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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 28 - Evidence


OTTAWA, Wednesday, September 21, 2005

The Standing Senate Committee on Social Affairs, Science and Technology, met this day at 9:02 a.m. to examine issues concerning mental health and mental illness.

Senator Michael Kirby (Chairman) in the chair.

[English]

The Chairman: Welcome. I thank our out-of-town guests for taking the time to appear before the committee today to give us their input on the issue of whether mental health and addictions services should be integrated, and if so, how that can be accomplished. A number of provinces are doing that, and we need to understand the views of people in the field on that question.

The format this morning will be the usual round-table presentations followed by discussion. I would ask each of the witnesses sequentially around the table to give the committee a summary of what they would like to see in the committee's report of recommendations in the area of addictions. The committee has found these round tables to be incredibly instructive, having held several of them — one on children's mental health and another on seniors' mental health. All of us were emotionally drained yesterday after the meeting on Aboriginal mental health, where we heard the data on the reality of everyday occurrences in that area. We picked up some information on addictions at earlier meetings, but we needed a more concentrated day on the issue, and that is why we are here today.

Many people have asked me how large our staff is, given the output of the work we did on the hospital-doctor-acute care system. The research staff is pretty well what you see here — the senators, plus two full-time people, Tim Riordan and Howard Chodos — in addition to a handful of others we conscripted to assist us. Relative to any royal commission, the numbers are few. At times, people express the view that we must have a large research group behind the committee, but unfortunately, when we look behind us, there is no one else.

Dr. Stockwell, please proceed. I would ask that you take five to ten minutes to present your recommendations for the committee's final report.

Mr. Tim Stockwell, Director, Centre for Addictions Research of B.C., University of Victoria: Thank you for the opportunity to be here. From an outsider's perspective, some of my comments will seem to come from left field. I spent most of my career in the addictions field in the U.K., and, for the last 16 years, in Australia. I have been in Canada for one year, at the new centre in Victoria. I have worked as a clinician and researcher and have also been on national policy committees. Please forgive me — I hope I do not offend anyone.

The Chairman: Trust me; the members of this committee, as we have proven in our previous report, are quite prepared to offend many people. Our strategy is to tell it like it is, and being loved is not high on our priority list.

Mr. Stockwell: I hope I do not test that principle too far.

I have a few general comments and some specific suggestions. I read your report, and what struck me — and it is indicative of what happens when addiction gets absorbed into mental health — is that there is little specific comment on addiction issues. It gets lost there. That typifies what I think happens, that addiction falls down the agenda. Through the lens of mental health, it is seen as just 5 per cent of the diagnostic categories. It is written off, seen through different lenses, and the specialist's knowledge in that area gets devalued and lost. That plays out in many ways. That has happened in some provinces in Canada. From my observations, there have been some problems with trying to integrate mental health and addiction.

In my experience in the U.K. and Australia, there have been statutory authorities in place in each jurisdiction and state with a particular mandate to be responsible for addiction services, prevention and public awareness. They have made great efforts to collaborate with mental health services for that important group where there is co-morbidity. That has always been an issue and has to be dealt with. That is my first comment.

For example, the report does not mention harm reduction, which is a major issue in the addiction and drug field. Under ``research,'' it does not mention the Canadian Addiction Survey. The Canadian Health Survey is excellent, but for the first time in 10 years there was a major national addiction survey in the field last year. That deserves some mention.

I am a little skeptical about full integration. The report needs a more realistic perspective. One of the backdrops for the entire issue around substance use and related problems is that only a tiny proportion of people have been in contact with treatment services at any one time. It is the tip of the iceberg. Most people with alcohol problems, particularly, will get better without any contact with treatment services.

That is not to say that is ideal. The services we have are greatly underfunded; we need more of them. However, the bigger picture is it is a massive problem pervading society, and it plays out not just in mental health. It plays out in general health, in the criminal justice system, in the workplace — which is covered a little — and in the education system. By locating it in mental health, we are thinking of DSM disorders and criteria and not looking at the broader social dimensions of alcohol and drug use in society. There are so many other policies required to limit the overall extent of the problems and their impact across society.

The focus is on the treatment system, so I have a few suggestions about that. There will never be a Utopian system where everyone's needs are catered to and it is seamlessly transferred. There are times and places where particular problems need to be addressed expertly and different parts of the system need to be connected with each other; expertise must not be lost.

Full integration is fine, as long as it can retain the expertise and provide doors that people are comfortable with going through. My experience is that with alcohol and drug problems, people are nervous and feel stigmatized. Mental health is not necessarily the door they would want to go through; there needs to be a variety of access points that people feel comfortable using.

Full integration can allow that and maintain specialist skills, whether it is methadone maintenance, skills with group therapy, drug rehabilitation programs, training or brief interventions; that would be fine. There has to be a strong identity for addiction services. You need strong addiction services, strong mental health services and strong connections between them.

What has happened in B.C. with the absorption into mental health is that five health regions have taken responsibility for delivering services, each of which does not have much capacity. There is only one health region that has its act together on addiction services. They are not collecting records; they cannot monitor the standards of care and who is coming in and out. There is no consistent, coherent record-keeping system; it has been lost across five regions because it is such a small issue within mental health.

Minimum standards are required, just focusing on treatment services. We need to define the core services that people should have access to, given what I have said before about the size of the problem and how we will never respond to all of it. What are the basic measures that will work and make a contribution?

There should be certain national minimum standards, because there are some areas of the country that have no services, others that have fantastic services, and a lot of patchy arrangements in between. Minimum standards should require some community-based services as well as specialist residential and in-patient services and other services in between.

If we get an overreliance on either one, one extreme is you create expensive in-patient services. All the money goes into an in-patient unit and there are long waiting lists and half-empty beds. There seems to be a relationship there. They are also inaccessible. People often do not bother to refer patients because they know what the waiting list is. People with addiction problems need prompt help.

Motivation to change is transitory. The opportunity needs to be taken. My experience is working with community- based teams where there is an open door and ready access. You can see people on the day they want to be seen and you can arrange home-based or community-based detox and links with other services within 24 hours, not seven weeks or several months. That kind of ready access is a basic minimum, that doorway where people feel comfortable passing through and they can be assessed expertly. The specialist expertise needs to be in that assessment process.

An example of how we need to invest in cost-effective solutions, given limited resources, is home-based detoxification. The services that have been set up are just as effective and cost much less. One example in the service I provided in the U.K. is that we had one community nurse supervising as many home-based detoxifications for problem drinkers as the general hospital, which had been the other major service provider in the area, did in one year. The problem with making it accessible is that you get more demand and you have to be prepared to weather that.

The minimum standard should be accessibility. It should be easy for people to access and you monitor the take-up of that to determine how much service is required. The monitoring systems are key. They should look at waiting lists, dropouts, client satisfaction, health and safety standards and whether clients are followed up. If you monitor those things and design your local services around them, you will get somewhere.

One thing we know works well is brief interventions in primary health care settings — the five-star treatment approach, prevention approach, getting to people in the early stages; for tobacco/alcohol problems particularly, the evidence is strong. It does not happen often and I think we need remuneration arrangements to encourage basic screening, brief intervention and follow-up that are required in primary health care. There is some reference to that in the report and I endorse that.

How do you pay for this? I am sure you have heard this before, but I would like to see in your report, if you would consider it, discussion of a special tax on alcohol and tobacco. If you had a five-cent tax on every drink Canadians had, it would raise about $500 million in a year. One of the jurisdictions in Australia had a fund like that and it raised significant amounts of money. The evaluation that my institute did could demonstrate the saving of lives each year — road crashes and hospital admissions prevented. Raising the price is effective but people do not like it; however, people love raising the price for a particular purpose. The voters were happy. They could see it was for a good cause. Half a billion a year would be useful; you could get some good services for that.

A left-field suggestion, just quickly, is to put thiamine in beer; thiamine fortification in beer and cheap wine prevents the Wernicke-Korsakoff syndrome, which is severe alcohol-related brain damage. If not, you put it in bread-making flour. Even the heaviest drinker will eat bread. Rates of Wernicke-Korsakoff syndrome have gone down significantly over the last 20 years in Australia.

You might consider how welfare payments are made. I noticed that in Vancouver, on the day each month when payments are made, people stay in expensive hotels and blow all their money in one day. This impacts how the drug scene operates as well. Perhaps weekly payments would be a more appropriate method.

The Chairman: That will certainly generate many questions, which is terrific.

Mr. Jon Kelly, Chief Executive Officer, Responsible Gambling Council, Toronto: The Responsible Gambling Council is an organization that undertakes research and runs public awareness programs focused on the prevention of problem gambling. I spent about 25 years in the public service in Ontario, mostly in public policy, and came to the Responsible Gambling Council about seven years ago via a number of places, including some time in drug and alcohol policy in Ontario.

I read through the materials you sent me and became a bit bewildered, although I saw some good ideas. We need well-trained people and structures that work, and in the end, given the issues to be dealt with in the sector, particularly on the addiction side, it is hard not to say that we need all of the measures that the report has identified. Of course, that is the problem. From my perspective, the social safety net needs each one of those little strands in order to function usefully. We cannot say that we do not need well-trained professionals or that we do not need coordination.

Having said that, I would like to speak to two issues only that I think are most important in moving forward on enhancing mental health and addiction services. One has to do with stigma. There was a remark in the report about the committee's understanding of the importance of dealing with stigma. To me, the issue is not just stigma. The issue is public acceptance and public support for doing something in this area. No matter what recommendations the committee makes, in the end it will be important to address the issue of public support, public understanding of mental health and addiction issues, public acceptance of governments taking action in this area.

I too am something of an outsider to the system. I have not spent time in the mental health system. I have spent time in the addiction field and in the gambling area, which is somewhat on the outside of that system as well. I see it as having been lost to the public eye for many years and there is a need to dig out of that loss of profile, that loss of interest, that loss of coverage, except for certain types of media coverage that tend to be a more sensationalized, almost advocacy approach in this field.

In order to move forward it will be important to address public support for any move, which probably means social marketing campaigns and other programs to build public awareness and support that is sustained over time. I am not talking about a one-time initiative.

The other part that I have struggled with over time is how to get attention for mental health and addiction issues when they are associated with ministries of health. This will be an uncontroversial point, unlike those of the previous speaker, but ministries of health are dominated by issues of doctors and hospitals. The package of contentious issues every day is about doctors and hospitals. It is mostly not about mental health, certainly not about addictions, and certainly not about gambling addiction. The struggle is how to move forward with renewal in a situation where the ministers of health and senior bureaucrats in the ministries of health are completely submerged in issues related to doctors and hospitals. That requires some form of extrication of health and addictions issues from the large ministries of health and their large agendas. To me, that structure in the provincial departments of health is as important as any of the structural issues that have been raised so far. I did not see it directly addressed in the material and I think it is a crucial element.

David Kelly, Executive Director, Ontario Federation of Community Mental Health and Addiction Programs: I work with about 220 organizations across the province of Ontario. I have come forward with a few suggestions touching on some of the issues that have been raised. We first need to apply the broad determinants of health to the treatment of addictions. Treatment and supports will fail if people are worried about their housing. It is often the case that people go through the process but come out homeless, having been unable to afford to keep their apartment.

This also applies to income support programs, that is, getting primary care to people with addictions. We have to start looking at it in a more holistic way as opposed to the silo approach of simply treating an addiction and sending people out the door.

Another key factor is strong political leadership. People have already touched on this. We need strong political leadership to cross ministerial boundaries and jurisdictions. We need all the work that is being done in the criminal justice system to be done with people with addictions. Addictions are impacting the correctional system, youth, the education system, the ministries of health and community and social services and women's secretariats and chewing up their valuable resources. We need to start coordinating how we respond to and work with people with addictions who are caught in those various systems.

Someone mentioned stigma. I call it discrimination. The word ``stigma'' actually perpetuates the stigma or discrimination that occurs. We need to change how addiction is viewed in society. We have to stop the blame game and emphasize the positive outcomes of addiction supports. Significant financial arguments can be made about that. For example, $1 invested in addiction services can have a $6- to $12-saving in societal costs. There is real benefit in supporting people through addiction treatment.

We can start with an economic argument, and we will see other benefits from that. One positive way of doing that is to support consumers and family groups within the addiction system. I am sure that everyone at this table has had a family member touched by an addiction or mental illness. We know the toll it takes on people, but they are among the most powerful advocates.

In Toronto there is a special group called the Dream Team that makes presentations. They have serious mental illnesses and they talk about the impact of housing on their lives. After listening to their stories and hearing where they are now, none of us in this room can dispute what they say. They are powerful voices that we need to tap for addiction services.

The Chairman: They presented to us in Toronto and that is exactly the impact they had. I subsequently visited with a couple of them.

Mr. Kelly: There are such voices in addictions and we need them to be heard. A good strategy would be to support those consumer and family groups across the country.

Multicultural Canada requires multicultural solutions. We have a cross-Canada settlement system. We need to build stronger links between settlement services and the addiction field as well as the mental health field. In that way we can start to impact more people as they come in. There is a host of addiction issues that are not being addressed anywhere within the system because they are hidden — the different impacts of different cultures and how they respond to addictions. We need the work and the support of those communities to address them. One solution would be settlement support and connecting those settlement services further with addiction providers.

I know this is not a popular thing to say, but the system needs to be funded. That is a given. We know that health care is a big maw; you can throw whatever you want into it. There has been no strategic placement of dollars to support addictions, even though the cost continues to rise and the impact on the economy is huge. We have not seen some concerted efforts to start addressing the addiction system for a long time.

Lastly, there has been a significant degree of success in targeted programs. We must not forget that we need to fund holistically. It is great to be targeting specific groups, but you also need the organizations and providers and to give them the ability to respond to different needs coming through the door. Clients are complex and there are often hoops for providers to jump through to ensure that people get the help they need. Not only do we have to have targeted funding, but also we must fund in a holistic fashion so that organizations can respond and have the versatility to meet the next disaster.

How much work are we doing at present in the field of crystal meth, even though we know it is a wave? We have been tracking it across the country. The organizations do not have the flexibility or the responsiveness to start addressing that as a coming issue. Someone will show up at the door and we will try to piece together the services as best as possible. We need that flexibility. Looking at funding the entire service might help us to do that.

Mr. Greg Purvis, Chair, Atlantic Association of Addiction Executives: Honourable senators, I sent around a handout, our stakeholder letter, just to give a brief introduction to who we are. We are a new organization. We have been around for about a year and a half. We have gone through a couple of name changes since then. We were originally called the Atlantic directors group. We are primarily a group of directors within Atlantic Canada who are the government-funded providers of addiction services; their partners, the directors of addiction services from Newfoundland and Labrador, Prince Edward Island, New Brunswick, Nova Scotia; and their partners in Health Canada, CSC and CCSA.

I wish to thank the committee for the opportunity to speak here. It is quite an honour. I appreciate that you are giving Atlantic Canada a voice at this table. I would also like to applaud the committee for its work. As the chairman has said, this is probably not a committee where you receive many pats on the back. You have groups saying you need to do this and that, yet you keep putting out the reports and doing the work and that needs to be commended. Thank you for continuing to do it.

These reports are taken very seriously in the field. Your perspectives paper on concurrent disorders is frequently cited.

I wish to first address what would help the integration of mental health and addiction services, and how that could be done from a consumer point of view. The quadrant model has been mentioned before. The people who end up in the quadrant of severely addicted and severely mentally ill would benefit greatly from a systemic, integrated team. However, the fear of people within addictions is that if we fully integrate the entire system to service a small portion of consumers who need to be serviced better, and whom we want to service better, it would lead to a risk of a far larger system overshadowing the needs of a small system that requires expertise, champions and advocates to meet the needs of our larger consumer group.

It is great that you included the subject of addictions in your report and that you are meeting with us to broaden its content. However, as someone working in addictions, when I read the report, addictions is a small percentage. That is our fear of full system integration, that we become such a small part that we lose the ability to meet the needs of our larger consumer group.

That notwithstanding, we know that we need to capacity build. We know our people need to be able to deal with anxiety, depression, mood disorder, post-traumatic stress disorder because that is what many of our consumers are coming through the door with. Mental health, on the other end, needs to deal with assessment, referral and mild addiction. There needs to be a connection on a service level. That is different from integration at a systemic level.

As to what is the most pressing concern with targeted populations, I wish to add this to support the first point. In Nova Scotia, in 2002, we targeted groups that were underrepresented in our statistics: women and youth. We put together enhanced service teams. We put together protected resources in an envelope that could not go to the other budget. We hired people specifically for those and gave them a mandate to seek out best practices and deliver services where people needed them delivered. They went to the schools, the youth services and the women's shelters. Over the last two years, we had an increase of 25 per cent in consumers who were youth and over 30 per cent who were women.

Since we are able to dedicate those specialized teams to targeting those special populations, we are able to meet their needs. In a broader sense, addiction services, because it is specialized, targeted and resourced differently, is able to meet the needs of our consumers. In the same way, we are able to do that for women and youth. Full system integration and taking that focus off service provision within addictions puts us at risk.

Turning to the subject of major issues within the field, I will speak primarily from an Atlantic Canadian perspective. Although crystal meth is appearing across Canada, it is not within the Atlantic provinces. Our main issue is prescription opiates. The main complaint from our consumer group is about access to methadone maintenance therapy. We continue to address that. The other issue is access to acute detoxification beds when people need them. When they want to go in for the first time, and our wait list standard is within five days, five days may be too long. One of the ways to address that is with alternatives that can get people in much quicker, such as day detoxification or home detoxification. Unfortunately, it is not well known among the population in general. Our market analysis within Nova Scotia shows that most people identify addiction services detoxification as the detox centre. In fact the broad service continuum that we offer includes early intervention, prevention, community education, community-based services and day detoxification, and detoxification is a small portion of it. We need to market that to our consumer group because they are not sufficiently aware of the services that we offer to access them. That is a huge barrier.

You also asked about the use of peer professionals. Historically, addiction services had a model of treatment that was very similar to that found in the self-help community. We hired many peer professionals to help clients navigate the system and act as a link back to the self-help community. We are moving more towards best practices in Atlantic Canada. Right now we are using community reinforcement or motivational enhancement therapy. They are both cognitive-behavioural based. A higher proportion of professionally trained, master's level clinicians, social workers and psychologists, are delivering that. We still have peer professionals, and I do not think anyone can provide a sense of hope for change for a consumer group better than people who have gone through the system themselves. I do not think anyone can navigate or advocate better. There will always be a place for that, but the ratio is changing because of the type of service we are delivering. As we are now more attached to health care, with the onus of ensuring and ethically providing best practices, and when we look at research that indicates that we can double our treatment efficacy with a clinically driven treatment protocol, it is hard not to go in that direction.

The last issue was funding of self-help groups. In the main, self-help groups within addictions, such as AA, NA, et cetera, cannot traditionally accept outside contributions. However, there are several groups that would benefit from it. We know from the research that the two indicators that rise to the top as to whether people make or sustain a recovery have to do with social and family support and vocational training and job security. Instilling opportunities for our consumers to access that would be a wise use of funds.

I have a couple of suggestions as to an action plan. What touched me the most when I read the first report was a comment from Senator Kirby after the first-person accounts were heard. He said, ``You have to put a human face on it.'' I felt the committee had a sense of being grounded in what they were doing. It gives purpose and value to the work of the committee. Unfortunately, there is no first-person account on addictions. I would strongly recommend you give one of our consumers the opportunity to be that person to help you ground yourselves in this issue.

If I understood the report correctly, that was a pivotal step for this committee. I applaud you for it, as it shows forward thinking.

The second recommendation is that the committee continue to raise background information about the addictions system within Canada. It is quite different from the mental health system. They have been paralleled for some time. One is medicalized while the other is not. Both have been able to meet the needs of their consumer groups to some extent. There is value within both systems. We need to understand where the value is prior to making changes.

We already have some wonderful things happening within the field of addictions. We have a national framework. We have something of a strategy. There is synergy. I would not want to see that lost. We are a small enough community that most people around this table know each other. We are a small enough ship that we can turn pretty quickly.

Ms. Nancy Bradley, Executive Director, Jean Tweed Centre: Thank you for inviting me here. I want to talk about women in the system. I agree wholeheartedly with what has been stated before, particularly what Mr. Purvis had to say about the answers to the questions that were put to us.

I will not repeat that. However, I will add some of the differences from the perspective of women.

Substance abuse is a serious issue in general. However, if you are a woman, there is a huge difference between you and a man with an addiction. That difference involves both social and health issues. After listening to what was said earlier about the determinants of health, I can say there is definitely a health issue. Think about the physical impacts on women. Because women are smaller and because of the way they metabolize alcohol and drugs, there is a huge impact on their physical health. We know that women are at higher risk for liver damage, breast cancer, brain damage, heart disease, hepatitis and ulcers than the male of the species.

Women are also more likely to be prescribed drugs to deal with depression, anxiety, aging and other physical and emotional problems. These drugs are often misused with alcohol, as you may know.

A woman may be involved in high-risk behaviour such as prostitution and the use of injection drugs, which can lead to severe physical illness. Shame, stigma and criminal activity are intertwined and complicated.

In terms of access to services, women are often not identified early enough. Women are often at home and hidden. The family can sometimes hide the situation because of the stigma involved. However, more and more women are now in the workforce and being identified. More information is being put out. We need to do much more to help women get treatment earlier.

The other factor in the huge difference when we are looking at the female of the species is that women bear the young. We know that FAS/FAE is a big problem in our country. The cost of helping a child who has FAS/FAE could be as high as $1.5 million when schooling, the correctional system and mental health are taken into account. We need to begin — continue in some provinces — to provide services for women who are pregnant and parenting.

We have already talked about the stigma. I will not say much more about it, except that guilt because they are bearing the young often prevents women from getting help. Since they can be seen as morally bad, guilt is a huge issue.

Women who have substance use problems are marginalized. Other factors like poverty, disability, culture, language, age, et cetera, create a double burden. For pregnant women and those with children, stigma is usually accompanied by shame and fear that their children will be apprehended. Services for women need to be provided in a solid and integrated system.

Problems with substance use cut across all populations, all socio-economic strata and cultures. However, problems do not occur in isolation. The determinants of health play a huge role.

It is a social issue for women who struggle to find well-paying work and cope, often alone, with the care of families. We need a coordinated connection with adjunct services and supports to offer a full array of help.

Pregnancy and parenting is a major issue. Seventeen to 25 per cent of women report drinking at some point during their pregnancy, while others report doing it throughout the entire pregnancy. We now know that the placenta does not protect the unborn child. We used to think that it did prevent damage to the fetus. However, our experience with thalidomide tells us something different. As a result, we are seeing FAS/FAE. Our system is full of people who are experiencing the results of FAS/FAE.

The other big issue for women is trauma. Women in treatment report higher rates of depression, anxiety and extreme trauma, as well as eating disorders.

Two thirds of women in treatment report a mental health issue. It is important to stress the point made by Mr. Purvis that a small proportion needs the highest level of resources in the medical system.

We also know that alcohol is still the biggest problem. Prescription medication and marijuana are often part of the experience, as well as over-the-counter drugs. Cocaine, heroin and all the other illegal drugs have faster and more devastating impacts on women than on men. Seventy-five per cent of women drink alcohol. The greatest growth in this activity, however, is in women between the ages of 20 and 24, which are often the child-bearing years. It is most important that we address these issues.

Seventy one per cent of adolescent girls drink. Who comes to us for help? It is women between the ages of 20 and 35. It used to be much older, but the use of street drugs has brought the age down. It is an issue of poly-drug use. As I said earlier, a history of trauma and mental illness is always there with women.

There is an intergenerational impact on children and families. There are social costs as well in relation to lost productivity, housing, et cetera.

How can we better respond to and understand women? First, we need to understand that there is an interplay of biological, genetic, psychological, social, cultural, relational, environmental and spiritual factors when working with women.

We must work with women in a relational way — women are relational people — and we need connectivity.

The system must be inclusive and holistic in its response. I believe the system needs to look at more health promotion, more prevention, more detox, counselling and treatment, as well as housing, employment, justice; and similarly, all levels of government, with the vision, research, policy resource and evaluation, must be coordinated.

Research does show us that Aboriginal women respond better when they have the option to participate in treatment that is in keeping with their cultural practices and teachings. Because issues are multi-faceted and multi-dimensional, we need a system that can respond on multiple levels to multiple problems. Put it another way: How do we help a woman who abuses substances? She is possibly parenting or pregnant. She has a history of trauma, childhood sexual abuse, current sexual abuse, spousal violence. She may suffer from mental health issues or cognitive impairment. She may be homeless or in substandard housing. She has outstanding criminal charges, may lack formal education and employment, may be a new Canadian and have family members who are in need of help at the same time.

As I said before, women are relational so we have to understand that as an underlying factor. Then we need an infrastructure that will allow access to expertise in both substance use and mental health at any point on the continuum. The vast majority of women seeking help can be assisted in the community. The more severe the addiction and mental health problem, the greater the need for access to medical intervention, and that speaks to the point about the fourth quadrant.

I work in the community and you can see I am a strong advocate for community resources. When I think about how we can better service women, I see mental health and addictions being coordinated in an understanding of and vision for our system. However, not all women or people with substance abuse need hospital intervention, but we have to have that correlation. We need access to sessional fees, simple things such as prescribing medication, if that is what is needed. The community mental health organizations do have sessional fees for psychiatrists to come in and help in the community. I always think that is so strange, because the addiction field is often similarly affected with mental health issues and they are probably more compromised, but we have fewer resources to deal with the problem. Therefore we need to look at things quite differently.

Outreach is also an important part of what we need to do for elderly women, for youth, the chronic or severely addicted, women who are often homeless. Women who are pregnant or parenting often need outreach. They are not identified in their doctors' offices, they are not identified in community health centres, and we need to find ways to get to them so we can prevent the further compromising of their health and that of the unborn child.

Again, I will talk about the funding situation. The addiction system must be adequately funded to have the capacity to hire educated and well-trained staff so that service providers can adequately deal with the complex issues. We must have the capacity and the vision to provide seamless services to women who come to the system for help. The clients are partners in the care, but it is the system's responsibility to facilitate the service.

The parts of the system must work together and have the knowledge of what needs to happen and how. There should be a clear understanding and agreement between providers so that the client's best interests and needs are addressed. The care should move through the least intrusive intervention to the most pervasive and costly — that would be the most seriously compromised; the least being community education and health promotion through to the hospital and the more formal medical system. The medical system must be available and willing to work with the community services to help meet the clients' needs, and vice versa.

I will not speak too much to the questions that you asked. What I wanted to say has already been said. I thought I would speak for a minute about the families. Families and consumers are often bounced back and forth from one system to the other, and for those with concurrent disorders this can be particularly counterproductive.

Mental health services need to be informed about substance abuse and substance abuse services similarly need to be informed about mental health. In other words, the onus is on the service providers to have knowledge of both issues. It should not be the client's burden. I believe we need trained staff educated in both mental health and addictions.

It is important to recognize that there has never been a level playing field with respect to the resources for these two sectors and it is evident in the resulting infrastructure, or lack thereof, in the addictions sector. A fully integrated system would need to respond to historical inequities. Without this, addiction services run the risk of being absorbed into the mental health landscape. To be most effective, a fully integrated strategy could be achieved with a system-wide approach that incorporates the determinants-of-health model. Integration in this sense would work toward integrated planning and resource allocation, reducing the barriers between the sectors at the service delivery level. A merging of services across both systems runs the risk of erosion of the addiction services.

Mr. Jeff Wilbee, Executive Director, Addictions Ontario; Canadian Addiction Counsellors Certification Federation: I am from Addictions Ontario and the Canadian Addiction Counsellors Certification Federation. This committee has the opportunity to take new approaches and introduce innovation. That is essentially the message I would like to bring from my membership.

We want to present to you that some new approaches are needed. When I consulted with the leadership of our group, they spent a great deal of time on an interesting point that I will try to articulate. I will spend time trying to address the five questions. In our language here we talk about mental health and mental illness. We do not talk about addiction health or addiction illness.

The positive message that the mental health community has been able to articulate is that many people do recover and become healthy. I would suggest we are all addicted to something to some degree. It is a matter of the degree and the trouble that it causes us. Indeed, our members talked about this idea. We talk about mental health and mental illness, but do not talk about addiction health and addiction illness. That would take a while because I had to think about it.

We certainly know in our country and in the province of Ontario that we need to do more integration. Also, when we talk about the integration of mental health and addictions — and we agree with all the previous speakers here this morning — there is the sense that many times in our language, and sometimes in how we deliver our services, addictions can be seen as just an add-on. That causes us some concern. Our people would say that there is a need for integration, perhaps even the merging of administrations, but not at the cost of providing good clinical care. One of the major concerns in this area would be the need for training and certification. If in fact someone arrives at an addictions program and the person doing the intake or assessment is not properly trained to recognize that there may be a diagnostic mental illness, we do harm. We would also argue on the other side that people at a mental health facility, if they had not had proper training in addiction services, again may not be as effective as we would like.

I spent a little time south of the border, and I found it interesting that many of the states are moving to licensure for addiction workers. It would be a major plan to look at the kinds of accountability issues we have — licensure, certification and accreditation. One of the ways you try to reduce stigma — and I agree with Mr. Kelly about discrimination — is to provide within our systems that those who are treating clients for addictions and mental health issues have the qualifications, as for any other diagnosis.

Just talking about integrating mental health and addictions does not go far enough. We would suggest that integration also needs to be across the full health and social service sector. To make my point here, the legal drug alcohol is a contributing factor to other diagnoses such as certain cancers and liver and kidney problems. I do not need to expand on that

In report no. 3, you posed the question of where primary health care is on this. We talk about training and ensuring that we have the clinical expertise there. I would like to move to our physicians. I feel good that in Ontario we were able, with our colleagues at the Canadian Mental Health Association, to get some money from Health Canada to start doing some training with family physicians around early intervention on psychotic breakdown and proper protocols for withdrawal management. I deem that a very important project and one that needs to be built on.

However, as Mr. Purvis and Mr. Stockwell have said, we need to look at those who have the most severe, acute disorders. We are in strong support of a national strategy on concurrent disorders, but not at the cost of that other number that Mr. Purvis laid out, the majority of folks who arrive at my members' doors, at least.

Mr. Kelly referred to special populations. We need to look at the populations identified but also be acutely aware of the multiculturalism in our society. More particularly, given the Prime Minister's speech last evening on new Canadians, we would say that there needs to be some emphasis on what might be available as they enter our country.

Alcohol addiction has been referred to from time to time as a family disease. We know it affects 16 to 17 people around the person addicted, or whatever that data may suggest. In my experience, if people having difficulty with whatever the addiction is, problem gambling, sex addiction, alcohol and so forth, go back into the same environment, it makes them very vulnerable. I spent 13 years of my life in the community criminal justice and corrections area, getting folks out of our prisons and back into the community. Many times it made little sense to send them back to the family because it was so dysfunctional it was part of the cause of the problem. We would suggest that there needs to be support for family programs.

We would echo Mr. Kelly and Ms. Bradley's comments around funding as well. As a society, we will only get results if we invest. Our analogy would be that it makes very little sense or is imprudent to add a new wing to a run-down, dilapidated house and think you have solved the problem.

We have strong support for the idea of peer counselling. It has already been stated many times that those who have been through difficulty can gain trust, but this is not 1968, when we started. It is not good enough to say, ``Okay, you have been out of the withdrawal management and detox for six months, so we will now make you the clinical supervisor.'' Although I say that in jest, there is a certain amount of truth to it. We would suggest that peer counsellors need the proper training, accountability and certification. I will point out that in the United States, many states are moving to licensure. They see that as a strong plank in dealing with their problems.

Question no. 5 asks about the use of volunteerism. There is not as good a consumer movement in addiction as in mental health. That is a weakness. We would say that is because the self-help groups, Alcoholics Anonymous and Narcotics Anonymous, are quite separate. The point has already been made that many people can get help there. We would look for funds to be put into supporting consumers that can be attached to community or institutional programs. Again, we would say there needs to be training.

I have been in a personal recovery for over 30 years. Thirty years ago, I was able to access the system in Ontario. I have something to offer, not only at these tables but at other tables. However, I am not a clinician, and I am not sure I would be that effective as an attachment to it. I have a personal story, and that is powerful in its own right, but the kinds of problems we are faced with today and the people presenting with their serious problems need far more. I argue that we will get exactly the results we are prepared to invest in.

Wayne Skinner, Clinical Director, Concurrent Disorders Program, Centre for Addiction and Mental Health: Thank you for the invitation to be here today. It is an honour to be at this table. If there is national leadership in this area, it is coming from this group, and I think that is impressive.

I work at the Centre for Addiction and Mental Health. It has a provincial mandate in Ontario to do research and health promotion and prevention work and to provide treatment services. We are probably the single largest provider of treatment services for addictions in the country, and probably of mental health services as well. These issues definitely stir my colleagues, and it is a little humbling to be here today because there are so many others who could speak to this.

My background is in the Addiction Research Foundation, one of the four founding partners of CAMH, but in the last few years I have been working in the area of concurrent disorders, that is, people with co-occurring mental health and addiction problems, as well as the problem gambling area.

If there is a key message from our organization on this, it is that there needs to be a national policy in this area and that we would be committed to supporting it. We probably will continue to be a broken record in terms of that message, through this process and beyond.

That said I want to make a few comments for which I will take more personal responsibility rather than putting them on the organization.

The policy, as people are articulating around this table already and have said in other areas, needs to be consumer, family and community based. There needs to be a continuum of services. There is an interesting issue in what the relationship of this should be to a national drug strategy and to the national framework for action on substance use that is emerging. We would encourage strong links be made between these two areas, and it is important to think about that.

The other thing we need — and it has been referred to implicitly in our conversation already — is a larger idea of addiction than just substance use. We need to include problem gambling. We need to include other addictive behaviours.

Maybe prompted by Mr. Purvis, we need to have some positive notions of what behavioural health means and where addictions are located in a world where there are healthy behaviours and unhealthy behaviours and addictive behaviours need to be seen as a particular set that has huge costs for our communities.

In one of your earlier documents, you made the point that mental health has been living in the shadow of physical health. That point has also been made in the comments about the ministries of health and their preoccupation with issues from that domain. You point out that mental health deserves an equal footing with the physical health domain.

In the context of the work of this committee, one measure of success, from an addictions point of view, is that addictions be seen as an essential element in any policy statement on mental health. The issue of addictions needs to have a clear profile in any statement on mental health. Those of us from the ``addictions world'' will be looking to see whether it is tangibly present in that way; and I would like to flag that marker.

Another point has to do with what I call the revenue and funding imbalance. This can be illustrated with alcohol and gambling. We know that not everyone who drinks has a drinking problem, that 10 per cent of drinkers have a drinking problem and that that 10 per cent contributes over 50 per cent of the alcohol revenues. Recent research on gambling shows that not everyone who gambles has a gambling problem, that 5 per cent of gamblers have mild to severe gambling problems and that that 5 per cent contributes 35 per cent of the gambling revenues. The revenues to government and to the industries involved are being sponsored disproportionately by people who are negatively affected by these very behaviours. The problem is that our investment back into those groups of people is pretty woeful and embarrassing. That is one way of looking at the issue.

Mr. Stockwell has a suggestion for funding this area: Add money, but in a moral argument, one would say that some of this money should be going back. There is an argument for an investment. The issue is that government is increasingly dependent on these dollars, and I am most interested in Mr. Stockwell's comment on this. In conjunction with Mr. David Kelly, we have been writing about ways to look at a kind of behavioural risk insurance or a tax of one nickel per standard drink. If that were done in Ontario, the revenue would be more than double the money being spent on the entire addiction sector now. This imbalance between the revenue side of these issues and the investment in people with problems is a huge issue that needs to be tackled head on. I would be interested to hear greater discussion today on this view.

I will speak to the role of families and social supports. This derives from a broad level and from some recent personal involvements. A colleague and I have been working on supporting families affected by concurrent disorders. We have been trying to look at innovative psycho-educational materials and supports. It strikes me that the set of people affected by addictions is not only the number of people with the diagnoses but also includes families. The diagnosis of addiction problems has health consequences for them as well because of the preoccupation effect of having a family member with a severe mental illness and an addiction. Doing this work at ground level has introduced me to some heroic people who are willing to stay the course with those who are causing problems in their families' lives. We need to work with families in two ways: One is to stay involved and support them and the other is to realize that families are incredible resources. Supporting families so that they stay well and then drawing on their resilience as part of the continuing social support that people will need is important.

There is such a role at the national level through a kind of clearing house for information and connections to afford people the opportunity to find what is available, perhaps including guidelines for family support. Certainly, we know from our experience in this work that when we get families together to talk about these things, they find it powerful in terms of drawing a great deal of strength — observing a set of twelve people who met weekly over a three-month period to talk about these things allowed us to see tangible changes in their functioning and sense of well-being. We had to include issues about their own self-care as a key ingredient, which is important to have in the policy.

We have been suspicious about mutual aid for a long time but there is a growing evidence base that there is something to this. We have noted that these supports produce outcomes as good as those for formal treatments. Another role for a national clearing house of information would be to encourage people to look to peer support of various kinds, not just Alcoholics Anonymous or Gamblers Anonymous. There are many support groups available to provide a range of possibilities. This should be encouraged and supported to mobilize people in a community-building way. That should be part of today's considerations. It begins to locate treatment in a spectrum, of which we are only one part; other elements need to be activated and committed to if we are to have a national impact on these issues.

I will speak to the treatment system and make the argument for integration of addictions and mental health. My question is: What does integration mean? Many institutions are administratively integrated but you have to pity the people who expect an integrated care hospital upon admission. Generally, physical health and mental health are good examples of this, such that it is like going from country to country when having to go from department to department for those programs. It would be wrong to think that if we administratively integrate everyone we will create a better world. Rather, we need to think about integration in a functional way.

There is one way to create integrated practices that do not necessarily require dismantling of well-functioning organizations and sectors. There are strong traditions in both addictions and mental health that we need to try to preserve, and there are many gaps that we need to improve. When we think of integration, we must think of it at the level of the client. If it is client-centred then everyone comes together to make a difference in the client's life. Thus, there would be an understanding on the part of all involved. These jurisdictions are interesting. We all believe in holistic values and yet we have this fragmented world. The issue for me is how to go from holistic values to integrated practices. That is the practical challenge. The measure should be that there are demonstrated integrated practices and not just organizations that have been pushed together.

The organization that I work for was pushed together in a way, which has proven to be an interesting microscopic experiment. We realize that we have to make a continuing investment in our own integrated practices. We cannot simply sit back and rely on our name. We have a great deal of work to do to deliver integrated practices in our environment and be a resource that helps that to happen throughout the province and the nation. We need to switch the logic when we are looking at who is entering the specialized addiction and mental health systems. The systems are set up on the presumption that these people have primarily one problem or the other. People who work in those systems are good at dealing with one problem or the other. The logic should prevail that people coming into the addictions system and mental health system are more likely to have at least two co-occurring mental health and addiction problems. You should not have to prove that the person has one issue only. We live in a divided world these days, and so we see people coming in with complex problems who are being offered mono-directional solutions. That needs to be reversed, and there are ways of doing so. We need to be committed to a pragmatic way of working with people.

On Mr. Stockwell's comments about harm reduction, for people who have a straightforward issue whereby if they stop something everything will get better, you might want to say abstinence is the only solution. However, we are working with people with complex problems. There will be relapse issues and we have to have a longer trajectory of care that works with people over time. We need to start envisioning what a set of systems would look like that provides some of these integrated practices.

As a thinking tool and as way of wrapping up my comments, I want to introduce the quadrant model, which has been used by the Substance Abuse and Mental Health Services Administration in the U.S. in their report to Congress in 2001. They recommended it as a thinking tool; it is not something based on evidence but a way of thinking about things.

If you look in my speaking notes, it is better to give you a visual representation of this. On page 4, you will see the quadrant model as it is described in the SAMHSA reports. I want to use it to make a few points.

It says let us accept the fact that we have two systems and they are orthogonal; they are going in different directions. You have an addiction system and addiction clients and you have a mental health system and mental health clients; and you have a range of severities from low to high.

If we divide that into four quadrants, we will have one with low-severity problems but they do have mental health and addiction issues. You will have a quadrant with high addiction issues but low mental health issues and the reverse; and you will have another population with severe problems in both sets. How can we get this world organized so that even existing services can start to look at integrated practices?

If you look at the second slide and start to visualize this in a population view, you will see that the first quadrant, the low-low, has probably most people from a population perspective in that group. Most of our population have low to moderate mental health problems and/or addiction problems. The proper domain for dealing with those individuals is the primary community health care systems.

For people with moderate to high problems, the specialized system needs to be involved; but we need to keep in mind that fewer people have the more advanced problems. There are fewer people, but we know that the cost per case will be higher. They will need day treatments, in-patient treatments and detoxification centres.

If we go to the third slide and we want to start looking at integrated practices, without saying we have to rearrange the world and that we want to work with existing services, you could say for clients with low-low severity we should be looking to develop a community health care system that can screen for, identify and respond to these problems. Maybe they do not need specialized services. Maybe they need access to specialized services for consultation and support, but the site of delivery should be a community-based one, and it could be a generic one. It involves all the different sectors we have been talking about in terms of the particular populations — women, criminal justice and so forth.

When we look at people who have high addiction issues with low mental health problems, the lead agencies should be found in the specialized addiction system. However, they need to be connected to services that help them to provide integrated responses and the services need to be on the mental health side. Perhaps this fourth domain, of ``specialized integrated,'' as I call it, has not been created yet. We have teams that try to do it but maybe that is an area for development. The set of people who will need those services on a population basis will be the smallest, but we might have to be prepared to give them much more resource per case. We need to look at the ways they support clients as very extended. The ACT Team model of mental health demonstrates this. These teams are available for people for as long as necessary, including the life course. They have integrated addiction and mental health teams.

The final slide is on what types of care models we would be developing using existing mental health and addiction resources. This low-low quadrant needs consultative resources that specialized services can provide. The models for the high-low profiles are collaborative models, where you would have an identified lead. Then you need integrated care models, where you might have a single, confederated team to deal with people whose complex mental health and addiction issues require that you have solid resources available on a case-by-case basis.

If we look at this, one thing we could say — both as a credit and a complaint — is that the way we have provided care to now has been that people with complex problems have gotten help from these sectors in spite of that fact. That is a credit because it means many of these services have been willing to take people into care. However, they have not been geared up to deal with complexity; they have been geared up to deal with one problem or another. We need to build a system, through collaboration, integration and this consultative approach to the public health sector, where we are working with people because of their complexity, not in spite of it.

Mr. Brian Grant, Director, Addictions Research Centre (PEI), Correctional Service Canada: This is a great opportunity to speak about addictions within the context of the mental health/mental illness challenges.

As I mentioned in my introduction, I am the Director of the Addictions Research Centre in Montague, Prince Edward Island. This centre was established five years ago by Correctional Service Canada when it recognized that addictions were a severe problem that was not being addressed appropriately with the models that were in place at that time. We were not making progress in dealing with the addiction problems of our offenders. Our research at the centre is designed to meet the applied needs of the Correctional Service Canada, but we also work with partners in the community and many of those are represented here today.

My initial remarks are to set the stage as to what goes on within the correctional system. The correctional system is often much misunderstood, so some of these comments will give you an overview of what happens within federal corrections, in particular, on the addiction side and where the important issues within federal corrections are. Then I will get to some recommendations as to where we should focus.

The Addictions Research Centre is a unique Canadian resource. It is the only correctional facility dedicated to doing research in the area of addictions. It was established to address the challenges posed by the large number of offenders arriving at our facilities with addiction problems. Through effective treatment and research, we can reduce the impact of addictions on the offenders, their families and our communities. Effective treatment contributes to safer Canadian communities.

Addiction, and in particular, the addiction to drugs and alcohol, represents a serious challenge for all correctional agencies. Most offenders entering federal prisons have problems with substance abuse, either alcohol or drugs, that contribute to their criminal behaviour. Research has shown that reducing dependence on drugs or alcohol reduces the likelihood that offenders will return to custody after they have been released.

In addition to the issues of crime associated with addictions, health issues are extremely important within the correctional service. Injection drug use contributes to the spread of diseases such as HIV/AIDS and hepatitis C. Reducing the demand for drugs will reduce the spread of these diseases within institutions, and from the institutional population to the communities when these individuals are released back into their home locations.

Since the Addictions Research Centre was created, a great deal of effort has been directed at developing partnerships with other organizations that are also interested in the problems of addictions. While more than three- quarters of offenders entering federal corrections abuse alcohol or drugs, these offenders are also part of the communities from which they come.

They include some of the higher-risk clients of community treatment agencies and frequently have the most serious addiction problems, having used a variety of substances from an early age.

Either before entering prison or after release they are likely to become part of the caseload of addictions agencies. By coordinating the efforts of Correctional Service Canada and community treatment agencies and understanding each other's perspectives, we are better able to meet the needs of offenders suffering from addiction problems.

A smaller percentage, but a significant number, of offenders also suffer from mental health problems. Many of these offenders are also addicted to drugs and alcohol and we must work to assist them with these challenges.

Our mental health facilities provide primary care for offenders with acute mental illness, but all offenders have access to treatment for addictions. The Correctional Service provides approximately 3,000 to 4,000 treatment activities each year; that is, there are that many people involved in treatment programs. In addition, many more offenders participate in self-help groups like Alcoholics Anonymous and Narcotics Anonymous. The level of treatment depends on the severity of their drug abuse problem. We offer programming at three levels of intensity — low, moderate and high. In addition, there are maintenance programs both in the institutions and in the community.

In addition, and recognizing some of the discussions around the table, the Correctional Service has, over the past few years, been developing programs that meet the needs of specialized groups of offenders. In particular, our women offenders' program, which has been fully implemented across the country, has been uniquely designed to meet their needs. We have also developed an Aboriginal program that uses cultural-based ceremony to address some of the challenges faced by Aboriginal offenders.

Research is a critical area for funding for development within the addictions community. Twenty-five years ago, Canada was a world leader in addictions research. It has fallen off that pedestal since. We have the people and the skills in Canada and we need to bring up the level of research we are doing so that we can be sure that what we are offering to Canadians through other kinds of treatment interventions is effective. Research is an investment that ensures that the product you deliver will be the best possible.

The other area that we need a lot of work on in Canada is coordination of effort. We have been seeing that a lot in the last few years, and that is a fantastic opportunity. That change has occurred through the leadership of CCSA and Health Canada. The national framework on substance abuse is an example of how we might be able to pull together.

I strongly endorse the concept that we need more research and more coordination of effort, bringing together the various groups that contribute to addressing the problem of addictions.

Michel Perron, Chief Executive Officer, Canadian Centre on Substance Abuse: Thank you, Mr. Chairman, and committee members. It is always an honour to appear before you.

On behalf of CCSA, I wish to congratulate you on your work to date. This is a daunting task. We know that there are many and varied needs. Everyone has an opinion; everyone knows that he or she is right, and you have to navigate through this and find a path forward.

I do think that you are on the right track. There are some tangible steps that can flow from this work that will make a difference to Canadians. Notwithstanding the immensely complex and complicated world we are dealing with, much can be done.

[Translation]

The Canadian Centre on Substance Abuse is Canada's national non-governmental addictions agency, formed in 1988 by an act of Parliament, to address research and policy on substance use and abuse in Canada.

From our perspective, the Senate committee's examination of mental health, mental illness, and addiction in Canada highlights one of the most important issues affecting the addictions field today. We strongly agree that a more integrated, consistent and efficient system is needed to ensure the proper identification and timely delivery of evidence- based treatment services to clients challenged by mental illness and addiction.

We strongly endorse a model that is client-driven — as you mentioned in your first report — and one in which treatment accurately matches the client's needs, not only in terms of the severity of the problem, but with a view to the client's ethnicity, gender and age.

We believe that the committee's interim report sends an important message about mental health and addiction and today we would like to share with you our reasons for believing that.

[English]

Our position is quite clear. We fully support a new model for the coordinated delivery of mental health and addiction services to Canadians, and we believe that where appropriate, such a model requires a careful and strategic integration of approaches to treatment of mental health problems and addictions.

We also want to underscore that we need a national system rather than simply a federal or provincial one. The point made earlier about coordination is critical to how we wish to move ahead. We need a strong national system that brings into play not only governmental systems, but the not-for-profit sector and the private sector where appropriate.

As the committee is aware, a sizable proportion of individuals with a substance abuse problem also suffer from some form of serious mental illness such as schizophrenia or major depression. Indeed, research suggests that about one third of individuals who are dependent on alcohol also have a psychiatric diagnosis, while about half of those who abuse illicit drugs also have a mental illness.

It is important to note, however, that there is another stratum of individuals whose substance abuse is related to a less severe mental health issue and who often go unnoticed in discussions on concurrent or co-ocurring problems. The model that was presented earlier shows that gradation of need.

[Translation]

Second, it is our perception that the mental health and addictions treatment systems in Canada frequently operate in mutual isolation with little or no communication, collaboration or sharing of ideas — much less any clinical coordination of client treatment and care. Despite the complex interplay of mental illness and addictions, it appears that mental health professionals rarely look beyond a client's mental health issues, while addictions professionals tend to see only the client's substance abuse problem.

Clients with needs in both spheres are frequently bounced back and forth with no comprehensive and logical treatment plan. Clearly, this does not constitute optimal client care, nor is it efficient or cost-effective.

[English]

We have, however, witnessed amazing strides in the development of integrated theory and evidence-based practice in addictions in the past 10 to 15 years, with much of this work contributed by Canadian researchers and practitioners. The evolution of theory and practice development has brought the field of addictions into the 21st century, making collaboration with the mental health field all the more possible. In fact, we would argue that cross-fertilization has already started. Many recent developments in addiction treatments, such as relapse prevention and motivational interviewing, have been quickly adapted for use in a broad range of health and mental health settings.

Finally, new developments and advances in the biology and genetics of addictions are sparking technological innovation that warrants a meeting of the minds, in particular between the fields of health and addiction, as we look ahead. From our perspective, mental health and addiction partnerships are the logical way forward and we predict that the field of addictions will be transformed dramatically in the next 10 to 15 years.

[Translation]

However, while closer collaboration between mental health and addictions offers a clear benefit, it is also important to recognize the uniqueness of each field, and that addictions cannot simply be subsumed within mental health or vice versa. While there is clearly overlap and commonality among some methods and approaches, the behaviour associated with alcohol and drug consumption, problematic gambling, and other addictions is unique and requires specialized intervention.

Further, the backgrounds and professional credentials of those who deliver mental health and addictions services are often different, as Mr. Wilbee mentioned. Whereas more mental health professionals hold advanced post-graduate degrees than those working in addictions, there are more addictions service providers who themselves were involved with substance abuse. Our recent survey of the addictions treatment workforce in Canada bears this out: 60 per cent of addictions workers had a university degree — mainly in nursing and social work — but only 17 per cent had a master's degree. On the other hand, 19 per cent to 46 per cent of workers reported a personal history of substance abuse.

By contrast, it is our observation that the majority of mental health professionals hold advanced degrees, including doctorates in psychology and psychiatry. We believe that these differences in professional training have the potential to hinder collaboration, but they could also be viewed as holding considerable promise for innovative approaches to mental illness and addictions involving the use of professionals and paraprofessionals alike.

[English]

As has been pointed out, CCSA has collaborated with Health Canada and many other partners recently to develop a national framework for action to reduce substance use and abuse and, essentially, to coordinate the work that is happening across this country. The framework contains a vision statement, clear principles of the goal and a list of priority areas where action can lead to concrete and measurable results. This is a comprehensive model that reflects a full range of approaches that was referred to earlier as well, from health promotion, detection and prevention, to treatment, enforcement and harm reduction. At the heart of this model are partnerships with key stakeholders.

I mentioned to Senator Cochrane that we have a poster up at the office that says: ``Ready, fire, aim.'' That seems to at least replicate a little how we approached this problem in the past, notwithstanding good intentions; that there is such a visceral need to address the key problems that sit on our table and come through our doors every day that we do not necessarily take that step back. While the framework can be characterized as a little obtuse or esoteric, it is meant to be a starting point under which we can marshal our efforts. It is not done at the behest of working on real issues.

A number of priorities have arisen that need particular attention, such as First Nations populations. In addition, the issue of stigma is one that we are wrestling with and there will be a workshop on this in short order, led by our colleagues in British Columbia. We are dealing with issues of language, which are a huge impediment in our field. While seemingly innocuous, these issues are precipitating some of the collaboration problems.

One of the priorities that should be in the framework is on concurrent disorders. At least that is an area where we can say that this is where the merging is needed. We have to sit down and, as a first step, try to see how we can address that issue.

The national framework is a model that could be applied to, or at least inspire, some of the work around mental health and addictions. My colleagues and I would provide more information if you feel that is appropriate.

In closing, the development of a new system-level model for a collaborative approach to mental health and addictions will involve a detailed review of the way in which funding is sourced, allocated and managed. We believe that funding for research is critical to forming new approaches to service delivery to Canadian consumers and to evaluating their efficacy. The need for increased research on early detection and prevention work and for a national information database has come to mind as an important target for funding.

We often fund way downstream, and we need to conceptualize the value-added return on investment for funding upstream. Funding upstream is not as sexy, if I can use that term, simply because it does not provide that immediate return on investment, at least a visible one, particularly at the political level.

[Translation]

We appreciate the opportunity that the committee has given us today to present our views on mental health and addiction in Canada. We believe that the mental health and addictions systems are at a crossroads and we are excited about the prospects for developing an integrated approach that will better address the needs of Canadians.

We are prepared to assist and support you and your colleagues in any way that we can as you consider changes to the mental health and addictions system in Canada.

[English]

You are being asked to do it all, essentially. Everything is a priority. There is a need for new monies. That said, it needs to be organized well. There is a significant amount of money being spent on this system or this collection of systems, as your report points out.

How can we ensure that we are not all doing ``ready, fire, aim?'' How we can ensure that we are undertaking the right roles and responsibilities as key constituents in this field is where the focus needs to reside.

While there is a need to aggregate different types of addictions and so forth, you can get to such a high level of aggregation, you wonder who owns it. That is one of the inherent challenges. At the end of the day, systems that sit below policy discussions are the antithesis to collaboration. Budgets are not funded that way. Organizations are not performance rated along those lines. Addressing those key underpinnings that might prevent that collaboration is needed as we move along.

With that, I will close and thank you for your attention.

Staff Sergeant Michel Pelletier, Director, Drug Awareness Services, Royal Canadian Mounted Police: Honourable senators, first let me apologize for my tardiness in preparation. I had to deal with the loss of one of my colleagues and with coordinators in Whitehorse overnight. However, I felt it was important to come here to answer your questions and I am humbled by the invitation.

This morning I represent both the RCMP and the Canadian Association of Chiefs of Police as the technical adviser to their drug abuse committee.

My career spans over 30 years. During that time, I have been engaged in a balanced approach. In Montreal I worked in enforcement, the traditional role of policing, and supply reduction. The latter part of my career has been as Director of Drug Awareness Services in Canada, with the RCMP and the CACP.

I take a more pragmatic approach to some of my colleagues around the table with whom I have been happy to deal and collaborate with over the years. I come here first to clearly identify where the police find their role in addictions and mental health.

Policing has traditionally been seen as having an enforcement role. The reality is that policing is prevention and enforcement, and we have also been diverting people to treatment. Treatment may be globalized as harm reduction. When we talk about dealing with people, which I did when stationed in Montreal and worked at a treatment centre in Portage, in today's world we divert them to treatment. There are often times when we have to ask where we can divert these people.

I looked at the questions that you proposed, and one of the weaknesses that I see is that we need more treatment; specifically, the priority should be for youth.

Traditional policing also looks at abstinence as the way to treat people. We leave that for our health experts to decide. However, when we look at the importance of treatment, we look at diverting young people to treatment. When we look at your second question, we see fetal alcohol syndrome as a major problem, and that is being addressed presently by the government. There is a need for additional resources in that area and to ensure that people are familiar and used to working with the Aboriginal communities.

Even on the enforcement side, we need training in how to deal with people who have FAS/FAE, for instance, in terms of interrogation. On the prevention arm, we find we have a role to deliver that kind of prevention to young men and women who are affected by FAS/FAE.

The colleagues I have worked with will know that one of my pet peeves is neonatal abstinence syndrome, which is caused by utilizing drugs during pregnancy. It is critical we have more research done in that area. Our common sense tells us that if there are effects on newborns because of smoking and alcohol, that the use and abuse of drugs will also cause symptoms. We are looking at prevention from the very beginning.

I want to thank the addictions people with whom we have worked over the years. In the Drug Awareness Services we have had the important collaboration from all provincial addiction agencies in developing prevention programs for police officers. In essence, we have been your pony express. You have been able to help us develop the messages and we have gone out and delivered them. We hope to continue to do that.

I intend to stay as long as I can today to answer your questions. However, I know that much is out of my area of expertise when it comes to the issues of health and addictions.

The Chairman: I have asked Dr. Stockwell and Mr. Kelly, and I am now asking Mr. Perron, because the three of them in various capacities have costed out the impact of the proposal for a nickel a drink and translated it into dollars, whether that means just alcohol served in bars and restaurants, or whether it means you treat a bottle of wine bought in an LCBO store as four drinks and therefore is that 20 cents, et cetera. Dr. Stockwell will do it, but I know some of it is being done for Mr. Perron's organization.

This committee has always made a point of not only costing its recommendations but saying where the money should come from. We were roundly attacked for suggesting last time that the health care system needed an extra $5 billion, which is what the government ultimately gave, and that it ought to be raised through a national health insurance premium. It was simply because we should offer a way of doing it and, second, it was our view that the way you would begin to get Canadians to understand that health care is not absolutely free, which is the current perception, is if there was an earmarked tax targeted at providing them with the service. Even if the government did not need the money they could lower taxes somewhere else and have a national health insurance premium. For a variety of reasons that has not happened, although I am willing to bet that in our lifetime it does.

If we are to propose new money, which obviously the system needs, the way to do it is with a targeted tax, and we can figure out whether the nickel is the right number once we know the cost of our recommendations. I asked Dr. Stockwell to do it with help from Mr. Kelly and Mr. Perron, and it needs to be before the November deadline.

I have heard some mixed views on the question of whether to integrate or not. Mr. Skinner's comments and his charts are a middle ground, in that they indicate the quadrant approach, which works, and I would like to know are we at the two ends of either integrate services or not? What is the other reaction to the quadrant approach? Is that the way to go?

I open that up for comments. Does anyone have any views?

Mr. Grant: It is an interesting question and I had some answers to your five questions in my documents. I did not go through those, but it came up in my department as I was preparing to come to the committee because in my notes I suggested there are problems with fully integrating because very often, addictions get overshadowed by the mental health side.

As you might expect, our people responsible for mental health did not like the fact that I was inconsistent with their approach. I was asked, ``Are you against this?'' The answer is no. There is no reason to be against integration where it results in improved service for the client.

That is in that upper right-hand quadrant in Mr. Skinner's diagram, where you have a serious mental health problem and a serious addiction problem. It makes a lot of sense to have a fully integrated approach.

There are a great many people in that area. In Mr. Skinner's report, he talks about collaborative care, where you might have a high addiction problem but not a severe mental health problem. That is where we find ourselves in Corrections. While 80 per cent of our people who are suffering from mental health problems also have some kind of problem with drugs and alcohol, only 20 per cent of those who have a drug and alcohol problem also have a mental health problem. It depends on how you look at the picture.

The Chairman: Twenty per cent of those with a drug and alcohol problem also have a mental health problem.

Mr. Grant: Yes. Those are the people that an integrated care model might approach. A large number of our offenders who have a drug and alcohol problem do not have a mental health problem that has been identified in the past. A large number of people do not need to be addressed with services through a complex health model. They can be addressed through a much more effective addictions treatment approach.

Mr. Purvis: Regrettably for me, Mr. Skinner is far better spoken than I am. I do not think we disagree. The term Mr. Skinner used was ``functional integration.'' I do not think anyone disagrees with functional integration. What we disagree with is systemic or administrative integration for the sake of it.

We believe every door should be the right door. This should not be a burden for our consumers. No matter where you wind up for service, the service you need should be provided there. We should build capacity both within the systems of addictions and the systems of mental health. We should have knowledge of the most current co-morbid situations. We should have a fully integrated, fourth quadrant, severe-problem team. No one is disagreeing with that. The way I represented that initially was done better by Mr. Skinner. If you look at it as functional versus systemic integration, no one disagrees with functional integration

Mr. Stockwell: I take those two points. I think the quadrant model lays out the reality of the problems that have to be responded to. There are great numbers of people with just mental health problems, and you have to manage the substance use issues there, their addiction with a small ``a'' rather than big ``A,'' and vice versa. When people are controlling their substance use problems, there are many emotional and mental health issues to deal with, but they are not often at the diagnostic level. If you chart people's mental health when they come off alcohol or heroin or cocaine, what they present with at intake is more severe than two months or six weeks down the track, because as they come off their substances, depression and anxiety and a range of other mental health issues sometimes have just vanished. Usually, they are far less problematic than they were. This dynamic we often hear about is what percentage of people with mental health issues have addiction problems, and what percentage of people with addictions have mental health problems. It is all in flux. In managing either, you need to be aware of the other.

How we organize our services to respond to that reality has been summed up well. We need the systemic with some separate administrative. We need someone to speak out for the field so it is not lost within a big mental health bureaucracy, but we also need that integration to happen functionally.

In Canada, there has been a bit of a loss with ARF. The Addiction Research Foundation preceded the Centre for Addiction and Mental Health and was one of the largest, most renowned groups internationally. Canada was a real leader then. It has lost a lot of its capacity to speak out strongly on addiction issues in the intervening years. I do not think with that you necessarily carry this idea that it will all be separate and not integrated.

Ms. Bradley: I think the way that Mr. Skinner talked about it is true. I think of it in a linear way. People have various degrees of illness, whether it is addiction or mental health, and it is where you put your resources along the continuum. I see the most severely compromised people who have severe mental health and addictions problems on the continuum where we need the integration and the expertise of both.

The vast majority of people who come to our system can be treated in more of a community model or a less intrusive model. It probably needs to include residential services, but if you compare the cost of residential services in the community with residential services in a hospital setting, it is dramatically different. It is how we will decide how to set this up.

Going from promotion and early intervention work right through to the furthest end of the continuum does not mean that those in the middle do not need some collaboration with the service providers. That is often the medical system, because sometimes we need medication to be prescribed. We may need a short hospitalization. We may need some assessment. Certainly, assessment for addictions can be done in the addiction community, but sometimes you need something a little broader. There is a grey zone where we need to also work a little more effectively, and then, at the end, work really effectively.

I think it is up to the service providers, both in mental health and addiction hospitals, to work collaboratively with that grey zone, but the vast majority of people do not need that kind of service.

Mr. D. Kelly: When you look at the community sector as a whole, and I do not mean just addiction providers and mental health providers, it is also long-term care and it is children's services. It is a maze. We should be moving to a point where there is no wrong door and it is the obligation of those community providers to ensure that people are getting to the services that they need. We will see a system that will develop so that if it is mainly an addiction, we will have addiction providers taking a lead. If there is an addiction and mental illness, either they have that expertise within the addiction agency to address it or they make sure that clients are getting to the person who can best serve them.

It is the same in the hospital system, where we often see the homeless person discharged out to the bus shelter. All that does is perpetuate the next costly visit to emergency. We need to change how we look at it, and the integration that needs to happen to get people to the services they need.

The Chairman: I do not think anybody would argue that integration is not a good thing, but it is hard to think of anything that is more easily said than done. To try to get that done on the ground, given the size of the various organizations, given the turf protection of all kinds of people — and to get back to the fact that we try to be pragmatic and not theoretical — how do we do that? What do we have to recommend to make that start to happen, either by brute force, if that is what is required, or by incentives? How do we actually get it done?

Mr. D. Kelly: It is a combination. It should be mandated. People will often say, ``This person falls outside my mandate, so I have no obligation to address the issues.'' It is happening at the community level. Community health and mental health and addiction providers and long-term care providers are already doing that, to a large extent — unfunded, but they are following that process.

It is a matter of getting the medical system to begin that kind of work to ensure that that person is taken out to those community services.

Mr. Perron: I have a couple of comments to give you a glaring example of how this can play out. At the provincial cabinet level, most heads of liquor control commissions report to economic ministers. The ministers might ask for increased sales to boost government revenues. The LCBO remitted $1.3 billion in profit and its revenue was approximately $5 billion. How much did they allocate to social responsibilities and other matters? The fact remains that while the head of the LCBO claims that there is a desire to be socially responsible, the position falls under an economic minister. Why is that person not under a health minister? Where is that discourse at the cabinet table? It is an interesting example of how the system falls apart at the macro level, at a small table.

We need a champion to get this done — one who will not hedge the bets on one player at the table. The CCSA's structural model might serve as an interesting one for the mental health world because we do not play the role of government, but rather we interact with government and we try to be its conscience. That role is important. The best way to sustain the attention that this committee is providing is to turn your minds to a practical form.

We have to be specific when we talk about systems such as the alcohol industry. In saying that, who do we mean? Are we referring to the manufacturers, the associations, the licensers or the regulators? Let us speak to the details. While we need system collaboration and integration, what do we mean by ``addressing the continuum of care?'' Much of the discussion today is about when care is required as opposed to preventive care. We have to look at that continuum of care well before someone presents with some illness and troubles. You need a champion; you need to be specific about it; and you need to effect change at the macro level and at the community level to address how communities are funded and remunerated and how their grants are working. You need to reach that level of specificity.

Mr. Skinner: I like the quadrant model not because it is right, but because it is useful. Mr. Perron, your pragmatic appeal is truly important. My question is: Do we have to wait around until the perfect system is designed or is there a way to derive change now? That model helps to organize how change should happen and it describes roles and activities, of which there are three. Specialized systems should support the community-based system in a consultative role. They should be collaborating with one another on clients who have complex needs. Either they should get out of the way or join up to ensure that services for people with serious mental health/addiction problems can be provided by integrated teams. There is strong best-practice evidence that that is what helps individuals the most. I want to see something happen without delay and so I recommend that model.

Conceptual discussions can take place and some people will want to punch a hole in it, but it is a useful heuristic tool. In Ontario we have been trying to work with concurrent disorders. We have begun to use this tool as a way of getting organized. When we truly want to do something, how will this look? Well, this tool can be applied at the ground level, and that is what I like about it.

For all addiction and mental health agencies we use this notion of two constructs: Is the agency concurrent- disorders capable; and is the agency CD specialized? In our view, a CD-capable organization in addictions and mental health would be able, at a minimum, to identify concurring problems in a client and refer the set of problems that it could not deal with. Part of the work everywhere needs to include the recognition that people often present with complex cases. The more people step into the specialized system, the more likely it is that they will have complexity. We need to have the CD-capable response and the services that are CD specialized. In that way, they are able to work with people because they can bring together the set of resources needed to deal with difficult cases. At times, the diagnostic issues to which Mr. Stockwell referred are huge. At one moment someone may seem to be psychotic and suffering from a major mental illness, but when detoxified, the person appears quite normal within one week.

In Ontario we have been trying to get people into methadone treatment over the last decade. We had to do in the 1990s what you are trying to do in Atlantic Canada now. We were able to increase the available methadone treatment, but in our clinic we found that two or three years after methadone treatment, these individuals showed mental health symptoms; typically, they were depressed. They were in methadone treatment and had social things happening, but they were unhappy and depressed. Likely they had issues that made them use drugs in the first place. Having a drug- using career messes a person up, so when they are sober and trying to deal with all kinds of emotional content that arises, they find that they have no way to do that successfully. Therefore, we had to offer special programming. We set up a group for methadone patients who had mental health issues, which surfaced only two to four years after the methadone treatment. You have to have a dynamic notion of what people need and let the clients lead you, because they will identify the hot issues when they come into care. You might tell them that they are eligible for more programs but they might say they have had enough, thank you. We need to maintain an open door so that the client can ``drive'' and that set of well-known services to connect the client. Then we play the game, which has to be client and family driven. We need more ways to enhance that pragmatic side of the issues. The model begins to drive the more collaborative conversation.

Mr. Wilbee: I agree with Mr. Purvis: Do not ever follow Mr. Skinner. My thought on your basic question is that none of us is arguing against integration. However, what does that mean and how is it to be implemented? Whether using the carrot or the stick, accountability comes to the funders. If you are handing out the cheque, why not demand accountability and mandate the activities? There needs to be incentive. In my experience over the past 13 years, I have found that the ``my turf'' attitude has diminished to some degree. I have talked to people in the community who have said that there might be battles at the provincial level, but at the community level, everyone gets along fairly well.

We need to consider the vastness of and the differences in this country. It is one thing to do this kind of integration in a major urban centre, but it becomes a different kind of challenge in rural or other areas, not just in Northern Canada. For example, when a person presents with a psychotic episode or has a need for withdrawal in a major centre such as Ottawa or Toronto, emergency wards have the necessary resources. However, it is a different situation for a general practitioner in a smaller community who gets called into the emergency ward. However, it could be that the smaller centres and communities develop better collaboration. I simply wanted to share that with you today.

Ms. Bradley: I will speak to the concurrent disorder issue and the range of issues. Many clients will have concurrent disorders, especially women. They will have anxiety, depression, for which they will use alcohol or drugs to try to help them through. The issue of sexual assault is often a longstanding one for which they use alcohol or drugs to numb the feelings. However, I would not say that these people are severely mentally ill at this stage.

They have some issues that we need to work collaboratively on, but for the more severe at the end of the spectrum is where we need more of the integration.

I wanted to give you an example of a pilot project that Mr. Skinner referred to that is happening in Toronto. We have brought a group of service providers together and we will have formal memorandums of understanding. We have a community agency, a hospital, a housing agency — a number of agencies that we think that the clients will need. We will have a point person who will be at our organization for this particular project. Anyone who identifies any of these people in the community calls a point person and we get the action going.

If they need to be hospitalized, assessed, whatever it is, that is where we go. We have a formal agreement. It is a small pilot project, but you are asking how we can do this. This is happening in a metropolitan, large city, but these are the people who need to be involved if we are to make a big difference in the lives of clients.

Mr. Purvis: Over the last 14 years I have worked in both systems. My trade is as a registered psychologist and I have been on the front line in a mental health clinic and in addiction clinics. I have acted as director in both so I have a vested interest in both consumer groups.

Having said that, I need to be cognizant of the fact that providing medical treatment within a mental health setting such as mental health short-stay units that are psychiatrist and physician run is about twice the cost of providing in- patient beds within a detoxification centre. That is the most expensive part of what we do. Community-based services, day patients, day programs and day detoxification are far less expensive.

We take a behavioural approach versus a medical approach to what we do because most best practice that is coming forward indicates that is what is working; therefore, we are more cost effective. The number one and number three cost drivers to the health care system are addictions — nicotine number one, alcohol number three; sedentary lifestyle is number two.

Keeping in mind how much it costs, even though it is probably only the third most prevalent disorder, we cannot afford to handle addictions poorly. Our health care system cannot afford to do them poorly. It is important when we look at how we are going to best serve the clientele; no one is arguing about integration at the severe end, but I think everyone agrees we need to look at building capacity within the system. My answer to your question, senator, is that I believe we need to look at competency sets.

We know what needs to happen within the addictions field. We know the most common coexisting disorders — mood disorders, anxiety disorders, post-traumatic disorder. We need to provide the competency to address those issues with our clients because they arise frequently; and we need to ensure the capacity in the mental health system. That would allow us to maintain our specialization and the uniqueness within both systems. There needs to be funding to ensure that capacity gets build in, as well as for fully integrated, severe addictions/mental health problem treatment.

Senator Keon: Let me thank all of you for providing an extremely interesting morning. As I listen to you and others on this enormous challenge, I think there are two major problems confronting this entire area. One is integration and the second is funding.

I have a comment on integration. Since you have all made your contributions, I will not ask you any further, but I will ask for contributions about how to fund an integrated system.

Integration interests me because I spent my whole life working on it. For 35 years of my professional career I worked on an integrated cardiac care system for Eastern Ontario and Western Quebec. I integrated 42 hospitals between James Bay and the St. Lawrence in Eastern Ontario and Western Quebec into the Ottawa Heart Institute hub; integrated the primary care services in those cities into the Prevention and Rehabilitation Centre of the Heart Institute; and integrated the family physicians into the cardiac care of the 50,000 patients per year who walked through the Heart Institute doors.

The barrier that I could not break down was the lack of community services, because there were no community facilities. When you reached the point where you needed the combination of medical, nursing, physiotherapy and other health professional services and social services, they were not there. This is the big failure that I will be asking you to comment on in a minute. This is the big failure that all health professionals in Canada have been guilty of as we spend all our time building the top-end tertiary services. We have done nothing about primary care and community services, and now we are left with this huge hole and consequently cannot build our systems.

Let me give you a tip, though, for when you set out to integrate something. If you are to be successful, there is one principle: Integration is not ownership. Every time you step out to talk to someone, the first thing out of your mouth should be ``Integration is not ownership.'' Then you can begin to have a conversation.

The second thing is, let us agree that our thinking will follow a patient. Wherever the patient goes, we will collectively try to provide the best service we can.

In what success I enjoyed — both at the local level here in Ottawa and subsequently for Elinor Caplan, when she was the Minister of Health for Ontario, in establishing the Cardiac Care Network for Ontario, I stuck to those two principles and they paid off very well. I do not think it is any different in mental health, although your problem is much more monumental.

Let me come back to some comments that were made by virtually everyone around the table, but to focus on them, David Kelly, Dr. Jon Kelly and Tim Stockwell's comments are the most important. Leading maybe with Dr. Jon Kelly, we can get into a discussion of this, because you hit something bang on when you said the problem with ministries of health provincially is their doctor/hospital systems. I was one of the major offenders because I was both a doctor and a hospital administrator my entire life and I used this influence to get what I wanted. Now that I have been to confession, I will try to do something useful from here on in.

Let me have you people around the table address this issue. How will we ever break this total control? You look at provincial ministries of health and the people in control are either doctors or hospital administrators. They move out of the system for a little while and get rich. When they are rich enough to retire, they go back and become deputy minister, because the pay is small. Their thinking is absolutely pervasive.

Consequently, there is no money for the most important needs that the health system, and in particular the mental health system, now faces, that is, primary care, community services, psychological counselling, social services, et cetera.

I have put it on the table; now solve it.

The Chairman: We did not say that this would be an easy day for you.

Mr. Stockwell: First is the tax solution, which I think the general public would bear. A nickel a drink would generate from $750 million to $800 million a year in Canada. The best mechanism would be an excise tax on alcohol. A sales tax like the GST does not hit the very cheap drinks that are the most misused as hard as an excise tax.

The Chairman: Are you counting wholesale or just drinking at a bar?

Mr. Stockwell: Everything.

The Chairman: Do you convert a bottle of beer to one drink?

Mr. Stockwell: Apparently a standard Canadian drink is 13.6 grams. It is a bottle of beer, a medium-sized glass of wine or a drink of spirits.

The other issue, which is probably even tougher than taking on the doctors, is the pharmaceutical industry with regard to the cost of drugs in the health care system. It is a huge money-gobbling enterprise. We do not need new drugs. The new ones that come out are effectively no different, we are investing billions in that enterprise, and the cost of health care is going up astronomically to fund these new drugs.

I know that doctors are paid pretty well, but you need funding mechanisms for the primary health care portion, which addresses the great numbers of people who are beginning to have problems or already have problems and are not in touch with special services. The poor GPs and their support staff need systems to address that, and they need to be carefully streamlined and built into their ways of working so that they are not a huge extra burden. They can be designed to assess a range of lifestyle issues, including substance abuse. They need support services that are not scared to ask the questions when they do not know what to do with a person once they have identified a problem. These need to go hand in hand, and they need some way of billing for that time and that service. As I understand it, it is not always the case that they can do that. There are successful models in the U.K. and Australia of funding that practice in primary health care.

Senator Keon: You are fundamentally saying that there will have to be new money for new ideas because you cannot leach any money out of these powerful people.

I must confess that I prescribed red wine as a drug throughout my career because it is the most powerful anti- oxidant known. When I operated and saw a terrible-looking heart, the first question I asked the patients before discharge was whether they had a drinking problem, although I already knew the answer. If they did not have a drinking problem, I told them to have a couple of glasses of red wine every day, to take an aspirin every day, and to take B-complex vitamins every day.

Many doctors are telling their patients this, so with regard to taxing alcohol, red wine should probably be tax free for seniors. Their drugs are free.

Mr. Stockwell: With regard to red wine, the science shows that if there is a benefit, it is in beer and spirits as well. There may be some extra magic in red wine that you can also get in red grapes, but it is the alcohol.

The argument about whether we should treat alcohol as a health product and subsidize it rather than taxing it comes up, and we have to get that in balance. Taxation is a very controversial tool, but it affects most harshly the people who drink the most. There are issues about it being regressive and what to do about disadvantaged poor people, and that needs to be debated. It will cost those who take one drink a day to get the maximum health benefit five cents a day. If you start making exceptions, the whole idea unravels. I know you have your tongue in your cheek, but it is a serious argument. People say that it should be treated as a health product. That is wrong because the costs outweigh the benefits.

Mr. Perron: I want to speak primarily to the question you posed with respect to the deputy ministers, but before going to that, we have to acknowledge the elephant in the room that no one seems to be tackling, which is that notwithstanding the need for looking at meaningful taxation processes for alcohol, volume content and the like, the government already collects a tremendous amount of revenue from this product and it is not earmarked for the right purposes. Although it may go to other good purposes, at the end of the day we should acknowledge openly that the government continues to encourage activities that they know will cause harm, such as gambling, notwithstanding that resultant harm and the commensurate amount of front-end investment that is needed.

While we need to look at taxation, we must also hold accountable those who are receiving major revenues from this for why they are not earmarking a portion of it for health costs.

I would say the same with regard to proceeds of crime and illicit drugs. We have talked about earmarking funds from proceeds of crime for years and have got nowhere.

With respect to the deputy ministers and how to break that system, we must differentiate between a bureaucratic system and a politically driven one. Where do the senior bureaucrats, that is, the deputy ministers, take the heat and where do they run with it? Often, it is tainted or at least spun by the political priorities of the day. Access is all we hear about today, and it is what rises to the top of the political barrel.

We need to focus on the senior bureaucrats, as they have a role to play and there is a balance between driving a ministry and a minister to engage here. We need to make the economic argument, and it is there to be made. They get tremendous push-back by saying that access is a political issue and is where we are moving. It is classic.

To wrestle with this we have to educate and build a business case that shows our politicians, who are well-meaning, of course, that this is an area to invest in, that we can have a return on investment and that it is not either/or. This is critical. If you want to ensure that the deputy ministers execute it, put it in their mandate letter and have the prime minister put it in the mandate letters of cabinet ministers. The same should be true for premiers. That is where you get the attention.

I have talked to deputy ministers in the past about addictions. They say that the Canada Health Act has major issues. One of the biggest challenges for addictions in the health system is that ministers have to choose between MRIs and junkies, to be blunt. There is no political traction, notwithstanding the visceral need to address this marginal population, when we also need to do MRIs.

I think we need to populate all levels. We have to be specific, but it is up to us, the practitioners, to build a business case.

We are certainly getting to that point.

Senator Keon: Coming back to the question that I would like to see all of you address, do you think there has to be new money? Do you think there is any possibility of diverting money out of the current system?

Mr. Perron: Do we need new money? Yes would be the easy answer, but there is a lot of money being spent already, not necessarily most efficiently. At the highest level, there is not enough attention to optimizing dollars. There is absolutely a need for greater investment. If you look at the proportionality of harm resulting from alcohol and drug abuse and the investment made, it is miniscule. From a basic economic argument we can make the case that you need to put more money there. Why is more money not being put in? Again, this is not a real attention getter. Nobody wants to talk about these issues. There is not a significant amount of political traction there. The money does not only have to come from the federal government, it has to come from the provinces, the regional health authorities and the private sector. There is money being put in from the not-for-profit side as well.

Looking at the current dollars in the system, optimizing how they are being used is a priority. Looking at new sources of funding is very much needed. We must be accountable for how we spend those dollars. If it does not work, stop doing it and change; but we do not do that. We keep adding to our to-do list. We do not have a stop-doing list. We need to make better use of what we have.

Mr. J. Kelly: On the issue of ministries of health, there is some opportunity to de-concentrate large ministries. Ontario has just done that, following the lead of Nova Scotia in carving out health promotion to create a separate ministry to give government some focus and accountability related to prevention issues across a number of domains.

I am most familiar with Ontario, but where you have two systems, for example, children's mental health versus adults, in two ministries, there may well be opportunities. I agree with Mr. Perron that we have political demands for access to MRIs and services in the physical health care system that are undeniable. However, if there was another minister with a responsibility focused exclusively on these areas — and I do not know what combination, I do not know if just mental health and addictions is the answer, but some form of removing all of the issues from the deputy minister and the Minister of Health — that would be helpful. There are several models that one could look at for doing that.

On the issue of integration, I have always been skeptical; if we believe in integration, what is the other side? Why is there a proliferation of agencies? I am not familiar with the mental health area. On the area of problem gambling, I am on the board of an agency in Toronto in the developmental services sector. I will give you an example. There are a growing numbers of agencies involved in gambling. There are 50 agencies in the developmental services sector in Toronto. When David Kelly was talking earlier about being able to get in the door and there being no wrong door, in terms of integration, I would raise the question of how many doors. I think that the more doors you have, the more difficult integration becomes.

I understand why there are multiple agencies. The agency I am at is a Jewish one, and how a retired Catholic could get on a Jewish agency is another topic, but there is the Jewish agency and there is the Catholic agency and the multicultural agency. You can see the demand, because it is not just the purity of what is the best way to deliver the service, it is where am I comfortable going. A completely separate issue is women's agencies and Aboriginal agencies. There are demands in all of these sectors that counterbalance the issue of integration.

Governments need to shrink the number of organizations who are in the business and, in a growing sector like problem gambling, the multiplicity of organizations with specialized roles. This means governments sometimes saying they have to consolidate. Developmental services in Toronto do not need 50 agencies. Maybe it should be 10.

There are other clearly recognizable demands. Integration has to do with how many doors, too, as well as focusing services around the individual.

Senator Keon: Government should never be the integrator. You are getting to the point where you are saying if government would integrate, then they could decide how many agencies there would be. That is a formula for failure, I am afraid.

Mr. J. Kelly: My thinking is that government is the source in the sense that government gives the money. It depends on what form of integration we are talking about. If the issue that I have raised is about the number of organizations funded to do similar or related tasks, then those are basically government decisions about who to fund for what. I know it does not address the issue of integration that you raise, but it is services versus organizations.

Senator Keon: It is up to government to chop whomever they want. Integration is for those who are left standing.

Mr. D. Kelly: I will comment first on that integration part. This is an issue that continues to arise, even though there is proof that the more doors available for people with mental illness the better the outcome, because they do not necessarily follow the care paths that we may lay out.

Second, when you look at organizations out there, why are they there in the first place? The community came together to start those organizations because their needs were not being met by the medical system.

Third, why eliminate the richness of the health care system? Each of those groups has dedicated volunteers. They have a group of people who participate in the governance of that organization and they spread the impact of that government funding. A dollar of funding for a not-for-profit, community-based organization actually creates $1.43 in services. That is an HRDC statistic.

Sometimes it is difficult. That is why I talk about no wrong door, in the sense that it should be seamless for the people going through, whether or not they are at one organization or the other, but it is the obligation of the providers to start getting them to the services that they need, as opposed to leaving it to the clients to fight their way through the system.

You were asking about changing the dynamics. We have ADMs for the hospitals, and that control that they seem to have of almost every ministry of health in the country. Part of the difficulty is the lack of research that demonstrates the effectiveness of community services.

We know that people in a supportive housing project have their hospitalization rate reduced by 69 to 80 per cent within two years. That is a fantastic amount of savings, but it is a very hit-and-miss situation. Research informs policy and policy will inform service and service delivery, which will inform research. We desperately need to have that cycle built into the community. We see that in the hospital system. You can research everything, down to the soap on the floor.

In the community it has never been a priority. It has never been funded or supported. As well, it is difficult for a community organization to garner the resources to do it. If we want to start changing that, we need to look at it as one component.

There are different ways of doing things. We have joint planning in Ontario. For instance, we have the joint planning and policy committee, which is a made up of hospital workers and members of a civil service committee. They do all the planning in the health care system. We need something equivalent for the community sector.

We talked about how ministries should be formed. I am hesitant to say mental health and addiction organizations should be moving away from ministries of health. However, we could think of an acute ministry of health and a community ministry of health. I started in long-term care, working with seniors and seniors' groups. There are huge resources there that could benefit people with mental illness or addiction. Having the division at the ministry level would be helpful. However, breaking down the silos between the different providers in the community would also be helpful.

It is almost impossible to get help for a senior with an addiction. In my 10 years in the seniors' area, I was never once able to get an addictions counsellor to make a home visit to a senior with a drinking problem. We need to change that around.

You asked whether this is new money or whether we can spend the money we are getting differently and in a better fashion. It is well recognized in mental health and addictions that spending in the sector needs to be reversed. At the moment, about 64 per cent of our spending is in the acute care system while about 34 per cent is in the community. All our research studies have shown that should be completely reversed. Ideally, it should be an 80/20 split, with 80 per cent based in community services. When I say that, I do not mean just health services but the broad determinants, which include housing and transportation.

When we look at hospital deficits, I do not know if we can get money out of that system. We are now looking at that in Ontario through the hospital planning submissions process, which is ongoing. Right now there are hospitals eager to get rid of their mental health and addiction programs. However, they do not want to get rid of the funding. They are happy to have the community take it on, but they want to keep the money because that will address their deficits. In any process like that, mental health and addiction services are the first to be cut, without consultation with the community or other providers in the system.

There is a definite need for new money. You have experience as a hospital administrator. If you know any secrets about prying the money out of there, please share them with us.

The Chairman: This is a classic case of where you stand depends on where you sit. The money did not disappear easily when he was running the hospital.

Ms. Bradley: In thinking about how to do this I have a small example. We have done much more outreach into the community. With regard to seniors, if the system were funded in a way that would allow us to do more outreach to get to those populations that we are not reaching, then a big investment would not be required. That is one idea.

We were working with a hospital physician in trying to get physicians out into the community to help with some of that population in the grey area. We wanted them to do some community consultations once or twice a week. When he took it back to the people he was working with, they would not agree because they were afraid that the clients would not be there. It is time out of their offices, when they are not able to bill OHIP for their consultations. If they were on a payroll and not billing OHIP, it would not matter where they were seeing their clients. I know that has been a problem in terms of integration on an out-patient basis.

Mr. Skinner: Senator Keon, you have us playing with at least two pucks on the ice here and it is interesting to watch.

When it comes to integration, what should we be doing versus what is the reality? Certainly, at the provincial level in Ontario, the Ministry of Health is regionalizing and integrating their addiction and mental health administrations. They will candidly admit that they do not know how to do it, but they have directed it to happen. Back to the pragmatics — integration is happening.

The local health integration networks in Ontario held big meetings where people asked what they should be doing. Everyone everywhere had as one of their top two priorities to integrate addictions and mental health services in our region. The entire health care system was there. Across the board, they thought of that as a pretty quick win. There was a big endorsement of it. I do not know what it means. We have to come back to what integration means. Pragmatically, we have to deal with this as a direction that is unfolding. If we want to resist it, we can. We will have to move with it in some ways and try to shape it.

Perhaps I am being a little semantic, but it is important to make the distinction between integrated and integrative. From a client-centred point of view, we need integrative practices rather than integrated administrations. If we are letting the client lead, following the wonderful principle that you articulated, that is where the test has to be for this. It is not whether we have administrations that are integrated, but are clients saying, ``When I go into the system with the mess of needs I have, which pop up variably over time, there is no wrong door. They are identified and I get to the people who can help me. The people who help me vary over my career of seeking service.'' That is the way we have to try to operationalize it, and then this broader notion of integrative is important.

I see us trying to balance opposing things. No one is opposed to integration. However, there is another principle, which is specialization. You need to protect skills at the level of diverse communities, that is, the multicultural dimension. A pragmatic model would be to balance things.

There are terrible ways of undertaking integration that throw specialization out the door. You bring everyone together and say, ``We are an integrated service now and you are an addiction and mental health worker. You will work with everyone. We think all of you have the knowledge to do everything. We will not have any specialized people.'' You ignore people's professional training. One thing we know in concurrent disorders treatment, where we are deliberately trying to work with people with complex problems, is you need people with multidisciplinary skills. You need the psychologist who can do comprehensive assessments. You need the psychiatrist who really understands pharmaco-therapy. You need the social worker who can understand how to work with the family. You need all those people present.

There is a way of doing this that is perverse. You throw the principle of specialization out and say it is all about integration. You have to balance these issues when you try to set up a practical strategy for dealing with this.

The other puck that you had in play was the money puck. How will we fund this? You did not say it, Mr. Perron, but you pointed to an option that I had. That is to say, you could tax the industry. You could say, ``We are taking more money from you guys. You are doing well. We are keeping you in business. You have customers. For every standard drink that you sell, we will take a nickel. You can handle it.'' Let us do it that way. You could just say, ``We will look for it there.''

In gambling in Ontario, the 2 per cent figure comes from slot machines. The industry has the attitude that they are giving us the money for the work we do with problem gambling. However, going there and looking for it as a source is another option to think about.

Mr. Stockwell: I do not know how to play ice hockey, but on the money issue, there are a number of things lining up here. In dealing with the difficulties of the current health system, its enormity, the power centres within it, doctors needing to count beds and build up their empires and how hard it is to get services out in the community, there is existing enormous revenue from legal drugs. It would be great if more of that was directed towards treatment. However, if there is an opportunity to set up something like a nickel a drink earmarked for community-based services that are so desperately needed, you might be able to bypass this mess and get something to happen quickly.

Mr. Wilbee: When we are talking about integration — and Mr. Skinner gave that example of Ontario — my impression of those meetings as well is that not only were we talking about integrating mental health and addictions, but we are talking about mental health and addictions also being integrated across the systems. We talk about, in terms of integrating, whether it is the organizations, the government structure, the operational structure or, functionally, the clinical services. The other thought is do we integrate information, because information is power. Some of us in the room have spent a lot of time in Ontario sitting on a number of the electronic e-councils, and although it will take 10 years to achieve, there is a struggle over how referrals are done. Is it possible to integrate at that level? There is a small agency preparing the case notes, then an assessment and a referral out. How well is that information doing? I did not see much in the reports I read about where e-health records are going. There are some real challenges in terms of language, but in a practical sense that will eventually achieve that kind of integration across the system. If a physician is able to electronically see what the community program can offer and make a direct referral, it is easier for clients to access the service they need. Certainly in Ontario, there is some effort being made and time spent on that. Some of us have put a lot of time into sitting on those committees. I see that as part of integration of information.

Mr. Perron: With respect to the taxation issue, there is a point I wish to speak to. I entirely agree that the industry needs to be held account for what they do and how they contribute to it. With respect to the earmarking of funds collected by government, it is materially important for them to understand that if we make it the industry's problem, as opposed to understanding what is it that we are collecting and how will the revenues generated here affect the system later, there is a relationship. It might not be immediate. It might be two or three years downstream. However, they need to acknowledge that the monies they take in now will need to be paid out later. That is the point that I believe is often lost because it goes beyond a political cycle. The understanding from an economic perspective that monies gleaned will have a commensurate cost downstream and how can we invest upstream is critical. It is not either/or. I appreciate the interventions and we certainly need to explore having meaningful taxation, but we cannot let huge revenues be streamed elsewhere without an acknowledgment of their commensurate flow-through costs.

Mr. Purvis: I tried to stay out of this one but I could not, so I apologize.

With respect to integration, Senator Keon makes a great point, especially with respect to primary health care. If we look at the quadrant model and if we are to make our biggest impact with regard to integration, it will be within primary health care. As Dr. Stockwell mentioned, some of the best practice evidence is around brief interventions through primary health care practitioners, and how do we look at building that capacity and integrating it. That needs to be addressed, not just the severe-problem smaller portion. Let us look at where we can impact the largest number, and that probably is where we can make our most significant impact.

We have been arguing within the field for years about dedicated taxation. It has been a popular topic. When we put together the tobacco strategy in Nova Scotia, the one pillar that made the most significant impact in the reduction of tobacco use was taxation. This is crazy coming from a Canadian, but sometimes taxation is a good thing.

Mr. Pelletier: In my opening statement I mentioned the role of police, and one I thing I failed to mention but which shows a good linkage between policing, health, and, specifically, enforcement — and building on Mr. Perron's comments on anti-drug-profiteering legislation — and that we would support is taxing the outlaws. When we talk about profits from drugs, a good example of that is the drug treatment court. Mr. Perron might be able to give examples on how that works. However, a good example of the way the police are working with the health community on addictions is the drug treatment courts. Again, one thing we might consider is encouraging judges in the sentencing to impose substantial fines for marijuana growers or plant labs to be put back into those kinds of addictions services.

Senator Keon: That is a good idea if you can do it. Why should these fellows get a free ride?

The committee suspended.

The committee resumed.

The Chairman: Welcome back.

Senator Cochrane: I must tell you how pleased I was to hear from all of you and that you took the time to come before us. As you know, we are doing this report, and it is so important for all of Canada and those Canadians who need our help. I am pleased to have you here.

I must tell you that I was deeply interested in our earlier discussion, and it has added much to our deliberations. I think it is an absolute disgrace that, as someone mentioned this morning, Canada was the leader in addictions research 25 years ago but today we have fallen well below that mark. We should be ashamed of that, and I am hopeful that the work of this committee, together with your input, can help remedy that situation.

While I was eating my lunch, rather quickly, Mr. Chairman, I was reflecting on what was said this morning. We focused quite a lot on integration. I think it is fair to say that it was agreed by everyone around the table that integration is definitely needed. The challenge is that there are different ideas as to what integration means and how it should be realized. I am wondering, as we prepare our report, what our recommendations should be with regard to integration.

I should like to hear your focused thoughts on what the first step toward integration should be. What is a definition of ``integration'' that we can all agree on? What is the first step to take to begin the process? Is this something that is ongoing, where we will need a five- or ten-year plan? What are your thoughts?

Mr. D. Kelly: One of the first steps toward integration is bringing it to this type of level, a federal discussion, getting input from across the country and coming out with a plan that will support that.

The second step is the political will and political push to ensure that this agenda keeps going forward. That is and has always been the key for mental health and addictions. Without that political push, we fall by the wayside and the doctors and hospitals take over that issue. Quite honestly, we need the support to nurture the sectors.

I want to touch on what integration means. To me, it means seamless service delivery and the ability for people to go through the system without necessarily knowing that they are switching organizations. It is not a governance issue. Governance is separate, and should be kept separate, from integration. Governance will be addressed in the long run when you start looking at standards, outcomes and effectiveness and then measuring those. If organizations are not meeting what we could consider standards, then you will start to see integration happening; they will start looking at different ways of integrating their governance structure to get there.

The biggest commitment here is the political push and identifying this as an issue, so you have taken the first step. Congratulations!

Mr. Wilbee: We do need a plan. You cannot get to where you want to go without looking at the map. We need to do better in terms of planning it out.

I may be naive, but I have a suggestion. Our ministers of health get together every once in a while to talk about general issues. It would be nice to have a summit where the ministers or the deputies got together and talked specifically about this issue and the good work of this committee as well. One of the concerns that we have about how you make those changes politically is not only increasing the awareness, but educating people as to why it would be good to invest in this area. That is where I would start. As Mr. Perron has said, we do have our political masters, and if it is not on their agenda, we could have the best plan in the world and never get there.

Mr. Perron: I would have responded earlier, but you did say ``focused'' thoughts, so I needed a few minutes. Thank you, Mr. Kelly, for focusing much quicker than I could.

With respect to the definition of ``integration,'' much that is on the table today would be helpful, as would the specificity the report can provide, perhaps even a glossary at the back to add to what you have: integrated versus integrative, systemic versus functional, continuum of care versus explicit interventions, the quadrant, yes; plus looking at the upstream investments and the prevention and promotion is all part of that definition of ``integration.''

I also asked the question, integration by whom? While I agree with the comment that we need to tackle community- and program-level interventions, I think we have to deal with governance at the same time. Otherwise, we will never get out of the gate. We can look at taking a page out of what we have done on the national framework for substance abuse. We tried to tackle the governance side at the same time as the specifics side. You have to do both at once; otherwise you do not see the interest, leadership and willingness to change at the macro level that the programs need. From my perch here in Ottawa and some of the other work we are doing, I think of doing both.

Also, one of the first steps is an understanding of what mechanism you will put in place for sustainability. What mechanism can you put in place that will carry on the work of this committee over the long haul once your mandate comes to a close? How can we capitalize on the expertise that you gathered and the recommendations? You need, in my mind, a champion, an entity, something that will carry this forward. I think there are many out there that are prepared to do that. There are many different models by which you can do it.

Among the other first steps is to build on what we already have. From an addiction perspective, if I can speak that way, acknowledge the work we have done with respect to the framework and the thematic workshops where we are trying to drill down to priorities, the work we have accomplished, while also recognizing there is more to do.

Let us tackle some of the easier problems first. Maybe we want to start with concurrent disorders. It is highly specialized. Let us start there, work our way back and pick some of the low-hanging fruit.

Ultimately, this does require sustained attention well beyond two or three years. It is a generational issue. When we look at prevention, there is a new grade 5 every year. We have to think in those terms. How do we ensure that sustainability? Again, that speaks to a champion for this issue.

The Chairman: A good example of that is that it took a generation to change attitudes towards the physically handicapped and people in wheelchairs.

Mr. Skinner: Those are the most compelling questions we should be struggling with. In my written comments, I tried to put some words on this, but again I do not know how helpful it is: The idea of a network of appropriate resources that can be effectively accessed and mobilized to help deal with the wide range of problems that people affected by addictive behaviours experience. The other notion is that you have an integrated system that is able to respond effectively at any moment, but also it needs to be able to help people over time; those elements need to be in it.

When we talk about concurrent disorders, sometimes people might think we are trying to build a third entity here. It is important not to get that idea. For the concurrent disorders, it is a synthesizing of existing resources and drawing on the most specialized expertise from both of the streams to help people with complex problems. It is important to realize that. How could you effect that? You could start on a population basis and look at going that way. You could think of maybe the severely mentally ill with the most severe addictions. In fact, we have a lot of best practices there. The best- practice information gets weaker when you consider some of the other populations. We could draw on some leadership in that area. There are some definite things to do.

Another thought is training. We have an entire cohort of people out there who work in both systems. When we do training in concurrent disorders, our start-up message is not that you guys are back in boot camp and we have to train you all over again. Our assumption is that you have 80 per cent of the skills that you need to work with concurrent disorder issues, and our job is to give you the other 20 per cent. The 20 per cent will vary from system to system and from program to program. We have just developed at CAMH, where some colleagues of mine are trying to do concurrent disorders training, a self-assessment tool so mental health workers can identify the areas in addictions where they are competent and where they are not. Rather than giving people blanket training, you could specialize with particular individuals and be more economical and cost effective in directing the training. You will have more motivated learners. Rather than subjecting them to material they are already well aware of, their own learning needs are driving the agenda.

There are things we could be doing with the workforce to get people more into the game. Certainly people often freak out over the idea that they will have to do concurrent disorders work. We all have stereotypes too. Addiction workers have stereotypes about the mentally ill, and mental health workers have stereotypes about addictions. The classic one in addictions is that those people do not change. How can you help people with serious mental health problems? People with addictions do recover. We have a recovery belief. In the mental health system, people tend to view addiction clients as causing their own problems. They can understand schizophrenia because that is an organic process but they think that people who do stupid things such as taking drugs should simply stop taking drugs. Training is highly satisfying work because it begins with attitudes, values and beliefs and then moves on to particular skills. The idea of targeting the learning needs of particular groups of people with a view to making them more competent makes sense.

The other message of the Current Disorders Program is, It is not that we will give you new clients to work with but rather that we will give you a new lens through which to look at people in your care. That is the big message at the outset. These clients are in the programs but receiving only treatment for addictions or mental health stuff. If treatment providers recognize the complex needs of these clients, then perhaps some of these treatments for current disorders, CD, could be added to the programming, although there might be a need for collaboration and connections. That is the first message for people.

There is also a subversive message. If we consider concurrent disorders seriously, then we have to admit that a section of the population would be excluded because some people are not in either system because neither one meets their needs. That becomes another policy matter to consider the marginalized people who might be homeless, for example. They might be the most eligible for these services but are the least likely to become involved, or to do well, in these programs. I name that as another challenge. For starters, though, concurrent disorders training would help people to work more effectively and comprehensively with their clients.

I have another angle to be considered. This angle could be thought of as a capacity-building challenge in both addiction and mental health to help workers more readily identify and assess the complex problems that people have, in order to work with them. Outside those domains, many community services work with these clients. For example, the Scarborough Addiction Services Partnership receives funding of $100,000 from the ministry each year. Rather than hire two workers for the centre, we call for proposals from community agencies to build their addiction capacities. They can receive grants and are supported by the addictions players in the Toronto area. The idea is to help non- specialized programs in the primary care system to develop their addictions capacity. You could do that on a broader basis. That is a good object lesson, an experiment if you will, or a practical on-the-ground illustration of ways in which it seems to be working.

There are a number of ways to mobilize people. In Scarborough it began with a small amount of money. That was a one-time fund initially but the ministry saw the potential and realized that for $200,000 they were supporting an underfunded area that still needs more resources. We are doing more and government is getting more value for its $200,000 by working this way than by having two addictions specialists work in a corner of Scarborough.

Mr. Purvis: I like Mr. Kelly's definition: It is not governance. A more positively framed definition of ``integration'' is ``the capacity to address multiple client needs at every entry point.'' If we could do that, then we have integrated successfully.

I also like Senator Keon's comment that it is not about ownership. We need to find a way to address this and view it in terms of what is best for the client. In my position as director, when we look at service changes or working-hour changes, I think that the requests need to be framed through, ``This will improve client service by....'' If people can do that effectively, we will consider the proposed service change. People working in these systems truly care about their clients. If we can say, ``This will improve the lives of your clients by...,'' then we will get the audience.

It can be a bit of a process. As Mr. Skinner alluded to, the first step is to raise awareness. There is much research and information to justify doing that first. There are bigger questions about how to do it but there is consensus on this being important and right for our clients.

Allowing public forums is important. One thing I like about this committee is its goal to encourage public debate. I am sure the committee has experienced a great deal of public debate, given some of the issues. If people have the freedom to talk, discuss and disagree on the process and work their way through it, then that will breed far more grassroots buy-in. If we do not have that kind of debate, then it will be deemed another push from the bureaucrats, with all due respect.

Once the awareness-raising happens, and people begin to get their heads around it, we will need resources and opportunities for them. Without those, it would be much ado about nothing. The resources must be available in your back pocket before you step forward into consciousness-raising. Otherwise, you are setting people up to disagree, and for it not to happen.

Also, you need to build in outcomes, measure the outcomes, and feed them back to the field. Nothing will increase the buy-in more in the field of mental health and addictions for a change in process than positive outcomes. People want to succeed and do well by their clients.

There needs to be an expectation around skill sets and the training and competencies that accompany them.

Ms. Bradley: My comment is on integration of addictions and mental health. If we accept Mr. Skinner's suggestion to perform the assessments, et cetera, we need a place for people to go. Often that is some kind of housing. We have to look at the broader determinants and have some integration and connections with the greater system. Otherwise, those clients will simply return to the system. Community resources, housing and education are important parts to be considered. We need to think broadly.

Senator Cochrane: I have two more questions on comments by Mr. Purvis and Mr. Skinner. You talked about the need for more research. Is there an information-sharing or network, either formally or informally, in use today. For example, is there a database of success stories and best practices readily accessible to people working in the fields of mental health and addictions? That would be extremely valuable to their work.

Ms. Bradley: Yes, in Ontario there is such information available. At the federal level, a best-practice document was put out on concurrent disorders and women's issues. A large, best-practice document is available in Ontario that contains areas to enable agencies to check their own performances.

Mr. Purvis: As Ms. Bradley mentioned, Health Canada has been good at publishing best practice documents. In 1999, Alan Ogborne and Gary Roberts authored Best Practices: Substance Abuse Treatment and Rehabilitation. Brian Rush wrote The Best Practices — Concurrent Mental Health and Substance Use Disorders. One of the bonuses of working in the field of addictions is that there are several meta-analyses, available through the literature, showing what does work. There are four prominent ones, three of which were used by Alan Ogborne in his 1999 document. Much of the information is available. I cannot speak to mental health in that respect because I have not followed it as closely over the last six years.

Mr. Grant: In addition to what has been mentioned, there is a database of researchers in addictions. It is a joint project between Correctional Service Canada and the Canadian Centre on Substance Abuse. That was put together so that when someone had a question, there would be a resource to find people. Research literature is published in journals and also in government reports.

To build on that, one area where we lack resources in general is the ability to offer research expertise to smaller agencies. If Ms. Bradley's organization wants to do a comprehensive analysis on some program they have implemented, we do not have a way of directly supporting them. Certain organizations such as the Centre for Addiction and Mental Health have people, but on a national level we do not.

Many good programming opportunities or activities are going on in the community, but there are no evaluations of those programs. We do not know whether they have the kind of impact that they could have. Then, if we do not have the evaluation — the research that goes with those programs — we have no way of communicating those positive results.

That is why I had raised research as one of the key points in my recommendation. It is less an issue of getting the large multimillion-dollar Canadian Institutes of Health Research grants but rather the smaller ones that deal with the innovative program that somebody has put in place in Nova Scotia, Prince Edward Island or wherever in the country, so those kinds of smaller projects can be evaluated. That is where the innovation will come from, and what works and what does not.

Mr. Weekes: I must have sat in the office beside Mr. Grant for so many years that we think along the same lines. That is what I was going to say regarding the availability of expertise to assist programs and agencies with determining the efficacy of their interventions.

I thought I also heard the senator ask if there were databases that capture the successes. I got the sense that she meant in human terms. As a researcher, I get excited about statistics but like Mr. Purvis and perhaps others, I was trained as a clinical psychologist and what is lacking is what all this means, whether you are talking about major mental disorders and serious addiction or perhaps somewhat less severe problems and so on. What does that mean for Canadians who have those kinds of problems or who are fighting with them? I do not think that the kind of information exists. There are lots of stats but not a lot of human faces.

The Chairman: It has struck us as a committee, not just in mental health but on the rest of the health care system, how little resource allocation is outcome driven as opposed to input driven. When you think about it, the outcome is the only thing that matters. Are you telling us this is the same problem?

Mr. Stockwell: I think you have pointed to the key area. A lot of research has been done; and there are a lot of reports out there that people are not usually aware of. There is this whole need to disseminate and communicate.

The Centre for Addictions Research of B.C. has funds tied up in knowledge exchange. We have websites that have success stories but also draw on the latest literature reviews. Best practice information is accessible for anyone who wants to log into the website, silink.ca.

The whole area in this information age is ripe for development. The idea of having sites where the latest information is fed in, summarized and synthesized expertly, but in a simple, continuous process, would be worth investing heavily in.

Senator Cochrane: You have talked about mental health and its determinants. I know education is one that is often cited. I am a former educator myself. In terms of addictions, what do the data tell us about the relationships between education levels attained and addictive behaviour?

Mr. Skinner: I was looking Mr. Stockwell's way, as our preventionist, but we know from the determinants-of-health point of view that socio-economic disadvantage correlates directly with problems in addiction and mental health. In the broadest sense, I suspect that, but I do not have anything specific.

Mr. Stockwell: Specifically in education, it is complicated. Generally speaking, the relationship, particularly with illicit drug use and addiction, is clear — that there is one indicator of disadvantage or lack of social assets, et cetera. Poor education is associated with an increased likelihood of problems with illicit drugs.

With legal drugs, there is still that association. However, what is different is that the bulk of people misusing alcohol and tobacco, while there is an extra risk of people who have various indicators of disadvantage such as lower education, the bulk of risk behaviours are engaged in by everyone. It is across all levels, particularly with legal drugs. For illicit substances, it is much more concentrated in groups that are disadvantaged.

If you look at income, the more people earn the more they spend on alcohol, for example, but the pattern of use may be less spiky. People who earn less are more disadvantaged; they have to save up and get really blasted one day a week as opposed to drinking a nice Chardonnay every day.

Senator Cook: Let me say at the beginning that the complexity of the dialogue around this table is limited only by my inability to understand it all. In a nation as diverse as this one, it is difficult to try and sort out what you are talking about. I believe it was Mr. Stockwell who talked about minimum national standards with the appropriate protocol for policy. Then, over the lunch hour I had an opportunity to glance through Mr. Perron's submission; and in his report he said he has collaborated with Health Canada and other partners to develop a national framework for action. We are looking at a framework and we are advocating national standards for this integrated process.

If you want to layer that over my thought process, I come from Newfoundland where there is a limited framework to integrate. When I thought about the integration, there is only one of each if we are lucky, but I guess everything starts with one.

If I want to dream a little and look at the gaps that would make life and living for the people that I represent more fulfilling or rewarding, I see some gaps. I want to put it out for you to think about.

What about the curriculum-based education for nurses, doctors and all professionals? Who is the gatekeeper if I am not feeling well? I cannot find a person that we care about; we have lost it in the systems, in the integration and whatever.

If you are not feeling well mentally, the gatekeeper is your family practitioner, who may or may not recognize what is happening to you. As well, in my province, the bill is covered for the first visit, but only three subsequent visits are allowed. Across this country, a cap prohibits family practitioners from treating addictions, substance abuse and mental illness. It is called the referral system and we are building a hierarchy.

There must be continuing education. We have to go into the medical schools and the nursing schools with this system. An integrated system is a structural thing, but I also see it as something more than that. We can integrate all we like. I was part of a board that integrated six hospitals in the 1990s, one with two sites. That was painful and it cost a lot of money. Talk of integration makes me nervous because there are not enough dollars to go around.

We must put many elements into this process to serve the client that we are here to serve and that we care about.

Ms. Bradley spoke about the lack of training for counsellors. Can people be adequately trained in our colleges with two-year programs?

We talk about the nurse practitioner in primary health. We need to address gaps in our learning before we can integrate a system.

I am speaking to the reality of where I live, and I know that reality is entirely different from the large populations that you have. What are the gaps that we need to address to put out this national framework? You want to use the word ``national'' rather than federal. We must somehow work around the federal system. Health Canada is a reality. When I get time, I will study the structure of Health Canada to see where this all fits. However, we must work within the reality of where we are.

I would like to hear what you see as the perceived gaps, where we can tell the government of the day and Health Canada how we see it and how we think we can fix it. Maybe we can piggyback on the national framework for action. Is there an opportunity to get into the new public health agency? We have to get in somewhere to integrate the services. All the ideas are wonderful and our people will be well served if we can move it forward, but I am looking at the reality.

We have not talked about obesity and we have not talked about school curriculum for children, which I think is the basis of the system. At what point does this happen to a human being?

I see a number of gaps. How can we package them? Maybe we can get it in this national framework for action.

Mr. Purvis: Senator Cook makes a great point, especially on service delivery in rural Canada, which is near and dear to my heart. A colleague of mine, with whom I share a private practice, was the only psychiatrist in Port-aux-Basques for about 15 years.

Senator Cook: If you want to see a paediatric psychiatrist in Newfoundland, you have to wait for one to come from Nova Scotia. I say that to illustrate how diverse this country is.

The Chairman: Since many Torontonians think the country runs between the Don River and the Humber River, it is useful to understand that there is a different perspective in the country.

Mr. Purvis: My colleague was the psychologist for the mental health clinic in Port aux Basques: she was the addictions counsellor and the gambling counsellor. Necessity integrated her.

The problem is really access, which is what Senator Cook is speaking to — one person doing many tasks. We are talking about delivering services within rural populations. One advantage is that you know the other partners, and people tend to do extra once they know each other. There tends to be that synergy, but it is an access issue.

It struck me that it really worked for my colleague because when she came here she had these diverse skills because she was the one-stop shop.

With regard to who the gatekeeper is, we know that our primary health care providers, the physicians, are our primary gatekeeper. We also know that 20- to 30-minute interventions by physicians provide some of the best outcomes for clients in reducing harm, mitigating damage and providing treatment outcomes.

When looking at integration, we need to look at how we compensate and train, and how we move toward the primary gatekeeper, which is the primary health care system.

With regard to obesity, it is possible to have synergy and collaboration back and forth. People who work within the addiction field are primarily behavioural change agents, and one of the issues behind obesity is behavioural change. As was mentioned earlier, the first and third cost drivers in the health care system are addictions, and the second is sedentary lifestyles leading to obesity. The second largest killer in our society sits in your living room; it is called your couch.

Ms. Bradley: The first issue is that addictions is not on the agenda. It is important to all of us, but for many portions of the population, and even government, it is not spoken of very often. This kind of thing brings the issue forward. We need to talk about it more and understand it better.

With regard to training physicians, nurses and social workers, some universities now have specialty programs for addictions. However, many of our clients will say that their doctor never asked them about their alcohol or drug use, and that it was only through their family, friends or work that the problem was picked up. Physicians are often embarrassed to ask the questions. This issue has to get on the agendas of the universities and the nursing schools to make it more of a normal question.

Children are hugely affected. They are the next generation to whom we will offer services. Any agency that is working with women needs to help women learn how to take care of themselves while pregnant and to how to parent.

We recently put a child care centre in our organization. It is the most fantastic thing to see women coming in with their babies and children. They breastfeed during their treatment and it normalizes the whole experience. To help the next generation, we have to help the parents; we have to help the mother. These children are getting support at a very early age. One way to address healthy living for the family and the next generation, the child, is to not treat just the person with the identified problem. It is a big family issue and we cannot treat it in isolation with regard to the other things that are going on.

Mr. Perron: Ms. Bradley makes a couple interesting points. One is what I call ``relevancy.'' You are right: we get up in the morning and we think addictions are mental health or mental illness. When Canada had a national drug strategy from 1992 to 1997, it died during program review. Eight bureaucrats in Ottawa shed a tear and we moved on. I was one of those bureaucrats. The point being is that it was also Canada's best kept secret. One challenge for us is to get people to understand the relevancy of these investments as it pertains to them.

My mother-in-law came to visit us from Winnipeg this week, decided to have a heart attack and went into the heart institute. The relevancy is immediate for me. It is something that we all think of, but alcohol, drug issues and mental illness is something people see as out there. The relevancy of our work is critical to its long-term success.

With respect to the missing pieces, my first reaction was there are not many, but that is probably not the correct answer. What is missing is someone or somehow to connect the dots out there. Let us keep it simple. There is tons of structure, governance and research. I am convinced we do not know what we know in this country. With all due respect to researchers, if we never did another stick of research we could live on what we know for the next 10 years. We do not want to do that because there is a significant amount of new stuff coming online that we have to take advantage of. One missing piece as we move this along is leadership and coordination.

Ms. Bradley spoke about two interesting community programs. Who paid for that first pot of coffee? That is what CCSA does and what we are supposed to do. Notwithstanding all our busy days, who calls meeting, pays for the coffee and says, ``Let's talk about it?'' Somebody had to take the initiative to forge that partnership and you did it or someone else did it. We are looking for something of the same nature. It sounds easy, but it is difficult. Invariably, the person who calls the meeting comes with his or her mindset to it.

CCSA and Health Canada have tried to come at it from a government and non-government perspective, pay for that pot of coffee and say, ``Who can then connect? Where are the gaps?'' That is one thing that might be missing. I say that with a tremendous amount of respect to those who are championing the cause. I do not mean to cause any disrespect. It is being able to make that next step.

We would be silly to carry on the national framework thinking there is nothing out there beyond our worlds. Having something specific, whether it be concurrent disorders or reacting to the reports of the committee here of embedding recommendations in that process, is essential. As a custodian of that process, I will be more than happy to do that.

Many national frameworks are bouncing around the halls. Many have brilliance in them, but they have little ownership and governance flow-through. I am sorry to sound like a broken record, but that is where the rubber meets the road.

You can piggyback with the national framework. Speaking to the point that Senator Keon mentioned, as a custodian and as part of this framework — everybody is part owner of this — we will take it up and we will see how to move it along.

Mr. Skinner: I will start with the point of how to work from where we are. In some ways, there are good stories to be told about how rural communities do it better and quicker than urban communities in terms of integrating addictions and mental health.

Muskoka-Parry Sound has one addiction agency and one mental health agency. They read the best practices document. Their executive directors spoke and said they ought to do something about it, and they needed to put resources into it. They set up a concurrent disorder team to work with the severely mentally ill with serious addictions. They ran into a problem. They could not get a psychiatrist. There were some psychiatrists in their community, but they did not feel competent to do concurrent disorder work. They called our concurrent disorder service in Toronto. For the last few years, one of our psychiatrists has been going online and doing tele-video consultation and supervision with that team.

You are right that it can be paralyzing when you think of it nationally. On the other hand, you can do some things too if you start thinking nationally, or larger than your locality, if you will.

One thing a place such as Toronto that is often self-absorbed needs to be reminded about is that we have resources that do not belong just to us; they belong to everyone. How can we access that? With new technologies, there are many ways that we can support people on the ground and give them access to services.

We have been talking about the problem-gambling area, but this issue extends beyond that subject. We have an appointment book for psychiatric consultations. We have a psychiatrist who specializes in gambling problems and their co-morbidities. That appointment book should belong to everyone in Ontario. They should be able to dial up, book an appointment, come online and have the consultation. We have a significant amount of expertise at CAMH. All that information should be available to help people with problems throughout Ontario. That is the way we need to use the specialized resources we have. The resources should not be enclaves that are withdrawn. We should have mechanisms of access. We can build that.

My experience with the people who use that is that they are stimulated by it. It is professionally satisfying to be involved in this area. You need to have ways of paying somebody to do a session. If somebody gave you three hours of consultation, the agency had the sessional monies, so they were able to negotiate that. That was the other bit of oil they needed. There are interesting ways we could begin to construct solutions where locally there are no paths if we start thinking about some of the forces we have nationally.

Another thing about addictions training is that most of the professions do not do it well, if at all. In psychiatry, for example, it is now a requirement of the Royal College of Physicians and Surgeons of Canada that psychiatrists have residency training in addictions. However, there has been a problem across the country delivering that because schools do not have the expertise. The University of Toronto trains about a quarter of the psychiatrists in the country. We have a concurrent disorder service. We are getting learners from Alberta, Manitoba and Newfoundland who want to get into our environment because they want to learn this stuff. We are facing the reality that we have to grow the expertise. We must look at a generation and a building process to get people to come through training to develop their own addiction psychiatry expertise to support communities. That is difficult to find.

We have been trying to recruit a chair in addiction psychiatry at the University of Toronto ever since the merger. We have not been able to find a candidate who will work for Canadian dollars and on Canadian terms. They are in an international market. There are too few experts in Canada. That is just psychiatry. It is probably worse in nursing. We need to do that in social work, as well. There is a huge curriculum agenda around addictions for health care and social service professionals.

Mr. D. Kelly: The difference between urban and rural areas begins to come down to capacity issues. If you look at this on a national framework, and you want to address the capacity issues, you must look at the health accord and the health accord funding. The health accord presently goes to 2006-07: To take forward a framework, to have that be effective and to have an impact across the country, and to look at what is happening with mental health where you have seen varying success coming out because of the agreements or the accord funding. The process to look at what will happen after 2006-07 should start soon. If we were to come forward with a national framework after looking at some of the outcomes in mental health, and if we were to see the good that has come out of it, we could go forward with regard to addictions.

Senator Cook: There are protocols for wait times regarding heart disease, for instance. How do you learned people feel about wait times for people with mental illness and addictions?

The Chairman: Thus far, we have not heard anything about the wait time issue. We heard about it in connection with our previous study. For better or worse, we put the issue on the national agenda. I do not know if there is an issue of wait times for addictions and mental health services.

Mr. J. Kelly: Senator, you asked about pieces that are missing. What struck me immediately was the number of times I have read and heard presentations at conferences about childhood trauma, abuse and addiction. What I am about to say is not just about how to improve the treatment system but how to decrease the demand for the treatment system. An increased effort to deal with damaged children will have as much impact on the addiction treatment system as anything done directly in the addiction treatment system.

A five-year old child who is damaged will be in the Children's Aid Society system, in the addiction system and in the correctional system. It all starts early. If this committee can reinforce the inevitability of this, then that would be a useful thing to say.

Ms. Bradley: I could say something about childhood trauma and the work that some women's agencies are trying to do in terms of braiding the recovery of the woman with her addiction recovery. People that have been traumatized will often traumatize the next generation. If they are in the system, it has to begin at the parenting level. There has to be identification of the issue and an understanding of what is abuse. We have to look at much broader issues than just addiction.

We are a provincial agency with a three-month waiting period, which is just a snapshot of the way things are now. We have women all over the province who are waiting to get in. However, another dilemma emerges. We have a specific program for pregnant women. It is an outreach program in the city of Toronto. We see more and more women coming in who are pregnant. There is a small window through which you need to get them in because that is when you are trying to prevent the fetal damage. We already have a three-month waiting period. Somebody on hold at our centre, or getting out-patient services, will have done everything they are supposed to do to get themselves ready to come in. They may work in their community to keep themselves supported the best way they can. Then we have a pregnant woman who needs to jump the queue. We are trying to think of client-centred care and best practices. However, both these women need service. We do not have enough beds or services to accommodate them.

In the short time we have done the Pathways program for the pregnant and parenting women, we have had many births. We started the program four years ago. I cannot tell you the exact number. However, the birth weights are up. The women are going to full term. They are scoring much higher on the Apgar. We know this will make a big difference if we can intervene at that early stage. It is where we need to get to for the future, but we do not have enough resources in our system to accommodate what we have.

We created a program. I remember saying, if we build it they will come. They are here now, but they are putting more pressure on already scarce resources in our system.

The Chairman: Mr. Purvis, do you have any sense of the waiting time?

Mr. Purvis: In my capacity as director for mental health, one of my jobs was triaging the wait list. We would have emergent patients, who would be seen that day. Those labelled urgent would be seen in a month. It is pretty fuzzy classifying someone as urgent when the list gets long. Those classed as general would be seen in six months. There were euphemisms around the therapeutic effect of the wait list because, eventually, once six months rolled around, people would not show up. Go figure.

One thing I like about the addictions services system in Nova Scotia is that for basic service there is a three-week quality standard behind access. However, when folks decide for the first time that they want to address an addiction, three weeks is too long. If you cannot get them in that day, it will be several months to a year before they phone you again. However, three weeks is much better than six months.

When you move that into specialty and longer-term structured treatment, in New Brunswick, for example, they have several hundred on their wait list for methadone maintenance therapy. As you push further into the specialized treatment, the wait lists become more reflective of mental health. Access is probably the single greatest complaint we have with the system.

The Chairman: As you know, the federal government appointed Dr. Brian Postl head of the Winnipeg Regional Health Authority to help make progress on wait times. He has been talking to various provinces. He came to the conclusion that the wait times for mental health and addiction services were every bit as long as, or worse than, some of the other five items that were on the list including joint replacement, imaging and so on. He had the courage to raise with the provinces the issue that maybe this ought to be added to the list. He was totally shot down in flames. I have not heard that from him. I have heard it from several provinces.

Senator Cook: What prompted my question was that last Friday on the flight coming up I read a full page article in The Chronicle Herald of Halifax around the issue of wait times for various categories, including addictions and substance abuse. The last paragraph said it all; there should be no wait times. If you have a problem, and you are told you have a wait time, you sit in emergency until you are seen.

The issue is out there on the public agenda. It is on the front page. It was a full-page article.

Senator Callbeck: Thank you all for coming today and sharing your views.

This morning, we talked about whether new funding was necessary and, if so, where we would get it. The idea of 5 cents a drink was chucked out. I want to ask a question about a pot of money which, to my understanding, is just sitting there. It is money that comes from the proceeds of gambling.

It is to help people who have problems with gambling. However, millions of dollars are not used. The money just sits there. Why not use that for other addictions? In other words, do we need a stream of money from one place for gambling and another stream of money for people with problems with alcohol? Why can it not all go into one pot?

Mr. J. Kelly: Where the money is, I do not know. Ontario was behind for a while in terms of the money that was coming in. In fact, money was reallocated through the back door to addiction programs that were not gambling.

Several provinces have not spent all the money. I imagine they are catching up on that now. Part of it was that when a system was started, such as the gambling counselling programs across the country, almost all the provinces had gambling counselling available and relatively little demand. They had counsellors that were ready but not getting many customers. I believe that is changing, at least in Ontario, and I hear that demand is growing all the time. It is like any other human service. When it is available, there is not a quick uptake. Then seven years later there is a long waiting list and you have the same problem. I have seen this pattern in group homes for people with developmental handicaps and services for disabled people. I think the issue of not spending the gambling money is not going to last, or likely it is over in most places right now.

Senator Callbeck: Is it possible for this money to go into one pot to service addictions, or do you need to have certain streams for specific things?

By the way, the person I was talking to indicated that they felt in Ontario there were millions and millions of dollars sitting there.

Mr. J. Kelly: No.

Mr. Perron: At some level, having all the money sitting in one pot, as it were, is appealing in terms of leveraging investments, understanding, reducing duplication and things of that nature. Practically speaking, I am not sure how ready we are for that sort of thing. Some would say we have it in one big pot called the General Revenue Fund, and then we have problems getting it earmarked for this type of thing. Putting it into one pot would be interesting if we could create some means by which the provinces and the federal government, through memorandum of understanding, would agree to share funding research commonly for the Institute of Neurosciences, Mental Health and Addiction, INMHA, or perhaps contribute generally to the priorities that are identified commonly as part of a framework or whatever the case may be.

Structurally, I could see a lot of red flags going up for some of the bureaucrats. The other issue that is a problem vis- à-vis budgets is that if you do not use the money there is no intention in supporting another arm of the system that is short of money. Invariably, the opportunity of using it for anything else that might ultimately support the system is limited today because of the attention to detail: the accountability to make sure that dollar goes from here to there and you can measure exactly where it goes, particularly at the federal level, given the hyper attention to following the dollar and making sure it gets to where it is supposed to go.

I believe something of that nature could be cobbled together, and in fact should be cobbled together, because these funds should not only be drawn from federal reserves but other reserves. It is a matter of starting the discussion of putting the money on the table. It is possible. We have seen proxies of that in the way some of our projects have been funded, the Canadian Addiction Survey, for instance.

We did not have addiction-survey prevalence data for 10 years in Canada. We were sitting around in 2002 in Montreal, and Alberta finally said, this is nuts — I am paraphrasing — I will put $200,000 down to get a national prevalence survey. I am sick of waiting for the feds to do it. The feds did not have the money to do it. Then Ontario said it had some money, and little by little we came up with $500,000. I asked Health Canada to match that. They said, wonderful, and from there we actually got a $1.3-million project off the ground with a lot of money at the table. Ultimately, it resulted in more interest in the actual project at the end of the day because everyone owned it. There are proxies of what you suggest and it could be exploited even more on a project basis as a suggestion.

Senator Callbeck: I have a question for Mr. Grant on the harm-reduction programming in the correctional institutes. What is the status of that right now?

Mr. Grant: The major focus of all our treatment programs and interventions in corrections are wherever possible to reduce the harms associated with drug and alcohol use through our treatment programs. We do not currently have harm reduction programs such as a needle exchange and other things such as that because we view harm reduction as existing on a continuum. It is not this or that but rather a continuum of activities that can take place that will impact on the client or the user. We provide bleach kits to institutions to sterilize needles to prevent the spread of HIV and AIDS. Our programs are designed in such a way that to enter those programs you do not have to make a pledge that you will never have a drink again. Rather you will explore that possibility through the program, so that is a form of harm reduction.

Harm reduction is an overarching philosophy that we try to apply to all the work we do. We do not go as far as some people in the community are able to because we run institutions with highly violent people in them, but we try to move that as far as we can so that we can reduce those harms.

Senator Callbeck: Legal substances such as alcohol and prescription drugs seem to account for the bulk of the problems. Are the bulk of our resources and attention devoted to legal substances? Why?

Mr. Stockwell: Mr. Perron and others may have the exact figures about the allocation of funds. I can speak about one little example. If you look at all the research funding that the Canadian Institutes of Health Research have allocated to the addictions area — we did an analysis of it — it is heavily tilted towards injecting-drug use. There is almost nothing on cannabis. There is a bit on alcohol and tobacco, but it does not reflect the prevalence of the harms at all.

In terms of requests for service, you would have to do an analysis of spending and waiting lists, but I suspect because of the media attention and sensational fears or hysteria even around illicit drugs, and lack of concern around legal drugs, that is what has happened. It biases the spending decisions of governments.

The Chairman: Just ballpark, what is the relative percentage between legal and illegal drugs, in terms of the number of people who are impacted or the economic cost?

Mr. Stockwell: Ballpark, it would be 90 per cent of deaths caused by drugs are from alcohol and tobacco. If you look at disability and quality of life, it would probably be more like 95 per cent. The analysis done by the World Health Organization globally, including looking at economically developed countries such as Canada, shows this very clearly.

The Chairman: If you take alcohol and tobacco out, what about prescription drugs versus illegal drugs?

Mr. Stockwell: The data is not very good on that and we do not really know.

Mr. Perron: On this point, a cost study was undertaken by the Canadian Centre on Substance Abuse, CCSA, in 1996 that identified the social, economic and health costs of drug and alcohol abuse to society. The study earmarked it at $18.4 billion per year, of which $1.4 billion was for illicit drugs. The balance was alcohol and tobacco. We are now replicating that cost study as we speak. New numbers will come out in the spring.

Using my mother-in-law's analogy, if it is now $25 billion, is that not just a lot of money? Why keep measuring it? The point is measuring and identifying avoidable costs.

The Chairman: Are you separating out pharmaceuticals?

Mr. Perron: No, the issue of pharmaceutical abuse and quantifying it is something that has eluded us for some time, and it continues to do so.

Mr. Purvis: That is a wonderful question. In our treatment centres, if you take nicotine and caffeine out, it is alcohol, marijuana and prescription drugs. It has been that way since I have worked in addictions for the last 12 years. We are now seeing more people with multiple drug issues mixed together. The question that I really like is, why do we not put more attention on alcohol?

I will give you an example. Two years ago, the media in Cape Breton started tracking deaths related to prescription opiates. They got to around 20. After that, a citizens group got together and a methadone clinic was put into the Cape Breton Regional Hospital. We know that is a small percentage of the people we see, but the attention and political will behind addressing that was there. In a lot of ways, this happens with crystal meth. It has happened with Dilaudid and oxycodone. It has made folks within the addictions fields, opportunists. We know we should direct finances and resources to alcohol because that is still what affects the majority of our population, but the opportunities to access resources come more from politically and media-generated issues.

The Chairman: That shows that not just politicians are susceptible to the press.

Mr. Wilbee: It is a valid question. Mr. Purvis has made the comment I wanted to make. It makes me a little nervous to separate them out. I do not know about the research, but I know what I hear from the clinicians and directors of programs. Most people who have been in the service for some number of years talk about how the acuity of those presenting has increased. It is polydrug use. In fact, they almost cheer if they can find a pure alcoholic from time to time.

An essential point that we are not aware of as a public is the danger of those prescription drugs, not just for those who abuse them. I tried to say earlier that when you have a broader look at using the legal drug of alcohol, it is a contributing factor. You do not have to be addicted to cause yourself some difficulty in other areas such as cancer of the larynx and throat, and those kind of things. The experts in prevention and public health promotion such as Dr. Stockwell indicate there needs to be more concentration in this area.

The results of illegal drugs is fairly clear. I want to make that point. It makes me nervous when you try to break that out. As a non-researcher and statistician, I do not know how you work that out. On the front line, people are polydrug users, and that includes alcohol and prescription drugs.

Mr. Grant: Just to give you a perspective at the correctional level, within our offender population, around 10 to 20 per cent come in with an alcohol-only problem, another 10 or so per cent come in with a drug-only problem, and the vast majority come in with both alcohol and drug problems. That finding is based on interviews and testing that is done at admission. If you add up those who are addicted to alcohol and drugs and alcohol, that certainly is a large group, but the illicit drug component within the correctional population is high, as you would expect, so that is usually where our focus is.

On the alcohol side in our operation, certainly in the community we are worried about the problems of impaired driving and stuff like that. They are serious factors. In the correctional population, those who abuse alcohol tend to be violent offenders. When we look at that alcohol group, they have serious violent histories.

Senator Cordy: This has been an amazing day. I thank each and every one of you for coming today with your presentations and your contribution to our next report, which may be thousands and thousands of pages long.

Many of the issues have been dealt with during the day. We have certainly dealt with integration and funding. One comment I took particular note of was on the idea of integration but protecting specialization. I think that was an excellent comment.

The comment that every door should be the right one should probably be the title of a book on the health care system. We have heard over and over again the frustrations of people trying to wend their way through the system, be it mental health and addictions or the health care system overall.

I also agree that we need a bigger picture of addictions than from just substance abuse.

Aside from integration and funding, which we have dealt with, I would like to talk about the idea of young people within the system of addictions. We heard earlier from the RCMP officer who was here that young people should be a priority.

When they come into contact with the judicial system, often the young offenders in the judicial system have addictions of some kind. I spoke to my sister who works with young offenders in Nova Scotia, and she said one of the biggest factors in terms of whether or not the young offender will be back before the court system is the family. She said when a family is supportive, there is a high chance that this young person will not be back, but if a family is blaming everyone else but the family, then the child will likely be back again. Having been a teacher for 30 years, I know that sometimes families are not all what we would like to think they are.

My question is, how do you include the families when you deal with young people with addictions? How do you include the family so it is part of the support system and part of making the young person better and not addictive any more? What is the point of having a dysfunctional family supporting the child when, in fact, the family needs a tremendous amount of support? Where do you begin?

Are there any success stories or best practices in the field? Ms. Bradley spoke earlier about young people coming in with their babies, and the success rate there. Are there programs that are working where, in fact, you go upstream and deal with the family, and then the young person?

Ms. Bradley: I would like to talk about a couple of things. Certainly, I think it is the same with all people that have this problem. The more the family is involved, whoever they consider their family to be, the better they will do. I think it is a best practice to include the family right from the beginning, if you can. You can provide them information and support through the process. The families need help because, in a way, they are reconstructed. Best practices would tell you that the family needs to continue with counselling and group work. That is where you get your best results.

The system is poorly funded to do that. We also were involved with a project called Strengthening Families. Do any of you know about that project? It was a study. We partnered with the Centre for Addiction and Mental Health on this. It is a particular program working with families. One group received only the written information, and the other group received face-to-face interaction. The outcome is amazingly higher when they have time together. We must always consider the family when looking at this problem because they are pivotal to the treatment.

Mr. Skinner: There is an irony in this. Families experience these problems. It is not as though something is happening somewhere else. Often, it happens in the family nexus — the environment. When people go into treatment it is as though a veil drops down and families often feel excluded. My question is: Why cannot families who experience the problem also experience the solution? How do we want them to experience the solution?

Families have the right to know what treatment services are about and how they are perceived and structured. We do not do a good job of orienting families as a routine. We neither encourage nor talk to people about the roles of social support, and to get people to nominate their closest, positive connection in their life and ask if we can work with them in this helping process. As a matter of fact, we lower a veil of secrecy, hide behind confidentiality and construct it in ways that are not necessary. Principles of confidentiality need to be respected when working with people but we should not use them to create exclusions. We do not know how to work well with families. Our systems are set up to deem these problems as belonging only to the body and brain of the patient or client. In reality, these problems have a social, cultural and environmental dimension to them. We help our clients better when we can address that dimension. It is a big challenge to extend it to addiction and mental health services so that we have systematic approaches to inform families about the treatment and even about what happens when a relapse occurs. Normalizing the relapse possibilities and making relapse a learning process means the person can still make their way. It can create a great deal of calamitous conflict in a family if someone says, ``You are using again,'' or other such negative comments. Families have a right to support whether the person with the substance abuse problem is in treatment. They have the right to access the system to get help because their family member has a substance abuse or mental health problem.

Atlantic Canada should be applauded for championing the Community Reinforcement and Family Training, CRAFT, intervention, which is a program that works with family members dealing with addiction problems. There is good evidence that when you work with family members who are willing to seek solutions you can produce as good an outcome as anything else could do. There are some bonuses to this approach because you are building social support that is likely to extend. Intervening through the family avenue is another consideration.

I mentioned earlier that we need to help families to connect with one another and to do peer support with family members. It is incredibly sustaining for family members to have the opportunity to connect with other people for support.

I make a distinction between family counselling and family treatment. In family treatment, the family is willing to be the unit of treatment — the patients. The family agrees to treatment on that level to deal with the intergenerational issues and the dysfunctional aspects. In family counselling, the family is worked with only in respect of the addiction problems of a family member so that family members know some of the good things they can do to help in the recovery process, and some of the bad things to avoid. Family members are enlisted as active allies in the change process. If there was a report card on the existing system, we would not get good marks in this area. However, there is better practice evidence to guide us and so we should be challenged on it.

Even with the policy-makers there has been an issue over jurisdiction and who is mandated to work with families. If your mandate is to work with people who have addiction problems, then you clog up the system when you work with the families. That way of thinking is wrong because we know that social support is primary and that there is probably no greater factor in producing better outcomes. We should be mobilized to draw on this factor and to work with it.

The Chairman: We heard exactly the same thing from families experiencing mental illness. One chapter written for the report of the committee deals with family reaction. The stories are heart-wrenching, precisely along the lines that you talked about.

Mr. Purvis: I want to comment on the CRAFT program. One thing we know about best practices and treating youth is around building a long-term relationship because youth typically bounce back and forth in and out of treatment. It is important to make treatment as experientially based as possible so it would be beneficial to have a different way of delivering treatment to them, which senators are likely more familiar with than I am. The social support system is important. Positive outcomes in the treatment of addictions depend on two key ingredients: connection and continued connection to your key social support system, as well as employment or, in adolescents, education.

We have encouraged that through our choices program, which is our adolescent in-patient program in Nova Scotia. One condition of admission to the program is family involvement. The family will attend a couple of weekends and will be involved in sessions throughout the period of the programs. Even if adolescents are in the program for one month or two months, they still go home to a social system. That is one of the premises and why we moved into CRAFT and the outpatient offices. CRAFT is a community reinforcement approach, which is an evidence-based best practice in the treatment of addictions. In Family Training, FT, some of the principles of social work and behavioural psychology on a simple basis are taught to family members, which they can apply to their concerned significant others, to improve or reduce harms involved in their drinking, and to move them towards abstinence or treatment and to improve functioning. We do that because the early warning system is initiated by a family member. The problem bothers the family long before it bothers the people that are using the substance. The family has the hangover without having the party the night before, and is usually far more motivated than the person who is still enjoying it.

Thus, there is a highly motivated workforce to utilize that, has all kinds of access to a clientele consumer base, and has far more interaction with the person than the treatment worker will ever have — 24/7 in most cases. Why not take the principles that you would take generally within therapy and teach them to the family members who are motivated because they want their relative to improve on the harmful interaction with the substance they are involved with. The basic premise behind this practice is teaching people how to reward abstinence or harm-reduction behaviour, and withdraw rewards or enabling when people are using.

The people who developed this at the University of New Mexico at the Center on Alcoholism, Substance Abuse and Addiction, Dr. Bob Myers and Dr. Jane Smith and Dr. Bill Miller, framed it in the best way: It is teaching a positive spin on putting praise behind the behaviour versus putting negative consequences on the behaviour. For example, when someone comes home drunk, the typical reaction is anger and other negatives. Under the CRAFT initiative, a positive spin would be taken because nothing changes behaviour like positive reinforcement. That paradigm shift is the backbone of what happens in Community Reinforcement and Family Training. There is a great deal of evidence behind it. We just started using it in Nova Scotia and, hopefully, we will have some good outcomes to bring back. The family has the best chance of impacting on those with problems. The stats coming out of the U.S. show that seven out of ten treatment-resistant addicts, who would never go to treatment before, volunteered for treatment by the fifth session of CRAFT for the family member.

To enter the study, they have to refuse — ``I would never go to treatment.'' They cannot be someone who is considering it; they have to be someone who is outright refusing it. I think there are some interesting, fun, good programs out there.

Senator Cordy: My last question has to do with stigma and education. In Nova Scotia we have a public health ministry; that is the good news. The bad news is that it is poorly funded.

Mr. Purvis and I spoke at lunch time about the addiction to smoking and nicotine. I think we have done an excellent job of educating people as to the harmful effects of smoking. He said people come freely to the clinic or whatever it is in Pictou to ask for help for smoking. As an educator, that was part of the curriculum for many years, and we are now seeing the results. It is not acceptable to smoke in public areas.

When we talk about other addictions, we have a stereotype of a person with an addiction and it is not meeting the information that Senator Callbeck just received. When you look at the idea of somebody who is addicted, you tend not to look at alcohol. If you do, it is a person sitting in an alleyway with a brown paper bag. You do not look at it as being the drinker inside the home; you do not look at prescription drugs and those kinds of things. The sensationalized reporting does not help because what is in the news are the sensational stories, not the day-to-day lives of people.

Without education, the stereotype will continue. The discrimination and stigma will continue.

Mr. Skinner, you said addictions need a clear profile. How do we move upstream? We can see the results with the anti-smoking campaigns; 20 years later, it is having an effect although there are sometimes a few dips. Where do we start in educating and reducing the stigma?

Mr. D. Kelly: I go back to the experience of the dream team. Nothing is more powerful than to put a human face and understanding to it by somebody who has been through either addiction or a mental health problem. If we could encourage people to come forward and talk about their experience in addictions and how they have recovered or are in recovery, we would see a better understanding and we would reduce the stigma that people face when they go into any parts of our health care system.

If we started in our health care system with emergency room workers so they have an understanding of the person with alcohol poisoning, how they may have gotten there and how they are trying to get out of it, I think it would have a tremendous impact.

Mr. Stockwell: This is going upstream in a slightly different way. In terms of the educational piece, although there are guidelines in Canada for low-risk drinking, they are not promoted much and they are not accepted. Some might argue they are not credible. They might be on the conservative side; the Australian ones are about twice as high.

However, there is hardly a general practitioner in Australia that does not know those guidelines and use them in consultations. They are promoted on beer mats, on posters and in bars. There is a national media campaign. Also, there is the whole thing about how it is not just an addiction problem — that most of the deaths from alcohol are from people getting drunk. If you really want to go upstream, you need to look at risky patterns of use that, downstream, lead to dependence of some degree. It starts with getting roaring drunk. Most harms are among people who drink a little on average but get blasted once or twice a week, and that is a common pattern. We need to move upstream in conceptualizing our correlated problems, and say other things about other drugs and have national guidelines that are clearly disseminated about risky use of alcohol.

Mr. Wilbee: One struggle we have in the addictions field strictly with alcohol use is the great success of the self-help groups such as Alcoholics Anonymous and Narcotics Anonymous, where the whole business of anonymity is entrenched. In that case, it does lead to stigmatization.

I saw a panel a few months ago at a conference dealing with alcoholism, which had some high-powered media people in the U.S. on it. What they talked about, particularly the television people, is that television is a story medium. When they show people in shadows in public service announcements or just their hands, they feed into that whole sense of stigma. They said they, in the media, are prepared to run the stories if people are prepared to tell them.

I was invited to a summit in Providence, Rhode Island, called the Providence Summit, where all the American gurus come and talk about these issues. They have similar issues to us and, in some cases, even more severe issues. They use the term ``parity'' in terms of funding — getting mental health and addiction to reach that level of parity where they receive the same amount of dollars, not 80 per cent on the dollar.

I am shocked to hear that south of the border if you have been in rehab, using their term, that may disqualify you for a student loan. I think in many ways we are not quite there.

The message coming out of that group as well — and this goes to the point I first made in the presentation when I said you may have to work your head around this — is addiction health. As I think Mr. Kelly is saying, mental health has been successful; we have not been that successful in addictions in getting that voice out there.

I am impressed that George Bush declared the month of September, about three years ago or so, National Alcohol and Drug Addiction Recovery Month. Clearly, there are all kinds of issues going on there. I would like to see something similar — I would not call it substance abuse — but to take a look at that. There is this challenge of how to get those messages through. We love to hear success stories in our families in other areas — that people have overcome their cancer through high-tech treatment and good support. I am a diabetic so I am interested in that kind of research — that is, behavioural, if I do not eat properly. I just wanted to point that out. We have not talked about that a bit.

There is a history here. The involvement of my organization comes out of that kind of abstinence; self-help kind of stuff. Somehow we need to break through that barrier. I think it will happen.

Mr. J. Kelly: I would like to address the market side of stigma and messaging. First, stigma is a complex idea. It depends on who is perceiving what. I am in favour of highly researched and highly targeted messages to get at components because to deal with the stigma of drug and alcohol problems is many stigmas in many audiences. That always requires enormous focusing and clarity about what we want to persuade people to do, and going to the audience and finding out what they believe, what message is believable about stigma. We can say many things; we have had discussions here that the general public probably would not believe — for example, that alcohol is more important than crystal meth. There may be truths but the public will accept truths that are believable or that fit their frame of reference. What will influence a person? Where do they go to listen to a message? How does that message have to be crafted?

Often in the human service system, while we want to get the message out, we do not do an adequate job of assessing who the audience of that message is and what they can accept at the time.

We have looked at many successes in persuading people to avoid certain social problems. The massive and growing consensus around tobacco fed itself. We reduced tobacco use 25 per cent in 25 years. There are many more examples of successes that are sustained over time. They are not a campaign but a strategy, a multi-faceted strategy with many messages.

A man from Britain attended our conference last year and spoke about promoting traffic safety in Britain. The central government in Britain spends about a million pounds a month on traffic safety. They target use of seat belts, proper care of children in cars and maintenance of cars. They have been successful, but they have put resources into it. They have carefully calculated each message along the way and have had to change them over time.

It needs to be sustained and it needs to be constantly targeted to different pieces of the problem at different times. Stigma is a global issue made of many little perceptions.

Mr. Purvis: Every door leads to the right door, and if we go up the stream we know that primary health care practitioners need to be one of the doors. We can go beyond that and look at virtual doors. We can look at less intrusive involvement and early intervention with problem drinking. We are not doing enough to market what is normal drinking. We are not providing advertisements about what normal drinking is. We are not advertising this in newspapers. All that is required is, ``If you can answer yes to three or four of the following questions, you may have a problem with drinking and you may want to try one or more of the following suggestions. You may want to visit a website, download a self-help manual, attend a session, or call this 1-800 number.''

There are many less-intrusive interventions. We do not market what ``normal'' is or what ``problem drinking'' is. We invest way upstream when we can make a huge impact upstream for very little resources.

[Translation]

Senator Gill: Thank you for your contribution. We have heard a lot of excellent ideas today.

I would like to draw your attention to our Aboriginal communities. I am sure that many of you already have a general understanding of the situation. I am sure that you know that Health Canada is responsible of the provision of health care services to both on-reserve Aboriginal people and Inuit, but not for the Metis or off-reserve Aboriginal persons. I am sure that you also know that both physical and mental health care services are provided directly through clinics. While these clinics are often under Health Canada management, they are sometimes managed by band councils in the communities.

Where these clinics exist, and especially in isolated areas, they tend to be staffed primarily by nurses along with the occasional doctor. For example, the clinic in my community has one female Aboriginal doctor. Some other communities in Quebec also have a doctor, and I believe that Canada's other provinces are faced with a similar situation, where they only have occasional access to the services of a doctor. We have a few psychologists, and perhaps also some psychiatrists, although I am not certain of that.

You are doubtlessly also aware of the problems that we face: suicide, drugs, our socio-economic conditions, et cetera.

It will soon be time for us to write our final report and make recommendations.

We have heard from a lot of people across Canada, both Aboriginal and non-Aboriginal. If I am correct in my understanding, I would summarize what I have heard by saying that a significant number of Aboriginal people, as well as non-Aboriginals who work with Aboriginal communities, would like to see health care services being managed directly by Aboriginals with, of course, a far higher number of Aboriginal specialists and experts to take charge of health care delivery.

My question is as follows; indeed, it has already been brought up and so we must surely seek to find an answer. I would like to know what you make of the following observation: It would be fair to say that, in general, health care is currently directly managed by the federal government. We can also say that, in practice, health care is generally administered by the provinces when it is provided off-reserve in hospitals or other service centres across Canada. Generally speaking, the services are provided by the provinces and managed directly by the national health care system.

Do you subscribe to the view expressed during these hearings that the services ought to be managed by Aboriginal people themselves?

As regards governance, one must also take into consideration the level of government involved. For example, at a federal level, were the Department of Indian Affairs and Northern Development to decide to decentralize its services or service management to its regional offices, which in turn decided to delegate to band councils, there should still be accountability to the department in terms of objectives, programs, program parameters and reports in order to determine whether the system is working well.

What should be done regarding health care? Would you support the provision of health care services being controlled by a body which includes Aboriginal representatives, or would you simply be in favour of decentralization at a local level, a regional level and so forth?

I would like to hear your thoughts on that matter. You also spoke of integration. Personally, when I speak of integration, I have a different idea in mind. Do you think that those services which are currently provided ought to be integrated with those available to non-Aboriginal persons, or should there be a specific tutelage system in place for the delivery of services to Aboriginal people?

Your comments would greatly assist us in drafting our report and our recommendations.

[English]

The Chairman: Senator Gill lives on a reserve in northeastern Quebec and is a former chief. I am interested in the B.C. experience. There are several reserves on Vancouver Island. Also, I know that the Centre for Addiction and Mental Health has had experience dealing with reserve First Nations people living in the Toronto area.

Mr. Stockwell: I really am not expert enough in the local situation in B.C. I am aware of some excellent programs run by indigenous people in B.C. and on Vancouver Island. I think that the corny adage of every door is the right door springs to mind. Incidentally, that is the name of the B.C. government's policy on addictions. One would have to talk closely with the communities themselves to see what fits best in terms of geographic access and cultural appropriateness. I think there is a level at which it would work well for some. There may be some benefits from having good access to other services where they are acceptable and mainstream as well.

Mr. Skinner: I do not have special expertise in this area, but the area interests me. Currently, I am involved with some native First Nation communities in Ontario, around the whole area of concurrent disorders, and their interests in having better responses to these complex problems in their communities.

Some principles that we talk about can be applied to what is a special set of circumstances when you look at First Nations; that is, the whole idea that the system should be centred on the client or the person receiving the service.

Your questions around how to organize them: I think there is complexity there. Principles of empowerment would suggest that communities should articulate what their needs are and how they are responded to. That is one issue.

There is an interesting dynamic here too that the local issues will vary and challenge it, but, somehow, there is a special need to mobilize a set of resources that you can only almost think of by going to a national or regional level. If people have special needs for diagnostic services or assessment resources, you cannot provide them locally. How can you create networks and connections where people can tap into the professional expertise that they will need to deal with complex substance use, gambling and mental health issues? There needs to be a mechanism for that to be available.

The other issue that we have been asked about at CAMH, with our Aboriginal services and our concurrent disorder resources, is the whole issue of professional skills of staff who are working. In some communities, you have just a nurse or a worker who is dealing with many different issues. We try to think of some ways that we can provide a mixture of online training and face-to-face training to help them build their skills so that they are better able to identify the addiction and mental health problems in their communities. Then we work with them around the kind of responses that they will need.

It is a situation where we are learners and we need to be led by what the needs are, as articulated by the First Nation communities themselves. The issue needs to be seen not as a brief journey but a kind of journey that we continue along together. We probably have to learn as we try things.

For example, in northwestern Ontario right now we are working with the Newcomers and Natives community, NAN, and they have identified three of their own communities where they want training. We will evaluate that to see if what we have done is effective. If it is, then there will be an interest in extending it. As we go from community to community, we must be open to making adaptations in each community so that what we do fits with local needs. It needs to be that kind of process, where, again, I think our role is to act as resources to needs that are identified and guided by the communities themselves.

Mr. Perron: I can give you a sense of where we are with respect to the addiction side of the question you posed to us because we have discussed it a great deal — that is, Health Canada and I. When we did our national consultations — and I am sure you are all aware — the situation among First Nation communities across the country was identified as being deplorable and one that needs immediate attention and redress. The last thing we want to do is perpetuate what has been done in the past, namely, jump in and try to fix it, to be candid.

With our consultations, we quickly realized that we do not understand enough of the First Nations world. We asked: How best do we do this? We recently engaged, and I have had meetings this week with, the five national Aboriginal organizations, recognizing — from the Assembly of First Nations to ITK, and so on — that each of them is involved in mental health addiction issues as part of the blueprint issues. A huge amount of work is occurring with respect to the fundamental issues of self- governance and service at the local level. We are working with them to identify how best we can complement and leverage the work they are already doing vis-à-vis the initiative on the blueprint exercise. The First Nations and Inuit Health branch at Health Canada is doing an extensive strategy — and, I hope you have heard from them — on mental wellness. I sit on their committee. They bring together the five National Aboriginal Organizations, NAOs, to deal with the mental wellness of First Nations.

The issue of on-reserve or off-reserve is an artificial federal distinction. To the person who is in corridor, as we call it, or who is off-reserve falls out of the system and is very much short-changed. From my perspective — and I do not mean to speak for the government because I cannot do that — there is a growing understanding that the artificial nature of how the services are delivered does not necessarily work the best. There is a lot of rich experience that we can transfer that looks at how best to make use in the future of the experience of the National Association on Drug Abuse Problems, NADAP. The vision of how insured health benefits plays out is not necessarily benefiting everyone.

Without perpetuating what has been done in the past by trying to do what we think is right, we ask how best we can do this. It is not much of an answer to you other than to say that we need to find the solutions in the communities and we need to see and recognize it is not only on-reserve but also off-reserve; it is Aboriginal, Inuit, and Metis all across the country that see strict federal confines in certain geographic areas.

We were in Iqaluit this year with my board of directors when Premier Paul Okalik said, ``If I want to send someone for treatment, they go to Ottawa. When I come back, there is no aftercare. What do I do?''

These matters are being taken up as part of the blueprint exercise. We are still working with them. It speaks also to the nature of the best practice and evidence that we cannot necessarily hold the bar only to scientific findings. We also have to look at qualitative experiences that we have seen in the North as to how best we can deal with the issues of addiction so that it transcends the strict laboratory type of evaluation to those experiential and culturally specific experiences.

Senator Gill: Something that will be difficult and we must face at the committee level is that Aboriginal people would like to control stuff. That is, they would like to manage, to establish the needs, and so on.

When you met with the provincial minister, I am sure those ministers would like to have the money and manage. I am not sure about that because I did not meet those people, but I think we will have to decide which one at the Ottawa level.

Mr. Purvis: I was briefly involved as a consultant with Health Canada on Davis Inlet. I think Davis Inlet is a wonderful example of what not to do, where we removed people from the community, held them for a while and then moved the community.

Having said that, I can only repeat the points I made. We need to be responsive, available and not prescriptive. There is a trust issue with our Aboriginal people, given our track record with them. That record needs to be acknowledged and worked through. There should be a trust issue. We have not done a great job.

The Chairman: We know that the Canada Pension Plan Disability Benefits, CPPD, is targeted at people that have a physical disability and not a mental disability. Indeed, it is virtually impossible to get CCPD if you have a mental disability. We are attempting to do something about that, but that is the current state of play.

If someone has an addiction problem sufficient to prevent them working, and if they applied for CCPD, does anyone know if they get it or not? You are nodding yes: they do get it?

Mr. Purvis: There have been cases in Nova Scotia where people have gotten a disability pension based on addiction.

The Chairman: Does anyone else have any experience on that? That is interesting. They recognize addiction as a disability, but not mental illness. I am not asking you to comment on the mental illness, I know that fact.

Mr. Purvis: This would have been a while ago. I have been out of the field for six years on the front lines.

The Chairman: There is some history.

Ms. Bradley: I have seen that with mental illness. I saw maybe one for addiction but, again, it was a long time ago.

The Chairman: I would also ask you to send me some data. Early on, one of you made a comment about knowing how much cheaper it was to provide at-home service than institutional service. You were specifically talking about detox services. Since everything in the government comes down to money, not outcomes, one thing would help us. If anyone has any hard data — I look at Mr. Perron and Mr. Jon Kelly — that would enable us to make the argument, which seems to me to be self-evident for all the reasons of moving care out of institutions and moving the community into the home, it ought to be more economically efficient, assuming that the quality of service is there. That is obviously a constraint. If anyone could document that, could they send it to us? I need the numbers.

Mr. D. Kelly: We have a document that relates to the benefits of funding addiction and health services, which has those statistics. We have another that speaks to outcomes and evaluation of mental health and addiction services, which shows the costs. I will forward that other one, but the first document is here now.

Ms. Bradley: There probably is some documentation on outreach and working in the home with seniors out of a program in Toronto called Community Outreach Programs in Addictions, COPA. We could probably get you some statistics there.

The Chairman: That would be great.

Mr. Stockwell: This morning I mentioned that you can get one much cheaper. I talked about the one nurse who did as many detoxes as the hospital did. There has been documentation of cost benefits in Australia and the U.K. I said I would forward that to you. Plus, they have better usage by older people and by women who tend not to use traditional services. It is a stigma thing.

The Chairman: They are willing to have someone come to their house because nobody knows about them.

Senator Keon: I am wondering if I can exploit the panel for a minute. As you know, within the next month or so, I have to participate in a conference on crime and mental illness, which was delegated to me.

The Chairman: Now you know why they say politics is the art of shifting the blame.

Senator Keon: I was interested in the discussion on addiction and the young offender. What you did not cover was addiction and the young criminal, the 20-year-old who, under the influence of alcohol, crashes his car, kills some people, and is a convicted criminal from there on in. Could any of you enlighten me as to how these people are managed?

Mr. Grant: I am not certain what you mean by ``managed.''

Senator Keon: As far as I can see, they are written off.

Mr. Grant: That probably depends on the correctional system that they enter. At the federal level, they would be assessed and directed to treatment programs that were appropriate for their needs. Usually people who come into the correctional system have needs in a number of different areas, so the could go into substance abuse programming since it was a drunk-driving issue. They might also have issues with anger and those sorts of things. That kind of treatment would be available to them. They are then followed and supervised in the community when they are released and their behaviour is monitored. I would not say they are written off.

It is more difficult in the provincial correctional system where people are serving much shorter sentences. That would not be likely in the case of serious injury following a motor vehicle accident. It will usually be a first adult offence, if they are 19 or 20, and they are likely to go into the provincial correctional systems where sentences are short. It becomes difficult to provide effective treatment for those people.

In our experience, when we look at our data, what often happens to them is they will cycle through the provincial system a few times and then graduate into the federal correctional system where there are treatments available and where we hope that we can have some kind of impact.

Does that answer your question?

Senator Keon: That is helpful. One thing that troubles me is that it seems that a 20-year-old in this predicament faces absolutely nothing in life but brick walls. He cannot get into university, he cannot leave the country, he cannot work in the civil service and he cannot get into a police force.

In some of the research material I am drawing up, I am alarmed at the numbers of these people. Society seems to accept this predicament. I do not know what they are supposed to do. I do not know if they can even pump gas.

Mr. Weekes: Having worked as a psychologist in Corrections Canada in the same prison where Greg Purvis worked as a psychologist, the reality is that a 19- or 20-year-old coming into Drumheller Institution for three years for aggravated assault or assault causing, has frequently been through juvenile homes, open custody, closed custody, suspended sentences, community service and provincial time. Then they come to the big house at Drumheller or whatever of the 50-odd institutions around the country. It is almost that they are damaged individuals. There is a fair amount of variability, but they are thoroughly institutionalized. For a 19- or 20-year-old, this is the unfortunate reality for many of them. It is the way they think of reality on a day-to-day life that involves incarceration.

The fact that Corrections Canada can get any change out of an individual like that, and to some extent they show that they can, is amazing. It is a big uphill battle. By the time they are 20 years old in the federal penitentiary they have a big history behind them.

Ms. Bradley: The example I was going to give is of a young man with a concurrent disorder. He had a schizophrenic episode and killed another young man while he was in university. He was at Penetanguishene for many, many years. When I first ran into him he was in a community mental health centre. He had been released to the community. He was heavily medicated, hugely overweight and scary. He had a big beard. We were afraid of him.

He stayed in the community mental health program for about five years. He found work. He has been employed for about 15 years. This young man had a fair bit of support. He still lives with his parents.

There are some successes. However, I think this was an unusual success. It was a result of the community having jumped in. They taught him how to cook and how to manage his money. They taught him the really practical living skills.

Senator Keon: I guess I come back to the fact that this is reality. However, it seems awful for a young person to have no future.

The Chairman: On that sobering note, may I say thank you to all of you who came from out of town. We appreciate you allowing us to pick your brains for six hours or so. It has been extremely helpful to us. We hope our report lives up to your expectations.

The committee adjourned.