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
The CNA puts forward two recommendations to address these procedural
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
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
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.
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.
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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,
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
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
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
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.)