words, mitigate the statement or the opinion expressed by my colleague Senator Boisvenu that InSite does not address the problems of rehabilitation; it just maintains people in their consumption of drugs.

You mentioned that studies have been conducted that led you to that conclusion. Could you expand a little more? Were those studies checked and recognized as scientifically based? Or were they preliminary or first evaluations but not really conclusions that would withstand scientific scrutiny?

Dr. Kendall: The study I was citing was conducted by the B.C. Centre for Excellence in HIV/AIDS and their Urban Health Research Initiative. They looked at people who were using InSite on a regular basis compared with an equal number of drug users who were not using InSite. They followed them over a period of time and looked at how many of them were actually referred to and entered into an addictions treatment program.

InSite, as you perhaps know, has a couple of floors above it called OnSite, where people can go for withdrawal management, can be inducted into treatment and then referred to treatment programs.

These data showed that the people who were attending InSite were about 30 per cent more likely to enter a treatment facility than people who were not attending InSite, largely, I think, because these are marginalized populations who are not engaged in care. Once they become engaged in care and can sort their lives out a bit, they are more likely to accept an offer into treatment to get out of their addiction or to move into a maintenance program with Suboxone or methadone.

This study was published in one the leading journals, but I forget whether it was the Canadian Medical Association Journal, the Journal of the American Medical Association or The Lancet. It was one of 30 or 40 studies that were peer- reviewed and published in the world's leading journals.

Senator Joyal: Ms. Ashley, did you want to add to this?

Ms. Ashley: Certainly.

Yes, there have been systematic literature reviews that have pulled information from across the world, globally, that have been peer-reviewed. There has also been research as well in The Lancet. For InSite specifically, it has demonstrated increased clinic visits, overdose interventions, referrals made to social and health service agencies, the vast majority for detoxification and addiction treatment. The latest I read about the completion rate at OnSite was 54 per cent, I believe, so it's quite high.

Ms. Thumath: I have the paper by Dr. Wood and several colleagues, so we'll follow up and make sure we get that to the committee.

I can say as a registered nurse who has worked at InSite, there is a common misconception that after someone overdoses we just leave them and send them back out on the street, but in fact I can assure you that we meet with them. We have a clinical room there where we provide full-scope primary care. We have HIV testing, and we make a huge effort to connect that person to care and treatment. A big part of my role is actually accompanying them to detox facilities and even to long-term treatment referrals. We have a staff dedicated to ongoing treatment referral. It's certainly a huge part of our role and of the continuum of registered nurses.

Senator Joyal: What's the percentage of Aboriginal people that might come to your service?

Ms. Thumath: It's quite high, definitely overrepresented, and much larger than the typical British Columbia population. I believe it's in the 60 to 70 per cent range, in the neighbourhood. I don't know if someone wants to correct me. We can follow up.

Senator White: Thanks to all of you for being here. I apologize for being late. My question is about the illegality of the drug being used.

Presently, organized crime is involved in the production or distribution. Drug dealers sell it to addicts on the street, near a safe or supervised consumption site. I was at the facility a couple of weeks ago for a few of days. The challenge, of course, is that we then have people in need of health care using a non-pharmaceutical in a facility.

I know you talked about looking at this. Doctors today could provide opioids at every single health centre in British Columbia if they choose to, and, for the assistant deputy minister: I think they should. In fact, my argument would be they should be offering stimulants as well. We don't need a supervised consumption site to do this. We have six supervised consumption sites in the City of Ottawa for opioids now called methadone clinics. If doctors chose to, they could provide anything they wish in a continuum of care.

Why isn't that happening instead of propagating illegal activity? I'm talking about drug dealers and manufacturers, because that's the problem with this discussion, I think.

Mr. Jang: Thank you for the question. From my perspective, as somebody who teaches at UBC's medical school, it's about some of its physician training.

I know that Dr. Kendall recently released his report looking at the number of physicians who were actually adopting training and getting the appropriate training in order to do exactly as you wish, and the number is modestly increasing. It's really a training issue to some extent.

For us, it's more centred on the patient. The patient is going through withdrawal, and it is painful, so they will do anything and take anything they possibly can, legal or illegal, to alleviate that. That's the other issue that's not talked about here. It's legal or illegal. From the patient's perspective, it's "I have to feel better.''

Senator White: I could let everyone answer and I'm sure the answer won't be much different.

Right now, $4.7 million a month goes into East Hastings in social assistance, and probably half goes to drug dealers. I've seen photos of the lineup of people getting their money from the ATM and handing it to drug dealers, and now they owe for the next month as they continue down this path.

If training is about money, we're already wasting money. We should be focusing on developing a Swiss model and going beyond opioids, because opioids is the thin edge. We know it's also about stimulants. Most people here won't agree with me. I'm at the point now where, honestly, it seems like we're propagating illegal activity, organized crime, drug dealers, and hoping to keep people alive long enough for one more day.

We have a solution for this. The Swiss model has been there for two decades, and nobody is saying, "Let's do that.'' We don't need a supervised consumption site to do that, doctor.

My perspective is that we have to stop playing this game of looking for a soft path to success and take the hard path. That's what you should be here selling us on.

It's like "Jeopardy,'' so I have to put it into a question: Don't you agree?

Mr. Jang: I absolutely, 100 per cent agree with you. In fact, a mayor of Vancouver has asked for that consistently, substitution treatment like the Swiss model, like Portugal. You were at the conference I was just at, and we heard very clearly: Legalize it all and manage it well. We're doing that with cannabis. I completely agree with you. That's the model we need.

Unfortunately, we're seeing a cautious approach by the Ministry of Health sometimes in B.C. for whatever reasons. I won't criticize them. We've used methadone and Suboxone. What about hydromorphone and the other ones? That's exactly what we've been asking for.

Senator White: So that amendment will come forward. I appreciate that, councillor.

Senator Pate: This is not exactly along those lines, but picking up on some of that in terms of arguing for a more comprehensive approach, have you looked at some of the approaches given that you've linked it already to crime rates? I appreciate your response to colleagues.

Have you also looked at the long-term human, social and fiscal cost of the approaches being taken now, including how much more could be saved in terms of human life, social cost and fiscal cost if in fact you took a more radical, progressive approach?

Mr. Jang: Certainly from my perspective, yes. We're starting to collect that data.

Currently, we see the European Drug Report released in 2016. We saw countries like Estonia, which had no treatment or anything at all. We have huge rates in Vancouver, whereas in Switzerland and Germany and other places, there is a comprehensive system. Some of my colleagues in Switzerland are reporting rates of people staying in treatment up to 80 per cent because they have a good wraparound service. That's where we need to go. You're absolutely right.

Data sharing is an issue. I don't think anywhere across this country there is as much data sharing currently as there is now between the City of Vancouver, British Columbia Ministry of Health, BC Housing, all trying to get at this question. But we don't have anywhere in this country an early warning system where there's regular testing of anything we get. For example, when somebody dies, we need a full report on why a person died, not just the toxicology but whether they had been in treatment before. What other treatment had they been in before? We need to actually see where people are falling down in our system, and we just don't have that yet. But I completely agree with you.

Ms. Thumath: Thank you for the question. We've been speaking about supervised consumption and its role in preventing overdose, but another area is hepatitis C and HIV. We know that each HIV injection costs between $200,000 and $300,000 per person for their lifetime. That's certainly something that was pointed out in the InSite evidence, that we've been able to avert HIV and hepatitis C infections.

I would point you to the evidence around the Crosstown Clinic, which we'd be happy to provide. It was previously known as the NAOMI and the SALOME trial, so that might get at the senator's comment around prescription heroin.

Senator Omidvar: Thank you all for joining us.

I want to ask Dr. Kerry Jang a question about cooperation and collaboration across the country with local departments of health on this matter. We've heard you talk a lot about the federal government, about provincial governments, but I know these services are administered locally and there is variation from locality to locality.

Can you describe how you work with the City of Toronto, the City of Ottawa and other jurisdictions to keep each other abreast on things that work and things that may not work?

Mr. Jang: Thank you very much for the question. We have extensive staff contacts with our colleagues around the country. Vancouver Coastal Health is our main contact, and they have staff that also talk to other jurisdictions. We get regular calls from city councillors, mayors, provincial health officers and from across the country asking what's happening. We even had New York City recently reach out to us because they're experiencing fentanyl now. Some of the plans they have adopted are right out of the experiences of Vancouver.

The big city mayors have also created a caucus at the Canadian Federation of Municipalities, and they're calling for exactly what Senator White was talking about, looking at those types of things.

You're going to hear a unified voice from across the country, I think, within the next month. I know they're working on that now.

Senator Jaffer: Dr. Kendall, this bill requires consultation, and I'm wondering how much consultation you had with the federal government to produce this bill. What is your consultation like on an ongoing basis with the federal government on this very difficult issue?

Dr. Kendall: The health minister and I wrote separately, along with numbers of other people, to the Honourable Jane Philpott, asking that Bill C-2 be either repealed or substantially changed to facilitate the process of requesting an exemption from the Controlled Drugs and Substances Act. There was a fair amount of consultation there.

In British Columbia, it depends on the region. It was very simple. There was not very much consultation required to get a number of other exemptions within the City of Vancouver, because people were accustomed to that. In Victoria, the city had been talking about this for years, so the amount of consultation that was required there had actually been happening over the last five years. In other areas of British Columbia, because some regions were not so socialized to the idea, the consultations were longer and a little more complex. It really does vary on the nature of the community that you're working in.

Senator Boniface: My question is for Dr. Kendall.

The sponsor of our bill, Senator Campbell, mentioned earlier this week concern for smaller communities, smaller cities. We've heard a lot about Vancouver and I think many of us are familiar with it, but I'm interested in what you're seeing in other parts of British Columbia in terms of the problem and how you see this bill being part of the solution.

Dr. Kendall: Looking at our overdose fatality numbers, they are basically the same, and high in every region of British Columbia. No region of B.C. has been spared from this issue.

We have tended to focus on those areas where the numbers are sufficiently high that you would actually have a client population coming in. Most of the sites that are proposed would be built in existing clinics that already are serving people who have these problems or HIV, hepatitis C, homelessness or street-oriented people.

We are one of only two places in Canada that is also proposing a mobile supervised consumption site, which can travel between more isolated communities and serve the people where they are.


Senator Boisvenu: You talked about evaluation programs. Are the evaluations conducted internally or by a company or organization that is not involved in the project?


Ms. Thumath: It's external academics that are subject to ethical review. They publish in peer-reviewed scientific journals, which are reviewed by external peers from other countries.


Senator Boisvenu: So it's not an external organization. We are talking about students or people —


Ms. Thumath: It's not internal; it's external. There are several colleagues around the world who participated in the research. It's external. I'm happy to share the research summary.

Senator White: Dr. Jang, would you recommend that we bring forward an amendment stating that first and foremost people must be offered replacement drugs if they enter a supervised consumption site?

Mr. Jang: Offered, yes.


Senator Dupuis: Did your consultations with other Canadian cities or other provincial departments give you the impression that people agree with the way you are evaluating the problem on a continuum? In other words, is Vancouver, or British Columbia, at the forefront of addressing this public health crisis? Do you feel that your concerns are shared by people from other provinces and other Canadian cities?


Mr. Jang: I wouldn't consider Vancouver's approach avant-garde. It's simply good public health. My colleagues in Calgary had over 100 deaths last year, and New York City is adopting what we're doing. It's plain, simple, good public health policy.

The Chair: Thank you, witnesses, for being here today. It's very helpful for the committee in their deliberations.

Joining us for our second hour, from the Canadian Drug Policy Coalition, Donald MacPherson, Executive Director of that organization; and from the British Columbia Centre on Substance Use, Kenneth Tupper, Director of Implementation and Partnerships, who is joining us via video conference from Vancouver.

If you're looking at your agenda, you'll notice one of our witnesses has yet to arrive. If he does arrive during our deliberations, I'll introduce him at that time.

Thank you for being with us. Mr. MacPherson, perhaps I can ask you to begin with opening statements, sir.

Donald MacPherson, Executive Director, Canadian Drug Policy Coalition: I appreciate it. You have my brief and I've prepared a short opening statement.

In the midst of Canada's worst drug overdose crisis in our history, the Canadian Drug Policy Coalition, representing over 70 organizations advocating for evidence-based drug policies, welcomes the government's introduction of Bill C-37. We agree with and support in whole the submissions and recommendations that you have, made by our colleagues at the Canadian HIV/AIDS Legal Network, the Pivot Legal Aid Society and the Canadian Nurses Association, that call for amendments to the bill that would empower provincial health officers to respond quickly and issue exemptions under the act and also further reduce the criteria needed for application for an exemption.

Drug use and drug addiction are both public health concerns first and foremost. Globally, despite a monumental effort and an estimated $100 billion per year for tackling drug use, the number of adults using drugs increased almost 20 per cent between 2006 and 2013, to roughly 246 million. Clearly, harsh and prohibitive criminal laws are not deterrents to drug use.

The Canadian Drug Policy Coalition supports drug policies based on evidence. We know with certainty that the current overdose crisis is primarily a result of the consumption of adulterated street drugs of unknown quality and potency. The increase of both fentanyl and carfentanil in samples of heroin purchased on the streets was a death sentence to hundreds of people within Canada this past year.

There is a strong and persuasive case to be made for legal regulation of all drugs. Canada is already a global pioneer in committing to regulate cannabis by summer 2018. This is a significant change in direction and is well-supported by evidence.

However, the relative safety of cannabis compared to other drugs does not make the case that cannabis should be an exception but, rather, highlights the necessity of bringing more harmful substances under government control, in addition to cannabis.

Like the current situation with cannabis, markets for other illegal drugs have also existed for many years and will continue to exist in the absence of strict regulatory oversight and market management.

Our goal should be to ensure that drugs that people are choosing to use are produced, distributed and consumed in the safest manner possible under government control rather than the control of organized criminal groups. Our efforts and resources could then be fully targeted at health services, including treatment and recovery supports for those people who develop substance use disorders.

Decades of evidence, including two controlled studies in Canada, makes the strongest case for legal access across Canada to prescription heroin and other opioids in a supervised, supportive and controlled environment. Heroin- or opioid-assisted treatment has been proven to be not only effective but also cost-effective, reducing health costs and loss of productivity. We call for a commitment from the federal and provincial governments that this life-saving treatment will be scaled up dramatically across the country.

Lest you think these calls for change are new, I would remind the committee that in 1994, B.C. Chief Coroner Vince Cain recommended in his Report of the Task Force into Illicit Narcotic Overdose Deaths in British Columbia — yes, we've been here before — that a commission be struck to consider options for Canada towards legalization of drugs, and Cain went on to recommend decriminalization of all drugs for possession and personal use.

In 2011 the Health Officer's Council of British Columbia, in their policy paper, Public Health Perspectives for Regulating Psychoactive Substances, recommended that public health-oriented regulation has much potential to reduce the health, social and fiscal harms associated with all psychoactive substances.

In 2015, the Canadian Public Health Association, in their public policy paper, A New Approach to Managing Illegal Psychoactive Substances in Canada, supported the development of public health approaches for addressing the needs of people who use illegal psychoactive substances, while recognizing the requirement for a public health-oriented regulatory framework for the production, manufacture, distribution and sale of these products.

Most recently, public health officials in British Columbia, including Patricia Daly, Chief Medical Health Officer, Vancouver Coastal Health, have called for regulation of currently illegal psychoactive substances:

Most public health physicians believe that the best way to decrease the harms associated with any psychoactive substance — whether it's illegal drugs like heroin, cocaine, marijuana or alcohol, tobacco, or even prescription drugs — is they should be all legal but very strictly regulated.

In closing, facilitating the opening of supervised consumption sites across Canada is a much-needed and long overdue start to addressing the overdose crisis. But it addresses only a small part of the problem with the flourishing illicit and uncontrolled market for drugs. There is a strong consensus that it's time to adopt a public health approach to drugs, and to that end we recommend that the federal government initiate a serious conversation about legal regulation and control of drugs within Canada.

The Chair: Thank you.

Mr. Tupper, the floor is yours.

Kenneth Tupper, Director of Implementation and Partnerships, British Columbia Centre on Substance Use: Thank you for the opportunity to speak to this committee. I'm presenting in my role as Director of Implementation and Partnerships at the B.C. Centre on Substance Use. However, my knowledge on this topic is informed by my previous employment as Director, Problematic Substance Use Prevention, in the Population and Public Health Division of the British Columbia Ministry of Health, a position I held for 14 years from April 2003 to February 2017. During my time at the ministry, I led the development harm reduction policies, which have been supported politically by the British Columbia provincial government.

The Chair: Could you slow down, Mr. Tupper, for interpretation purposes? I'm still going to keep you to the five minutes.

Mr. Tupper: The federal government's Bill C-37, introduced as part of the New Canadian Drugs and Substances Strategy, is a welcome shift towards a public health approach to substance use and addiction issues in Canada. I would like to comment specifically on two important public health interventions that may be supported by its passage, both of which are likely to have important impacts in reducing drug overdose deaths, which have been a public health emergency in B.C. over the past year.

In particular I want to speak to amendments to section 56 of the CDSA, which gives the federal health minister the power to authorize exemptions for activities involving substances procured outside the legal pharmaceutical supply chain, i.e. obtained in a manner not authorized under this act.

One of my files at the Ministry of Health was policy development for supervised consumption services which, for the past 14 years, have been offered at InSite and the Dr. Peter Centre, Vancouver's two such services.

When InSite was opened in 2003, there was considerable debate in the local community about its merits. However, the scientific research evaluations that were conducted for the next several years corroborated evidence from a range of European countries that supervised consumption services reduce overdose deaths, risk behaviors that had led to blood- borne pathogen transmission, reduce public disorder and inappropriately discarded injection-related litter. At the same time, they function as a point of contact for primary health care and mental health and addiction services, and they do not increase crime or have other negative community impacts. Economically speaking, they are very cost-effective public health interventions, saving money and saving lives. For these reasons, many local opponents to InSite became some of its biggest supporters after it got up and running.

As you know, the previous federal government was not receptive to the scientific evidence on harm reduction, and after losing a Supreme Court of Canada case that recognized the health benefits of supervised consumption services, it put in place legislation that superficially complied with the ruling, but in practice made it extremely difficult for provinces and territories to expand these services.

Bill C-37 is a welcome change to more easily allow for health authorities to apply for exemptions for supervised consumption services. However, it could go further still. Ideally, there would be development of responsibility to PTs on a decision about whether or where to establish supervised consumption services in the context of a public health emergency. Broadly, I believe the establishment of these kinds of health services should be a provincial health and public safety matter and should no more involve the federal government in the decisions about where to locate immunization clinics during a communicable disease outbreak.

The other intervention that could help address the opioid overdose crisis in British Columbia and other parts of Canada is something that section 56 exemptions could potentially allow for: street drug testing or drug checking. However, this is not a service that would necessarily, or even ideally, be located at a supervised consumption service as specified by the section 56 amendment. Drug checking refers to a harm reduction service that allows for people to submit samples of street-acquired drugs to have them chemically analyzed and receive information about the results of the test. Drug checking has both a harm reduction benefit, in as much as it allows for more informed decision making by individuals, and public health surveillance benefits that allow authorities to monitor the illegal drug market.

Drug checking services originally emerged in the nightlife and dance festival community in response to deaths from contaminated ecstasy and are now available as a public health service in a number of European countries. As you can imagine, in the context of fentanyl adulteration and the illegal opioid market, there is potential to save lives if people can have drugs checked to determine what is in them. However, these should not be limited only to patrons of supervised consumption services but more broadly accessible to consumers who may seek ways to submit samples by mail or anonymously at community-based drop-off depots.

In Canada, drug checking interventions are currently limited by potential application of the Controlled Drugs and Substances Act, which prevents provincial laboratories or public health clinics from accepting samples of controlled substances for drug checking purposes.

I urge you to consider whether the proposed amendment to section 56 is adequate to allow for provinces and territories to establish drug checking as a public health service. It can be important of the continuum of harm reduction responses to illegal drug use, especially in the context of the current opioid overdose crisis.

The Chair: We will have to leave it there, Mr. Tupper.

We will begin with questions from Senator White.

Senator White: Mr. MacPherson, in relation to your comments around replacement drug therapy, I have looked at the Swiss model and the Netherlands model. I'm wondering why you're not suggesting that we come forward with an amendment that for anyone entering a supervised consumption site with drugs, they be replaced with pharmaceutical grade, in an effort to move to the Swiss model, which is people showing up without any. So there's none of the illegality and organized crime in the background in Switzerland that we're seeing in Canada.

Mr. MacPherson: That would be an excellent amendment and a step forward to getting people a cleaner drug supply.

Senator Joyal: My question might be related to putting the cart in front of the ox. If cannabis is legalized, do you think it would have an impact on the people who are addicted and they would find confirmation that is it is okay to take a drug?

Mr. MacPherson: Will legalization increase use? It's hard to argue that cannabis legalization could increase use because we have one of the highest prevalence rates in the world. I think the argument for legalization of cannabis is that we failed at controlling the situation, the market, so let's try some public health regulatory levers, see where we get, and evaluate those. Right now, I think there is a sense that it's totally an uncontrolled situation.

Regulation, that's the experiment. We are entering into that territory so we can learn what kinds of regulatory levers work best in reducing cannabis use, reducing harms from cannabis use, and we have to separate cannabis use from the harms of use. I think we will be in a much better position to do that with a regulatory framework in place.

Mr. Tupper: I would point out that control of tobacco is one of the biggest public health success stories over the past 40 years. We have managed to achieve results in reducing both use and harms without criminalizing the people who use or the people who manufacture and distribute. There are excellent examples in the public health world of how to use regulatory levers, which were mentioned, and apply them to other drugs.

Senator Joyal: Your approach is essentially to establish parameters to make sure that we control the situation. I was almost going to use the word phenomenon. We have to control the situation that is there. We've tried to fight it, and we have to continue to fight organized crime selling drugs; there is no question. But how do we manage our social services and health services in order to make sure that if we want a comprehensive approach, we are hitting the right buttons?

My own reflection is that this bill would have a major impact to alleviate social problems, if its philosophy — that is, its five principles — is well understood and implemented. It seems to me that if we are to implement it, somebody has to have an overall responsibility to supervise that. We can't just let it go because as we heard from previous witnesses, there has to be follow-up and scientific evaluation. Somebody has to be there with real data, with peer reviews and so forth. I wonder if the way we approach it is taking into account everything we should have on the radar if we are going to be effective in our policies.

Mr. MacPherson: In terms of supervised consumption services, they are probably one of the health services with the most oversight.

InSite was opened in 2003. There is a tremendous body of evidence globally and from the Canadian experience. There has been a tremendous amount of oversight and that's because we have been in a learning mode. We know so much more about supervised consumption services, the support services needed, the array of services that Vancouver Coastal Health connects to InSite, and that's a very good start. We need more of those across the country, but we still have the problem with the unregulated supply of drugs.

Supervised consumption services are great for those people who use them, and we need to expand their reach. Just like with drug treatment programs, most people who use drugs will not be in a drug treatment program, by definition, and for a bunch of different reasons. We need to find ways to help them stay alive until they can make those decisions to enter drug treatment programs.

Senator Joyal: Mr. Tupper, in your function as director of the British Columbia centre on substance abuse, is there something we should know about the Aboriginal people who are part of the services you aim to implement and offer to that community in particular, or should we just approach the Aboriginal community in the same way that we approach the other communities?

Mr. Tupper: First, let me correct you on the title of our institution here it's the British Columbia Centre on Substance Use, not abuse. It's a crucial distinction there.

Senator Joyal: I'm sorry; it's a lapse. Maybe it tells you what I think about drugs.

Mr. Tupper: I can go on at length about the distinction between "use'' and "abuse,'' but I'll save that for now.

With respect to Aboriginal peoples, I would point to the devolvement of the responsibility for health services for indigenous people in British Columbia that happened with a tripartite arrangement where First Nations governments, working also with the BC Association of Aboriginal Friendship Centres and Métis Nation BC, worked collaboratively with the provincial and federal governments to put in place a service delivery not managed out of Ottawa but within the provincial First Nations governance structures established through the tripartite relationship. So I would look to the Aboriginal communities themselves to provide the answers about what it is they need. That's what we are starting to do.

The British Columbia Centre on Substance Use was just established in February 2017, so we are still putting in place the governance structures, but it includes strong indigenous partnership in our governance. We will be continuing to work with those partners to not prescribe from our perspective what they need but to seek input from them on how they might benefit from our systems.


Senator Dupuis: My question is for Mr. Tupper. Do you have data on the importing and distribution of illegal substances by Aboriginals in cities as opposed to those living on reserves in British Columbia?


Mr. Tupper: To be blunt, I do not have that data. I think public safety and law enforcement officials would be the people to ask. I have been focused on health intervention. I believe that drugs are widely available in both urban and rural contexts. Drug dealers don't tend to follow boundaries.


Senator Dupuis: If I understand correctly, one of the problems related to illegal psychoactive substances, by comparison with other substances that are considered legal — such as tobacco, alcohol or other products prescribed by physicians — is the fact that the market is unregulated.

My question is for both Mr. MacPherson and Mr. Tupper.


Mr. MacPherson: Yes, that's exactly what we are saying.

Mr. Tupper: Looking back, among the biggest public health intervention successes in history, after immunization and clean drinking water, was the passage of pure food and drugs acts in the early 20th century where we put in place regulations to control the production and distribution of foods, beverages and pharmaceuticals. That extends now to children's toys, automobiles, hand gliding equipment, et cetera.

The failure of our approach to illegal drugs that are psychoactive and used often for non-medical purposes is to think that applying criminal law enforcement penalties would reduce and curtail their use. I think we have ample evidence from the past 100 years, frankly, but certainly the last 20, 30 and 40 years where we scaled up a war-on-drugs approach that has had counter effects. None of the key indicators of success have been obtained. Drugs are cheaper, more plentiful and more easily available than ever before. I think Donald will concur it is time for us to look at other approaches.

Mr. MacPherson: The fentanyl crisis is driving this discussion. You have people from the street level to medical health officers and a health minister who are all saying we have to look at all options, and they are right. We do have to look at all options, and it may take a shift in our mindset to consider some of these options.

The data is in. I have worked for 25 years in the Downtown East Side of Vancouver. Enforcement is not doing it. We have been here before in the 1990s with an overdose crisis. I thought we had made some progress, but the illegal market produced this fentanyl and carfentanil phenomenon, and it's beyond the pale what is happening in this country. Suddenly you start hearing people talking about regulation of drugs.

We were having a conversation with the Minister of Health in British Columbia, Terry Lake. I said, "We need to consider this,'' and he said, "Donald, in politics it is the art of the possible. You have to be able to get from A to B.'' I said, "Yes, but you have to start to talk about B before you know what is it is and where you are going.''

I witnessed this in the city of Vancouver when injection sites were just being discussed. The Vancouver area network of drug users brought in a coffin to city council. They walked into city council, put it down on the floor, and city council was like, "Oh, my god, what's happening?'' There were 200 hundred people a year dying in the city of Vancouver alone in 1995, 1996 and 1997. They spoke for five minutes, and they took the coffin out and they left.

I was sitting there as a staff person — and I have a background in literacy — and one by one, the councillors got up, and started to try to talk about what had just happened to them. They said, "Those drugs users, they wanted these s- s- s- —'' and they couldn't say the words, "supervised safe injection sites.'' They didn't have the conceptual framework. And I said this is a literacy problem. We have to be conversant in all of the options before we can consider them, and if we can't even mention them or talk about them — for years, drug regulation has been sort of verboten territory.

We have to get something good out of this crisis, and I think we will get better health services. I think we will get some more heroin prescription treatment. If Senator White's amendment passes, we'll get people getting to exchange their street drugs for good drugs.

Scott MacDonald, the guy who runs the heroin-assisted treatment clinic in Vancouver, said to me the other night at a public event that even with the high threshold that they have of entrants, they could take 500 people off the street in the Downtown Eastside tomorrow if they had the resources. That's 500 people not going to a drug dealer, 500 people not at risk of dying from fentanyl.

Senator Omidvar: Thank you to both of you. This question is for either one of you.

This is a very complex issue. Any issue that has health care in the middle is necessarily a complex issue, made more so because you have a crisis. But I have observed that when there is a crisis of some proportion, there is also innovation and creative solutions, and you have alluded to that.

Let me get back to the complexity of three levels of government along with local institutions. You have the federal government that is developing criteria for opening safe injection sites, and you have the provincial and local governments, departments of health, police officers and local communities. Do you have a policy perspective within this context of how the relationship works now and should work better between the three levels of government?

Mr. MacPherson: Yes, I do, and I did in the 1990s.

The rubber hits the road at the municipal level. When drug dealers show up on corners, when people start dying, people start calling their city councillors. The Minister of Justice is far away in Ottawa, or far away in Victoria, in our case of Vancouver.

I think provincial and federal governments need to be way more responsive to the calls from cities to help. That's what the four pillars project was about. It was Mayor Owen saying, "Help us; we have a big problem.'' It took a long time to marshal those forces and to coordinate that work. We had the Vancouver agreement at the time, and that helped.

Response is absolutely critical in this situation. We can build an addiction system over time, and Ken is working for an organization out in B.C. doing that.

A quick response is what Bill C-37 is about, helping communities put things in place quickly and in a timely fashion so people aren't left hanging out to dry at high risk of death in the illegal drug market.

My experience is from a municipal perspective, where both provincial and federal responses were slow, because we had identified the problem of where the sites could go very early on in the epidemic that ramped up in the early 1990s.

The Chair: We have had several witnesses talk about giving the provincial health ministers the authority for temporary exemptions. I'm assuming both witnesses support that approach, or am I wrong?

Mr. MacPherson: Yes, absolutely. In the case of an emergency, what do you do? You do things differently from how you would do things day to day. If things are fine, there is one process. If there is a declared emergency, which we have in British Columbia, you do things differently. That's eventually what happened in terms of the overdose prevention sites that have opened up in British Columbia.

People are dying at such a rate that it's tragic that it took six years to get InSite into the ground — from 1997 to 2003. A lot of people died in those years. Response time is absolutely critical. I know that governments can't move fast, but in an emergency there must be mechanisms to respond to a crisis.

Mr. Tupper: I would absolutely concur. Provincial health systems need to be empowered by whatever federal regulations are in place to respond to a public health emergency such as we are facing. We have seen a good job of that kind of cooperation emerge over the past year, but I think things could go further.

I would look to Portugal as an example of a country where decriminalization of all drugs has resulted in a shift of resources towards a public health perspective and away from the criminal justice law enforcement perspective which, as I mentioned already, clearly has limitations.

In addition to supervised injection sites, I would echo my opening remarks that I wasn't able to quite finish. Drug checking services are a crucial component of a set of interventions that can help shift the illegal drug market. Drug checking will allow for accountability between consumers and distributors that currently does not exist in the unregulated market, whereby people can submit samples, have them analyzed, find the results and ultimately — this is a hypothesis; we need the empirical evidence — shift the drug market whereby dealers who are selling stuff that is contaminated or adulterated or of poor quality won't be patronized. Users will be empowered to learn what they've purchased and make different choices about whether, where, how, with whom to use and whether to go back to the same dealer or not.

Senator Omidvar: We asked the Minister of Health last week about this notion of empowering provincial governments — temporary exemptions, a greater role — and her response, if I remember correctly, and her concern was that we would have a variation of responses and services across the country. She wanted to ensure that there would not be these variances. Would you respond to that response?

Mr. MacPherson: I can see that's a concern for her, but I can also see that it wouldn't be that difficult to arrange that. Government works through FPT processes all the time and figures stuff out. From the municipal perspective, things need to speed up.


Senator Dagenais: Mr. MacPherson, you have probably heard about mobile supervised injection sites that seem to have the Department of Health excited. They are somewhat similar to food trucks, which bring hot dogs closer to the consumer.

Do you think that this bill is a good idea or that it lacks discretion, despite the open-mindedness it illustrates? In your opinion, if it turned out that the project worked, what would be the benefits of the health services that could be provided through those mobile supervised consumption sites?


Mr. MacPherson: I would support mobile injection sites. I think it's a combination strategy of a supervised consumption service and an outreach strategy that allows coverage of a wider terrain. It accomplishes some community concerns and issues because it's not a fixed site. I would see it as ancillary to fixed consumption services integrated into other places.

If you only had a mobile site, I think that might be a problem. I think it's probably a reasonable thing to add on to as part of a more comprehensive plan because there are pros and cons to fixed sites, too, since people who use drugs are distributed broadly in the community.

Mr. Tupper: Mobile sites are an innovation. I don't think they have been well researched. I'm not sure of any evidence from Europe, but certainly we haven't seen any such services yet in Canada, although they are being proposed in a few municipalities and health regions in British Columbia. Certainly with respect to variation and a varied approach to responding to these kinds of issues, I think that's something to be welcome.

With all due respect to Minister Philpott and her desire for consistency, this is a complex problem, and complexity requires a whole set of different types of responses to be piloted, trialed and evaluated to see what works. It might be that something new will come out of Edmonton, Winnipeg or Halifax. When different places to try different things, we can see what the evidence generates from evaluation of those and hopefully improve results more consistently through the generation of scientific research.

Senator McIntyre: Gentlemen, thank you for your presentations.

There is an issue with which I am very much concerned and that's the issue of over-prescribing and I'd like to have your thoughts on that. Let me explain.

On one hand we have a national crisis of opioid abuse and overdoses. On the other hand, prescriptions for painkillers as well as therapies for treating dependency have increased. New figures show that over-prescribing is behind the epidemic that has worsened in recent years with the arrival of illicit fentanyl, leading to an increase in overdose deaths. As a matter of fact, Canada ranks as the world's second-biggest consumer of pharmaceutical opioids. It's just unbelievable.

Are you concerned that the bill does not contain specific measures to fight over-prescription and the diversion of prescribed pills to the black market?

Mr. MacPherson: This is not my area of expertise in some ways.

Senator McIntyre: I would like to have your comments, though.

Mr. MacPherson: There is no doubt, after spending some time recently in Portugal and in Europe, at the European Monitoring Centre for Drugs and Drug Addiction, there is more prescribing going on in North America. We're number one and two — the U.S. and Canada — and that is a problem. I think it's being addressed not through this bill but in other areas of the federal process around this because the minister has talked about prescription drug monitoring programs and all those sorts of things.

The concern we have with that analysis is that we've created a situation where we have a supply and demand thing going on — this is a concern for Ken's shop now, too — and if we're talking about reducing or suppressing prescription drugs, we're potentially putting more people at risk for overdose.

We have to be cognizant that if we're suppressing supply of prescription opioids, we should, at the same time, be scaling up supervised consumption services and naloxone, because we know from the U.S., where they've had some success in suppressing demand, fentanyl and heroin have now outpaced prescription drug deaths from overdose.

We've created a situation. There are a number of drivers for the situation, and we have to be very careful when we start reducing the supply. We have to plan that. We have to sequence what we're doing very carefully.

Mr. Tupper: The issue of over-prescription is, likewise, a complex one. It has been 15 to 20 years in the making with the active promotion of new types of medications by the pharmaceutical industry, such as OxyContin, and the lobbying of doctors to liberally prescribe these new drugs which were marketed as safer, which we now know is not necessarily the case.

I don't think Bill C-37 or the Controlled Drugs and Substances Act is the appropriate mechanism by which to deal with that. It's a matter of health professional education for physicians and nurse practitioners, and to work with the colleges of physicians and surgeons, the colleges of nurses and provincial health ministries to address the issue of prescribing.

At the same time, Donald is correct in that we need to ensure that physicians who are prescribing for patients who are opioid naive and who are dealing with pain issues need to be educated about how to not ramp them up to very high-dose and long-duration regimens of prescribing. But for patients who are currently on those kinds of regimens, maybe have been stable and on relatively high doses for years, to suddenly curtail their prescription and push them off into either the black market, I've heard a few cases here of suicide where patients were reduced in their medications and decided they couldn't survive without that.

Certainly there are important considerations that need to be applied to how we manage the iatrogenic situation that's been put in place for the last 20 years. That's a matter for provincial health systems and colleges to work on together through health professional education.

Senator McIntyre: From what I've been reading, educating doctors has had little impact on the issue of prescribing, and that worries me a lot.


Senator Boisvenu: I understand that this is a humanitarian bill. The idea is to save lives. It is a feel-good bill, and it calls for urgent action, but when urgency becomes a pattern of social behaviour, how far does our tolerance, as a society, go when it comes to letting people take drugs and giving them drugs to prevent deaths? People are given drugs to prevent their death, and they are allowed to take drugs. That is not a life in my opinion, but that's your view and that of the federal government.

Normally, a society manages urgent situations, puts an end to them and they go away, but if those situations become permanent, what limit do we set for ourselves as a society when it comes to giving people drugs to prevent them from dying?

That is where the problem lies. We should rather invest in detox to empower those people and help them get on with their lives. Do you not think that this is a feel-good bill rather than a medical project to help people beat addiction?


Mr. MacPherson: No. This bill is dealing with a tough situation. I hear you when you are talking about what is wrong with our society that so many people are using drugs and developing substance use disorders. That's a very complex issue, and there are many drivers for substance use disorders. There's trauma, poverty, abuse. A situation like this is like holding up a mirror: This is us; this is our community; this is what's happened. Of course we want to keep people alive, but we need to figure out what other kinds of things we need to do.


Senator Boisvenu: Through this bill, we basically work on the consequences of the problem without addressing its causes. The bill should have included fundamental measures attacking the causes in order to avoid constantly needing to manage the consequences. This is a problem that would be solvable without us having to invest in the consequences.


Mr. MacPherson: I agree with you. We need to take this issue of substance use disorders very seriously, traditionally, and I would talk about the provinces as well. They have not done a good job of building coherent systems to address substance use disorders. If you go to some other countries, you find much better coordination between the national and state levels.

The fact that we're still here in 2017, when we were back there in 1993 in a very similar situation, says something about our lack of ability to build a good, coherent health system.

I see this bill as part of a comprehensive response, but not a comprehensive response. We need a much more comprehensive response, and the federal government needs to work closely with the provinces.

If you are, for example, a patient on methadone, try and travel across the country. You have 10 different systems of methadone treatment. It's the age-old problem of the federation trying to build a standard of health services for people who use drugs that has universal access across the country.

I hear what you're saying, and I don't disagree, but I think the services that this bill is talking about are part of an important component of a more comprehensive approach.


Senator Dupuis: You once again mentioned 1993. What's shocking to me is that I have so far been under the impression that we were talking about a crisis that occurred in 2017, but this is actually a situation that has been causing a lot of problems for 24 or 25 years. You pointed out that something could have been done earlier. Since we are talking a lot about consumed products, do you have data, through your work, on the categories of users of those substances?

A witness told us earlier today that about 60 per cent of Insite's clients were Aboriginals. Do you have specific data on those groups or categories of drug users?


Mr. MacPherson: I would ask Ken that question.

Mr. Tupper: I would say that substance use disorders are widespread throughout different classes of society and different kinds of communities. Certainly the consequences of colonialism have left indigenous communities much more susceptible to a whole range of health problems, including addictions.

The reflection of InSite's clientele base is perhaps more a reflection of the local community in which it's situated, Vancouver's Downtown Eastside, which is one of if not the poorest postal code in all of Canada, and a gravitation of First Nations people to that part of the province when they're down and out and seeking street life and disengaged from their traditional communities.

I'll go back to the previous question about the causes of addiction being very complex. There are genetic, social and economic factors. Those can affect every community. There are very wealthy communities that are affected by addiction as much as very poor communities.

Senator White: Mr. Tupper, unless I'm wrong, in most provinces in the country there is currently about a six-month wait-list for residential drug treatment. When we talk about somebody entering a site and being advised that they could get help, we're really not realistic. It's half a year away. In Ontario, it's six to eight months to get residential drug treatment. Is it different in B.C.? Do you have more access?

Mr. Tupper: For opioid use disorders, I don't think the evidence is very strong that residential treatment is necessarily the best option. The World Health Organization has methadone and Suboxone listed as essential medicines for the treatment of opioid use disorder. Certainly that's what we've been trying to scale up in British Columbia. The wait-list for methadone, especially through mechanisms like supervised injection sites or the overdose prevention sites, means that they're much more easily accessible than previously.

Senator White: I'm not referring to consumption sites. My complaint is that people can't get residential treatment. That's my concern. In Ontario, it's six to eight months, regardless of the addiction.

In British Columbia, is it 24-hour access or six to eight months like it is in the rest of the country? This is not about whether or not they can get methadone or Suboxone. I want to know whether or not people who ask for residential treatment have greater access in British Columbia.

Mr. Tupper: I can't make a comparison between British Columbia and Ontario.

Senator White: I just want to know about B.C. I don't want you to compare. Is it easier to access residential drug treatment in British Columbia, period? What's the wait-list?

Mr. Tupper: It depends on the health authority. Some health authorities have longer wait-lists. I believe it's as short as a few days to as long as a few weeks. I don't believe that anywhere it's six months.

Senator White: If I walked into InSite today and asked for residential drug treatment, I'll be there in days — not in detox but in residential drug treatment, within days?

Mr. Tupper: You would be referred to OnSite, the short-term stabilization upstairs, and they will work together to find a residential treatment centre very quickly.

Senator Joyal: I would like you to comment on the initiative that the provinces take. A federation can work positively to allow what I call regional creativity. InSite was an initiative of B.C. Adding fentanyl as a prescribed drug was an initiative of Senator White. If you think you will standardize everything from one ocean to the other, I think you will miss the opportunity of creativity. I think of initiatives that can be taken by groups that are sensitized to this problem and can help to create the momentum. If the Canadian Minister of Health waits until there's harmony everywhere before moving nationally, I think we will wait a long time and this crisis will have peaked to an unseen scale. What is your own experience on that basis?

Mr. MacPherson: It's obviously a balancing act. You want to have innovation within a certain framework. But you're right; there are different forces. There are different levels of leadership in municipalities, provincial governments. There are different capacities in communities to address some of these issues. The trick is finding that right mix and allowing the innovation to emerge.

All of these things we're talking about that happened in Europe — heroin-assisted treatment, supervised consumption service, needle exchanges — were all innovations that came out of crises. Right now, we're ripe for more innovations and we hope we can evolve some that will begin to lower the death toll.

I agree with you, and there's that tension. The federal government has to work with the provinces and municipalities within a framework and allow for some experimentation and for some new things to emerge.

The Chair: Gentlemen, thank you both for being here today and taking time out of what I'm sure are busy schedules to assist the committee in its deliberations. We very much appreciate it.

Members, tomorrow we will hear from law enforcement officials and community representatives. The gentleman who is on our agenda today, Dr. Mark Ujjainwalla, will be able to join us tomorrow as well, so we won't be missing out on his testimony.

(The committee adjourned.)

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