Health — Issue No. 30 — Tuesday, July 12, 2016 (HTML)

2800 CN Strategy Room, Segal Graduate School of Business
500 Granville Street, Vancouver, B.C.

Present: Linda Larson, MLA (Chair); Judy Darcy, MLA (Deputy Chair); Dr. Doug Bing, MLA; Dr. Darryl Plecas, MLA; Selina Robinson, MLA; Sam Sullivan, MLA

Unavoidably Absent: Donna Barnett, MLA; Marc Dalton, MLA; Sue Hammell, MLA; Dr. Jane Jae Kyung Shin, MLA

2. Due to the initial absence of the Chair, opening remarks by Judy Darcy, MLA, Deputy Chair.

3. The following witnesses appeared before the Committee and answered questions:

The following electronic version is for informational purposes only.
The printed version remains the official version.

REPORT OF PROCEEDINGS
(Hansard)

SELECT STANDING COMMITTEE ON
HEALTH


CONTENTS
Page
Presentations	571
G. Ganci
J. Cooksey
D. Marks
T. Dovey
B. Keith
B. Gutray
J. Morris
L. Hildebrand
R. Baker
C. Bishop
C. Doucette
D. Berner
I. Bushfield
B. Wood
H. West
P. Vohora
R. Pawliuk
J. Ranallo
P. Farnan
G. Leekha
A. Richmond

J. Darcy (Deputy Chair): Hello. Good morning, everyone. My name is Judy Darcy. I’m the MLA for New Westminster and the Deputy Chair of the Select Standing Committee on Health, which is an all-party parliamentary committee of the Legislative Assembly of British Columbia.

As part of its mandate to identify potential strategies to maintain a sustainable health system for British Columbians, the committee undertook a public consultation in 2014-15. This summer, we launched an additional call for submissions looking for new or updated information on the following three questions: how can we improve health and health services in rural British Columbia, and what long-term solutions can address the challenges of recruitment and retention of health care professionals in rural B.C.; how can we create a cost-effective system of primary and community care built around interdisciplinary teams; and, how can we enhance the effectiveness of addiction recovery programs?

As part of its consultation, the committee held public hearings in Victoria, Prince George, Kamloops and Vancouver. British Columbians are also invited to participate by sending a written, audio or video submission. You can make a submission or learn more about the consultation or the committee by visiting our website at www.leg.bc.ca/cmt/health. The deadline for submissions is Friday, July 29, 2016.

As a committee, we determined to focus today’s meeting on the third question: how can we enhance the effectiveness of addiction recovery programs? All the input we receive will be carefully considered by the committee as it prepares its final report to the Legislative Assembly.

As far as our meeting format, today’s meeting will consist of 15-minute presentations followed by 15 minutes of questions from the committee. Please note that our meeting is being recorded and transcribed by Hansard Services, and a complete transcript of the proceeding will be posted on the committee’s website. All of the meetings are also broadcast as live audio via our website.

I’ll now ask the members of the committee to introduce themselves. Linda Larson, the Chair of the committee, who would normally be in this seat, will join us by conference call later on today. I will ask the other committee members to introduce themselves.

S. Robinson: I’m Selina Robinson, the MLA for Coquitlam-Maillardville and the opposition spokesperson for local government, sport and seniors.

D. Plecas: I’m Darryl Plecas. I’m the MLA for Abbotsford South. It’s so great to see you here today. You all even look like nice people.

J. Darcy (Deputy Chair): Also assisting the committee today are Kate Ryan-Lloyd and Stephanie Raymond from the Parliamentary Committees Office. Ian Battle and Alexa Hursey from Hansard Services are also here to record the proceedings, as mentioned.

G. Ganci: Hello, everyone. Good morning. My name is Giuseppe Ganci. Thank you for giving us this opportunity.

I am the director of community development for Last Door Recovery Society. Last Door is a youth program, an adult program, a treatment facility that provides primary care treatment for approximately 100 clients in six facilities that are set up in an urban setting. One of our facilities is also in Mission, B.C.

Last Door is integrated. We do a blend of the holistic model, the medical model, the therapeutic community model. We blend all those together, depending on what the client’s needs are.

We are a long-term treatment centre, which means the average person stays a minimum 90 days to four months. We’ve had some people stay over a year. I think one of our clients stayed about two years. It really all depends on what the client’s needs are. Once again, we’re an advocate for long-term treatment, which is about four months.

Our treatment centre provides services for substance misuse, for alcohol and for drugs. We also work with process addictions such as gambling. We have a psychiatrist that works with us when dealing with clients with trauma and PTSD. We try to work on all issues at the same time within our program.

What happens with Last Door is…. We’re considered by some a PPP, a private-public partnership. We’re unique in a way. We have contract beds with Fraser Health for people that qualify for Fraser Health beds. We also have private beds. Because of our reputation and our ability to help people, we’ve got families from across North America that wish to send their loved ones to Last Door, and they privately pay for treatment.

Then we also have another section of beds that are used for people that can’t afford the fees, can’t qualify for
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certain levels of assistance. We also have insurance beds, where different insurance companies will fund beds.

We also have a family program. We encourage all families to participate in the entire recovery process. We have a parents group, co-parenting group, partners groups. What that happens is…. Instead of just having visitation hours, an hour a week, clients can have their family and loved ones visit throughout their stay. It’s encouraged. That way, the family gets to become part of the recovery process.

One other highlight that I’m really proud of is that Last Door is nicotine-free. We’ve been nicotine-free for about 20 years. That means no clients smoke. They quit smoking when they come to our facility. What happens there is clients learn about being healthy and working on all of their addiction issues and all of their affairs. Somehow nicotine sometimes gets pushed aside. That really changes the value of our groups, when clients aren’t smoking.

I’m going to pass the mike off to some of our clinical team. Beside me here I have Jessica Cooksey. She’s Last Door Recovery Society’s operations manager, and she’s going to bring some insight to this presentation as well.

J. Cooksey: Hi. Thank you for having us here this morning. Of note, I also want to touch upon that we are accredited through Accreditation Canada. That’s voluntary. We’re also provincially licensed through health care services in Fraser Health. Our programs are licensed care facilities. All of our addictions counsellors are certified through the CACCF, which is the Canadian Addiction Counsellors Certification.

What that means is that in addition to our internal ethics monitoring and accountability framework, and our Fraser Health accountability and Accreditation Canada, we also have this other body that governs the safety and monitors our counsellors and that any of our clients could provide complaints to and grievances as well. Our clients are very well taken care of in that aspect.

In addition, most of our staff actively participate in recovery-focused committees. I’m on the CACCF board. Giuseppe leads Talk Recovery Radio, Vancouver Pride Society. Daniel and I attend the regional addiction committee, which is led by the Fraser Health Authority. So we do have our voice in a lot of different committees. We are the only contracted service on the substance-use screening committee for Fraser Health as well. That’s to help clients determine whether or not they’re suitable for funding or whatnot.

Daniel is one of our senior addictions counsellors. He’s been with Last Door for over a decade.

I’ll let you speak to what we see as the vision for health services and addictions.

D. Marks: Hi. I’m Daniel Marks. Thanks for having us today. Thanks for listening.

Up on the PowerPoint is the vision for the B.C. Ministry of Health and services, which I think…. Working in the addictions field for over ten years, I truly believe that this is a good vision to start with, that any door is the right door. As long as we’re starting some services, somewhere, it will eventually lead the individual to the services they genuinely need.

We also have another saying: “Not every door is the right door.” Not every service is right for every individual. But starting somewhere will eventually get that person to where they need to be.

I, myself, have worked in detox and outreach and with Last Door for the last ten years. So starting somewhere is important. Multiple points of entry, timely referral of appropriate prevention and treatment support — that’s the idea of every door is the right door.

Speaking to one of the larger gaps that we face at the Last Door Recovery Centre and pretty much throughout all addiction services…. It’s that we come across a three-tier system in working with individuals. It’s commonly talked about — our health services having a two-tier system, public and private. I actually find it more of a three-tier system.

The first tier is the safety-sensitive workers, the private pay, the individuals who are able to get the top-notch treatment right away because they either have the insurance or the money themselves to pay for it.

Then we also have the third tier, which is the poverty class, the Downtown Eastsiders, the people who are on employment and assistance, who have absolutely nothing. They have those services completely provided by the province, with multiple options and multiple different types of treatment. We have noticed a trend where the majority of those individuals are kind of being skirted into maintenance therapy programs — the methadone, the Suboxone. For some people, that’s fine. That’s what they’re looking for. But for others, it’s not okay. For some people, that’s not a good fit.

The biggest gap that we face today is the middle class, the second tier that not a lot of people seem to be talking about, which is the working poor, the demographic that’s in the $20,000- to $50,000-a-year income, the ones with families, the ones who can’t pay for private. Those individuals don’t actually qualify for the welfare system either.

An individual — maybe like Tyler here, who’ll be speaking later — would call us up and ask: “You know, I’m looking for treatment. Can you help me?” We would, you know…. “Can you get on welfare?” “No, I can’t get on welfare.” “Can you pay privately?” “No, I can’t pay privately.” “Then we can’t help you.” That’s a very large demographic of people.

To us, that sounds kind of crazy, because they’re the ones that are working and paying taxes. A lot of those people just end up on the maintenance programs, which is a large problem for those individuals. A gentleman
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like Tyler can’t go on a maintenance program because his work requires him to be absent because he’s working in a sensitive area. He’s a ticketed individual who could hurt himself or somebody else if he’s under heavy medication.

This is a rather large population that is unserved. We believe that a more robust user fee assistance program for that working demographic could help that. Another issue is the EI lag time — if the individual is able to pay for treatment with their EI. It takes time to get EI started, so then they’re left in the wings waiting for that to come into play.

J. Cooksey: With someone who is, say, a parent of a young family and who doesn’t want to go on opiate replacement therapy and wants to access residential treatment, while they’re waiting for services, their family witnesses their drug use. They miss work. They have emergency visits. They continue to relapse while they attempt to remain abstinent and try and solve it themselves.

Most clients in this demographic aren’t aware of all the services available to them. They don’t know that health authorities provide out-patient counselling free of charge, and they don’t know how to access that. Their EFAP workers have no idea what addiction looks like. They’re given substandard counselling services because their EFAPs don’t have those experiences.

What happens is that the entire family suffers. They drop into poverty. They become a tax on the emergency services. Their substance use gets more severe. Then we’re looking at generations of substance users instead of just a father.

That being said — there’s that gap, and there’s that underserved…. There are a lot of successes in our health authorities when it comes to substance use and mental health services — namely, that we’ve connected mental health services with addiction services. I’ve seen a lot of organizations and a lot of programs collaborate and help bridge those gaps. We really are dealing with the same population. It’s the chicken and the egg. They come together.

D. Marks: Speaking more to the recovery programs’ successes, we have had a lot of success with the family programming at our facility. We have a parents’ group that we hold once a week. We support the Nar-Anon meetings in our community. Actually, our parents’ group is so successful we’re almost debating if we should either be turning family members of drug addicts away or expanding it because we’ve had so much success.

J. Cooksey: Part of how we think that, as a system, we can enhance recovery services, the effectiveness, is that rather than just focusing on home care or home detox methods, you allow some of our longer-term programs to provide that service on site so that people’s children are not witnessing daddy being sick at home and they’re being checked every couple of hours. A lot of our recovery programs are capable of providing home detox services on site.

Another thing is what Danny talked about. In the past, income assistance workers would go into withdrawal management and help that application process and help secure funding so that people could go directly into residential treatment. That is no longer the case. They do an on-line application. They wait for a phone call that doesn’t come because they don’t have a phone to be called back on, and they fall through the cracks.

Another thing that we have noticed is that with 100 beds in New Westminster, we have three walk-in clinics that are maxed out with the small families that live in New West. New West has grown substantially, with small families. What we would recommend is that between multiple residential programs, perhaps we share a GP or a CSM doctor on site. I know that between our program and Westminster Health’s per se, we have the resource space to share. I know that a lot of residential programs could provide that. In addition, sharing a psychiatrist among programs would decrease the tax on mental health services and out-patient services.

Also, that user fees become a provincial pool of money, not just health authority money. I don’t know if you’re aware that it’s depleted this time of year, so anyone who’s working class, who’s paying taxes, cannot access treatment until April 1 at the earliest. Sometimes there is a top-up, depending on what the budget looks like, but there really is nothing available to that demographic until April 1.

I know that there’s no additional money available, but perhaps making it provincial will help those people from, say, Prince George or from more rural areas access residential programs before they tax the rest of the health programs.

J. Darcy (Deputy Chair): Thank you. I’m going to just interrupt. You have about three or four minutes left if you want us to be able to ask you questions.

G. Ganci: Where we’re at now — and I want to get Tyler to say a few words — is we want to encourage no stigma. We want to encourage the idea that being in recovery should have no shame. Last Door Recovery Society, along with some of our other organizations that we work with — our goal is to put the message out there that addicts do recover. It is a possibility and when we recover, we do amazing things.

We also want to keep recovery services equal for everyone — not just depending on your income and depending on your insurance — where someone that wants to get addiction treatment gets the same treatment. Whether or
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not they’re on welfare or living in the Downtown Eastside, they get the same services that a nurse or an airline pilot gets. Right now that’s not happening. Airline pilots and doctors and nurses go to amazing facilities, and if you’re living on the Downtown Eastside, you’re given harm reduction models that have no goal of abstinence. That’s completely unfair.

We also want to make sure that the ability for people to participate in recovery is supported. Last Door invites you to also help end the stigma of addiction. We’re partnering up with other agencies to host a recovery day, which is on September 10. It’s going to be in New Westminster. We’re having a street festival.

We also pioneered, in 2009, a clean and sober space amongst Vancouver Pride. This has also turned into a street festival. British Columbia has the only substance-free zone in the world during a Vancouver Pride Day, right in the middle of the Davie Village. No other city does that. We’re closing Bute Street down on Pride Day. It’s a clean and sober space. I’ve been part of that committee for a while, and it’s our biggest year yet. We’re really excited about that. Nowhere else on the planet do they do that, so we’re pretty happy about that.

Just a little bit about my story. Last year I was trying to get clean, and in the process of doing that, I ended up going to the hospital from excessive using. They sent me to a program, a detox-type program across the street from the emergency in Surrey Memorial. I spoke with a counsellor for about 15 minutes, and he gave me a sheet of paper and said, “Come see me in a month, and if you feel like using, write it down on the piece of paper,” right?

Like I said, I didn’t have any money for private treatment, and I didn’t qualify for welfare at the same time, because I’m an electrician by trade. That wasn’t in that bracket. Waiting to get into the Last Door, trying to get in, I ended up going to the emergency another three times in that month.

Fortunately enough, one of my family members lent me some money to start the process to go into treatment. I was there for four months and it was the best decision I’ve ever made. I’m ten months clean today, and life’s good. So yeah, it was a good decision. It would have been nice if that process had sped up and I didn’t end up going to the emergency and having those close calls in that month.

J. Darcy (Deputy Chair): Thank you so much, Tyler, for telling your story, and to Giuseppe, Daniel, and Jessica. I can certainly attest to the amazing work that Last Door Recovery does in New Westminster, and we’re very, very proud that you’re part of our community.

S. Robinson: Thank you very much for your presentation. Before I became a politician, I was an alcohol and drug counsellor. You have a long and solid reputation in the community, so thank you for all the work that you do.

I appreciate you coming forward and talking about that middle group. I’ve certainly seen it in my own family therapy practice — not being able to find resources for those folks who are paying taxes. They can’t get any counselling, pretty much, for just about anything. It’s really, really hard.

I have two questions for you. One has to do with the recovery end, once someone goes through treatment, and what your thoughts are about the recovery process after the intensive work — how people get back into their lives. What kinds of supports do they need? What should that look like? If you could address that.

The other one is around youth. I can’t tell you the number of parents I’ve had in my office, as an MLA, crying because there are no resources for their children. They are terrified about what’s going to happen for them. If you could just speak to what we ought to be thinking about doing in order to respond to these parents who are at their wits’ end.

D. Marks: To answer your first question…. You’re talking along the lines of transitioning from treatment back into the…? Our facility is a very family-friendly program. We try to get the family and their entire network as much involved in their recovery as possible. One of the biggest downfalls for people doing recovery is that they silo it. They’ll do their recovery here, and then they move home. It’s two separate worlds, and they go right back to the same system of addiction and unhealthiness they were living before.

We’ve had a lot of success having the families participate in the program, participating in family groups. They attend their recovery meetings with them, as well, out in the community and as they continue to practise their recovery upon leaving. That has been shown to have the greatest success for longevity in recovery — like going to 12-step meetings, being a part of the community setting, being part of a bigger family.

G. Ganci: Last Door also has two alumni groups. When clients do finish treatment, if they do move back to their home communities, Tuesday nights and Wednesday nights we do groups that are about 2½ hours long, and there are open book rooms for anybody that has been through our facility. Some clients from 20 years ago come to our alumni groups, and some people from a year ago.

We also have a kind of open-fridge policy. I mean, you can’t come over for dinner every day — but if you want to come and hang out and have dinner with the clients. Our clients learn from the senior clients. They’ll talk to someone like Tyler, who’s gone back to work. They might be a week clean, talking with Tyler at dinnertime or on a
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visit, and he’s saying: “You’ll get through this.” The therapeutic value of that is pretty strong.

J. Cooksey: What maintaining the connection with the programs that they’ve completed does is that when that second tier of recovery issues starts coming up, we’re able to connect them with either out-patient counsellors or private practice counsellors, because in the second stage of recovery, issues do come up that weren’t in the course. As long as we maintain contact with our client, then we’re able to refer them out as needed.

Usually youth, especially who have done long-term treatment, are not interested in any further counselling. They feel that they’ve had enough. But 18 months abstinent, they start coming up with challenges about what they want to be when they grow up, what college they’re going to go to. Maybe their grades have lapsed a bit. Maybe a family member has substance-use issues as well. They’re able to connect with counselling then, and they’re safe enough to ask for the help they need because we’ve maintained contact.

One of the free services that we attempt to connect any parent that contacts the youth program to — I’ve worked there for 20 years — is Nar-Anon. Not all Nar-Anon community meetings are made equally. I know the ones in New West are large because of Last Door and Westminster House. But we do try and connect the parents with services because they are going to need the support while they weather the storm of their child using.

I know that Burnaby Substance Use Services is creating a parents group for people — older adult parents with 40-year-old children. It doesn’t matter if they’re youth or adults; parents are struggling for what to do.

The thing that has been a godsend this year is the provincial funding. The Crossing closed, and the provincial funding opened up to the Last Door youth program. We were able to provide services to someone as far as Kitkatla, which is just west of Prince Rupert. All of those rural areas you don’t have any treatment services — or outpatient, really — available.

Again, I’m always advocating that any door is the right door and that youth are very selective in what programs they go to. Making all of them available is better than specific ones in different pockets.

S. Robinson: I’m just curious about the demand for youth. When I speak to these parents, they’ve tried everything, and there’s no room anywhere. What’s your sense of what’s out there?

J. Cooksey: Well, Creekside Withdrawal Management actually created a stabilization bed to help bridge that gap between withdrawal management and treatment, for that very reason. We have a wait-list of anywhere between two weeks and four months, depending on the time of year.

D. Plecas: First, congratulations, Tyler. Very close to that first birthday. That’s great, quite an accomplishment. And congratulations to all of you. I, too, have heard about the great work that you’ve done over the years.

My question is: what can you tell us about the percentage of people who come through your door who get to their first birthday?

G. Ganci: I can answer that. We’re really excited to say that we’re partnering with UBC right now, and UBC is going to be doing a five-year study of Last Door and Westminster House and the quality of life of clients five years after treatment. The results are going to take a little longer to get than five years. We’re excited about that because we wanted to see what the quality of life is of people that go through a social model program which is like Last Door and Westminster House. The numbers will tell us.

We’ve got an electronic health recording system that tracks all of our client data. About 75 percent of all of our clients finish treatment and get past their one year. We’re going a step above that. There are some people that will relapse, and then they’ll get back into recovery. Then there are some people that will become just normal drinkers and become successful and go back to work. So we want to study what the quality of life is from somebody that comes into our facility dying from opiate abuse and alcoholism and so forth and what their quality of life is five years later.

J. Cooksey: Our focus is not only on completing treatment and staying abstinent. Our focus is: are you exiting the emergency services? Are you still accessing them, or has your quality of life improved such that you are not taxing our system like you were prior to treatment? That’s our goal — to pull people out of the acute services and into mainstream living.

D. Plecas: Great. Just so that I heard that correctly…. I thought I heard you say that 75 percent of your clients get to their first birthday. I think that’s a pretty impressive statistic.

G. Ganci: Well, they’re with us for primary care for four to six months. Then they’ll do our alumni groups. Then you’ll have all those invitations. We do a pretty large-scale event every two to three months. That gets all of our alumni to volunteer and do service and be part of…. So that idea that my life is going to get boring when I stop drinking is just gone; it’s not real. Life gets pretty fun and very active, and we’re proud of that. That’s what
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made New West the recovery capital of Canada. We go above and beyond.

D. Marks: Yeah. It gets people thoroughly embedded into a 12-step program, into NA within New Westminster. So it’s a lot easier for them to carry on. All their friends are there. Their community is there. It’s not like they’re left on their own — or like a 30-day program where it’s a quick spin cycle, right?

S. Sullivan: It’s been a long time since I’ve dealt with this issue, but I think the issue is that when you take these substances or you have an addiction, it’s the dopamine in the nucleus accumbens that floods the cells. It actually changes the neurons so that it down-regulates the whole system and so that it needs more dopamine. The cells are different now. They’re changed.

How do we deal with those cells? I guess that’s the root of the problem. Is there any drug therapy or anything that can revert the cells or…?

G. Ganci: Our first response is time — time, time, time. The world is turning to the American model, where it’s like: “Let’s do this as quickly and shortly as possible so you can get out of this centre and go back to work.” We really focus on time.

Sometimes the therapy really doesn’t start till 30 days after intake. It’s eat, sleep, shower, make friends, go have some fun. Dr. Hedges is our medical director, and he sees all of our patients every week in the beginning and then every couple of weeks after a while. So our first response to addiction isn’t medication, but it’s definitely an option for those that need it.

J. Cooksey: With our youth program, Fraser Health has an early psychosis intervention outreach person that will come and do an assessment. Once our youth — up to age 24 — are stabilized, if they’re exhibiting low morale or are struggling, then we connect them with mental health. That system can assess them, free of illicit substances, to see if they do need some kind of medication to help them balance out chemically and what that looks like.

We’re able to advocate for our clients to have that service without them ending up in a psych ward or discharging treatment. That early psychosis intervention program has really helped our under-24s. The brain is not fully developed at that stage anyway, so it really helps to have those professionals be able to come on site and connect with our clients. They’re very vulnerable at that point.

I agree with Giuseppe that no amount of medication is going to replace structure and good living, but they can go hand in hand.

G. Ganci: With the idea of time being put into the treatment timeline, you end up in an environment where you’ll see somebody 45 days later, and it’s night and day. They came in. They self-diagnosed with every disorder the planet has ever come up with. They know more about medications than Dr. Hedges. Then, three months later, they’re fathers again. They’re sons again. That changes the environment.

When you do staggered intakes where…. Out of our 100 or so clients, about 80 percent of them all have three months clean or more. So there’s sanity. There’s more than the crisis…. In a lot of centres that do shorter-term out-patient programs on the Downtown Eastside, there’s too much insanity going on. Everybody is still in the detox phase.

If we can get longer-term treatment centres funded more, you’ll end up in an environment where somebody from the Downtown Eastside who has no social skills and has lost everything gets put into an environment where the aspiration isn’t how you’re going to get B.C. Housing. The aspiration is: how are you going to get your life back? How are you going to get a job? How are you going to get an apartment? How are you going to become a productive citizen? It changes the game. But when you have an environment where everybody’s goal is how to stay on welfare and how to be on the system, there’s no aspiration. And that’s what…. Our clients that come in on the funded beds all say: “Thank you.”

I wanted to finish with one more statistic. One hundred percent of all of our welfare clients all get off of welfare when they finish treatment. You can go through all of our records. None of our clients stay on welfare. That would be considered a failure of treatment. If they’re on disability and have medical conditions, that’s a different story. But if they’re on the system, on welfare, they will stay with us for nine months, a year, a year and a half until they have a job. Their first couple of paycheques we help manage. We’ll get them their first apartment. To us, that’s success. You go through the whole treatment of care. I’m pretty proud of that statistic.

J. Darcy (Deputy Chair): Thank you so much. I’m afraid that’s all we have time for today.

I just want to give a personal testament to and encourage my colleagues to visit Last Door and experience the program for themselves. When you’re immersed in that, even for an hour, or attending one of the events and celebrations in the community…. I know my reaction was that I wish everyone who was dealing with addictions could have a place in the Last Door recovery program. And that’s really our challenge — to build more Last Door recovery programs and enable more access to those kinds of services.

J. Darcy (Deputy Chair): Our next presenters are Bev Gutray, Barb Keith and Jon Morris from the Canadian Mental Health Association, British Columbia. Welcome. Please begin. You have 15 minutes to present and 15 minutes for questions.

B. Keith: Good morning, members of the select standing committee. It is an honour to be presenting to you this morning on the traditional and unceded territories of the Musqueam, Tsleil-Waututh and Squamish peoples about one of the most pressing issues facing our provincial health system.

My name is Barb Keith, and I’m the provincial chair of the Canadian Mental Health Association board of directors. I’m a registered social worker and have practised in the field of addictions care for over 25 years, currently at Central City Lodge’s addiction recovery program in Vancouver. Each day I see firsthand the acute challenges and the opportunities facing people living with a range of addictions.

The committee is seeking guidance on the following question: “How can we enhance the effectiveness of addiction recovery programs?” This morning our response to your question will focus on three core components.

First, we’ll provide a snapshot of the state of the union of addiction care in British Columbia.

Second, we will identify three gaps in the current state of addiction recovery that warrant urgent attention. Gap 1 is the need to reinforce the recognition of addiction as a chronic and treatable health condition like heart disease, diabetes or chronic respiratory problems. Gap 2 is the need to act before stage 4 in addictions care, much like we would for other chronic and treatable health conditions. Gap 3 is the need to resource and join up the key ingredients for high-quality addictions care in B.C. in a way that responds to the complex journey experienced by the person living with addiction.

Third, we will propose three recommendations to enhance the effectiveness of B.C.’s addiction recovery programs and to respond to these needs.

We believe that strengthening primary care and investing in education and training for non-specialist human service providers hold promise. A fuller description of the gaps and opportunities for strengthening B.C.’s addiction recovery programs will be included separately in a full written submission to the committee later this month.

In March 2009, the B.C. Medical Association, now Doctors of B.C., released a powerful policy paper called Stepping Forward: Improving Addiction Care in British Columbia. Their number one recommendation called upon the provincial government to formally recognize addiction as a chronic, treatable disease under the B.C. primary care charter and the B.C. chronic disease management program.

The government of the day acted, and on April 1, 2011, B.C. became the first jurisdiction to recognize alcohol addiction as a chronic health medical condition. Acting on this recommendation meant that physicians had access to guidelines and protocols to support better recognition, diagnosis and care for patients living with addiction and additional training through the physician support program.

The Minister of Health at the time, Colin Hansen, said: “If somebody is diagnosed with a chronic illness, then treat it in a preventative way, rather than in a crisis intervention way.” Because of the influence of this policy paper, the Canadian Mental Health Association awarded the Dr. Nancy Hall merit award for leadership in public policy, in 2012, to the Doctors of B.C. and the physicians working group who crafted the recommendations.

The words of former Health Minister Colin Hansen have particular relevance as we fast-forward to 2016 and examine whether our systems of care have really moved towards prevention or whether we wait until stage 4, responding in a crisis intervention way. When Stepping Forward was written in 2009, 201 British Columbians died as a result of an unintentional overdose while using illicit substances.

From January to the end of May this year, 308 British Columbians have already died as a result of an unintentional overdose death — a 75 percent increase over the number of deaths occurring during the same period in 2015 and a death rate of 62 per month this year so far. Also, 484 British Columbians died in similar circumstances last year — a 140 percent increase over 2009.

Recently, B.C.’s Ministry of Health has released data focused on the cohort of British Columbians living with mental health and substance-use problems, utilizing publicly funded systems of care. According to their data, amongst that cohort, there were 681,496 visits to the emergency department in 2013-2014, and 21 percent of those visits related to substance use.

Put another way, out of a total of 1,260,628 emergency department visits in 2014-2015, one in ten related to substance use. Visits to the emergency department and hospitalization are some of the most expensive ways to pay for addictions care.

This last point is particularly important given some recent research that shows that people who present to the emergency department with a substance-use-related acute trauma do not meet criteria for moderate to severe substance-use disorders. A crisis resource appears to be all that is available for people who would benefit from less acute resources in the community.

Finally, research published last week by researchers at Simon Fraser University continues to demonstrate the over-representation of people living with mental illness
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and addiction in corrections populations. They found that addiction is the main driver of reconviction among the so-called psychological or psychiatric disorders. In other words, addiction — a chronic, treatable disease — is a key pathway to becoming repeatedly ensnared in the criminal justice system.

What story does this data start to tell? The story is that we have not yet realized former Health Minister Colin Hansen’s vision. Our systems of care are not working together to prevent addiction as a chronic and treatable health condition. Instead, we continue to wait until stage 4, where someone’s health has deteriorated to a crisis point where the outcomes involve family breakup, exclusion from the community, loss of employment, hospitalization, potentially jail and sometimes death.

The first step in responding to your question — “How can we enhance the effectiveness of addiction recovery programs?” — is to recognize gaps 1 and 2. Gap 1 is the need to reinforce the recognition of addiction as a chronic and treatable health condition like heart disease, diabetes or chronic respiratory problems.

Gap 2 is the need to act before stage 4 in addictions care, much like we would for other chronic and treatable health conditions. We work together to build and strengthen an addictions recovery system that doesn’t wait for someone to hit rock bottom at stage 4.

We can stop paying for addictions care in the most expensive ways possible — in human, social and financial cost — instead, spending smart and investing in change much earlier. British Columbians believe this too. In a recent Ipsos survey, a majority, 79 percent, of British Columbians agree — 33 percent strongly and 46 percent somewhat — that substance use is preventable. Meanwhile, more than seven in ten agree — 27 percent strongly and 45 percent somewhat — that addictions are preventable.

Numerous reports have been published, including the 2009 Stepping Forward paper, describing the absolute need to build a truly integrated continuum of care for addiction in British Columbia. You can see on our slide an ideal continuum of care compared against the current reality in B.C., which tends to be fragmented, uncoordinated and inaccessible.

Some have argued that there is no system of addictions care in our province and that there is a need to join up and resource each of the key ingredients for high-quality care of a chronic and treatable health condition like addiction. Take a look at Stepping Forward for a list of key ingredients of an effective continuum of care. We brought along copies for your reference.

Further, people who use various levels of addiction care in British Columbia often describe a system that is not designed with the person in recovery in mind.

For example, when someone arrives at a point ready for treatment, the service they could use has a wait-list, is far from their home community or has such restrictive criteria that they cannot get in.

All of this points to gap 3: the need to resource and join up key ingredients for high-quality addictions care in B.C. in a way that responds to the complex journey experienced by persons living with addiction.

I’m now going to turn to our CEO at the Canadian Mental Health Association, B.C. division, Bev Gutray, who will speak to three of our recommendations for the standing committee.

B. Gutray: Good morning, select standing committee. I will now turn to a set of the three recommendations designed to respond to the three gaps identified by Barb.

In response to the question, “How can we enhance the effectiveness of addictions recovery programs?” our first recommendation focuses on Stepping Forward, the policy paper that we have been referencing throughout our remarks. Seven years has passed since the release of the report. While there’s evidence of action in response to the physicians’ recommendation, the B.C. provincial health officer recently declared a public health emergency in response to the number of illicit substance overdose deaths in our province.

It is clear there’s a road ahead to improve addictions in this province, given the tremendous loss of life our communities are experiencing on a monthly basis. As we all know, addictions are never experienced alone. They are experienced by the whole family.

Arguably, many — if not all — of the recommendations in Stepping Forward, the policy paper, still have merit and continue to align with the latest evidence of addictions care. The document is an example of sound public policy and has direct relevance to the select standing committee’s question.

The first recommendation, to enhance the effectiveness of addictions recovery programs in B.C., is for the select standing committee to review and report on any progress made against each of the recommendations set forth in the policy paper. The select standing committee’s review of Stepping Forward would serve as an important opportunity to take stock of the actions government has already taken in response to the physicians’ recommendations and examine where progress can still be made.

Our second recommendation focuses on investing in the role of primary care to support the effectiveness of addictions recovery. As I listened to the previous presenters…. Really, primary care is our significant opportunity going forward. It actually starts to link all services and all professionals together, versus this non-linked service that we currently have.

We recognize that no one part of the health system is fully equipped to provide high-quality and effective care for the entire cohort of people living with addictions problems. We also recognize the provincial government’s strategic policy direction to the establishment of the pri-
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mary care homes as the cornerstone of health services across the province at the local service level….

We understand that primary care homes will include a full-service family practice, linked to or integrated with a health authority or a health authority–contracted interprofessional team, offering a range of primary care services that, in the case of mental health and substance use, will include assessment, short- and long-term care and medication monitoring.

Given the relevant advent of primary care homes, strengthening the provision of addictions care in primary care is critical for four key reasons. First, primary care is an optimal site. That’s the door we all knock on to provide care for people living with a full range of addictions when specialists’ support is not yet required.

Second, access to high-quality addictions care in primary care is patchy due to a variability in physician training, expertise and capacity. Third, there are excellent evidence-based interventions that can add addictions expertise to primary care settings that drive significant improvements in outcomes. Finally, effective addictions care in primary care settings yields enormous medical cost savings and improved patient satisfaction.

While the full details of primary care homes have yet to be publicly released by government, we would urge that the addictions care available on primary care homes go beyond screening co-location of mental health providers in primary care clinics, education and training, and referrals to specialist care. Research has shown that these three approaches alone and in combination do not improve patient outcome.

Building on this second recommendation, we encourage the application of a collaborative care model, a specific type of integrated care that operationalizes the principles of the chronic care model to improve access to evidence-based treatments for primary care patients.

In usual primary care, the treatment team has two members — the primary care provider and the patient. The collaborative care model adds at least two additional vital roles in addictions care — a mental health and substance-use professional, functioning as a care manager, embedded into the primary care home and a psychiatric or addictions specialist typically participating via telehealth. That is a significant opportunity. If we are redesigning the system, let’s get it right for all British Columbians this time around, and the primary health care home is that opportunity.

Robust addictions care and settings like the primary health care home should incorporate screening, brief intervention and referral to treatment; engagement with patients who are not ready for special treatment; early detection, effective referral processes and ongoing care coordination. These primary care–centred activities would serve to enhance addictions recovery in B.C. and, most fundamentally, the access to addictions recovery.

Our final recommendation for today’s presentation focuses on investing in the power of education about addictions and, I would really like to add, that education that comes from that lived experience. We have certainly seen, in mental health care, with champions like Clara Hughes and B.C.’s own Shelagh Rogers…. When champions who have struggled with mental illnesses speak out, it really does open the door for others to knock on the mental health door. We know that this, as well, is a very important step going forward in the whole addictions recovery system.

Arguably, one of the main barriers to enhancing addictions recovery in B.C. is the persistence of stigma and discrimination. We see it in all kinds of places. You’re more likely to end up in a jail than you are into treatment. That’s the unfortunate way our system is woven together.

The Canadian Mental Health Association, with funding from the Community Action Initiative, has recently launched a cost-effective, on-line, self-paced course called “Understanding Addiction.” It is designed to assess non-specialist human service professionals to better understand addictions.

Specifically, when you think about the people who run housing programs or you think about the employment service or the vocational rehab program, these are places where we need to expand the knowledge and the expertise of addiction. It’s similar in format to the widely used indigenous cultural competency training authored by the Provincial Health Services Authority.

Recognizing that our time is drawing to a close, I will end here. Just a couple of remarks. I want to say: “Where have we got it right?” I think as far as youth in transition, the integrated youth hubs, we’ll see how the research proves, but the investment that the province has put forward in that area is a good step.

Just to remind everyone, September is Recovery Month. As elected officials, I think it’s really important that you add your voice to bringing out the awareness, which will allow people to reach out for help earlier.

J. Darcy (Deputy Chair): Thank you so much. I’m afraid we only have about seven or eight minutes left for questions. A wonderful presentation. I will open it up to my colleagues.

S. Sullivan: You defined it as a chronic, treatable disease, which seems to be an oxymoron in a way. Chronic, to me, means long term. I have a chronic condition, quadriplegia, and it’s not treatable. Or I guess it’s treatable in that I can live with it.

The treatable part…. What I’m thinking about are the brain cells. They do recover over time, I think. The last delegation spoke that there seems to be some sort of a half-life, that cells do eventually recover at some point. I just wanted to get some feedback from you on this definition of “chronic” and “treatable.” How do these relate?
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B. Keith: I think that one of the things we know about addiction is that it is a chronic condition. It continues. But there are times when people are in treatment…. I’ll give an example. We used to think, with people who suffered brain damage from crystal meth, that when they recovered, that was the way they were going to be forever. They had things like psychosis and that sort of thing. But what we’ve found out through research is that after two years, the brain’s capacity to function is much improved. So given time, there is a healing that can happen.

There is also evidence around treatment that assists people to live normal lives, like opiate replacement therapies. It allows them to move and gain more capacity in daily functioning and be able to continue in a recovery way and typically eventually, hopefully, get off the opiate replacement therapy. It doesn’t mean that they no longer are potentially going back into that lifestyle. That’s always a possibility. But they can lead more productive lives through treatment.

J. Darcy (Deputy Chair): Thank you so much for your presentation and for your wonderful work.

One of the constituents of mine…. Certainly, I think we could all attest that of people who visit our constituency offices, a large percentage of them are dealing with mental health or addictions, and they come to us out of desperation after bouncing around and not knowing where they can get help.

A young man who came to see me a couple of weeks ago — first, his uncle came, and then he came — was dealing with substance use. He was also bipolar, schizophrenic, had anxiety disorder and ADHD and had bounced around from one place to another. He didn’t quite fit anywhere and couldn’t find a place that would accept him.

I wonder if you could speak to…. I know we’re talking about recovery programs today. We also know that in his case, he has some very, very serious conditions. But even if they have more moderate or mild mental illnesses, people are often self-medicating, as you know. Can you speak to the needs in that area in particular and what you think we need to be doing?

J. Morris: That’s a brilliant question. In lots of ways, I think that with mental illness and addictions, we do typically wait too long. One of the things I think is very clear to us is that there’s actually a whole array of evidence-based programming that could get to someone much sooner.

Of course, there is part of the population, like the young man you’re describing, that arguably require quite complex services in community and people to walk alongside him to make sure he’s housed, that he has access to education, employment and those pieces so he can thrive with those illnesses.

I think programs like some of the programs we offer at the Canadian Mental Health Association, whether that be Bounce Back…. Bounce Back is a telephone-based coaching program for people with mild to moderate, low and severe depression problems — physician-referred, evidence-based, delivered in people’s homes so people don’t have to leave their homes to access this program. We would say that Bounce Back yields great results with mood.

As you were saying, with that correlation of people self-medicating because they’re depressed, probably the more success they experience in a program like Bounce Back and other ones that we offer and other organizations offer…. The likelihood of continuing to self-medicate in that way, hopefully, does reduce.

I think the last comment I would make is seeing in our system that mental illness and addiction aren’t separate. Our systems of care typically silo and restrict, and that’s not how human beings function. We bring things together. We separate them; we bring things together.

Arguably, I think, looking at humans as integrated people with whole experiences of health, whether that’s mental health or physical health, is the step forward so that we don’t compartmentalize young men like him into different parts of the system. A great question.

S. Robinson: Thank you very much for your presentation and for highlighting this report that the Doctors of B.C. put out in 2009. I pulled it up and just took a really quick look. Of the ten recommendations that are here — I’m assuming you’ve been tracking — have any of them been implemented?

J. Morris: I think some of the data attached to the implementation of these recommendations is sometimes a bit tricky to track. For example, we do know government has moved forward with the creation of addiction bed spaces. There’s a target of 500 beds by 2017 that Minister Terry Lake often reports upon in the Legislature.

I think recent news has demonstrated that, in pockets, those beds are increasing in health authorities, with funding attached. So absolutely. Government has made movement on some of these pieces. Whether it will get to that 500 goal, which is an ambitious goal, of course remains to be seen when we get to 2017.

The big part that we referenced was that absolutely, the government of the day, in 2011, enshrined at least alcohol addiction as a chronic treatable condition. It opened up resources for physicians to do their jobs better when it comes to this. That’s probably the most notable recommendation that was acted upon at the time.

This is why we’d asked the committee, given the influence and the power that the committee has, to ask: where are we at with these ten recommendations and to report out? It represents an opportunity, actually, to not reinvent the wheel with new policy directions. This is sound stuff.

The other piece that I think we’ve probably made less progress on is recommendation 5, ensuring that access
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to addiction care is without financial barriers. We have PharmaCare, which provides access to some opioid replacement therapies, Suboxone being one of them. But still, financial barriers to some of those treatments is an issue.

We do have a tiered system, whether one needs to access private addictions care, which costs thousands and thousands of dollars, or per-diem fees to access programs like the one of Barb’s that can amount to $60 a day. That can be a restrictive barrier. We don’t charge per diems for cancer care in residential. We do charge per diems for addiction care.

I think we’ve made some progress. That’s why we wanted to hold this up, that government has acted, and there’s an opportunity to take stock and evaluate.

J. Darcy (Deputy Chair): Thank you so much for your presentation. We really appreciate the work that you do. A very, very thoughtful presentation, and we will be going back and looking at that report, for sure. Thank you.

J. Darcy (Deputy Chair): Okay. I think we’ll move on with our next presenter, who is Lorne Hildebrand from Edgewood Addiction Treatment Centre. Welcome. You have 15 minutes. If you go over 15 minutes, we have less time to ask you questions, and we’d very much like to ask you questions.

L. Hildebrand: Great. Thank you. I’ll try to keep it short. Thank you very much for allowing me to address you today.

I want to talk just a little bit about our company and what we do and then get on to some of our recommendations. We were established in 1994 in Nanaimo as a treatment centre. We currently have 120 beds in Nanaimo, with offices across Canada.

The history of Edgewood is kind of interesting. We have a number of things that we’re first at. We were the first private centre in western Canada and continue to be completely private. We have an open-ended program — we were the first to do so — which means that people can stay anywhere from seven to eight weeks in our primary care and then move into our extended care anywhere from one week to four months, as an average, although we’ve had some dually diagnosed people stay as long as a year.

We use a therapeutic community model, which means that there’s a lot of peer interaction. It allows folks to not only get some help in care but prepares them for the world outside, where we believe that therapeutic communities such AA and other 12-step-based programs keep them sober. The extended care is 60 to 90 days, but, again, it can go on a lot longer than that.

We also do a phase 3, which is: how do we get someone who doesn’t fit either of those two categories but needs something a little, closely, in the middle? That’s kind of important for what I want to talk about later.

We also do continuing care. Clearly, treatment without follow-up care for at least a year is not effective. We like some of the physician health care models that use five-year follow-up care that include drug testing and a lot of work in support groups and one-on-one counselling.

At some point, we realized that as we became well known…. We have contracts with the military, the RCMP, Morneau Shepell, various cities’ fire departments and a number of other folks, including WorkSafe. As we started to do that work in B.C., and we opened offices to support ourselves in places like Calgary, Victoria, Seattle, Toronto and a number of other places, we started to get folks who are national providers saying to us: “Why are there so many different models of treatment, different costs, and different not only from place to place but province to province?”

They asked us if we could start looking at a national program so that they could feel comfortable in sending around Canada. So we formed EHN, which is the Edgewood Health Network. We now have beds in Toronto. We purchased the old Bellwood and are removing it back to the Donwood. So in fairly short order, we’ll have slightly under 300 beds across Canada, and we have those various clinics in each of those places that I’ve been showing you.

One of the reasons that I would like to talk to you today is…. What we’ve really discovered, particularly in our own facility, is that as we have a number of people come in to our Vancouver clinic or our Calgary clinic…. We have a range of people that come in, showing up on the continuum of the disease. So what we recognize is, as the continuum of the disease increases in its intensity, we have to be able to offer treatments that match that.

Let me give you a bit of an example. On the mild end of the continuum, you might have somebody who’s run into some trouble, perhaps a DUI. They don’t necessarily have the disease of dependence. As we heard earlier: what is a chronic disease? For some people, that chronic disease, on the severe side, is brain changes that do not recover.

So if you go to somebody on the mild side, and you say, “Listen. We’re going to put you in a program. We’re going to tell you never to drink again. You must be abstinent. You must attend 12-step meetings for the rest of your life,” that’s inappropriate. In fact, what happens when you do that is somebody will come out after a year, start to drink normally and say: “My goodness. They’re all wrong about the disease. It actually doesn’t exist. Look at me. They diagnosed me with that, and in fact, that wasn’t the case.”

On the other side of that spectrum, on the severe side, you start to deal with people that do have, definitely, a brain disease. It’s not going to heal. It’s not going to re-
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cover. There may be some brain re-balancing, but generally you’re talking about someone that will never have the ability to look at their drinking and drugging for the rest of their life.

It’s a chronic disease. We say chronic, and that side of it means that it’s never going to go away. Treatable means that you don’t have to drink. You don’t have to let that limbic system of your brain control you. There are things you can do to lead a normal life. That’s the description of a chronic, treatable disease.

However, you can see that by improper placing of patients, you get bad results. So we look at the continuum of care, and we use the ASAM levels of care. That is the American Society of Addiction Medicine. We’ve looked at a lot of them. We found this the most effective. We essentially look at levels 1, 2, 3, 4. Again, as the severity of the disease increases, you get more and more brain damage as it becomes more and more permanent. Clearly, there has to be a different way to approach the disease and treat it.

What we actually offer in our organization is a series of different levels of treatment — anywhere from meetings in an office with an addictions counsellor who’s going to deal with you one on one, group sessions, all the way to long-term, medically monitored in-patient treatment of durations sometimes up to six months.

By the way, around results, we did our own internal study and had it looked at. We had an 86 percent recovery rate after two years. Now, again, these are internal studies, and all internal studies should be suspect, so we’re also working with a university to see if we can get someone to come in and study ours. We’re going to see if we can band together a couple of the other private centres so that we can get a good cross-section of how those things actually look.

We also came up in our own system, internally, with something we call the ASI, which is our assessment supplemental inventory. Essentially, what we did is take the DSM-5 — that’s the Diagnostic and Statistical Manual, 5th, which is the psychiatrists’ bible around diagnosing and classifying illnesses — and we added that to the ASAM criteria.

Between those two things, we developed this tool that allows our clinicians to sit with a patient, walk through about a two-hour process and, at the end, come up with a placement. That’s one of the things that we see as so critically important in what we do, and we think it’s something that we might be able to offer some of our other folks around to help really do a better job. Again, bad placement means bad outcomes, bad treatment.

What we do in our system is try to get our client into one of our out-patient offices, get them in front of a licensed addictions counsellor, get them to walk through an assessment program and then try to make the right placement.

The other thing that’s really key about that ASI tool is that it needs to be done on a regular basis. As an example, someone will go through two months of in-patient treatment — and yes, we are private; it is expensive — and we’ll suggest that they need more treatment.

As we all know, NIDA, the National Institute of Drug Abuse, suggested that anything less than 90 days in intensive treatment is probably ineffective. What we’ll do at the end of our 60 days is complete another ASI, and we’ll have a look at that to see whether or not there’s been enough improvement, whether there have been enough changes in the dimensions that we think they’re able to move on back into our regular aftercare program.

In many cases, they’re not. About 30 percent of our patients fall into the more severe category, and they will be asked to move over into an in-patient residential program called extended care. That is really interesting because, obviously, we’re dealing with parents and families and other folks and many payers, like the military, that want to know that their money is going to be well spent if they move to another level of care.

What the ASI does is help the patient, help the payer, help the family see that. It’s not a money grab. There’s a good, solid framework based on a good gold standard to allow someone to move into a better level of care, and our numbers reflect that. People that go to extended care actually do better than those that don’t.

Often people won’t go because of money. That’s an issue we’re not really sure how to deal with.

This is a quick look at the ASAM levels of care. We certainly would class ourselves as a 3.7, which is a medically monitored, intensive in-patient service. One of the reasons we also like this is not only is it important for families and patients and us to know that someone’s properly placed; it’s really important for people that refer that way.

Our best view of the world would be for someone who’s an independent counsellor in any sort of system, government or not, to be able to have a look at a patient, do a screening and come up and say: “Oh, my goodness. You are a patient that would require a 3.7.”

The real problem is that if you go and look at all the private centres, and you pick up the phone — and I’m going to say that about government centres too — they all claim they’re the best. That’s one of the problems that we’ve had in this society.

I think one of the things that’s held us back from trying to do good treatment is that everyone’s running around with a slightly different model all talking about what’s best. Well, I happen to think that everybody does a great job, but I think it’s based on the level of care that they’re actually able to provide.

So it’s very clear. We’ve created a little cheat sheet, but you can get it from ASAM. It actually tells you what levels of care fit into what categories. For example, if you have a 3.1, it means that you’re doing a 24-hour structure, but you’re missing a lot of other pieces to it. It’s actually a very simple system to look at and determine where somebody might fit.
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What we’re suggesting is that, at some point, every treatment centre be classed according to an ASAM level — or there are some others that are also out there — on a very specific set of circumstances so that those people that refer know exactly what they’re getting.

You know what? A lot of people are going to do a 2.5 and do very well. But don’t put someone who needs not once in a while a doctor to come in on contract but full-time regular physicians and psychiatrists. Don’t have them go to a place where they are not going to get that kind of care. They’re going to fail, and we’re going to see relapse rates.

The take-home message: addiction is a highly treatable disease, and long-term, sustained recovery is possible.

Also, one of the things that we use as one of our models is the physician health care programs. Physicians that come to us from…. We treat the Alberta and Saskatchewan physicians, not the B.C. ones because they’re actually paid to go to Homewood. But we treat out-of-province physicians, and those out-of-province physicians have a 90 percent success rate over five years. These are physicians that have opiate addictions and also include a dual diagnosis and a lot of other kinds of issues.

What they do is a program that we try to emulate, which is they class them according to an ASAM standard. They put them in a place that’s capable of dealing with it. They ask that they stay in a monitoring program for at least five years, including drug testing, and they have absolutely amazing success rates.

I think the answer to the fentanyl problem is not to provide other drugs but to provide those people with good, long-term, positive treatment. They will get well, but it’s costly and it’s time-consuming. Based on proper assessment and proper placement, patients can and do recover.

J. Darcy (Deputy Chair): Wonderful. Thank you. You’re actually under your time, so we have more time for questions.

D. Plecas: Thank you, Lorne. It’s always great to see you. I know how spectacularly successful you are.

Why is it, do you think, that we don’t have more of the kind of treatment facility that you run? Why is it that we’re not more focused on, clearly, the recovery side? What’s been going on there?

L. Hildebrand: That’s an interesting question. If you’ll allow me just to be blunt, I think we’re in a situation where we have people just really finally understanding that this is a disease. I’ve heard some speakers that, two years ago or three years ago, if you asked them if this was a disease, they wouldn’t be sure about that. I think we’ve taken a while to come to this point where we clearly understand what the disease is.

Now we’re confused because if you have a mild case of this disease, it’s very different from a more severe case of this disease. The old DSM-IV, the Diagnostic and Statistical Manual, said you were an abuser and you had the disease of addiction, and they kind of drew a line. That actually made a lot of sense for a lot of people because it allowed us to clearly see how to treat those folks and maybe how to treat these people differently.

The problem with that was, and the problem with addictions is, it’s confusing. There’s that middle area that got really grey, where we didn’t know how to place people, so the American Psychiatric Association changed the way they looked at it in the DSM-5.

I think we’re still trying to understand what the disease is. I think we’re still trying to understand how to treat them. I get it. If you’re in a 28-day program and you come out with no follow-up or aftercare — you don’t have a physician; you don’t have a psychiatrist — the chance of getting well is about 5 percent. So what happens is you throw your hands up and say, “This is an untreatable disease,” how horrible it is. “Look at all the great work we’re doing.”

I’m not saying they’re doing bad work. I’m saying they’re capable of maybe treating at a level 1 or a level 2 at best. If we clearly understood the levels of this disease and how to place it, I think we’d go a lot farther with that.

But basically — and I remember one of my old partners, who was a wonderful clinician, saying — it’s a dirty disease. You have people that are not in recovery or active in this disease saying all kinds of things, and it becomes very difficult to treat.

D. Plecas: Maybe I can ask you another related question. You have clients who come from all sectors of society. Let us just say that I said: “Lorne, I’m going to have you do something for all of those people who are on the Downtown Eastside who are very much entrenched in a harm reduction model.” I don’t mean this in any way to be disrespectful of that model. I mean, we know there’s a place for that. But the one thing that’s very noticeable about what goes on there is there’s not a whole lot of success.

If I said to you, “I need you to step in there and do whatever you can,” thinking about your thoughts on how we should approach this, what percentage of people do you think you could get to a place where they’re having their first birthday?

L. Hildebrand: If you gave me the time and the money, 80 percent, absolutely. I know that because we’ve had people come in.

First off, not everybody with addictions lives on the east side. Ninety percent of addicts of all sorts hold down full-time jobs. But they have families, and we have gone a number of times down and picked up somebody off the
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east side because the family has asked. We’ve brought them back, and they’ve done just as well.

Support networks turn out to be really important. If you can build in support networks in a community…. If they don’t have families that are going to support them, if they don’t have employers that are going to support them, you build a community around that.

We’re doing some work in First Nations where they’re getting terrible rates of success. We’ve created a notion for the Northwest Territories called critical mass. We’re finding that what happens, if you go into some of the native, First Nations bands — and we’ve done a lot of work with them — is five of them will go back into a community of hundreds that are still actively using, and they actually get teased and laughed at and start using again.

The notion — we’re going to start this program pretty quickly — is that if we can get critical mass, 20 people to create their own subcommunity, a subculture inside of a culture, they may be able to help keep themselves together. I think the same thing would probably work down in the Downtown Eastside.

How do you get critical mass down there, get a group of people that are doing well enough that others look over and say: “You know what? I would like some of that stuff”? My belief is no addict wants to be an addict. They’re forced to because they have part of their brain that tells them they have to use.

I think we could do a way better job. Those folks that we have had come from Edgewood from the east side have done very well. However, you don’t put them all in an east side centre where they’re all going to sort of…. Clinically, that doesn’t work. They need to be in a greater milieu, where they’re exposed to different kinds of things.

It’s not good having an all–First Nations treatment centre. It’s not good having an all-RCMP treatment centre. The military found out it’s not good having an all-military treatment centre. They’re has to be some cross-pollination of ideas.

L. Hildebrand: In the long run, we could; in the short run, it’s highly expensive. We get calls all the time. People are desperate. They’ve tried every program they have. They’ve heard something good about us. We take them in. It costs a lot. Come in to treatment, and you’re looking at a $30,000 bill coming from us.

However, we also have physicians and psychiatrists. We have three — with an exception of a fellow right back here — of the top CSAM-ASAM psychiatrists in Canada. They’re expensive folks to keep, but it’s all paid for privately.

S. Robinson: My brother-in-law is one of your success stories. He’s been ten years, so I want to thank you for the work that you did with him. It’s been fabulous, and it’s great to have him back.

I want to talk a little about the ASAM levels of care. I think it’s a very interesting model, and I just have some questions about it. I mean, I’ve done a bit of reading and a bit of research in the area. I understand that many people who have addictions just quit on their own, and they don’t go back. Then there’s this other group that needs intervention.

Is there research that allows you to sort of pick and choose? I think it’s a very accurate assessment, based on my own clinical experience, that there are these many different kinds of programs all saying that they’re the one. Is there research out there that allows you to do a good match, in terms of who needs what kind of intervention, at what time, and that has some outcome data to support that?

L. Hildebrand: Much of the research was done through ASAM. I think that’s one of the things that we felt really comfortable with as we started to look for levels of care and criteria for placement.

There are a number of different levels out there. SAMHSA has the TIP protocols that are very good. These are all well researched. But our committee looked at all of the various ways of classifying and placement. Really, the amount of work that’s gone into ASAM and the DSM-5 are phenomenal.

You can’t get more researched than those gold standards. Although there was some attempt to come up with our own set, it was like: “Why are we going to go out and defend somebody else saying, ‘Oh, you’re private, so obviously, you’re skewing things’?” We just found that the ASAM placement criteria were very, very well researched. They are the gold standard.

In the States, by the way…. This is kind of interesting because we do treat a lot of folks from the States and around the world. In the States, we find that if you’re an addictions counsellor, you must…. If you’re going to be licensed in the state of Washington, you must use a DSM-5 diagnosis, and you must use the ASAM criteria. They won’t license you as an addiction counsellor if you don’t do that. It’s that that really tipped us off to answering.

It was one of the senior folks from the military that said to us: “Hey, how come everyone we send to you ends up in your most expensive long-term program?” I said: “Well, probably because you send us about 1 percent of your really seriously affected people. We believe about 10 percent of your folks probably have issues. So by the time you come to us, it’s the worst, and things are really out of hand. However, if we use the ASAM placement criteria, would you be more comfortable that we’re actually doing the right thing?” They said: “Yes, we love it.”

I think we did a training of clinicians in Vancouver two months ago. We had almost 20 people attend the EASI
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training, and more and more are interested in doing that.

I just wanted you to clarify a couple of points. You’re the first private clinic in western Canada. Is that right?

L. Hildebrand: First private hospital. There were a couple of other small ones before that tried, but we were really, essentially, the first.

D. Bing: And you’ve got the same numbers as you had when you started — 80 — is that right?

L. Hildebrand: No. We started with 40 beds, and we’re 120 now just in B.C. Again, we have another 100 beds in Toronto.

D. Bing: You mentioned the number $30,000. Is that for the initial treatment — seven to eight weeks?

L. Hildebrand: The initial treatment probably runs around $20,000. By the time you get into the aftercare programs, the drug monitoring and the testing, probably the average cost is around $30,000, yes. I mean, the bills can be as low as $18,000. They can be as high as $50,000. Again, it’s very individualized, and it’s based on our placement criteria. What do you need? What is it that ASAM is telling us is a good placement for you?

Again, the key part of that, too, is to continue to do it. It’s not just a one-time thing. It’s dynamic, and we record the results. So as you go through a period of time, you can actually see the change in the dimensions.

If you’re interested, as a committee, please pick up the ASAM textbook and read it. For us, it’s critically important. It sits on my desk all the time.

L. Hildebrand: Well, the average person is probably in in-patient treatment for seven to eight weeks. We probably have about 85 percent continue on to that. Others are discharged or walk out on their own. Then about 30 percent of people will carry on for another average of about two months in extended care. Then we have an aftercare department. People stay in our aftercare department for about two years.

That’s the reason we have the out-patient clinics. We have an out-patient clinic in Vancouver. The reason it’s there is we have so many people from Vancouver. They get to come and stay there, and it lasts about two years.

By the way, we have an app where if you even walk into an area that’s questionable, it sends a note to our counsellor. One of our aftercare counsellors picks up the phone and says to you: “What are you doing in that area?” So that’s one of the reasons…. A high success rate is about really following up aftercare in a very intensive and aggressive way.

L. Hildebrand: Well, we did an internal study and had 86 percent success after two years.

S. Sullivan: It was helpful to see not evaluating all people with addictions in the same way — that there are different levels. I imagine that the most difficult level would get the least success rate, if you define success as no longer having use for any substances. I know some people define success as being able to live a full and enjoyable and functioning life, which some people do with still using opioids and things.

I guess my question is…. You do say that there will always be some people who will never, as you call, recover or be abstinent. These people are the ones that usually are causing the most social dysfunctions, with the crime and prostitution and things like that. Do you see that there is a role for substitution treatment or maintenance treatment for a certain group of people?

L. Hildebrand: Yeah. Excellent question, although I do want to just make one note. I don’t think that if you’re a level 3.1 or a level 3.7, the recovery rates are any better or any less. It has to do with how intensive and what good quality treatment you have. There is definitely an area….

Level 4 is high hospitalization. It’s a level that we don’t do. I mean, someone could be actively suicidal. Their liver is failing. They have a heart condition. We can’t take people that are that compromised, because we’re simply not capable of dealing with it. I think that there are probably a lot more deaths in that situation, probably from medical reasons than otherwise.

Now, having said that, I personally don’t believe the level 3.7 or the level 4s are not treatable. I think they are. We’ve had some very, very serious cases. I think that you can treat somebody, but it’s going to be much longer in terms of time, and it’s going to be much more intensive and cost a lot more. Having said that, there probably is about 5 percent of people that simply don’t respond to treatment for a number of reasons. They may require multiple times, and then they will respond. There is clearly a place where a substitution therapy…. But it’s limited, and it needs to be last resort.

I keep seeing people that want to walk forward and say: “Well, let’s use substitution therapy first.” I’m going: “Well, really, that’s sort of like saying, ‘Before we try to
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treat that wound on your arm, let’s cut your arm off in case you get gangrene’.” It makes absolutely no sense. Try the less intensive, less invasive one that will give them a longer-term life and a chance of having a decent life — or put them on a substitution program. I think there’s a place for that at the end.

It’s not just an opioid substitution. There are other medications that seem to be helpful. We use Seroquel as sort of an anti-anxiety, off-label medication. People can stay on that for a year before we finally taper them down from that, and they carry on into other things.

Substitution therapy has a role, but I think it’s limited. You have to be very, very careful. I think people think it’s cheap. It’s easy. It keeps them off the street, but I know people that laugh and say: “Even when I went in to get my opioid substitution, I got high because I knew I was going in to get something. My brain doesn’t work the way a normal brain does, so when I go in to get my opioid substitution, I’m already high.”

What that means is when your brain is no longer functioning and those abnormal circuits are starting to fire, you’re about this far away from walking out into the street and buying your illicit drug, shooting it in your vein and starting all over again. That’s the real issue with the substitution therapy.

S. Sullivan: Is there a role for steady reduction? I know it’s illegal because our system doesn’t allow a steady reduction. We have to do cold turkey, which is very traumatic for people, but if they could be provided some sort of maintenance in a reduced schedule.

L. Hildebrand: Yes. I think, absolutely, that’s correct. We’ve had some people…. As our sister organization, as Bellwood, starts to deal with folks that are not as capable of doing that, they send them over to us. We’ll often take them out of in-patient treatment after two months, and we’ll put them on a six-month taper program in our extended care and walk them to an extended care program. When they’re finished extended care, sometimes we’ll flip them back into in-patient for a couple of weeks and then go back out to an extended care program.

Long-term reduction in dosages is absolutely acceptable but not on the street. You can’t do that on the street. You’re asking the sick person to make healthy choices, and then you’re giving them less of the drug that they need. Why are you putting them back on the street? It makes no sense.

J. Darcy (Deputy Chair): Just one last question. I had the opportunity — I think, about 15 years ago — wearing a different hat as an employer with an employee and a friend doing an intervention, of supporting this person and someone to go to your program. When I run into her, she still says as recently as when I saw her a couple of weeks ago that her life was saved. She’s retired but living a full and productive life.

She had the advantage of a well-funded, employee assistance program and extended health benefits. That’s one of the recurring tragedies of all of this — excellent programs that so many people don’t have access to.

I wonder if you could just talk a bit. You refer to different groups. What are some of the places where you get people referred from? Does it include people from EAP, who have coverage? I assume you have to have good….

You either have to have money or your organization pays or you have a good plan that will provide for it. Is there any subsidy at all? Are there any referrals from health authorities? Can you just talk about who’s able to come?

L. Hildebrand: Sure. Health authorities generally don’t refer to us, and we’ve had, I think, not a happy relationship. It was not long ago that I had to phone several government agencies and ask their counsellors to stop referring to us as a money-grabbing organization and turning people away from us. That’s been a problem — not necessarily for us, because we’re usually full, and alumni refer to us.

About 60 percent of our patient population is self-paid. They pay, themselves, or their families pay or somebody else. Another 40 percent are funded by third parties. We also deal with Great-West Life. A number of insurance companies that have EFAP programs pay for them. The military works through Blue Cross. Veterans Affairs works through Blue Cross. Morneau Shepell represents many of the big industries that will refer to us and go through there.

But the vast majority is self-paid. I mean, I feel bad about this. Let me also say that we’re a private company. We’re for-profit. But there isn’t a person that works in our entire organization who wouldn’t happily give up everything if we could snap our fingers and magically make the disease go away. Everybody that works for us has somebody or knows somebody or are, themselves, in recovery.

We’re a private organization, and I just want to say this: I’m grateful that we are, because we’re not subject to the dictates of whatever less best practices are. I’ve heard the word “best practices” and I’ve heard the words, “This is fully research-informed,” and I see drug companies come along with research that’s laughable and that just talks
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about one particular thing. So I’m kind of glad that we’re not subject to that kind of stuff. We’re an abstinence-based facility. We believe in long-term care, and it works.

Having said that, what would really be wonderful would be simply: if this is a disease, it’s all paid through our medical services. MSP should pay for everyone that comes to a doctor.

Now, that’s on the basis that doctors actually understand what they’re doing and just don’t start prescribing without really knowing what they’re doing. But the very best thing would be to have physicians that understood how to deal with this disease. They’re our first line of care. Give them the training to know, and then have someone say, “Sure, go to Edgewood,” just like you’d go to the cancer clinic, and it’s going to be paid for as part of the Medical Services Plan.

The Medical Services Plan actually pays for physicians and nurses to go to Homewood. And I’ve got to be honest with you. It’s a bunch of smoke and mirrors about why they do it there and nowhere else. Oh, it’s dual diagnosis….

They have no aftercare out here, and they have a level program. They have people go on weekends. It’s probably about a level 3.1, and they let people go on weekends, and they come back and they relapse. They don’t really have the long-term aftercare that they need.

But what the system should be is you go to your physician. He’s had training in addictions. He understands that abstinence-based is an option. He’s able to refer to another specialist. The specialist says: “You need to go for treatment. And here’s where I’m going to go. I’m going to do a placement criteria based on you, and I’m going to send you to a place that’s appropriate for that.” And it’s picked up by the government.

By the way, whether you pay or not or whether you’re forced into treatment or not seems to be no indication of how well you do.

R. Baker: Thank you, Madam Chair, and thank you, committee. Although it sounds like the polite thing to do to say thank you for inviting me, in 40 years of medical care — the last 30 of it involved in addiction medicine — I’ve given expert testimony at hearings, national Human Rights Commission hearings, arbitrations, Supreme Court and disciplinary body hearings, and I don’t think I’ve ever been involved, from my perspective, in a more important process, or potentially important process, than this. I’m so excited you’re doing this, and I really do appreciate the opportunity.

Please take the opportunity to read…. I wrote this paper specifically for you, attempting to give you information you need. It’s written specifically. It’s very concentrated. You might find it heavy slugging in places, but it’s backed up with a lot of evidence. I urge you to read it.

During my presentation you might notice that I get emotional. I’ve been known to be, my wife would probably say, over the top. I’m really invested in this topic. I really, really care. So if I get overly emotional, forgive me now. Bev Gutray and Barb Keith…. I was on the board of the Canadian Mental Health Association. They got used to my outbursts and forgave me.

I’m not here to talk about addiction. I’ve taught — my career — about addiction, and I’ve taught a lot of people about addiction. I’m not here to talk about treatment. I’m here to talk about something much more exciting. I’m here to talk about recovery. It’s not the same thing. Although you will hear people talk about treatment programs and call them recovery programs, it’s something bigger. Recovery involves addiction, and it certainly includes, in many people, treatment, but it’s much, much bigger than that.

The 15-minute presentation — now it’s a 12-minute presentation — is going to be fast, and it’ll be a little bit like drinking, sipping, from a firehose. The point is there’s a lot of information out there. There’s not nearly as much about recovery as there is about addiction and treatment. There’s a huge body of knowledge and skill accumulated about those things.

The recovery movement, much ahead of us in the United States than in Canada, has been accumulating really good information for the past 20 years. They’ve established some stuff that’s really, really exciting. I just want to talk about it.

I know you’ve heard from my colleague Marshall Smith and from Rita Notarandrea from the Canadian Centre on Substance Abuse. I work with them on a couple of committees. We’re really excited. I’m missing a presentation on our life in recovery survey that’s going on right this minute, as I speak. They’re presenting our preliminary results. Marshall’s back there getting it on the webinar right now and sharing things. So it’s very, very exciting.

But as a semi-retired person that spends most of his time writing a book and the rest of his time training for marathons and triathlons, I’ve got time. So if you want to learn more or talk to me more, please do so.

I’m a family doctor. Between ’90 and ’95, I established and taught the UBC addiction medicine curriculum —
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won a national award for it. But when the new curriculum came in and the turf war between the hierarchy of medical specialties occurred, addiction medicine got kicked off the curriculum. There really, essentially, for the past ten years has been nothing other than token, so the kids coming through medical school aren’t learning about addiction, and they’re certainly not learning about recovery.

For a year before taking up my job at the university, I was the provincial medical adviser to ADP when it was housed in Labour and Consumer Services — the same people who sold booze, or regulated it.

I’m on a couple of committees with the CCSA, and I’m writing a book entitled “Recovery Medicine” right now. Out of that 275-page book, we’re going to make it now a ten-minute talk.

I’m a person in recovery from addictions. This year I celebrated 30 years of continuous abstinence. I can say that one of the reasons that recovery is so exciting is that my quality of life is better now than if I had not had the disease of addiction. Recovery gave me something that made me better than when I got sick.

I also have another dopaminergic disease. It was interesting listening to Mr. Sullivan ask about the dopamine depletion and the irreversible…. I also have been diagnosed with Parkinson’s disease, another dopamine disease that’s progressive. My recovery process for that is very, very similar to what I do with addictions and appears to be similarly effective.

What is addiction? It’s a chronic disorder affecting parts of the brain — several, more than just the dopaminergic reward system. We used to think that, but now we realize it affects many parts of both the cortex and subcortical regions — and not just dopamine but other receptor and neurotransmitter systems. It’s often progressive. It’s variable. Like MS, it’s variable. But it’s often a progressive disorder that affects every part of a person’s life — biological, psychological, social and spiritual.

Lots of things will result in remission. One size does not fit all. There are a lot of evidence-based interventions that can begin the remission process. If somebody says, “I know what works all the time for addiction,” you know they’re wrong. There are many different modalities that have been shown to be effective, depending on the person and their needs.

Now, the reason we keep talking about it being chronic, or chronic and potentially relapsing, is that if we look at outcomes and say, “What’s your success rate with an acute intervention?” — even an acute intervention like 90 days of treatment — that’s irrational. That’s illogical. That’s like taking your diabetic, sending them to the diabetic teaching centre and saying: “What’s the outcome?” Recovery is only beginning then. It’s what they do afterwards.

That’s why, when you hear later today from Dr. Paul Farnan about the physician health programs, it becomes very, very clear that the reason doctors have 80 to 90 percent recovery rates is that they have ten years of rather enforced recovery activities that these people are expected to do. It’s what happens after treatment that’s way more important than what happens in treatment. Not that it isn’t important.

The point is that the majority of people who get into recovery from addiction, across the spectrum of severity…. The majority of them get into treatment without ever seeing a treatment professional. We need to recognize that, and that’s why we’re doing the survey. How did they do that? What did they do to get there and then stay there? We’re only beginning to learn that about that population.

What is recovery? This will address…. Mr. Sullivan, a couple of times you’ve addressed the issue of replacement or medication-assisted treatment. Medication-assisted treatment, when it’s selected properly, is compatible with recovery, but it has to be selective — very, very selective. By far, the majority of people that I’ve ever treated with addictions aren’t appropriate for long-term medication-assisted treatment. But there’s a small subgroup that are, and if they don’t get it, they’re more likely to die. We know that. The evidence is clear.

The key to recovery is cessation of the addicted behaviour, with improved global health. That’s the real measure of health — level of function and contribution to the community or citizenry. Most definitions of recovery include that. Is that compatible with medication? In some people, it is. By far, the majority of people will do better without medication in the long run.

Many, many entry points into recovery. My recovery began in 1984, when I picked up the phone and called the person who was then running the physician health program. I told them about a physician I knew who was stealing drugs and injecting them into himself. That moment that I made that phone call about this other doctor — I didn’t fool them — my pursuit of recovery began.

Now, my recovery date isn’t until 1986, when I had a near-fatal relapse. However, recovery is something that’s big. It’s still going on. I’m not recovered. I’m still in recovery. If I neglect to do certain things, the emotional parts of my disorder become evident, especially to people who love me. They tell me: “Maybe you should go for a run and go to a meeting.”

It’s an inside job. Ultimately, recovery isn’t something applied by an expert. It’s an inside job. The locus of control must eventually…. As Lorne Hildebrand ended with, people who are forced into treatment do just as well as the voluntary ones. That’s true. But those people — the physicians who are in mandatory treatment — ultimately take it on themselves. It becomes self-driven because they can’t help noticing the incredible benefits of recovery.

For recovery to take hold…. And the sooner that we can encourage that to occur — that they’d not be patients but they’d be consumers or clients; they take over their own care — the better. It’s sustainable.
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I’m like a puzzle with a bunch of missing pieces. For me, I had to figure out what those missing pieces were. I had some big ones. I couldn’t recognize a feeling from a tree. So how am I going to learn to deal with my feelings? I didn’t know boundaries; I had to learn boundaries. And everybody’s different in the missing pieces for their puzzle.

Once I develop the knowledge and the skills and start practising them in the company of other recovering people, magic happens. That is recovery. That’s kind of the universal process of recovery, whether they do it through their church or through Amway or through AA. It’s not to be confused with treatment, although a certain percentage of the people at the higher stage and severity will require treatment.

Some of the stats. Somewhere between 10 and 20 percent of the population would have alcohol or other drug-use disorders. With DSM-5, there’s an expansion. So it’s a larger percentage that meet the criteria, even though they don’t have the disease of addiction. It’s a little bit too inclusive, from my perspective.

There’s something like 10 percent of our Canadian population who once had the disorder, but they’re no longer in acts of addiction. As a politician, that’s an important piece of information. If Canada has 35 million or 40 million people, that means you’ve got several million contributing members of society who also vote and who are in recovery but have been, until now, hiding that fact, including myself. I didn’t come out of my closet until fairly recently.

People with addictions are expensive. We use an awful lot of…. When you see the emergency department utilization rates, they’re so under-reported because they’re not recognized. We did a study at Lions Gate Hospital 30 years ago. At Lions Gate and Royal Jubilee Hospital, one in four hospital beds is occupied by someone with an addictive disorder that’s undiagnosed — one in four. So we’re wasting our health care dollar.

The other thing is the co-morbidity. We’re sick puppies when we come into treatment. We have medical morbidity, and we have psychiatric problems. Most of our psychiatric problems are secondary to our addiction but not all. Treatment of those conditions is virtually impossible unless you address the addiction. It’s just wasting a lot of resources, looking the other way, not asking the questions and not making the diagnosis.

Over half of the recovering population…. This used to bother me, as a treatment professional who made a living out of treating people. When I find out that half of the people in recovery got there without treatment, it’s a little bit threatening, but it’s true. That’s been replicated in various epidemiological catchment area studies in North America.

There have been studies looking at primary care early interventions — education, screening, detox, early treatment. There’s great return on investment. For people for whom it’s appropriate, when we intervene, it works. But that is just intervention. That is treatment — important, essential — but it’s not recovery. We do better in recovery.

What is a recovery-oriented system of care? This is the new lingo that has evolved. It’s accepted language around recovery that’s been written about more in the United States than in Canada. It’s patient-centred, as I said. The locus of control is on the shoulders of the person to take responsibility for themselves. That means I have to give up some power as a doctor.

It’s expedited. We engage people early, partly because we educate them, partly because we educate the primary service providers. Whether they’re social workers, teachers or health care professionals, they get early evaluation and ongoing evaluation.

Community-based facilities. In April, I was in a community-based recovery facility in the downtown core of Baltimore with the disenfranchised, and it was working wonders — where the siloes were gone, the mental health people were there, the harm-reduction people were there and the 12-step program was there. There are these community-based centres that are in effect.

Case management is key. So there’s a thing like a coach or a recovery coach, but a professional who can get people the help they need when they need it — early — and then get them hooked up with the right service.

You include the families in support in a recovery-oriented system of care, and you include a recovering network of volunteer people. I think Mr. Smith talked about some of the specific recovery facilities, like schools and living places and workplaces, that are recovery-friendly.

Now, if you compare obesity, type 2 diabetes and cardiovascular disease, they’re very much like the disease of addiction. Typically, we don’t address them till late in their care. We do pharmacal and surgical interventions after they’ve gone over the waterfalls and are drowning, rather than deal with them at the lifestyle area, and we don’t have a recovery-oriented system of care. Although, in my Surrey newspaper, I just got an advertisement asking for diabetes coaches, people in recovery from type 2 diabetes wanting to volunteer and do telephone support — brilliant. That’s a recovery-oriented system of care.

Typically, us physicians wait until they’re almost drowned, and then we do late-stage interventions and expect to fix people. Well, that’s what we do with treatment of people with addictions often, and then we’re mad at them when they relapse.

With community-based, patient-centred behaviour change, those things, like Dr. Ornish’s programs and various other programs, have been shown to be more effective than bypass surgery and other interventions for coronary artery disease, hypertension and diabetes.

The commercial interests right now support the status quo, both in medicine and in the treatment of addiction. There’s a reason to keep people…. Treating them after
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they’re over the waterfalls, because we can make a lot of money by continuing to medicate and to focus on treatment. We do have some treatment. We could coordinate it better, but we could move up above the waterfalls.

Shifting the model of care to…. We need to be thinking in terms of starting with our kids in grade school, pre-high school, letting them learn about addiction and about recovery. We need to teach all health professionals and primary care people what addiction is, how to screen for it, how to diagnose, how to motivate people, and then do assertive referrals into community-based treatment. Involve families in the social network way more than we have been doing and make use of the computers. There are some great addiction medicine docs who have a cadre of volunteer recovery people that they hook their patients up with, and it’s a really neat model.

In summary, there’s a lot of us out there in long-term recovery from addiction. It’s worth investing in. There are many pathways into recovery. It’s not one-size-fits-all, and there are many unconventional and inexpensive pathways — especially if we catch people early. Treatment is a small but essential part of early recovery for the more severely addicted. Long-term recovery requires people to take the mantle and put it on their own shoulders, change their behaviour and stay motivated to do so. But that’s not hard to do once you get into recovery, because the benefits become so obvious.

Those of us in recovery find that we function better, we’re healthier, we’re happier. We’re just better people. So I can say with gratitude that I’m a recovering addict — although “addict” is such a pejorative term that I generally say I’m a person in recovery.

As health professionals, if we took this and applied it to other chronic, self-inflicted diseases, like diabetes and heart disease, we could actually teach medical care something, because recovery is…. See, the difference with us, though, is it’s life and death. We’re more likely to keep doing it because we remember how close we came to dying from our disease of addiction.

D. Plecas: Dr. Baker, you’re truly an inspiration. I was reminded of that before you got here — that you would be.

I have two questions. Let’s imagine for the moment that you were in the command module responsible for addictions health in British Columbia. You know what the lay of the land is. You know the numbers of people out there with addictions. What percentage of people do you think you could get to their first birthday and on the road to an appropriate, basically lifelong, recovery program?

R. Baker: That’s a question about treatment of addiction. It’s not so much about recovery. Of the people who’ve gone over the waterfalls, what percentage of those could we get out and into recovery? It’s a question that depends upon the stage and severity of the individual, and it also depends on the recovery capital. The people in the Downtown Eastside — who have very little recovery capital and, as Mr. Smith talked about, barriers to recovery — have a much lower likelihood of successfully attaining any recovery, and what we define as “recovery” is smaller gains.

As far as the percentage of people for whom we could make their life better — the percentage of people, let’s say, if we worked towards abstinence — I would agree with Lorne, who went ahead of me, that we could probably see somewhere in the range of 80 percent. We do get that with physicians, and many of the physicians we get are at a late stage of disease because it’s been concealed and enabled for so many years.

D. Plecas: The other question. This is so significant for me, thinking about how we get people to change, to do anything, to think differently about their lives, and your comment about how it’s an inside job. Where a psychologist might, say, have people go through a process of prospective transformation, just that process, it seems to me that we could use that in so many areas of life, with people who have one difficulty or another, but we never hear about that. It seems to me that that’s such an absolutely critical component of the whole process.

R. Baker: There are some active barriers to us hearing about that. Part of it is the medical profession, because we make a living out of our interventionist pharmacological approaches. We don’t have a health care system in Canada; we have a disease management system, and we get them pretty late. It’s a pretty good disease management system if we’re going to focus way down the road, over the waterfalls and down the river like that.

There are barriers in place. There are a lot of people who are attached both commercially and professionally to the status quo. The smoking cessation phenomenon didn’t come from the top down. It was grass roots up. With this change, the thing about this recovery movement that’s so exciting is that it didn’t come from us experts, and it didn’t come from government. It came from the grass roots. All we have to do is recognize it, acknowledge it, validate it and get on board, and change our systems so that they fit more closely.

I’m afraid, in these last days, as I go off into the sunset with my retirement, I’m watching. We’re not making
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progress on addictions in British Columbia. We are going downstream.

When I, 25 years ago, was involved in the physician health program, it was a much better physician health program than we have now. It has deteriorated. I was involved in some wonderful College of Physicians and Surgeons programs that don’t exist anymore or that are not very effective. I put the AMIR curriculum, the addiction medicine curriculum, in place, and there’s nothing there. I’m afraid that this recovery-oriented system of care is going to fade as the flavour of the month, which would be an awful shame.

That’s why I’m so thrilled that you’re doing this, because if we can crystallize this — this isn’t expensive stuff, by the way; this is cheap stuff — by empowering the public, educating people, getting back out to the community and making use of the volunteers, selling people on themselves, on hope, on recovery, it’s something that’s very, very doable.

The cardiovascular professional community has said: “Oh yeah, lifestyle. If you could get your patients to change their diet and start to exercise and go to stress-reduction groups, that is great. But they won’t do it.” Well, actually, nobody really tried until recently, and they do it like a hot damn. They really do. They benefit, and they get better outcomes than bypass surgery and pharmacological management of hyperlipidaemia, coronary artery disease, type 2 diabetes and hypertension.

It’s all the same thing. Health is health. We just have to motivate people, get the information out to the people and get out of the way.

My job is to teach other health professionals to become a mirror and a set of tools, a health coach, rather than being the all-knowing MD minor deity, where I lay and bestow my great knowledge and tell you what to do. We even use the wrong language. We say “patient compliance” rather than “adherence.” It’s up to them to hold on, not up to me to make them do it.

Patients don’t comply with treatment. It doesn’t matter if it’s addiction treatment or hypertension treatment. We know they don’t comply. They have to adhere. That takes motivation. They need to hurt badly enough and recognize that their behaviour wasn’t working. Then they need to have hope. We can help with both of those.

J. Darcy (Deputy Chair): I don’t want to wait for Hansard to get that quote, but you said “become a coach.” You said something with “mirror” in it.

I was an intern at Robson Clinic back in 1989, and I remember when you were the doc to go to when we had questions. It is unfortunate to see that there was some progress, and then we’ve slid back.

I’ve had a chance to scan through your secondary document that you gave us explaining the different phases of recovery as well as some recommendations. I just want to ask…. I’ll go through it later in more detail. You mentioned towards the end about the mental health issue needing to be the absolute priority — and its relationship with addictions.

R. Baker: Is that my document, or is it somebody else’s? The background paper I wrote looks like this.

S. Robinson: Well, then, I apologize. I thought it was yours. I thought it was actually a fabulous document — whoever provided it.

If I can just ask the question, then, around mental health and addiction and its relationship. How should we be addressing that complicated relationship?

R. Baker: Addiction is a primary and chronic disorder. Primary means it stands alone. It’s not secondary. I may have used more because of my dysphoria and my depression and my anxiety. But once I have addiction, it’s a stand-alone primary disorder.

Addiction itself will block recovery from any mental health disorder. When I have symptoms of depression, bipolar, ADHD — all of those things — and I am using in an addictive way, it’s absolutely impossible to address the psychiatric stuff unless I incorporate fairly aggressive treatment of addiction.

I have to do that. I treat some psychiatric symptoms, the ones that block treatment, and then I watch. What will happen over six months, but really keeps happening over two years, is the psychiatric symptomatology fades down with good recovery. It becomes very difficult to separate them out. Even personality disorders, with time — like five years of borderline personality disorder — fade down in their intensity.

When you treat them together, when you treat the symptoms together and keep re-evaluating — this is not a one-time biopsychosocial psychiatric evaluation — with time, you can adjust your treatment appropriately. You’re treating the whole person, including their medical…. It has to be coordinated holistic treatment.

J. Darcy (Deputy Chair): Thank you so much. I’m afraid that’s all we have time for. Thank you for your passion and your commitment. I know that we will all read this very carefully and reflect on what you’ve said in our final report.

J. Darcy (Deputy Chair): Cameron Bishop is our next presenter. If you could introduce yourself. You have 15 minutes to present and 15 minutes for questions.

C. Bishop: My name is Cameron Bishop. I’m director of treatment, health policy and government affairs for Indivior Canada Ltd. We are an addiction treatment company that manufactures Suboxone, buprenorphine and naloxone sublingual tablets.

Madam Chair and committee members, I’m very pleased to be here to present some of our perspectives on how to enhance the effectiveness of B.C.’s addiction recovery system. As I noted, we are an addiction treatment company that manufactures Suboxone, buprenorphine and naloxone sublingual tablets, the first opioid medication approved for the substitution treatment of opioid dependence in an office-based setting.

For some that may not know how Suboxone works, let me give an overview for you. Suboxone was approved by Health Canada in May 2007. It is a fixed-dose combination of buprenorphine, a partial agonist, and naloxone, an opioid antagonist. It is indicated for medication-assisted treatment in adults with problematic drug dependence and is available in two strengths: two milligrams of buprenorphine with 0.5 milligrams of naloxone and eight milligrams of buprenorphine with two milligrams of naloxone.

The intention of Suboxone’s naloxone component is to deter intravenous and intranasal misuse. Naloxone has poor bioavailability when it is taken sublingually or swallowed. However, if Suboxone is taken intravenously, naloxone is 100 percent bioavailable and precipitates withdrawal symptoms in patients dependent on full opioid agonists.

Suboxone has been available in British Columbia since 2010, and PharmaCare transferred it from a special authority treatment to a regular benefit on the province’s formulary in the fall of 2015. On July 1 of this year, the College of Physicians and Surgeons of British Columbia ended the requirement for physicians wishing to prescribe Suboxone to have a methadone exemption. We believe this will have a positive effect on opening access to treatment for patients in the province.

Opioid dependence — a chronic, relapsing medical condition of the brain — is a well-recognized clinical and public health problem in Canada. A 2009 study indicated that between 321,000 to 914,000 non–medical prescription opioid users were among the general population in Canada. Further, the estimated number of non–medical prescription opioid users, heroin users or both among the street drug–using population was about 72,000, with more individuals using non–medical prescription opioids than heroin in 2003.

Historically, heroin has been the main source of opioid dependence. However, the current reality of illicit opioid use has become much more diverse and complex. In Canada, illicit opioid use also includes a diversity of prescription opioids, as we all well know, which include oxycodone, codeine, morphine and fentanyl. As a result, there has been an increase in demand for opioid-dependence treatment across the country.

We know the costs of addiction. In 2002, the nationwide costs of counselling and psychosocial supports, treatment for co-morbidities and addictions costs to the social welfare system and criminal justice system were estimated at $39.8 billion. In today’s dollars, B.C.’s share of the cost burden would amount to over $6.2 billion. Knowing that opioid abuse has surged since 2002, the real cost is certain to be much higher.

As this unique crisis continues to unfold, we are looking at a sweeping drain on economic resources. Given the financial impact that addiction issues carry, I wish to focus on strategies that can help to mitigate the financial costs of addiction and substance abuse. Despite being a very prevalent and costly disease, addiction is routinely overlooked in the health care system, resulting in huge downstream medical and mental health costs.

Focused energy, through a dedicated provincial addiction centre like the Centre for Excellence in HIV/AIDS, is clearly needed in British Columbia. The Ministry of Health has identified several key priorities — among them, across-the-board addiction service expansion; effective community services for patients with addictions to reduce hospitalizations; effective secondary and tertiary prevention for addictions; and expanding the role of family physicians, primary and community care professionals and support staff.

In the context of these priorities, Indivior recommends the following: creating stronger infrastructure for a continuum of care to retain patients in treatment and to better ensure successful outcomes; working with the College of Physicians and Surgeons of British Columbia on education programs to stem the overprescribing of opioids for non-severe, chronic, non-cancer pain; limiting PharmaCare coverage of opioid analgesics outside specified uses while completely covering costs of addiction medication for everyone who needs it, regardless of their deductible, similar to what is done for psychiatric medications under
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PharmaCare’s plan G; recruiting and training more physicians and allied health practitioners to treat addictions, particularly opioid use disorder; and addressing a disparity in the access to addiction treatment options faced by members of the B.C. public service through their extended health provider, Pacific Blue Cross.

In its 2013 report A Call for Evidence-Based Medical Treatment of Opioid Dependence, Dr. Evan Wood’s team at the B.C. Centre for Excellence in HIV/AIDS identified restrictions on office-based opioid substitution treatment as one of four key areas of concern with respect to the disease in this province. Greater access to treatment in primary care settings such as family doctors’ offices creates a less stigmatizing environment than clinics and further enables care of co-morbidities, including HIV, hepatitis C and psychiatric disorder.

These improvements in access and in patient outcomes would lower the costs of opioid dependence to the health care system writ large. The Ministry of Health should, therefore, work with the College of Physicians and Surgeons of British Columbia, the existing expert faculty on Dr. Wood’s team at UBC’s faculty of medicine and key addiction specialists to mandate addiction education again in medical schools. This is an initiative that has been undertaken in both Quebec and Nova Scotia and was a recommendation that was made by the Senate Committee on Social Affairs in its 2014 report on the unintended consequences of prescription drugs.

Taken together, these measures would help facilitate effective addiction treatment, as well as help reduce unsafe prescribing of opioid analgesics and other addictive medications by physicians.

The ministry should also discourage addiction physicians from keeping stable patients on their roster longer than necessary. If a patient is stable, they should be transferred for management back to a family physician for ongoing maintenance treatment and to ensure that their primary health care needs are being addressed. At the same time, family physicians with more complex patients that require more specialized care should transfer these patients through to addiction specialists in their respective communities.

As of 2015, Vancouver Coastal Health guidelines indicated that Suboxone is a preferred first-line treatment, since buprenorphine is six times safer than methadone in terms of overdose risk and has a safer side effect profile. The guideline also recognizes that most individuals will benefit from the ability to move between treatments, and it highlights the role of support recovery programs.

While methadone is a good treatment option for opioid use disorder, it is not a one-size-fits-all panacea for all patients. Ensuring proper training, compensation and access to multiple pharmacological treatment options, as well as access to high-quality psychosocial support, will stand to benefit patients across the province.

As it stands today, physicians are compensated $22 per week to retain patients on methadone treatment on their roster. That’s code 0039. However, should a patient need to be on buprenorphine-naloxone treatment instead of methadone, the physician is not compensated. This compensation structure can lead to decisions being biased towards a treatment option that may not be in the best interest of a patient and, I would submit, encourages physicians to sometimes write a script and send a patient on their way. This is not good-quality treatment for a patient.

Patients need more than just a methadone or Suboxone script. They need psychosocial support and, often, treatment for co-morbidities, including alcoholism and other drugs of abuse.

Addiction treatment codes should be adjusted to reflect those needs and to ensure fair compensation for treating physicians. The government currently pays $41.98 for “counselling to methadone patients for each patient on welfare.” Unfortunately, patients not on welfare are not covered under this structure, which means some have to pay out of pocket. In many clinics in larger urban areas such as Vancouver, the clinic fee can range anywhere between $60 and $80 a month. Patients are not, of course, required to pay clinic fees for diabetic care, stroke care and other similar health issues. That should be the same standard for addiction treatment.

The Ministry of Health can improve the continuity of care by also ensuring patients who enter the health care system through emergency departments, medical detoxification or rehabilitation centres receive follow-up care. The ministry should establish infrastructure such as chemical dependency teams that are adequately funded to assess and initiate treatment while a patient is in hospital and that align emergency care and rehabilitation centres in step with community primary care so that discharged patients are automatically connected with a trained physician in their community for follow-up and maintenance treatment.

Also key to outcome improvement will be enhanced interagency cooperation between maintenance therapeutic providers and providers of psychosocial support, counselling, social services and employment services, as well as family physicians. Insufficiency of appropriate programs complementary to medical treatment, namely psychosocial supports, has been identified as a very real barrier to treatment in the province.

My final topic relates to addiction treatment options for members of the B.C. public service. In September 2015, I wrote to the Minister of Finance in his capacity as the Minister responsible for the British Columbia Public Service Agency to advise him that, while Pacific Blue Cross has been contracted by the government of British Columbia to provide health benefit coverage, including prescription drug coverage, to over 30,000 provincial public service employees, their benefits do not include coverage for addiction treatments, be they pharmacological or psychosocial.
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Pacific Blue Cross has consistently indicated to us that there is no need to provide addiction treatment coverage under the plans available to their members because there has not been wide-scale demand for such coverage by their members. This puts members of the B.C. public service and indeed, I would submit, all patients in the province covered by Pac Blue, at a significant disadvantage to what is available to other British Columbians.

Under B.C. PharmaCare, patients suffering from opioid use disorder can access methadone or Suboxone, either the brand-name or the equivalent, as a medication-assisted treatment option. Yet, despite providing this benefit to patients across the province, the province’s own employees do not have access to addiction treatment medications under the plan the province has in place with Pacific Blue Cross. The absence of coverage for B.C. public servants is even more glaring when you consider Dr. Kendall’s declaration of a public health emergency due to rising deaths associated with opioid overdose.

On October 8, 2015, the director of total compensation for the B.C. Public Service Agency responded to my letter, indicating that public service employees with addiction can apply for a loan of up to $6,000 to attend abstinence-based residential treatment programs and reiterating that employees can access addiction treatments through B.C. PharmaCare. I’ve included that letter for the committee’s review, as well as email communications between myself and the reps of the service agency.

I also, following that, reached out to Dr. Paul Sobey, who, as you know, is president of the Canadian Society of Addiction Medicine, and Dr. Evan Wood regarding this issue. Both of them concurred that it was not evidence-based medicine to provide limited addiction treatment options to potential patients in the public service. Dr. Wood then connected me with representatives of the B.C. Ministry of Health on this topic.

I met by phone with ministry officials on February 15, 2016. The individuals at the ministry indicated that they were not aware of this lack of coverage for public servants and committed to look into it and communicate back. As of today, I haven’t heard anything, and emails and phone messages requesting an update have gone unanswered.

I have also communicated with various addiction experts — Dr. Patrick Fay in Vancouver; Dr. Mandy Manak in Kamloops, who runs the Interior Chemical Dependency practice; and Dr. Jennifer Melamed at the Alliance Clinic in Surrey — all of whom concur that Pacific Blue Cross’ failure to provide addiction treatment coverage poses a risk to potential patients.

I should also mention that Dr. David Juurlink, one of Canada’s pre-eminent experts in opioid addiction and dependence, stated on Twitter on April 14 that Pacific Blue Cross’ failure to provide addiction treatment options for the B.C. public service was “unconscionable.”

I would encourage the committee to encourage the Ministers of Finance and Health to ensure that Pacific Blue Cross include in their benefit package available to employees of the B.C. Public Service Agency access to both brand and generic forms of medication-assisted treatment for opiate dependence, as well as strong non-pharmacological forms of treatment support such as counselling.

If Pacific Blue Cross continues to refuse to expand their extended health benefit options to include pharmacological and psychosocial treatments for addiction and dependence, then the province should likely find a different extended health care provider for their public service.

The public health emergency declared by Dr. Kendall does not differentiate between those with coverage and those without, and we need to ensure that public servants have treatment options available to them through their extended health benefits. I should also note that Pacific Blue Cross is one of the only private plans in Canada that doesn’t cover treatment for addiction and dependence.

Given British Columbia’s leadership role in addressing opioid addiction and dependence, it’s baffling to me that its public service does not have equitable access to all treatment options as part of their extended health benefit plan. There must be the same standard of care for patients with opioid-use disorders as there are for others in different disease spaces. That means ensuring that these supports are available as a benefit, full stop — and not applying an income-based test before a patient can access that support.

In closing, I thank the committee for the opportunity to provide recommendations on ways the addiction treatment system in the province can be improved.

If the Ministry of Health takes action to reduce barriers to treatment, creates a stronger continuum of care, reduces reliance on medical detoxification, addresses the overprescribing of opioids to patients where it is not appropriate, ensures that B.C. public servants have access to addiction treatment as part of their extended health plan, and recruits and trains more physicians to treat opioid-use disorder, we believe that B.C. can continue to effectively address the public health emergency of dependence and addiction.

J. Darcy (Deputy Chair): Thank you so much for your presentation. We have, I think, about ten minutes for questions.

D. Bing: Thank you for your presentation. You made quite a lengthy part of your presentation on the difficulties with Pacific Blue Cross and what they’ve been doing. From what you’ve described, this is like a dereliction of duty. Why do you think they’re doing this?

C. Bishop: Honestly, I probably, in the last five years, have tried absolutely everything I possibly can — not only just on opioid dependence but, writ large, on addic-
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tion. They’ve come back with comments such as: “Well, we’ve spoken with the executive committee, and they say it’s not a priority. We’ve talked to our members, and there’s no great cry for addiction treatment.”

It’s absolutely baffling, because every other Blue Cross in this country covers addiction treatment — every other one. Pacific Blue Cross — which, by our estimates, could cover up to, potentially, 50 percent of potential patients in this province, whether it’s at the B.C. Public Service or some of the trade unions or what have you — refuses to cover.

I can’t tell you why they’re not doing it, but I can tell you that it is not for a lack of will that we have tried to work with them in any way, shape or form to get something, and it’s just a dead end.

D. Bing: It seems kind of baffling. I mean, as you say, every other Blue Cross across the country does this.

C. Bishop: Yes. Even if they wanted…. We’ve said to them: “Put in some form of criteria then.” I mean, other private payers have criteria in place for methadone or Suboxone treatment or treatment generally for opioid dependence. That’s completely doable.

It’s not, however, realistic, and it doesn’t stand up to the test of medical evidence, to say: “Well, there’s no outcry from members.” I’m not too sure that there’s any person I’ve met who’s an addict, an addicted patient or somebody in recovery, who has actively gone and advised their supervisor or their private care provider that they’re in addiction. The stigma is still there, and it’s very real, so of course they’re not going to get a huge outcry from their members. Who would want to do that?

The systems that are in place right now mean that a lot of companies that maybe have contracted with Pacific Blue Cross have systems in place that don’t promote that sense of wellness and inclusion. Often addiction means you’re probably going to lose your job. You’re probably going to lose your family. You’re probably going to lose a lot of things. So where is the incentive for somebody to say: “I’ve got this issue, and I can’t get coverage through my extended health benefit plan”?

To me, Dr. Bing, the Minister of Health and the Minister of Finance have a responsibility. They’ve been doing so well at addressing this crisis and putting it top of mind. I cannot understand why they won’t use the bully pulpit that they’ve got and say: “You’ve contracted with us, therefore we want addiction treatment options writ large for our 30,000 public servants, and if you don’t do it, we’ll go somewhere else.”

D. Bing: Very often, decisions are bottom-line or money-oriented. Is the cost of making this change quite substantial?

C. Bishop: Well, that’s a good question. I don’t know what the cost would be. I do know what the costs of untreated addiction are. You’ve got your direct costs to the health care system and your indirect costs from prison and everything else.

I can send to the committee — and I will do so — a copy of a report that was done by CADTH in 2013 that looked at the cost of untreated addiction, as well as one that was done by the York school of economics in the U.K. It found that the untreated costs of addiction were substantially more than adding the cost of treatment into a system or a plan. So I’m happy to share that with you.

D. Plecas: Cameron, thank you for your presentation. I gather your product — Suboxone — is a competitor to methadone.

C. Bishop: To be honest with you, when I got hired here, everybody at Indivior was told methadone is not a competitor. Methadone is a treatment option as viable as Suboxone, as viable as every other one. I’m not here today to say that every patient should be on Suboxone. I’m not competing against methadone.

D. Plecas: I guess what I’m getting at is…. You wrote in your paper and you said that Suboxone facilitates treatment.

D. Plecas: I’m just wondering how that works. In what way does it actually cause people to be better treated? I mean, I get…. At least I’ve heard Suboxone is…. Some people would say it’s safer than methadone.

D. Plecas: It’s got some safety features. But again, going to the treatment side, which seems to be a very relevant question when we talk about funding — whatever Blue Cross might want to do…. What could you say about that? In what way does it actually facilitate treatment?

C. Bishop: Medication in and of itself is not a form of treatment. It is one part of a broader treatment puzzle. Whether it’s methadone or Suboxone, as long as somebody is on it and if it’s deemed correct by their physician in consultation with their patient, a physician-and-patient partnership relationship….

If you get onto a medication-assisted treatment, your treatment outcomes are improved because you have more clarity. You have more of a desire to perhaps address some of the other issues that are inherent, that we know drive trauma — whether it’s sexual trauma, violence, what have you, some of the issues that we have from a psychosocial side that need to be addressed.
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Sometimes when you’re dealing with both at the same time, it becomes a little bit difficult to separate one from the other. I think that the last presenter made that very point, which is that you can’t effectively address mental health problems when you’re dealing with only addiction problems. They’re not siloes.

D. Plecas: Although, when a person is on Suboxone, they’re still in the addictions phase. So that would be different than what the previous presenter was getting at.

C. Bishop: I would respectfully disagree with that. We’ve never said that anybody should be on Suboxone forever. We’ve never said that anybody can be on methadone forever.

However, it strikes me as a little bit odd that we suggest that people may need to be on antidepressants forever or psychotherapeutic drugs, such as Seroquel or whatever, for schizophrenia. Or, for diabetes, we say to people: “You need to be on your insulin.”

Addiction is the only one where we seem to suggest that we should not have medication-assisted treatment for the long term. We don’t say: “Gee, Shirley, why is it that you can’t be done with your systemic lupus?” We don’t say that to people. We do say it in addiction, because we expect 100 percent compliance. Recovery is forever. Some patients may need to be on medication treatment forever. Some may not. That’s completely viable. But treatment isn’t just medication. It is ensuring that the psychosocial needs are being addressed.

D. Plecas: Right. I understand that. But I’m just thinking. In terms of those people who might say, “We want to think more in terms of recovery,” then what would your company say about the evidence which would suggest that your drug helps facilitate recovery?

D. Plecas: In other words, you would have some research that you could point to which would say that people who are on Suboxone are more apt to move into recovery.

C. Bishop: Absolutely. I’m happy to share those with the committee, and I’ll do that. I would just say again that — and I think the last presenter said it very well — recovery doesn’t look the same for everybody. In addition to having a medication psychosocial side, there’s also a need to address social determinants of health. That is the reality.

You can say that somebody is in recovery because they’ve got hope and they feel better. But if somebody is, for example, getting out of prison and then going back to the same community — where you’re living in poverty; there’s violence, inequity, lack of shelter and lack of opportunity — that is not recovery. Recovery may give you a sense of hope, and you may be on your medication, but the propensity is there to tip back into the other because of what is going on around you.

There are studies that came out, for example, in Illinois on the cost-effectiveness of treating writ large and looking at recovery from a wider spectrum, one of them being the Illinois Department of Corrections. They had a model in their prisons. What they would do is take non-violent criminals in the last three to four years of their sentence. They would transfer them to a facility where treatment, medication and psychosocial support was provided.

Then what they did was an environmental scan in the communities where these inmates would be discharged. They set them up with long-term treatment providers in their communities. They trained them on employment skills within the correctional facilities. Because of their environmental scan, they were able to match them to the communities where there would be jobs with those skills. The recidivism rate, as a result, dropped by 64 percent because these inmates weren’t going back into the same places where they originated from.

D. Plecas: Right. I hope you weren’t misunderstanding me. I get the need to be very holistic, and certainly, Corrections — federally here, anyway — has a great reputation for being able to do that.

I was only asking this out of a concern that…. At least some people would say that methadone has not been particularly helpful in moving people away from the phase of treatment where it is more holistic. Certainly, we wouldn’t want a situation where we’re saying: “Gee, we’ve got another drug, which is going to replace methadone.” It’s great that it has an advantage in that it’s safer. It’s my understanding it is, which is awesome. But does it do anything else? I think you’re saying that it does.

C. Bishop: Yeah, and I’ll provide that, but please don’t mistake me. I’m really not here to say that just medication in and of itself is recovery.

J. Darcy (Deputy Chair): Welcome to our presenters and to our observers as well today. We’re going to hear now from Chuck Doucette and David Berner from the Drug Prevention Network of Canada.

Linda Larson, who is the Chair of our committee, is joining us via conference call.

D. Berner: My name is David Berner, and I’m introducing Chuck, because we’re going to share these notes. Chuck will do the first phase. We’ll take turns.

C. Doucette: I assume you know that the DPNC is a federally incorporated society with a strong presence here in British Columbia. We do have special status with the economic and social council of the United Nations. Basically, we exist to try and help give a voice to those interested in abstinence-based treatment and recovery and prevention.

Addiction is not a temporary affliction. Once an addict, always an addict. Dr. Ray Baker, whom I see you are going to be hearing from later, if you haven’t already….

C. Doucette: Maybe he already told you this, but he uses a useful comparison when describing the change that a brain makes once a person becomes addicted to drugs or alcohol. He says it’s like the transformation of a cucumber into a pickle. Once a pickle, always a pickle. There is no going back.

However, there is some good news too. With help, one can learn to manage an addiction and go on to live a long, healthy and rewarding life in recovery.

To better identify the issues and our recommendations on how recovery could be more effective, we will refer to the four commonly understood phases of recovery, which include the following. Phase 1, the initiation phase, or initiation into recovery. For most people, this will occur once they have got into rehab, and it includes the detox portion. This can be a time of mixed emotions. Often the addict is still dealing with the effects of whatever drugs or alcohol is still in their system.

Some people will be initiated into treatment against their will and so can feel doubtful of success at this stage.

It brings us to our first recommendation. In the initiation phase, it is essential to have speedy access to detox. First responders and others often deal with people after an incident, which opens their readiness to enter rehab. The first crucial step to rehab is detox, which gets the person sober enough to respond to treatment.

If someone is ready to go to detox at the time of the first contact but then has to wait for a week or more before they get into detox, they are rarely still in that same willing mindset as they were earlier. Therefore, we can improve overall effectiveness by making sure there are enough detox beds provincewide available to handle the demand on a 24-7 basis.

D. Berner: Phase 2, early recovery, refers to the first few months of sobriety when an individual needs to adapt to living without alcohol or drugs. In this phase, it’s crucial that the addict, who has just finished detox, be placed in a legitimate treatment facility.

At this stage, their life and sobriety will feel new and fresh, and it will be the job of the individual to get used to this new way of living. Early sobriety can be like a foundation for a house, so it’s vital that the individual progresses successfully through this stage. This phase of sobriety is also the most treacherous and is when people will be most at risk of relapse back to their addiction.

Just to add to the notes, I can tell you from practical experience that what the addict is experiencing is grief and loss of their best friend — namely, their pipe, their needle or their bottle.

We are blessed in this province to have dozens and dozens of first-rate recovery programs that are already up and running. Day after day they do excellent work getting people away from these poisons and back to being fully participant citizens.

These programs are as varied as the people who run or manage them and as varied as the clients. Some are residential; some are drop-in. There are for-profit businesses. I work at one of them, one day a week. There are non-profit houses. There are foundations. Many of these programs do really beautiful and effective work.

However, as many of you already know, there are also a number of disgusting fronts for thievery and human abuses of every kind. The city of Surrey has had particular struggles in this area.

Recommendation No. 2. Let’s find a way, as a body politic, to support the legitimate and effective programs while using all means available to close the rogue operations.

In terms of support, please note that the size of the program is irrelevant. There are people who don’t understand addictions who think all programs should be big or all programs should be small or all programs should be middle-size. It’s nonsense.

The size of the program doesn’t matter. Programs large and small both do wonderful work. But right here in B.C., there are far too many small operators of first-rate recovery programs who barely and bravely function on a month-to-month basis. I think we should legitimize these folks. Give them an appropriate bed rate, and let them focus not on paying the hydro or food bill, which is what they seem to spend most of their energy doing, but on doing good recovery work.

Recommendation No. 3. Make sure that the decisions about which programs to fund and which to close are made by qualified people. When the health authorities fund a program, their job is oversight, not micromanagement.
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The closure of the Crossings in Keremeos was an unfortunate decision. The tearing up of the agreement with Portage, which is one of the oldest and best and most proven programs in Canadian history, was a sad day for recovery in British Columbia.

We can call for new submissions, for a new operator. That’s all very nice. But if the same health authorities continue, without truly understanding how programs like this work, we’re looking at another failure.

Please, pick the right people, fund them appropriately, and get out of their way. Hold them accountable, but don’t throw out the baby with the bathwater. We have a question for the government: when you buy an aircraft, do you lean over the shoulders of the pilots and the maintenance crew?

C. Doucette: Phase 3, recovery maintenance. In this phase, individuals are beginning to settle into recovery, but they need to continue to put work into staying sober. This can be a treacherous period because it involves moving from rehab back to the real world. The individuals will have been encouraged to build an armoury of recovery tools during their time in rehab, and now will be the time to use them. This is the time when people are most at risk of relapse. So long as they remain committed to recovery, they will make it through this period.

Recommendation No. 4. In the recovery maintenance phase, it is crucial that the addicts get adequate support to keep them on the path to advanced recovery. This can come in many forms, such as the 12-step and other support recovery groups that work well for many. However, there are still far too many that do not make it through this two-year period. The effectiveness would be greatly improved if someone was assigned to watch over and assist an addict for that first two-year period.

At a drug court graduation in Seattle — I went there as part of a contingent from Vancouver before we decided to open the drug court here in Vancouver; we went there to see how it worked — I witnessed a graduate there tell his story of how before he had entered the drug court system, he had relapsed several times, each time after months of being sober. Thanks to the drug court program, he had finally made it into the two-year mark required to graduate.

When I asked him what the difference was this time, he said that the drug court system provided a caseworker to follow him throughout his journey. Whenever he fell off track, the caseworker was there to put him back on track and help him make whatever alterations were necessary to keep him there.

I have visited many effective long-term treatment facilities in various countries around the world, and some here in Canada as well. While they differ greatly in many ways, what they all have in common is that they allow people to stay as long as needed. In some cases, that’s several years. No one that follows the rules is asked to leave before they are ready.

We strongly encourage the ministry to reward and support those residential programs that have thorough follow-up and aftercare programs in place. A 24-day or even a 90-day stay is a good start, but that’s all it is. Too many people are graduating from these programs and then falling off the cliff like lemmings. The longer we can engage with clients, the better the results.

D. Berner: Phase 4 is advanced recovery. After about two years, individuals enter this period of advanced recovery. It doesn’t mean they’re cured — frankly, there’s no such thing as a cure; there’s only an ongoing life process — but doing the things that keep them sober begins to feel like second nature.

Once people have been sober for more than five years, they will usually have created a comfortable life away from addictions. The risk of relapse never completely evaporates, but staying sober has become a good, healthy habit. The individual will have faced many challenges during the preceding years, and this will make it easier to deal with future challenges.

Recommendation No. 5. In the advanced recovery phase, as in all phases, it would help if there were more public awareness of how many thousands of people there are living happy, productive lives in recovery and how available the treatment is. We encourage the provincial Ministry of Health to allocate money and resources to advertise and market the fact that recovery is near at hand — that’s my little slogan I invented: “Recovery is near at hand” — and to encourage those in recovery to stand up and be counted.

Now, we appreciate that there are already several toll-free lines with a basic clearinghouse of information regarding addictions and recovery options. But frankly, this just reminds us of the old saw: “If a tree falls in the forest….” Families and communities which are stricken with addictions issues right in their midst are desperate and in panic mode. Far too often, we’re told they didn’t know where to get help.

The Drug Prevention Network would like to see a steady barrage of radio, TV, bus shelter, bus side and social marketing to let people know that there are already thousands of highly skilled, dedicated, knowledgable and caring workers available right now to help. Addictions aren’t the end of the road. They’re simply a big signal from life, shaking you by the collar, that it’s time to make some better choices and become your own best you.

Recommendation No. 6. Finally, it has become an almost universal practice today, with governments, to package mental health and addictions in the same departments, funding sources and action groups. We appreciate that this has a kind of convenience, but we question if it accurately reflects the realities or helps in the solu-
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tions. We would like to encourage the ministry to give this matter a longer second thought.

It is our belief — based not on theory or study but rather on years of hands-on, practical experience — that mental health and addictions issues are startlingly different both in their content and texture, and that they require entirely different approaches from helping professionals.

Well, you may say: “What about dual diagnosis?” That’s a phrase everybody likes to say a lot. I think it makes them feel like scientists. “Dual diagnosis. Dual diagnosis. I must know what I’m talking about.” Not really. My experience in the field tells me that dual diagnosis is hardly a runaway epidemic or anything close to it. In fact, if I encounter one such client a month — and I am active in this field — that’s a lot.

Yes, there are people who are very deeply troubled with mental health issues, and pot, crack, coke or alcohol may be a part of their coping strategies. But what concerns me is: how should we, as a community, respond?

My answer is this. The mental health issue has absolute priority. Let’s deal with that first, and deal with it in isolation from any addiction concerns. This is the work of psychologists and psychiatrists, and the solution is often pharmacological. I have witnessed schizophrenics and bipolar patients existing in a nightmare, and I’ve seen many of them find some peace and stability with the right doctor and the right cocktail of medications. By the way, that often takes years to find — largely by trial and error.

Often enough in these cases, the substance abuse disappears once they’re stabilized. If it doesn’t and the client has now found some kind of a measure of return to reasonableness, then and only then is it possible for those of us who actually practise addictions recovery work to begin to work with them.

J. Darcy (Deputy Chair): Thank you so much for a wonderful presentation. I see hands going up already, so I will begin with Darryl and Selina. Linda, let me know if you have a question.

D. Plecas: Thank you, David and Chuck. I know the both of you have done so much to help people with substance abuse issues — thousands of people — so we owe you a great debt for that. I know how much success you’ve had.

One of the points that you made was interesting to me, because it was different than what we had heard earlier in these hearings. That was your comment about we ought to…. I thought I heard you say that we should deal with the mental health issue and then the addiction. But we heard from I think even more than one person who said that we should be dealing with the addiction first and then the mental health issue.

D. Berner: Well, I can only speak from my own experience, Darryl. I tell you frankly that I don’t understand mental health issues, and to be bleakly honest, I’m afraid of them. If I’m confronted with someone who has very serious mental health issues, I almost shy away. I’m not very good at dealing with them, but I have a natural ability to help addicts — for some reason or other. My natural impulse is: “Could we please deal with this person? This person is mildly nuts, and I don’t know what to do with this person.” I can deal with the addiction. That’s a whole other issue.

I don’t know. Chuck, maybe you can reflect on this, because you’ve had your own experience as a former policeman running into people. I don’t think you can treat addictions when someone has enormous mental issues.

Please, let’s be very clear about something. Anybody who has addictions issues has, just like anybody in this room, issues. We all have emotional issues. We may be functional. We may be doctors and senators and whatever we are — recording people, whatever we are — but we all have issues of one kind or another. People with addictions have issues, but as I say to the addicts every week: “I don’t see any broken toys in this room. There’s nobody here who’s stark raving crazy. You have some issues. Let’s work on them, okay?” People who suffer from severe mental issues — that’s not my territory.

C. Doucette: I would like to add a little bit because I do have a fair amount of experience with people with mental health issues as well. I understand that it affects the same part of the brain and the same, you know, serotonin and other chemicals — neurotransmitters — in the brain. So there is definitely a commonality there.

But it’s interesting in that, similarly…. I was talking to a psychologist once, and we were talking about him treating people with mental illness. He said that he wished he was a psychiatrist. If he had to do it over again, he’d have gone in for psychiatry. I said: “Why? What’s the difference?” He says: “Psychiatrists can control the medication. The psychologist has to depend on someone else to control the medication while he’s trying to do the other part of it.”

It would be very similar with the addictions side of things. An addiction counsellor does not have the ability to control the person’s medicine. The psychiatrist does. I talked to our counsellor that works at the Little House Society, another organization that I’m with, after David and I discussed this before we prepared our presentation. He agreed that that becomes an issue for him. He’s trying to deal with this person who is probably on medication for their mental illness, and yet he’s trying to get them off the other drugs that he’s on. It becomes very difficult.

S. Robinson: Thank you for your presentation and for the work you do. I, too, have spent many, many years
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working with, mostly, youth with addictions, so quite familiar with the challenges, especially if there are some mental health concerns. It sounds like part of what you’re talking about is that there needs to be a team around for these folks. Not one or the other but a team. I think we’ve certainly been hearing that at our hearings.

My question had to do with the recommendation No. 4 where you talk about: “The longer we can engage with clients, the better the results.” I’m just wanting to know, from your experience and from the research that you’ve read, what that would look like when you say: “For a long period of time. The longer we engage with them….”

I recognize this is lifelong. People have to pay attention. They always have to focus on the stuff that keeps them on the right track. At some point they might need a touchstone, regularly, in their life. But when we think about recovery and moving through recovery and into the next parts, what’s the vision for how long we ought to be paying attention from a public policy perspective?

C. Doucette: Well, the latest research says it’s five years that you’re looking at. The first two are the most crucial, but five. When I first started getting involved in this sort of thing the magic number was two years. If someone took their two-year cake at an AA meeting, that was quite significant, because they sort of thought they were over the hump. But now they’re saying five years is more what it should look like.

We have just initiated a treatment program, again in the Little House Society that I’m part of in South Delta, and what we have said right up front is that anybody that comes into our door, our counsellor will stay with them for two years. Of course, like I said in my presentation, there are several self-help groups. David runs one, so he can speak to that. They’re not all like AA, the 12-step, but there are lots of those that should be encouraged.

Our counsellor, who’s going to look at that and follow these people for two years, is going to get paid from our society, but we’ll get no funding from the government for that. That’ll be only on donations and how we raise money ourselves. It would be awfully nice if there was some government funding for that sort of thing.

D. Berner: Selina, in the last few years, I’ve concluded that the biggest single failing of all of us who are interested in these subjects is aftercare. We just don’t hold on to people long enough. I work at a program that’s very strong and a beautiful program. It’s a for-profit. People stay for 28 days or 42 days or, a very few, for 90 days. Quite frankly, a lot of people fall off the cliff almost immediately.

The problem is that if you think that you’re some kind of scientist and you think you understand how addiction works and you focus on the drugs or alcohol, you’ve missed the entire subject. It’s not the drugs or alcohol. I always say to the clients: “The drugs and alcohol are the pimple on your ass. They’re nothing. The issue is how you think, how you operate, how you face the day, how you look at your friends, colleagues, lovers, spouses, parents, children and so on — how you approach your life. That’s what has to change.”

That can’t change…. We don’t expect people to change themselves. I’m the same David I’ve been since I was four or maybe three, but I can change what I do and how I think about things. Selina, it just takes a long time to groove in new habits of behaviour, okay?

I built the first residential treatment centre in Canada in 1967. It’s still running 50 years later. We had people stay for five years.

Oxford Houses in America — I believe there are about 20 in the province of Alberta — are sober living houses. There’s no program. They’re just houses where people can go and know that they’re safe and it’s sober. They only have one rule. The rule is: if you have one drink or one toke of weed, sayonara. You’re gone. They have no time stricture. People can stay forever.

Everybody is different, as you know from your own work, Selina. There are wonderful, rare individuals who clean up on their own. They never go to an AA meeting. They’ve never gone to a shrink. They’ve never seen David Berner. They’re amazing people. God bless them. Good for them. There are some people who never clean up. It’s a shame. It’s sad. Most people fit somewhere in between.

We have to just keep people as engaged as possible. What Chuck was referring to is that I started a new thing last year called Stay Sober. It’s a group on the street. It meets in a great location in Kitsilano, one night a week for two hours. All of the people who show up regularly are still sober a year later.

All we’re doing is sitting and talking about how the week went. We don’t do the kind of very colourful, psycho-dramatic therapy that I do at the clinic that’s very colourful and so on. We don’t do that. It’s just a conversation about sobriety and about how you’re getting along with your kids and your spouse.

D. Berner: Absolutely. It’s about community. Because, as you know, just to get it on the record, the disease of alcoholism.… The core of it is loneliness. The core of it is isolation.

I found it very interesting, particularly recommendation 6, where you say that mental health and addictions
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have been kind of packaged together almost universally, and yet your experience is that this isn’t the case.

I was reading something just a little while ago by Dr. Gabor Maté. You may be familiar…. He made a comment that it seemed that every individual that had this problem had a childhood trauma, and I guess they were trying to mitigate the pain from this childhood trauma.

D. Berner: Well, he’s wrong, Doctor. He’s wrong, as he is about many things.

Look, many of the people that I work with have childhood trauma. It’s absolutely true. I’m a kind of trauma specialist. A lot of the work I do is about exactly that. There are a lot of tears and a lot of anger and so on. People do carry the ghosts of their fathers behind them like chains, like Hamlet’s ghost.

But I’m working with a client right now who’s had a perfectly fine upbringing. He doesn’t have major trauma. He had a huge trauma a year ago, but it had no reflection with his early childhood. So I’m not working on that level with him.

There are many, many people who haven’t suffered from terrible trauma. But all of us, to some degree or another, have had some disturbance, some childhood that wasn’t absolutely storybook. There are only seven people in the world who had a storybook childhood.

D. Berner: No, I haven’t met them yet. If I do, I’ll think they’re psychotic. I won’t believe them. It’s just like the seven people who have the Budweiser Christmas, you know, with the Clydesdale horses and the jingling and the fireplace.

J. Darcy (Deputy Chair): I have a question that relates to what Selina asked earlier about the follow-up. You basically said — and we’ve heard this from other presenters — that this is a lifelong journey. It is a disease. You’ve never…. It’s striking that you talked about the drug court graduation in Seattle and that, in that case, a caseworker is assigned to follow a person through their journey.

We have a lot of different…. You spoke eloquently about this. We have big and small providers. We have them in the public and in the for-profit and not-for-profit sectors. What does it look like, and what do we need to do in our health care system to get better at providing those caseworkers or that support for a lifelong journey?

D. Berner: I think Chuck should really speak to this, but very quickly, one of the things I think we have to do is…. In the drug court system that we have here, I don’t think we’re thorough enough. I don’t think we follow through with people enough. We really do have to have, I believe, in the drug court system, a carrot and a stick. We have to have both. There have to be consequences for not sticking to the plan, and there have to be great, simple rewards for making it, for carrying on. I don’t think we’re being thoroughgoing enough in our approach.

J. Darcy (Deputy Chair): Sorry, I mentioned drug court but only because that was what you referred to there. Most of the people we’re talking about will not be in the drug court system. What do we need to do in how we provide health care services or primary care in health care to make sure that there is that kind of support and ongoing connection for people?

C. Doucette: Basically, it comes down to funding. One of the things that…. When I first got involved on the prevention side, a wise doctor said I had to learn about addictions as well. Otherwise, how could I prevent something I didn’t understand?

When I first started talking to doctors of addiction medicine and getting them to train me and other police officers, one of the things that they said is that this model that we use here is called the Minnesota model, which was developed — I forget the name of the town — in Minnesota. It was meant to be two years, and all of a sudden it got shortened to a 28-day program because that’s all anybody wanted to fund.

They knew it should be long term right off the bat, but funding is always the problem. It should be understood right from the get-go that it is long term so that the funding would include not only whatever residential period that is necessary, and that varies — it’s a very essential part of the program as well — but then the follow-up should also be funded. There may be ways we haven’t even thought of yet. I can’t say that I have the exact answer to that, but it definitely has to be thought out right from the start. This isn’t just a short period. This is a longer period.

The program that I started, Stay Sober, is not particularly brilliant or original. It’s just a place where people can come and feel that they’re still part of the ongoing conversation about sobriety. Yes, there are 12-step programs for that. There are lots of things. But this isn’t 12 steps.

You give me ten people who’ve just graduated from counselling classes somewhere, whether it’s the psychology…. Whether it’s people graduating from Adler here or graduating from BCIT or whatever, you give me ten of those people, and you provide the funds for one of them to be in Prince George and one to be in Kelowna and one
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to be in Victoria and so on. You pay them to do this work one or two days a week, and I will train every one of them how to do this work. It’s very simple. It’s not complicated.

Then every time someone leaves a program on the Island, they are told that part of this program means that you have to go and see Bob on Blanshard Street in Victoria and that you’re going to do that for the next year. I’d be happy to do that.

C. Doucette: The good point there would be that even though our counsellor that we just hired for the Little House Society will do similar group work, he will be paid to find a spot for everybody that comes through his door, whether he can handle them or not.

The people that David is talking about — we’d be able to put them in touch with 12-step programs for those that that would work for. But we know that because of the spiritual nature of the 12-step programs, not everybody will go to that, so there have to be similar programs that are available. Funding, where appropriate, but also that key guy who steers them.

D. Berner: Judy, it’s not that none of this already exists. Some of it already exists. There are programs that I could name that already have aftercare and sober-living houses and so on. We just need a bit more. The crucial point is that it’s cheap; it’s not expensive.

C. Doucette: Another point to make on that is that those ones are all funded in some other way, and it’s because of guys like Billy Weselowski, who absolutely runs a terrific program called InnerVisions out there. He knows it’s necessary, so he finds the money to make it work. He doesn’t rely on the government. He finds it somewhere. But there are lots of others that aren’t at successful at raising money, and if there was some way of getting some to help with that part of it, it would go a long way.

J. Darcy (Deputy Chair): Thank you so much. We could keep you here for a long time, but we have other presenters who are waiting. Thank you so much for what you do.

J. Darcy (Deputy Chair): Welcome. Thank you for offering yourselves to present today.

Our next presenters are David Byron Wood and Ian Bushfield from the British Columbia Humanist Association.

I. Bushfield: Wonderful. Thank you. Respectable members of the Standing Committee on Health, thank you for having me here today. My name is Ian Bushfield, and I’m the executive director of the B.C. Humanist Association. I’m joined by David Byron Wood. He goes by Byron now — Byron Wood. I’ll ask him to speak about some of his personal experiences with the addiction program later in my presentation.

The B.C. Humanist Association is a charity that represents the growing non-religious portion of the province who support secular and progressive values. Our health care system is of vital importance, and as an organization representing people whose world view is based on compassion and evidence, the questions you are tasked with are at the forefront of many of our minds.

Today I want to speak to just one aspect of one of those three questions, that of personal autonomy and religious freedom within the addiction recovery program in the province. My remarks will largely follow the written submissions that I’ve provided you with, and you can find references to things I talk about in there later.

Historically, the leading theory of addiction and alcoholism was based around a sort of religious view of individual suffering and moral failing. In the 1930s, following the end of Prohibition in the U.S., different Christian movements arose to try to treat alcoholics, using religious principles like sin and salvation.

The most lasting and famous of those organizations is Alcoholics Anonymous and its 12 steps, which you can see here. These steps refer repeatedly to God, a higher power, prayer and a spiritual awakening. While the steps make a minimal effort to be inclusive by referring to God “as we understand Him” or “as we understood Him,” for many atheists, including myself, this language is just needlessly divisive and irrelevant to the process of combatting addiction.

The program of AA and these steps have remained largely unchanged since they were written down in the 1930s, and efforts to establish a secular version have been met with hostility in different cases. In both Vancouver and Toronto, AA groups for agnostics and atheists were de-listed from the official intergroup directories. This meant that individuals who are required to attend AA meetings just don’t have a secular option.

The Human Rights Tribunal of Ontario is set to hear a case about the Toronto AA groups being de-listed, but otherwise I’m not aware of any case law, actually, in Canada about AA and whether it is religious. There is, however, lots of evidence from the U.S. courts, where they do consider AA as a religious program and mandating attendance there to be an infringement of their religious freedom and establishment clause.

I’ll note that the B.C. Ministry of Health’s own HealthLink B.C. website describes AA as “based on a spiritual connection to a higher power — such as God,” and it also points out the lack of scientific evidence supporting AA as a recovery model. As the website points out, there are lots
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of anecdotes of people who get sober who have attended AA, but systematic and controlled studies of AA have failed to demonstrate its effectiveness. A 2006 Cochrane systematic review concluded that “no experimental studies unequivocally demonstrated the effectiveness of AA approaches for reducing alcohol dependence or problems.”

This all becomes an issue because the religious program is increasingly out of step with a significant and growing number of British Columbians. The 2011 national household survey done by Statistics Canada found that 44 percent of British Columbians have no religion, which is up from 36 percent in 2001. But Statistics Canada includes “those who are no longer practising” among the religious.

To get a better picture, the B.C. Humanist Association commissioned Justason Market Intelligence, in 2013, to ask how many people do practise a religion or faith. When we asked that, 64 percent said no in 2013. We then had Insights West ask the same question again this year, just in June, and the number who said they were not religious had increased to 69 percent. These charts on the screen are of the question we asked: whether people believe in a higher power. In 2013, 70 percent said they do, while in 2016, that had dropped to 56 percent.

Put another way, 26 percent of British Columbians fully reject the idea of a higher power, and that idea still forms the basis of one of the most prevalent addiction recovery programs and one that continues to receive endorsements from the government, medical community and treatment facilities across the province.

On HealthLink B.C.’s website, again, which describes itself as medically approved information, AA is recommended as a support group for those worried about their alcohol use and just seeking home treatment. The only secular alternative recommended is to speak to your “family, friends or doctor.” Similarly, the addiction strategy group of the B.C. Medical Association puts 12-step programs such as AA in the continuum of care for addictions treatment.

We also reviewed a number of the public and private addiction treatment centres across the province. This isn’t a complete list, but what we did find was that the overwhelming majority of these centres incorporate the 12-step program in one way or another. Many, and not just those who have religious centres, base their entire philosophy on the 12-step program, and many others require frequent attendance at AA or NA meetings. Many of these facilities specifically target vulnerable populations, such as youth, women and First Nations communities.

I’m going to now allow Byron Wood to tell his story. Hopefully, it will become clear why he’s here today.

B. Wood: Hi. My name is Byron Wood. I used to work as a registered nurse for Vancouver Coastal Health Authority. In 2013, I was hospitalized, diagnosed with a substance use disorder and was deemed unfit to practise as a nurse. I reported my hospitalization and diagnosis to the College of Registered Nurses of B.C. I agreed to change my nursing licence to non-practising status and signed a monitoring contract, agreeing to participate in a return to work addictions treatment program.

I was referred to a doctor who performs addiction assessments and treatment recommendations for people who work in safety-sensitive occupations. The doctor recommended that I attend a five-week addiction treatment program at the Homewood Health Centre in Guelph, Ontario.

Homewood’s program is based on the 12 steps of Alcoholics Anonymous. It is a private facility that charges patients over $30,000. My fees were paid for by the British Columbia Ministry of Health.

The referring doctor also recommended that once I complete the Homewood program, I maintain complete abstinence, attend at least three 12-step meetings per week and submit to random drug testing and monitoring. I was informed by the College of Nurses of B.C., the B.C. Nurses Union and Vancouver Coastal Health that I must follow the doctor’s treatment recommendations in order to have my nursing licence reinstated and return to work.

I informed the respondents that I’m an atheist and objected to attending AA meetings and following 12-step treatment programs because they are based on religious principles. I did an Internet search and found more than 30 in-patient addiction treatment centres in B.C. Of those 30, I was only able to find three that are not either based on the 12 steps or require that patients attend 12-step meetings.

I asked the respondents if I could attend one of the secular addiction treatment centres. I also asked if I could attend secular alternatives to 12-step groups, such as SMART Recovery. However, my requests were denied.

I was told I could get a second opinion from another doctor if I paid over $2,000 of my own money. However, the assessment had to be done by one of three doctors who the respondents approved of and who, they told, me only refer to AA and 12-step programs.

I wanted to return to work, so despite my religious objections, I completed the Homewood treatment program in Ontario. At Homewood, I met three nurses and one dentist from British Columbia who’d also been mandated by their employers to attend the program and to follow an ongoing 12-step aftercare program similar to mine.

At Homewood, I was encouraged to pray and to turn my life over to a higher power. I was told to keep my mind open to having a spiritual awakening. I was told that character defects, including pride, envy, greed, gluttony, lust and sloth, were responsible for my addictive behaviours. I was required to attend daily 12-step meetings.

The staff used a confrontational approach to interact with patients, and I found this to be unhelpful and extremely humiliating.
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The religious underpinnings of the Homewood program were glaring. I found the 12-step program to be unhelpful, and I felt disrespected by staff. However, I completed the program and then returned to Vancouver.

The 12-step meetings in both Vancouver and Guelph often began and ended with a prayer. Sometimes this was the Christians’ Lord’s Prayer. During the meeting, people would stand up and talk about their addictive behaviours and perceived misdeeds and moral shortcomings. They talked about how they had been transformed after turning their lives over to a higher power and following the 12 steps. To me, this was in the style of a public confession.

I continued to ask the respondents if I could follow a secular addiction treatment program, but my requests were denied. I was unwilling to continue with the religious 12 steps, so I withdrew from my return-to-work monitoring contract, and as a result, my employment was terminated by Vancouver Coastal Health. The knowledge exchange leader for addictions services at Vancouver Coastal Health told me that the practice of mandating employees into AA and 12-step programs is likely happening across the province with all of the health authorities.

I filed a complaint with the B.C. Human Rights Tribunal against Vancouver Coastal Health, the College of Registered Nurses of B.C., the B.C. Nurses Union and the doctor. I’m arguing that the respondents could have, and should have, allowed me to follow a secular addictions treatment program rather than mandating that I follow a program based on AA and the 12 steps. By failing to accommodate my religious beliefs and terminating my employment, they violated the B.C. human rights code. I’m waiting for a decision from the Human Rights Tribunal as to whether my complaint will proceed.

Well-regarded experts in the field of addictions research from both Canada and the United States, as well as the B.C. Civil Liberties, have submitted letters to the Human Rights Tribunal confirming the public interest in my complaint proceeding. I’m hoping that a ruling in my favour will help put an end to the systemic discrimination.

I. Bushfield: Unfortunately, we don’t know how unique or rare situations like Byron’s are.

There are secular alternatives, as Byron mentioned. There are 55 meetings of SMART Recovery in B.C. LifeRing, I know, has worked with the University of Victoria.

I’ll close by just saying that, of course, it’s entirely within the right of religious organizations to form and operate religious-based treatment recovery programs and for individuals to seek those out as part of their recovery. However, it’s not the government’s role to endorse sectarian treatment programs. This is why we are recommending the government seek to ensure that provincial treatment guidelines for substance-use issues are secular, based on the best available evidence, and culturally sensitive.

This means ending the government’s endorsement of AA; ensuring that secular alternatives are available and that health care professionals, most importantly, are aware of them; and, of course, upholding each individual’s personal autonomy and right to religious freedom.

I’ve said several times today that I used to be an addictions counsellor, and I worked with youth. We certainly found lots of challenges with youth giving up the higher power when they didn’t even recognize that they actually had power, because developmentally, young people are just discovering that they have power. So it became, actually, a therapeutic challenge.

In my younger days, as a youth counsellor, I would bang up against AA as the only option. I really appreciate you sort of reminding us that there are other options, that they ought to be explored and that evidence-based is critical.

I want to just speak to your very first recommendation: remove links to AA and 12-step programs completely from the website. That’s because there shouldn’t be any recommendation at all to other forms, or is it the absence of others that’s the problem?

I. Bushfield: I think the absence of others is definitely an issue. I don’t think it’s the government’s place to be recommending people seek out a religious treatment. They, of course, can, and should, but it definitely shouldn’t be the only one. I would prefer not to see the government recommending a religious-based treatment program.

S. Robinson: But you wouldn’t be opposed to it being included with a whole bunch of other alternatives. Like here, there are 74 different kinds of programs, half of which are based in this kind of doctrine, and the other half aren’t based in anything like that.

J. Darcy (Deputy Chair): I have a question. This is a real eye-opener for me. It’s not something I was aware of at all, so I want to really thank you for coming forward and making this presentation and helping to open some of our eyes on it, who weren’t aware of this.
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Are there programs that are publicly funded that are of a secular nature — sorry, of a non-secular nature?

J. Darcy (Deputy Chair): Yes. Are there programs that are publicly funded that would meet the objectives that you’re talking about that you believe people should have access to?

B. Wood: I know when I was looking for a treatment program, to ask my employer if I could attend that one instead of the religious one, I came across the Maple Ridge Treatment Centre. It’s operated and funded by Fraser Health Authority. They claim to be secular and evidence-based. I also came across the Sunshine Coast treatment centre.

J. Darcy (Deputy Chair): Is that a residential one, in the way that Homewood is, for instance?

B. Wood: No. Sunshine Coast is a private facility, and it’s a private for-profit facility, so it’s very expensive. I think it’s $30,000. But it’s secular.

I. Bushfield: On the website for Sunshine Coast Health Centre, they put…. I was almost going to include the picture in my report and on the slide. It just says “Non-12-steps since 2008.” So they go out of their way to highlight that they are not 12-step-based.

B. Wood: I just wanted to mention, as well, that people are being funded by the government, in terms of their social assistance and government support, to go to these religious programs.

J. Darcy (Deputy Chair): My question was whether there was support to attend the non-religious ones. You’re saying yes.

J. Darcy (Deputy Chair): But you’ve been told it doesn’t qualify. In your situation, this is not considered acceptable for you to be able to practise as a nurse again.

B. Wood: Yeah. I mean, I can’t speak to the motives of my employer, but I was only given one…. I was told I had to go to this particular treatment program, otherwise I wouldn’t get my job back.

D. Plecas: So if I ask a question related to Selina’s…. I think you answered the first part of it. You do not have an objection with AA being available alongside a smorgasbord of other possibilities. Did I hear that correctly?

I. Bushfield: The question at the committee level is: how do we improve the effectiveness of addictions recovery programs? Based on the evidence that I’ve seen, AA is not effective, and it’s potentially coercive, religiously. So I would not support the government’s…. I wouldn’t oppose an individual choosing AA, but I don’t think it should be the focus of the government’s health program.

D. Plecas: Right. I mean, I guess I’d be leaning toward at least saying the jury is out on the effectiveness of AA. I guess you have to say: what part of the treatment process are we talking about? It’s my understanding that AA has over one million people on this planet involved in AA, attending regularly. Apparently it works for them, by their self-reports. Now, the complication, of course, is the nature of AA. People are anonymous.

If we’re saying in terms of treatment that the goal ought to be, “What works best for who under what circumstances?” respecting a whole range of things that encompass a holistic approach to treatment, it seems to me that it’s one thing to say, “I wish I had an alternative or there ought to be. I shouldn’t be forced into one that’s based on religion,” but then there’s also the fact — by your own stats — that we’re still talking about a majority of people who believe in a higher power. For those people, this is very appropriate for them. If that’s the path that it takes….

I guess the other part of it is the leaning towards, or the implied assumption or the conclusion, that somehow religion has no…. There’s no basis for believing it’s effective. Well, that flies in the face of a lot of medical research, which says the opposite.

I. Bushfield: Let’s look at a different example. If we were discussing how we improve cancer addiction and the majority of cancer treatment programs still involved going to a prayer group, but then people started to object, and the jury was out on whether the prayer group actually helped cancer patients, and we had a finite amount of money to help people with cancer, should we not choose to focus our money on groups like SMART Recovery and LifeRing that are willing to adapt their programs as they find out that some things don’t work and can be inclusive?

I mean, we have a very dark legacy as a country of forcing religion on people, and I think we need to be very culturally sensitive, especially in First Nations communities, especially with so many vulnerable populations, when we’re talking about religious treatment programs.

D. Plecas: Right. I’m only saying I’m not sure we would want to throw the baby out with the bathwater. Like, it’s not clear to me that there is a preponderance of evidence which says that AA isn’t helpful to some significant group of people. Nor is there evidence out there….

In fact, there’s evidence to the contrary that would suggest that belief in a higher power has an incredibly
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powerful healing effect with people with all kinds of disorders. I’m just saying that’s the medical literature, which is telling us that.

I. Bushfield: Well, I would disagree with that. I haven’t seen the study you’re talking about.

D. Plecas: Well, I think there’s a fair amount of evidence which says that such things as prayer would be helpful to people.

Now, I’m not trying to take away from your point about, you know, the availability of options. Nobody should ever force something down somebody’s throat. If that’s your argument, that’s one issue. I don’t think you necessarily have to have an underlying assumption that AA has no place in the process. That’s all I’m saying.

I. Bushfield: Well, as I said, an individual is free to choose their own recovery path, and most AA groups are small church basement-run organizations that don’t require provincial grants. But if an addictions doctor is going to recommend treatment programs, he or she should be listing secular alternatives as well and not just 12-step by the default, which is the case right now.

D. Plecas: Right. But I’m not sure of a single program on the planet with AA, because I think it’s your fundamental assumption that they don’t take government funds…. I don’t think there are government funds anywhere for AA. Governments don’t fund AA, and AA, as a matter of practice, doesn’t ask for it.

I. Bushfield: Although when there are treatment facilities that individuals are being funded to go to, and those are based on 12 steps, they are receiving tax dollars. When they receive grants, they receive public funds.

It’s not that little prayer group that’s receiving public funds. It’s that the….

D. Plecas: Well, then, I guess my point is…. I was only saying there’s a point, as we’ve heard from others here…. When we look at the continuum of what’s required to be helpful to somebody with a substance abuse issue, I’m saying there may be a place along that continuum. And in the case of AA, for the most part, it’s that continuum of support as somebody has gone through treatment and is in recovery.

I. Bushfield: I’m arguing it’s on the onus of the individual to choose that and not to have the default recommendation from the government to be a religious option.

J. Darcy (Deputy Chair): If I can just go back to your recommendations. Really, you’re saying that people should have options and should have choice, and there should not be one particular form of recovery program that is forced on people.

J. Darcy (Deputy Chair): In earlier discussions that we’ve had — not so much on recovery programs but on our consultations about building interdisciplinary, team-based care…. We heard from a wide variety of health care providers, for instance. We’ve also had several presentations from First Nations Health Authority, from various clinics or health centres that are very much focused on developing programs that are culturally sensitive and appropriate and that really meet the needs of a particular community — and that it’s not one-size-fits-all.

I think while there may be some dispute about some of the issues in your presentation, I think that core message is one that we certainly….

D. Plecas: Chair, given what you’ve just said, which I agree with completely, it doesn’t match with recommendation No. 1.

J. Darcy (Deputy Chair): No, I referred to 4. I was zeroing in on 4 there — to my esteemed colleague.

I’ll see if there are any other questions. I was just trying to bring us back to what I think is certainly some common ground.

Thank you so much. You’ve really given us something…. I think it’s been a very thought-provoking conversation, and it certainly speaks to the diversity that is our communities and the diversity that is our province and the need for us to recognize that in the programs that people have access to.

H. West: Thank you, and good afternoon, everyone. It’s my privilege to be able to speak to you this afternoon. I have a couple of projects that I’m very excited to present to you. So hopefully, something that you’ll be interested in.

The first thing I’d like to do is provide you just a minute, if you don’t mind, to tell you a little bit about our company, since some of you might not be familiar with us.
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Also, to talk to you primarily about two different initiatives that we feel would really help to improve health and health services but also enhance patient care, enhance or improve the value of pharmacists and also decrease drug spending, particularly in rural B.C.

I do have a relatively content-rich presentation, so what I’d like to do is just skim through that, if you don’t mind. Leave lots of time for questions and answers.

H. West: Perfect. So you’ve got the deck in any event, and we’ll go from there. Excellent.

In the 30-second elevator speech, I’ll tell you who we are. My name is Heather West. I’m the national director of market access and government relations for Apotex. Apotex is a $2 billion a year sales company that is, believe it or not, Canadian-owned, privately held and in our 42nd year of business.

We are Canada’s largest pharmaceutical company. About one out of every five products that are dispensed in Canada are dispensed with an Apotex product.

You might think of us or know of us as a generic pharmaceutical company, but I think it’s important, particularly in today’s discussion, for you to know that we are also an innovative company. We’re a company that wears many hats. We spend more on R-and-D spending than all generic brand pharmaceutical companies alike.

We also own a number of patents. As you can see, some 179 active, innovative patents for our business.

We are a fully integrated company. We do most things…. About 90 percent of everything that we do is done right here in Canada. We have four primary arms to our company, the first of which is in raw materials development through Apotex Pharmachem.

Apotex Inc., of course, is the generic development company of our business. Apobiologix is a new division of our company involved in subsequent entry biologic or biosimilar medications. We just launched our first biosimilar medication to Amgen’s Neupogen this year. ApoPharma is our innovative discovery and development arm or, in essence, a brand pharmaceutical company.

The two programs that I have for you today are a generic substitution program…. Primarily, this was a program to increase generic substitution while decreasing overall drug spend and educating around the importance of the sustainability and affordability of our drug programs in Canada.

The other one is really a mobile app. It’s called iPharmacist, but it houses a number of very important tools for pharmacy and allows them to be more productive and efficient in their business.

The first one, the generic substitution program, is a program that has been working in Quebec. It was first introduced to Quebec in 2011. It’s a very active program. We have about 800 pharmacies that are participating in it. It is, in fact, a generic substitution program, but in essence, it is a series of reports that allow the province or the pharmacist to measure and benchmark their activities versus the norm.

The reports can be passive, or they can be really targeted so that you can take a look at any kind of level that you want to, to find out things that are very specific to the market — you can look right at a pharmacy; you can look at a product — again, trying to drive the lowest-cost dispensing out of the system and also educating at the same time.

I brought with me three examples of reports. I’ll go through them — again, very quickly. The first one here is an example of an actual pharmacy’s dispensing behaviour. To protect the innocent, I won’t tell you who it is, but it is a B.C. pharmacy.

You can see from the pharmacy that the generic purchases, or the number, as a percentage, of times that they dispense a generic drug in this pharmacy, is about 67.5 percent of the time. But the B.C. provincial average is about 71.7 percent of the time, so for this particular pharmacy, we would know that they are dispensing more higher-cost brand-name drugs than the lower-cost generic equivalent. So lots of room — about 4.2 percent — for growth out of this particular pharmacy.

You might ask: why is that important? It doesn’t sound like a lot. Well, it is important to the overall sustainability of the plan. Every 1 percent increase in generic utilization results in about $30 million of savings to the province — again, really important when you think about this particular pharmacy being at about 4.2 percent below the provincial norm.

If we were to take it a step further — and I know we’re all interested in getting the maximum amount of savings that we can — if we looked at the Canadian, or the national average, the Canadian average is about 74.2. So B.C. actually lags behind the national average — so some room for B.C. at large to grow, and certainly, this pharmacy more so.

If B.C. were to engage in a concerted effort to increase generic utilization, they would see savings annually of about $75 million. Again, it’s a great opportunity to look at these programs and to try to drive some improved behaviour from them. If we look at the U.S. — and I know it’s certainly out of the scope of this project — the U.S. is actually at a 88 percent generic utilization rate. If we did that in B.C. and every pharmacy contributed, then it would be about a half a billion dollars of annual savings.

I mentioned earlier that you can take these reports and you can tailor them or you can target them. In this particular case, I thought it was just really important to note that in the case of new generic launches, products that have just launched recently, sometimes a generic utilization rate isn’t what it should be. Sometimes that’s simply
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because of a lack of education or knowledge about the potential savings or even that the products have launched.

I just took three recent launches. You can see in the first one, with Tecta, we only have about a 10 percent generic fill rate. In other words, 90 percent of the time, although there is an interchangeable generic alternative, the brand is still being dispensed. You can see from that product alone that we have about $11½ million of potential savings that could happen if those drugs were being dispensed with a generic alternative. Again, it’s important to note that.

This also creates a great report card for pharmacies to benchmark themselves against their own provincial norm, against the larger community or whatever criteria you establish.

The second opportunity — so moving away from the first one — is actually a mobile app. We call it iPharmacist. It was developed a few years ago, really as an information or communication tool. This is simply an app. It houses about 30 different resource materials for pharmacy. Some of these materials are very important to their practice. We’ll get into that in a minute.

Most importantly, the pharmacists that use the program…. There are about 1,500 of them in Canada — I think a couple of hundred of them, in any event, in B.C. currently but not in the majority of the rural B.C. areas. This program actually has, as I say, communication tools and materials that assist pharmacists to be more effective and efficient in their day-to-day activity, saving them time and allowing them to reinvest that time in patient services.

In the clinical reference guides for the iPharmacist program…. There are nine different references that are mandatory to be in a pharmacy according to the B.C. College of Pharmacists. Our program offers six of those nine in addition to…. Well, there are 30 or so of them in total. If a pharmacy was to buy these individual references versus subscribing to the iPharmacist program, they would save about $1,300 in the program versus paying for them individually. That’s a great savings for the pharmacist.

Also, it gives them a lot of tools that they don’t readily have available. In particular, in retail areas where they don’t have the head office and the urban services available, this program will assist rural pharmacy to find out if there have been legislative changes or regulatory changes to the drug program. It also houses a number of programs and services to assist patients to improve their health overall, such as smoking cessation tools. There are diabetes management tools. There are all sorts of assistive aids — how to use your inhaler. There is really a host of them. So it’s a great opportunity for rural pharmacists to be educated outside of the urban communities.

The other thing is it does provide B.C. the opportunity to customize materials specific to the B.C. rural market or to the B.C. market at large. So if there was something that you wanted to push out to the pharmacy community, this would be a great way to do that.

As far as the opportunity for this program goes, there are 28 rural communities as such — certainly a number more pharmacies than that — that don’t have anybody using this program right now. As I mentioned earlier, it is being used in B.C. but primarily not in the rural communities. So a great opportunity for them. What we would propose with this particular program is that we provide the application to those rural pharmacies and also, again, partner with you to upload any information that you would want to push out to those pharmacies.

In summary…. I’m trying to talk really quickly to get my presentation in, in under 15 minutes. The one thing that I wanted to note, going back to the first program, is that the pharmacists that have been involved in the generic substitution program have seen, on average, a 6 percent increase in the generic fill rate. Of course, we know what that means — every 1 percent delivering about $30 million of savings to B.C. If we were to take that Quebec number and assert it to B.C., it would be about $180 million of savings to the system. So again, I think a really great education opportunity.

It does allow for any type of scaled-down reporting that you want. It also provides education, whether it’s at the patient or consumer level, whether it’s training the pharmacists. It also, specifically in rural B.C., would allow you to have them be actively engaged in driving savings.

The iPharmacist program. Well, we’ve just chatted about it. It really is an outreach program. It’s a communication tool and what we would see as an opportunity to partner with you to deliver that tool to people who don’t already have access to it.

That’s really what I came, in a nutshell, to talk about today, and I’m open to any questions that you have.

D. Plecas: Thank you very much for your presentation. Wow. You’re talking about saving us a lot of money potentially. Hello? What’s the stall? Is there a reason why we’re not doing this, from your experience?

H. West: Well, I think there are a number of things at play. I think that physicians are still largely influenced by brand-name manufacturers. There is still a lot more brand-name prescribing than needs to be the case. I think there’s education — honestly, all across Canada at the physician level — that would be required to make sure that they’re aware and accountable for the potential savings that the system can derive.

I think our Canadian system, unlike some systems in Europe, for example, is not necessarily as tied to accountability when it comes to prescribing. I think we could do a better job educating there, for sure. I think that patients, particularly in some communities, have a great prefer-
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ence for branded medications over generics, so we see an awful lot of that as well.

I think, frankly — if I can skip over to the private drug plans — the private drug plans have a different set of rules altogether. They are largely looking at employee retention, and they look at this more as a tool to get and retain good talent, versus what it means to the sustainability of our drug systems overall. I think there are a lot of mixed messages.

As a result of that, I think we’re just not doing as well as we could be — all of us. Whether we’re a consumer, a prescriber, a dispenser or a payer, I think we could all do a better job of making sure that we’re getting the maximum value from our drug programs.

D. Plecas: I’m just wondering, basically, what you do. You’re in the business of providing cheaper drugs for people. Who could possibly disagree with that? You’re big in Canada; Canada is your home. What about other countries? Why wouldn’t they be doing this as well, or do they?

H. West: Well, I think a lot of different countries have different methods of doing that. In England, for example, drugs are tendered to get the lowest-cost alternative, and physicians are also incented through a budget. So we’ve got that going on. In the U.S., of course, it’s driven through the health maintenance organizations, and again, they have a mandatory formulary. There are a lot of different things that are being done in different countries. In our country, we do lag behind most of the industrialized countries in generic utilization.

D. Bing: Thanks for your presentation. I was wondering, first of all, about the percentage of original versus generic drugs that you manufacture. What is the policy? It’s sort of like a copyright when a company produces an original drug. They have so many years of exclusive right to it. Then after that, other companies can copy it and make a generic drug. Is that how it works?

H. West: Yeah. Those are two really big questions. I’ll tackle the first one first, if you don’t mind. That is to say that there are generic drugs available in the Canadian market for about 80 percent of the drugs that are branded. So there would be an interchangeable drug about eight out of every ten times. Of course, the newer medications are still patent-protected, so they wouldn’t have generic alternatives, but there are therapeutic alternatives to those medications that usually would have a similar medical outcome. Specifically, though, direct, interchangeable drugs — about eight out of every ten would have a generic alternative.

Now, the process of getting a generic drug to the Canadian market is very complex, and it’s unique to Canada. We’re the only country in the world that has what’s called a dual-litigation system.

For example, let’s say that our company wanted to challenge a patent because we didn’t think that it was valid or whatever — new, innovative and useful. We would take that challenge to court. If we were successful in proving that the patent wasn’t valid, we would be given a notice of compliance, which is the marketing rights to bring our product to Canada. That’s all done within the patented medicines (notice of compliance) regulatory system. Then we would launch.

During that time, we’d launch at a lower price from the brand-name drug. Lo and behold, any time up to two years later, the brand company can sue us again, not in the patented medicines court this time but in the regular court, where Coke and Pepsi and BlackBerry and Samsung would fight. The process kind of starts all over again. The issue is that if you lose in that second court, you have to pay back all of the brand company’s lost sales from the date that you marketed to the date that you’re found to have infringed.

So it’s a very difficult process in Canada to bring drugs to market. Oftentimes, however — about a third of the time, at least — drugs are litigated. Generic drugs litigate against the brand company to bring the products to market. In other cases, of course, they wait until the patents expire. Of course, that means that there’s a period of time when there aren’t any savings incurred, but in some cases, you can incur tens of millions of dollars by litigating and bringing patents to market many years earlier.

Thank you for your presentation. You rightly pointed out that Canada is behind many, many other jurisdictions in our use of generic versus brand-name drugs, at huge costs to our public health care as well as to individuals. I wonder if you take a position. I certainly find your arguments on that score very compelling.

There are many people, including myself and others, who would argue that in addition to doing that — making greater use of generics — we also need to be looking at a national PharmaCare program so that we are in a position not just to reduce costs to public health care but to reduce the costs that individuals who don’t have coverage pay. Because there are people with good plans that cover just about anything, and then there are people who….

If you’re very, very poor, you get coverage — not great — and there are a lot of people who don’t qualify for subsidies, who make choices every day about which prescription drug to take because they can’t afford to take both, are month by month. I wonder if that’s something that your company is also supportive of or advocating for.
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H. West: Well, we are very supportive of affordable medications for all Canadians. It’s something that, by virtue of our business, we do provide. I can say national PharmaCare…. Although I have no definition for that as of this minute, we definitely, again, support that. We don’t think that somebody shouldn’t move to B.C. to get better cancer care than they would have if they lived in Ontario, and we don’t think that anybody in Canada should be uninsured or under-insured. So that’s absolutely where we fall on that argument.

The other thing that I would say is that we are active in the negotiations with the Council of the Federation as far as providing transparent generic drug prices — worldwide standard pricing. So I would agree with your comments.

J. Darcy (Deputy Chair): Thanks. You did the comparison with Quebec, where you said that by using this particular model, there were 6 percent lower costs for pharmaceuticals. Do you have those stats for other provinces? Do you have them for other jurisdictions around the world as well?

H. West: This particular program has only been piloted and implemented in Quebec. It’s been working since 2011, but we only have those figures. It was a 6 percent increase in generic utilization through the program, so not a correlating 6 percent decrease in drug spend but a 6 percent increase in generic utilization.

S. Robinson: As I heard you speak some more in answering questions, it sort of spurred this other question. In Quebec, which is also a lot of rural, so they’ve got some major centres…. Have you noticed the drug utilization rates shift between rural and urban in terms of who…? Did groups come up? Are you able to do that analysis?

H. West: You know, it’s interesting, because I didn’t really know what the definition of rural versus urban meant, except for the obvious, what you think in your mind. We did a whole lot of research on that in B.C. to come ready for this presentation, but we haven’t looked at that. But, again, through this program, because it’s tailored, you can take it right down to the pharmacy level. You could look at various communities and find out how they relate to their urban counterparts or the province at large or even to other provinces.

The program that we run is adjudicated through Telus Health. It’s obviously a national pharmacy benefit manager and adjudication engine.

Welcome to our presenters, Rosemary Pawliuk and Praveen Vohora from the Society for Canadians Studying Medicine Abroad. You have 15 minutes to make your presentation and 15 minutes for questions. If you go longer presenting, we’ll have less time for questions, but we’re looking forward to hearing from you.

P. Vohora: Thank you. Good afternoon. We don’t have any special tools, like slide shows or anything like that, so it’ll just be plain old me speaking up here. We’re just going to address the one question about physicians in rural areas. That’s the question we’re just going to try and address and will not address the other issues that you have on your committee.

Basically, we are a non-profit society under the Society Act of British Columbia. We were created on August 17, 2010. The primary goal of our society is to support Canadians studying abroad in their struggle to access postgraduate training in Canada — so when the students return, for them to be able to get residencies. We are concerned that there is negative stereotyping and prejudice, with undue barriers being placed that hinder and prevent CSAs from accessing postgraduate medical training in B.C. and other provinces in Canada.

Myself, I’m a chartered accountant. I received my fellowship about two years back, and I’m in practice. I was in practice in Prince Rupert for 30 years, so I’ve been in the northern region. Since then, we’ve branched out, and we have offices here in the Lower Mainland. My son, who went to UNBC, got his BSc and then went on to the Caribbean and has completed all the steps. The steps that they are required to do are the USMLE 1, 2 and 3. He has completed all of those. He has done all the Canadian examinations to be eligible to be in a residency program in Canada.

Rosemary is a lawyer and the president of our association. Rosemary’s daughter aspired to being a surgeon. There is no access to training — for Canadians who choose to study overseas — in surgery in B.C., so she’s currently training in the U.S.

Myself, in my practice, I had many clients who’ve practised medicine — so physicians and specialists, some of them originating from South Africa and so on — as clients of my firm. We also conducted audits of hospitals in the area — the Queen Charlotte–Haida Gwaii hospital, the Hazelton hospital, Bella Bella hospital. These three hospitals are actually run by the United Church.
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Since then, this has become part of the health authority. What’s happened is that the Northern Health Authority looks after the Hazelton hospital and the Queen Charlotte hospital, and then Bella Bella and Bella Coola become part of the coast transitional health authority.

The point that we want to address is about the dire shortage of physicians in our province. We provide an article, listed as appendix A, that was just recently in the Province. It shows as a headline that we’re 667 physicians short in practising family medicine. Sometimes, I know, people sort of say, “Well, there isn’t really a shortage” — that it’s only a shortage, maybe, in the northern communities — but I think there is a real shortage all around the province.

When there’s a shortage in the Lower Mainland, then what happens is that the physicians find it easier to move and fill in these vacancies. There’s an attraction for them to move out from there. The reason why they will do that is that sometimes in the rural communities, they find it stressful. Because they’re the only ones practising, they have to attend to all kinds of emergencies and so on.

What we found is that people that have grown up in the smaller communities have a stronger commitment to these smaller centres. It’s more likely that they will stay and practise in the community that they’ve grown up in.

Of the ten different South African physicians that moved to Prince Rupert, only four of them remain now. Six of them have moved away. The four that remain, if you look at their background, came from smaller communities within South Africa, and they like that lifestyle. They like the outdoorsy lifestyle. That’s the reason why they have settled in well. The ones that have moved have moved for the same reason. They came from the larger communities. The first chance they got to move to the big cities, that’s where they moved to.

Just as a comparison, to give you a little bit of background…. In my accounting practice, what I found is that when I first started, in those days, there was no UNBC. What we were doing was attracting staff from the Lower Mainland. The minute there was a shortage in the Lower Mainland, all these staff would move, and we would have real difficulty in retaining staff because of the fact that they didn’t come from the community.

As soon as UNBC opened up, we realized that one of the things for us to do was to, firstly, set up some sort of scholarship program within the two high schools. We would provide a scholarship to the high school students to get into the commerce program. That way, they were from Prince Rupert. They would then go into a university, whether it was UNBC or UBC or SFU, and they would then come back to Prince Rupert after they’d received their commerce. This is where we found that retention improved a lot, as long as we attracted students from the local community.

The second part that we learned was that it’s always…. You think you need two students in the year, but we would actually then hire three, because we knew that at some point, there was always going to be attrition. Somebody is going to want to move. That way we made sure that we had at least two students here.

Based on some of these experiences, what we’re doing is actually making some recommendations here about how we can retain physicians in the rural communities. In the recommendations that I’ve listed here, I think the very first one — I don’t know if you’re aware — said that there’s a real disconnect in the process of how residency positions are selected.

UBC selects the positions, and they may or may not receive input from the community or understand the needs of the community. This is — just using an example — just like an accounting association selecting articling students for KPMG. I mean, it sounds ridiculous, but that’s essentially what it boils down to — the way the process is.

What we’re saying is: involve the communities to identify and promote students within their community to start a career in medicine. There should be programs available for these students to access assistance, financially, and career advice so they can choose their field of study.

When we converted to the health authorities, we took away the local hospital boards that were locally manned. Now there’s a larger health authority, and it’s impractical to have each community have a representative on the health authority. But what we’re suggesting again is, perhaps, having some kind of local chapter where they would provide some recommendations back to the health authority.

The next one we’re recommending is to increase the number of residency positions. Really, supply and demand is something that’s very hard to tell. What is the need going to be in two years time or three years time?

There should always be a bigger number of residency positions so that we do supply trained physicians to the community, not only just for natural population growth. We also are all aging. Then there are physicians retiring, or so on, right? This really will provide some assistance in reducing the shortages.

I think the general fear has been that if we oversupply, it would actually bring down the incomes of the doctors. I really believe that if you take any other profession, that does not happen, right? Market forces just take over. People go into something because they believe that they’ll be able to earn enough money in that profession.

You look at dental services. Everybody does well, and everybody feels happy. Nobody’s complaining that they don’t have a dentist to go to.

In appendix B, which we have provided, there’s a study done looking at CMGs — that’s the Canadian medical graduates — looking at Canadians studying abroad and looking at international medical graduates. Basically, the study, when you go through it, concludes that there’s a
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higher likelihood that you would have the CSAs move and stay in the local community, and for a longer period than CMGs that have gone to the northern communities, because they’re likely to move back to their place of residence.

In the case of the IMGs, generally what happens is that they will move to where there’s a larger group of their own ethnic background’s people. That’s where they feel comfortable living.

The next point that we raise is that a lot of times, students from the smaller communities are hampered by the fact that their resumé is not exactly Ivy League. They’re not from the schools or so on — to try and get admission — so they move to the outside communities to get the training. I don’t think they are any worse as students just because they didn’t get a position in UBC. I think they’re just as clever or just as capable. It’s just that they didn’t have the opportunity.

What I’m trying to say is that we look at the Canadian fabric and we see different people from different countries providing services. Myself, I was born in Africa, received my chartered accountancy in England, and I’m practising here. There is that mobility, and I don’t think there should be that bias or the prejudice that these people that get training from overseas should be restricted in some manner.

I believe that as long as they’ve passed the exams, demonstrated that they have passed the local exams, then they should be given an equal opportunity for every residency as compared to somebody who has just come out of UBC. Right now that’s not the case.

Then, essentially, the last point that we raise is that underserviced areas should be allowed or be part of the process to select some of these residencies. They should be able to have some input, because there is the higher likelihood that once they interview — and also see the fact that the person has the proper background — they will stay in that community. They would be part of the community. Essentially, our conclusion is that if the community is allowed to participate in the process, then I think we will have better services in those communities.

R. Pawliuk: I just wanted to emphasize a couple of things that Praveen has said. First of all, I just want to make sure, because we used acronyms…. IMG is an international medical graduate. There are two types: the Canadian who chose to study abroad and then also the immigrant physicians. A CMG is a person who studied in a Canadian or American medical school.

A couple of things that I’d also like to underscore in terms of…. It’s about economics. We should all be very concerned about economics, considering the substantial portion that health care takes in our budget. There are a few things that we could learn from other jurisdictions. One of the things is that the Ministry of Health often talks about not being able to afford more resident physicians. Praveen was telling from an economic point of view, and Praveen is an expert in that field. That’s why he’s been speaking today.

Resident physicians are workers. What they do in hospital is they provide services that a physician must provide. Those services cannot be provided by a nurse or by a physician aide or somebody else. To do the services that they do, you need a medical degree. The amount that is paid to a resident physician — in first year, they are paid $50,000. I’m rounding off, but in British Columbia it goes up by about $5,000 for each year that they’re in residency.

By the time they’re in their third or fourth year, depending on the area, it’s hard to distinguish between somebody who’s fully licensed in what they do, and what a resident physician does. They work approximately 80 hours per week. Physicians in the field have advised me that in order to replace a resident physician, you would need two fully licensed…. Maybe one and three quarters, because there are some inefficiencies, or maybe one and a half. You would definitely need more than one to replace — if you got rid of resident physicians.

The average physician who’s licensed, at the low end, is in the $300,000 per year range. The point that I’m trying to underscore here about what Praveen said is that it makes no sense not to increase the number of resident physicians.

That’s what the United States does. What they do is they have a program, the J-1 program, where they invite the rest of the world to come and do the work, because it’s economical. Yet we in British Columbia and the rest of Canada have this idea that we’d better keep the number of physicians low because that’s going to save us health care costs.

There are a number of economic studies that demonstrate that that is not the case. I don’t say: “Hey, hon. You know, I’ve got nothing else to do today. What do you think? We’re going to go and see the doctor. What do you say about that?” I mean, it’s a fixed-need thing. You go because you need to go, not because there is an excessive supply of physicians.

At any rate, the point that I’m trying to make here is that the concept of not providing more resident physician positions is an economically poor decision and the concept of keeping Canadians who are educated as medical doctors out of British Columbia and out of Canada is really very unwise from an economics point of view.

The cost of graduating…. We subsidize, in B.C., a UBC medical student to the tune of $400,000 per person. That’s what it costs us, and 57 percent of UBC graduates in 2015 have stayed in British Columbia. The rest have left to go elsewhere. We have a retention rate of 57 percent — 288 graduates. We’re talking millions and millions of dollars.

The irony is that Canadians who study abroad — who get their degrees and pay for their own degrees — in or-
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der to come back to get residency training, have to sign a return-of-service contract, which is rather unusual. Without the taxpayer investing in the Canadian who studied abroad, they cannot access a benefit of the province without paying for it through servitude. Yet a person who we have paid $400,000 for has no obligation whatsoever.

It doesn’t make sense. This thing needs to be overhauled. At any rate, that’s the extent of it.

Who would like to start? Well, I will then. I don’t see any other hands just yet.

We heard…. I’m trying to remember. This is our sixth day of hearings so I don’t quite remember which day, but we heard from the College of Physicians and Surgeons of British Columbia. One of the questions that we asked them — because we certainly all hear from these folks in our constituencies, in our various roles — was on international medical graduates who talked about the barriers to them, in being able to gain residency spots or to be able to practise in Canada or to have their qualifications recognized.

They referred to…. I don’t remember the number. I think it might have been 32 countries. They gave a figure — countries that they believed had comparable credentialing as far as physicians. They talked about that being the first hurdle — the recognition of the medical education in those other countries. Then, in addition to that, it was that there was pretty fierce competition for a very limited number of residencies, which you have spoken of.

I wonder if you can speak to that first issue. That was sort of their starting point — ensuring that the training that people have gained abroad is comparable.

P. Vohora: When I was on the council for the chartered accountants, one of the challenges we felt we came across was the fact that we had all these international students coming in or people who had done chartered accountancy overseas, and there was a limitation. We would say: “Are you really trained to be able to practise chartered accountancy here?”

Under this labour mobility thing, we created what we call a CARE exam. As long as the person passed the CARE exam [audio interrupted] exams that CMGs or the UBC students write. They all pass the same exam, but there’s a difference in the sense that although you say there are so many residency positions, it’s not an open-residency position. Firstly, the CMG is given preference, as compared to the overseas.

When I hear talk about the fact that maybe these people are not trained, I’m never proposing that we allow untrained people to practise. No, I’m not saying that. I’m saying: as long as these people have demonstrated to us that they’re capable, then why have this additional door that you’re going to block? Let’s have an open competition. If their education is so superior, they should win, hands down, compared to somebody coming from overseas. Really, why not keep it open?

R. Pawliuk: Originally, there was difficulty showing equivalency, or substantial equivalency, and the Medical Council of Canada, some years ago, developed a medical knowledge exam. It’s called the MCCEE. If you pass it, that establishes that you have the medical knowledge of a Canadian medical school graduate.

In 2010, in the push for access — and also in the push for global education — the NAC OSCE was developed and made available through the Medical Council of Canada. What the NAC OSCE is, is a clinical exam. That was the shortfall, because people could have the knowledge, but they don’t have the clinical knowledge to be able to practise effectively. You need the two in order to practise medicine.

As of 2010, the NAC OSCE was available, to prove. The NAC OSCE states that if you pass this exam, you have demonstrated that you have the clinical skills and clinical knowledge that is equivalent to Canadian medical school graduates.

So as of 2010, we have the tools, simply by…. This isn’t a paper-and-pencil exam; it’s an exam where you have actors and people…. As of 2010, there is no longer an issue in respect to proving equivalency.

What we simply have is a protectionist policy. In 1993, interning was abolished, and that put residency selection in the hands of the universities. The first thing that the universities did in 1993 was make a move to protect their graduates, so they made rules that basically prevented international medical graduates from competing against their graduates. Now, that is different from every….

At this particular time, there is no other profession that prevents people who have established substantial equivalency from accessing post-graduate training. In all other professions, it’s all based on who’s the best man for the job. In medicine, that is not the case. It is not a matter of who’s the best man for the job; it’s a matter of….

R. Pawliuk: Or woman. In my world, man, woman…. But yes. The point is that in….

J. Darcy (Deputy Chair): I think there are more women graduating these days than men, from med school.

R. Pawliuk: Actually, that’s very true. Sixty-three percent of CMGs, according to the study, are women.
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But the point that I’m trying to make is that we have, by some maneuvering, now, the academics, rather than the College of Physicians and Surgeons and rather than the people who are doing the hiring, determining who will be hired. So a British Columbian who is a Rhodes Scholar cannot come back to British Columbia. If he wants to be anything except a family doctor, pediatrician, psychiatrist or internal medicine, he can’t come home.

People get very hurt, so when you read these things about people not wanting to come — you know, with our doctor shortage…. They feel rejected by our country. Everything we’ve ever learned in school is equality, equal opportunity, those kinds of things. It’s a very difficult thing for people to be pushed away. Then we say: “Well, come on back home.” Well, they don’t want to come back home after they’ve been pushed away and found another route.

D. Bing: Thanks for your presentation. In defence of the College of Physicians and Surgeons, of course, their main mandate is the protection of the public and not the protection of graduates.

This is something that, unfortunately, from past history, may have biased their feelings, in that the complaints that they received in the past were more often foreign graduates. This may have biased them a little bit in terms of how they look at the qualifications of foreign graduates versus ones trained in British Columbia and in Canada.

Of course, I think MLA Robinson mentioned that there are 30 countries that are considered equivalent. They’re basically the Commonwealth countries, the United States. There are certain, I’m sure….

R. Pawliuk: The same places CSAs all study. But I would like to address that, Dr. Bing, in that the College of Physicians and Surgeons has a definite duty to protect the public — absolutely, no doubt about it. They also have a duty to ensure that when there are restricted positions, the best candidates get that job. They have fallen down on that responsibility, in my opinion.

They’ve fallen down in two ways: one, by exclusion of Canadian and immigrant physicians who have not got their degrees in Canada or the United States. More importantly, where they have fallen down….

As a lawyer, I can tell you that where a lot of these complaints come from is a totally different area. That is what we call visa students or visa residents. What has happened is that UBC and other universities in Canada sell residency positions, whereas everybody else who wants to be a resident physician must prove that they have the knowledge of a Canadian medical school graduate by taking the MCCEE and the NAC OSCE.

Resident physicians from the Middle East countries, primarily Saudi Arabia, are and have been for years and years exempted from taking those exams, and that exemption comes from the College of Physicians and Surgeons.

How they get that exemption is because they pay $75,000 to get residency training, whereas UBC only gets about $20,000 to $30,000 for training a Canadian medical school graduate, an international medical graduate or a Canadian who studied abroad. So the College of Physicians and Surgeons is not looking after the public, in my respectful submission.

P. Vohora: I think the public interest is to make sure the service is available, that the public is being served so that when I want to see a doctor, I should be able to get to see my doctor.

My executive assistant moved to Prince George. It’s now been nine months. She still does not have a physician. She still has to come back to the physician here. How is the public interest being served?

If you’re going to limit people because it’s going to make sure the income of the physician is being looked after, that’s serving your own interest. It is not serving the public interest. I think that that’s the disservice the college is doing.

D. Bing: That’s one of the things I don’t agree with. I don’t think that they’re looking at the interests of their incomes. I think they’re looking at the interests of protecting the public. They’re guaranteeing that if this person is there advertising their services, they are qualified to provide the services to a Canadian standard.

P. Vohora: I think the point that we were making is that they wrote these Canadian exams, just the same as a UBC graduate. When they come out, they have to write the same exam. If they pass the exam, then what is the restriction?

D. Bing: Well, I think that you’ve made a slur upon the profession in the sense that you just said that they’re doing this for monetary reasons. I don’t think that’s the reason.

P. Vohora: Yeah, but at the same time, you have to listen to what we are also saying in the sense that there is a bias here. There is something that is not right with the system — if you’re interested to know that. If you’re not interested, I’m sorry.

D. Bing: Well, I respect your opinion. I just don’t agree with it, that’s all.

P. Vohora: But you do agree with me on the fact that they do write the same exam? You do agree with that?

R. Pawliuk: They don’t write exactly the same exam. Basically, the MCCEE and the NAC OSCE are designed to determine substantial equivalents.

Dr. Bing, in respect to controlling the numbers, I certainly am not going to allege that the College of Physicians and Surgeons is trying to control the numbers because I don’t have an evidentiary basis for that. But I do know that the provinces are trying to control the numbers.

They’re not only trying to control the numbers in terms of access to residency in British Columbia and other provinces; they are also trying to put barriers to prevent Canadians from training in the United States. As of 2016, they have put huge barriers to prevent Canadians to do their residency training in the United States.

I can talk to you about that aspect of it, but there certainly is a lot of evidence that demonstrates that there are forces in our province that are geared towards controlling the number of physicians. Again, I can provide you with the evidence. Whether that rests at the footstep of the college, I’m not going to make that allegation.

The allegation that I will make is that the college is not protecting the interests of the public. It allows the system, which is protectionist, to be in place so that the best-qualified person is not allowed to compete in residency competition. If the college was concerned in respect to the best-quality position, it would be an open position for whoever has met and proven that they have the knowledge and clinical skills of a medical school graduate from Canada.

There is no defending what they do with visa residents, where they allow UBC to sell access to…. In the freedom-of-information requests that I’ve done, Dr. Bing, I have seen letters from the college complaining about the fact that these visa students are causing a substantial number of complaints, and there are issues with them.

It is very difficult when the college says to you that there’s a problem with IMGs, because there are several kinds of IMGs. One of them is a CSA, and one of them is an immigrant physician. Another one of them, where there is a substantial number of complaints, is visa students from Saudi Arabia who buy their way in without doing the equivalency exams.

I do note — and I see it’s in the attachment to your package here — that the newly elected president of Doctors of B.C. has identified this issue as one of the challenges that he wants to work on. Certainly, while people have raised questions of various sorts, I think we also recognize that there are some significant barriers that we need to look at in order to ensure that more British Columbians have access to a family practitioner and that people are genuinely able to compete on the basis of their qualifications and not on any other basis.

R. Pawliuk: Thank you. And thank you, Dr. Bing, for raising that issue. It’s a really important one — about public interest. Very important.

J. Darcy (Deputy Chair): Welcome, Joseph Ranallo from the British Columbia Association of Traditional Chinese Medicine and Acupuncture Practitioners. You have 15 minutes and then 15 minutes for questions, hopefully.

J. Ranallo: Thank you for having us here, on behalf of ATCMA. ATCMA is the largest association of traditional Chinese medicine practitioners and acupuncturists. Actually, their office is only a block from here. We would like to become part of the British Columbia health care system.

We’ll start with page 2. Basically, these are my talking notes to make sure that I get in, in 15 minutes, what I think I need to get in there.

While the basic concepts of traditional Chinese medicine were being formulated in ancient China, inhabitants of the planet Earth were constructing impressive projects such as the pyramids, which are in the news a lot these days, Stonehenge and other stone structures, and a variety of other engineering marvels.

The ancient Chinese, who were fully informed about numerology and astronomy, were definitely familiar with the concept of balance, the cornerstone of traditional Chinese medicine. The people who formulated the components of TCM, or traditional Chinese medicine, determined that when the big bang happened, the universe’s matter and antimatter collided. As they did so, they destroyed each other in a kind of atomic explosion and became energy. The grapefruit-sized particle of matter that was left untouched ultimately became the current universe in which we live.

The first diagram there shows the matter, the hydrogen atom. The centre part in the first one is the positive. The electron on the outside is the negative. But in the antimatter, the anti-hydrogen, the outside is positive and the inside is negative, and when these two bodies come together, most of the antimatter disappeared with a big bang. But when they come together, they destroy each other and convert from matter to energy, which is one of the things that led to the E=mc².

According to — this is getting into a bit of mythology — the he tu, the Yellow River diagram that appeared on the body of a horse with a dragon’s head which was spotted near the Yellow River, the energy released by the big bang formed the five elements, a critical component of traditional Chinese medicine. The current belief is that the same energy is still circulating our universe today. It
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enters the bodies of both humans and animals under five distinct categories that are connected to specific organs.

When I was reading my material over on the plane, I noticed that I had missed an editing. Wood and wind are very related, but wood is connected to the liver and gallbladder. Fire is connected to heart, small intestine, pericardium and something we don’t consider an organ here, but the Chinese do. That is the cavity, the upper and lower cavity — the abdominal and upper cavity. The earth, which is one of the five elements, is connected to the spleen and stomach. The metal is connected to the lungs and the large intestine, and the water is connected to the kidneys and bladder.

To the right, a diagram, is what we frequently see as the five elements that move into waves. As the energy circulates the universe, the five elements continually fluctuate from strong to weak. To my patients, I like to explain it’s a bit like when a snake is swallowing a mouse. When the mouse is in its mouth, the head area is strong, but the tail end is weak. As the mouse moves closer to the tail end, the parts of the body change.

As we draw in our initial breath after our umbilical cord is severed, we breathe in the universal pattern of strengths and weaknesses. In most cases, we usually inhale three strong elements and two weak ones. Then we spend the remainder of our lives compensating for the weakness we have inhaled.

In our modern day, along with other tools, traditional Chinese medicine uses the following utensils or tools — whatever we want to call them — to treat, and there are others. At the bottom of the page, there is an electronic device on the Internet that’s called Visionware, and it’s a very useful device. It can help us to identify the strengths and weaknesses of the universal energy we inherited with our first breath.

It doesn’t happen at the moment of birth. It happens when the umbilical cord is severed, because at that point, we’re no longer part of our mother’s system, and we become our own. Whatever we breathe in at that time affects us for the rest of our life.

To access this information, we only need to provide two simple details: our birthdate — and we don’t have to provide the time, just the day and the year and the month — and the number of the time zone we were born in. This information can provide us with a starting point to calculate the current organ imbalance of the addiction patients and every other kind of patient as well. It can also give us a partial start in the development of a healing protocol.

This data can assist us — all healing modalities — to develop their unique healing strategies. It’s not limited only to traditional Chinese medicine.

The Visionware has another useful device in it. It can help us to identify which acupoints — every two hours these change — connect us with the original energy of our first breath.

That is interesting when you look at the patients, because even though many years have gone by, we are affected by what we breathe in with our first breaths. Once we balance a person, we have to try and keep that person balanced. In traditional Chinese medicine, there are three things that can take us out of balance.

One — and this is a good time of year to talk about it — is weather related. If we feel too hot or too cold, we don’t feel a total balance. If we feel too damp or too dry, we don’t feel a balance. If we are overwhelmed by wind…. A good example of a wind is fibromyalgia, where the pain one day hurts here, another day goes somewhere else, and it continues to do that. So that’s number one — weather related.

The second one — our emotional imbalances that can happen when we are too angry. That’s a wood and liver issue.

J. Ranallo: I worked with a person who was so joyful — and it’s wonderful — that I’d go home exhausted every day because the overwhelming joy has taken the people around out of balance. We all know, when we’re at a party, someone walks in, and the party just booms. Another person walks in, and it dies. This is part of that energy.

Too pensive — that’s earth and spleen. This happens often at night when we are trying to go to sleep. We just turn the light out, and all of a sudden, we begin to think: “Gee, did I turn off…? Did I lock the basement door? Did I turn off the car?” That is an issue that happens because the earth element and the spleen is overactive at the time.

Too sad or too grieved — metal and lungs. Too frightened — water and kidneys. But the fright here is not the fright of being afraid of a ghost. It’s the fright of making the wrong decision. That can happen in a variety of things. If we’re stopping at a stop light, many of us have probably at some point wondered: “Can I go through? Maybe I shouldn’t, because there may be a police car around the corner.” It’s that kind of frightening.

Although to keep us in good physical, emotional and mental health we need each of our emotions, which are connected to our five elements and to our organs, to do their job properly, the emotions must remain in balance and in proper proportion to each other.

Now, there are all sorts of other causes, and I could use another 15 pages of imbalances, but these are the other things that can happen: infections, accidents, animal bites and so on.

My neighbour, who is an arborist, is very strong. But in the last job that he did, a branch fell on his hand and broke the bones. He’s not the strong person he was three weeks ago, because he has met one of these imbalances.

When necessary, we can use the tools listed on item 5 to regain our balance, at least temporarily.

An addiction can be seen as a condition in which we can only feel totally balanced when we access a specific substance. The addictive substances can include alcohol, nicotine, medicinals, foods and other things. Because we only feel that balance while the substance is within our system, addiction can be viewed as a balance issue. As we lose the balance, the condition worsens. When the substance works its way out of our body, we feel withdrawal symptoms, which can be as disturbing as the addiction itself.

Traditional Chinese medicine provides the most effective cure for issues of imbalance. After all, balance is at the heart of traditional Chinese medicine. Traditional Chinese medicine addresses the balance issue mostly by treating the body organs that have lost their equilibrium. To do so, traditional Chinese medicine has relied on the wrist pulses, which determine which of the organs have fallen out of balance. On both hands, there’s a set of pulses.

During the Han dynasty, 2000 B.C. to 2080, a doctor by the name of Bian Que wrote the Nan Jing, the classic text of pulse analysis. This text — which has been translated into English, under the title of The Classic of Difficulties, by Bob Flaws, 1999, of the Blue Poppy Press — is a critical component of most of today’s B.C.’s traditional Chinese medicine training programs.

The pulses can certainly help us to determine accurately the addictive patient’s organs and their energy imbalances. The pulse analysis, which has been a part of traditional Chinese medicine since inception, has become highly sophisticated in today’s world. China sponsors yearly world-level conferences on the subject. These conferences present the results of the most recent research on the topic. Some practitioners have become so competent that they can almost use the pulses like an MRI to identify the condition of the body. Some of these skilled practitioners are currently practising in B.C. today.

During the past six decades, other practitioners from around the world have developed simpler, more obvious and easier-to-understand strategies to diagnose the organ imbalances. Three of these are: the Korean food packets, which were made by a doctor in Korea in the 1970s. Those packets are so accurate that they actually produce the same vibration as a healthy organ.

The Korean fingers. The same doctor discovered that each of our fingers in our hand corresponds to a specific organ. The thumb corresponds to the liver. The first finger corresponds to the heart. The middle finger corresponds to the spleen. The ring finger corresponds to the lungs, and the small finger corresponds to the kidneys.

Two metals can help here. A coloured metal brings energy to an area. A white metal…. The best of these: the colour is the gold, and the white is a silver. By wearing a ring that is either gold or silver, we can affect the energies by wearing the ring on that specific finger.

It’s kind of an interesting world because in Europe, to be an acupuncturist, you must first of all be a medical doctor. Today in Germany, there are 40,000 doctors of brain medicine who are also acupuncturists. They understand acupuncture in a different way. Those neurologists are skilled in both areas.

These four approaches can make it possible to diagnose the organ imbalance of an addiction patient. This information is critical to the patient’s treatment. The understanding of organ imbalances can do much to enhance the addicted patient’s addiction recovery. Traditional Chinese medicine is currently employed both as a primary and/or complementary modality to treat addiction in the following places.

In Canada, it’s still mostly limited to a traditional Chinese clinic, and that’s the same with all the provinces. But in the U.S., those following states have connections with other medical providers. Europe does the same thing, and so does Asia.

No. 20. Two acupuncture protocols merit special attention when addressing addiction recovery. The first one is called the NADA system. Now, “nada” means “nothing” in Spanish, but it’s not what it means here. It’s the National Acupuncture Detoxification Association.

This system, which works on the ear and was developed in the ’70s, uses the following auricular points to treat addiction: the sympathetic — you see on the little map where it is — calms the nervous system and relaxes the body; shen men, which is in a triangle at the top of the ear, reduces anxiety and reduces nervousness; the kidney calms the body fears; the liver detoxifies the body, purifies the blood and attends to aggression, which is very much a part of an addiction; and the upper and lower lungs.

Because we have two lungs, there are two spots on the ear, and right in between the two lungs is the heart. What the lungs do is they bring oxygen to the various parts of the body. In emotional, they reduce grief and sadness. This is one of the common approaches to the treatment of addiction.

A second one…. I’ve just become interested in this in the last year. There was a doctor by the name of Dr. Tung. He developed a system which uses more than one needle. Each point has at least three needles. Because of the additional needles, each point treats more than one symptom.

For instance, in No. 23, Dr. Tung’s point 12.12.02 — he developed his own numbering system, which is different from the traditional — consists of three needles, approximately four Chinese inches above the navel. Now, the Chinese inch…. What the Chinese do is they look at the individual body as being unique, so the Chinese inch is the thickness of the thumb at the first joint. So if you were to measure your thumb, and you go in the middle of the navel, and you go four of those up, there’s one point right in the middle of the line at the navel, which goes through the navel, and then one on either side.

It is used primarily for drug overdose, but it can also treat the following symptoms as well, which are part of the drug overdose. This approach, which is becoming
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really common now, can help with the addiction by attending to more than one item, because the addiction does include more than one symptom.

No. 25. Many B.C. traditional Chinese medicine practitioners know and use a variety of other approaches to address addiction issues in their own clinics. ACTMA, the association that I represent, is both willing and capable of encouraging its members to share their knowledge and skills and to cooperate with other health care providers to help the B.C. Ministry of Health develop the most effective regimen to address addiction recovery. ACTMA is both willing and prepared to do its share to help make B.C. the healthiest province it can.

It is with this thought in mind that we, as the largest B.C. traditional Chinese medicine association, submit the following recommendation for your consideration: that the standing committee on health care explore the possibility of including the BCTCM profession into the official provincial addiction recovery program.

J. Darcy (Deputy Chair): Thank you so much. I’m afraid we have time only for five minutes of questions.

The one question I have. You must have treated people with addictions. I know people who’ve gone to a person from your profession to get help with quitting smoking, and they’ve actually succeeded. Let us say that somebody sent you 100 patients. What percentage of those would be free from their substance use one year after treatment?

J. Ranallo: Well, a lot depends on the patient himself or herself. When I do get somebody that wants to quit smoking, I ask them: “Come to me when you’ve made the decision that you’re going to smoke the last cigarette, and that’s it. Until you’ve made that decision, the treatment — not only traditional but any treatment — isn’t going to work.”

I’m actually from a small town, and I don’t get that many. I would say that at least 50 percent of the people that are treated for smoking have managed to drop it. The ones that haven’t are the ones that, as I watch them leave my clinic, pull out a cigarette and light it right after — when you can’t get the patient to the point that they’re able to say: “This is going to be my last cigarette. I’m not going to do it again.”

If the patient is in the right frame of mind, I think it would be 100 percent. But my experience is that the people, at least the ones I’ve dealt with who are addicted to smoking, are not prepared. When they come, they’re not prepared to give it up yet.

S. Robinson: It’s actually a little bit more about the B.C. Association of Traditional Chinese Medicine and Acupuncture Practitioners. I don’t know a whole lot about it. I’ve been reading at little bit about in on line. How many members do you have? Is everyone who practises Chinese medicine a member? Is it an optional membership? I’m just trying to understand a little bit about who you’re representing.

J. Ranallo: There are about 2,000 practitioners in B.C., and we have about 400 in our association. It’s voluntary. What we’re looking at is that there are ten other smaller associations. Hopefully, the day will come when we all become one association, because we need more money than we have right now.

I was a teacher before I went into acupuncture. When I left teaching, my dues for the association, which is now a union, were $1,500 a year. We charge $180, and we only have 400. With the teachers, we had 40,000. I chaired a committee of the teachers association where we dealt only with people for whom we had already spent $50,000 on legal fees, helping them out. Now, with $180 a year and 400, we can’t do that. So we’re looking to encourage more people to join us. Does that answer your question?

J. Darcy (Deputy Chair): Thank you so much. I’m afraid we’re at the end of our time for your presentation. Thank you for presenting.

I am, indeed, Paul Farnan. The most important thing about me is I’m married to Mary Louise, and we have five children. I work as a physician. They are the priorities.

I guess just a little bit about me. I’ve been asked if I’m from the Maritimes. I’m not. I’d be very proud to be from the Maritimes. I’m from a smaller island a few thousand miles east of that. I’m from Ireland — born and raised, medical school.

It’s interesting, with your other presenters. I came to Canada temporarily for six months to help out a small town in Saskatchewan who couldn’t find a Canadian physician to go to it.
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In Ireland, I had quite an interest in a lot of things. One area I’d worked in was addictions psychiatry. I couldn’t figure out why people with addiction seemed to get better while they were in our service. They went home and shook our hands and said: “You’ll never see me again.” Then they’d show back up again. I left that residency to come here to do some work and go back. I never went back.

My work in addiction medicine has spread over a lot of areas. It’s from front-line work — where I ended up in Prince George running detox, running a chemical dependency program in the hospital — but very much at the interface of where addiction interacts with occupational medicine. It’s an important area. It’s about safety at work. It also means that we can work harder at helping people, often before they’ve reached the street-entrenched stage of their disease. So I have a lot of different areas of interest.

In amongst all of that, I directed a physician health program, which is a confidential program we have for physicians in B.C. which I’d like to tell you a little bit about. Very difficult to know what to say. You’re very busy people. What can I say to you? Maybe I can bring a little bit of a different perspective on a few things that, perhaps, some other people haven’t spoken to you about.

I wanted to show you this study from 2002 which talked about a missed opportunity, a national survey in the U.S. on primary care physicians and patients on substance abuse. This is one of my pet concerns and worries. The vast majority of primary care physicians — 94 percent in this study — fail to diagnose substance abuse when presented with early symptoms of alcohol abuse in an adult patient. It is not on the radar of my colleagues.

I teach this. If you don’t look like you are street-entrenched, Downtown Eastside, for most of my colleagues, it doesn’t cross their minds to ask. If they look well dressed, like yourselves, no one would…. Why would we even ask what your history was, how you drink? It doesn’t happen.

Forty-one percent of pediatricians in this study failed to diagnose illegal drug abuse when presented with a classic description of a drug-abusing teenage patient. These physicians and pediatricians, when asked to list their five potential diagnoses, didn’t include substance use disorders in their diagnostic formulation.

Most patients said the primary care physician did nothing about their addiction. So 43 percent said the physician never diagnosed it, and 11 percent of people who said that the physician knew about it did nothing about it, often because they didn’t know what to do about it. Less than a third of primary care physicians carefully screened for substance abuse.

I do have some other thoughts closer to home about addiction training in B.C. that I’d like to share with you, but that’s not my only item or concern.

If we really believe that this is a chronic, progressive disease…. And it is. Where I’ve failed over years and where we fail collectively, I think, is we look at this as an acute with the acute model, and we episodically — in and out, and expensively and in a discombobulated, disorganized way — don’t provide care that looks like what chronic care should look like. We focus on emergency room treatment. We focus at the end of the line on very specialized harm-reduction care, but we don’t have a continuum to look at.

If we speak to experts about chronic disease — who know chronic disease, who know diabetes, heart disease, hypertension — they will tell us that what they look at and what they realize and what they accept is that chronic diseases’ causes can be complex. There’s nature, there’s nurture, and there are risk factors. So they’re interested in prevention. These things can take quite a long time to develop. They can become very long and progressive illnesses. Often they can reach a point where they’re very resistant to treatment. They lead to significant functional impairment, disability, costs, time loss from work, and they can cause premature death.

Specialists in the chronic disease world emphasize that there are many places to intervene along the way before the sickest people present with end-stage kidney disease, end-stage diabetes, repeated emergency room admissions, repeated emergency services calls, etc. There are some of the principles of chronic disease that have always struck me as important when we talk about addiction.

The people who manage chronic disease very well have protocols. There are many. I just picked a handful of themes that come up again and again. They say that earlier identification is, obviously, the most important. We don’t do much about earlier identification in addiction in this province and, indeed, in North America. It’s almost like we want to wait to see if it’s really bad before we do something about it.

People who manage chronic disease set clear goals with their patients. They have problem-solving, and it’s appropriate to the stage of the disease. It is appropriate to address this illness early. It is appropriate to address it before it reaches the category of full-blown addiction, when it’s still at a substance abuse stage.

They emphasize the importance of seamless access to resources that are less specialized and less costly initially. Wouldn’t that make sense? Why wouldn’t we help people with diabetes and heart disease to get into where they need to go earlier on rather than waiting to get to the clinic that’s so specialized that the waiting list is two years? Seamless access.

Preparing an informed, activated patient. The people who do this well work with the patient to activate the patient about what they need to do, and they prepare a proactive supportive team around. It’s not…. We need to get away from this model of: “We provide all the care. We fix it for you.” So shared care planning that supports
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self-management and empowerment rather than enabling dependence on providers — on me, my colleagues, the nurse, the clinic, the drug, the medication. True self-management, true empowerment, self-efficacy are really important.

The experts — the people who do chronic disease really well — have active, regular review and sustained follow-up. We don’t say to the diabetic: “Your coma is fixed. Leave Royal Columbian now and give us a call if you have a problem.” We don’t do that. We say: “There’s proactive management. You’re going to watch your blood sugars. You’re going to test your sugars. You’re going to stay in touch with the diabetic nurse.” It is all laid out with support and follow-up. We keep that in place. The experts who are expert in chronic disease management are looking at: how do the supports change as the disease changes? What needs to be introduced? I find it very hard to find that in our system.

I don’t need to…. You’re smart people. You know a lot about principles of treating addiction. I just picked the NIDA, the National Institute of Drug Abuse in the United States. There are 13 principles. Just to emphasize to us, again — maybe a little bit — we know that no single treatment works. We know that for sure. No single treatment is appropriate for everybody. We need to match individuals with different interventions at different times.

Treatment needs to be readily available. How many times patients say to me: “The day I wanted to go to detox or the day I wanted to go wherever, I phoned, and they said there’s an eight week waiting list.” That doesn’t work. The door needs to be open when it needs to be open, or we can lose valuable time.

Effective treatment attends to multiple needs. You know that. It’s medical needs. It’s psychological needs. It’s social needs. It’s vocational needs. It’s legal issues. It’s a lot of stuff, and there’s a danger that we just get locked into the addiction medical model. Treatment needs to be flexible, of course, because of the ongoing assessments and how the needs are changing.

Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The threshold for significant improvement is reached at about three months in treatment, and additional treatment can produce further progress. In fact, programs need to incorporate strategies to prevent patients from leaving early. We need to encourage and try to ensure that people are not leaving treatment prematurely, because that’s what happens again and again in the revolving door.

Individual and/or group counselling and other behavioural therapies are critically important. We seem to have forgotten about this a little bit, about the importance of individual counselling and therapy but also group therapy, group counselling, mutual support, self-help. This helps teach not just relapse prevention strategies and how to replace drug use activities, but also problem-solving activities. Behavioural therapy facilitates interpersonal relationships, which are often so badly damaged with this disease of addiction.

Medications are certainly an important element. We’ve seen this with varenicline or Zyban. We know that medication-assisted treatment can be of great benefit, but it’s not a fix-all. Medication, by itself, will not fix a problem, and it needs a lot of psychosocial supports and contingency behavioural management and other issues.

Addicted or drug-abusing individuals with co-existing mental disorders should have both disorders treated in an integrated way. I’m sure you’d agree. A sentence like that — we all nod and say: “That would be a good idea.” We can’t seem to get to that place. It seems to be really disconnected. Colleagues of mine who’ve trained in psychiatry will say that we’re trained a lot on dual diagnoses, but many have not had a lot of exposure to the disease of addiction and training in that regard.

Of course, medical detoxification is but the first stage. How often we hear people saying, “Well, he went to detox, and he didn’t get it,” or: “He didn’t get better.” Medical detoxification does little to change any long-term drug use, and it really just manages a kind of acute physical situation and maybe starts a foundation for treatment.

There’s a myth, I think, that treatment needs to be voluntary to be effective. Enticements — some people call it benevolent coercion — by family, by employers, by unions, by the criminal justice system…. All of these things can significantly increase treatment entry, retention and success. We do it all the time. I’m going to tell you how we do it with physicians and why they appear to have better success rates. It’s not because they’re any smarter.

We have literature to show that you do not have to want to go to treatment to do well in treatment, right? If I were to wait for some of my patients until they think they’re ready, they’ll never be ready. And as their disease gets worse, their prognosis gets worse.

Possible drug use during treatment must be monitored continuously. We have to do that. It’s not tyranny. It’s part of therapy to follow up — urine drug testing and so forth. That’s important, also, in early recovery.

Treatment programs also have to, of course, provide assessment for HIV/AIDS, hepatitis B, hepatitis C, TB and all those other important medical conditions, although not everybody will have those conditions. But treatment programs need to be able to look at that.

We’ve got addiction services that don’t know how to look after medical issues very well. And we’ve got a medical system that not only doesn’t help treat the co-occurring addiction, but it misses it at times. We’ve got people in all our hospitals, and the missing piece on their chart is that the reason they’re stabbed, the reason for their motor vehicle accident or the reason they fell and broke their leg is because of an underlying addiction that wasn’t addressed.
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We don’t treat that. With all respect to my specialty colleagues, when you’re in an orthopedic ward, that’s not the kind of question you’re asking people about: “How often do you drink and drug?”

Finally, the Americans, in their final bullet, put: recovery from drug addiction can be “a long-term process and frequently requires multiple episodes of treatment.”

They talk about this concept of recovery, and I’d like to mention it in a later slide. What it emphasizes is that with any chronic illness, people will relapse. They’ll have good times, bad times, until they get to where they need to go. We don’t fire our diabetic patients because they eat doughnuts or their sugars go off for a bit. We don’t fire them. We accept. We know that stuff happens, but we still have the long-term goal in mind, which is long-term recovery. Participation in self-help, mutual-support programs helps to maintain abstinence.

I said to you I directed a physician health program. You say: “What’s a physician health program?” I suspect most of you wouldn’t know much about it, because it’s kind of kept as a very confidential program. We are as bad as politicians. People have us on a pedestal. They think their physician….

J. Darcy (Deputy Chair): If I might venture, doctors are probably on a higher pedestal. We admit that.

P. Farnan: We have physicians, nurses, police officers, their local MLA. They’re up there as: they can do no wrong. There are bad doctors and bad politicians, but not my politician, not my doctor, my nurse, my dentist. People believe. When you believe that about your physician, it’s very hard to go get help. So the physician health program is a confidential program, and I directed it.

They started it in the United States in the ’60s, when it was decided that an approach to addiction was not to try to drum the person out of the profession, but maybe they could be rehabilitated and give back to their community. Ours started in 1979, and I directed it in this province for seven years.

I’d like to tell you I brought something dramatically new to the table, but I didn’t. The key elements have been the same forever, and that is that we start, as early as we can, educating the profession that this is a stressful business. You can get very sick, and one of the things you might choose to do, if you’ve got the wrong genes or the wrong situation, is drink and drug. That will get you into difficulty. So we promote early identification, education and, especially, early referral. We don’t say: “Let’s see how bad it gets — that you can’t go to work or you’re messing up with patients.” We promote early referral.

If somebody is sick enough and they’ve gone past the point where they’re not seeing how sick they are, we will do professional intervention services to get them where they need to go. They get a very, very formal assessment by experts in the field, and they get referred to a very comprehensive, abstinence-based treatment program. The goal is not: “Let’s see. Can you use a little less or drink a little less?” The goal is: “You will not use. You will get better, and you will come back and provide good-quality care for your patients.”

To do that, because of the risk of relapse, we have long-term monitoring. For physicians, it’s five years. For dentists, it’s five years. For nurses, it’s typically three years. It’s monitoring the individual’s compliance with abstinence over that time frame, including random biological testing, and assessing the quality of their recovery.

In the document — I don’t know if you have it — I wrote: “Within the physician health programs in North America, the success rate over five years is that between 70 and 80 percent of those men and women will get through their five years. They’ll never have a positive drug test. They will be doing all that they’re supposed to be doing in recovery, and they will have switched off that terrible dangerous switch that was driving a lot of behaviour. They will have the experience of recovery with other colleagues who are in recovery, and they live very full, productive lives.”

The PHP model works. Is it just about physicians? No. My office…. We have dentists, police officers, firefighters, airline pilots, public servants. All kinds of people who have responsible jobs come to my office. They come shamed and embarrassed. When I ask, “Can we take students and residents?” they don’t want people there.

Today, I swear to you — I have no reason to tell you otherwise — at one o’clock, I saw a man that’s to be promoted to a very safety-sensitive position. He’s sober for seven years, in rock-solid, sustained recovery. He’s doing really well, and he was terrified to come and see me and talk about his recovery.

We talk about cancer survivors. We don’t come in and say: “I’m an addiction survivor.” We don’t brag about that. There’s a shame and a stigma that carries on, for some reason, into recovery from active addiction. We don’t celebrate recovery.

So that’s a bit about physician health programs. I wanted to talk a little bit about if we set standards for….

Over the years, I’ve been involved with addiction a lot. There wasn’t a lot in this country, and I was certified in Canada. But prior to that, I was certified in the American system, and I’m board-certified with the American Board of Addiction Medicine and so forth.

I understand that my standards…. This is a disease that I’m passionate about. I can’t realistically expect to have that of my colleagues every day in Terrace or Kitimat or wherever. But these are the kinds of standards that are expected for somebody who’s going to, at all, bump into addiction.

I would qualify by saying this isn’t a disease that physicians have a monopoly on, by any means. There are a ton of people who should be involved in trying to help
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and treat this disease. But I can speak most confidently about physicians. Physicians need to be able to assess and diagnose. For many of the people who come to my office, that hasn’t happened. I showed you in the first slide that hasn’t happened.

Physicians need to understand what is withdrawal management. How do you do it as an out-patient? If you say to your patient, “Oh, you’ll have to go to Creekside” or “You’ll have to go into detox,” one is they can’t get in, and two is that there’s a huge stigma about doing that, so they carry on. We don’t have physicians who do good assessment, good diagnosis, withdrawal management.

Then, as you come down this list, maybe it becomes more specialized with the treatment planning, with treatment management, with how to understand care transitions and care coordination. We don’t train our docs very well on this. Most importantly, we don’t explain to them the importance of continuing care management and follow-up.

In fact, the gentleman who I saw today told me that he changed physicians. He gently tried to bring up the fact that he was in recovery. It was very quickly obvious to him that the physician knew nothing about what recovery meant, so that just went underground. He has a physician who doesn’t know he’s in recovery. How sad is that?

If we’re not addictions specialists or very much practicing in that area, the very basic principles and framework that has been recommended for all physicians with regards to brief interventions in addictions…. It’s called FRAMES. There are many models, but this is just one. It talks about feedback to the patient, which means you have to assess the use.

We know feedback works. If I don’t ask you if you smoke cigarettes and then, afterwards, don’t say: “I think it’s bad for your health that you smoke cigarettes; I’d strongly recommend….” Many people stop smoking on the recommendation of their dentist or their physician. They stop smoking. But if we don’t ask, we’re never going to know. Giving feedback is important.

Responsibility is the patient’s, ultimately. We can help the patient, but it’s the patient’s.

Advice is about setting goals together. How do we do that? How do we lay out the menu? “This is what you might do. This is another option. This is an option. Which one do you want us to pursue?”

We need empathy. You know, I’m assuming your offices are not dissimilar to busy doctor’s offices. You’ve got constituents and mothers and fathers coming in broken-hearted, and they need empathy. These are not bad people. These are sick people. It’s not a character flaw. It’s a brain disease, and they need empathy, or they will not come back.

We need to encourage self-efficacy. We need to make sure our system doesn’t endorse and support a dependency on going to this clinic or taking this medication or doing this, which, in the long term, is not good.

I didn’t come here to talk about the training of physicians, but it upsets me. I think Dr. Ray Baker might have been here. I don’t know if he would have told you that he developed the addiction program for UBC. It was an award-winning program, known all over the world — 33 hours of training over four years, integrated with many different specialties. I used to teach in that. Each year it got whittled down, and now we don’t teach. We have no formal training in addiction for our undergraduate doctors. Now, if someone’s here from UBC…. They may have some lecturers or they may be doing something, but the formal program of training is not there in addiction medicine.

The other thing that’s terribly upsetting for me personally is what ends up coming to my office as a result of, quite honestly, unsafe prescribing. Physicians have been misled for years, of course, by big corporations. Of course, they’re going to support a lot of prescribing. We’re living the legacy of that right now. In fact, in Ontario, at least, we have a situation where, in a population of 50,000 people, there are three to four times more people on methadone than would be estimated in a similar cohort in the United States. So we’ve got more methadone. We’ve got more Suboxone. We certainly need safe prescribing, but what is safe prescribing?

Then there is no exposure to the concept of recovery. In the addiction medicine training program at UBC, many people — some of them were my patients — would proudly go and speak to medical students and say: “This is what it was like being a police officer addicted, and now I’m in good recovery. I’m abstinent. My life’s going better.” Right now I don’t know of anywhere for physicians in training to get to meet people in recovery.

I started out with a missed opportunity about identifying. I think another missed opportunity is: what is recovery? In my mind, it’s about being solution-focused at the start rather than being problem-focused. It’s about “How can I help you be more well?” and not just “See if I can keep you less sick.” So it’s a different framework. It’s a different agenda.

What I know from every discipline in medicine, whether it was general practice doing physical medicine or back pain or diabetes or whatever, is that the patient looks to me to give some guidance with the treatment goal. If I imply that “You know what? It’s not really worth your while. I don’t know whether physiotherapy will really work….” Sending a message that does not give therapeutic optimism is really something where we do a disservice to our patients. We need to tell them, especially earlier on, “Okay, we can approach this with a view to you being abstinent and well in the fullest sense of the word,” or we can say: “Well, you know, try not to use that much of that.” And then when they come back, we can start looking at how we get the most advanced training.

You are aware, of course, that we have a fellowship training program through St. Paul’s. That is for physicians
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who have graduated and who have done a residency in some discipline, usually family practice or psychiatry, and then they will do a year of fellowship training. Last Friday, I gave one of my annual lectures to that group. They are so specialized in almost the intensive care end of things on the Downtown Eastside and people who are so sick that need such harm-reduction strategies, that I’m not sure…. I would like to, actually, check who’s going back to other communities or what they can do back in other communities. That would be important.

What is recovery? It means a lot of different things to a lot of people. A panel at Betty Ford in 2007 defined it as “a voluntarily maintained lifestyle characterized by sobriety.” That’s a part of the goal, but it’s not the only goal. Recovery is not sobriety, and sobriety is not recovery. Recovery is about improved personal health, mental health, physical health, emotional health, and it’s about this concept called citizenship. It’s about being part of the community, embracing the community, giving back to the community.

When we speak to physicians, nurses and other people about recovery, it’s not just about, you know: “Don’t drink. Don’t drug.” It’s about looking at how you can make your life better, how you can be more well rather than just less sick.

So that you’re aware, this isn’t such an outlandish idea. SAMHSA in the United States has emphasized the importance of recovery-oriented systems of care. They describe a ROSC as “a coordinated network of community-based services and supports that is person-centred and builds on the strengths and resiliencies of individuals, families and communities to achieve abstinence and improved health, wellness and quality of life for those with or at risk of alcohol and drug problems.”

How can I wrap up? This is a chronic, progressive disease. I know you know that. We talk all the time about intervening earlier, but we don’t seem to do that. I would hope that we will improve training for physicians, at least, on assessment, diagnosis, early management of addiction, appropriate management, and also to give people hope that recovery needs to be a treatment option.

We need to reduce the stigma of addiction in every way possible and in recovery. And we need, I think, to encourage the recovery community in enhancing the effectiveness of addiction recovery programs. This is a very significant community that is essentially invisible to the public, and hidden, and is an amazing resource. We don’t tend to ask: “What did you do? How could we do things better? What would you suggest that we would learn from you that would help us earlier on, when you were earlier in your disease process?”

I appreciate your time. I thank you, and I’m happy to take any questions, so long as they’re not too difficult.

J. Darcy (Deputy Chair): We would all love to ask questions, but I’m afraid that you’ve taken the entire half hour. I was reluctant to interrupt you because you were on a very powerful roll there. But just a question: are we able to get copies of your presentation? Because I think it was certainly….

P. Farnan: Yes, absolutely. I will send that in. In fact, I sent it in this morning, and I also had a written submission.

J. Darcy (Deputy Chair): Wonderful. Thank you so very much. Sorry we don’t have time for questions.

G. Leekha: Good afternoon. I’m going to turn my timer on so I don’t run over. Apparently that can happen.

J. Darcy (Deputy Chair): Optimally, if I can use that term, we would like a 15-minute presentation and 15 minutes for questions. But we’ll leave that in your hands. I won’t take up your time. I’ll just let you begin.

Many of us have had the opportunity to attend presentations in Victoria that your organization has put on. Go ahead.

G. Leekha: Thanks for having me today. My name is Gurpreet Leekha. I’ve practised optometry for about 15 years now. A few of those were in New York City. Then when I came back to B.C., I practised in Kelowna, Victoria, and now, for the last few years, I’m living in Victoria, B.C.

I’ve done some volunteer work in optometry. I’m passionate about the profession. I’ve been to Mexico and Chile and am now serving as the president of the B.C. Doctors of Optometry — the advocacy group. We advocate for B.C. residents’ eye care needs and also for our profession’s ability to serve them.

Our job as optometrists is taking care of the visual welfare of our patients, whoever we can reach, and their precious gift of sight. This is something we do every day, something that we live and breathe, and we’re located across B.C. We’re in rural communities. We’re in urban communities. We’re everywhere.

We’re considered the most accessible primary eye care provider as well. When I say primary eye care, it’s the person you go to for your first problem in your eye. Whether it’s an issue of pain, of sight, prescription issues, medical treatment, you always have to go through that primary point of contact first. That’s what we do.

We are trained — for many years now — to do medical care along with eye care. Medical care, if you recall, would have been the domain of medicine only, but many decades ago, optometry was available where ophthalmology was not. So we entered into the medical arena and — for years now — we can diagnose and treat medical problems
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of the eye, including giving prescriptions when necessary and referring, of course, when necessary as well.

We’ve been partners with the Ministry of Health for many years. We’re one of a few professions that direct bill the Ministry of Health for patients that we see. We concluded a six-year agreement in 2009, and a five-year agreement was just signed last year. They’re always, mostly, cordial agreements in that the government recognizes the role that we can play. In each agreement, usually we’re asked to do a little bit more, and we’re usually trained for that many years before we’re asked to do so. That’s what today is about too.

We’re also partners with the B.C. Falls and Injury Coalition. This is something that some of my colleagues were even surprised by a couple of years ago when we got involved with them. It turns out that vision plays a role in falls. The more important aspect of that is if someone does fall and they’re over a certain age and they do develop, let’s say, for example, a hip fracture, there is a reduction in their number of years left to live.

When my colleagues that are chiropractors and physiotherapists came to me with questions about “Why do you prescribe those glasses that way?” we became aware that this is something that we do — not in isolation. We’re collaborating with our other colleagues that are taking care of patients at those ages.

By joining a coalition, we were able to cross-reference what we do, make sure that it’s done safer and make sure that we provide education to the public and to our fellow colleagues, in all walks.

The a-b-See campaign, listed there on the slide, is a very important one to me. Preschoolers are often missed. I think Judy knows about this one. Those kids are five to eight years old when they’re struggling to read. They’re ten to 13 when they’re struggling with all aspects of school, before these things are finally caught. There are way too many people like this across B.C., more so in the rural communities, where eye care is just not the first thought when that child is struggling.

The a-b-See program puts materials out there to preschool teachers, parents and the kids to remind them and educate them on the importance of screening for those conditions young. Children’s eye exams are a benefit of MSP. It’s just not utilized the way it could be.

Moving on to the next slide, it kind of continues from the a-b-See program. It’s called the Eye See, Eye Learn program. It’s only in its third year of implementation. We’ve got about 200 plus doctors in 100 plus clinics across B.C., across 15 school districts.

Rollout had to be bit by bit. We had to test it and see how it did. Eventually, it’ll be across the province. The goal is to provide free eyewear to those kids, removing that barrier that parents sometimes have from going in and seeking care for their children.

We’re also partners with the CNIB, ensuring quality of vision, and with the Diabetes Association as well, because diabetes…. Eventually, for those who are affected with it, they realize that it affects their vision. It can cause bleeding in the eyes, glaucoma, cataracts. So that’s our opportunity to work with other key treatment providers in that arena.

There’s an aspect of price involved when it comes to vision issues. There’s a cost. The 2014 estimate was about $19 billion, direct and indirect costs combined. Vision loss for B.C., the portion in B.C., is about $2 billion — the cost of direct and indirect vision loss. If you want to put it in perspective, in Canada’s economy, vision loss costs more than a combination of all three of diabetes, cancer and musculoskeletal diseases. We’re talking about the diagnosis, treatment, monitoring and the consequences as well.

About 10 percent of patients that come in for a routine eye exam in the adult years — in the years where they’re not covered by MSP for a routine checkup, ages 20 to 64 — will come in and be diagnosed with an acute risk of vision loss. Sometimes they’re symptomatic. “Doc, I woke up. I can’t see in one eye.” Sometimes they came in perfectly happy, just wanting new contact lenses, and we discover a retinal detachment or a problem with their cornea — so one in ten.

Those numbers are going to grow, because these problems will increase with an aging population, and conditions like glaucoma sometimes increase at all cohorts — or diabetes, for example. It’s not just the aging population. We see ourselves as partners in that prevention and in that cost reduction in the long term.

In 2012, that was a great example. After optometrists had been able to prescribe for glaucoma for many, many years in the States, we were finally given the option in 2012 to do so in B.C. for the simpler types of glaucomas — another area in which the government saw that they could turn the care over to a group that was willing to take the patients and do it at a lower cost.

We think that there’s going to be — the estimates are — about a 30 percent rise in costs of vision loss to Canada. As you probably know, many people turn to the emergency room in certain communities, in urban and rural, and what kind of experience is that for someone with a red eye? It’s one of the longest wait times they can go through for something they could have walked into an optometry office for at a much lower cost to the system and to the patient. We are heavily underutilized in these areas.

If you wanted to look across B.C. and see what we do and how we’re available, there are about 196 physicians that practise and specialize in ophthalmology, in 37 communities. In comparison, there are 700 doctors of optometry, in 90 communities. We’re everywhere.

When I was talking to my rural colleagues in advance of this meeting, one of them shared an example for a patient of his, Tonya. She was willing to share her case. She’s
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a single mom. She had an accident in 1996 that caused problems, and because of the ongoing care and the monitoring required, she has to make these trips at her own expense, including the wait times, the travel, the time off work. She basically was sharing with her optometrist that there’s got to be a better way, a simpler way — “A way I could just do this right here, without travelling.”

She’s right. There is a way. We’re underutilized as a health care asset and as a potential partner with the B.C. government. I know I’m speaking to a group that is from across B.C., and when we get to the questions period, I think I’d also like to hear from you, in your questions, if you are experienced representing rural or urban patients, if you’ve also heard these same stories, or if there’s anything different that you’ve heard from them.

What I’d like to represent is in response to the Setting Priorities document that you must be aware of. That was put out in 2014, I believe — late 2014. It was a policy paper, and it was from the Ministry of Health, seeking feedback on what groups can do to help improve care and collaboration in health care. We submitted two key ideas, and these are the ones I want to share with you today.

One is the authority to prescribe both topical and oral medications. We already have topicals. We want to add orals to that. The second is provision of telehealth services. We’ll start with orals.

Optometrists have been trained through our university education and our clinical training from the mid ’90s to prescribe orals. It was always something that the profession and the governments that received those graduates felt was required for the populations. Bit by bit, provinces adopted this — but not in B.C. We’ve fallen behind.

Nowadays you can prescribe medication through various methods. There are sprays, topicals, ointments and drops, injections. There are even contact lens medications coming in the not-too-distant future. Google’s one of the pioneers in that area.

When these things come to market, in the health care community — ophthalmology, optometry, physicians, ER — they all know that optometrists are trained on this area. But they also know that we’re not licensed to prescribe it, and so they take on the burden of doing that prescribing. The patient is in our office, but we then redirect them to the other office for the actual prescription. It just seems silly. It seems silly to us, and it seems silly to a number of our patients as well.

More than half of optometrists currently in Canada can prescribe orals — in Alberta, Saskatchewan, Manitoba and Ontario. In the States also — 49 states, almost the entire country. And we’re educated to the same level as optometrists in both Canada and the U.S.

The journey that patients then go through…. As I described, they’ll be in our office. They’ll then make that trip, and sometimes, if it’s Coquitlam or Victoria or Kelowna, it’s not that far a trip. There may be some wait time, weeks to months. We know of an example in Vancouver where a sty, a little red bump on the lid, has maybe a six-week wait time to get to an ophthalmologist for excision or an oral medication. Either way, it could have been written the first day of contact.

Another example. A patient with inflammation of the optic nerve, which is serious, visited a doctor of optometry who was aware of the problem, knew what to prescribe and wrote the note to the GP. The walk-in clinic at the GP said, “Well, I’m not comfortable with this,” sent it to a retinal specialist, and that took a few days. By the time the retinal specialist received the patient, the vision was not recoverable. This was a recent case, about three or fourth months ago, in New Westminster.

Another example. A patient comes in with a scratchy eye. It could be many things. It turns out to be a herpetic infection of the cornea — herpes in the eye. That requires a topical and an oral right away. The topical we can give. The oral — depending on where you live, you get it soon or you don’t get it very soon. Again, that doesn’t seem right.

There are consequences to these delays. There’s another way around these consequences: the concept of telehealth. Telehealth you probably are aware of. You may have listened to this in a previous hearing. You may know that GPs do it.

Some dermatologists do it. Some retinal specialists do it in isolation. What we see happening, though, is that it’s not taking care of the whole of the patient.

When it comes to eye care, it’s the whole of the eye. If you treat the cornea, let’s say, by telehealth, have you detected the glaucoma in the back of the eye? If you treat the retinal bleeding using telehealth, have you detected the glaucoma? Have you detected the other issues or the potential vascular problems or hypertensive problems?

We think that this telehealth model should be given to optometry. We’re not saying that we take it over from another group. We’re saying that we should be added to the discussion and to the model. When it was discussed and implemented a couple of years ago, optometry was…. We proposed something, but we weren’t invited back to the table to participate. We know we would do it at a lower cost. We know we’d be able to do it for the entire eye and every layer involved. Again, we’re located everywhere.

There are many models of telehealth. There are a couple that are very, very acutely prepared to take on eye care as well, including for optometric. What we’re asking for this particular area is just to be invited back, by the Ministry of Health, to discuss what role we could play and to demonstrate the cost savings and the time savings.

In summary, the benefits that we think would come from adding oral prescribing for optometry and adding telehealth would be improved access; more collaboration; better care in the rural and the remote communities; and reduced costs in many ways, including in travel. Also, the government wouldn’t be paying for those tests to be done
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twice, once in the optometrist’s office and once again in the ophthalmologist’s office or in the emergency room.

When it comes to mobility and age, again, we’re going to be doing a much better job of serving seniors everywhere they live, especially those with mobility issues. It’s a much better use of staff and equipment, and it exactly meets the goals the Ministry of Health proposed from 2014 onward. It’s collaborating with other professionals.

The next steps we would request are to amend the regulation, a simpler step to add oral prescribing in addition to topical prescribing, and to begin having optometry provide telehealth in B.C.

Given that our health is connected…. The eyes are part of the body. It’s often a surprise when people find out we’re diagnosing a tumour or blood pressure or diabetes through their eye exam. I think providing optometrists with the ability to work with the government on these issues would be an excellent education tool for the public — that the Ministry of Health is working towards wellness overall.

D. Plecas: You mentioned that you expected there to be an increase in the need for your profession. What would be driving that increase?

G. Leekha: People are living longer. The longer they live, the more important it is to take the cataract out so they can continue to drive. I’ve practised for 15 years. I remember that when I first graduated, people said: “Well, cataracts only happen when you’re really old, like 60, right?” Nowadays they say: “Well, doesn’t it only happen when you’re really old, like 80, right?”

People are living longer. They’re working longer. They’re driving longer. We have to make sure that those patients and those citizens are having those needs met at the appropriate time — if it’s in their work world and they want to be productive, if they’re still driving and they want to be safe for themselves and others. So cataracts, glaucoma — everything that involves preserving your vision for the long run.

Diabetes is an excellent one, too. Diabetes causes vision loss in three areas of the eye: glaucoma, retina and cataract. We expect those things to increase. We also know that diabetes is not just increasing in the older population. It’s increasing in youth. I had a 19-year-old patient — Christmas Eve, two years ago — go blind from bleeding into the retinas from inappropriate control of his diabetes.

D. Plecas: What about the demographics in terms of different ethnic groups and the changes we’re seeing there? Do you think, as we have more people from different parts of the world, we’re more likely to see more people with issues with their eyes?

G. Leekha: I studied and then practised for over a total of nine years in New York, and it was absolutely true. There were certain ethnic groups that had higher rates — the African Americans and the Hispanic Americans.

In B.C., I miss that demographic. I don’t see as many of them, but I know they’re increasing in numbers. I remember my stats, and if I see someone of Hispanic origin, I do ask about siblings and parents with those conditions. Glaucoma, for example, retinopathy and cataract are going to be higher in some of those groups, absolutely.

Since I’ve been back in B.C., the demographics here are the South Asian, like myself, and then the Asian populations. We do know that there are higher rates of types of glaucoma in the Asian population and higher rates of diabetes and the consequences in the South Asian population. So absolutely.

D. Plecas: Chair, if I may ask one more quick question. I think I know the answer to this. It seems such a no-brainer.

G. Leekha: I’m not an expert on that. I can give you my theories, and I can give you, perhaps, some of what I’ve learned serving in this role.

Once in a while, there is opposition. If we add in an area that we logically should be doing, like prescribing orals — even when we added glaucoma in 2012 and topicals, in 2009 — there are groups that have always done that. Even though we work together day to day, on a political level they’ll sometimes feel like it’s their turf and they don’t want it impinged upon.

Once you actually crossed that 2009 and 2012 barrier, what actually happened is they loved it, because they love that you’re taking on those cases for them and they can focus on what they were really trained to do. If it’s ophthalmology we’re referring to, they love doing surgery, and they don’t always like their day being clogged by emergency calls for red eyes.
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Is there opposition from them? Traditionally there has been every time we’ve had a change, but usually, as soon as that obstacle is over, we collaborate beautifully again, because the patient’s best interest is always served.

Are there other reasons? Probably we haven’t banged the door hard enough. That’s our fault, but we don’t want to bug people. But we do think that at a time when the government was coming to us, saying, “Can you save money?” and “Can you help us?” we raised our hand.

We’re not asking for a lot of funds in this. In fact, with the orals request, we’re not asking for any funds. The patient is already in our room. We’ve already billed the Medical Services Plan for that visit. We triaged it. We’ve prescribed the drop. We just can’t prescribe the oral. It would cost nothing else to the system.

In telehealth, there has to probably be either a pilot project or funding or a fee in place, because for us to upload the data and give it to the ophthalmologist, who’s 100 miles away, there’ll have to be a system in place. We think, again, there’s a cost, but it’s going to be a much lower cost than what’s currently being funded in B.C. for telehealth.

S. Robinson: Thank you for your presentation. I’m thrilled that you came to see us, because this is part of a theme that we have been hearing. You’ve sort of fed right into the theme — there are already people coming, but we can’t, because there’s another group, and there’s a bit of territoriality — which we’re hearing about. But at the end of the day, it actually fits with what we’ve been hearing, which is to then allow those experts to really focus on their expertise. We haven’t heard anyone from the eye world yet, so it’s actually really helpful.

Part of what we’ve been doing is looking at integrated teams of care. How do you see the eye people…? I’m going to lump you all in one, even though I know you have different roles. Where do you fit in? For example, around a diabetes clinic, if someone has a chronic health condition, would it be appropriate for some of the eye people to be at that table? When would that happen, and when wouldn’t that happen?

G. Leekha: Great question. There are already examples of that which have been funded as studies in the U.S. at a centre called Kaiser Permanente, in California. There’s an article. I think it’s been shared with somebody. I’ll have to figure out when, but I can bring it forward again. There are examples in Alberta, as well, called PCNs, primary care networks.

In both of those examples, diabetes has already been established as something that eye care professionals should be involved in the protocol of management, monitoring and treatment. For example, my father is diabetic; my mom is diabetic. When they go in, they’re told by their endocrinologist, “Make sure that you get your eyes checked every year,” and then they brag that their son is an optometrist, of course.

The point is that the endocrinologist is the one that’s aware of how important that is to that patient’s welfare. The endocrinologist cannot see the retina. They cannot tell if the eye is showing signs of any diabetes progress. It’s an incredibly important piece of the diabetes puzzle. If there’s a diabetes clinic, if their protocols are followed, that patient would be screened annually for vision. Now, should that be done in that building, or should it be done by their own optometrist with the data sent in? I think both are excellent models, as long as it’s done.

S. Robinson: Right, but it’s up to the patient to track it. They may report, “Yeah, yeah, yeah. I’ll get to that,” but they may not go for years.

G. Leekha: Well, this is true, but in those examples, the optometrist always writes a letter to the endocrinologist or family physician. So the quarterback is the one who should know whether it was done or not. There could be a protocol signed to the family physician, saying: “Hey, did you get the eye results for this patient this year?” Often it’s a nurse or an administrator who tracks whether it’s done

In Victoria, for example, when I moved there, I’d say maybe 15 percent of patients who are diabetic get eye exams every year. That’s incredibly low, given that endocrinology would think it should be 100 percent. Family physicians, more and more, are increasingly recognizing the importance, but not quite 100 percent of family physicians are sending their patients for the exam.

But in the PCN model in Alberta, they see the optometrist as probably…. The current model doesn’t include optometry. It’s being invited in right now. They see the optometrist as taking over and reducing cost on the annual screenings for all diabetics and then the ones that require the laser treatment going to ophthalmology, rather than ophthalmology taking time to do routine eye exams for diabetes. They don’t have the time for that in Alberta, nor do they in B.C.

D. Bing: Thanks for your presentation. I was wondering: do you bill the Medical Services Plan currently?

D. Bing: So what percentage of your income would come from the government versus your patients?

G. Leekha: We are unique in that we receive billing both from the patient directly or through extended
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health insurances and government. Let’s say, as a clinician, my breakdown is probably somewhere about 55 or 60 percent private and 40 percent government billings. If I see more seniors and kids, it’ll be higher on the MSP side, lower on private. If I tend to work in a place that’s more glasses- and contacts-oriented with routine eye exams included and I don’t see kids, it would be a lot less MSP billing.

D. Bing: Do you have an issue with the government in terms of your reimbursement for your fees?

G. Leekha: It’s incredibly low, and a number of my colleagues do. But we also have balanced billing in B.C. Balanced billing is something that…. In 2003, when optometry routine eye exams for 19 to 64 were de-insured, the government said: “We recognize that the $47 we’re paying you for a routine eye exam has an economic value of $173. Why don’t you bill the difference?” So optometrists have traditionally billed the extra $30 or $40 — it’s somewhere around $45 to $55 nowadays — the extra fee.

So if you’re diabetic and you come in, you’ll pay your $55 fee to top up to the full service that’s provided. MSP covers the remainder. That’s balanced billing. That’s unique in B.C. Other provinces don’t have that. Again, that’s under MSP’s approval, because they recognize that they don’t want to be paying that full $100 fee for the eye exam for people with cataracts, diabetes, over 65 and so on.

G. Leekha: There’s almost nobody that doesn’t accept MSP. It’s called opting out fully. As far as I understand…. It’s an option, but as far as I know, I don’t think any of our members or optometrists in B.C. do not. We all accept.

J. Darcy (Deputy Chair): I have had the occasion just last week to hear much of the same presentation from Dr. Brenda Horner, who is my local optometrist. I got my glasses from her as well. So I’m very familiar with the work of your organization.

I think I just want to echo what my colleagues have said. We’re hearing from everybody that people need to be able to work to the full scope of their practice, the full scope of their training and their skills, and that it really does take a team for us to ensure that health care is sustainable and improved for the long term.

You said you weren’t accustomed to making a lot of noise, as an association. But I think it’s fair to say that the work you’ve been doing in Victoria and presentations like this — and also, very importantly, the work that your association is doing in communities — is really building awareness of what optometrists do. Programs like the a-b-See and the Eye See, Eye Learn programs certainly put that right in front of communities and parents and families. So I thank you for that.

G. Leekha: That’s great feedback. Thank you very much for the opportunity. I appreciate it.

A. Richmond: Thank you for the opportunity to speak to you folks today. I know many of you — some of you, anyway. We debated sending you a presentation, and I said, “No, I need to go talk to these folks” and express what’s going on and sort of allow you the opportunity to ask us questions.

With me today is one of our senior policy analysts, Josh van Loon. If I get in trouble, Josh will endeavour to try and bail me out. Josh is new to UBCM too. He’s only been with us about a month.

Our members, of course, as you know, have a significant interest in health care sustainability. So we’re pleased to be here to look at and present to you an overview of what we’ve done on three topics that you’ve identified for discussion. We really appreciate that the select standing committee is conducting important work and would like to thank the province for the undertaking of several initiatives.

We always go places, and we complain. But I think we need to highlight some of the things that are working well, that have been successful. We want to see more examples of that. They’ve been working to address our members’ concerns. These include items like the community paramedicine initiative and the emergency medical assistants education fund, which some of you may be aware of and some of you may not.

I was surprised — at a session last year at UBCM, I believe it was — when the minister wasn’t aware of this fund, and I had to tell him what great work they’d done. We do so much work, and we forget some of the things we’ve put in place. This is a fund that the UBCM healthy communities is involved in administering and that we work with on almost a weekly basis.

I’ll begin with a quick overview of UBCM. Of course, we were established in 1905, and we’re the common voice for local governments in B.C. Our role is to bring forward the interests of local government to both the provincial and federal governments.

On the three topics you wanted to talk about, recruitment and retention of health care professionals.… First, remote and rural health has been a long-standing concern for UBCM members. The key issues of concern are recruitment and retention of health care professionals, ambulance service and access to health care services.

UBCM, through the healthy communities committee, has been very active in addressing these concerns through participation in workshops on rural health care, including the Perinatal Services B.C. rural maternity and surgical services forum, the Doctors of B.C. physician re-
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cruitment and retention summit and the access and exchange to quality health care forum. These are all things that are going active. I’m assuming you’ve heard from some of these organizations and groups.

It was really surprising. When we first started the rural maternity and surgical services, there was a suggestion from some in the room that this was surgical for maternity services. In rural communities, you can’t have surgical services for maternity without the other general surgery that goes on, or you can’t keep your surgeons there. Of course, the challenges we have around keeping certified anaesthesiologists…. If you can’t give them enough procedures to perform, they can’t maintain their proficiencies. Then it becomes a spiralling thing for smaller communities.

In 2015, we provided feedback on the Ministry of Health’s Rural Health Services policy paper. UBCM’s membership called for the provincial government to develop incentives for doctors and other health care professionals to encourage greater interest in working in rural communities.

The incentives included financial assistance for training health care professionals; equal pay for standby ambulance attendees in rural and remote areas, where some are paid $2 an hour to be on call, which is pretty much difficult, when you’re trying to encourage someone to go to a rural and remote area and be available, with those kinds of funds; bursary programs for students; funding for nurse practitioner overhead and operating costs; and local and on-call relief for our doctors.

An additional approach was raised by UBCM members which would see senior levels of government work with the College of Physicians and Surgeons and other certifying bodies to reduce the barriers of recruitment for foreign-trained health care professionals. There’s been some movement on that. That’s been really appreciated.

Training health care professionals in regional centres, such as Prince George and Kelowna, has been encouraged as a means to recruit doctors who will stay in communities where they’ve trained. That’s had some success, with the rural medical program at UNBC. We’re really fortunate to have that program and the graduates that come out of that. We’re seeing nurse practitioners come out of that. We’re seeing doctors come out of that.

You’ll hear shortly that we think more could be done with respect to the establishment of a physiotherapy program at the University of Northern British Columbia. UBC is the only university currently offering physiotherapy in school in B.C.

Finally, our members have put forward the possibility of establishing a medical transportation service to transport patients requiring service and care in larger centres.

The cost-effectiveness of primary care around interdisciplinary teams. On the topic of interdisciplinary teams, I’d like to highlight the community paramedicine initiative, which was launched by the Ministry of Health in 2015. This initiative represents one example of how these teams can be applied towards health care sustainability, particularly in rural areas.

The practice of community paramedicine has shifted away from the existing emphasis of pre-hospital emergency care to a model which includes prevention, health care promotion and primary health care. The concept utilizes paramedics in an expanded role as part of the community-based team of health care services and providers and would include services such as home visits, blood sugar and blood-testing procedures, as well as seniors care, to assist in aging in place.

It’s a strategy deployed in communities that have limited access to health care services that are seeking to improve the outcomes and reduce unnecessary costs to the system overall. The overall goal of the initiative is to create at least 80 new community paramedic positions within a four-year period in rural or remote communities in B.C.

UBCM is a member of the advisory committee which facilitates the implementation of the community paramedicine initiative. Currently, the communities of Chetwynd, Fort St. James, Hazelton, Creston and Princeton are operating, and there’s great excitement about the potential expansion recently announced for Wells and a few other communities. They’re eagerly waiting for that to happen.

I’d like to thank the province for their contributions towards the emergency medical assistants fund. UBCM sits on this advisory committee for this fund, and I happen to chair it. I’ve been trying to get rid of the job for five years and haven’t got anybody to come forward. It’s a very good thing to do, but it’s very time-consuming. It increased the number of paramedics working in rural and remote communities in B.C. Since its inception in 2007, over $5 million has been distributed from that fund to support the education of 435 primary care paramedics, who generally practise in rural communities, and 159 advanced-care paramedics, who practise largely in urban communities.

To give you a flavour of what that means, each primary care paramedic receives a $5,000 grant to do his training. Each advanced-care paramedic receives $22,000 towards their training. This is a significant contribution towards putting these people where they need to be and the training, and the government needs to be applauded for the foresight to do that kind of work. It has been great. It’s wonderful to adjudicate these processes three to four times a year, and we appreciate the occasional top-up from the government.

Many more students will be supported in the coming years, as there’s about $3.5 million left in the fund, which is invested by the Vancouver Foundation. Then we request funds from them, usually three or four times a year, for the grants for the people entering the Justice Institute program.
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Beyond these initiatives, the UBCM membership supports adequate funding and training and resources for first responders and emergency personnel as part of the interdisciplinary community care. This includes addressing a number of considerations — that there are sufficient ambulance services to meet time criteria, particularly in rural and remote areas of the province; that there’s a standardized level of training within the province to facilitate the portability of training between agencies that require emergency trained personnel; and that there’s a fair and equitable cost-recovery model developed to compensate local governments for first responder calls.

Currently, first responder calls are voluntary, and we do receive some medical equipment — for want of a better word: supplies. Largely, the people who are running a volunteer fire service end up becoming first responders, if they can muster the people to train to do that, so that comes out of the fire service protection. Taxpayers are paying for that.

I will say that despite that, when we’ve introduced those services in our region, it’s probably one of the services that our residents are most thankful for — that someone will come probably more quickly than an ambulance does. Someone with a uniform will stand there and help them, give them a little bit of oxygen. It’s well received by the people in the province as a community initiative.

Members of the Association of Vancouver Island and Coastal Communities have just forwarded a resolution to UBCM to encourage the province to look at physician assistants to relieve the demands facing doctors throughout the province. This issue will be formally considered at UBCM in September. Physician assistants, if you’re not aware of them, have been practising in Canada since 1965. The PAs are licensed medical providers and are well established in Ontario, Manitoba, New Brunswick, Alberta and the Canadian Armed Forces in several countries, including the U.S., U.K., Netherlands, Guyana, Germany and South Africa.

The British Columbia Medical Association supports the establishment and deployment of PAs to address B.C.’s shortage of health care human resources and recommends that PAs be recognized as a regulated profession in British Columbia. Although the UBCM membership has yet to take a position on physician assistants, they recognize that it’s complementary as a medical service to help health care professionals and could play an important role in primary health care delivery.

In this vein, we recognize the important role that nurse practitioners play, particularly in rural communities. We’ve seen them play a very large role even in urban communities, where we’ve seen doctors hire them because of their expertise in preoperative care and postoperative care. Finally, UBCM’s membership supported the financial compensation and increased level of training for firefighters that they offer as first responders.

With respect to addiction recovery programs…. Always a challenge, particularly in urban areas but also in rural areas. We support addiction recovery with an emphasis on early intervention. Our healthy communities committee has worked towards establishing a role for local governments in the development of mental health care initiatives.

Current work in this area includes contributing to the development of local government action guides as social connectedness through the B.C. healthy communities plan, called PlanH initiative. We also addressed mental health addiction at our 2015 convention. A large urban forum session of the convention profiled the work of the city of Surrey, the city of Prince George and, specifically, the partnership that was developed between the RCMP and their respective health authorities.

Kamloops had a very active program of having a mental health worker ride along in a car with the RCMP at night and at different times of the day. It was very successful and managed to de-escalate some of the incidences that took place. It sounds silly, but an RCMP officer is not fully trained to deal with mental illness issues, and when that mental health worker was with them, it made a marked difference in some of the outcomes of some of the interaction.

We’ve identified a number of effective recovery programs that often require mental health services concurrently. You can’t really have one without the other, because there usually is an underlying problem of mental illness that drives these issues.

That brings me to the end of my presentation. When we talk about recruitment and retention, we see our health authorities doing a lot of work. We see B.C. doctor’s match, I think it’s called…. It’s escaping me. Health Match B.C. That’s the one.

We’re also seeing our local governments chime in and put money in. So the Peace River regional district provides money to Northern Health to do recruitment and retention. The Cariboo Chilcotin regional hospital district provides money to the health authorities to look for recruitment and retention. We modelled it somewhat after the Creston experience, but we’re doing that through the divisions of family practice so that the doctors are driving it, and it’s not being done by a person out of city hall, for example. Because if you lose that person, you lose the initiative to do it, and it’s a wasted process.

Through the divisions of family practice we’ve found that once the doctors took ownership, it really went a long way to making things more successful, because they were, sort of, the drivers of the bus, and we helped fuel along. The partnerships with the health authorities have really, actually, made some differences, in our region in particular, and we look forward to more successes.

But challenges in health care…. I don’t think money always solves it. It’s difficult. But we really appreciate what has been done, and we’d like to see some more, par-
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ticularly in rural areas with the challenges of health care professionals. So when we go through rural maternity services surgical information, and we cut that service out, we lose the ability and attractiveness of a doctor to come to a small hospital. We have to find some way to balance the challenge of being sued or having some malpractice situations out of that versus providing a service.

We had a situation in our small hospital once where a fellow from IH was injured in a car accident, was taken to a small hospital and received surgery immediately. He was very thankful that was available. But today the same service may not be available because we’ve lost those people. So it’s a challenge to find the people who will come to rural communities and offer those types of surgical services at a rate that gives the government comfort that there’s not a risk.

But sometimes, when people have been doing C-sections for 30 years…. I suspect it’s somewhat like riding a bike, and you don’t forget that. My doctors say: “We know what we’re doing. Train us some more. We’d like to do the work.”

S. Robinson: Well, thank you, Al, for that presentation. I’m thrilled that you’re here. I think it’s the right place to hear from local governments. This is our sixth day of hearings, so we’ve heard from, probably, 60 different groups and organizations.

We’ve heard from a number of presentations about the role of community, particularly in rural, around being at the table around integrated health care and making sure that the community is, sort of, represented when it comes to health care, that there’s a role that communities play in making sure that people aren’t isolated, that they’re part of a larger group of people, that they’re socially integrated, but also making sure that physicians and their families are welcomed to the community. That’s been part of the issue.

My question to you is: where does…? I recognize that the UBCM represents a large membership. Where do you think the UBCM would position around the role that they would play, that local governments would play, around ensuring that we have integrated health care in all of our communities?

A. Richmond: Well, we would support that. I think it’s a difference as to how the community approaches it. Sometimes it’s based on the need that they experience. If you lose all your doctors, you suddenly become very motivated.

The success of being involved — in this case, our region providing funding through the divisions of family practice…. We had an experience, I guess I would say, for a doctor that came from South Africa. Here’s a misconception as to what you think: you’re getting a doctor.

He came with five children and his wife. Interior Health — the person who would normally do this work — hadn’t filled the position of doing recruitment and retention for four years. The mayor of 100 Mile House and I drove to Kamloops in our vehicles, we picked up the family, and we brought them home. We had a realtor donate a house to live in for a month. I had to go to the local car dealer to get him to donate a car. Then we found that they had no furniture and they had no money. We got a call from a furniture store, saying: “Could you underwrite the loan?” We can’t do that.

We found furniture for them. We found things for them. We found that we had to get engaged. That’s what spurred on how we do our red carpet treatment. When they come now to even look at us, we show them everything. We take them out for lunch. We show them our community. We say: “Here are our physicians. Here are our facilities.”

In this case, with this doctor, he’s still in 100 Mile House. The high school principal sold that family on that community, when they were looking at Salmon Arm and Clearwater and a few other places, based on his philosophy of education. If the community is involved, and if the school is involved…. It was July. I called the school principal. I said: “I need you to give me a hand, because we’ve got to show these people what our community is all about.” He came in.

That’s the community involvement we have to have. I think it’s there, but unfortunately, some local governments will say: “It’s not my responsibility. It’s a provincial responsibility.” I do agree that it is, but you can’t do it alone. You’re stronger if you can work together.

I use that example regularly as to what it meant to that doctor. Now we have divisions of family practice. We have someone hired to do it. But they still call us. “Can you meet this doctor? Can you take him for lunch? We’ll pay for lunch, but would you engage with him?”

The other part to that is having something and somewhere for the spouse. We’ve lost physicians because there are no jobs in our communities for this person who is highly trained. You can only have so many dietitians. It’s a challenge.

You can get them engaged. We stand on getting engaged as local governments. Sometimes it’s a push in some places. But closer to you, in Port Moody, on a healthy communities committee, I heard how many people in Port Moody couldn’t get a doctor.

A. Richmond: Eight thousand in Kamloops can’t get doctors. My daughter-in-law was lucky. She got a doctor for having my grandson. But it’s not just what you think it is. It’s not just the rural outposts. We just have a short-
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age, and we know we have a shortage. We need to train more, but there are some limitations on how quickly you can turn them out.

I think people need to be engaged. UBCM’s encouraging people to be engaged. But there does come the fiscal reality. Go back to the old thing that I continue to say: local government has one source of revenue, and that’s property-based taxation. We have to be really cautious with how we spend that money and allocate those funds, because our taxpayers tell us really quickly if we get it wrong.

I have a question. We have heard from a number of people, especially in rural B.C., but not exclusively…. It’s not that I don’t think there’s a big appetite on this committee. Our mandate is not about how health authorities ought to be structured or not structured. But we’re certainly hearing a lot about there not being enough of a community voice, not enough listening to the community about what the needs are in that community.

The mandate of this committee is very much to look at strengthening team-based care in communities, because it takes a team to deliver health care. Do you have any thoughts? I’m not asking you to go back and say what…. We had health boards before which had a community voice. Has UBCM given any thought, or have you given any thought, to what a community voice looks like today in ensuring that the teams in health care, especially primary care, meet the needs of communities?

A. Richmond: From our membership’s point of view, the membership has called for the ability to have elected officials on some of the health authority boards. They’ve done that.

My experience…. We have a split personality in the Cariboo, because we straddle two health authorities. We work with both Northern Health and Interior Health. I was chair of the hospital district when that split happened. Previous to that, I also served on the hospital board for 100 Mile. We actually had a hospital board that ran the hospital. I also served on the community health council.

So since 1993, I’ve been involved with health care in my community. It’s sort of my passion. You might have noted that.

When we first started, Interior Health was No. 1. Northern Health, based on its leadership, just didn’t cut it. Today? Northern Health understands rural health more than Interior Health does. There’s been a change in Interior Health. We’ve seen Chris Mazurkewich come back. We see a new chair, and we’re seeing re-engagement of how the community can have involvement.

Some of our members want elected people on these boards. I’m quite happy if they come and listen to me and I get things done. If they listen, if the leadership…. If you take someone like Charles Jago, you just don’t find many of those fellows in Canada — forget about British Columbia — who has brought leadership and direction and passion, and his CEO, Cathy Ulrich. You just don’t find better people than that.

So Chris Mazurkewich coming on board, back to B.C. Chris is a very firm individual. You might not like what he says, but at least you know where he stands, and you can have a debate with him.

We need to be engaged. I can’t comment for how they do it in AVICC on the Island or how they’re doing it with Fraser Health or Coastal Health. I think the people that are there are there for the right reasons, but there has to be more incentive for them to get involved and engaged more with the communities. I think when we ran the hospital, if you asked the people in the 100 Mile hospital, when we ran it with it with local people, they were probably happier.

Do I want to see any government take and turn us upside down and say: “We’re going to look again at health authorities, and we’re going to go back to something else”? I’m going to tell you that if I see one more assessment of facilities and another dynamic in how we’re going to manage health care…. I’d say: make what we’ve got work, and don’t tinker with it. My experience has been that when you turn it upside down and say, “We’re going to start new,” you’ve got five years of studies, and studies don’t provide health care.

I think we need to fight to make it work. I’m prepared to make it work. I would never recommend to anybody that you throw everything out. I think you need to work with what you have. We have experience working with both. They both have their pros and cons.

J. Darcy (Deputy Chair): Well, no. It’s not about the restructuring. It’s specifically about the community voice. Certainly, we’ve had the occasion, some of us, to meet with the Northern Health folks, including very recently, and you’re absolutely right.

In Northern Health, also, necessity has been the mother of invention. There’s a whole lot of innovation, really good innovation, happening there in primary and community care.

A. Richmond: Well, the primary care clinic just opened in Quesnel. Here’s the difference, though. They opened that. The hospital district funded 40 percent of that, of which it’s a leased facility, so it’s not something we normally do.
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Doctors have come back. They’d left to come to Vancouver Island. They’ve come back to Quesnel because of what that’s offered them. Our concern is that they’re going to look at these primary care facilities and look on the basis strictly of a dollar value versus a service value, and you may lose them again.

But actually, that primary care clinic, if you want to look at what happened with what Northern Health did in Quesnel, has brought back…. I think it’s two doctors. Both left the community of Quesnel, went to Vancouver Island and have come back because of the values and what they see in the primary care clinic in Quesnel.

The difference is that when we had a meeting in Quesnel more recently, Chris Mazurkewich and one of his capital planning people took the time to tour that facility. He said: “We probably need to look at doing more of these.”

I’m afraid that one time, when you look at what they’re providing, it may not fit the actual fee-for-service billing. They’re doing a little bit more, and I think sometimes we need to do a little bit more. But it’s a structure, and it’s just difficult. The doctors here probably know better than I do this stuff. It’s a challenge.

My doctor says to me: “I wish you could help me get funding so I can have a massage therapist and a physiotherapist in my clinic. But I have no ability to do that, because they come in, and I can’t get them that kind of help. I’ve got to send them somewhere else.” They say: “If we had the ability to form a better care clinic and had the ability to bill for this stuff, it would be better.”

So small steps. It won’t be fixed tomorrow, but we’re just going to keep trying.

A. Richmond: No problem. We’ll leave you something, and thank you for the time. Appreciate it.

Access to on-line versions of the report of proceedings (Hansard)
and webcasts of committee proceedings is available on the Internet.

6) Drug Prevention Network of Canada	David Berner
	Chuck Doucette
7) British Columbia Humanist Association	Ian Bushfield
	David Byron Wood
8) Apotex	Heather West
9) Society for Canadians Studying Medicine Abroad	Rosemary Pawliuk
	Praveen K. Vohora
10) British Columbia Association of Traditional Chinese Medicine and Acupuncture Practitioners	Joseph Ranallo
11) Dr. Paul Farnan
12) BC Doctors of Optometry	Dr. Gurpreet Leekha
13) Union of British Columbia Municipalities	Al Richmond

Chair:	Linda Larson (Boundary-Similkameen BC Liberal)
Deputy Chair:	Judy Darcy (New Westminster NDP)
Members:	Donna Barnett (Cariboo-Chilcotin BC Liberal)
	Dr. Doug Bing (Maple Ridge–Pitt Meadows BC Liberal)
	Marc Dalton (Maple Ridge–Mission BC Liberal)
	Sue Hammell (Surrey–Green Timbers NDP)
	Dr. Darryl Plecas (Abbotsford South BC Liberal)
	Selina Robinson (Coquitlam-Maillardville NDP)
	Dr. Jane Jae Kyung Shin (Burnaby-Lougheed NDP)
	Sam Sullivan (Vancouver–False Creek BC Liberal)
Clerk:	Kate Ryan-Lloyd

1) The Last Door Recovery Society	Giuseppe Ganci
	Jessica Cooksey
	Daniel Marks
	Tyler Dovey
2) Canadian Mental Health Association, British Columbia Division	Barb Keith
	Bev Gutray
	Jonny Morris
3) Edgewood Addiction Treatment Centre	Lorne Hildebrand
4) Dr. Ray Baker
5) Indivior Canada Ltd.	Cameron Bishop

REPORT OF PROCEEDINGS(Hansard)

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REPORT OF PROCEEDINGS
(Hansard)

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