The committee met at 1:04 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Good afternoon, everybody. I would like to get going, for this afternoon, on the Health Committee. Just a little bit of housekeeping items.

First, I want to make sure we acknowledge that we’re all gathered here on the traditional territory of the Coast Salish people, the Squamish, Musqueam and Tsleil-Waututh people. We pay our respects as we do this work.

Today we have a lineup of three panels and, of course, a special guest, Dr. Perry Kendall.

Just to let everybody know, the slides are on your SharePoint. You should be able to access them that way.

Dr. Kendall, we have you for 20 minutes of presentation, and then the rest of the time, up to an hour, of just discussion and questions and answers. We have some MLAs joining us on the phone, and they’ll be able to let us know if they have questions just by speaking up.

Without further ado, I will pass it over to you, Dr. Ken­dall.

[1:05 p.m.]

Briefings on
Drug Toxicity and Overdoses

PERRY KENDALL

P. Kendall: Thank you very much, Madam Chair. Thank you for this opportunity.

I’ll just say a little bit about my current status. I’m a consultant. I’m doing part-time consulting. I am still a clinical professor at UBC’s School of Population and Public Health and an adjunct professor at the University of Victoria.

I sit on a number of boards — the BCCDC Foundation board and the Portland Hotel Society board. I also sit on a board which might be seen as a potential conflict, in that I sit on the board of Fair Price Pharma, which was established by Dr. Martin Schechter with the mission of trying to bring affordable diacetylmorphine treatment to people who cannot manage to get maintained on methadone or buprenorphine. We are not, in fact, yet in business. That’s a potential conflict. I should declare it.

I have spent 40-plus years in public health looking at health promotion and disease prevention. When you look at the burden of disease that actually impacts a health care system, about 80 percent of it is, at least, theoretically, preventable, in that it comes from behaviours or environments or social conditioning that lead to the antecedents to a whole bunch of chronic diseases, a not insignificant piece of which is related to how individuals in communities use both legal and illegal substances. So predominantly alcohol, tobacco, cannabis, opioids, other illicit drugs. That costs us, in B.C. and nationally, billions of dollars a year.

Prior to 2018, all of the costs of these drugs were borne by society. When they were measured up, it was clear that tobacco and alcohol were, by far, the most costly. Cannabis tended to follow that, but most of those costs were in law enforcement. Since 2018, those costs would have gone down. Revenues would have gone up, because the tax is going to government. A fair proportion is still going to the black market. Use has gone up a little bit. Opioids and other drugs, stimulants, etc., at least prior to 2016, were relatively small in the order of things but, nonetheless, important.

There are some interesting trajectories with drug use in those 40 years. Tobacco use, as you know, has become much less common than it was. We are protected from it. We have advertising. We have warnings. We have high prices, etc.

Cannabis has been legalized, and as I said, costs have gone down. Use has probably gone up a little bit, but we don’t know the harms yet.

Alcohol has been counter to that. Alcohol — since I’ve been in public health, anyway — use has become more prevalent. Risky use has become more prevalent. Hospitalizations have gone up. In fact, some years ago, at least five years ago, the trend for alcohol hospitalizations crossed the trend for tobacco hospitalizations, which were coming down. So that’s an interesting point.

With opioids, we have seen a significant change recently. Historically, since at least the 1980s, we’ve seen a lot of concern around injection drug use. HIV brought that to the fore. Hepatitis C really built up on it. We’ve seen a move from complete criminalization and stigmatization to more of a nuanced discussion around it. Is it a health issue? How much is it a health and social issue? Is it a criminal justice issue? How do we best manage that?

One thing is clear for all of these substances that I’ve talked about. The nature and the amount and the extent of the harms result not necessarily and only from the intrinsic quality of the drugs themselves but the conditions under which they’re taken, who takes them and how society views and regulates those drugs.

I’m trying to put that in the broader context. Then I’ll move to the topic you’re here to talk about, which is the opioid and the toxic drug crisis.

[1:10 p.m.]

If we could go to my first exhibit. I apologize. My exhibits aren’t nearly as fancy or professional looking as the ones you’ve seen previously. I’m doing this on a kitchen table. Anyway, thank you for that one.

Exhibit 1 is basically…. You’ve seen this before, many times. It’s the coroner’s illicit drug death data from 1996, when they declared the emergency, to March 31.

If you look at that graph, you can see a little spike in 1998, which was when Vancouver declared a public health emergency and Vince Cain wrote his report around HIV, overdose and IDU. It was driven by a temporary spike in more potent heroin, accompanied by serious outbreaks of HIV and hepatitis C, which were also due to more frequent injecting on a daily basis. Of course, cocaine came into the mix. That spike led to a number of investigations and actually ended up in 2003 with the opening, in Vancouver, of North America’s first sanctioned supervised consumption site.

If you look at that graph again, you can see there was really a steady trend in overdose deaths at around 200 per annum until about 2010 and 2011. Over this period of time, we were also seeing about 60 or 70 deaths associated with prescription drugs, including prescription opioids, but these were all prescribed. So we had 200 deaths from illicit drugs, which could include diverted prescription drugs, and also about 60 or 70 deaths from prescription drugs.

This is against the background in North America that you’ll be familiar with, of the whole range, of Purdue and OxyContin and the massive, sometimes legitimate use — because pain was untreated — but also, probably, inappropriate use of long-acting, very potent opioids. But in B.C., that wasn’t, as it was in the United States, associated with an increase in overdose deaths. Even when we stopped that massive prescribing, we didn’t see, immediately anyway, an increase in overdose deaths.

The extent to which that excessive prescribing is relevant to the toxic drug supply — in Canada, anyway, or in B.C. — is not nearly as clear as it is in the United States, where, when the prescription opioid numbers came down, nothing was really done to replace them in terms of people who had pain management. Nothing really useful was done to stop the demand for these drugs, which is why we saw a massive switch to heroin, and then the overdose deaths from heroin came in.

Then we saw the overdose deaths from fentanyl, because fentanyl is a lot easier to smuggle and a lot more profitable. It’s also a lot more potent. A tiny amount of fentanyl equals very large amounts of heroin. That’s, I think, what underlies the overdose pandemic in North America.

If I then look at…. We’re still on this. We declared an emergency. This rise in overdose deaths was accompanied by a lot of activity on the ground, in terms of harm reduction, distribution of naloxone, training the first responders, including law enforcement, on how to give naloxone. But the numbers still kept on going up. We were working at BCCDC, with policing and with people who used, to try and figure out how to get ahead of this.

We declared a public health emergency. The Hon. Terry Lake, who was Minister of Health at the time, phoned me up on a Monday and asked what we were going to do about this, because the numbers were going up. I said I was thinking of declaring a public health emergency. To his credit, he said: “Could we do it on Thursday?” I said: “Yes, I think we could.” So we declared the public health emergency, and that was followed by a really significant range of harm reduction initiatives — overdose prevention sites, supervised consumption, etc., which have been continued and expanded on to this day.

We still saw deaths rise until 2019. The we saw the death rate come down by 30 percent, which was really significant, and there was a lot of hope in that. There was a darker side to that, in that while first responders were able to stop people dying, they weren’t actually stopping the overdoses. We were seeing, as people survived, a certain rise, an increase in people with anoxic brain disease. That’s when COVID-19 hit, and the services, across the board, closed down.

[1:15 p.m.]

We’ve seen ever-increasing trends in overdose deaths since then. If you look at exhibit 2, you can see that there’s a really close correlation between the overdose deaths going up and the finding of fentanyl in the drug supply. Once you exclude it, take fentanyl out of the picture, you just see a decreasing line, so more and more fentanyl and its analogs going in.

When you see the overdose deaths on television, they always take pictures of the Downtown Eastside, and you get the feeling this is a big-city problem. But if you look at the maps on the coroner’s exhibit 3, you can see that this is a problem that affects the entirety of British Columbia.

In fact, if you’re doing rates per thousand population, it’s actually worse in the north, because although the numbers are less, as a proportion of the population, they’re higher. We know that First Nations, Indigenous people, particularly women, are significantly more at risk than are non-Indigenous people in this province.

If you look at exhibit 4, you can see that at least since 2015, overdose deaths and illicit toxic drug deaths outstripped all other causes if unnatural death, so it’s a very significant issue.

If you look at exhibit 5, this is a sort of conceptual model that psychologists use called a transtheoretical model of change. People have got a behaviour. They’re happy with the behaviour or they’re not happy with the behaviour, but they’re not, at this point in time, trying to change the behaviour. That’s what’s called precontemplative.

Then people start getting ready to change. When we use this in the substance-use area, it means they’re thinking about: “Should I get treatment? Do I need help for my condition? Do I need to go into recovery? Is something better for me?” Then you move into a program, and if you’re lucky, you can stay on a maintenance program. That may be just psychological maintenance or AA meetings or whatever it is.

For all of the addictions, we know that there’s a really high rate of relapse. Addiction is a brain condition, partly, at least, and it’s a chronic condition, a chronic relapsing condition. So it’s like a lot of other chronic conditions. It’s hard for people to maintain their treatment, and the dropout rate for addiction is about the same as it is in the U.S. for people trying to maintain their blood control or their diabetic control or whatever. So relapse is an issue that needs to be recognized and dealt with.

If you’ve been on opioids or replacement opioids, or you’ve been on a decreasing, tapering, dosage, or you’ve been in jail, or you’ve been on an abstinence course, and you relapse, you’re actually more at risk of an overdose than if you actually stayed in treatment or stayed on the street. It’s a tragic complication in people with overdose, with opioids particularly. Opioid addiction is particularly, I think, prone to relapse.

It’s on a par with nicotine addiction. I don’t know if you have known people who’ve been trying to give up cigarettes. You know how many times…. I think it’s comparable to that in its relapse rate.

What do we know about the people who are in this cycle or not in the cycle? Could we treat our way out of this emergency? Would a medical model suffice?

Well, we know from the coroner’s data that the deaths are predominantly, nearly 80 percent, in males between the ages of 20 and 60, and the majority of those are be­tween the ages of 20 and 50. Participation in the construction and resource extraction trades is not uncommon.

[1:20 p.m.]

We also know from the coroner’s data and from chart reviews that a substantial proportion of these people are not daily users. Some of them are occasional users, particularly the younger ones. Some of them might be called recreational users, at the weekend or monthly. As I’ve said, we know that Indigenous people are overrepresented.

Of the people who are dying — not the ones who overdose but the ones who are dying — almost 80 percent are using, probably, alone, in a hotel room or a motel room or their own home. They don’t go to overdose prevention sites, which are full of other people that they may not want to meet. They may not want to tell people that they’re using. They may prefer to do it in the comfort of their own home, with some music playing, or whatever, but they die alone. These are people that naloxone won’t reach.

We have limited success with the apps that you give to a friend and say: “I’m going to use.” I think that stigma has a lot to do with that.

We also know, from chart reviews, that a substantial proportion of the people who are dying wouldn’t actually meet the criteria for an opioid substance use disorder. They wouldn’t actually meet the diagnostic criteria to put somebody on a medical course of methadone or Suboxone. Many are just, as I’ve said, occasional users. Most are poly drug uses. Forty percent will be using alcohol, and 45 percent will have cocaine. There’d be a variety of other things. What we’ve been seeing more and more of is long-acting benzodiazepines in the mixture of drugs that people are taking.

If we move on now to look at exhibit 6…. What has been known since the 1980s is the paradox of prohibition. It’s based on the work of a British psychiatrist, John Marks, who suggests that it’s at the extremes of drug policy that the most harms happen. He developed a u-shaped curve. On the right-hand side, you have unregulated legal profits of an unregulated commercial market, where the business model is: “Get as many people to use this as we can. We’ll maximize our uptake.”

That’s what tobacco was like in the 1960s. Fifty-plus percent of males smoked. Thirty to 40 percent of women smoked. It was a completely unregulated, other than the age, market. What we’ve done since then, with governments at all levels, is bring the level of tobacco use down towards that bottom place.

What we’ve done with alcohol, conversely, is…. In ’74, when I first came to Toronto, if you wanted to buy a bottle of spirits, you went to a nondescript store. There was a counter. There was a list of what you could buy. The man, always a man, in a khaki overall…. You’d write down what you wanted. You’d give it to him. He’d go into the back. He’d come back with a brown paper bag. You paid your money, and you went away. Things have changed considerably since then. So has consumption. So have the harms.

We’ve moved tobacco in the right way. Alcohol, I think, in the wrong way. Cannabis, obviously, was a way up on the left.

If you think back to the 1920s and prohibition and, I would argue, what we’re seeing now with the opioid crisis, the prohibition and the criminalization model don’t work for those drugs. It creates illegal profits, for one. It funds the black market and criminal enterprises, for two. And three, because of the stigma….

Of course, another of the economic articles of prohibition is: why bother to deal with Mexican cartels or warlords or Sicilian mafia and try and import a tonne of heroin or opium, which occupies a huge volume, when you can get it on the farm and on the black web, the dark web? Find some illicit pharmacist somewhere who will produce something which is hundreds, if not thousands, of times more potent and thus smaller and easier to smuggle. That is where I think we’re at now with carfentanil and fentanyl.

How do we move towards that sweet spot? Well, I think we did it with cannabis. It took a long time. The Le Dain Commission first recommended regulating cannabis in 1972. They also recommended forced treatment for people who were addicted to opioids. B.C. actually tried that in 1974 at Brannen Lake, but it didn’t work. There’s a list of things that if you can regulate, license, standardize, inspect, tax, audit, etc., it will give you the best deal that you can probably get. If you have people who want to use cannabis, this is the safest way of doing it, from a regulatory, an individual and a community perspective.

[1:25 p.m.]

I want to shift now and talk a little bit about the hows and whys of why we do some things to some drugs and some things to other drugs, irrespective of the harms that the drugs cause and, really, irrespective of the damages that we might be inflicting by that control mechanism that we’ve chosen to put in place.

Epistemology is the science and philosophy of: how do we come to know what we know? What is it that makes us believe that this is right and this isn’t right? It’s the acceptance of a claim based on the assumption that the claimant is a reliable source. I would argue, I think, to you guys that the way we regulated drugs historically — and currently, to some extent — is way less than reliable, way less than scientific. It doesn’t look at the economics, it doesn’t look at the behaviours, and it doesn’t look at the impact on people.

How do we get an epistemic trust that a new way of thinking or looking at things is actually meaningful? I’ve learned, as a public health advocate — I’m sure that you have, as elected officials — that it isn’t necessarily the science that drives decision-making. You have voters; they have opinions. Sometimes they’re ahead of the elected people; sometimes they’re not. How do you get that constellation of science and social influences to change things? That happened in 2003, with supervised consumption sites. It happened with overdose prevention sites. I’d like to think that it could happen as a result of, tragically, our illicit drug crisis.

If you look at slide 9, we started with an epidemic curve. I’d like to introduce an epistemic curve, which is a rise in the epistemic trust that folks have in changing laws and policies so that we can move away from some of the policy paralysis, the inertia and the stigma, and look at Canada’s drug laws in a different way.

Now, that’s maybe a longer-term thing. What could we do first for the overdose crisis? I support everything that the coroners death review panel said. We need to get more of a safer supply into more people who are at risk of overdosing and dying from toxic drugs. I think we need to do it quickly. We also need to move on with the decriminalization so that we’re clear that we’re moving from a criminalized approach to a health approach.

That means building the capacity to see people who need help. It also means ensuring that we don’t make the police overzealous. The last thing, I would argue, that we need…. Although we have a limit of 2.5 grams coming in, that may not be enough. The last thing we need is, I guess, to give law enforcement little scales so that they can check everybody’s stash to make sure they don’t….

I don’t think they’d do that. That’s not the intent, but it has happened before, in other jurisdictions. When legal penalties were removed and administrative penalties were put in, the number of people who got a ticket went up. The number of people who didn’t pay the ticket went up. The number of people who then became in contempt of court went up. We need to be sure that we’re doing this, and we have, fortunately, some months to do it.

I will end the presentation. Thank you for listening.

N. Sharma (Chair): Thank you, Dr. Kendall.

I’m going to take questions from the committee.

S. Chant: Your discussion on relapsing was discouraging. One of the things that you talked about was looking at the number relapsing, with people with an opioid need being similar to or worse than people with tobacco. Is it a higher relapse percentage, about the same or…?

P. Kendall: My guess is it’s about the same. It’s frequent; it’s not uncommon.

S. Chant: About the same. Would that be, would you say, 60 percent, 30 percent, 90 percent?

P. Kendall: For opioids, it’s certainly at least 50 percent, I think, that would have some risk of a relapse. I would have to go and check that out, for better numbers, at BCCSU.

S. Chant: Okay. Just as sort of a thought.

P. Kendall: Yeah. Well, if they’re in an abstinence-based program that doesn’t tell people that they might relapse and how to look out for cures but kind of kicks them out or says they’ve failed or stigmatizes them for failing, then that isn’t terribly helpful.

[1:30 p.m.]

Evidence-based programs are the ones that tell people that relapse can happen. “It’s not your fault; it’s not a failure. Here’s a strategy to work with it.”

P. Alexis: I have a couple. I’ll just do one. Then I’ll pass to somebody else and come back.

I read this week that the incidents of women overdosing are on the increase significantly. A lot of our work so far…. We’ve heard from the trade sector in particular — and young men, which certainly impacts my community.

I was wondering if you could maybe address the increase in women and perhaps the demographic, the profile there — if you have any information on that.

P. Kendall: I know for sure, and I know that the First Nations Health Authority are well aware and working on it and have been for years, that Indigenous women are at significantly higher risk, many times more so than Indigenous men, who are more so than non-Indigenous men. I think that is just yet another inheritance from the school system that we’re trying to deal with.

I would suspect, although I don’t know, that a piece of it is also because of domestic violence issues, family issues. We do know that most of the people who run into the really problematic substance use have quite horrendous histories of family abuse, physical abuse or mental abuse and are disconnected. Many of them are wards of the children and family services.

P. Alexis: It makes sense, too, when we see a rise in domestic violence through COVID, for example, where people had to stay home. Okay. Thank you for that.

Am I allowed to ask a second question? It’s just regarding the decrease in the rates in 2019-20, pre-COVID. We knew that we were making some headway. But you added something else that I wasn’t sure about. I just want to go through…. You said that we saw a decrease, but…. I wanted you to explain that second part.

P. Kendall: People weren’t using less and weren’t overdosing or finding their drugs toxic at a lower rate. They were actually being reached more. So we had an expansion in overdose prevention sites. People were carrying naloxone. People’s friends were carrying naloxone. People’s families were carrying naloxone.

P. Alexis: Okay. I see.

P. Kendall: First responders were seeing larger numbers of people as well.

P. Alexis: All right. Thank you for that.

N. Sharma (Chair): I have a couple of questions. Thanks, Dr. Kendall. The first one being…. We heard from many experts such as yourself that are talking to us about the best ways to approach policy to drive down the death toll that British Columbians are seeing across the province.

I was just curious, through your work in public health, if you have or know of any best practices or things that, in your view — maybe from other jurisdictions or here — have worked in terms of the approach of driving down stigma and getting people to the help or to test their drugs or to do things to keep them alive.

P. Kendall: B.C. has had a pretty good history since 2016 in upping the amount of…. Well, the anti-stigma campaigns have been really good, I think. The decriminalization, I think, will help that.

The primary prevention, I think, goes back to trying to build healthy families and secure families, healthy children and healthy babies, which has been a policy priority for quite a number of years, and then trying to recognize kids in schools who are having problems and put the appropriate supports in for those kids so that they can learn or socialize. There are a number of programs, like Roots of Empathy.

My son has just gone into teaching, and it’s quite obvious that there are still a lot of problems out there. There are still inadequate resources in the classrooms to help.

Then, when I was at the Addiction Research Foundation, they did some work. They said that if you find your kids who, at age 12 or 13, are problematic and are the ones who are going to start smoking or drinking earlier on, don’t address them about drugs. Go in and find out…. Just help them to be better kids who are having more fun at school, making friends, know how to socialize and are actually doing a little bit better.

[1:35 p.m.]

Many of them can’t read or write or are not very numerate. That actually had a much better impact on their subsequent less drug use than did talking to them about drugs and how bad they were. Then, if you have kids who are using drugs and are at risk, try and provide them with supports. One adult connection with a kid at risk really decreases their risk of getting into problems. Then, early recognition in our primary care system really needs to be expanded.

Also, putting in minor mental health and early substance use issues, even as a criteria for what primary care physicians and nurse practitioners can do, so you get early recognition and intervention.

R. Leonard: A lot of the things that you’re saying, just in the past few years…. I know that we’re putting in programs and working towards that and expanding programs, especially in K-to-12 and looking at those early years as well.

I wanted to ask you…. When you spoke about the death review panel and you said we need to act more quickly, what I keep going back to is the statistic that about 72 percent of the people who have overdosed and died had had an interaction with the health care system in the last three months and did not seek treatment. They had never sought treatment. You made a reference to that, too. I’m curious what you anticipate would help. What kind of actions would create a quick response, when these people seem really quite disconnected?

P. Kendall: I don’t say it’s going to be easy, but I think there are a lot of people out there now who, if safer supply was more available, would be lining up to get it. I think doctors are a choke point. They don’t want to be, but in the main, they don’t want to be the gatekeeper to what they see as a non-therapeutic regime, and not everybody is ready for the therapeutic piece of the regime.

To expand the safer supply piece outside of a medicalized model, I think, is critical, but that would probably, at some point, need either a lot more doctors or nurse practitioners to get on board with it, and pharmacists as well, but also some form of an exception under section 56 of the Controlled Drugs and Substances Act. I know that BCCDC is looking at that, and I know that Health Canada are looking at that as a pilot. I mean, we’re Canadian. We’re not going to jump into everything wholeheartedly. We’re going to do pilots and make sure we learn from them first.

The other area — and this is why I gave you my potential conflict of interest — is that we have about 23,000 people on methadone in any year in British Columbia. That’s a lot of people who are trying to get into treatment. The number who are still in treatment at the end of the year is about 15 percent, at best. We know that you can’t just come in and get off methadone and taper. The relapse rate is very high, but there isn’t any alternative for those people for whom methadone or buprenorphine hasn’t worked. There are thousands of them in B.C., obviously.

In a bunch of countries in Europe, starting in 1985 in Switzerland, people who fail that first-line treatment but still want to be in treatment can get access to diacetylmorphine, or heroin. The objections to that in Canada have been that it’s been really hard to import it because of Health Canada’s rules. Health Canada’s rules have gone now. You can get heroin with a drug identification number. The other is the price. It’s been very expensive.

That was why Fair Price Pharma was formed. It was to try and get an affordable supply as an alternative to the pharmaceutical supply, which has currently got a very, very, very high markup. Fair Price Pharma was trying to do it as a philanthropic initiative. I’m not boosting Fair Price Pharma. I’m just saying that was what it was.

R. Leonard: Can I just confirm what you’re saying was that in terms of those first actions, it’s safe supply and being able to have them?

P. Kendall: Yes, and then if you had another drug for the people who can’t be maintained on methadone or buprenorphine….

[1:40 p.m.]

If your first line of treatment for cancer doesn’t work, we usually have a second-line treatment. If your first-line antibiotic doesn’t work, we often have a second-line treatment. We don’t have that anywhere in North America, except for maybe 200 or 250 people in Vancouver and a few in Fraser.

S. Bond (Deputy Chair): Thanks, Dr. Kendall. Thank you for your, I think, almost two decades as the public health officer in British Columbia. It’s an incredible record and body of work that you’ve done in our province. We appreciate that, and we appreciate your time today.

A couple of things. I really appreciated the model-of-change diagram. When you think about…. I can’t speak from personal experience. When you read the chart, peo­ple have a precontemplation phase, and then they have a contemplation phase. Then they get ready to make some change. If you extend that thinking, when they get to the part of the diagram where they’re ready to take action…. One would assume it is essential that when they are ready, there be resources there to support them. I’m assuming if there’s a delay…. Or is that an over assumption on my part?

I mean, it’s obvious. It takes a lot to get to the place where a person can say: “I want to change. I want a different pathway in my life.” It’s a pretty big risk — if there’s not immediate support for that person for them to actually continue on, even to make it to the relapse phase — if they can’t get immediate help.

P. Kendall: That is important. Most supervised consumption sites have programs in hand. If somebody doesn’t overdose but is ready to seek help, they can get a quick referral somewhere.

Insite had Onsite, which were stabilization rooms up­stairs. In a number of emergency rooms, though not all of them, when people come in and have a recognized opioid issue or have overdosed and revived, they have a fast track to a rapid assessment centre. St. Paul’s Hospital does. You can get on a fast track through to treatment, but it’s not the same across the board. The addictions system for years has been marked by just different silos.

You could be ready to get into a detox…. I hate the term “detox.” “Withdrawal management” is much more appropriate, I think. If people want to get into withdrawal management, they should be able to do it when they’re ready, instead of having a waiting list to get in. Often by the time you’re ready…. You’ve relapsed, and you’re not ready for it. Then the 30-day treatment after detox, after withdrawal management….

It’s not a coherent system; it never has been a coherent system. I know governments — yours and the current one — are trying to build a coherent system, but it’s not as fast as it ought to be.

S. Bond (Deputy Chair): I guess I wanted to emphasize the point…. Getting to that place in a person’s life is probably a pretty steep journey. If there is a sense that there isn’t immediate help….

It is not the same everywhere. We’ve actually heard that at this committee — that geography can make an enormous difference. If you live where I live, and even more remote or rural, the chances of you getting that immediate help diminish. If you are an Indigenous person living somewhere even more remote….

That chart reminds us that we have a long way to go in terms of…. When you finally make it to the place where you’re saying, “I want to make a change….” There better well be some help there for that person, wherever they live in this province. Otherwise, I can imagine that the trajectory doesn’t continue.

If I might, Chair, my second point is related to….

You talked about when we saw deaths drop, but it doesn’t mean that people weren’t continuing to overdose and continuing to use. Can you speak to us a little bit about acquired brain injury and all of the other things that occur, where a person may well survive but their quality of life is impacted forever? Was that a factor in the drop that we saw? I think it was 2019, or wherever it was, on your chart.

There is certainly a lot to be said about survival but with long-term impacts. I was wondering if you could speak to that.

[1:45 p.m.]

P. Kendall: Yes, I can try. I was at the B.C. Centre on Substance Use during that period of time. We became aware that while deaths were going down, the overdose responses from first responders weren’t. They were still high.

We started taking some inquiries from the hospitals that we were linked with, which are Vancouver General Hospital and St. Paul’s. Yeah, they were starting to realize that they were seeing people with a range of disabilities, cognitive disabilities, after the overdoses. Some people were overdosing many times. Those people were particularly at high risk.

COVID happened, and I left. My term was up there before we got any sense of the magnitude of the issue or what’s happening. I don’t know what’s happened since then.

S. Bond (Deputy Chair): I’ll wait. Others might have other questions. Thank you.

N. Sharma (Chair): Okay. I’ll just check on the call.

Doug, if you have any questions….

Please, go ahead, Pam.

P. Alexis: I just wanted clarity on the opioid prescriptions. You said that we had a different reaction than the U.S., where they saw a remarkably different rate. We didn’t see that much change when we made the changes, I guess, to what the doctors were able or should do, as opposed to whatever….

Can you tell me a little bit about that? I don’t really get it. Why would it be different?

P. Kendall: I don’t really get it either. I think we probably were not…. Physicians in B.C., or in Canada, were not as drastically affected. Although the changes decreased prescriptions, the recommendations to do that were not as strident in Canada as they were south of the border in the U.S.

I don’t know. I don’t have a really good answer for it. We also were ramping up, at that time, our naloxone and our harm reduction, and we had a different approach to it.

I mean, interestingly, since safe supply came in — a year or two, two and a half years ago — many thousands of prescriptions for Dilaudid hydromorphone, which is part of what has been prescribed…. That isn’t showing up in the overdose deaths either. So people aren’t overdosing from the prescription drugs that have been going out there as part of the safe supply, which is good news. It’s probably not…. If it is being diverted, it’s not being diverted and causing death. It’s being diverted and maybe averting deaths because it pushes fentanyl out.

P. Alexis: Got it.

P. Kendall: I don’t have a really good answer to that. The coroner is quite adamant that we had a different situation during that period of time than they did in the United States.

P. Alexis: Okay. All right. It helps a little bit.

I have one more, but I’ll let….

N. Sharma (Chair): I’m going to go to Doug, actually. He did want to ask a question, and there was bad reception.

Go ahead. Can you hear us, Doug?

I don’t know what’s going on with that.

P. Alexis: Can he text you his question?

N. Sharma (Chair): Maybe we’ll give it a second to see if we can sort out the tech issue.

Go ahead. Ask your question.

S. Bond (Deputy Chair): You were asked earlier, Dr. Kendall, about your look around the world and other jurisdictions. You certainly have done a lot of work in Can­ada, mostly Ontario and B.C.

You talked about decriminalization. When we think about decriminalization, in and of itself…. It’s not going to be the be-all and end-all here. In fact, in December, the chiefs of police said that, in essence, we were de facto decriminalized anyway, because they weren’t charging anyone at 2.5 and under.

[1:50 p.m.]

In Portugal, they’ve had some recent reviews of what’s happened, in terms of decriminalization. Have you looked at the work in Portugal and had an ongoing sense of what works and what doesn’t?

It was very interesting, in the last couple of days. We will ask this, I’m sure, of a number of people. The point being made there is that decriminalization…. There were certain steps that were attached to that when it came to Portugal. For example, that a person is stopped more than once or twice or three times…. There were other steps that took place. That person just didn’t drive off.

Can you just sort of talk to us a little bit about the Portugal model, if you’re familiar with it, what work you see there? I personally think the committee needs to do some thinking about the evolution of what has happened there. It is held up as sort of the model, yet now, as we watch it evolve, there are some things that are changing, and there are different perspectives on what’s being done. Do you have a view on that?

P. Kendall: I would say that my knowledge of the Portuguese model is probably good up until about four or five years ago. I’m not aware of what, if anything, major has happened in the last few years.

There are a couple of differences. One is that what they took as a personal use amount was enough for a week for an individual, so significantly more than 2.5 grams. It would be considerably more than the police chiefs were ready to start with in Canada.

The other thing is they did put a significant investment into counselling, into treatment, into harm reduction, into job training, etc. — many millions of euros into that. That was in 1999, and they implemented it in the early 2000s onwards. They saw significant decreases in overdose deaths, which I think still continue. They’re still lower than they are in surrounding EU countries.

They also put in place, as you’ll know, those committees that people could be referred to. They would determine if they were in need of medical treatment and offer it to them, and if they didn’t get it, they could have harm reduction. Selling, dealing, was still criminalized, and people could get administrative penalties or fines if they were persistent offenders, as it were.

I think they were hit by the economic recession in 2008, and some of those helps died out, but I’m not really much more up to date than that, to be honest.

S. Bond (Deputy Chair): Okay. Thank you.

D. Routley: Thank you very much for all your work on this presentation. It’s greatly appreciated.

There are two things. The urgency of the matter, the reality of how long it takes to organize people into service for any of a number of services. Like 911 operators or nurses or mental health professionals, treatment specialists will also take time to deliver to the front of this battle. Given that reality and the reality of how long it takes to build the appropriate facilities, would you suggest that the expansion outside the public health system of safe supply is the most urgent step that could yield better results for people?

[1:55 p.m.]

Secondly, if you could describe for me a little bit the Brannen Lake experience of forced treatment, how that played out. Maybe I’m glad to say that I finally heard something that was before my ancient time.

P. Kendall: The first question was: what could happen to stop overdose deaths immediately? I guess three things. One is stop fentanyl and other dangerous drugs coming in. I don’t give that a high likelihood of success, to be honest. Two, stop people wanting to take drugs because of the risk. I think if that was a really meaningful factor, it would have happened by now because of the risk and the deaths and the number of people lost.

I think that leaves us with a third option, which is try to replace toxic drugs with drugs that are less toxic, which is challenging from a number of perspectives. Even if everybody is in favour of it, it would take a while. But I think that’s the one that is more likely to be pragmatically successful in a shorter period of time than the other two, although there’s no reason why you shouldn’t try the other two as well. But I wouldn’t pin my hopes on just one thing.

Your other question. Remind me again.

D. Routley: It was about Brannen Lake.

P. Kendall: Oh yes, Brannen Lake. That was an initiative brought in by the Socreds. It was one of the recommendations of the Le Dain commission in 1972. While they recommended that the impact of law enforcement on people who use illegal drugs should be gradually lessened, they also recommended that dependent opioid users should be not offered but mandated treatment.

The British Columbia government of the day did develop a treatment facility up in Brannen Lake, which I think was on Vancouver Island. This was in around 1974, ’75 or ’76. I think it was ruled to be against human rights, so it was closed down after a relatively short period of time.

D. Routley: Thank you, and I’m from that area. I’m just wondering. It was ruled to be against a person’s human rights, but was it unsuccessful as well? It strikes me that it would be.

P. Kendall: There’s a lot of controversy around constructive coercion, as it’s called. It could work under certain conditions. If you have somebody who’s employed and has issues with alcohol and substance use, constructive coercion can say: “We’ll give you several choices of treatment, but if you can’t make it, at some point you’re going to lose your job.”

Physicians and lawyers. It works for physicians and lawyers. They have a lot of capital involved. They usually have a lot of social capital, so it tends to work for them. But outside of that….

The U.S. has had drug courts. B.C. has had drug courts. Other provinces have had drug courts. The evidence is that it works for older people who have had longer careers of misuse and dependency. That’s also the group who tend to age out, if they survive, of dependency anyway. They’re the ones who would go for treatment if treatment were available and accessible and appropriate.

There isn’t one brand of treatment that works for everybody. You need a continuum of treatment modalities and, if you can, try and match them with the person.

It has limited success. It depends a lot on the type of treatment and who it is you’re ordering. It can certainly help some people. Others it doesn’t.

S. Furstenau: Good to see you, Dr. Kendall.

Apologies if I might have missed this earlier. Further to Shirley’s questions around Portugal and the development of a system there that included, as you say, counselling, access to harm reduction treatment…. We heard from the coroner here that B.C. currently doesn’t have an evidence-based model of treatment and that we have a kind of array of approaches. There’s some work now going into ensuring there is some data collection, at least.

[2:00 p.m.]

When Portugal moved in this direction, what was the way in which they constructed that aspect of it, access to counselling, access to treatment? How have they made sure that, as you say, a safety in the system…? How did they bring the safety to the system?

P. Kendall: I don’t know. I’m sorry. It’s not an area that I actually looked into. I should have, but I didn’t. I haven’t. Apologies.

S. Furstenau: Save it for next time.

P. Kendall: Yes. Sorry. I would say this. Some treatment systems are evidence-based, but some of the evidence is also based in the treatments that we offer. We have a mix, I think, at the moment.

R. Leonard: Where I want to go with this is…. You spoke of the fact that 80 percent who die, die alone and would not go to an OPS. They would not go to a safe-injection site. There’s such a range.

Sometimes I feel like when we’re talking, it’s like there should be one answer for this dilemma that we are faced with as a society, and I’m cognizant that that’s not the case. It comes back to what I was talking about, that statistic about people who have not sought treatment, who have had that interaction with the health care system — the fact that so many of them are recreational users or occasional users versus the Downtown Eastside, entrenched with poverty and other traumas.

It just strikes me that whatever we need to do, beyond safe supply, has got to recognize that there are different approaches that we need to take. I know there’s a lot of reference to Portugal, but their numbers went up too, during COVID, in the early days. So it’s not a panacea.

I’m just wondering if you could reflect on that a little bit. How would safe supply impact those occasional users, those recreational users who are dying?

P. Kendall: What I envisage is actually quite, I think, politically challenging, if maybe not impossible at the present time to put in place. That would be to do kind of what governments did with cannabis: create a licensed supply for competent adults through a licensed outlet. I can’t see that happening tomorrow, but I think it would make a certain amount of sense.

It means changing a whole lot of conditions. It doesn’t mean promoting drug use. It means doing everything you can not to promote drug use but recognizing that some people are going to use drugs and, if they get into trouble, they’re going to need help.

New Zealand, about a decade ago, was facing a lot of issues with party drugs, club drugs — MDMA and phencyclidine and things. Kids were getting quite sick, and some of them were dying from it. They actually proposed a law which said: “If you can come up with a party drug that is safe within certain limits” — like at least as safe as, say, alcohol, which isn’t very safe, but like that — “and you can convince us of it, we could license it, and then clubs could have a licence to give it out.”

They started doing that, and it made an awful lot of sense. But I think the government changed, and the law was taken away. The opportunity was lost to find out if it would have worked.

R. Leonard: So the solution has to be consistently applied throughout time.

P. Kendall: Over time. Yes.

N. Sharma (Chair): I have a question. We’ve heard from quite a few people also about how much expertise is in B.C. when it comes to people like yourself and other people that have been dealing with the front end of how to combat or deal with addictions but also the toxic drug overdose. We’re stepping into an area now in B.C. where we’re taking a lead again on decriminalization in Canada — or North America, I think — to figure out how that will play out.

When you were talking about the three things that you can do, I thought that was an interesting way to frame it. One is to stop them from coming in, right? We’re going to hear about that whole thing. It sounds like there’s local production of some of these things, so that may be, like you said, a difficult thing.

[2:05 p.m.]

Then the second one was to stop people wanting to do drugs, which is a prevention thing, essentially. Then the third one: replace the toxic drug supply.

I would love your comments on the safe supply, decrim aspect of that, because as MLA Leonard was talking about, lots of people are dying alone. I think the hope that we hear from experts about the decrim policy is that it’ll get people less stigmatized and able to get to that point where you can do No. 3, which is, I think, what you’re saying we’re left with now in terms of saving lives. I would love your thoughts on that.

P. Kendall: I think that that would need getting to the social networks in which these people live and work. So if you belong to a trades union and you’re in a group that’s at risk there, you come to the reality that we’ve offered help and we do what we can. But maybe we come around to the point where we actually let individuals we know who are at risk know where they can get a safe supply from, whether that’s a kind of co-op model or whether it’s a little red door in a government liquor store or whatever it is. I don’t know. Something like that.

Then the same for other communities. But it means bringing communities along, and there’s going to be a lot of resistance to that. I think our treatment system would be a lot more flexible and durable if we could have the abstention side, the 12-step side as part of that continuum and recognize that the other parts of the continuum are equally valuable, as opposed to…. We still have this kind of almost theological debate about which is the right way to go. Both are the right way to go. It depends on who you are.

That would make it a lot stronger and, I think, a lot more understandable. When Marshall Smith, who’s the adviser to the Alberta government, was here, he was working on trying to bring the abstinence side together with the harm-reduction side, but I think it was too hard, and he had a better opportunity in Alberta.

S. Chant: They were more open there, are you suggesting?

P. Kendall: They were more open to hearing his version. He’s a very 12-step, abstention guy, and he was having a hard time from that community in British Columbia, working with the B.C. Centre on Substance Use, who were promoting heroin compassion clubs at the time. The two things didn’t work together.

P. Alexis: I just want some clarity around the comment that you made about how doctors don’t necessarily want to be gatekeepers. Can you elaborate on that for me so that I understand that completely?

P. Kendall: Well, the kind of view you have of a classic injection-drug-using addict is not necessarily the easiest person to deal with. You get the picture of the Downtown Eastside or somebody who’s drug-dependent and drug-demanding and unpredictable, chaotic lifestyle — all of those things. Not every general practitioner or primary care practitioner wants to have that person in their waiting room along with the moms and the grannies and everybody.

It was interesting, though, that when the government was recruiting physicians through the college to come into practice, physicians and general practitioners would be very happy to work in a clinic, and they would go to the clinic and work in the clinic, but they really didn’t want to have that as a component of their primary care practice. Given the shortage of access to primary care that’s going on at the moment, I suspect that outside of a really well-funded clinic model, with lots of nurse practitioners, it’ll continue to be a challenge.

As well, I think people are reluctant to ask for drugs, and physicians would be reluctant, given the college position, to actually prescribe to do safe prescribing outside of some very well-delineated, sponsored model.

S. Chant: To continue on that, please, we heard from another presenter that some physicians were actually be­ing audited when their prescriptions of certain substances went up, even though they were already recognized as folks that were dealing in the addictions arena.

[2:10 p.m.]

Is that something the College of Physicians and Surgeons could work on? Does that have to happen at a provincial or a federal…? Excuse my ignorance in that area. But is that something that…? What level would that particular…?

That’s a very non-supportive sort of backlash on people that are trying to do work that is recognized and necessary. However, if they’re getting audited for it…. Anybody who thinks about auditing thinks they’re being penalized.

P. Kendall: Anecdotally I heard from two physicians about being audited, and it did seem to me that the auditors were being way overboard on interpreting what the college’s recommendations were. The college did subsequently revisit and reword their recommendations.

S. Chant: Oh, did they? Okay.

P. Kendall: Yes. People with legitimate pain needs were being cut off rapidly or tapered too fast, and no alternatives were being offered them. Anecdotally you had really sad stories and bad outcomes.

S. Chant: That was around pain. What about opioid agonists, and so on?

P. Kendall: Physicians are leery about that. BCCSU trained a large number of physicians, but they want it to be curative, rather than — what’s the word? — maintenance.

S. Chant: May I have a follow-up?

N. Sharma (Chair): Okay.

S. Chant: If BCCSU trained a bunch of physicians, how many of them are actually using how they were trained, do you think, as a guess?

P. Kendall: I think every regional health authority has an addictions lead who probably has a BCCSU addictions fellowship. The degree to which personally they are in­volved or supportive of a safer supply, plus a therapeutic supply, varies. Some of them are really quite reluctant to move into that area. They’re worried about the college. They have got enough to do trying to keep people in the therapeutic mode. So it’s not consistent.

S. Chant: Okay. That says that there were nine or ten trained. I’m hoping there are more than that.

P. Kendall: Oh, yes. Those were the ones who were just heads of the addictions programs. There are actually hundreds of physicians trained. I think there are over 1,000 pre­scribing methadone and buprenorphine, maybe close to 1,500. Then there are a lot of pharmacists who have received training. There are different levels of training, up to a medical fellowship.

S. Chant: Right. Okay. That was actually the meat of my question. I just didn’t get there effectively. Thank you.

P. Alexis: It’s a follow-up from mine, if that’s okay.

Do you think that the doctors not wanting, necessarily, a patient of this profile that we’ve spoken of…? Does that encourage the stigma of the user? If you are not conducive to going to your doctor because you know your doctor doesn’t really want to deal with you, then you won’t go. He or she won’t seek treatment. How do we fix that?

P. Kendall: I don’t think there’s a button that you can press or a switch that you can flip. I think the College of Physicians and Surgeons is actually more supportive than the College of Pharmacists at the present time. The College of Pharmacists definitively have some issues, from my perspective, in supporting safer supply.

For instance, during the height of COVID, the clients of The Crosstown who were receiving heroin-assisted treatment would have to come daily for their injections, and the physicians there thought that was unwise, and they actually gave them carries to take home. These were stable people who wouldn’t be selling their drugs on the streets. That was stopped. I, at first, thought it was stopped by the Ministry of Health, but it turns out that it was stopped by the College of Pharmacists, telling the pharmacists not to dispense this. Now, that’s hearsay.

N. Sharma (Chair): Okay. Those are all of the questions that we have for you, so on behalf of the committee, Dr. Kendall, I want to thank you for your many years of service but also your expertise and letting us have this time to ask you questions and get answers, and for your presentation. It’s been really helpful.

P. Kendall: Thank you very much. I appreciated the opportunity.

[2:15 p.m.]

Committee Business

N. Sharma (Chair): All right, committee members, we have a little bit of time before the next panel, so I’m hoping we can move up the committee business, if everybody…. At 5:30, we were going to do committee business. I don’t think it’s going to take long, but if we can get it done, then we can adjourn at 5:30.

S. Chant: Do we have committee business?

N. Sharma (Chair): Yes. It’s just an update from the subcommittee that I wanted to provide to members that are not on the subcommittee.

At the last subcommittee meeting, we talked and, I think, had a consensus about figuring out a way to offer a written submission so that the public and British Columbians have a way to give us input over a period of time online that’s to do with our terms of reference. There was a general consensus in the subcommittee, but we need the committee to agree to that process.

What would happen is…. If we all agree that we want to have a written submission process, Artour’s team would come up with an online questionnaire that would be posted online for a period of time that would leave enough time for his team to assess all of the written submissions and have it ready to submit, probably around September, to our committee as a whole, so we get a summary of what British Columbians want to say.

I wanted to make sure that people that are not on the subcommittee had a chance to weigh in and whether or not they agree to take that approach or what their thoughts might be.

R. Leonard: I obviously like that idea. I’m curious about the rollout of it so that the general public is aware. I mean, we can have it and set it up, but I think back to the Finance Committee, where that kind of work is done, and I just know that there’s a lot of work to it if there are a lot of submissions.

P. Alexis: Staff work.

R. Leonard: Yes, staff work.

N. Sharma (Chair): Yeah, we did talk about that at the subcommittee. The approach will be that we would use…. There’s a communications plan associated with this, so that would be part of the work that we do.

Also, to make it as applicable to the work we’re asked to make recommendations on, Artour’s team is going to make sure that the questionnaire or the survey or the way to give responses leaves room for people to add things but also focuses on what we are looking for in terms of what we’ve been asked to make recommendations on. That will help his team to make sure we get the best input possible from British Columbians and make sure that that process…. I think he’s learned a lot, also, from other committees, like you talked about.

Any other thoughts or comments about that?

R. Leonard: Just one other question, on the content of the questions and that. Will it come back to us?

N. Sharma (Chair): We needed to make sure, as a committee, that everyone was in agreement about the written submissions. I’m going to say that what we would do is Artour can take that away, and then we can all do that, maybe not in a committee meeting but over email or something. We can get a chance to look at the….

He’s whispering to me that the plan was to let the subcommittee, if the committee is okay with that…. If the whole committee wants to have input, good, but also the subcommittee can go ahead and do that work and circulate it.

R. Leonard: A draft or the final?

N. Sharma (Chair): Maybe we’ll circulate it before we post it to get input.

S. Chant: I want to say I’m very, very much in favour of that. As Ronna-Rae was saying, I would like to be able to see the questions before they go out, just so that we’re knowledgable about what’s out there as well.

N. Sharma (Chair): Sure. Let’s do that. We can do that.

D. Routley: I’m very supportive of it, but I also caution that it can’t be really seen as a survey of the population of B.C., us asking for input from people who we’re likely to reach. It would be good, perhaps, to avoid inferring that this is the measured view of British Columbians. That’s all.

N. Sharma (Chair): Thanks for that.

Okay. Generally, it sounds like there’s agreement about the approach, and we’ll make sure that everybody gets a chance to look at the questions before they go out.

We have about ten minutes for a recess. We’ll come back at 2:30.

The committee recessed from 2:19 p.m. to 2:31 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome back, everybody. We have a series of panels this afternoon, because the committee really wanted to dig into some experts on particular areas of the opioid crisis. Our first panel before us today are experts on substance use and research. We have Dr. Karen Urbanoski, Canada Research Chair in Substance Use, and Dr. Brittany Barker, B.C. Centre on Substance Use.

We want to thank you both for being here today. You both have 15 minutes to do your presentations. We have our materials on the screens in front of you. Then we’ll leave about 30 minutes for questions and answers. So we’ll just pass it over to you. Welcome.

Briefings on
Drug Toxicity and Overdoses
Panel 1 – Experts on
Substance Use and Research

B.C. CENTRE ON SUBSTANCE USE

B. Barker: On behalf of my colleague Dr. Karen Urbanoski and myself, I would like to thank the Select Standing Committee on Health for having us here today on the unceded and continually occupied territories of the Musqueam, Squamish and Tsleil-Waututh Nations.

My name is Brittany Barker. I am a white settler and a scientist with the Canadian Institute for Substance Use Research, the B.C. Centre on Substance Use, and working on behalf of the First Nations Health Authority. We’ve prepared a slide deck with some high-level overview findings from our recent provincial evaluation of the risk mitigation guidance or prescribed safer supply that was introduced in the beginning of the pandemic.

We’d like to acknowledge the other study leads, including Dr. Amanda Slaunwhite, from the BCCDC; Dr. Boh­dan Nosyk, from CHEOS and SFU; and Dr. Bernie Pauly, from CISUR and UVic.

We’d also like to acknowledge that our research took place on the territories of the 200 First Nations, what is colonially known as B.C., and that as uninvited settlers of this land, we recognize the disproportionate impact of the toxic drug supply crisis on First Nations, Indigenous, Métis from across Turtle Island as a result of the historical and contemporary impacts of colonization, including the deeply racist roots of drug policy, criminalization, that brought us here today.

Moving to slide 5 in the handout, we wanted to situate the risk mitigation guidance, or RMG, as a policy intervention that was introduced in March 2020 into an existing system of substance use care operating in the province.

It’s worth considering for a moment what a well-functioning system of care for substance use looks like. Acknowledging that there are different ways to present these ideas, we’ll focus here on the core functions of well-performing systems, as supported by a large body of international evidence, and it’s also consistent with previous presentations to this committee.

These functions are achieved by services comprised of a variety of different interventions. Systems work well when those services talk to each other, when there’s integration and appropriate tailoring based on people’s strengths and needs. Services and the interventions they offer depend on each other to be maximally effective. If one service succeeds or fails, it has ripple effects. By extension, when you introduce a new intervention into the system, it has implications for existing services, and vice versa.

[2:35 p.m.]

RMG was introduced against this backdrop onto an existing, overburdened system of substance use care that was contending with the dual public health emergencies.

In B.C., there are long-standing population-based and regional inequities in the system of care such that these functions are not universally achieved for all.

Moving to slide 7, with this context and systems view, I will briefly highlight our study approach before spending the remainder of our time together here talking about our findings. A team of scientists from across B.C., we were able to draw on multiple data sources, including provincial surveillance and population-level linked administrative health data. As well, we conducted primary data collection, including a longitudinal survey among people who use substances and qualitative interviews with people who use substances, prescribers and health policy–makers.

Rarely do studies bring together such a broad range of data sources, and this really allows us both a breadth of understanding at the population level as well as depth into the implementation and impact of RMG in the lives of people and those prescribing and delivering this novel intervention.

S. Chant: I’m sorry. Can you tell me what RMG means?

B. Barker: Risk mitigation guidance, or prescribed safer supply.

S. Chant: Oh, I should have known that. Sorry. I was challenged.

B. Barker: No worries.

We published our study protocol in the British Medical Journal, with the objectives to determine the impact of RMG on COVID-19 infection, non-fatal and fatal overdose, all-cause mortality and continuity of care for substance use disorder and other health comorbidities.

The second was to determine the impact of RMG on the uptake of public health measures to reduce the spread of COVID-19 as well as other behavioural and psychosocial outcomes among people who use substances.

The third was to identify individual interpersonal and systemic barriers and facilitators to RMG implementation from the perspectives of clients, prescribers and health planners.

Now moving to slide 9, we will shift into our findings related to the uptake of RMG prescribing in the province. First we’ll start with the BCCDC surveillance data from March of 2020, when the intervention was implemented, to March 2022. It revealed that a total of 12,721 people were prescribed RMG medications, including alcohol withdrawal, stimulants, opioids and benzodiazepines, with two-thirds of the sample receiving an opioid medication like hydromorphone, or Dilaudid.

Administrative health data analysis from the first six months of the intervention indicate that not surprisingly, those with high substance use loads were much more likely to prescribe RMG, probably because these clinicians had experience working with this population and felt more comfortable with it, as well as knew more about the unregulated drug supply.

Nurse practitioners and OAT doctors were more likely to prescribe RMG, compared to general practitioners, or GPs, with psychiatrists being the least likely to prescribe. Relatedly, co-prescription of opioid agonist therapy, like methadone or Suboxone, was very common, with nearly a quarter of all RMG prescriptions being co-prescribed with an opioid agonist therapy medication. I want to stop and highlight this because the way that RMG was implemented was it was meant to roll out via primary health care, but what we found was that general practitioners, or GPs, were less likely to prescribe.

I’ll now move on to our implementation findings, starting with what we heard from prescribers. That includes doctors, nurses, nurse practitioners and pharmacists. We conducted interviews with a range across the province, and what we heard was that programs were underfunded, unsustainable and oversubscribed. Prescribing added to clinician workload, and in practice settings like primary care offices, without nurses or peer supports to help with RMG, it made implementation very difficult.

Early adopters of RMG did so because they didn’t want their patients to die, and an increasingly illicit drug supply. They were acting in accordance with their ethics in a life-or-death situation, in the face of the dual public health emergencies.

[2:40 p.m.]

Early adopters also saw opportunities for substance use care, including alternatives to OAT and new medications, such as sustained-release oral morphine and stimulant options like Dexedrine and Ritalin for people who use stimulants, as well as an opportunity to connect folks with primary care.

Prescribers also talked about how common lateral vio­lence was, within their practice settings and in health authorities, between those who were prescribing and those who did not support safe supply. This left prescribers feeling unsupported, attacked and increasingly scrutinized. The scrutinization was structural as well. It was compounded by regulatory bodies and the colleges, which were reluctant to update their scopes of practice or would do practice audits. Prescribers were doing what was approved in the risk mitigation guidance, and then they were being audited.

Now moving on to our survey and interview findings from people who use substances. We found implementation of RMG was not widespread, with particular gaps in northern, rural, remote and Indigenous communities. Living in an urban area was the strongest predictor of access to RMG, compared to those who lived in rural areas. Having to pick up meds daily from the pharmacy or daily dispensation, inadequate and low dosing and mismatch of medication type and route of administration were common barriers.

This was confirmed by the surveillance data, which revealed 94 percent of prescriptions were dispensed daily. This is interesting, right? RMG was originally rolled out as a COVID-19 measure, to help people isolate and stay home. But if you have to go pick up your meds every day, you’re not staying home.

Lastly, 58 percent of our sample reported that their dos­age was insufficient to prevent withdrawal. I want to stop here for a second because preventing withdrawal is really the minimal clinical goal of safe supply. It’s a necessary precursor if you want people to stop using illicit drugs or relying on the illicit drug market and, therefore, reducing your risk of overdose, let alone the broader reasons that we heard for why people were trying to access prescribed safer supply, or RMG. Withdrawal should be 100 percent. Nobody should be going into withdrawal.

Moving on to the second implementation successes and challenges findings slide, we also heard that the medicalized primary care delivery model was a barrier for many, especially problematic for Indigenous people trying to access RMG, given the systemic racism in our health care system, as evidenced by the In Plain Sight report last year, and the intersection of racism and drug use stigma for Indigenous people trying to access safe supply, and substance use care more generally, in this province.

Peers and drug user groups, telehealth, particularly the First Nations Health Authority’s virtual substance use and psychiatry service, which was implemented during the pandemic, as well as individual harm reduction commun­ity champions…. You would get these pop-ups of outreach workers or pharmacists that were really amazing and worked at stopgap measures to facilitate access, particularly in northern and rural communities. But this is the absence of a structural approach to implementation.

Integrated teams and infrastructure for integrated care such as supportive housing with pharmacy delivery options facilitated access and kept folks retained on RMG. However, again, these supportive housing units in integrated care are frequently only available in large urban areas like Vancouver and Victoria, further exacerbating the regional inequities that we were speaking to earlier.

Lastly, we found 25 percent of those who had recently been stopped by police or a bylaw officer had their RMG medication confiscated, which highlights the issue of im­plementing an intervention like safe supply in the context of drug use criminalization. This is important as B.C. moves into decriminalization, which I believe my colleague Dr. Kora DeBeck, from the BCCSU, is going to speak to this committee about later this afternoon.

[2:45 p.m.]

Drug use criminalization will have negative impacts on implementation and, ultimately, the effectiveness of the intervention and safe supply in general. This is why we need to start thinking about these larger system pieces, which is what I started off talking about.

Before I hand it over to Dr. Urbanoski, I’d like to conclude with the staircase on slide 13, which is the staircase to receive, access and be retained in RMG, or on safer supply. It’s a metaphor that our colleague Dr. Pauly and peer researchers on the study came up with after analyzing interviews from multiple stakeholders. Individuals have to climb a high staircase to get a prescription, with the potential to get kicked down the stairs at every step.

First, you need to know about the program. Many that we spoke to thought it was only available in Vancouver and didn’t realize it was a provincial thing. Then people had to find a willing prescriber. Programs and clinicians were over capacity, where they were available. As I said earlier, there were large swaths of the province where you simply could not access RMG.

Further, participants commonly reported provider discrimination and drug use stigma that made it difficult or traumatic to access a medicalized system. This was especially relevant for Indigenous people, as well as parents and mothers who use substances, with many not accessing treatment because of a fear of MCFD involvement. I’ve already mentioned the tension of implementing an intervention in the context of criminalization.

Then, even if you are able to get a prescription…. I think we all know now that there is a significant difference, in terms of strength and potency, between hydromorphone, an RMG medication, and fentanyl. It’s about one-tenth of the strength, give or take. So for many, the dosages were not strong enough to prevent withdrawal or reduce reliance on the illicit supply.

The last step on the staircase was…. If you were able to access a prescription and did make it work for yourself, then you had to go to the pharmacy every day. This was a big barrier, especially if you live in a rural community an hour away from the closest pharmacy or you didn’t have transportation and had to rely on the one bus that went into town per day or it was minus 40 out or you had to go to work or you wanted to pick up your kids or go back to school.

Having to go to the pharmacy every day really keeps people entrapped in these systems of poverty. If folks didn’t pick up the medication for two to three days, then they had to start all the way over, at the induction dose. Then you’re also entering the possibility for screwing around with people’s tolerance and potential for overdose risk.

Thank you. I will hand it over.

CANADA RESEARCH CHAIR
IN SUBSTANCE USE

K. Urbanoski: With this grounding in what was actually implemented around prescribed safer supply through 2020 and 2021 in B.C., we can now move to considering what the impacts were. Benefits, harms to the population. What happened?

As with our look at implementation in this program of research, we were able to examine impacts by using a variety of different methods, different data sources. By combining across these, we’re getting a fuller picture of what those impacts look like across different areas of health.

The findings that I’m going to speak to now are on pages 14 to 16 in your handouts.

At a population level, big picture, we found that receiving an RMG prescription, receiving the prescribed safer supply, was associated with lower mortality relative to a control group of people who were eligible for but didn’t get a prescription. However, this difference was not statistically significant. There was also no apparent effect of safer supply on substance-related ED visits or hospitalizations.

Now, in this part of the study, we used administrative data. We selected for all residents of the province who have a substance use disorder. So it’s a very large sample. However, our team has only had access to data from the first six months, from March to September of 2020. With these data, it takes a fair amount of time for them to be cleaned and to be processed, and our team is currently updating the analyses through August 2021.

[2:50 p.m.]

We will shortly have findings that tell us what happened over the first 18 months, which is our study period for evaluating RMG prescribing. But we can just report on those preliminary findings as of now.

Administrative data. They are, obviously, a fantastic source. They can tell us a lot about people’s health based on their use of health care services. They can’t tell us every­thing, so we paired these analyses of administrative data with analyses of self-reported outcomes. These are what people who use substances have said about their own health and wellness.

We chose the outcomes we did in collaboration with our study partners, who are people with lived and living experience of substance use, based on what they said was important to them with this kind of intervention. We looked at quality of life; substance use — continued use of the illicit market; mental health and reliance on criminalized income sources, which included sex work as well as drug-selling and petty theft.

We surveyed people who had received or were trying to access an RMG prescription, and we followed them for approximately three months, with repeated follow-ups, to kind of get a sense of how things were changing for them over that period of time.

We found that receiving an RMG prescription was associated with better mental health, specifically lower depression, over the study period relative to people who did not get a prescription. However, RMG was not associated with a change, any meaningful change, in any of our measures of outcome — the criminalized income sources, with quality of life — over that three-month period.

It, granted, is a short period of time for instituting change. However, it was during a period in which we would expect to see some fluctuations as people were getting their prescriptions and deciding whether to continue with them.

In short, we did not find that receiving RMG was associated with average benefits, benefits in average to the population, across a number of measures. We do see a signal of effects on mortality and depression, in both cases indicating benefits, and we are investigating these further.

Nonetheless, in in-depth interviews with people who use drugs, those who had been able to make RMG work for them, those who had been able to get a prescription and stay with it, reported positive benefits to a number of areas of health, including their sense of stability, finances, parenting, reduced overdoses and substance use.

These in-depth interviews were conducted with a subset of people who completed the survey. We just asked people to relate their experiences and their perceptions of the intervention and what it meant for them in their lives.

Now, contrary to first glance, these findings from the different parts of the study are not actually conflicting. They answer different questions. The findings from the survey and the administrative data analysis I described tell us about what happened on average with the ways the RMG-prescribing was implemented at the time — so fairly early on in the development of this intervention.

The interview data, on the other hand, tell us that RMG was helpful for at least some people. These findings are consistent with one another. Together they really point toward the room for improvement.

There are different potential underlying explanations for why we didn’t find effects in the full population. We’ve thought about that as a team. It could be because the intervention itself isn’t effective. As Dr. Barker mentioned earlier, hydromorphone as a pharmacological agent is not as strong as fentanyl. So it could be that the intervention itself was not effective.

It could also be because of the way it was implemented. Here it’s interesting to reflect on what Dr. Barker shared about implementation. We know there were issues with the medications in terms of the type but also the form, how people could use them, and the dosage not being able to be sufficient to prevent withdrawal for everyone. Additionally, we heard issues with the way the medications are picked up, how they’re dispensed, how people get them.

The effects of an intervention like this can also depend on the service model overall and whether prescriptions are offered as part of a suite of services and supports. Consider here: what does a medication mean if you are unhoused, if you can’t work and if you don’t have supports to deal with trauma and loss? We heard clearly from people with lived and living experience on our team that the medications do have to be offered with wraparound supports and peer navigation.

These findings speak to the early implementation of RMG, what happened with a particular intervention at a particular point in time. I just bring that up to convey that they do not speak to the effectiveness of safer supply as a whole, as a construct.

[2:55 p.m.]

Before we leave impacts, I do want to highlight one more finding gleaned from our analyses of surveillance data from the BCCDC researchers who are on our team. Numerous concerns have been raised, since the emergence of this intervention, about whether RMG implementation was linked to the increase in overdoses that was observed through 2020 in B.C.

The idea here, the logic of this argument, goes that prescribing was linked to greater availability of opioids, which led to more overdoses in the community. We are able to speak to this definitively. It’s not the case. On page 16 in your handouts, we offer our findings that very clearly show that overdose deaths are caused by illicit fentanyl.

The most common medication prescribed through RMG was hydromorphone. Overdoses attributable to hydromorphone were negligible, almost non-existent. We raise this because it’s important that concerns are considered as they come from the community and tested for their validity so that we’re able to make decisions that are based in evidence.

I will end off now with some key messages that bring together all of this evidence from this program of research and circle back to that system lens that Dr. Barker spoke about earlier. This is pages 17 and 18.

First, it’s important to acknowledge again that RMG was not widespread over the 18 months. It’s a small minority of people in B.C. who have substance use disorder who did actually receive access to this intervention. And it depended on where you lived in the province — as Brittany mentioned, very sparse access in, particularly, the north and smaller communities, which disproportionately affects Indigenous people. These are areas of the province where we know rates of overdose are high, so it suggests that the reach is not as broad as it needs to be.

As Dr. Barker noted earlier, RMG in B.C. was introduced into an existing overburdened system that was contending with dual public health emergencies and long-standing inequities and gaps in its ability to meet the functions of a system of care. Factors such as housing shortages and criminalization of people who use substances are going to affect the impacts of this kind of intervention, as will the fact that there were no mechanisms to support uptake or ensure equitable access across the province.

Within our research, we nonetheless found the stakeholders we spoke with, on the whole, wanted the intervention to continue and to evolve. They made numerous suggestions for improvement based on their experience — a broader range of medication, including stimulants, options for smoking, inhalation, in particular.

This committee has already heard about some of the innovations being developed and implemented around the province as policy and practice continues to grow in this area. This is an active area of research for ourselves and others. Further development of wraparound services was also an area for improvement.

I would say, at a policy level, increased attention to the facilitators for prescribers, to address their real concerns around regulatory approvals, education, clinical protocols, is needed.

Toward the end of thinking about how we integrate various forms of prescribed safer supply beyond RMG into our system of care, we have a few final key messages and considerations.

First, it’s important to envision prescribed safer supply as an emergency response to the volatile and toxic unregulated drug supply. It’s not the same thing as the overprescribing that happened in the 2000s. We’re in a different context now, and it’s not the same. We know this crisis is caused by the toxic drug supply.

There are a lot of gaps in our knowledge of that supply side of things. We talk about the illicit market as though it is one singular thing, but in reality, it’s hyper-local. It’s dynamic. There are differences in pricing, in norms of how you access it and in the composition of substances, even within localities.

Most of the research being done in B.C. focuses on reducing demand for substances and responding to the demand to reduce harms and support health, through different services and supports, including the research that we’ve been talking about here today. There’s a gap in what we know about the supply and how it differs across the province. This really hampers our ability to respond. The effectiveness of different safer supply options can be expected to vary, depending on the unregulated supply available in a local community.

Second, with ongoing criminalization and the lack of affordable housing, there will be limits to what can be accomplished with safer-supply-prescribing, as you saw from the point about medications being confiscated.

[3:00 p.m.]

Relatedly, in taking a step back to view the full system of care, any new service that is added to a system isn’t added in a vacuum. Accessibility and effectiveness of a given service ultimately depends on what else is available in the local community, whether counselling, housing, opioid agonist therapy — can they access detox? — primary care, which we know is a challenge in many communities. The addition of RMG to the system will have affected these other services and vice versa, leading to a multitude of experiences and impacts that differ locally and regionally.

Third, and finally, general principles of system design at a population level tell us that people really need multiple readily accessible options. You’ve heard about some of this in prior presentations — for instance, treatment on de­mand. No single intervention works for everybody. Evidence supports the need for systems to be built on multiple services and supports that offer a range of different types of clinical interventions. Yes, those interventions need to be evidence-based, but no single intervention works for everybody.

In many ways, this issue in particular signals a mismatch between this health condition and the services and supports that are designed for it. In reality, we don’t have treatment on demand, for instance. So if RMG and prescribed safer supply…. They can add to the service landscape, certainly, but they are not going to replace the need for system enhancement efforts needed to strengthen the system of care overall.

N. Sharma (Chair): I’ll start to take cues for questions. I have one, maybe, to start us off.

It seems like your study…. We were learning about the process to get on what exists for the RMG. Am I right that you have to have a diagnosis of an opioid use disorder to get considered to even get access to this? Is that the threshold to getting…?

K. Urbanoski: No, because there was also prescribing for stimulants and benzodiazepines and supports for alcohol withdrawal as well, so it was a broad array.

N. Sharma (Chair): I guess my question is more like: does there have to be some kind of a medical diagnosis for you to get into whatever array of that treatment?

K. Urbanoski: In practice, I would imagine probably.

B. Barker: The policy says no. It’s anybody who’s at risk of an overdose or at risk of contracting COVID-19, which is everybody. It was both risk of overdose and risk of COVID-19. But in practice, I think that especially because it was rolled out of primary health care, there had to be those clinical benchmarks.

K. Urbanoski: Really what was implemented was a form of opioid agonist therapy — the model of witnessed dosing, daily dispensation. It did depend on where you were, but much of it proceeded in that way. It was what prescribers were familiar with.

B. Barker: That is why we saw the uptake of OAT doctors and co-prescription of OAT, right? A lot of physicians we talked to saw this as OAT-plus, because you’re trying to get somebody from fentanyl to Suboxone, and here are some Dilaudids to top them up. That’s fine. It’s a great tool. But that’s not what safe supply is.

S. Furstenau: Thanks for the presentation. It’s very interesting to hear about a study having been done, be­cause I think that’s one of the missing pieces we have.

Dr. Barker, when you talked about the experience of people that accessed RMG, one of the lines you used was “handcuffed to the pharmacy.” Can you go a little bit more into depth around the onus that was on the individual to access this program and then, secondly, how much that onus contributes to the capacity of a program like this to actually be successful?

B. Barker: I can definitely take the start, and then I feel like Karen is going to want to jump in there.

I did most of my interviews in the Northern Health region. For a lot of people…. Like we said, we know from surveillance data that 94 percent of prescriptions had to be picked up daily. That’s annoying and hard to do in Vancouver, but that looks a lot different if it’s an hour-plus away. For First Nations communities, there aren’t pharmacies on reserves.

[3:05 p.m.]

Maybe the telehealth was helping you connect with a doctor who was willing to prescribe, but if you still had to get into town and you didn’t have transportation, then you’re relying on the one bus in town, which does one loop per day back to your community.

People talked about how, then, they’re being dropped off in the local drug scene, and then they’re being dropped off in a risk environment, because their peer group that they’re trying to stay away from, perhaps, is there. And if it’s minus 40 out, who wants to go to the pharmacy every day, right?

The other thing that was big in the North was people went away to work in camps. You can’t do that, because there are no carries. So if you have to go to the pharmacy every day, you can’t work. So if you’re trying to…. RMG stabilized a lot of people, so then they could go to work, because you’re not out hustling for street drugs as much, but then you’re still handcuffed to the pharmacy.

The terms “handcuffed to the pharmacy” and “liquid handcuff” come from methadone. This has been a long-standing issue among people who use substances. It really does keep people trapped in systems of poverty, in my opinion.

For Indigenous people who want to stay at home in their community, it’s a different type of barrier. It’s barriers to Indigenous-specific determinants of health.

Karen, do you have anything to add?

K. Urbanoski: I always try to reflect a little bit on what someone’s options are when they wake up in the morning and they want to make a change or they’re tired of the life. If we think through, in those terms, some of the conditions that are placed upon getting access to services, like what Dr. Barker just described….

These are not easy decisions to make. You’re needing to make choices between your own health and the health of your family and your community responsibilities. These are not easy situations to be in. I find it can be a helpful lens if we think through things in that way, as opposed to just approaching this with the idea: “Well, why don’t they just get treatment? We have effective treatments. Why do people not want them?”

S. Bond (Deputy Chair): Thank you very much for your work and for your time spent with us today. It raises a lot of important questions and something that….

Certainly, I live in Northern Health. I live in Prince George, so I can absolutely relate to what Dr. Barker has said. An hour is a generous reflection. Those of us who know…. In my riding, for example, if you live in one of the smaller communities, it’s two hours just to get there, and if it’s winter, it’s a heck of a lot longer than that.

I think one of the themes that’s emerging is the inequity and inconsistency across British Columbia. We heard that when the health authorities were here as well. They recognize it. That’s a big problem when you’re dealing with a big province, so I really appreciate better understanding, especially in light of this.

I also thought that it is difficult to think about people experiencing lateral violence as a result of their willingness to participate in this. That speaks volumes about the challenges we’re facing in the system. It’ll be fine if the Health Committee comes up with a recommendation. There is a lot of work to do on the ground as people grapple with this individually, whether you’re a health care professional or a British Columbian.

Part of our job is to bring people along, because I find that that is horrible to think about — that a person who has been asked to use this clinical guidance is experiencing criticism and, potentially, lateral violence as a result of doing what they’ve been asked to do. And they’re willing to do it. I think we really need to be paying attention to that.

It took me a while to figure out that in essence, this was about dealing with COVID and not the long-term impacts of the opioid and overdose death crisis. So when I looked at the report that was done in January, one of the things that jumped out at me was the fact that as the need to manage through COVID diminished, the suggestion was: is this a model that should continue to be trialed in another context?

[3:10 p.m.]

We have to remember that this wasn’t about the opioid crisis. It was about the combination of both, but it really was to deal with people who were isolated because of COVID.

Do you have a view about how RMG…? Should it continue? I know that you’ve said we need to look at it from a more systemic perspective and making an independent…. Adding on another program or approach without a bigger look….

It was really interesting to read that as COVID diminishes, the suggestion is: should this continue in some other context? Do you have an opinion on that?

K. Urbanoski: I do think it takes a while for any new intervention to find its feet. It was very clear that people did not want this intervention to disappear entirely. They had lots of ideas around how to improve it and saw the need for further evolution and improvement, which is what you would expect normally, with any new intervention such as this.

Absolutely, I think there is something here that warrants continuation. I cannot fathom, for the people who it’s working for, the idea of tapering them off. In the context of a continued and actually worsened overdose crisis, that makes no sense to me. Absolutely, I do think that there is value in continuing it and continuing to study it as it’s implemented in different ways — finding different ways to implement it in the North, to meet that context, for instance. That’s not something that we’ve figured out yet.

In July of last year, the B.C. government released the policy directive on prescribed safer supply, which was meant to decouple, to some extent, the intervention from COVID such that it could continue. There’s sort of that landscape. It is emerging as an intervention in that way, and it’ll find its way into the system to integrate with other services and supports. But that will take time. That will take time, and unfortunately, we don’t have a ton of time, because we are in a crisis.

This is not going to solve everything. A prescribed safer supply is not going to solve everything — in particular, because there is some hesitancy among some providers, and there need to be other options. That’s why pairing it with decriminalization, pairing it with other forms of safer supply, such as compassion clubs or other options that do still need…. It doesn’t replace that.

B. Barker: May I add to that quickly? One of the things they’re doing with decoupling it with the MMHA policy directive is now they’re putting fentanyl products into the formulary. There’s talk about one day powdered cocaine or crystal methamphetamine being added to the formulary as something you can prescribe safe supply.

That’s great, but if we can’t convince — sorry to pick on northern — northern doctors to prescribe Suboxone, then what are you going to do? You’ve got people leaving the community and ending up in the Downtown Eastside.

N. Sharma (Chair): Do you have another question?

S. Bond (Deputy Chair): No. I was going to just build on something that Dr. Barker said.

N. Sharma (Chair): Okay. Go ahead, quickly.

S. Bond (Deputy Chair): Actually, I think one of the critical recommendations was, for heaven’s sake, for people who have found this to have benefit, don’t end their prescription. I think that’s what you’ve said. Has the practice continued?

B. Barker: Yes.

S. Bond (Deputy Chair): Okay. Good. When I read that, I thought: “Oh, my goodness.” For those where there was benefit found, their prescriptions have continued?

K. Urbanoski: Yes.

B. Barker: As long as they continue to meet the clinical and dispensing…. You miss three days at the pharmacy, you get dropped back to your starting dose.

S. Bond (Deputy Chair): So if you miss three days picking up your supply at the pharmacy, you’re off. Okay.

S. Chant: The framework is painful.

S. Bond (Deputy Chair): Those are really important things for us to know. Thank you.

I have some others, but I’ll wait until others have a chance.

S. Chant: One of the presenters earlier on spoke about transporting — the difficulty. So even if there were clinicians that were able to prescribe and there was not a pharmacy available, they weren’t able to transport and have it available to them.

Was that ever spoken about, being able to transport? If there was an ability to have it available to people but we weren’t able to get it from point A to point B because of transportation regulations…. Has that been looked at? Is that feathered in anywhere or dovetailed in?

[3:15 p.m.]

B. Barker: I know the First Nations Health Authority just met with the College of Pharmacists around this, because Health Canada actually implemented a whole bunch of exemptions around transportation. I’m not sure if it’s the medication getting to the….

Now they’ve loosened it so that you can have peers or other health care–allied professionals transport it to clients. It’s supposed to make it more accessible and low barrier. Those Health Canada exemptions have been in place for over a year and a half, but the college hasn’t updated their scope of practice or….

S. Chant: So the College of Pharmacists has not updated to reflect those. Ouch.

B. Barker: That’s my understanding, yes.

K. Urbanoski: There were some instances of pharmacies that deliver — so pharmacists that do deliver to, for instance, the COVID hotels in Victoria. But again, these are urban.

R. Leonard: I’m going to go in a different lane here, because you’re researchers. One of the things we heard early on is around being able to access data quickly and being able to make change on the go. Part of my history is around participatory action research, and that, I would say, is a part of what you have been doing. I would just like you to comment on the ability to learn as we go, which is basically what is being recommended.

K. Urbanoski: Interesting. It depended on the part of the study. The parts of the study that rely on administrative health data are very challenged by being able to shift and adapt, given the way that they apply for and access data and how long it takes for the data to come to them.

Then there was this other arm of the study Dr. Barker and I were on, where we were constantly shifting as we were learning more about the intervention and speaking with communities. So we were shifting the ways that we were recruiting people for the survey and how we were accessing populations based on what we heard from communities about what was happening across the province.

I would say a good example, Dr. Barker, was when you started recruiting for people to interview in the North, and we were finding a hard time finding anyone who had access to RMG, which was our eligibility criteria, so things had to shift because we had no participants.

B. Barker: There were only two major sites in the North that were prescribing, the two bigger cities, where Member Bond is from and Quesnel, although that’s changed a bit since we finished our data collection.

K. Urbanoski: Yeah. It was a very rapidly changing landscape that we were conducting this study in, so that was an interesting challenge for how we went about the work.

N. Sharma (Chair): I have a question here. I’m really curious, now that you’ve done this research and have taken a look at how this program worked and have seen the gaps, especially in northern B.C., have you spoken to the Northern Health Authority? Do they know this research, and what are the responses from the other side of that?

K. Urbanoski: We have presented to Northern. There is cohort of representatives from the Northern Health Authority that have been partners and close collaborators throughout the process of the project. I know there’s hesitation in other parts of the health authority, and we support by providing information and data when they ask.

Yeah, I don’t know. Are you able to speak to any larger shifts or not?

B. Barker: No. We had the stakeholder consortium, so we had an advisory body and all the regional health auth­orities were invited. Addiction leads to pharmacists and their network would attend, and Northern Health had a couple people, but maybe not as much as we had hoped for.

I think there are a lot of challenges in Northern with just keeping doctors — period — for anything. Yeah, it’s ongoing work that we’re doing with them.

S. Bond (Deputy Chair): I was just, actually, going to build on the Chair’s question a bit more about the northern situation.

[3:20 p.m.]

What’s interesting is…. When you look at some of the details around what happened with this program, rural and remote considerations actually had a little section of its own, because one of the recommended ways of reducing barriers to access was telehealth. Well, there’s a big problem with that, in that many of the communities that would have difficulty accessing a pharmacy also don’t have Internet service. Again, it is such a complicated issue, in terms of looking at consistency across the province. I’m sure that you’ve heard that, Dr. Barker, in your work.

It’s not just the physical issue. It’s that when we say, “Okay, well, let’s just use telehealth,” there are parts of this province where there is still not Internet connectivity. The really interesting connection to what we have learned about who’s impacted — First Nations women, Indigenous people generally, people who work in the construction industry and trades…. Where do we think most of those people would live? Many of them are in the areas where access is severely limited.

I guess, looking at the strategy, one size doesn’t fit all. We heard earlier…. People referenced Portugal. I’m not, for a moment, suggesting that Portugal works for everyone. I live in a part of the province where people don’t have a pharmacy. They don’t have Internet connectivity. Trying to figure out how to support them….

The work that is ongoing…. Is there somebody, some group — somebody other than Northern Health, for example — tasked with saying: “What are we going to do?” The First Nations Health Authority is obviously doing some fantastic work, but there are some pretty basic barriers here.

I guess it’s across many ministries. Internet connectivity isn’t the responsibility of the Health Ministry, but boy, it impacts the delivery of health care. Hearing from you today about…. This is a much bigger process than simply the Ministry of Mental Health and Addictions and the Ministry of Health. There needs to be a cross-ministry approach. Is that accurate?

K. Urbanoski: Yes, 100 per cent. It’s not completely clear to us yet. We both have an interest in how MCFD is intersecting with this. We know that there were many families that were reluctant. You are essentially admitting to your family physician that your drug use is out of control if you’re asking for this. That’s a risk.

A Voice: And you lose your kids.

K. Urbanoski: Yeah. We know that there are policies at MCFD for how substance use is addressed. They’re not always followed, but they have them. This is a bit of a grey area. That’s one ministry. Availability of these forms of prescriptions within work camps and all that that entails is another area. Obviously, the Solicitor General is deeply involved, however this ends up rolling out, going forward.

The shortcomings in primary care. If we even think that…. The original RMG, the original guidance document, had laid this out to be rolled out through primary care. This was to enable primary care physicians to be able to contribute to what was foreseen as being a surge in overdose rates with the emergence of the pandemic. Even if that had worked, and it didn’t, there are so many parts of this province where people do not have access to primary care. Strengthening primary care is clearly a huge need to support this population.

N. Sharma (Chair): I’m going to try to get to the last two questions in the last few minutes that we have.

Go ahead.

S. Chant: It’s actually asked and answered. I’m okay. Thank you.

N. Sharma (Chair): Okay. I was really curious when you were talking about housing and that connection be­tween housing…. Complex care housing, which is something that the province is doing, actually helps to wrap around the services that you talked about. We’ve heard some examples of harm reduction and ways that you can use that to actually get prescriptions, in any kind of a stable way, to the people while they’re living there.

I’m just curious about your thoughts on that, based on your research, as a way, maybe, to tie a lot of your findings together.

[3:25 p.m.]

K. Urbanoski: I do think that the complex care housing ideas are worthy. Again, it’s in the implementation, as to how that rolls out.

Housing-first approaches — absolutely. But the services and supports that are offered to people in those situations also have to be in line. They have to be culturally appropriate and in line with what people are going to participate in, but they also have to be supportive.

People cannot just be left to their own devices if they are really struggling. I’m talking about, here, severe concurrent disorders and other physical health disabilities. It’s definitely a challenge. It’s difficult to see how a program such as this can succeed among folks who are chronically underhoused and unhoused and living in parks or encampments.

I guess I’m cautiously optimistic with complex care housing and other housing initiatives simply because, as with the RMG, supports have to be put into place — mechanisms to support equitable access and to support implementation. As we see with RMG, those were not in place, and things did not roll out as they were initially intended. So I don’t see why it would be different for complex care housing either.

B. Barker: I would just add to that. We work with this really large group of peers from across the province, and a lot of them are doing the peer navigation to keep people on their OAT and RMG. Very clearly, it’s not just a bag of pills. You need someone there to help you. Like I said, you’ll get kicked off your prescription if you don’t go pick it up every day.

A lot of individual peers and these harm reduction community champions — that’s what I call them — are working to do that work to be kind of the same thing that you would get in a wraparound care model in a housing. But I think expanding that is always something worth looking into.

Peer navigation models are critical, because that gets a lot at the cultural safety issues. It gets a lot at that mistrust of medical services and health care providers if it’s someone from your own community that’s helping you.

K. Urbanoski: Going to the doctor is very scary. Having an advocate there with you can make all the difference for this population.

N. Sharma (Chair): I’m going to try to take the last question. We have three minutes left.

S. Furstenau: Hearing what we’re hearing from you, and we’ve heard it from a lot of other folks who have presented…. When you talk about this staircase, there is a lot of control being exerted onto people from so many different avenues. Then you come in to try to access a program like this, and you’re inviting more of that control.

I wonder. This is maybe more a comment than something I think you could answer in 2½ minutes. If we reoriented and said, “Are these systems ensuring that we are meeting the social determinants of health?” — for a person who is in front of us — and the control and accountability actually turned back onto the systems, do you think that would produce different outcomes?

K. Urbanoski: Please make that happen.

S. Furstenau: Okay. You do.

N. Sharma (Chair): That was a succinct answer that you got.

On behalf of the committee, I just want to really thank you not only for the work that you’ve done for British Columbians that are facing this challenge and how articulately you put together this presentation to help us understand what your findings were and what you learned from all the work that your doing. We really appreciate your time. Thank you for all the work that you do.

B. Barker: Thank you for having us.

N. Sharma (Chair): Great. So we have a minute for a change around. Then we’ll get ready with our next panel.

The committee recessed from 3:29 p.m. to 3:31 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): We’re going to welcome our next panel this afternoon, and that’s for first responders. Today we have Dave Deines of Ambulance Paramedics and emergency dispatchers of B.C., and Lee Lax, B.C. Professional Fire Fighters Association.

I just want to welcome you on behalf of the committee, and we just want to thank you for your time. Each of you will have 15 minutes to present, and then we’ll try to get 30 minutes of discussion afterwards.

I’ll hand it over to you. Who’s going first? I’ll let you decide. I don’t believe there was a presentation provided to us from…. No.

D. Deines: I can go first, if that’s okay.

N. Sharma (Chair): Okay.

Briefings on
Drug Toxicity and Overdoses
Panel 2 – First Responders

AMBULANCE PARAMEDICS
AND EMERGENCY DISPATCHERS OF B.C.

D. Deines: Thank you, Chair and hon. members. It’s my pleasure to be here today. My name is Dave Deines. I’m the provincial vice-president of the Ambulance Paramedics and emergency dispatchers of British Columbia. I’m also the national president of the Paramedic Association of Canada.

It’s my pleasure to be here today presenting to you. I hope to give you the gift of some time back. I don’t expect to be 15 minutes in duration. Most of you are familiar with the work that first responders do in British Columbia.

First of all, I’d like to acknowledge I live, work and play on the traditional, unceded territory of the Musqueam, Squamish and Tsleil-Waututh First Nations, and I’m grateful for their stewardship of the land and happy to be here.

As you know, the British Columbia emergency health services was formed in 1974. It is the largest provider of paramedic and paramedic dispatch services in Canada and one of the largest in North America. Paramedics, along with our colleagues in fire, have been on the front line of the opioid crisis long before 2016. I mean, paramedics have been responding to substance use disorder patients since the ambulance service started in 1974 and really pro­vide that cutting-edge front-line service to people in crisis.

Many of the services that we provide are characterized as, if I were to describe…. If someone asked what a paramedic does, I’m sure most people would close their eyes and envision two people in the front of an ambulance with lights and sirens or the news clips that you see nightly of us responding to the overdose crisis.

More recently, not just in British Columbia but around the country, paramedics are playing a more integral role in primary and community health through some very innovative projects out there. One of them, and one we think would be of value to this committee’s work, is what we term community paramedics. Those are paramedics that fill what we characterize as a non-traditional role, so not the lights and sirens in the front of an ambulance but more to deal with chronic health issues as well as substance use disorder.

There are some very, very good examples around the country where community paramedics have played a role in that gap. One of the most successful is in Manitoba, out of the city of Winnipeg.

[3:35 p.m.]

The Winnipeg fire paramedic service has a program called the Main Street Project, where they deal with vulnerable populations in the inner city of Winnipeg, addressing the whole gamut of social determinants of health as well as primary health, substance use disorder, addictions — all of those things in play — and also the role of a health care navigator for those vulnerable populations.

One of the reasons that it has been so successful is that the community identifies with first responders and paramedics that are there every day and that have responded to them in their time of need and crisis. They know that generally, we’re there to help. They feel comfortable approaching paramedics in that non-threatening setting of a community centre, for example.

One of the things we advocate to this committee that can help is some increased funding to B.C. emergency health services to expand that community paramedic model. Right now — and thank you to government — it’s rolled out in over 140 communities in rural and remote British Columbia. It’s been highly successful in terms of call demand mitigation, where we’re taking the pressure off the 911 system, the acute care system and the emergency departments by addressing patients in their home with chronic disease such as diabetes, hypertension and congestive heart failure — all of those things that can be addressed outside of an acute care setting.

We believe, based on the experience with the rest of Canada, that a metropolitan community paramedic model would serve the community with substance use disorder and the opioid crisis very well, both in terms of call demand mitigation as well as that navigation and primary access to health care. When I say that, again, I’ll reference the Main Street Project of Winnipeg, where vulnerable patients can access everything from navigating substance use disorder treatment and addictions counselling…. Paramedics do communicable disease monitoring and testing at that site. They can do things like tuberculosis skin testing. They can draw blood for hep C and HIV testing. They can also access dietitians, nutrition and all of these global, peer-care team services that really surround and overlap that 360 care model where paramedics can play a very big role in that.

In British Columbia, there are a lot of communities outside of the Lower Mainland and big urban centres where paramedics are the only access to health care. I started in a very small place called Port Renfrew, on the Island, on the west coast, where the ambulance station was the only access to any type of public safety or health care. We believe that…. That’s one of the recommendations.

Obviously, some other things we would recommend are an increase in support for the British Columbia emergency health services both in terms of the traditional — so I’m talking about, of course, staff and physical ambulances and equipment to respond to the growing call demand, which really saw an intersection with the climate calamity, where we saw three or four overlapping emergencies come together — as well as for non-traditional things. We talk about community paramedicine. The B.C. Ambulance Services established a paramedic bike squad in the Downtown Eastside, which allows rapid access into scenes that, traditionally, paramedics would have to park at, get out and move the equipment to, things like that.

Finally — again, I promised I’ll leave you with some time — we’ve also been collaborators on policy documents since around 2016. We published a white paper on policy collaboration for naloxone, for example. We believe there are still some things that can happen with take-home naloxone programs. One of them, of course, is the change from a sharps-based or a needle-based delivery system to a nasal-based system. I’m sure you’ve all seen the nasal inhalers. We believe that that is a good move to make for the lay responder — so the public. They’re very simple to use and, of course, it takes away that additional danger for first responders of those increased needles around the scene. That’s another recommendation we made in that white document.

From a national perspective, you may or may not be aware that the Paramedic Association of Canada collabor­ated with the Canadian Standards Association, and we published a standard. It’s Z1650, I believe, off the top of my head, and it’s titled “Paramedic Response to the Opioid Crisis in Out-of-Hospital and Community Settings.” It’s, in retrospect, a bad title, because people think that that talks about how we actually treat patients as paramedics and what we should use and how much naloxone, but it’s not. It’s actually a teaching document for community-based groups that are dealing with the opioid crisis — so everything from what this broad, pan-stakeholder group thought an overdose prevention site should have, for example.

[3:40 p.m.]

This group included, obviously, paramedics, educators, service providers, people with lived experience, Indigenous groups and service providers like Insite. The Overdose Prevention Society of British Columbia was there. A wide stakeholder group produced this document.

I can provide it for you through an email. I would en­courage you to read it. There are some really good things in there about take-home-naloxone programs across the country, some good educational materials that paramedics can leave with the scene.

Finally, I’d just like to thank you for the opportunity to present. After my colleague, I’d enjoy any questions.

N. Sharma (Chair): Okay. Thanks a lot. Yes, we probably will take you up on having that white paper sent along. We can make sure it’s part of our materials. Thanks for raising it.

Over to you. Go ahead.

B.C. PROFESSIONAL
FIRE FIGHTERS ASSOCIATION

L. Lax: Excellent. Thank you.

Good afternoon. I’m Lee Lax. I’m a suppression firefighter here in Vancouver. I’m stationed at Fire Hall 20 on Victoria and 38th. I’m also the vice-president of the International Association of Fire Fighters Local 18. I’m here representing the B.C. Professional Fire Fighters. I’m here to speak on behalf of our president, Gord Ditchburn.

Providing all levels of government with views and perspectives on the overdose crisis is something I’ve been tasked to do multiple times throughout my career. I’ve been to Ottawa. I’ve spent time in Victoria. I’ve spent time at city hall. I’ve got to be quite honest. I’m growing tired of speaking about this. I’m tired of the impact on our members, and I’m tired of the impact on our communities.

I’m going to keep the scope of what I’m going to talk about within the scope of what firefighters do. Firefighters in pre-hospital care…. Our job is to sustain life, and that’s exactly what we do in this overdose crisis. Our job every day is to breathe for people when they’re no longer breathing. That’s our role in this.

We’re not experts in many other fields, as some of the speakers before us, but you’ve asked us to use our perspective and bring forward some tangible solutions. What are you going to do next? There’s no other answer, from the perspective of firefighters, that will make a greater impact than low-barrier safe supply. That is the number one thing, from our perspective.

I think we just need to jump back a little bit and look at what’s happened over…. Really, since 2011-12 is where we started to notice the uptick in overdose responses.

In 2011 — this is the example I’m going to use for you — in Vancouver, we responded to 2,000 overdoses at that time. Get to the end of 2021, and we responded to over 7,600. So it’s four times the amount over that period. We’re adding 1,000 overdose responses a year in the city of Vancouver.

I take with great respect the…. Our members across B.C. see the overdose crisis a bit differently in every community, but let’s not be mistaken. The Downtown Eastside of Vancouver is the epicentre of this. This is where we are having the greatest amount of problems.

I’m just going to wrap up on a couple of points here. I want to touch on…. If we’re adding this many overdoses to Vancouver and across the province every day, every month, every year…. Our death rate isn’t actually going up that high, and I think I’d be remiss if I didn’t reflect on the great amount of work from the overdose prevention societies, the volunteers walking the streets, firefighters and, obviously, our partners in pre-hospital care, the ambulance paramedics.

Our second recommendation to this committee would be to start thinking about the impacts of the increased overdose responses on municipalities. How is this affecting their bottom lines?

[3:45 p.m.]

The tiered, pre-hospital care system that we have in B.C., where you, many times, get a first responder followed by ambulance paramedics, who provide a higher level of care and transportation to the hospital…. The two pieces are integral to the system, right? We’ve witnessed many a time — through the overdose crisis, the heat dome last year — where we needed all pieces of this. We’ve got to think a little bit of how municipalities are going to be supported through these continuing requests to keep doing more.

On behalf of our 4,000 members of the British Columbia Professional Fire Fighters Association, really appreciate the time you’ve given us to continue to come back to this committee and speak.

N. Sharma (Chair): Thank you very much. We’ll move to questions. Maybe I’ll start us off.

One thing we’re learning…. The change — since you reflected on earlier, when you started, till now — is the increasing toxicity of the supply of drugs and the relentless, it seems like, types of drugs that are showing up that are resistant to naloxone, sometimes, and resuscitation.

I really want to know. What are you seeing and what are your members seeing when it comes to that level, and how has it changed your responses when you see people?

D. Deines: Well, definitely…. You’re absolutely correct. We’ve moved from…. Traditionally, we were seeing single agent overdose — fentanyl, obviously, being the big one — now into a poly or mixed overdose with very, very toxic, high concentrations of not only opioid but associated substances with, most commonly, barbiturates.

From a response perspective, it really doesn’t change the way we respond to the patient. But from a treatment modality and the impact on health care in its totality, it makes a huge difference now. We’re seeing patients that are on massive infusions of naloxone, in an intensive care unit, at St. Paul’s or Vancouver General or Kelowna or Prince George or Quesnel. That takes a tremendous draw on that health care system, because of the type of overdose.

From a paramedic response, the modality is similar. The way we treat them may be altered in the amount of naloxone we have to use or the amount of breathing support that we have to utilize for them. But definitely the toxicity and the agents of use are making a huge difference, not only in the vitality of resuscitation, if I can say that, but also the impact on the global health care system, in that they have to stay in an acute care or an intensive care setting longer, with more resources focused on that recovery, for sure.

L. Lax: I will put it in the terms that I understand it as a firefighter. I can remember distinctly the day where the naloxone training was finally provided to firefighters. We were instructed, quite clearly, that each dose is 0.4. Give them one, wait a little bit if they need another.

In the Downtown Eastside, many times our members get there, and a citizen that’s down has probably got four doses already and probably leaves the scene with 1.2 in their system. When we first started, it was 0.4, so we’ve tripled — a lot of times, not all the time. That’s how toxic it is.

S. Furstenau: Thank you, both.

Lee, I really appreciate your frankness and your frustration. I think it’s really important that we hear that.

Dave, you just said: the tremendous draw on the health care system. This is just in terms of data. If we have gone from 2,000 to 7,600 overdose responses in Vancouver since 2011, what does that compare to, to overall paramedic response? What percentage of responses for paramedics and firefighters are related to the toxic drug supply?

D. Deines: I can’t give you a number off the top of my head. I can certainly get the data for you. It’s easy to pull from BCEHS, and I can provide it.

[3:50 p.m.]

I can say probably a very similar experience. We have members who, on a daily basis, respond to multiple overdoses in the same area and, in some cases, the same person. They will respond to an overdose. They’ll resuscitate the patient, and sometime within that 12-hour shift, they’ll go back and resuscitate the patient at least once or, sometimes, two or three times again.

From a provincial perspective, the Ambulance Service does — it depends on how you count — somewhere around 850,000 calls a year. That makes us the largest ambulance service in Canada, obviously. From that, I can extrapolate how many overdoses are done. I can definitely get you that data, for sure. Whatever the number is, it has definitely increased dramatically.

L. Lax: I’ll just touch on…. How I look at it is…. If there was something in your home that would constantly catch fire, you’d just get rid of it. You’d change what you were doing, right? We know what the solution is. How do we want to knock back this impact on the health care system to not have to put as many resources into it? It’s the toxicity of the drugs that keeps us going back.

P. Alexis: I just want to talk about the community paramedics model. Is there a different use than we’re currently using to help us with this crisis? Is there something out there that we’re not doing, with community paramedics, that we should be doing?

D. Deines: Excellent question. Again, I can draw on examples from around the country to compare. The really useful thing about community paramedics is it’s tailored for each community. It’s not the same solution wherever you go in the province, which is a big draw to community paramedicine.

In the same breath, though, there are some things I think are core that they could be doing in every community and that they’re not. One of them, of course, is to deal with the opioid crisis. It’s everything from harm reduction to patient navigation and education to Peer Assisted Care Teams.

I just presented yesterday. There’s an innovative project around mental health that’s happening in Victoria and New Westminster, developing a Peer Assisted Care Team, or PACT.

S. Chant: And in North Van.

D. Deines: North Van. Sorry. Yes, I didn’t know that until this morning.

Very innovative around mental health emergencies, which, as we know, are coinciding with a lot of substance use emergencies. That peer team, certainly, I think, is a core component.

Then finally, expanding the use of community paramedics into large urban and metropolitan centres will, I think, realize a few things. It’ll help reduce wait times for care as well as…. Anything we can do to call demand mitigation, onto the public safety fleet right now, is what we need to do, for sure. We know, from a B.C. Ambulance perspective, it’s around 6 percent per year, the call volume increases, totally, just based on society. Then you add a crisis on top of another crisis on top of another crisis, and the demand far exceeds the supply.

Anything we can do to reduce the demand on the general fleet, as I will refer to it, I guess, is certainly…. I think some innovative solutions using community paramedics in Metro, large urban areas — patient navigation, education, harm reduction…. Assisting with access to safe supply is another innovative program, for sure.

P. Alexis: Is the Paramedic Association ready for such a shift?

D. Deines: In B.C. or nationally?

P. Alexis: B.C.

D. Deines: Absolutely. We’ve been advocating for community paramedics since the late ’90s.

It actually started, in all of North America, on a tiny lit­tle island off the east coast called Long and Brier Islands. It was necessitated because, very similar to what we have in our great province, any time that population needed to access health care, it required two ferry trips off the island, which wasn’t serving anybody’s need. That’s where that program, in the early ’90s, developed, to bring a paramedic into that community.

I should have started by saying that we are by no means advocating that we use paramedics to replace other allied health professionals. That’s not what we’re saying.

P. Alexis: No, I understand.

D. Deines: Certainly, the Ambulance Paramedics of B.C. have been, for a long time, championing the use of paramedics in non-traditional roles like that.

[3:55 p.m.]

R. Leonard: First of all, let me say thank you very much for the service that you provide to people in need every day, all over the province. One of the things that has been, I think, on everybody’s minds and in their hearts is around the stresses for first responders. I just want to recognize that. You guys are heroes.

I wanted to ask a question around…. You said there were 140 communities with the community paramedics program. Are they all in rural areas? My understanding was that was filling a big, huge gap in remote and rural areas. Do they exist in Indigenous communities as well?

D. Deines: Yep. I need to correct myself. It’s over 140 paramedics in about 140 communities. Some communities, for example, will have two community paramedics.

It is primarily in rural British Columbia. There are some remote community paramedics. Again, I can provide a list of all the communities. There is access to Indigenous communities, not on the territories themselves.

It’s an excellent question. We, nationally, have partnered with Indigenous Services Canada, INAC. We have the of­fice of the chief paramedic now, within that group, that navigates putting community paramedics into isolated territories. Northern Manitoba and northern Ontario are the big ones right now, where we put a community paramedic in there to conduct COVID screening, for example, back in 2020. The best part about that was the access to federal dollars to fund that.

Certainly, to answer your question, I think it’s an opportunity that’s there. It’s under-tapped, for sure.

R. Leonard: Right. One of the initiatives that has been developed and supported is the Lifeguard App. I don’t know if you know about the reach, in terms of rural areas. It is to alert those first responders to come if they’re using alone. I’m just curious if you have any read on how that is rolling out, in terms of the uptake and the impact for paramedics.

D. Deines: I can say, anecdotally, it’s very well received. It’s saved countless lives, for sure.

I think one of the opportunities for improvement is to get the info out further. There are a lot of vulnerable patients that don’t have access to a cell phone, for example, and that can’t navigate the app. So things like that. I think it, certainly, could be an opportunity to roll out or partner with a provider, for example, to provide low-barrier access to cellular phones with that app on it, or a different mechanism to access the Lifeguard App.

In terms of anecdotal evidence, it’s saved lives, for sure, and it’s been well received by paramedics.

S. Chant: First off, again, thank you. I had the opportunity to be involved in the rollout of community paramedics for Bowen Island.

D. Deines: Oh, nice. They’re good.

S. Chant: It was great fun and certainly made our life easier. I’m part of home and community care on the North Shore.

Harkening back to my colleague’s question, my concern is…. I’ve been hearing that there are an awful lot of first responders that are off on stress leave over this last two years.

I think this is maybe slightly out of scope. If it is, Chair, please advise me.

What can we do to help support those folks so, hopefully, they can get back online? The resources get smaller and smaller, not necessarily because we’re not trying to put people in but because people leave related to stress. As a nurse, I understand that fully. What would you suggest there?

D. Deines: I would first reclassify that and call that an occupational disease.

S. Chant: Yes. Okay.

D. Deines: You look at most services. You can look across policing. You can look across the paramedics service. You can look across the fire service. The work that we are doing internally to make ourselves more resilient at identifying when we’re having a tough time….

[4:00 p.m.]

I’m going to take a quick second and speak, from my perspective, on what I see every day in the paramedics service. We have seen demands in the paramedics service increase at an insurmountable rate. These guys are run off their feet every day. We saw some significant additions and changes last year, but it keeps getting busier for them.

They battle every day to take a lunch break. If we ask…. In any work environment where people end up getting to the point that they need a break, it’s just too much work.

S. Chant: All right. Thank you.

S. Bond (Deputy Chair): Well, thank you for being here. We appreciate what you do every day.

I think part of what we struggle with is imagining what it’s like when you feel like you can’t do enough, when you can’t respond quickly enough to every single call that arrives. It’s got to be really hard on your colleagues and the people you work with. You’re here today to talk about the opioid overdose situation, but it is part of a bigger, more complex problem. The pressures are enormous.

I want to thank you for your commentary about community paramedicine, because I know what a difference it’s made in my communities. I think there was a small number of prototype communities in about 2015, and then, in 2016, a big expansion.

I know that in McBride and Valemount, which I represent, rural communities, people make a really big difference in terms of that role. Thank you for that. I think it’s a really good recommendation, and I think it’s important. I’m going to take a look at the Manitoba primary care paramedic model. I think that’s another really positive suggestion.

We should be really clear about what you do every day, and that is you save lives of people who have overdosed in a parking lot. The other day in my community I saw Prince George fire rescue with their truck in the Save-On parking lot dressed in, basically, hazmat gear as they were dealing with an overdose. There were three or four first responders in that parking lot with a fire truck, trying to help save someone’s life.

I think the story we don’t hear enough about is exactly what Lee said. You know, sometimes it takes more than one shot of naloxone. It takes two or three, and, according to first responders that I know very well, you can see the same person two and three times in a day — not once but two or three times in a day.

What I’m concerned about is…. I think Lee characterized it well, in terms of what the impacts are on municipalities. Firefighters are there, first responders, to support their communities and their jobs, but I’m not sure they thought they would taking the percentage of time they take now to administer naloxone in our communities right across British Columbia.

What impact is it having on your members, and how are you managing the stress and the personal trauma people are facing in your own, whether it’s BCEHS or whether it’s the B.C. Professional Fire Fighters or whoever it is?

Secondly, the response that you are now required to be part of in communities in order to do your jobs — has that now been incorporated formally into training that, for example, first responders receive? I remember the debate about whether or not first responders, firefighters would be trained on using naloxone. Well, they certainly are now. Is that now incorporated into the ongoing training of first responders across the province?

Most importantly, impact in your municipalities. What about your members, and how are you managing in the circumstances?

Then lastly, have you incorporated specific training that’s ongoing?

L. Lax: I’ll touch on the point again about training. Firefighters across British Columbia have been very fortunate to have some pretty strong advocates for mental health amongst us. We have developed a program called resilient minds that has spread across the province — and across the country, actually — to build on that, to keep ourselves mentally prepared for the work that we do.

[4:05 p.m.]

To backstop that, we’ve got to thank members from all sides of the House on the work that was done to clean up language in the WorkSafe act to properly identify occupational stress injuries and realize the impacts of: “What I saw five minutes ago may have triggered what I saw five years ago.” That’s what happens for us.

From firefighters’ perspective, we’re an all-hazards re­sponse in our communities. It doesn’t matter what it is, be it a medical incident, some type of fire or hazmat incident, technical rescue. We’re just here to help our communities.

We have a terribly great relationship with the ambulance paramedics. It’s a very streamlined service. As an example, in Vancouver, we have 20 fire stations located throughout the city. There’s opportunity for us to probably get there quicker, because we have four-minute travel time everywhere in the city, based on fire insurance reasons. It works well: early access to the patient, critical interventions. Then the patient gets passed to a higher level of care, where advanced paramedicine can be provided by the ambulance paramedics, and off they go.

The impact we’re seeing now…. We have overdose calls in the Downtown Eastside where our firefighters, in a fire truck with four members, could be on scene for an hour. The Downtown Eastside, as an example, is one of our busiest fire response districts in the city as well. So now you’ve eliminated a fire truck out of service for the time being. Where that issue is, is still on the shortages that we’re having, as far as enough ambulances on the street. We’re seeing that every day.

I think at this point, that is the biggest point. The whole pre-hospital care system has still got some growth it needs to do in order to make sure the impact isn’t too great on the municipalities.

D. Deines: Yeah. Certainly, I can speak to the impact on our members.

We talk about compassion fatigue and occupational stress injuries. Again, I also would like to thank all sides of the House for including not just paramedics but dispatchers. Our dispatchers are separate from E-Comm, obviously, and frequently get left out of the conversation just by the nature of the work they do but, in some cases, suffer higher occupational mental health illness and injury than paramedics do.

I also would like to shine, maybe, a positive light, if I can, on the conversation, in that if anything positive has come out of this terrible crisis, it’s recognition — just the ability to sit here and speak with the hon. members at the table here is a big deal for us — of the impact it does have on all of public safety and first responders.

We have a fantastic tri-service mental health committee that has been very active over the last five years now, where destigmatization and treatment options are definitely a lot more robust than they were five, ten years ago, for sure.

Certainly, I think I agree with my colleague that some work still needs to be done on some of those benefits that we could increase to all first responders out there — as well as, definitely, the role that it plays on municipalities and just the surge in demand.

Unfortunately, all things interconnected, we’re coming up on another — it’s happening right now — freshet, flood, fire. Those are all going to intersect again with toxic drug supply out there that will impact the ability for all first responders to respond.

When police or fire are waiting for an ambulance for an extended period of time, that takes that resource away from not a primary role but a role in their community. The same is true about paramedics. When we’re waiting at a hospital with a patient on an offload delay, it’s just a never-ending, vicious cycle, where that increases wait times for our partners in public safety. We can’t offload at the hospital because they don’t have a space for us, for example.

[4:10 p.m.]

It’s a very complicated, complex issue, as I’m sure you’re all well aware. But I did want to put a positive note out there that there are definitely a lot of improvements that have been made in terms of benefits for first responders, particularly paramedics and dispatchers. We’d like to see that go farther for sure.

N. Sharma (Chair): Okay. We don’t have any more questions.

I wanted to say that you’ve heard from this committee, through their questioning and their response to your work, how important all the work that you’ve done and continue to do on this topic, for sure…. I know just from what you’ve said today and from what I’ve seen and we’ve all seen in our communities, it’s been tough being the first responders out there during the two health crises. We just really appreciate the work that you do to show up for people and save lives. I just wanted to thank you for that.

Also, I just wanted to make note on the record that this panel was for first responders, and we did reach out to the police representatives. They just weren’t able to be here during this time. They will be coming at some point, and we’ll get to hear that perspective as well.

Thank you very much for coming. We have our next panel in about 20 minutes.

D. Deines: Thank you so much. I will send that information back through the email.

The committee recessed from 4:11 p.m. to 4:30 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome. Thank you very much for coming. You’re the third panel this afternoon, and we’re so grateful to have your expertise. I just will introduce you and tell you a little bit about the way we’re going to do the process today.

We have Dr. Christy Sutherland, from PHS Community Services Society, and Dr. Kora DeBeck, from B.C. Centre on Substance Use. We want to welcome you. You have about 15 minutes each to present, and then we’re going to go to questions and answers and have a discussion with the committee after that.

Briefings on
Drug Toxicity and Overdoses
Panel 3 – Experts on
Substance Use and Research

PHS COMMUNITY SERVICES SOCIETY

C. Sutherland: I’m delighted to be here. I’m a family doctor and an addiction medicine specialist. I’ve worked in the Downtown Eastside for 12 years, and it’s been a pleasure to have the career down there with my patient population. I’ve definitely changed over the years, and the overdose crisis has changed me. Half of my career has been during the crisis, and it makes you reflect a lot.

This past year I’ve been thinking a lot about: “How did we get here?” Let’s unpack a bit, because every time I do a overdose intervention, I wish I could rewind ten minutes and just give that person something different than what they took. I’ve done more than a hundred, out on the street in the rain. The nurses at my clinic joke that we need umbrella hats for doing overdose interventions so that we have two hands for managing someone’s airway.

You guys have my little handout that I had, PowerPoint. John Ehrlichman here, and Nixon, is one of the reasons that we’re here today. You guys might recognize his name because he went to jail for Watergate. In 2016, he was interviewed by Harper’s Magazine. He didn’t want to talk to them. He was just sort of speaking through a crack in the door, and he said:

“You want to know what this is really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the anti-war left and Black people. You understand what I’m saying?

“We knew we couldn’t make it illegal to be either against the war or Black, but by getting the public to associate the hippies with marijuana and Blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings and vilify them, night after night, on the evening news.

“Did we know we were lying about the drugs? Of course we did.”

To me, when that came out, I thought we were going to see broad policy change. This just shows me, like a naïve young family doctor being, “Oh, hey, the architect of this system has told us that it was based on racism. Now, surely, we’ll change,” and really, no change was spurred.

I also think about alcohol prohibition. It was universally acknowledged that this was wrong. So here’s young, handsome Al Capone, age 26, who made $1.4 billion in today’s dollars and ended up going to jail for tax evasion. Think how many people died or went blind because of that system. Then they changed the system in America but then stopped there and kept other drugs illegal, trapped in this system of being controlled by organized crime, and those are the harms that we’re seeing today.

I think Dr. Kendall talked with you this morning about this U-shaped curve of trying to get to this ideal future state where we’re not seeing these deaths and we’re not seeing this harm. Right now, we’re in unregulated, illegal profits, where organized crime controls the supply chain, they control the contents, they control the dose, they control the price, and they’re interested in profit. They’re trying to pursue new drug users and increase the needs of current drug users.

What we also don’t want is unregulated legal profits. Think about tobacco in the ’60s, saying that they had nothing to do with lung cancer, sponsoring jazz festivals, creating Joe Camel to entice young people to start using. We don’t want profit for drugs, because we don’t want to increase drug use, right?

We want to be there in the middle of the public health model. What does that look like? It can be different for each substance. Often, when I talk with my colleagues about unpacking the war on drugs and medicine’s role in opioids, people think of a dystopian opiates-for-all kind of party, but it’s not at all like that. Regulation is what brings safety.

That’s the next slide, to say licensing standards, inspections, supply chain standards, audits, taxes, creating re­strictions on who gets profits, advertising, price controls, driving regulations are what gives safety to a system. What’s not on this list is physicians being psychic. I think a lot of the response to the opioid crisis has relied on physicians being gatekeepers to euphoria — which is not what we’re trained for, and not our role.

It’s very uncomfortable, as a physician, to be a gatekeeper. Patients will ask me for sick notes, a note for the airline so that they get an extra seat. I’ve filled out so many prescriptions for medical marijuana in my career before that became legal. That was a waste of my time as a family doctor. I shouldn’t be the gatekeeper for who gets marijuana. That was not good policy. I didn’t provide safety to the public or safety to my patients by being that gatekeeper. The public in Canada got very inconsistent access to cannabis because of those requirements.

Now that’s unpacked, and physicians are so glad. I don’t have to fill out cannabis prescriptions for people anymore who say that they need it for their glaucoma, when there’s no research to show that it works in that way, right?

[4:35 p.m.]

I’m happy to take care of my patients longitudinally as their primary care physician: to do their PAP tests, to start them on methadone, to do medical interventions. What has been really challenging in this crisis is trying to be psychic and use my crystal ball to figure out what people need to be safe in a way that’s also safe for the public. That’s why what I want is a huge system change that’s upstream from individual physicians doing interventions.

As well, when we look at our interventions like methadone and Suboxone, and Kadian, which we have in Canada — we don’t have that in the States — the dosing that people require is much higher than it was when I first started. When I first started in 2010, methadone was the only intervention for opioid use disorder, and the doses were reasonable. People would be on 80 milligrams and feel comfortable. I have patients on 180 still in withdrawal.

It’s also complicated by the benzodiazepine contamination in the opioids. They’re also in benzodiazepine withdrawal. But how can that individual know which kind of receptor is causing their discomfort and how to alleviate that?

When we look at the research, most of the research for opioid use disorder was done in a heroin context, and our context has changed to fentanyl. So it makes sense to me that these drugs that are old didn’t work anymore. I wanted to change to PEP fentanyl, which is what we have worked on over the past few years, but it’s a very challenging molecule. I can really understand how organized crime has killed so many people, because the molecule itself is incredibly hard to work with in the community setting as well as in hospital. The formulations we have are not strong enough for what my patients need, and the volume that we’d have to give them is just too high.

The next slide is sort of my career, in a nutshell, of trying to innovate ways to get patients out of withdrawal. At the PHS, we offer a continuum of care that people can flow along: methadone; Suboxone; Kadian; injectables, we’ve been offering since 2016; Dilaudid tablets, we started in 2019, and then that was scaled up for the COVID crisis; sufentanil, which is an analogue of fentanyl that’s often used in palliative care; fentanyl patches, Fentora; and fentanyl powder, which is our newest innovation.

The fentanyl powder I wanted to talk about specifically, because it’s a new protocol. Our team of nurses, pharmacists and physicians partnered with a national pharmaceutical supply chain company and compounding pharmacy to create a new way to deliver fentanyl in community at much higher doses than ever done before.

If I went to the hospital with a broken leg, they would give me 12.5 micrograms of fentanyl. I have patients on 40,000 micrograms in one day, injecting. The dosing is astronomical. I was talking with an anesthesia colleague. It’s more than she uses in a month in the OR at St. Paul’s — in one day, one person. So working on the supply chain and the lab to validate these doses has just been so challenging. No wonder my patients are suffering, right? They are even still using on top of what I’m giving them, and still in withdrawal.

We’re trying to create safety with this system. For me, I want safety for the public, and I want safety for my pa­tients. That’s why we created this enhanced access program. It’s a sales program that runs in parallel with the medical model.

The medical model is based on iOAT and TiOAT, all of our other interventions that we had been offering, where it’s all observed dosing. But I don’t go to my doctor to get observed alcohol, and a lot of my patients don’t want to come see us, even though we’re very nice. I don’t take it personally that they don’t want to see me to observe their doses. Fentanyl has a very short half-life, although it can accumulate in the fat and then become sort of a long-acting drug. But people use at night; they don’t just use eight to four, the hours that we’re open.

I wanted a way to think about: how can it be safe to have people have take-home dosing of these large doses of opioids in a way that’s public-health focused? I want to be at the bottom of that U-shaped curve. So we created this enhanced access program. It runs in harmony with the medical program, where the patients purchase their fentanyl powder capsules for take-home dosing, and they can flow back and forth as they gain stability or lose stability between the medical model and the sales model.

The work flow is very similar to everything else we’ve established before. It’s a physician assessment, a documen­tation, a urine test, a PharmaNet check, a consent process. Everyone goes through a specific titration with a nurse to get to their specific dose. It’s a decision-support tool that the nurse uses based on our protocol, where people have escalating doses until they say: “Here. I’m at the right dose.” We haven’t got there yet. We don’t know what that right dose is going to be, because it’s higher than what our supply chain can supply at this time.

PHS acts as the agent for the patient, so we purchase the drugs on their behalf and then try to recoup our costs. We are not making money, but it’s easier for our pharmacy. Physicians are paid an hourly rate — I’m not making any money — and the nurses as well.

We wanted to make it as easy as possible for the patients. They can do partial purchasing. They can have prepaid tabs on file. Family members can pay. They can pay cash or credit card.

[4:40 p.m.]

It’s not attached to medicine in a coercive way. They can start medicine at any time. I’ll prescribe their anti-retrovirals and optimize their blood pressure and do their Pap tests and prescribe their methadone, but that’s not a requirement to be in this program, which I think is so important.

If we look at alcohol, which is not an ideal solution…. I think alcohol is not regulated enough. I think we should have less fancy alcohol labels. I think they should all just be plain text with the information on them. Then it would be much less appealing. I don’t think the newspaper should be able to run wine of the week. There should be no sommelier columns talking about different varietals. I think that’s too much enticement to drink more. I want more regulation for alcohol, and then I want those same regulations imposed on opioids.

One of the other safety systems we put in place is that if someone wants to increase their dose, they have to come back and have it witnessed. Because I’m always conscious of my vulnerable patients being taken advantage of by organized crime — to say: “Dr. DeBeck, you go sign up for that program, then I want 30,000 a day from you” — I have to observe that person take it, to know that they’re able to tolerate that dose.

The regulatory system for opioids doesn’t exist right now. Right now it’s individual prescribers deciding what is the right clinical plan for their individual patients based on evidence that’s out of date and a lack of guidance, really. So our team created the regulations that we think should be in place. We priced it at the same amount as the illicit market so that it does not have resale value.

For the patients, it’s how much money they were spending anyway, so it’s no change for them. That decreases the risk of diversion, decreases the risk of organized crime hijacking the program. Then there is significant benefit to the patient, where they have autonomy, they’re treated with dignity, and they know what they’re taking.

Just as if I go and buy a Malbec, I know what’s in there, I know the percentage of alcohol. And if I died, there’d be an investigation about what happened at that vineyard, right? I just really want to reframe it. I don’t think my patients are sick.

When I was in med school, I memorized the criteria for substance abuse. One of the tick boxes on the DSM-IV was encounters with police, and 2007 Christy did not know that that was wrong. But 2022 Christy can see that that is so racist and that when we unpack the DSM and the criteria for substance use disorder, it is steeped in racism. It’s also steeped in bias towards poverty and the social determinants of health. How severe your diagnosis of substance use disorder is does not correlate with your risk of death, which is not like any other medical condition.

I’ve come to realize, as an addiction medicine specialist who has been practising for 12 years — I teach at the fellowship with Kora — that I don’t think it’s a disease. I think we’ve pathologized drug use, and we’ve medicalized well-being. That’s all done in the context of a broken criminal justice policy that harms marginalized individuals. So I really want to unpack things from the top.

I want to stop having these individual physicians with individual patients trying to make an impact on this overdose crisis. I order 20 pads of duplicate prescriptions from the college, and I go through ten a week, probably. I can’t prescribe fast enough to prevent my patients from dying, so it really calls to me. To me, it’s a call for a system change.

To me, I want safety for my patients, which is the intake process with a physician that’s just a one-time intake, the observed titration process, connection to primary care, low barrier…. Lots of my patients go to recovery and stop using drugs, and I am so happy for them. But they do, there, with support and with non-judgment, and when it’s their decision. I’m just there to help them, and then I’m there to celebrate along the way as they get on their anti-retrovirals and get housing and as they connect with their family. It’s all about a continuum of care that people can flow along.

Then we have an independent evaluation, by the BCCSU, that the dose increases after the initial titration are observed. The policy and procedures are hundreds of pages long. We had a legal review by Arvay Finlay, so we meet all of the legal regulatory requirements, federally and provincially, for all three colleges. All three colleges had very positive receptions to this program. I met with nursing, physicians and pharmacy.

One of the keys to this is that fentanyl powder is not covered under PharmaCare. If it becomes covered under PharmaCare, I can’t sell the drug. Then we are locking our­selves into a medical model, saying that we’re having to urine drug test 100,000 people, because that’s how many people would need this intervention. To have clinical eyes on those 100,000 people doesn’t exist. There’s no capacity in B.C. to do that.

I think it’s wrong to pathologize a normal part of being human. I think about how many friends socially I know who have used drugs in their life and how many friends socially I know who have been arrested — zero. Most people who use drugs never meet the criteria for substance use disorder. Most people who use drugs never need medicine. It’s just a natural part of being human, and we’ve created a system of danger for people.

So 56 seconds left. I’m surprised. Thank you so much.

N. Sharma (Chair): Thank you, Dr. Sutherland.

Over to you. Then we’ll open it up for questions.

[4:45 p.m.]

B.C. CENTRE ON SUBSTANCE USE

K. DeBeck: Thank you for having me. My name is Kora DeBeck. I’m a researcher at the B.C. Centre on Substance Use. I’m also an associate professor in the School of Public Policy at SFU.

I’ve been doing research around substance use and drug policy for the last 15 years. I’m really here to share some research that we’ve done and then, as you were requesting, some tangible solutions for the overdose crisis.

I wanted to, first, start off by giving you a bit of an explanation for our research platform. It’s a very unique research platform. So just let you know some of the features of that so that, then, you also understand the context of some of the research that I’m going to share.

I want to note that our research takes place on the traditional and unceded territories of the Musqueam, Squamish and Tsleil-Waututh First Nations.

As Dr. Sutherland has noted, and I’m sure many presenters before, and as you all know, drug policy has an incredibly differential impact on Black, Indigenous and people of colour. Our history of colonization here in Can­ada is central to this and our research as well.

The research platform that I’m speaking to you about is a network of three longitudinal cohort studies. They were established in Vancouver — the first one in 1996. It’s funded by the U.S. National Institute on Drug Abuse. That is, I think, important because it shows the unique environment that we have here in Vancouver and a lot of interest from the States to even fund the work that we do.

We’ve been following people who use drugs, about every six months. We now have three different cohorts. One is street-involved youth who use drugs, one is adults who inject drugs, and one is people who are living with HIV who use drugs.

This research platform has been, as I was saying, very established. It started in 1996, and then the youth study started in 2005. We follow over 1,000 people who use drugs. So we’ve been able to get a lot of information about their drug use patterns, their risk behaviours.

I haven’t presented evidence for this, but many studies show the harms of drug prohibition and criminalization. Some of the newer studies that I wanted to bring your attention to are in the COVID era.

We asked over 700 people, between July and November 2020, about their perception of the drug supply. Did they think that it had gotten worse since the COVID pandemic started? We found that 37 percent of them said that it had declined. Their experience was that it had declined.

Through statistical modelling, we were able to demonstrate that those who reported that it had declined were significantly more likely to experience a non-fatal overdose event. So we know those are predictive of fatal overdose events.

This is the kind of data…. Anyone in the community would say we don’t need data to show this, but it’s just another piece of information showing that yes, indeed, the root driver of the overdose crisis that we’re seeing really is in the drug supply.

I also wanted to highlight another study. One question that had come…. I don’t know if it has emerged in any of your work or any of the discussions. The COVID emergency income support that people were receiving was po­tentially driving overdoses. People had more money. There was some sort of effect there.

We looked at that with our data. We asked people: who had received COVID emergency income support? Many of them had. Sixty-two percent of our sample had received COVID emergency support in that period of time, but we did not find that it was associated with an increased risk of overdose.

I think that’s an important piece of evidence. We haven’t published it yet. It’s still under preparation. But just to bring home that economic security, in this natural experiment, did not lead to an increase in overdose risk.

The final piece of research that I wanted to note is with respect to decriminalization. I think that’s another area that your committee has been looking at.

One of the things we did with our cohort study was…. When the city of Vancouver was preparing their application for decriminalization, with respect to thinking about thresholds and where the threshold was for personal possession, where that should fall, they really didn’t know how to go about it. So they asked us to look into whether we could generate estimates for the volume of drugs that people consume, which is actually incredibly difficult. I’m sure Dr. Sutherland’s presentation underscored that.

[4:50 p.m.]

We do have, with a related study we have…. Researchers went in very carefully and asked people, actually, the amount of money they were spending on drugs per day and, in really careful detail, tried to get at how much people were consuming per day. With those estimates, we were then able to apply it to our data, which was surveying over 1,000 people, to come at some estimates of the true volume of drugs that people were consuming.

Now, our estimates are…. We consider them to be ex­tremely conservative and likely underestimating the true volume of drug consumption. I’m just going to highlight a few reasons, because I think they’re really important. One is that our data ended in 2019, and as we know, the drug consumption and the supply of drugs has absolutely changed. This was — and I think Dr. Sutherland could confirm — in a much different era.

Also, this was people’s…. There’s a lot of polysubstance use that happens. These are people’s overall, all of their, drug use. If you average out what type of drug, then…. If you think about someone who just uses one type of drug, their drug consumption is probably a lot more in those single categories. There’s a lot of polysubstance use that happens. But when we’re using these averages, it can be difficult to extrapolate it for everybody.

Essentially, with these estimates, what we came to is…. People with severe substance dependence, those people who reported the most amount of drugs, were reporting over four grams of opiates — and this was, again, in the 2019 era — five grams of powdered cocaine, 7.5 grams of crack cocaine and six grams of amphetamines.

Also, there has been a lot of discussion around the principle that thresholds should be at least a multi-day supply for people. When we think about those numbers in the context of a multi-day supply and what our current threshold is right now of 2.5, our data would suggest that a lot of people are going to be left out.

In coming to — I’m going to end quite early, actually — tangible solutions, our data really underscores…. I think Dr. Sutherland has brilliantly laid out the importance of the details in this policy option but, certainly, focusing on safer supply options.

We do have some other preliminary data, which I didn’t share but would be happy to send along. Within our co­horts, many people didn’t know about the safe supply options. They didn’t know even that they were available, or if they were available, they weren’t able to get enough of what they needed. So really documenting a lot of the challenges that Dr. Sutherland laid out. Those were verified in our data as well.

In terms of another tangible solution, being responsive to data that emerges from decriminalization…. If we’re seeing that people are being excluded from the system, which has been improved and which will be rolled out in six months’ time, to be responsive to that.

Then the last part, in terms of all of my experience in the last 15 years of doing research in this area, is the importance of including people with lived and living experience in all program work, in all policy work. I think Vancouver has a very rich history of doing that well, but having been someone who was part of the city of Vancouver’s application for decriminalization, they did not do it well. Even in this era, we’re missing the boat sometimes.

I really want to underscore the importance and the richness that brings — including, also, importantly, adolescents and young adults. They haven’t been included in the decriminalization. That is something that they’ve…. I know a number of them have come forward and put principles forward for harm reduction for young people and do want to be included in these kinds of policy initiatives.

I will close there and translate my time to questions.

N. Sharma (Chair): Great. Thanks a lot.

Okay. Go ahead, Pam.

P. Alexis: I have a question for Dr. DeBeck regarding the 37 percent that felt that things had gotten worse as far as the quality of the drug that they were using. Was that at all a deterrent for further use? Was it an opportunity for conversation? Was it at all impactful?

K. DeBeck: We have another question which I didn’t include, which is: did you use more drugs or less drugs since COVID? More people reported using more drugs than people reported using less drugs. I would say, given people’s experiences and condition, it’s not so much of a deterrent.

[4:55 p.m.]

C. Sutherland: Can I add to that?

It doesn’t seem to make sense to use something that you know is poisonous and when it might kill you. Opiate withdrawal is so profoundly uncomfortable, with vomiting and diarrhea and sweats and lacrimation and tears. Seeing patients in withdrawal…. My gosh, I really understand why you’re having to use again. It’s so stressful for them, especially the women, I think, who are so vulnerable.

As soon as you use, the clock starts, and you’re ticking down to the next time you’re in withdrawal. Back with heroin, it used to be eight hours. So you would use three times a day. Now, with fentanyl, you can use much more than that throughout the day.

People are using to escape withdrawal rather than using to get euphoria. It’s the same with alcohol use disorder. Often people are drinking to avoid seizure. They would like to not be drinking. A lot of my patients are like: “I don’t want to be doing this, but I’m sort of trapped. That 100 of methadone you’re giving me is not touching what I need.” Really, they have no option.

That’s why I think these drug alert systems that say if it’s a poisonous drug don’t really help people. They can’t be: “Oh, I’m going to trade these in for less poisonous drugs.” I either go through excruciating withdrawal…. Maybe I’m homeless. I don’t even have a bathroom to myself, and I’m having diarrhea on the street. I try to go to Dr. Sutherland, and she tries to do some math to try to get me out of withdrawal. She can’t, because I take more than anaesthesiology gives in the OR.

They’re really trapped. They don’t have safe options.

K. DeBeck: I think that’s another…. To add on to that, with drug checking…. One of the limitations of drug checking…. If you get your drugs checked, and you have no other options and you’re going into withdrawal, whether it was fentanyl or wasn’t fentanyl….

We’ve had to change the questions on our survey over time. Initially we had questions about: “Are you seeking fentanyl or avoiding fentanyl?” Really, people just don’t have a choice. That’s what’s there. People can say, “Yes, I’m seeking it,” not because they initially wanted fentanyl. But now they’re in a situation where that’s what they need. That’s all that they can get.

It is that choice piece we found really difficult to…. It just changes over time. There’s not the choice that we may think that people have.

C. Sutherland: The longer we go, the worse it will be. Organized crime is so profit-driven. They want the highest concentration in the lowest volume that’s the most potent, because that’s the most profitable.

If we were doing this 100 years ago, we would be re-establishing opium dens, which used to be here through­out Chinatown. A family-run business. Maybe we’d have organic, fair trade opium. It’s all observed. You’re in a safe place. It costs money. They check your ID. They have age limitations. To think about all the lovely regulations that could come with that…. Instead, organized crime has been driving us forward with billions of dollars of profit. That’s why we’re seeing this poisoning.

I always feel I’m running behind, basically. Then my patients…. The other day someone told me that quaaludes were in his dope. I was like: “Oh my god.” I just am always behind. Quaaludes? What am I going to do about quaalude withdrawal? I don’t know if that’s true.

The contamination is only going to get worse, because the profit gets bigger.

S. Furstenau: Thank you, both.

Dr. Sutherland, I think providing the historical context for drug policy is really critical. I think you’ve done a great job of laying out how we got here and that it is really…. These were political decisions, not decisions based in evidence and not decisions based in harm reduction or the social determinants of health. None of that. These were political agendas, and here we are, 70 years later, or what­ever it is, 60 years later.

You said over and over again: “Safety for the public. Safety for the patient.” I think one of the barriers we’re up against, in today’s political context, is the fear of…. Where are we trying to get to? We’re afraid of: what does that look like? You just mentioned opium dens, for example.

I think what is essential…. Maybe if you can elaborate on this. You did a little bit just now on the organized crime piece of this. Right now we’re not achieving either of those things. We do not have safety for the public. We do not have safety for the patient.

Can you provide some more context on that lack of safety? Can you also speak a little bit to what you see in your patients who have access to a regular supply that is safe and that is predictable, and the tangible outcomes that they have in their lives? You are trying, in your realm, to achieve safety for the patient. Can you tell us what that looks like so we can have a vision?

[5:00 p.m.]

C. Sutherland: Yeah, for sure. For safety, when I create a system, I create it as if it’s regulated how I think it should be, even though those regulations don’t exist.

Our nursing team last week…. We just were talking about sourcing childproof packaging for our fentanyl. I think it should be the same as cannabis for how Health Canada sells it — that it’s childproof.

We were thinking about labelling it, because we want to label it like: “Fatal if taken by anyone other than prescribed for.” Especially thinking about youth, youth overvalue a prescription. They think pharmaceutical drugs are safer than fentanyl. I don’t want youth to start using fentanyl because of my prescriptions. So how do I create a system that protects them?

I think when we’re thinking about youth as well, we want a regulated supply because then we can put parameters for how people access it. They’re not going to be at a school yard trying to sell drugs in a regulated market, but that’s what organized crime is doing. It’s more dangerous right now for youth in an unregulated context.

It’s like not regulating asbestos. If we had asbestos in schools, and you could open it up…. We regulate asbestos because it’s dangerous, and then think about schools and youth. You want to regulate something that’s dangerous. That’s what gives safety.

I think about how if our drug dealers had supply chain audits and inspections and quality testing, less people would have died. Thinking about safety is that public health lens, and we can take lessons learned from alcohol and tobacco. I actually think that we don’t want to mimic those, because they aren’t regulated enough. We still have people dying of lung cancer. We really want those to be more tightly regulated.

For the second part, that’s the joy of my job as a primary care doctor, following my patients longitudinally through­out their lives. When someone gets on a program that works for them, we called it the hipster effect for a while. They would suddenly come in, in cuffed jeans, collared shirt, looking like a million bucks. They called their sister who they’d not called in years. They were reading a book, going to the movies, spending time with their kids, eating more, gaining weight.

They’re saying: “Remember that lung test you wanted me to go for? I’ll go for that now.” So you get their pulmonary function test; you optimize their puffers for their asthma. Just so many joyful moments along the way. That’s why I love being in primary care, and that’s why I love harm reduction, because you celebrate all of these mo­ments, not just abstinence, although when people get to abstinence, if that’s what they want, I also celebrate that.

Then I think about this practice I have that’s rooted in harm reduction and thinking about how we produce less harm, rather than trying to reduce harm from a system that’s in place. That’s what I want. I want less harm production. I think a legal regulated market would do that for my patients. Then I could just see them for regular primary care things, rather than always seeing them….

Sometimes I can’t leave work, because as I’m leaving work, there are people overdosing on the stoop of my of­fice. So we’re resuscitating people. Or it’s my patient, and they show up after five o’clock and say: “Aw, Doc, I didn’t get my dose today.” I’m like: “Oh my gosh, okay. I’m worried you’re going to die tonight.” So I’ll go and log into my computer really quickly and write them a prescription for their methadone for that day, because the risks are so high. So it really breaks your heart, over and over again.

I’ve had so many patients die. My medical record will remind me when someone’s due to get called in for a follow-up pap test. Then I open their chart — it happened to me this morning — and they’re deceased. Your heart is broken. Then you turn around, and there’s a full waiting room. You just keep working. It’s so hard. I really want to see big change for the people that I care about.

I love those two questions together. To me, they’re overlapping — that we want good outcomes for individuals who use drugs, and we want good outcomes for society.

S. Chant: One of my concerns about our committee is…. It’s really very easy to get the first responders here and you guys here, relatively speaking. I am worried about getting people with lived experience to talk to us. Would you be willing to help us with that?

C. Sutherland: Yeah, of course.

S. Chant: We need that as well. I’m sure we’ve got mechanisms and stuff. I’m not overstepping my boundaries, I hope. I am very concerned about getting access to and hearing from people that are working within this.

C. Sutherland: Absolutely. For this enhanced access program, we had people with lived experience every step along the way, at every meeting. They devoted so much time to listening to us go through the bylaws of all the colleges to make sure our narcotic records met all of their regulatory requirements. It was so kind of them to come to all of these meetings.

[5:05 p.m.]

One of the things that really struck me was this shifting of the narrative from being sick, coming hat in hand to your primary care doctor and trying to negotiate opiates to get out of withdrawal to saying: “I don’t think you’re sick. I think this is a system issue, and it’s a supply chain issue. Let’s solve that, and you go can and access drugs just the same way, a similar way, that I access drugs — safely.”

N. Sharma (Chair): Just for information purposes, we are working on trying to have access to people with lived experience in a very respectful way, so we can connect with you kind of outside of this meeting to see.

R. Leonard: Sonia asked part of my question.

First of all, I want to say thank you for this. I feel we can jump into big questions for your guys. Thank you very much for the work that you do and for taking the time to come and inform us, as well, and engage with us as we explore this whole issue.

A couple of things I was really struck by. Earlier today we heard from Dr. Perry Kendall, talking about trust. I just witnessed that in your conversation. It’s a two-way street. It’s you, trusting in the veracity of what is being presented to you, as well as the people who come to you trusting you too.

C. Sutherland: You mean like my clinical relationships.

R. Leonard: Yeah. It’s big, and not everybody has that. Not every family doctor, primary care doctor or any other allied health professional has that right now.

I’m curious how you see…. I’m afraid you’re going to be burnt out one day soon. How do we expand you to be part of that bigger system? Because it is bigger than you, right?

C. Sutherland: Oh, 100 percent. I’m so glad that you…. Yes, I absolutely agree.

I think that this is interesting, because it comes up…. The definition of being a primary care doctor is having a longitudinal relationship of trust with your patient. That’s what gives you joy in your life, that it’s relationship-based care. That’s why I love going to work, because I’m seeing people that I’m happy to see, that I’m happy to talk with. I’m like: “How can we figure this out together?”

I think that that is one of the reasons that it’s so challenging for clinicians to be the gatekeepers to opioids. It is not part of our job description, when we’re having this collaborative, fiduciary relationship with our patient, to then suddenly be like: “Oh, but your urine drug test is due” and “You didn’t quite meet the bar for this program.”

Gatekeeping is not part of primary care. It gets put down on us a lot, but it’s not part of that longitudinal relationship of trust. When you have that power imbalance, then it can create so much tension.

That is why I don’t think it would be successful to have expansion of safe supply funnelled out through primary care in B.C., because then you have disparate access, disparate practice. You know, some family doctors won’t prescribe birth control because of their religion. How can we say: “Well, you have to provide fentanyl powder?”

That’s why I think the government needs to change our criminal justice code and say: “We are going to regulate fentanyl the way that the federal government has regulated cannabis.” I think it was so successful how the Canadian government regulated cannabis. We’ve not seen an in­crease in youth, no driving, pediatric poisonings. The bad things that we were worried about didn’t happen because of really good regulation. We saw an increase in boomers using cannabis, but perhaps it’s safer for them. Hopefully, they’re using less alcohol. Or maybe they’re just telling the truth finally in a survey, and they were lying before. I don’t know.

I think it needs to be a systems change that’s centralized. We could have a standardized system, a standardized in­take, a standardized titration for all of B.C. that people can call into, that’s a satellite throughout B.C., partnered with local nurses and local pharmacies, rather than trying to drive this through individual physician offices.

R. Leonard: What you’re talking about is, basically, legal supply as opposed to decriminalizing it.

C. Sutherland: Yes, exactly. I think decriminalizing is very good. I very much welcome it. But it’s a gesture, almost, rather than an actual functional difference for my patients.

N. Sharma (Chair): I have a couple questions.

This has been a really interesting addition to the kind of journey we’ve been on so far as a committee, I think. There’s this kind of thing that I think a lot of experts have talked about, which is separating people from the toxic drug supply. I kind of see this presentation and what you’ve presented as the front line of that, how you’re doing that and the complexities of what that looks like.

[5:10 p.m.]

I understand you are talking about bigger structural change. If we focus on that part…. There are a couple of things that I’m just really curious about. We’re talking about bringing people along on this journey. Everybody has different comfort levels with their relationship with drugs, really. We’ve all grown up different ways — and lots of that.

I wanted to ask you, specifically…. You said something about the doses that you try to give to people. When I hear you say 40,000 a day, I’m worried about that person. I’m thinking that seems like a dangerous amount for somebody. I don’t understand, just to be fully frank.

We’re learning about how fentanyl is so deadly and the doses can…. Is there a safe amount of fentanyl? How do we get…? Are you, as a doctor, comfortable with that amount for somebody without thinking like, “I hope they’re okay,” when you prescribe this stuff?

C. Sutherland: You’ve hit the nail on the head for what is wrong with prohibition.

Fentanyl is a molecule that works on the opiate receptor, the same as all opiates. It’s a class effect. What is so dangerous on the street is that it’s so hard to mix, because one dose of fentanyl can be as small as a grain of sand. Then there’s so much variability in the analogues of fentanyl — the carfentanil and the furanyl fentanyl — and then the addition of the benzodiazepines.

What’s dangerous for people is not the molecule. All drugs are just molecules. It’s that it’s a totally unpredictable dose and content of what they’re using. That’s what causes them to overdose.

For our programs, we have post-dose observation, be­cause this is exactly what I’m worried about. I don’t want to kill a patient. I’ve had patients that have said, “That dose is way too low for me,” and I’m like: “It’s a firm policy. I try not to kill people.” They sort of laugh at me. They’re like: “All right, Doc. I’ll go through this titration with you, even though what you’re giving me is doing nothing.”

When I first started the fentanyl powder titrations, I started them at 250 micrograms. The patients sort of laughed at me. They were like: “This is like nothing.” I was like: “Okay, well, we’ve got to start somewhere. No one has given this before in this format, so I want to be cautious.” We watch them for 20 minutes after they take the dose, so we can see the peak in the serum and know that we’ve seen them at the most sedated that that dose will make them before they go.

Once they get to the dose that they say, “This is my dose,” then they stay at that for several days. Then if we see no post-dose observation in all of the doses, they don’t need post-dose observation anymore.

I absolutely have that in mind when I’m designing programs.

N. Sharma (Chair): That’s really helpful.

C. Sutherland: People at 40,000 are not sedated, sometimes still in withdrawal.

N. Sharma (Chair): Another interesting thing that’s been happening, I think, is some people have really talked about primary care as being…. There are statistics we’ve seen from a couple of presenters saying that a lot of people, from the coroner’s report, that had passed away from an overdose had some kind of interaction with the primary case system.

We had some people, experts, saying that we need to figure out the best interventions during the primary care system to get people whatever interventions they need not to die, and that being a critical juncture from the coroner’s report and the evidence.

I think what you’re saying here is we’ve had that a little bit to the contrary one, which actually is that it shouldn’t be a primary care–health care model. It should be something else, which is like a regulated system from the government.

I’m curious how you would respond to that — that other experts are saying that the primary care system actually is a place that is an interface with a lot of the people that have died from an overdose crisis and could be an effective way to support them to not die.

C. Sutherland: Absolutely. It’s such a good question. I think the answer is both. I think I’ll also have a job during the legal regulated market, and that my job will be methadone; Kadian; doing special, like, loop-dy whirls of these opiate conversions that I do to get someone on the Sublocade, which is the injectable Suboxone.

People will still want to come to medicine for medical interventions, the same way alcohol is legal, but patients come to see me. I start them on naltrexone to decrease their alcohol cravings. I talk with them about their seiz­ures. I talk with them about their liver health.

There’s still a medical role for people who use drugs, but if a regulated system existed in parallel and patients only came to see me when they actually to see me and wanted medical interventions, that would make my job a lot easier. Then I would feel much more effective to say: “Oh, I’m so glad you’re here. Let’s talk about your options that are the medical interventions for your goals, but I know you’re not out there overdosing and dying while I’m trying to do these medical interventions.” So I think it’s both.

S. Furstenau: The other thing we heard about earlier today was lateral violence between health providers, so those willing to prescribe and those unwilling to prescribe be heard. Certainly, when we had the health authorities, as Shirley pointed out — a real inequity of access to every­thing from safe supply to treatment.

[5:15 p.m.]

You are very clear about where you’re at. You do not seem to have any doubt about where you’re at. How did you get there? Was this your starting place? I know you said that there has been a bit of a journey. Can you elaborate a bit on that?

You’re not just clear; you exude a kind of joyfulness in your clarity. That’s been different from a lot of the presentations we’ve had so far here. A lot of them have been very sombre and very serious. You are not conveying that. You really seem to know, so tell us about that.

C. Sutherland: My friend calls it stubborn optimism, that I have stubborn optimism. I think that we’re at a moment that will change, and I want that for my patients. I think the interventions that I provide are really impactful to the patients, so that gives me joy in my work. I love doing this.

I love a good idea, and a lot of times good ideas come from my patients. They’ll be like: “You know what we should be doing? We should be doing this.” I’ll be like: “Ooh, I love that. Okay. Let’s get the nurses together. Let’s see what the pharmacist is saying. Let’s see what the people with lived experience in the community think. Let’s work on this and make this happen.”

I think there has been a huge change in physicians’ opinions on drug policy over these past years. I would give, in a talk on drug policy…. I gave a keynote at a family medicine forum a few years ago, before COVID — ten years ago, however long ago that was. The questions were spicy. People got up, and they asked me: “Aren’t you worried about organized crime then doing increased human trafficking if drugs are legal?” I’m like: “How…?” That’s not a reason to keep drugs illegal. Spicy questions.

If I would go to meetings…. I used to be the education lead at the B.C. Centre on Substance Use. I’d sort of truck around B.C. and give lunch-and-learns to local community physicians and nurses. People were very skeptical.

These days they are not. My physician colleagues are so welcoming. They want change. I always call a physician colleague if I’m seeing one of their patients, because sometimes a patient will just come to our clinic and say: “I really want a fentanyl patch.” I’ll be like: “Okay. Come in. Let’s have a look at you. Tell me about your life.”

Then I’ll call their doctor. I’ll say: “I just need to talk to your doctor. I’m not to going to start prescribing for you if you’re followed somewhere else.” Universally, they’re like: “Oh god, Christy. I’m so glad they came to see you. Please, yes. Can you start them? Can you titrate them? I’ll take them back after they’re stable. Please. I’m so worried about them.”

As doctors, we care about our patients. It’s our patients that change our practice. To me, as research comes out, and I’m always so grateful to the researchers, I think: “Okay. How does this apply to my practice? Oh gosh, I don’t know.” I’ll sort of mull it over, and then I’ll think of a patient. I’ll be like: “Oh gosh. That person needs this, so I’m going to figure out a way to get it to them.” Then to see them get better and stabilized, and then they bring their mom in…. There’s nothing better than that.

S. Bond (Deputy Chair): Thanks a lot, both of you, for the work you do every day and for the presentation.

I was going to ask a similar question to Sonia’s, but perhaps I’ll ask it this way. I was going to ask about the lateral violence, because we heard that just earlier today.

This is very bold and very unique. Basically, you sell the drug to your patient. There’s probably a lot of…. We probably have to go a long way to explaining to people more broadly why it’s important. I mean, you do a great job of talking to those of us who are listening and anyone that happens to be listening. So it’s been really interesting, and it’s an important element of what we need to learn.

Is your program…? Is there potential for replicating it?

C. Sutherland: Oh, 100 percent. It’s very scalable. The limiting factor right now for us is the supply chain. We only have 15 people on our observe program. We had one person on our sales program, and he has graduated to re­covery. So we are limited by our supply chain, and that’s the thing holding us back.

It’s quite complicated to compound a drug, because it needs to meet a high standard for the pharmacy and then have external testing. So Health Canada’s doing our ex­ternal testing of our capsules, and it’s quite a delay.

The other delay was that we were so wrong about the dosing that people would need. We had ordered so many 250 microgram capsules, because when you’re starting a program, you think you’re going to need them. We don’t use 250 microgram capsules at all anymore. We go up by 1,000 each dose. So if someone’s going through the titration, they would come in the morning and be at 3,000, and they may come at noon and be at 4,000, and at three, it would be 5,000. So they go up by 1,000 each time.

[5:20 p.m.]

That created delays. The lab was ready to test…. They created a protocol for testing 250 microgram capsules. We had to call them up and be like: “Oh, can you create a protocol for 10,000, please?” So they had to create all-new protocols for how to even test these capsules.

To me…. I’m the medical director of a non-profit, and I’m a family doctor. My sweet team is working on the supply chain, but I would love this to be the government — to think about a PPE supply chain for COVID and that massive response. For Canada to say: “Look, we need this emergently.” I think it’s very scalable, and I think that it’s very palatable to the public to have a sales program.

I was ready to be roasted in the media when we launched it, and it was surprisingly, incredibly, positive. I shouldn’t say surprisingly. Maybe that’s too self-deprecating. But I was delighted with the response from the public, the response from Moms Stop the Harm, saying: “How can I sign my kid up?” For my patients being like: “Oh, I really just want to buy it.” It doesn’t require as much medical follow-up because of the price. The price is what gives us safety.

It is quite nuanced, to your point. Why is it safe? Why is charging something that brings safety?

S. Bond (Deputy Chair): We’ve also learned along the way that there are groups that are more impacted — First Nations women, for example, and typically men who work in the construction sector. That’s a deep concern. The other thing that’s really troubling is that there is no consistency in British Columbia in terms of access.

You serve in an urban environment. How does it work in a rural community?

C. Sutherland: Oh, I think it’s perfect for rural. I have done a lot of support over the years, when I was education lead at the B.C. Centre on Substance Use. I was also the lead for the rapid access to consultative expertise phone line, and eCASE line, for years. It was often rural docs to say: “Oh gosh, this guy lives in the bush. He has no phone. It’s an hour’s drive to a pharmacy. How do I get him on methadone?”

The challenges there, with the take-home doses of large-dose opioids, are true. But when you have the price there and you have a patient-specific prescription for how they pick up that is based on the context of their life, and you specify the parameters as the prescriber…. I can think of patients I’m going to start on the program who use once a week. They are on their methadone, doing well, but they’re still chipping away. Perhaps they’re on a monthly pickup. So they come once a month, and they buy their four points of fentanyl, and they’re working full-time.

Then I have other patients who are homeless and have schizophrenia, and they are quite disorganized. Maybe they’re on daily pickup or maybe multiple times a day pickup. You can create parameters of a program that fits the context of a person’s life and the needs of that community to make it safe and pragmatic.

R. Leonard: This gets more complicated by the minute.

C. Sutherland: Yeah, totally.

R. Leonard: I’m still back at Niki’s question around the 40,000 micrograms and the safety of the person.

If we were…? Maybe I should just back up a little bit. What you’ve just been describing is a fair bit of intervention to get the dose right. If we were talking about regulated legal supply, would the…?

I can go and buy a case of beer. I can go and buy a case of wine. Can I go…? How regulated is it to buy whatever drug it is that you’re doing and not kill yourself? If I took 40,000 micrograms of fentanyl…. Somebody else might be able to do it handily and say: “Okay. I need a little more.” I’m going to probably….

C. Sutherland: Well, if we divide it amongst everyone in the room, it would kill us all.

R. Leonard: Yeah. So I’m just wondering. I’m thinking of the general public. You’re dealing, I think, in an environment where people understand, especially families. But there are a lot of people out there who are still living in a world of prohibition, and I’m thinking of what you can say them today, because this is on the record, that will give them some assurance that this path has those kinds of built-in protections against unintended consequences, I guess.

C. Sutherland: Yeah, it’s such a good question. When I think about alcohol, there are limits, in terms of happy hour pricing, for how much you can buy in a shot. We do have public health limitations on how much alcohol someone can purchase.

[5:25 p.m.]

I think about the day of the Stanley Cup riots. They closed liquor stores early. That prevented violence. I think about safe-serving courses that every server in B.C. has to take. Those are the things that bring safety to alcohol. So if we want to decrease motor vehicle collisions and decrease domestic violence, we would scale those things up to make it harder to drink more.

For my program, I want to think: okay, what does that mean in the world of opioids? To me, that meant an individual titration process for every person that comes in. It’s staffing-intensive, it’s nursing-intensive, and it’s a lot of time for the person. A lot of my patients work full-time. They’re like: “I can’t come in. It’s four doses in a day.” I say: “Come in on a Saturday. Bring a book. Let’s just find out what your dose is, and then you can graduate over to the sales program.”

Could you imagine if, with alcohol, we made it that everyone had to have test doses that were observed with nurses? Maybe that would be good. I don’t know. On the record. “Oh my gosh, what are you saying?” But we can take these elements of public health policy that we see in other drugs and apply them to fentanyl.

To me, as well, that person has been titrated to be out of withdrawal, not having cravings and being comfortable, so they have no motivation to sell that on. That is exactly what they need for their personal use. I’ve figured out the exact dose. If they want to go up, they come back. They need to come back for a full day at that new higher.

R. Leonard: So the titration is built into it.

C. Sutherland: Yeah, everyone goes through an individual intake with a physician, intake with a nurse and nursing-led titration that’s specific to them, and then has an individual prescription. That’s how I was able to meet all the regulatory requirements.

R. Leonard: But a prescription, again.

N. Sharma (Chair): I have one more question, and Shirley has one. We’ll try to just get both of them in there before our time is up.

S. Bond (Deputy Chair): I’ll try to be quick. I might get booted out of the room, but I’m going to ask it anyway. What about recovery?

C. Sutherland: Oh, I mean, love it, yes. My patients go to recovery all the time. I think everyone can get better. Everyone can stop using drugs. Often in the Downtown Eastside, people will call my patients palliative, which just makes me apoplectic.

I used to work in the palliative ward, SETCT, that PHS runs with Vancouver Coastal Health. People would come in palliative, homeless, CD4 count of nine, lymphoma — just really dire diagnoses. You would give them food, a safe place to live, a nurse, a doctor. They would live for months and months, and suddenly they’re having to get transferred to housing because they’re not palliative anymore.

I think a lot of times my population gets written off because of their drug use and their social circumstances and the things they’re trying to survive. My patients get better, and they leave the Downtown Eastside. My trouble was that I was providing these high-intensity medical interventions that were physically located in the Downtown Eastside, and they’d say: “Well, I want to move to Mission. Can I go on the fentanyl patch program in Mission?” “Well, it doesn’t exist.” That was one of the reasons I wanted to create this program — to support people leaving the Downtown Eastside, working on recovery.

When people have one place in their life that’s stable, they’re no longer having to overdose over and over. Then they get the next level of stability. Then they bring in their art that they’re working on. Then they sign up for night school. Then they move back in with their parents. I had one patient just fly down to the States. He’s moving back in with his dad and not using anymore.

Absolutely, people stop using drugs, but they can’t do that if they’re dead. They can’t do that if they’re overdosing every day — thinking about that person you spoke about earlier overdosing three times in one day and having paramedics resuscitate them with Narcan. To go from there to no drug use is quite a leap, but to go from there to coming to see me and the sweet nurses in my clinic, getting some fentanyl powder, coming back every day and then starting your anti-retrovirals that are paired with those medications, then getting housing, your wounds taken care of, then you get there.

N. Sharma (Chair): Interesting. One of the things that we’ve also been learning is just the kind of, sometimes, medical interventions that happen after an overdose, so the longer-term medical care that’s needed when somebody resuscitates, and you didn’t talk about that much.

I’m curious if you follow people, too, in that circumstance and what kinds of medical supports they would need from the long-term effects.

C. Sutherland: Yeah, it sort of doesn’t exist as a system right now. If someone has….

It’s always compared to a heart attack, when you then go through this heart attack pathway through acute care. Then you’re discharged to the Healthy Heart clinic, and you have the Healthy Heart nurse practitioners calling you and the dietitian — really wraparound longitudinal services that decrease your risk of mortality. That system is not in place for people who use drugs.

Definitely, my patients, when they overdose, I want see them. We get the emerg report that they’ve overdosed, but often that’s not until the next day. Then I try to call them. I’ll look on their PharmaNet. I’ll try to optimize the drugs that they’re on.

That’s my personal response, clinically, but there’s no system coordination.

N. Sharma (Chair): This has just been so interesting. We’re just up on time.

On behalf of the committee, I want to thank you for the work that you do and really leading in a lot of ways, it sounds like, on some of the things that have been recommended in different ways. Thank you for that.

I think you had a very engaged committee here with all the discussion we had. We probably could talk to you for longer, but we’re out of time.

Thanks a lot.

P. Alexis: Unbelievable. I think it’s the most impactful that I’ve experienced so far. Thank you so much.

N. Sharma (Chair): I need a motion to adjourn.

Motion approved.

The committee adjourned at 5:30 p.m.