The committee met at 10:02 a.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome, everybody, to the second meeting of the select standing committee, where we’re taking witness testimony. We have two witnesses here today that we’d like to welcome on behalf of the committee.

Thank you for your time and your preparation to attend.

We’re all on the traditional territory of the Lək̓ʷəŋin̓əŋ-​speaking people, the Songhees and Esquimalt First Nations.

We’re going to start with Dr. Gustafson. I think each presenter has 20 minutes. Then we’ll go to 40 minutes of questions and answers afterwards.

I would like to welcome you.

Dr. Réka Gustafson is the vice-president of public health and wellness, Provincial Health Services Authority, and deputy provincial health officer, and is from the B.C. Centre for Disease Control.

I want to tell everybody that’s listening that there is a presentation — that we will all see — that you will be able to access after the presentation, to take a look.

Briefings on
Drug Toxicity and Overdoses

B.C. CENTRE FOR DISEASE CONTROL

R. Gustafson: Good morning, everybody, and thank you so much for having me. Please let me know if I go longer than my 20 minutes. I will try not to.

I’m very grateful to be meeting with you here today on the traditional lands of the Lək̓ʷəŋin̓əŋ-speaking peoples as well as the Victoria Métis chartered community.

The first page that’s in front of you — I will describe it to those who are on the line — is an analysis that the B.C. Centre for Disease Control has done to try and put the magnitude of the impact of the overdose crisis on our population into context.

[10:05 a.m.]

You see two graphs. On the left side, in descending order, are the potential years of life lost due to a variety of conditions. Potential years of life lost in our population is a really important measure, because it not only measures what people die of but how young they die. We all have a life expectancy, or as a population, we have a life expectancy at birth. If you die younger, then there is a greater number of potential years of life lost.

What I’d like to bring to your attention is that illicit drug toxicity is the second-highest cause of potential years of life lost in British Columbia. If you look at the median age of death among the conditions listed, such as malignant cancers, heart diseases, stroke, it is by far the youngest median age of death of the population, at age 44.

To compare that to a little bit…. Again, it’s not one versus the other, but to put into context of what we’ve just been through together with the COVID-19 pandemic, COVID-19 was the sixth potential years of life lost during this pandemic period — by the way, these graphs represent the pandemic period — with the median age of death at 82.

On the next graph, this information is a little bit further analyzed and looking at what the top causes of death are in various age groups. Overdose is the top cause of death for young adults and the top preventable cause of death for children. If you look at 19 to 39, look at the absolute number of deaths and how many times more it is than any other cause of death in that young adult population, in that population who are in the prime of their lives. If you look at children under 19, it’s the third top cause of death after perinatal conditions and congenital conditions, and these are not necessarily preventable causes of death. At 40 to 59 years of age, it is the second cause of death.

The importance of these analyses is to really put into context where the overdose crisis sits in the magnitude of the harm that’s being caused to our population. It outstrips the magnitude of the COVID-19 pandemic. That’s, in part, due to the cross-governmental, cross-sector response to the COVID-19 pandemic. And it does give us a sense of what it takes to respond to a crisis of this magnitude. It is essentially the equivalent of a Boeing 727 crashing in British Columbia every month.

The next graph is really what got us here. Well, as you know, the public health emergency due to the overdose crisis was declared in 2016. But then there was an additional…. And we were actually making significant progress, albeit incremental progress, but progress was being made. And then the pandemic arrived, and substantial societal restrictions were put in place to control the pandemic. What you will see on the next graph is an immediate increase in the number of deaths due to overdose in our population, which began as soon as pandemic restrictions were put in place. That increase has been sustained and, in fact, increased further in November of 2021.

What were the drivers? Well, we know from our experience and also from analysis done at the B.C. Centre for Disease Control that three interventions combined — overdose prevention sites, naloxone distribution and opioid agonist therapy — do reduce the risk of overdose death in the population.

In the first graph, you will see that what happened after the introduction of the pandemic measures was an immediate and precipitous drop in the number of visits to overdose prevention sites. Basically, what happened is that after five years of creating safer spaces for people to use and have their overdose responded to, should it occur, we put restrictions and recommendations in place that advised the exact opposite.

On the next graph, you will see the take-home naloxone distribution services, which did continue throughout the pandemic, although there was a brief period of drop in January 2020. And then on the next graph, you will see that there was a substantial decline, an immediate decline, in visits to health care services.

[10:10 a.m.]

If you look at what was put in place in order to manage and respond to the pandemic, all of them suddenly declined when the pandemic restrictions were put in place. Many of these, however, recovered over time, and the deaths did continue to increase.

It is important…. With respect to this last graph, I would like to also point out that contact with the health care system…. Although the loss of contact with the health care system had an impact, contact with the health care system by itself was not enough to prevent death. You know, from the coroners death review panel, that 72 percent of those who died in B.C. from August 2017 to July 2021 had a visit with a health care professional less than three months before their death, and 87 percent the year before their death.

A chart review done by Vancouver Coastal Health had very similar numbers. Additional information that came from that chart review showed that the vast majority of times the provider knew of the individual’s substance use, yet linkage to care, by and large, was not made for a variety of complex reasons.

We know that there can be substantial improvements within the health care system to prevent death. I won’t be focusing a great deal on those.

Here I would like to draw your attention to some very important work being done at Vancouver Coastal Health’s regional addictions program. I understand that, throughout your deliberations, you will have an opportunity to speak with the health authorities as well.

The next graph is about opioid agonist therapy. Opioid agonist therapy is the current evidence-based treatment for opioid use disorder. It’s kind of a busy slide, so I’ll walk you through it.

There are a number of things that are important to know about opioid agonist therapy. If you look on the left side of your blue bar graph, you’ll see the number of people who are estimated to have an opioid use disorder. Then the descending graphs show you the proportion of that population who have been diagnosed with an opioid use disorder, have ever been on these treatments, whether they’ve been recently on it and, as it descends, if they are on it today. What you will see is that although opioid agonist therapy is the evidence-based treatment for opioid use disorder, the retention in that treatment is extremely poor in our population.

What you’ll see in the little graph on your right side is a study that demonstrates that, for those who are on opioid agonist therapy, it remains protective against death, even in the context of the fentanyl contamination of the drug supply. But a very, very small proportion of people are retained on this treatment.

Again, there are complex reasons for this. There are multiple complex reasons for this. One of the reasons, however, is actually open to relatively short-term intervention. That is that the range of medications that are provided do not include even second-line medications such as diacetylmorphine at this time in British Columbia. While the system of care will need to be improved, there are some short-term, immediate improvements that could make those treatments much more effective.

The other thing I would like to bring to your attention with respect to this information is that this relates to people with opioid use disorders. People who have an opioid use disorder are not the only people at risk for an overdose death. Again, referring back to a chart review that was done at Vancouver Coastal Health in 2017…. At that time, only about 40 percent of those who died in that year actually used opioids regularly. There were multiple other substance use disorders diagnosed. While this is an important evidence-based treatment, this is not the only population at this time who’s at risk for an overdose death.

I would also like to just draw your attention to the number of people, even in this subpopulation. In 2018, it was 100,000 people. The sheer size of the issue is something that means that we need to think about and implement interventions that aren’t incremental. They are commensurate with the size of the issue.

I would like us to go back, just for a moment, to what we did for COVID-19, how we responded as cross-government, cross-sector to a crisis of this magnitude. I’m hoping I can impart that to you. I think it’s a really important thing to consider. We are not in a situation where incremental improvements are going to address the magnitude of the issue.

[10:15 a.m.]

This is probably a graph you’ve seen many times. One of the things that you will find…. In case you lost me, it’s “Restarting services.” This is from the Coroners Service. What we will see is that restarting services after the initial restrictions has not decreased deaths. Deaths have continued to increase.

You will see on this graph that after the declaration of the overdose emergency, deaths continued to increase, then stabilized, then declined in 2019. Then, in 2020, they increased rapidly, and they have continued to increase. The main driver of this increase is the increased toxicity of the drug supply.

This graph, also from the Coroners Service, shows you that after the start of the pandemic restrictions, the proportion of people who had a very high concentration of fentanyl detected in their blood supply after they died increased immediately, continued to increase or remained high. So that is the most proximal and significant driver of the current increase in deaths.

The reason I emphasize this is because the overdose crisis is a complex crisis. It is a complex crisis with many, many drivers: poverty, stigma, colonization, childhood trauma. It is incredibly important to think about those drivers. But in the current emergency, it’s also really, really important to think about: what is immediate? What is actually driving the number of deaths that are occurring today? And the primary driver of the number of deaths that are occurring today is the toxicity of the illegal drug supply.

Based on this information, as you know, the B.C. coroner convened a death review panel. I had the opportunity to be on that death review panel. Three recommendations came out of that death review panel.

The three recommendations.

To ensure a safer drug supply to those at risk of dying from the toxic illicit drug supply — I will probably spend most of my time focusing on that today.

The other is to develop a 30/60/90-day illicit drug toxicity action plan with ongoing monitoring. That’s a really important recommendation. It reflects the urgency of this issue. Every day that we don’t act, six more British Columbians die.

The third is to establish an evidence-based continuum of care, recognizing the gaps in our system of care and the fact that there is a significant amount that we could do in the health care system that we aren’t doing right now. By itself, it won’t solve the issue, but there are significant improvements to be had in the health care system.

I’m going to talk a little about that first recommendation, which is to ensure a safer drug supply to those at risk of dying from the toxic illicit drug supply. Before I do that, I’d like to go back to the recommendations for a moment.

There are three recommendations there, and those three recommendations also reflect that it’s not one or the other. Some of our conversation has been treatment versus safe supply. That is not the conversation that we need to be having. It really is a question of both and the full spectrum of services that people require in order to stay alive. That full spectrum of services does include prevention: early childhood prevention, early childhood development, investment in children, investment in youth programs in a systematic and population-level way.

I do not want to leave this conversation without talking about that. I’m a public health doctor. I can’t not talk about prevention.

The recommendation that I would like to focus on is that first one. Really, it’s about making available alternates to the illegal drug supply. The prescribed alternatives that are available today are life-saving for some, but it, by itself, will not be effective. It isn’t in the appropriate scale, and it isn’t necessarily appropriate for everybody.

[10:20 a.m.]

There are significant limitations to the models based on one-to-one medical oversight and prescriptions. You cannot scale that system to the magnitude of the problem, to the tens of thousands of people at risk of overdose.

Most physicians, quite rightly, are reluctant to prescribe. Frequent physician or nurse-practitioner intakes and reassessments are required. Current pilot projects support an insignificant proportion of those at risk of overdose death. The medications for many are really poor cousins to what’s available illegally. And many of the physicians who are trained to prescribe these medications and do so are experiencing significant moral distress, knowing that what they’re providing is simply not enough.

These services are also a very high barrier to a number of individuals. It misses those who do not access health care or who do not want a record of their substance use. Daily pickup at a pharmacy is highly disruptive compared to the access to the illegal market. It essentially traps people in a system that does not allow them to manage their lives and manage their substance use in the context of a life that contains all sorts of other things that are important for individuals — work, social connections and, really, just participating in society.

The other challenge we have at this time is that the regulatory bodies and federal and provincial policy frameworks really have not kept up with the need for innovation to address the rapidly evolving drug toxicity crisis.

To meaningfully address the drug toxicity crisis, we do need, ultimately, a tightly regulated market with consumer protections akin to those for other legal substances. On the left, you will see a U-shaped curve. I’m assuming you’re all familiar with that U-shaped curve, but what it describes is our understanding of how the regulatory framework in which psychoactive substances are consumed in our population can cause significant harm. We know that a completely unregulated illegal market maximizes harm, and an unregulated legal market also can maximize harm.

The unregulated legal market is what we had with tobacco for many years. The unregulated illegal market is what we have with opioids and stimulants today. We have many decades of experience that tell us that to minimize harm, to get to that bottom of the curve with respect to harm, you need to be in the middle.

We need to go for a regulated market with consumer protections as well as a variety of features, such as legislation that allows legal production and distribution of substances of known purity and potency, pricing that strikes the balance between undercutting the illegal market but still high enough to decrease use. You have to acknowledge that we are currently in the context of an illegal market.

There’s clear and accurate labelling. There are advertising bans and other measures to prevent initiation of new users, and restrictions on access that disincentivize use, not prohibit it. That’s just a small portion of the types of regulations that we would have in a regulated market that we know minimize harm to our population.

What can we do right now? That’s a big task. We know that systems transformation takes time, but we can still act now to save lives. One of the most important things that we can do right now is to support the rapid implementation and evaluation of non-medical models of safer supply. The decriminalization work that is currently being undertaken has many benefits. Among its many benefits, it decreases the risk of innovative community programs that support people who use drugs.

One of the important things that I’m going to spend a little bit of time to talk about is to support models of access that involve payment for substances. That payment really is acknowledging the fact that we are operating in the context of an illegal market.

On the next slide I’m sharing with you, I had the opportunity to take this information, or to receive this information, from Vancouver Coastal Health and Providence Health Care’s regional addictions program, looking at the range of non-prescriber models that are being either developed or are in place and evaluated right now. The reason this graph — it has lots of little print on it — is important is because it emphasizes that it’s a range of interventions that we are looking at.

[10:25 a.m.]

One of those interventions that I will just describe in a bit more detail is this enhanced access model, which the Portland Hotel Society has implemented recently. It does take us, again, incrementally closer to the public health vision of a tightly regulated market. Purchasing the substances is a key component.

It consists of a physician assessment of the risk of overdose. Again, it’s the physician assessment of the risk of overdose. Are you at risk of dying?

Then a prescribed, pharmaceutically manufactured and compounded powdered fentanyl for witnessed consumption, eventually moving to a prescribed and pharmaceutically manufactured compounded powdered fentanyl for at-cost purchase for take-home.

These enhanced access and other paid purchase models have important advantages that I’d like to spend a little bit of time on. They vastly reduce the incentives to diversion, particularly the more harmful types of diversion. There’s real-time feedback on consumer preferences that drive evidence and innovation. It incentivizes treatment of addiction, because the treatment substances are available for free for individuals.

If you’ve got purchasing medication, and there’s an alternative that you’re not purchasing, that’s an incentive. It does not encourage increasing dependence on high doses of the drug. It does not preclude making prescribed products available at no cost to select populations. It requires less medical oversight for each individual enrolled and has greater capacity. As you know, capacity is one of our rate-limiting steps.

It’s available to those who do not meet the criteria for a diagnosis of a substance use disorder. It functions within a current regulatory and legal environment. It is critical, therefore, to maintain the option to purchase at cost for take-away doses. That’s a policy decision that is actually being currently considered, of adding some of these medications to the provincial formulary.

Counterintuitively, that may actually close the path to a scalable model that’s available to a larger number of individuals. So I really do encourage you, before making any such a policy decision, to engage, in a meaningful way, the people who are actually delivering these services to ensure that a well-intentioned policy doesn’t actually close the path to a sustainable and scalable model of providing individuals with care.

The potential for these public health models…. Really, they’re the only models that can scale to the magnitude of the issue. There is no capacity in our current health care system to provide a medical model that will scale to the magnitude of the issue. It’s also not just a medical issue. Therefore, medicalizing this issue does not necessarily solve the problem. These kinds of public health models would need to be subject to real-time, independent evaluation and feedback, and feedback from participants, to generate evidence in a rapidly evolving drug toxicity crisis.

You will often hear the term that some of these things aren’t evidence-based. Not all of them are. Many of them are evidence-generating. The real advantage of both implementing and evaluating these programs in real time is that we can adjust to a rapidly evolving toxic drug market.

It is important, again, for us to stop and think about the magnitude of this issue and maybe compare it to our most recent crisis. Not everything that was implemented was necessarily based on a randomized, controlled trial over the last two years. What we can commit to in a crisis is to implement in a careful and rigorous manner, evaluate and use the evidence to adjust the models as necessary.

These kinds of public health models are complementary to investments in prevention and therapeutic programs in an integrated system of care. I would like to take a moment, as I didn’t spend a lot of time talking about it, to just share with you one image of what we mean by an integrated system of care.

It starts with prevention. It starts with addressing the drivers of the opioid crisis, which are broad-ranging and start with adverse childhood experiences, poverty, stigma and colonization. Early identification and early intervention for populations and individuals at risk, overdose prevention for those who are already using, withdrawal management, treatment supports, supportive housing, and recovery and community supports. That integrated system of care is not in opposition with the safer supply recommendation. It’s complementary to it.

[10:30 a.m.]

I would like to leave you with…. Thank you very much for your attention. It’s really just that B.C.’s public health emergency related to the overdose continues to worsen, despite an ongoing response that is now in its sixth year. The scale of the problem is well beyond the capacity of the current models of response. There’s now an imperative and an opportunity to enable the establishment an ongoing evaluation of a non-medical safe supply to complement investment in therapeutic programs and an integrated system of care.

I was on the other end of the phone when a phone call came from the Minister of Health to implement overdose prevention sites in 2016. That was an opportunity to make a fundamental shift that supported a change in the regulatory and legislative framework to address the crisis we had on hand. The crisis is different now. It’s of even greater magnitude. Again, there is a very similar opportunity now to support the non-medical models to address the issue at hand.

I’d like to thank you for your attention, and I’m happy to answer any questions that I can.

N. Sharma (Chair): Thank you so much.

Please raise your hand if you have a question. I’ll try to get to everybody.

I see MLA Leonard and then MLA Chant.

Go ahead.

R. Leonard: Thank you very much for your presentation. I have two questions. Just stepping back and looking at the overall picture — on one of your slides, you talk about the enhanced access model. It starts with a physician assessment of risk overdose. How does that jibe with the notion of a non-medical supply?

And then I had one other question, which is…. I don’t know if you could see my confused face when you were talking about expanding the provincial formulary so that doctors can prescribe a range of alternatives that don’t fit into, necessarily, the intended purpose.

I don’t quite get how it’s counterintuitive, and what is the solution then?

R. Gustafson: Those are two different questions. The enhanced access is a model that is being implemented right now, which is why I was sharing it with you. One of the things I emphasize is that it’s an incremental step toward that non-medical safer supply. It’s an incremental step because it does still require a physician assessment.

However, it’s a one-time physician assessment for some. It isn’t that day-to-day medical monitoring necessary. It allows people to take away medication, so they don’t have to keep coming back for daily monitoring. It’s an incremental step. It is one small step away from the daily medical monitoring model that really isn’t sustainable and traps people.

What I would say is that it’s just one example of the many models of non-medical. That one is still medical. That model is more amenable to expansion than the many models that we have in place right now that rely on that observed ingestion or observed consumption. But it isn’t the scalable model that some of the even less medical models that are being proposed now can provide.

If there is an initial intake that can programmatically be provided to non-physicians and non-clinicians, the capacity to expand and the acceptability to the people who use these substances increases exponentially.

So you’re absolutely right. It’s one example, and I put the word “incrementally” for a reason. But it is starting to look at some of those features that will need to be important to consider in a non-medicalized model, which is a reduced medical oversight — perhaps medical oversight at a programmatic level rather than at an individual level and an ability to take away your doses with measures in place, such as paid access, that reduce the risk of a diversion.

Thank you for asking for that clarifying question. Can you repeat the second question?

R. Leonard: It was around the provincial formulary and how it’s counterintuitive.

[10:35 a.m.]

R. Gustafson: Oh yes. There is some consideration at the moment to put some of the medications, such as powdered fentanyl, on the provincial formulary. That would make them accessible, or, essentially, it would enable a prescription for free. If we think about that, it would seem that that’s a good thing to do, right? We are making available for people the medications or the substances that they want to use for free.

However, experience from similar programs has told providers that that actually increases a number of things and reduces safety. It increases the likelihood of diversion. It increases the incentive to increase your doses. So a parallel system that allows for free but observed consumption of the product or at-cost paid access if you take it away acknowledges the fact that individuals who are using substances right now live in the context of an illegal supply.

We need to think about what other options individuals have when we design our programs. Purchasing your substance which is of known composition and known purity is a clear advantage than purchasing it from the illegal market, where it can be contaminated and it can kill you. That’s what I meant by saying it was counterintuitive, because in many ways, it could seem like one is limiting access. But in fact, it’s making sure that access is provided in models that are scalable and can exist safely in our current context.

S. Chant: Thank you for your presentation. I appreciate it.

You talked about a couple of data sets, including one out of Vancouver Coastal Health, etc. Is there sufficient data to look at…? B.C. is vast, geographically; it’s vast, population-wise. We’ve got urban, suburban…. You know. I’m talking to the choir here. It seems to me that those different areas and populations actually may need different solutions to their issues. Do we have enough data that allows us to start looking at those kinds of solutions — that’s disaggregated enough that we can start looking at different things with that lens?

R. Gustafson: Thank you very much. That’s a really important question. There are two parts to the answer.

It is a broad, provincewide issue. Overdoses are happening everywhere in the province. But the situations in which people live and in which people are using their substances vary widely, so we do need to understand the local context. The local context — the knowledge of local public health as well as people who are providing services at the local level and people with lived and living experience at the local level — is key.

With respect to data, it’s not the amount; it’s the timeliness. That’s one of our biggest issues. We do have linked data sets, for example, available to us for people who died of overdose. We link the coroner’s data with the medical data to understand what the experience of those individuals was with the system when we interacted with them. We recently received the 2020 data. It’s 2022.

So I think what’s really important is to prioritize the real-time linkage of overdose data in the same way we did for COVID-19. Think about the amount of daily information available to us for COVID-19. We need to do similar data linkage with a similar rapidity so that we get real-time information.

This is a rapidly changing situation. Often, by the time you’ve analyzed the data…. If we analyze data from 2020 today, the information is still valuable but largely out of date.

S. Furstenau: Thank you for the presentation. I just want to parse through a few different things in here. You indicated the increase in deaths at the beginning of the pandemic, when the restrictions were in place, but that those deaths continued to increase afterwards.

[10:40 a.m.]

Clearly, as you point out, there’s a driver here that is the toxicity of the drug supply. That is really critical. I know that in Duncan, for example, we had the mayor of Duncan and John Horn from Cowichan Housing set in motion a lot of work at the beginning of the pandemic to provide housing and wraparound supports for people.

I’m curious about whether the data shows…. In some regions where that kind of proactive step was taken, did those increases in deaths match, or were there areas that actually succeeded in limiting the harms and deaths that were happening at that point?

Secondly, you identified that we need interventions that are not incremental and need a response commensurate to the magnitude of the issue. Then, in your response to MLA Leonard, you said that enhanced access represents an incremental step. What is the non-incremental step that needs to be taken?

R. Gustafson: Thank you. The first question. Whether we have granular-enough data to show that those kinds of interventions actually led to an overall reduction of overdose in those communities…. I don’t have that information for you.

What those interventions did, however, show is that it was possible. We actually implemented interventions during the COVID pandemic that are very similar to some of the recommendations that I spoke to you about here. In order to support people to isolate from COVID, we made sure that they had access to the substances that they were using, in the form and the way that they needed to use it. It was possible during COVID; it’s possible now. I think that’s probably one of the single biggest things that we learned from that.

The drivers of the overdose crisis during that time likely overwhelmed any other potential local interventions. That would be my concern. But it would be worthwhile looking at it at a granular-enough level to look at whether or not it had an immediate impact on deaths in those communities.

With respect to what the non-incremental step is, the non-incremental step is demonstrated in the U-shaped curve. It is a commitment to a regulated drug supply. A legal, regulated drug supply is the non-incremental step.

There is a large incremental step that we could take, which is non-medical safer supply models. The least medicalized and the most scalable in the context of ongoing evaluation is probably the biggest step we could take to address the issue right now.

T. Halford: Thank you for the presentation. When you look at the numbers…. We saw them come out yesterday — 165 for the month. For my age demographic — I know this firsthand through people I’ve gone to school with or neighbours — they’re not individuals that I would assume would want access to safer supply. They’re hiding their drug use. They’re doing it in their basements, their living rooms, when people are going to sleep or when they’re alone, after work.

That, to me, is a major challenge, because people don’t know they’re using, or they’re not confronting them on their using, and they’re using alone. It’s oftentimes too late. But these are not people that I would think, going through your presentation, would want to be seeking out that assistance. Some of the people that I’ve talked to have said: “Oh, well, what I do is go online. I go to Walmart, and I buy drug-testing kits. That’s how me or my partner or others actually have comfort in what we’re taking.”

Just your comment on that approach for people that probably are trying to hide their usage — whether or not that’s something that you’ve seen in other jurisdictions that’s working. What are your thoughts around that?

[10:45 a.m.]

R. Gustafson: The safer supply models. I think one of the important things to remember about them is they’re not yet completely formed. So that ongoing evaluation and monitoring is there to monitor safety and monitor access. Why would those individuals not access the current models? What are the things that we need to do with the current models to make sure that individuals at risk do access them?

The drug testing kits are an important intervention that people can take to basically inform them about the contents of the substances that they’re about to take. In many ways, they’re a do-it-yourself step toward a regulated supply, because when I buy food or when I buy a can of pop, it clearly tells me what’s in it. I’m a public health director. I don’t drink that pop. But for any food or drink that I buy in British Columbia, I know that there was a safety process in place as it was produced. I have information about what’s in it. And if it has any risks associated with it, it says so on the label.

Many of the innovative programs that are being developed are actually trying to emulate that — to do drug testing, make sure that the drugs are labelled — even in the absence of access to a legal supply. These are all really important steps toward a safer supply, so the measures that the people you’re talking to are taking are really in line with what we’re trying to achieve, and we’re hoping they don’t have to, ultimately.

The last thing I would like to say about that is that you’re absolutely right. I think, in the current context, drug use is so stigmatized that many people will continue to hide their substance use, certainly from their families. One of the things that we want to do with that safer supply is that even if it’s not information you want to share with your family, the substances you take are of a known quantity and a known purity, and you can survive.

D. Routley: Thank you very much, Dr. Gustafson, for this presentation and also for your obvious, lifelong commitment to public health and everything that you and your colleagues have done through this crisis and COVID. On behalf of my constituents, thank you.

I’d like to know: where is the best example of a system that’s come the closest to a non-barriered access model, whether we can look to any kind of example there? What barriers do you see besides federal government criminal law reform? What barriers do you see to unbarriered access? How would you recommend that we overcome those barriers within the time frame that’s been recommended here?

R. Gustafson: Some of the models that people often refer to are in Europe — Switzerland and Portugal. They’re comprehensive models that have significant features that give them advantages — for example, making second-line medications such as diacetylmorphine available to people as part of their opioid agonist therapy, decriminalization, ensuring surrounded supports for individuals.

But I would also like to emphasize that, actually, in British Columbia, we have an incredible depth and breadth of expertise and experience on how to do this. I mentioned earlier the Vancouver Coastal Health regional addictions program, the Portland Hotel Society, the rural programs that are existing in other parts of the province.

What I would say is that if, in your deliberations, you are able to speak to those individuals who are actually doing this work…. I am forever impressed by the rigour, by the evaluation, by the appreciation for the fact that opiates are medications that can do harm, their commitment to make sure that individuals don’t increase their dose or don’t initiate, while at the same time trying to reduce the harm with the current drug supply. So I would say that we have looked at, and people do look at, models that are being implemented elsewhere.

[10:50 a.m.]

I think, in many ways, the processes and the expertise exist in British Columbia today, and we really need to draw on it. We really need to make sure that we engage those folks who are doing the work today and enable them and empower them to do so.

In addition to that — to making the full spectrum of services available — I think exploring what levers exist at the provincial level to ensure that people are able to deliver as innovative programs as possible in the current legal environment….

Again, this is not necessarily my area of expertise, the legal framework, but I do recall the time that the overdose prevention sites were established, even though, in the context of federal legislation at that time, those were restricted. Then by a ministerial order, they became a reality — in some places, within 24 hours. Then working with the federal government to change — I’m going to say it incorrectly, but you’ll be aware of it — the controlled drugs act.

I think a really important body of work is to look at what provincial levers are available now and to ensure that health authorities and organizations are encouraged and enabled to implement these programs with as few restrictions as possible.

I think you had a second point to make.

D. Routley: Just how would you see overcoming those…? You’ve partially covered that. But what do you see as barriers, and how do we overcome them within the time frame?

R. Gustafson: I think, actually, the recommendations of the coroner’s report are a really, really helpful start. That report — I was in the room — gathered a very broad range of experts and stakeholders, and much of the work was done. I think one of the things that’s really important is to have a clear understanding of the magnitude of the issue and the resources that we need to put in place to make it happen.

Again, I think when we look at the fact that it’s the second-highest potential years of life lost in British Columbia after malignant cancers and think through the effort we put into cancer prevention, screening, treatment and primordial prevention, I think we start to get a sense of the magnitude of the issue.

One of the things I would say is that we cannot have pilot projects that serve 200 people anymore. Certainly, that is what we are working with right now. There’s a great deal of innovation and learning that’s happening from them, but pilot projects are not an emergency response.

N. Sharma (Chair): We have about eight minutes left, and I’d like to get to the three other first-time questions that we had.

MLA Bond, go ahead.

S. Bond (Deputy Chair): One of my questions was very similar to Doug’s about: where do we look? I think you’ve given us really good advice, Dr. Gustafson — to look inward, look at B.C. I think it’s imperative that we actually have some of those people present so that we can understand exactly what the model looks like on the ground. That is incredibly helpful.

I just want to observe something that you’ve said. I have felt very strongly about this — the fact that the response to this needs to replicate the COVID response in terms of urgency, real-time information. To me, there seem to be very few barriers for that actually occurring. It’s a matter of making that choice that this needs to be in the public’s eye on a regular basis, as COVID was.

When you look at the numbers…. I can tell you, when I read that overdose is the top cause of death for young adults and the top preventable cause of death for children, one would suggest that would move us rather rapidly to take this on with a sense of urgency.

I very much appreciate the reference to prevention, because while we need to deal with the now, we need to be dealing with the future as well, in order to try to stem the tide. I certainly understand the complexity of the issue, but not using in the first place is actually a pretty good place to be. It should be a common goal that we have. So while I understand Dr. Henry’s comments about, “We can’t stop people from using drugs….” I understand the urgency of the now, but I actually care about the urgency of the future as well and what we do to deal with that.

One specific question. I really want to urge the committee to think about the replication of the COVID response. Dr. Gustafson’s point was across ministries, real-time information, public domain….

[10:55 a.m.]

I’m interested in the retention in OAT and the fact that there is such little retention. That’s a huge issue. You note that one of the challenges is that additional drugs are important and necessary. What is the barrier there other than simply making government aware of the fact that there are additional drugs that would help increase retention in OAT?

R. Gustafson: Thank you for that question. I think Cheyenne, who is going to speak next, actually has a great deal more depth about that information. There are multiple barriers. One is the cost, and many of the logistical barriers that are currently in place due to regulatory requirements of storage, of transfer, of handling, who can dispense and where you can dispense.

There are multiple logistical barriers that have actually been gathered and articulated by those who do this work. I think, again, Cheyenne will probably be able to give you much more granular information about that.

Right now there are some domestic suppliers of dia­cetylmorphine that are being brought online — and again, removing regulatory barriers to ensuring that these are made available at an appropriate scale, when necessary. And there are regulatory barriers both at the provincial level and at the federal level that need to be addressed, one by one.

S. Bond (Deputy Chair): If I might make one additional comment. Not unlike what it took to organize vaccine distribution, handling. All of that was as complicated as what you are describing.

N. Sharma (Chair): Okay. I have MLA Davies and then MLA Starchuk. Let’s try to get both of those with the time we have left with the doctor.

Go ahead.

D. Davies: Thank you, Doctor, for your presentation. I know that the responses are going to be a little long, so hopefully we can get through. I’ve got two real quick questions.

You talked about some of the work being done that is not evidence-based but evidence-generating. I’m not sure if you can talk just ever so briefly, a little more in-depth, of what that means.

My second question was…. It kind of follows up with what MLA Bond had mentioned. If you could just share some of the stuff that the CDC is doing in regards to the preventative piece, the education piece, preventing people from using in the first place.

Those are my two questions.

R. Gustafson: With respect to that term “evidence-generating,” it’s my term, so thank you for catching it. In the context of an emergency or an evolving situation, we don’t have the luxury of lengthy, randomized controlled trials. Those are the types of evidence that we tend to use in medicine.

The option that we have in public health, which we have actually implemented in a variety of such situations, is to implement the interventions based on the best rationale and evidence that we have available to us and commit to ongoing monitoring and evaluation to generate the evidence that you don’t have at the beginning.

We actually changed the system of HIV care in British Columbia based on exactly that. There were interventions that had a strong rationale to improve early diagnosis of HIV. We implemented them and evaluated them as we were implementing them and generated the evidence to fundamentally change the system of care.

That’s what I mean by evidence-generating. We need to be implementing and evaluating at the same time. I hope that clarifies it.

I seem to not be able to remember the second question after I answered the first one. Oh, the prevention part with respect to the B.C. Centre for Disease Control — a really, really important question.

Recently, the B.C. Centre for Disease Control has established a stronger population in the public health workforce that is working very, very hard to make the connections and continue the evidence generation around the mental health and well-being of the population and youth. We work with UBC and our partners at SFU to gather evidence with the early middle years and youth development instrument to look at the mental health and well-being of students.

[11:00 a.m.]

We have had significant interaction with the educational system during COVID. That is going to become an ongoing partnership focusing on the mental health and well-being of young people.

We are actually looking at — again, from a B.C. Centre for Disease Control perspective — an ongoing assessment of the health of the population during COVID. You may recall that we had two large surveys, the COVID SPEAK surveys that were really largely looking at things like how people are doing. How are people doing financially, emotionally, with their substance use, with their education, with their work, with their families?

Our role, as a public health body, is to continue to both monitor and respond to identified issues. Again, addressing the social determinants of health is something that is a cross-governmental and cross-sectoral challenge. That’s where we have recently invested, and by no means is that enough.

N. Sharma (Chair): MLA Starchuk, last question.

M. Starchuk: Thank you, Chair.

Thank you for your presentation. I’ll be as brief as I can.

You touched on, at the beginning…. Toxicity is what’s at hand. That is the main issue that’s there. That is the driver that took this into an upward arrow. As you had also mentioned at the beginning, there was a downward tick before the pandemic had hit us.

Witness consumption is a bigger part of making sure, for that safe supply that’s there…. I liken it, I think, to the way methadone was being utilized years ago. It went from, “Take home as much as you want” — and then your numbers went up — to that daily witness consumption. With that in mind…. You seem to put that out at the front of the table as a solution that’s there for the immediate.

Is there some model that’s out there that says: “This is how we should do it”?

R. Gustafson: Again, the information that this is how we should do this is coming from the experience that we have here in British Columbia. Here in British Columbia, a great deal of information was gathered before and during the pandemic through models that allowed people to have both witness consumption as well as take away doses. The other evidence that we have is that people aren’t being retained in the existing models.

One of the biggest things to keep in mind is…. The burden of evidence is something that is upon any new intervention. We need to gather it as we are implementing it.

At the moment, we have very clear evidence that what we are doing is not working. The other thing that I would say is…. There is evaluation that was done at the B.C. Centre for Disease Control about the risk mitigation guidance. It is important that while it didn’t have sufficient reach, the medications or the substances that were provided through that program did not contribute to increased stats.

I think that’s where your question was coming from. No, those interventions did not contribute to the increase in overdose deaths in British Columbia.

N. Sharma (Chair): Okay. On behalf of this committee, I just want to thank you so much for putting your expertise and time into helping us understand your recommendations and what you’re putting forward — and, really, the depth of the crisis that you’ve presented for us.

We’re just going to take a 30-second break while we switch speakers. We’ll go on to the next topic.

The committee recessed from 11:03 a.m. to 11:06 a.m.

[N. Sharma in the chair.]

N. Sharma (Chair): On behalf of the committee here, I want to welcome Cheyenne Johnson, the executive director of the B.C. Centre on Substance Use.

We’re really grateful for the effort and time you put in, not only to this presentation but to the work you do on a daily basis. We really look forward to learning from you today.

You’ll have about 20 minutes to present, and then we’ll have questions and answers for the rest of the time.

B.C. CENTRE ON SUBSTANCE USE

C. Johnson: Good morning. Thank you all for having me to present to the committee.

To start off, I want to recognize that we’re all meeting today on the traditional, unceded territories of the Lək̓ʷəŋin̓əŋ-speaking peoples, including the Songhees, Esquimalt and W̱SÁNEĆ people.

Additionally, I want to further acknowledge that ongoing racism, criminalization and institutionalization and discrimination against people who use drugs disproportionately affects Indigenous people.

To introduce myself, my name is Cheyenne Johnson. I’m of mixed settler and Indigenous ancestry. I’m a member of the Tootinaowaziibeeng First Nation, which is in Treaty 4 territory in southern Manitoba.

I’m a registered nurse by training. I have specialty training in both the areas of addiction medicine and public health. I’ve worked in three out of the five regional health authorities here in B.C., clinically, as a nurse. I’m currently the executive director at the B.C. Centre on Substance Use and an adjunct professor in the school of nursing.

Today I want to focus my time with you on discussing the toxic overdose crisis and the urgent need for a new approach to prioritize reducing overdose deaths while simultaneously building a substance use system of care.

Why does the toxic drug crisis continue since being called in April of 2016? From the B.C. Centre on Substance Use perspective, there are five broad categories to why we have not seen sustained progress. For the purposes of this presentation, I’m going to focus on the first three, but I would be happy to touch on the others and address them in the Q-and-A portion of this presentation.

These five areas include ineffective and unbalanced drug policy, the fact that despite investments over the last six years, there is still no substance use system of care and that there are large discrepancies in the quality and reach of these services to support people in treatment and recovery, and that these services consistently adhere to the best available evidence.

Although progress has been made, which I will touch on, health care providers are still poorly trained to screen and treat substance use disorders, particularly in primary care. Additionally, due to the complexity of both addressing a crisis and attempts to build a substance use system of care simultaneously, this devastating crisis will today claim six lives in B.C. alone, although our approach, to date, has been incremental.

This is compared to both a national and provincial response to COVID, where expertise and research were mobilized rapidly to set clear goals, targets and clear communications and plans to the public. This is while COVID deaths in B.C. amount to over 3,100 deaths in total.

While incredibly tragic, there have been over 9,500 deaths in British Columbia from overdose since 2016 alone, over three times the numbers we’ve seen from COVID. That sense of urgency, we feel, from a COVID response in B.C., has been entirely absent from the overdose response.

Finally, stigma and discrimination against people with lived and living experience of substance use and habituation to this crisis — six years — plays an important role.

As a brief background to this conversation, we need to situate ourselves and recognize that substance use is on a spectrum.

[11:10 a.m.]

It starts with those who don’t use any substances at all. It moves to beneficial use for those who use medication as prescribed, have coffee and tea as a mild stimulant and ceremonial use of traditional medicines by Indigenous people. It then moves to low-risk casual use, such as low-risk drinking under Canada’s low-risk drinking guidelines, and moves to high-risk use, where there is no diagnosed substance use disorder. However, there are negative health benefits that do not meet the criteria for a diagnosis.

Finally, we have a substance use disorder, which is a diagnosable, chronic and manageable condition with several options for treatment and recovery.

Unlike COVID-19 or HIV, we cannot create a vaccine to cure addiction. We cannot treat our way out of this public health crisis. Substance use to alter our mood has and always will be a part of the human condition. As a society, we can work to reduce the harms of substance use through the creation of a substance use system of care that encompasses disease prevention, health promotion, harm reduction treatment and recovery.

Like other chronic conditions, such as asthma and heart disease, even with an effective system of care — which we currently do not have — substance use disorders will continue to exist. We need to focus on implementing strategies to prevent disease and promote health.

Compounding the challenge that we don’t have a functioning substance use system of care is ineffective and unbalanced drug policy. I think it’s very important to highlight for this committee that fentanyl contamination of the illicit drug supply is a predictable consequence of prohibition. This is such a critical point that I want to state it again in a different way.

Drug policy experts have actually predicted fentanyl contamination of the illicit supply. Data from the United States clearly indicates that the more money we spend on enforcement, the smarter organized crime becomes at finding ways to avoid detection and more easily transport substances across countries and borders. This has been demonstrated for all substances.

Take opioids, for example. Historically, people used opioids in the form of a laudanum tincture or in an opium format for smoking. But with the onset of the war on drugs, opioids became more and more potent in the form of powdered heroin, a more concentrated powdered form that was less weight to transport.

We now see broad contamination of the supply with fentanyl, an opioid that is 100 times more potent than morphine and 50 times more potent than heroin. Drug-checking data from across the province now shows an increasing contamination of other fentanyl analogues, such as carfentanil, and more high concentrations of a drug called benzodiazepines, another central nervous depressant which potentiates the effects of opioids, worsening overdose presentations and making treatment engagement more difficult. Over the last 40 years, the war on drugs has made drugs more accessible, cheaper and higher quality.

Although, over the last several years, there has been a groundswell to better understand some of the root causes of harm, there’s stigma and discrimination against people who use drugs, stemming directly from ineffective and imbalanced drug policy in Canada. These health and social harms have been well documented in the academic literature.

However, it is important to highlight that in B.C., in addition to COVID-19 and the ongoing drug crisis, we have a third crisis: an organized crime emergency. A critically underacknowledged consequence of drug prohibition is the tremendous wealth-generating potential for organized crime and the knock-on effects of money laundering, violence and housing unaffordability in many parts of British Columbia.

Organized crime in B.C. is primarily funded through the illegal drug market. For example, a 2017 B.C. Supreme Court case drew on the conclusion that organized crime groups can cut one kilogram of heroin, worth about $70,000, with about $12,000 of fentanyl and bulking agents, to turn that into 100 grams of counterfeit heroin worth as much as $7 million on the street.

As a member of the provincial core planning table that advised the B.C. government on submitting an application for provincial decriminalization, as well as sitting as an expert on the Health Canada Expert Task Force on Substance Use, which unanimously recommended that Health Canada end criminal penalties related to simple possession, it has been a tremendous few years for those who have been fighting to see change in drug policy.

The progress is promising. However, it’s critical to note that if key components are implemented poorly, such as the setting of thresholds, the benefits of reducing harms for people who use drugs, including overdose and the harms of criminalization, cannot be fully realized.

Researchers at the B.C. Centre on Substance Use provided critical data from several longitudinal research studies, undertaken specifically with the population of people who use drugs in Vancouver, to provide estimates of personal use for substances to be used for decriminalization.

[11:15 a.m.]

While these data have their limitations, some of these studies have been running for over 20 years and offer key highlights and insights into substance use to inform policy. Researchers developed inclusion coverage in the table that you see in front of you to estimate the level of coverage to guide thresholds.

These definitions included limited inclusion, defined as people who use drugs with the most severe substance use covered for less than one day; good inclusion, which is defined as people who use drugs with the most severe substance use covered for a one-day supply; and a comprehensive inclusion, to cover people who use drugs for a multiday supply.

Highly conservative estimates from these data of drug consumption volumes in Vancouver suggest that in order to provide good inclusion — again, that’s defined as covering one day of supply — thresholds would need to be set at four grams for opioids, five for cocaine, 7.5 for crack cocaine and six for amphetamine. Comprehensive coverage, defined as a full three-day supply, would require thresholds to be set higher, at 13 grams of opioids, 14 of cocaine, 22 of crack cocaine and 19 of amphetamines.

Higher threshold levels are also supported by a preliminary analysis of VPD, Vancouver police department, seizure data undertaken by researchers at the B.C. Centre on Substance Use, which was also submitted to the provincial government in September 2021. In order to reduce 75 percent of drug seizures — which should be a reasonable target, given the stated long- and short-term policy objectives of decriminalization — threshold levels should be set at, at least, over seven grams for opioids, five grams for cocaine and four for methamphetamine.

Collectively, these data underscore that a cumulative threshold of 4.5 grams, which was in B.C.’s application, and a subsequent possible counter by Health Canada, at 2.5 grams, will exclude those at greatest risk of drug-related harms and will be grossly inadequate at meeting the stated policy objectives of decriminalization.

Today I am only providing a high-level overview of these data. However, if this area is of interest to the committee, I would suggest a more in-depth presentation from researchers at the B.C. Centre on Substance Use to further discuss this issue.

The second major factor that the toxic drug crisis continues is that we do not have a functioning substance use system of care. Although system investments have improved access in some areas to a spectrum of substance use service, we simply do not have a comprehensive system where people seeking treatment can receive same-day, high-quality care. For the B.C. Centre on Substance Use, a substance use system of care must be comprehensive and include health promotion, disease prevention, harm reduction, treatment and recovery, all on a foundation of addressing the social determinants of health for people who use substances.

Along this continuum, there are many, many significant gaps. There are limited investments in programming, in health promotion activities across the province.

From a harm reduction perspective, although much progress has been made, there are still key geographic disparities in the reach of harm reduction activities that have been shown empirically to reduce deaths and engage people in substance use care if they desire. These include supervised consumption and overdose prevention.

Additionally, although the evidence is still being collected on the safety and efficacy of interventions such as safer supply, scale-up of prescribed safer supply through a prescriber-based medical model has shown to have very poor reach, and the medications used are currently ineffective at separating people from the toxic supply.

When you look at the treatment column, which includes medication-assisted treatment and psychosocial treatment interventions, there are so many challenges, including the lack of trained providers, reach, access and quality of services. Additionally, historically. we focused on tertiary services for those with both severe mental health and substance use disorders.

In the area of recovery, even more challenges abound. We have a highly tiered and fragmented system — no standards for the type of education and training for most who are providing care. It is poorly regulated. Research is outdated and needs to be updated. As well, we have very limited public supports for individuals in long-term recovery to support them over their lifespans.

But there is more. There are also critical gaps across these four areas, including very limited gaps in data to drive quality improvement, to provide key insights and metrics, to let us know what’s working and to fund what works. There is no consensus, in part due to outdated research or gaps in data, which leads to an ineffective middle ground — for an example, an approach to just fund more bed-based services, which alone is not the answer.

[11:20 a.m.]

Evidence exists but is still not well incorporated into practice. Again, there has been an overemphasis on combining mental health and substance use services, which I will touch on in a later slide, and very critically, the role of primary care has been largely ignored. Substance use is a chronic, relapsing condition, and like other chronic, relapsing conditions, like asthma and cardiovascular disease, primary care must and should be the coordinating centre for all chronic care.

Evidence of how the fragmented system of care is highlighted can be referenced from the most recent report to the chief coroner of British Columbia that the death review panel released in March of this year. Seventy-two percent of people that died saw a health care provider three months prior to their death, and we did nothing. This reflects the lack of knowledge and training of health care professionals as well as a challenging system to navigate both for patients and families and providers.

These data also reveal that the vast majority of those who died, almost 75 percent, did not seek treatment. Additionally, the report reveals that 62 percent had a mental health diagnosis or anecdotal evidence of one, further contributing to the outdated narrative that all mental health and substance use services must be combined, which I know we have tried for decades and have failed.

However, there’s a critical limitation in these data in that they do not comment on the severity of the co-occurring of mental illness and substance use disorder. There is very clear evidence that primary care providers can treat and manage mild to moderate mental illness and substance use disorders if properly trained and tools are in place. There is also very strong evidence that the use of commonly used psychoactive medications to treat mental illness worsens substance use outcomes and that treating the substance use first, for people that experience co-occurring disorders, has broader and better outcomes for both their mental health and substance use.

Another piece of evidence related to gaps in the substance use system of care that I will highlight is that we have clear evidence of key interventions that avert deaths. This paper from the Journal of Addiction by my colleagues at the B.C. Centre for Disease Control examined the impacts of three important strategies scaled up across B.C. to address overdose. These include naloxone distribution, expansion of overdose prevention and supervised consumption, and increased access to opioid agonist treatments.

In total, this study estimates that without access to these essential harm reduction treatment services, deaths would be 2.5 times higher. This directly relates to overall deaths across the province, where we started to see a reduction in overdose deaths in 2019 due to a modest impact of these three interventions combined, which was dramatically reversed in 2020 with the onset of COVID-19, where individuals were not accessing harm reduction treatment and recovery services to the same degree.

As the slide on the left shows, data shared from Vancouver Coastal Health’s regional addiction program shows a clear decline in visits to overdose prevention sites and supervised consumption sites in 2020 that directly correlates to the implementations of B.C.’s health pandemic measures, such as advice to stay and work from home, socially distance, etc.

The third component that I’ll highlight is often critically underrecognized in both building a use system of care and reducing overdose deaths, and that is a lack of training for health care professionals. As a registered nurse, I received three or four slides at nursing school on substance use as part of a mental health course, and I was wholly underprepared for the amount of substance use and related harms that I saw in my clinical practice.

Over the last 20 years, there has been a renaissance in the science of addiction, coming from out of the shadows of research solely focused on people who inject drugs who also are living with HIV to clear evidence on pharmacotherapies and other interventions that are effective at treating substance use disorder and promoting recovery.

However, these innovations have been poorly taken up by the health care system. On average, it takes about 17 years for innovations to reach practice, and even when these innovations reach practice, application is often inconsistent. The B.C. Centre on Substance Use was created to support closing the gaps from evidence to practice through the combination of our three core functions of research, education and training for health care providers.

I’ll share briefly some successes in these areas and where there are gaps. On the next slide, you’ll see a graph of the province of British Columbia that looks at prescriber rates across B.C. from June of 2020. For the last several years, our organization has been partnering with the B.C. Centre for Disease Control to map opioid agonist treatment prescriber density, which is only one small component of scaling up health professional capacity and training.

[11:25 a.m.]

As this image notes, there are still parts of the province — those are noted in white or very light green — where there are still inadequate numbers of prescribers. Overall, these numbers are still too low to meet population needs, and rural and remote areas remain largely underserved.

Since 2017, the BCCSU has increased the number of prescribers qualified to prescribe opioid agonist treatments by over 200 percent, which is correlated with an overall increase in the number of patients prescribed at any time — opioid agonist treatment increasing from around 15,000 to over 25,000 individuals.

However, still ongoing work to optimize screening, access and retention to these medications is critical, as retention still remains low. One area we’re currently focusing on with the provincial government is nurse prescribing of opioid agonist treatment for nurses to help fill critical gaps in rural and remote and other parts of the province, to start and retain people on these lifesaving medications.

However, implementation efforts are not without their challenges for scale-up, including provincial shorts of nurses and attrition through nursing prescriber roles, logistic and operational barriers with implementation in regional health authorities and, unfortunately, unequal acceptance in uptake of registered nurse and registered psychiatric nurse prescribing by our other health colleagues across the province.

Based on both the evidence I’ve presented today and calls from people with lived and living experience of substance use, there are three key areas which require a focus to reduce overdose deaths.

The first is to scale up harm reduction interventions where service density is currently inadequate. This includes immediately expanding access to safer drug supply in both medicalized and non-medicalized models while also scaling up supervised consumption and overdose prevention in regions that currently do not have access. The second is to decriminalize simple possession with adequate thresholds, and the third is to improve engagement and retention and treatment for opioid agonist treatment. Critically, this can only be accomplished with adequate monitoring and funding that is commensurate with the true size and scope of the issue.

Finally, while focusing on key priorities to end overdose is paramount, we cannot lose sight of the urgent need to create a substance use system of care. These last six years, although with some modest improvement, still leave us with major gaps and challenges and a situation of addressing the crisis on the backs of a non-existent system.

With careful planning, better utilization of key health systems partners, improvements in structural challenges and an emphasis on data-driven targets, it is possible to both address the ongoing overdose crisis and build an evidence-based, full-spectrum substance use system of care, from prevention to recovery, in British Columbia.

Thank you, and I’m happy to answer any of your questions.

N. Sharma (Chair): Thank you so much for that presentation.

I will take questions in the order I see them. Any questions, colleagues?

S. Furstenau: Good to see you, Cheyenne.

I’m going to ask, as I did with Dr. Wieman, about the non-medical model of access to safer supply — particularly given, Dr. Gustafson, when you talked about the barrier of accessing the health care system. I think that you’ve outlined this as well, but when you take that overlaying intersection of the Indigenous person’s experience with the health care system, as we saw in the coroner’s report, this is a very significant issue here.

Could you paint us a bit of a picture of non-medical models and what those would look like, how they would get up and running, and what role they would be playing in the non-incremental intervention, at this point?

C. Johnson: I think it’s important to frame your question that this was also a recommendation that came out of the B.C. coroner’s report. That’s something that the B.C. Centre on Substance Use and the BCCDC are currently working on. Really, what is at the framework? What is the continuum of safer supply distribution models which can exist and we can scale-up more rapidly?

These would include government’s current approach to prescribe safer supply, which we know has had an impact primarily on people who have an opioid use disorder and are already engaged in opioid addiction treatment, as more than 90 percent of people in current prescribed safer supply programs are also on opioid agonist treatment. But I think, critically, the data from Vancouver Coastal Health and also from the coroner’s review highlights that not everyone dying has an opioid use disorder.

[11:30 a.m.]

While prescribed safer supply interventions — again, we’re building preliminary evidence in this area — may be effective for people with an opioid use disorder that are already reached by the health system, there’s a large proportion of people that do not have an opioid use disorder, have another substance use disorder or use substances intermittently. That’s where other models, like non-medical models, can come in.

These are, again, non-medicalized. They don’t involve the use of a physician or any type of health professional to do an assessment. They do require very robust exemptions from the federal government and aligning applicable regulatory and provincial controls here in the province of British Columbia.

We are actually in the process of partnering with two regional health authorities in B.C. here — Fraser Health and Vancouver Coastal Health — to develop a non-medicalized approach to safer supply, called an opioid co-op model, in which we were requested specifically by Health Canada to put a model together and submit for an exemption. In these models, they are very low barrier, where individuals, if they were interested, can apply to become a co-op member. They need to actively participate and engage.

I think, importantly, there’s economic participation by members, where they pay for both a membership as well as these medications on a sliding scale to access them, unlike the current prescribed safer supply approach, which is all covered through PharmaCare. And we have heard concerns about diversion through that mechanism.

In these types of models, they function similar to other types of co-ops that exist, housing co-ops and others, where you need to actively participate. Again — can go through a process for screening and eligibility to ensure it’s an appropriate intervention for those individuals and can purchase and access drugs through those models. A very innovative approach, and something that requires a little bit of slow exemption requests and regulatory components, but something that is in the works.

S. Bond (Deputy Chair): Thank you so much for your presentation. Very much appreciated.

First of all, I want to recognize, as I did with the earlier presentation, that it is fantastic to see a spectrum in terms of the approach, which does include prevention — we’re grateful to hear that — and also recovery. We have not heard that word used very frequently because of the urgency of the situation now — basically just trying to keep people alive. But there is…. And we need to also have the conversation, which you raised so very well, around recovery and what that requires.

My primary concern is the geographic disparity that you have pointed out. For example, when you look at where OAT is provided…. We have an issue with retention in the first place, but if you look at where that’s available, the lack of prescribers in those very same areas, and when you look at the number of deaths when the reports come out every month, very high numbers per capita in northern and rural communities…. High population of First Nations people.

Maybe, could you just speak to that? I understand the need, and absolutely agree that the system is fragmented. But I think it is even more accentuated in rural and remote communities where people literally do not have those options at all at this point in time. Very concerning. Obviously, I’m biased. I happen to live there. But I also look at the provincial numbers, and they are extremely high in the parts of the province which you reflected on the maps that you provided us.

C. Johnson: A very challenging situation, as you’ve noted, in rural and remote parts of the province — the north sort of exemplified by that. I’d add to your comments that not only if you could attach to a prescriber, then you then need to have a pharmacy, and you may have a barrier to drive 45 minutes, which means you need a car. In the winter, roads may be impassable. It becomes very, very difficult to think about retention on some of these medications, which are office-witnessed and daily dispensed at pharmacies.

One silver lining of COVID has shown us that virtual care for treating opioid addiction is possible. That is a very important component that needs to be scaled up. Patients can be seen, effectively triaged by nurses, connected to social workers, and provided with prescriptions virtually and connected into care.

Another very important barrier…. Again, in the B.C. Centre on Substance Use, we have a partnership with the First Nations Health Authority called the integrated First Nations addictions care initiative, where we work to identify Indigenous-led solutions to overdose. Through that partnership, FNHA has really mapped out, I think, over 60 barriers that exist for patients to be accessing opioid agonist treatment in rural and remote Indigenous communities.

[11:35 a.m.]

Many of those barriers lie with some of the regulations, with pharmacy and other health professional colleges, in terms of dispensing medications to communities. There is a lot of work that we can do. There is a lot of evidence, actually, from Northern Health, led by a wonderful Indigenous nurse practitioner by the name of Mae Katt who has pioneered the use of buprenorphine, naloxone or Suboxone in northern and remote regions through a nurse practitioner–prescribing model, where care can be provided virtually and community centres and non-regulated health professionals provide those medications to community members on a daily basis, rather than going to the pharmacy.

Those are models, with urgency, we need to explore and reduce any pharmacy or other regulatory barriers from professional health colleges.

S. Chant: Thank you very much for your presentation. I appreciate it, and we’ve crossed trails before, you and I.

I’ve got two bits. The first one, actually, is…. You said that there is non-acceptance of other health care professionals around nurse prescribers. Can you expand a little bit on that? That’s the first one.

The second one is on the co-op model that you’re looking at with Vancouver Coastal Health and Fraser Health. Is it possible to bring the other health authorities to the table to do that work simultaneously, since we’re talking about scale of application?

C. Johnson: Thank you for your question. As many people may know, the scope of nurses — registered nurses, registered psychiatric nurses, licensed practical nurses and nurse practitioners are our four types of nurses we have in British Columbia — has really changed dramatically over the last ten years or so.

For example, when the B.C. Centre on Substance Use was created and took over the methadone program from the college, we included nurse practitioners in prescribing of opioid agonist. That was a nice change in scope of practice. Even that was not always well received by our physician colleagues in terms of the types of training NPs receive and their role and reach in the health system. We see that, yet again, with registered nurses and registered psychiatric nurses.

There are challenges, I think, primarily with our physician colleagues in scaling up what is the right role and responsibility and the level of care that nurses can safely prescribe. I will underscore that prescribing of a medication like buprenorphine, naloxone, is an incredibly safe medication. It has a six-times-improved safety profile over methadone and can be highly protocolized.

So nurses, again, need the right training, education and supports, of which the B.C. Centre on Substance Use, in partnership with the provincial government, has created and launched a 24-7 clinical addiction line, where nurses who are prescribing in communities can call this line to reach an addiction physician, 24 hours a day, seven days a week, and get advice on prescribing and which medication to select and how to retain and refer patients.

There is a change management approach that needs to be rapidly undertaken within the regional health authorities. I would say you see discrepancies in the regional health authorities in their uptake. Some regions have been faster to adopt, and some have been much slower.

The second piece is around the co-op model and the possibility to simultaneously scale up. I think it is possible. We’re really putting this as kind of a pilot project, where we’re working with two sites where their leadership and others have expressed a strong willingness to explore these non-medicalized models. That requires a lot of municipal engagement, as you can imagine, as well. So we need to select places where there’s a likelihood of being able to scale things up rapidly if exemptions are provided and funding is released.

The idea with this is really to do robust evaluation very rapidly and do knowledge translation activities simultaneously. If these programs are shown to be safe and effective, we, then, can scale them up. But at this point, it’s more of a pilot in two sites, and then rapid mobilization of knowledge.

P. Alexis: Thank you so much. You’re extremely competent. I find this absolutely fascinating, so thank you.

I have a question regarding your education, when you went through nurses training, on the addiction. I think there were four slides, you said, in your mental health unit.

Have things changed? Given that we heard in the previous presentation that we have many excellent resources as far as people and what they do, that could possibly provide the training, has there been some movement or change in the education system to provide more information to our new nurses that are graduating?

[11:40 a.m.]

C. Johnson: There has been some. I would say that our approach at the B.C. Centre on Substance Use has been primarily tackling those in practice for the last several years so that we can — those that are out there — get them more rapidly skilled up to prescribe opioid agonist treatment, to screen and treat addiction and to support people in long-term recovery.

Now there is some work underway. Changing curriculum is very challenging, and changing it on a broad scale is even more challenging across Canada. We are very grateful to partner with UBC health, who people may know brings together the 20-plus health disciplines at UBC to focus on interdisciplinary research and education. We co-fund a partnership manager, and they have determined that substance use is their area of focus over the next several years. We have been working with them on shared interdisciplinary curriculum development and other components, but that’s still to be said. The individual schools and faculties — there is still a lot of work.

What we would love to see is every physician, every nurse practitioner coming out of medical school or nursing school with the ability to prescribe opioid agonist treatment.

P. Alexis: That’s what I wanted to hear. Thank you so much.

D. Routley: Thank you very much for your presentation, and thanks on behalf of my constituents for your work.

I appreciate that your presentation acknowledges the fact that people use mind-altering substances and will continue. It makes me feel a lot better about my own personal choices, actually. Thank you. I’m not joking.

Harm reduction is so important, I think. In the previous round of questions, my friend MLA Halford mentioned people he knows who use alone, and the stigma keeps them from seeking treatment or seeking even opportunity of, say, a free supply. So much of what we’re focused on here is an urgent response — it’s in the title of the last presentation — but we also have long-term investments that we need to continue to make in the social determinants of health to support people, particularly who continue to use.

I don’t know how to ask the question. The long-term, the mental health connection, maybe the intersection is trauma in people’s lives, perhaps, but the urgent steps we’re being recommended to take around access are not temporary. They will need to be permanent in order to have sort of a partnership effect with those other foundational pieces. Do you agree with that?

C. Johnson: Yeah, I would agree with that. When I present on what a comprehensive substance use system of care is, it’s the disease prevention, health promotion, the harm reduction component, which is critical. Again, we’re gathering more and more knowledge around innovative interventions that can improve lives, obviously with the effect of decriminalization or moving to more of a potential regulated model. Some of those interventions with scale of changes in drug policy become less important with more of an emphasis on the treatment and recovery and prevention side. It is all part of one parcel.

I’d highlight that we’ve been trying for six years to do both things together and have failed. Really, it’s the new approach to focus with a laser focus, with targets and timelines, on key interventions that have evidence for, or we’re building evidence for, harm reduction, while still supporting building that system in the right way, in a coordinated way, and funding services and supports that have evidence.

R. Leonard: Thank you very much for your presentation. I want to just echo MLA Routley’s comments to say thank you on behalf of my constituents. I also want to take an opportunity to thank my constituents. We have an incredibly compassionate, responsive community. I remember that I was sitting on city council when our medical health officer was asking for the assistance of local government to get safe equipment for people who were using on the street.

[11:45 a.m.]

We have a nursing centre, and they picked it up very quickly with their mobile distribution of safe needles and all of the pieces that were required to keep people alive. That was a lot of years ago, and we have continued to provide service.

A lot of what you’re saying makes me very anxious because I know there’s a lot of work that a lot of people are doing on the ground. We have an organization called Unbroken Chain, which works with prevention and education. We have AIDS Vancouver Island, which were quick to jump on board for providing safe injection sites. We have just a myriad of organizations and local governments that continue to support trying to make a difference.

I wanted to ask particularly about the graph where you talk about service levels. I’m wondering about how you measure that. If the measure is solely on prescribers, all the people that I just described are not physicians, necessarily. There are some physicians that are involved, particularly in the nursing centre, and nurse practitioners.

But there are an awful lot of other providers. We have a recovery centre. We have all of those outreach workers. How can we measure what they bring to the whole service levels, just to make sure that we’re heading in the right direction? Everybody is trying to do their best.

C. Johnson: I agree. There are people that are working tirelessly day in and day out, long-standing organizations in many communities across B.C. that have been fighting overdose and promoting recovery and providing treatment for a long, long time in British Columbia.

The challenge is that none of these services are coordinated. They’re all siloed, as you mentioned. Some of those may or may not be connected to the health authority, doing work from independent grants, and then we don’t have a tracking system overall. Services continue to be funded, and beds continue to be funded, but an emphasis on coordination is totally lacking.

When I share that we need to build metrics across the system and to set targets, including wait times and following people, through health administrative data, to see what their recovery journeys are or what their pathways into recovery can look like…. Those are all of the components that we need to build, with a focus and an emphasis on coordinating some of the existing care.

My presentation was not meant that we need to build everything from scratch. There’s a lot that is working, that can be improved, that could adhere to better standards, that could have better-improved education, etc. — as I shared.

It really is that coordination and that metrics piece through the B.C. Centre for Disease Control, which has a lot of data on overdose cohorts and other activities, as well as some work that we’re currently doing to build a provincial substance use cohort at the B.C. Centre on Substance Use that could be a key tool for government to build that evaluation and metrics framework that is so desperately needed.

N. Sharma (Chair): Great.

I see two more people with questions, MLA Furstenau and MLA Routley.

S. Furstenau: I just want to pull together some information and then put a question to you.

Dr. Gustafson, you indicated this is the second-leading cause of decreased life expectancy in B.C.

Cheyenne, when you talk about substance use, generally, I think one of the challenges we have around the drug policy and the prohibition kind of mindset that’s existed for so long is that we think of the drug use as the cause of the mortality increase. But what would it look like, in terms of impacts to life expectancy and the death rate, without the toxic drug supply?

How much is that the contributor? I know we’ve hit on this, but I don’t think we’ve said it really clearly and really specifically. It’s almost like separating the drug use, which is one issue. But from the issue that this supply is so poisonous, could you kind of help us understand that?

[11:50 a.m.]

C. Johnson: Sure, yeah, and reflect on the coroner’s data. This just came out yesterday. I think I have that on slide 11, which shows that since the early 90s, the rates of overdose deaths that we’ve seen here in British Columbia range from around 150 to 300 deaths a year.

Without a regulated supply, and sometimes even with a regulated supply, one consequence and one harm of drug use is overdose. Just the same as when you use regulated substances like tobacco and alcohol, there are harms from those substances. No substances are without harm, including Tylenol, which you can poison yourself with if you take too much.

I think some level of overdose will always be an expected outcome of our society’s condition, which is continued drug use. But as of 2014-2015, we really saw those rates continue to rise, as those graphs show, with Dr. Perry Kendall calling the public health emergency in April of 2016, with thousands and thousands of deaths, compared to the low hundreds.

It is well recognized as being the direct contributor to overdose deaths.

D. Routley: I often think of it in terms of flooding. Communities prepare for radical tides and conditions that normally come once every 100 years. They build dikes and protections for the community. But then, when a tsunami comes, it completely overwhelms all of that. All that appears absolutely ineffective. Yet those are the things we need to regularly manage the problem.

Then, when that tsunami hits…. Then it subsides, and there’s wreckage left, and damage. We have to clean that up. But we implement, hopefully, ways to predict and cope with it in the future. Urgency, yes, now. The access issue is part of that urgent response.

Assuming that we are able to turn it around and begin to reduce numbers, then what would be the equivalent of a system that would give us warning, keep us prepared, for the next wave? Have you given any thought to that?

C. Johnson: I fully agree. In terms of also relating this to COVID-19…. In Canada, we would have such a different effect if we didn’t go through SARS and Ebola, build the Public Health Agency of Canada, build public health infrastructure.

If COVID-19 had hit soon after SARS did, we’d be in a very different situation because of the infrastructure, services, supports, expertise, etc., that was built and really well-fine-tuned over the last decade or so.

There are two pieces. The holy grail, to use that term, would really be drug regulation, like alcohol, like tobacco, like cannabis. We would know the quantities and amounts in illicit substances. The way that you would regulate that and provide them to individuals would not look like it looks like with cannabis. You’d have to build a totally different system for regulation. With that, we would know the quantities and amounts. Overdose would be much less likely, alongside building that very comprehensive system of care, with more of an emphasis on prevention and health promotion and also early recognition of substance use.

I talked a lot about primary care being the centre and the home of chronic disease management, including substance use disorders. It is so critical that we encourage all physicians and providers to be doing universal screening and asking people about substance use, not only asking when: “Oh, your liver enzymes are high. Maybe I should ask you about how much wine you drink or how much alcohol you drink on a daily basis.”

[S. Bond in the chair.]

That creation of a substance use system of care, along with a regulated drug supply, would sort of future-proof our substance use system of care, so to speak.

S. Bond (Deputy Chair): Thank you.

Were there any other questions?

MLA Leonard, please.

R. Leonard: One more question was going through my mind earlier, as you were speaking.

A lot of the folks who come to my office are family members seeking help for their loved ones, who are often initiated into the world of opioid use because of an injury.

[11:55 a.m.]

A few years ago — I think it was in 2018 — I was at an international conference where they were talking about the perception of pain and the use of opioids to control pain. The reaction of the medical community — to stop giving opioids to people who they had basically been supporting, and then just leaving them out — made the news a lot.

I’m wondering. Where in the world…. Where do we go to address how the medical world treats pain and how that fits into trying to make a difference here?

C. Johnson: Thank you for your question. Co-occurring pain and substance use are an incredibly important factor in all of this.

Sometimes you can think, in the medical community and other things, that the pendulum swings too far on either side, and we saw the pendulum swing too far with, obviously, the influence of Purdue Pharma and others in the overprescribing of opioids and pain as the fifth vital sign, which is what I was taught when I was in nursing school, to sort of the abrupt use of opioids and following evidence-based guidelines set out by McMaster, which we have here in Canada, to guide the use of managing chronic pain with opioids.

Moving forward, we really need to…. There are sort of two groups of people that you can think of. One is people that are already on long-term opioids for chronic pain and supporting management and tapering strategies for those individuals and adding on additional psychosocial interventions or things like physiotherapy and acupuncture and other types of non-pharmacological interventions, which have quite good evidence.

Then there’s the whole prevention piece, which is individuals who are not currently on opioids for pain and educating and training health professionals to use opioid-sparing medications as well as those other psychosocial interventions or non-pharmacological approaches before reaching for a prescription pad for opioids — unless it is medically necessary for short periods of time, lots of follow-up in between, etc. Included in that is sort of another subset of patients, which is those with an opioid use disorder and chronic pain. There is clear guidance and evidence on how to manage that.

It’s a huge issue, for sure, in our society, but I think we can really address a lot of it through prevention of inappropriate prescribing of opioids at the outset, which is some of the work our organization does as well.

S. Bond (Deputy Chair): Thank you very much for the presentation and for the interaction that we’ve had both with you and Dr. Gustafson this morning. I think you’ve given us a lot of insight and important information, but it’s also sparked a lot of questions, and I think there’ll be a lot of thoughtful dialogue.

Most importantly, thank you for the work you do on what is a complicated and complex issue but absolutely urgent in our province. Thank you for joining our committee this morning. We appreciate it.

With that, I do want to honour the time frames that the Chair has set. We do have the option for any other business. Do any members have any other items of business this morning?

One follow-up thing I would just like to raise…. I think that our excellent team that supports us…. We did hear this morning of a number of excellent suggestions of people who should present to this committee, and I think I saw a lot of head-nodding as names and programs were mentioned. I’m sure that our Clerk was taking note of those for future possible presentations.

With that, I would seek a motion to adjourn.

MLA Halford, seconded by MLA Routley.

Motion approved.

The committee adjourned at 11:59 a.m.