The committee met at 9:01 a.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome, everybody. We’re here on day 2 of this week of our hearings for the Health Committee.

I want to start by acknowledging that we’re all gathered here today on the traditional territory of the Musqueam, Squamish and Tsleil-Waututh people. We have to honour and pay respects to that in all the work that we do.

We have, starting us off, very special guests this morning: Kílala Lelum Health Centre. I want to welcome Elder Bruce Robinson, Leah May Walker and Dr. David Tu from the centre.

Thank you for coming. I’m going to pass it over to you. Actually, let’s do a quick round of introductions first, and I’ll pass it over to Elder Robinson to do a little welcome.

I’ll start with myself. My name is Niki Sharma. I’m the Chair of this Health Committee and the MLA for Vancouver-Hastings. Nice to meet you.

Maybe we’ll start over there and go around.

S. Furstenau: Sonia Furstenau, MLA for Cowichan Valley.

T. Halford: Trevor Halford, MLA for Surrey–White Rock.

S. Bond (Deputy Chair): I’m Shirley Bond. I’m the MLA for Prince George–Valemount, and I’m the Deputy Chair.

P. Alexis: Pam Alexis, MLA for Abbotsford-Mission.

R. Leonard: I’m Ronna-Rae Leonard. I’m from the beautiful Comox Valley, from a constituency called Courtenay-Comox.

S. Chant: I’m Susie Chant. I’m from North Vancouver–​Seymour.

D. Tu: I’m Dr. David Tu, a settler on these lands, from a family linked to northern China and Wales. I’ve been a family doctor working in the Downtown Eastside for the past 20 years.

L. Walker: I’m Leah Walker.

I’m Nlaka’pamux, and I have kinship ties and responsibilities at Seabird Island.

I’m privileged to be the executive director of Kílala Lelum.

Nice to be here.

B. Robinson: [Nisg̱a’a was spoken.]

My name is Owii`lo`ly`eyum`gaudlth`ni`Ki`insque. It means “grizzly bear with a big heart” in our language, in Nisg̱a’a.

I have to really rush this opening. They only gave me three hours to do it.

N. Sharma (Chair): I just want to make sure that everybody knows that Doug Routley is on the phone.

Maybe you want to jump in, Doug, and introduce yourself.

D. Routley: Thank you. This is Doug Routley, the voice that you hear. I can’t attend, but thank you for this meeting. I’m from Nanaimo–North Cowichan.

N. Sharma (Chair): Over to you.

B. Robinson: Thank you, everybody, for being here today.

It’s an understanding, when we gather in a sacred circle…. This is very sacred to our people. It’s an understanding that we’re all equal. There’s no one above, no one below. We’re all on this sacred journey together to try and make a difference for whoever we’re here to gather for.

We’re here to gather in a good way, with a good open heart and good open mind, the purpose of what we’re here for. This is a very sacred circle. We can all make a difference, not only for us but for everybody that we’re here for.

As I sing my song, you pray in your heart in your own way for the things you’re looking for, for yourself and for others.

[9:05 a.m.]

[Nisg̱a’a was spoken and sung.]

Great Spirits, grandmothers, grandfathers, so grateful for today. So grateful for bringing us together in a good way, with a good, open heart and good, open mind. I ask that you join us as one throughout Mother Earth.

Join us as one in soul, heart and mind so we can have good understanding of each other, to help uplift each other, to bring peace amongst each other, to bring love amongst each other, to bring harmony amongst each other so we can walk in harmony with our beautiful and loving Mother Earth.

Mother Earth, please forgive us for anything we’ve done to harm you in any way. Mother Earth, please forgive us and be kind and gentle to us when you bring back balance in this area. Mother Earth, be kind and gentle to us.

We love you and honour you, Mother Earth, for the sustenance of life. We love you and honour you, Mother Earth, for all our lives.

So grateful for the people of these lands and the ancestors of these lands, which is the Coast Salish people. So grateful for all our ancestors, for without them, we would not be here today. So grateful for your guidance, your wisdom and your knowledge that you share openly with us every single day of our lives.

Guide us well. Guide us well in all the good things we’re going to do for ourselves. Guide us well. Guide us well in all the good things we’re going to do for each other.

Guide us well. Guide us well in this sacred circle, Great Spirits, grandmothers, grandfathers, so we can have the best outcome for all the ones that we’re here gathered for. Guide us well. Guide us well.

[9:10 a.m.]

[Nisg̱a’a was spoken and sung.]

Thank you, Great Spirits, grandmothers, grandfathers, all our relations. Hay čxʷ q̓ə si:y̓em. Thank you.

In my prayers, I always honour the people of these lands, which is the Coast Salish people. It’s an honour to be here today. I thank you for allowing me to do that today.

N. Sharma (Chair): Thank you. On behalf of the committee, I just want to thank you for letting us start in such a great way this morning. Really beautiful.

Just to give a little bit of housekeeping, we have 20 minutes for your presentation, and then this is a committee that really likes to dig in with questions and discussion, so we’ve left lots of time, about 40 minutes, for that afterwards. We’re really looking forward to learning from you.

Briefings on
Drug Toxicity and Overdoses

KÍLALA LELUM HEALTH CENTRE

D. Tu: On behalf of Kílala Lelum, I just want to really thank you all for inviting us to speak to you. This is a real honour for us.

We’re here on behalf of our community, really, to give the perspective of Indigenous people’s health on this ongoing epidemic, public health emergency or crisis — whichever term you want to use that relates to the enormous amount of overdose deaths that we’ve experienced in our community and in British Columbia.

The three of us are, most of the time, really happy to work together at Kílala Lelum. Kílala Lelum is a name gifted to us by the host nations here. In the hən̓q̓əmin̓əm̓ language, it translates to “butterfly house.” A house of transformation, a house of healing, is what our aspiration is.

We opened our doors in 2018. It was a group of us who had been working in this neighbourhood for decades who came together to try and really take up the challenge of health system transformation. We chose to do that with a fresh start. We are a team-based care, non-profit cooperative. We provide full-service primary care across the spectrum, as well as cultural wellness providers. We are a cultural centre that does health.

We have over 80 staff working with us. We have a panel of members or patients that we look after, over 1,400 people, 95 percent of whom reside in the Downtown Eastside, and 70 percent of whom identify as an Indigenous person. That panel is growing month to month. We’re located ten blocks and a world away, just up Powell Street.

To speak to Indigenous people, it’s important to recognize that they represent 6 percent of the population of British Columbia and that 73 percent of those people live off reserve and in an urban environment, and just that we are blessed with a richness and diversity of cultures. There are over 200 bands. There are 27 different language groups, 30 distinct languages that are represented in this province.

I think that, quite thankfully, despite the ravages of colonization and an attempt at cultural genocide, many traditional healing practices have persisted, and it’s a real wealth to the medical community and to the population at large.

Sadly, for many Indigenous people, their experience is one of disconnection from many of these cultures and traditions. It’s that disconnection which is at the root of much of the disproportionate burden of mental health–illness. We see that in rates of depression and suicide. We also see it as increased prevalence of substance use disorder, and opiate use disorder is no exception.

[9:15 a.m.]

That, I think, leads us to the topic of the day, which is looking at the overdose crisis. Again, finding the right wording for this is always challenging. If you’re trying to medicalize it, de-medicalize it…. But the numbers do speak for themselves.

We don’t have the 2021 data stratified by Indigenous identities, so we’re looking still at 2020. We knew that there was an increase from year to year, about a 20 percent increase from 2019 to 2020. There were 254 individuals that died in 2020 who identified as Indigenous. If the proportions and numbers hold, a 25 percent increase means that there were about 300-plus Indigenous people who died last year. That’s an Indigenous person dying each and every day of an overdose. For every overdose death, there are many overdose events.

This is a disproportionate burden amongst Indigenous people. That gap between Indigenous and non-Indigenous peoples is growing year to year. The risk experienced by Indigenous people in 2021 was about fivefold that of a non-Indigenous person. I hope that it is plateauing, but if you are a follower of trends, it probably hasn’t, which brings us to try and look at the underlying causes.

From a public health perspective — and I’m going to invite Elder Bruce and Leah just to chime in as I ramble on — you can look at proximal causes. They’re quite obvious. I’ll speak more just on firsthand experience around the toxicity of the current illicit opiate supply and the changes that I think we’ve seen over the last six to seven years. That is the immediate cause or association of death for many. It doesn’t explain the disparity between Indigenous and non-Indigenous people. For that, you really need to look at the historic and ongoing processes of colonization that impact Indigenous peoples.

Our society, our cooperative, did a series of informal gatherings and note-takings, just to try to come to a consensus amongst ourselves in terms of what the right direction is for us to move forward and what our strategic policies are, if you like. There was unanimous agreement that this is a crisis that does demand an urgent and extraordinary response. I’d just like to lay that out — that this should not be seen as business as usual.

Our positions land in two boxes. The first is to address the proximal cause. We need to maintain the breath of life. If people don’t survive this crisis, there’s very little hope for those individuals or, really, the community to move forward in a good way. This is a quote from one of our staff: “You can’t help people if they’re dead.” Really, we know, empirically and ideologically, that if we were to provide a safer alternative to the illicit drug supply, we would decrease the number of illicit overdose deaths.

The second arm of our policy is one that we’ve held since our inception, which is that there does need to be a decolonizing of the health care system, and other systems as well, but our focus is on health care. There should be continued and, perhaps, a refocused attention to addressing systemic racism as well as implementing the Truth and Reconciliation calls to action in health. That process is necessary to address those distal causes that are resulting in the overrepresentation and the excess deaths of Indigenous peoples.

I’m just going to bring this back to a person that I’ve known, because I’m a clinician. That’s what I do with most of my day. I’ll call her Mrs. J. She’s a 42-year-old woman. She’s a survivor of the Sixties Scoop. She’s been living on her own since the age of 12. She’s the mother of two girls that were taken from her when she was in her early 20s. She’s been living in the Downtown Eastside for the last 13 years and has been part of my practice.

[9:20 a.m.]

Her health is complicated by chronic conditions, which include HIV, hepatitis C, post-traumatic stress disorder and a long-standing, since her teens, opiate and stimulant use disorder. I’ll just say that from the day I met her, it was like: “I want to be on a different path.” It was very clearly laid out: “This is not how I want to live my life.”

She arrived in Vancouver, trying to make a new start, fleeing some very difficult situations out of province, but she relapsed into fentanyl and crystal meth use kind of at the start of the COVID pandemic. This was complicated by a very distressing, paranoid psychosis that was related to crystal meth. Again, she’s motivated to have different life circumstances, and she’s currently receiving, as treatment, a high dose of methadone as well as hydromorphone tablets, but she still has ongoing illicit fentanyl and crystal meth use. This is really just to manage cravings and withdrawals; it’s part of her life.

Eight weeks ago, I guess the end of end of March, she had a near-fatal overdose that required EHS response and a hospitalization. Over the last couple months, it’s like: “I don’t want to die. I know that I want to reconnect with my grandkids.” She’s highly motivated to quit. Now she has comes to us, and really, the situation begs itself: “Well, what actions can we take for this woman to try and prevent the next overdose?”

We know statistically — this is borne out by St. Paul’s Hospital data — that if you present with an overdose event, you have about a 4 to 5 percent chance of dying in the next 12 months. That’s more dire than if someone just had a heart attack, and you’re really trying to keep that person alive. That’s the context that we’re dealing with.

What do we have in terms of tools? Well, we currently have prescriber-based models of opioid agonist therapy, as well as a more novel sort of safe-supply concept of treat­ment by prescribers. The existing models of opioid agonist therapy, we know, can reduce illicit opiate use, reduce overdose deaths and have other health benefits. This includes the use of injectable opioid agonist therapy.

Opioid agonist therapy — probably Christy Sutherland spoke to this yesterday — is a replacement strategy with a prescription opiate for a non-prescription opiate. But we’ve also learned, over the last six years, that this is an insufficient response. It’s an individualized response to a public health emergency, and the numbers speak for themselves. We are not levelling off this problem; we are not adequately addressing this problem.

There have been released, over the last three years, novel prescriber models — I’ll put it in quotations, “safer supply” — that have presented themselves to clinicians like myself. I think we’re in the process of trying to understand what their impact is. There are several cohort studies that are ongoing, looking at impacts, and they’re mixed. That has been the early experience, again. This is akin to trying to develop an Ebola vaccination. It’s an emergency response. We’re kind of, a little bit, having to use our best judgment and not having a solid evidence base, always, to work from.

I think the bottom line from our collective understanding is our health system is unlikely to successfully out-compete the illicit drug market in this, and in what opiates are going to be used. It is helpful for the individuals that are able to receive these treatments, generally — again, if they’re done in a thoughtful way — but it’s not a public health response.

[9:25 a.m.]

I think there is merit, certainly, in developing and improving these strategies in a clinical setting, because they are…. For an individual like Mrs. J., she’s motivated, she’s engaged, and she’s connected. She’s looking for solutions, and we’re reaching.

If I look back to her case…. I’ve maximized her methadone dose. She’s on a high dose. Going any higher gives her intolerable side effects. We tried transitioning to an injectable opioid agonist therapy, which we offer at our clinic, using hydromorphone. She didn’t tolerate the hydro­morphone.

Fentanyl patches. Again, part of this is that she gets this diaphoretic or sweating response. The patches just won’t stick. Fentanyl patches were not effective. She’s got the maximum….

[Interruption.]

D. Tu: That’s not me singing. That’s the nursing phone.

We’re going to turn them off right now. You guys are more important at the moment. They’re not actually trying to reach me. They’re trying to reach the nurse.

She’s had the full complement of risk-mitigation prescribing. She finds some benefit in having 14 hydromorphone eight-milligram tablets prescribed to her today, but it’s not sufficient. She clearly admits to me that when she is financially stressed, when she can’t make ends meet, she’s diverting those tablets. We’ve had this conversation with her.

A Voice: So she sells them.

D. Tu: She sells them when her hierarchy of needs demands it, and she’s open and honest with me about it. She said: “At times, they are really helpful, and I can’t really predict what the situation is going to be.” I appreciate her honesty and being able to have those conversations with her.

Again, we’re reaching. I don’t have a better…. I have not had a better solution to offer her, which kind of begs to look at non-prescriber-based models of safe supply, so just to create that dichotomy.

I was gratified by the federal announcement of the upcoming decriminalization of drug possession for personal use in British Columbia. I think there’s an acknowledgment that this is a really important first step, but as Minister Bennett said, this is the basement step. This is the ground floor. This is not the top. We need to layer things on top of this if we’re going to have a meaningful impact. The destination that would be impactful would be to have a regulated non-prescriber-based model of safe supply.

What does that mean? Well, if I look at it as a step-by-step process, just nuts and bolts, we need to have the right substance, the right opiate to be able to provide, which has been a struggle. So we need to actually identify what the right alternative product is that would be an acceptable substitution to what’s going on in the current context.

Then we need to be able to bring that to scale, and we need to decriminalize the sale of that product outside of the medical system. I can either be decriminalized or, ideally, regulated. There are a lot of parallels to the story of cannabis, where it went over the years of being a criminalized product to a medicalized product to now a regulated product.

I think the third thing that needs to happen, really, in this context is the support of grassroots organizations — such as DULF or VANDU, but there are others as well — to develop models of safer drug supply and distribution that actually could compete with the illicit market. This brings me just to dovetail a little bit about what Dr. Sutherland probably spoke to yesterday, in terms of fentanyl powder as an injectable option for opiate agonist therapy.

Kílala Lelum is certainly…. We’re part of a Health Canada SUAP. This is my shout-out to Health Canada for supporting us for the last three years, with another acronym, to develop models of care that are going to address this crisis.

Dr. Sutherland’s clinic is also part of that initiative. They have developed a compounded fentanyl powder that is in concentrations that you can reconstitute and inject in a small enough volume that it’s viable for injection. Recently, the formulations are going to allow for inhalation, hopefully, as well.

[9:30 a.m.]

The Portland Hotel Society currently has 14 patients that are on this therapy. It’s a daily injection, three to four times per day. The average dose to kind of mimic or satisfy or match what is being purchased illicitly is between 5,000 and 10,000 micrograms of fentanyl.

Now, I’m going to just pause for a moment. In my days as an emergency doc, I might give someone 60 micrograms of fentanyl to reset a broken bone. You know, 100 micrograms will knock out most people, and much more than that will cause a fatal overdose. We’re talking 10,000 micrograms. These are the doses that people are experiencing in the Downtown Eastside.

It’s illuminating in the sense that it’s hard to fathom the doses that people are taking in a day. So again, it’s somewhat less surprising that so many people are overdosing. Again, there’s going to be some variation. You’re basically on a knife edge, and just a little bit too far sends you over.

It also explains why our current therapies are really just not able to replace or compete. We’re not even in the right…. We’re a log off in terms of our strength of potency for most of our therapies. We have near 300 people that have opioid use disorder that we treat with opioid agonist therapy. We’re really only able to stabilize about a third of those individuals, and these are motivated people connecting to the health care system, looking for a change. So our tools are insufficient in the current context.

Unfortunately, this is a novel product that is compounded. It’s an off-label use. But there are these steps, and there are bottlenecks in the process. We’re next in line. Again, the current bottlenecks, which are related to quality control testing of the various strengths, will hopefully open up such that we can start prescribing this in August or September of this year. We’re next on the list.

Interjection.

D. Tu: I’m a minute over. Oh dear. Okay. I’m going to wrap it up, then.

For Mrs. J., I’m hopeful. I offered her, if they had this…. “If I could give you an injection in clinic that would match what you would be using outside, would you take it?” She said: “Yes, that’s a no-brainer for me. I don’t want to die. If it’s safe and it’s equally effective, I would take it.” That gives me a pathway with her to stabilization. “Okay. I can match what you’re getting. I can stabilize your dose. Then, if we like, we can try to gradually down-titrate you in a controlled way.”

I asked her: “If you were offered to purchase this same titrated amount that you know would be safe to take and you know would be unadulterated, and you could pick it up from a Portland Hotel Society pharmacy, would you purchase it for a comparable amount that you would pay on the street?” She said: “I think so.” She’d have to kind of process it through. But again, that’s an option to at least scale this up beyond just the number of people you can see in a clinic.

This gives the potential for a broader experience with the substance. Again, this is perhaps the substance that could…. Concentrated fentanyl powder might be something that the non-prescriber model could actually utilize as something to provide as a safer supply, if it’s been titrated and organized. It’s a nice synergy between the prescriber and a non-prescriber model.

I’m going to take one more minute in going over and just…. That’s the proximal. The distal is equally important. That’s the decolonizing of the health care system. That really means taking the best of what colonial medicine has to offer and finding the best of what Indigenous medicines have to offer and bringing them together in a way that respects both systems and is done in a spirit of trying to do the best work that we possibly can.

[9:35 a.m.]

I know Kílala Lelum, and we’re part of a movement of other health organizations that are involved in Indigenous health that are in this work to try and create a transformed system that is culturally safe and more effective for Indigenous people. We do this through Indigenous leadership at the highest levels and a partnership with Indigenous Elders.

We’ve done studies and published results showing how this type of model can reduce suicide rates, sustainably reduce rates of depression, cut hospitalization rates in half. Your provincial government created ten spots based on this work for Indigenous Elders to be part of the health care system, and Elder Bruce Robinson is one of those Elders. So we thank you for that.

We’re currently actually doing a study, very specifically, on people with opiate-use disorder, looking at introducing those Indigenous people with opiate-use disorder to connect with an Elder and watching how that impacts over six months. We’re seeing about a 50 percent reduction in spending on illicit opiate uses, and we’re collecting those stories right now.

I’ll just end with Mrs. J. She did, as part of a study, start connecting regularly with an Elder for the first time in the 13 years that I’ve known her. She says the benefits…. I’m way better navigating her relationship with her partner, who has been a very complicated person in her life. It’s increasing her sense of self-worth, and she’s got a very strong connection to both female Elders that work in our clinic.

She’s now actually thinking that she’d like to go with her partner to a residential treatment program. That’s something that you have to work towards. She couldn’t go right now. You have to be able to manage on a substitution therapy, so it’s something to work towards.

Honestly, since her overdose event, she’s actually looking the best that I’ve seen her in the 13 years, so there’s hope. Again, policy-wise, a two-pronged approach at least, probably more prongs required. But do address that sort of proximal priority to keep the breath of life going in people, and there are some practical steps that need to be taken to try and actualize that. Certainly, the intermediate distil is addressing the health care system, and then there is some deeper distil that also needs work.

I will end that, five minutes over, and I apologize for taking more time. I’m going to shut up now.

N. Sharma (Chair): We’ll have a good discussion, and we’ll make sure everybody gets pulled into the conversation. I’m going to take a queue.

Go ahead, Suzie.

S. Chant: With regards to Mrs. J., is she also in a precarious housing situation?

D. Tu: She’s in a better housing situation than she has been. She was absolutely homeless for a long time. She and her partner do not live in the same housing. That’s partly because…. They would, were it not for the disability setup.

Her housing — I wouldn’t say that it’s stable. She is always kind of one month away from a crisis that would make her lose her housing. Her last psychosis almost made her lose her housing because of her behaviours. But it’s as nice of housing in a supported drug-using environment that I think she could get at the moment.

T. Halford: In terms of your mobile clinics that you’re operating with Telus Health, how is that working? You guys are in Surrey as well, or you’re in…?

L. Walker: No, we’re not in Surrey.

D. Tu: I have to be on the van, actually, right after this talk.

T. Halford: How is that working, in terms of the mobile access and things like that? Actually, how is it working with Telus? That’s something I picked up on just before, in that partnership, and how….

D. Tu: Elder Bruce, you’re on the van every Monday. Do you want to speak to it first?

B. Robinson: Yes, I do. When I go out, to see them be able to access their needs of…. Whether they need bandages or something, they need to be able to…. Like cuts and scrapes and things like this. Some of them are very afraid to come into any kind of clinic.

So when they see the van, they’re more than willing to come forward. I can’t say enough. Kílala Lelum is a team. It’s a team. We’re all in it together. It’s in that understanding that there’s not just one person. It’s everybody together.

[9:40 a.m.]

For some of the ones that we see…. Some of them come and get some my medicine. They want to get brushed off, or they want to just talk with me. It makes a big difference for them.

I brought four medicines here. You only see three of them on the table, but there’s one sitting here. It’s that understanding. It’s the connection that we all have with each other. That’s why I say right now that what we’re doing here is going out into the community as a spirit.

That’s what’s missing within any kind of medical system, and that’s what we’re trying to change at Kílala Lelum. That’s the most important part of somebody and how much they have to feel good about themselves. Some of them come in and say: “I want to better myself.” I say: “No, you don’t. The most powerful thing you can do for yourself is to feel better about yourself.” There’s a big difference.

I can’t say enough for Dr. Tu and Leah and everybody there, especially our MOAs. When one of our members comes through those doors and they’re treated with respect, treated with dignity, treated as a human being, as a person, that’s the very point of healing, the very first point of healing for anybody that walks through those doors.

All the things you hear, all the stats and everything — you’re talking about me. You’re talking about my family. You’re talking about my people. I say “people” because we’re all in it together, no matter what. I tell them, “I’m not here to tell you what to do. I’m only here to try and make you look at things differently for yourself,” because this is their life. A lot of times I tell them: “No matter what I say here, when you go out those doors, the decisions you make are yours.”

What do you guys see? I would like to ask some questions too. What do you guys see as a solution in what’s happening right now? This is long overdue. Long overdue. I was in a Zoom meeting, and I said: “To have that safe supply, the way you can see and know and understand it’s working is by the amount of deaths that go down.” That’s totally amazing if you can see that.

I have a lot of problems with some of these big words that we use. Decolonization. I can’t…. Sorry. I guess you can see that this is very dear to me. I say I’m from the Nisg̱a’a people. I don’t say nation. If you look throughout Mother Earth, the nations are not doing too well with each other.

We’re all people. We’re all on this journey together, and we have to make a difference for each other. That’s the most powerful thing we can do. It’s starting here within each other. It’s that understanding that…. I always quote Wayne Dyer. If you change the way you look at something, it will change.

Stigma. That’s another word. Marginalization. But who’s doing all this? Who’s doing all those big words to the ones that are in the Downtown Eastside? Who is it? With our outreach van, I’ve gone to the tent cities, just to see them. They’re human beings.

I have a hard time with them saying “addictions, addictions.” Yes, they got addicted to something, but it’s also a coping mechanism. It’s how they’re coping through life. When you guys have a tough day, what do you do? Do you have a drink? So what’s the difference?

[9:45 a.m.]

It’s that understanding and how people are trying to cope with life. That’s why one of these things that we did start here at Kílala Lelum is to try and make a difference for each individual that walks through those doors. We have 1,400 members now. We didn’t want to call them patients, because that’s in that way…. I look at as if we’re all in a circle together to be able to try and make a difference for them.

N. Sharma (Chair): Thank you, Elder Robinson. You asked a question of us, and I just don’t want that to sit.

We are a cross-party committee. You have here, represented, people from the NDP, the Liberals and the Greens that are all very seized and open to trying to figure out what our recommendations would be to solve this crisis and to save people’s lives.

Right now we are in the educational phase. Really, we’re learning. We’re having as many people like yourself that are hearing and seeing things on the ground come to us and tell us what they think, in their experience, the best way forward would be. Then we will make recommendations to the government about what that is, going forward.

We’re all very, very committed to trying to figure out and learn from you and other people during the day. So thank you for that.

B. Robinson: The best way to do that is to come and visit us.

N. Sharma (Chair): Yeah, and that will be definitely part…. We’re thinking about that too. At some point, we’ll be out and visiting places, so we’ll keep you on that list. Thanks. I just wanted to make sure you had an answer.

D. Tu: Maybe just to add a little bit to Mr. Halford’s question, the outreach van is a logical extension of what we’re doing. We have a relational approach, which I think is the right approach for this community and allows us to meet people where they’re at, establish a relationship and then draw them into a circle of care.

Leah, if you want to speak…. I’ll say that we found alignment with Telus, in terms of the goal. We’re a service provider, and they were interested in providing us some of the means to provide that service.

T. Halford: It’s something they do nationally, right?

D. Tu: They have 13, I think, programs across the country in Nova Scotia, Ontario, Alberta and B.C. They have their…. They’re motivated by commercial interests and others, but generally, I’d say — and Leah you can speak to it — that the relationship has been one that we’ve found common ground. There hasn’t been conflict in terms of…. We want to provide service, and they’re happy to provide means. They’re name is on the van, most certainly, but they’ve been, I would say…

L. Walker: A good partner.

D. Tu: …a good partner, probably not the right long-term partner for health provision but a good partner.

B. Robinson: They gave us three years of funding for it, which is totally amazing.

You guys all here together. It’s going to be coming to an end soon, so a little push there.

N. Sharma (Chair): Yeah, thanks for that.

L. Walker: Well, actually, we’ve recently just been funded for the women’s mobile outreach for one year of programming.

D. Tu: It’s partial funding.

L. Walker: Partial funding, right.

R. Leonard: First of all, thank you for a good start to the morning. I appreciate all the words and all the wisdom you bring to the table for us.

I have to boast about my community. We have what’s called the Care-A-Van. It was started by a local nurse. She engaged with doctors and other allied health professionals to go out and go to where the need was. They’ve been going for — I don’t know — I feel like 20 years, maybe. It’s self-sustaining. They don’t want to be a part of the medical system, which has some issues.

I know that there are other communities…. Campbell River has one that’s going out in that mobile way. Where there’s community will, there’s a way. It’s good to hear that it’s working for you right now, and we’ll just find a way to continue that when you have found a successful model.

That brings me to the…. I have a couple quick questions. You talked about the pilot with the federal program. You began by talking about the urgency and need to take action. We’ve heard in the past, around pilots, that that’s not enough.

[9:50 a.m.]

How would you see escalating the response in this one? Within the legal framework that we have right now, is it possible? Do you see it as a possibility?

The second, sort of the mechanics of things. My question was: if you have a non-prescribed safe supply, how do you work in the titration that needs some kind of professional assistance to get you to the right place?

L. Walker: The funding from the federal government allowed us to fully realize our model of care, so it helps us fund what people consider the extras, which we consider the essentials — the cultural programming and some of the elder care. Social navigation is critical to the work. It’s that relational process that connects people to systems.

Right now we have systems that are very fragmented. We don’t have any access when people get out of treatment. There’s no communication. Our social navigators help create those relationships and conversations. And then after people get out….

A word about those treatment centres. They’re not long enough. People need coaching and support in being able to work through. Trauma is the root cause of all of this. If we talk about trauma, decades of trauma, and where we are now…. If you want to know why it’s impacting Indigenous folks the most, if you look at the 215 bodies that have been found, residential school findings, the day school action suits, it just keeps going. COVID had that impact as well.

Social navigators, Elders, all of that. We’re trying to meet the trauma. This model of care has helped us realize that. I feel grateful. We’ve created this beautiful model, and now we’re trying to sustain it.

It sustains not only the members that we serve. But you’re aware that the health care system is in crisis. I just want to acknowledge…. I’ve been hearing stories from physicians and others that are leaving their work, that are overwhelmed. Nurses, same.

We’ve been fortunate to do that, because we have created a community and connection, and our response would be to create more community and more connections. What I see in this fragmented system is we’re not making all of those connections either.

That’s the first part of the question, from my perspective.

D. Tu: When I think about your question from our perspective, it’s like we want to continue to exist. We have some existential challenges in terms of adequately funding to maintain the system and not have to start trimming it off and cutting it down.

At our organizational level, it’s the scramble. It’s the writing grants. It’s protocol. It’s responding to calls for funding. It’s trying to navigate to a place where there is sustainable three- to five-year timeline horizon attempts to actually do the work and not spend all your time writing outcome reports and working on the next grant so that you don’t have to lay people off.

I think this is an issue. When you find an approach that makes sense, then you adapt it and contextualize it into other things. There are lots of other people interested in doing this work if they are empowered to do so.

Again, some of the foundations…. It’s like that relational approach, take the patient medical home model and really strengthen it to make space for Indigenous culture, where you’re caring for Indigenous peoples.

There are lots of pluses, and there are lots of ways to do that. I would endorse the cooperative, non-profit clinic model as a good vehicle for establishing that. I think there are a lot of advantages over a fee-for-service or for-profit model of health delivery. I think it is doable. It’s not quick. It takes time and energy and finding the right people, but that is doable.

[9:55 a.m.]

In terms of the non-prescriber model, there’s a nice synergy that’s happening. Again, this is something that Dr. Sutherland, myself and others are trying to plot and trying to figure out. We’re trying to get the data on the potency in our neighbourhood of what the illicit opiates are like. It’s easy to get the percentage of how much fentanyl, but it’s not easy to say, in a gram of opiates, how many micrograms of fentanyl or fentanyl equivalents there are.

We’re drilling down, and I’m sure that’s going to be different location to location, but the equalizer is that we can actually titrate people. We have an injectable opioid agonist system within our health centres. Let’s start with 1,000 micrograms and work up from there. We can titrate to….

For you, your tolerance and the spot that gets you to homeostasis is 4,000 micrograms. Then you can take that information and that knowledge, or I can write you a prescription. “This person can tolerate 4,000 micrograms currently.” Then you could take that to a non-prescriber model and say: “This is what I’m looking for. This is what I know to be safe.”

There are synergies between a prescriber model and a non-prescriber model that I think make sense, to try and make it safer. It’s never going to be 100 percent safe, but long before this crisis started, there were overdose events happening on prescription opiates. I think “safer” is the right adjective to use.

There is synergy. I think you can do this. I can see a pathway, at least in our neighbourhood, to be able to care for hundreds of people. Then it’s some thoughtful systems work. There are thousands of people that you need to target if you actually want to make an impact at a population level.

N. Sharma (Chair): I have at least five more people that want to ask questions, and we’re probably going to go over our morning time, if that’s okay with everybody and if that’s okay with you.

P. Alexis: Elder Robinson, we wrestle with exactly your question, as Niki so aptly replied. But I can tell you that the lack of connections for me is really relevant.

Actually, Dr. Tu, your first sentence was about connections. And I think you also responded in the beginning, too, about the lack of connections and how we need to make those connections so people feel safe. I think COVID, of course, was all about the lack of connections, because we had to isolate. You think about how that works in the scheme of things.

As a former school trustee, I can tell you we were always looking for connections for our youth within the system, because they did thrive more than those that had no connections in that. I see this played over and over again. Thank you for providing that for me. Certainly, that’s been my takeaway so far, that we need to improve all of our connections.

B. Robinson: Yes, because I also work with the Urban Native Youth Association. One day I was asked to go and talk to a summer camp, the youth summer camp at Britannia. They called me up and said: “Can you come in and do some teaching?” I said: “Yeah, sure. I could do that.” The day before I was going to go, they called me up and said: “What are you going to do?” I said: “I don’t know. I’ll see when I get there.” When I got there, they pulled me aside and said the same thing, so I asked them what happened.

They said: “Well, we had a traditional grass dancer come in, and they were very disruptive, almost to the point of being disrespectful to her.” They asked me what I’m doing, and I said: “I don’t know. Maybe I’ll just talk with them.”

There were about 20 of them in a circle, and I had my traditional hat on and my vest. I sat down, and I looked every single one of them in the eye as we went around, and I said: “I’m just so honoured to be able to be sitting in front of such great, great people.”

That first song I sang today was a song of forgiveness. That came to me when the so-called discoveries came out of Kamloops. I kept asking, “What is it for?” and it came to me that the song of forgiveness was to ask the children for forgiveness for not recognizing them sooner.

[10:00 a.m.]

I call them so-called discoveries because our people have always known they were there. It’s just that humanity is finding out what the sole purpose of residential school was about.

Then I started looking at it and said: “We’re not residential school. We’re not colonization. We come from great, great people.” This is what I talk about with the youth, to see them and who they truly are, because it brings a moment of pride within them to start to make them feel good about themselves. That’s why I say: who’s marginalizing all these people? It’s society — instead of just seeing them for who they truly are as people.

I was in my own addiction for over 20 years. It wasn’t until I started talking…. It’s over 30 years ago since I stopped. I went to counselling. They didn’t know anything about residential school. They didn’t know anything about day school. I went to AA. I got up there, and I said: “My name is Bruce Robinson. I’m an alco…. I’m an alco….” I couldn’t get it out, because that’s what I was trying to stop being. But I have a lot of respect because they’ve helped millions of people throughout Mother Earth to stop what they were doing to themselves.

It’s in that understanding. It’s spiritual. We have to start to bring that within the medical system. I couldn’t say it enough about these young ones. They started asking questions like nothing after that. Just to say: “I’m just so honoured to be sitting in front of such great people.” That’s all it took.

P. Alexis: I have one further question for Dr. Tu.

Dr. Tu, yesterday we heard from Dr. Sutherland that the incidence of reselling their prescription was very low. But when you referenced Mrs. J., you said that she did this. I’m hearing two different opinions. If you could just respond to this, please.

D. Tu: Christy and I actually have talked about this. I know the Portland Hotel Society is really very strict about doing urine drug screening for people that are receiving risk mitigation prescribing. They will de-prescribe when you get a negative urine test. That’s a quality assurance. It’s a hard conversation to have with someone, especially when you know that they’re living on the margins and they’re financially strapped, and the people are going to have to make tough decisions. I think they make a lot of effort to de-prescribe to limit the diversion.

This was just a conversation. I had the same process. A part of standard of care or routine care is to do a urine drug screen. Her urine was positive for fentanyl, positive for methadone and negative for hydromorphone. Then she had an overdose.

Then we had a conversation. It’s like: “Yeah, I was selling then. I’m trying to get back on track now. I need it today, and I was selling it three weeks ago.” We know that you can buy right now, in the Downtown Eastside, a hydromorphone tablet for about 50 cents to $1 a tablet. That same tablet ten years ago would have been $10 to $20 a tablet.

I think it’s naive to think that there’s not diversion, but it’s not a black and white “This person doesn’t divert ever” or “This person always diverts.” It’s context. You’ve got to read it. It’s a judgment call. It’s like: “Well, do I continue to prescribe to you? You’re really trying to be in a situation where you’re not using it. If I take this away, it’s going to increase your reliance on the illicit system.”

L. Walker: And it’s garbage. The illicit system is garbage.

D. Tu: But it sucks. To be in opiate withdraw without something is a horribly painful thing, and it’s really hard to resist when you know that there is a solution that would make you feel at least not terrible. It’s a case by case. So I continued to prescribe in that circumstance. We did a risk benefit. It’s re-evaluate, re-evaluate.

[10:05 a.m.]

I think the diversion risk is real, and there’s not a simple solution to…. The way the system is set up, it’s an imperfect fit asking prescribers to try and take on this role, same as it was with cannabis in 2013, where you’re trying to square peg, round hole.

N. Sharma (Chair): I want to try to get through as many people’s questions as possible in the time we have left, so I’m just going to ask people if they can keep them as brief as possible, while still giving the information so more people can ask.

S. Furstenau: Thank you so much for this today. It’s really inspiring to hear what you’re doing and how you’re doing it. We hear a lot about approaches to this issue.

Dr. Tu, you talked about this: an individualized approach to a public health emergency. In a lot of ways, that individualized approach comes with a lot of exertion of control over individuals. What we’re hearing from you — especially you, Elder Bruce — is that relationship and community are really the non-individualized approach to this.

But how do we measure that? Does our system — our health system, our political system — have a capacity to measure the success of building relationships, of building community? I expect we don’t very well. How do we incorporate that into the path that we want to take to address…?

The opioid and the overdose and the drug poisoning crises are, as you say, symptoms of other crises. How do we de-individualize the approach in a way that measures what is actually successful in helping people? It’s a big question. I hope you can help me with that.

D. Tu: Health system–wise, building homes for people to feel belonging to. Belonging is a really important dimension of wellness. I think it’s one of my four constructs. If you feel that you belong somewhere, that you are welcome there, that you’re at home there, that is a big piece of being a well human being. The health system can do that for people if it chooses to.

Not all medical institutions feel like home or are made to feel like home. In terms of a systems transformation, that should be amended. People should be made to feel welcome in the system, feel like they belong to that system.

Again, the health system is not the only system to evoke to respond to this situation. We can do better in the health care system. I think if this crisis doesn’t push us to become better, it’s a tragedy, on top of crisis. We can do better, and I think there are metrics to say: “Does this place feel welcoming? Do you feel like you belong here?”

We know that question. This is Barbara Starfield, back from 20 years ago, a celebrated family physician saying that if you can ask someone the question, “Do you have a person that you can identify as the person who cares for you medically…?” If you can say yes and identify that person, your health trajectory is far different from the person who cannot identify a person. Just that sort of connection. You can systematize that. But I think Elder Bruce is going to have a better answer.

B. Robinson: That’s why I say with Kílala Lelum, it’s a team, everybody in the medical system, in our clinic. It’s understanding. Even in our van. Some of the ones that were so hardline of not coming in, the connection that they made with the van…. All of a sudden, you see them start to come into the clinic. So it’s important that we reach out to be able to let them know that there is something different that we can do for you.

[10:10 a.m.]

I had a couple of people come in and say: “I’m tired. I want to go to treatment.” I picked up the phone and I called one of the social navigators and said: “Look, she wants to go to detox.” They were right there. They came right in, and they said: “We’ll drive you to the detox centre.” And they did. It’s in that understanding that if it’s something that they can do right at that time, they can make a big difference.

L. Walker: But no social navigators help us make all those connections, because that person wouldn’t have gone to emergency or wouldn’t have…. If we didn’t have those connections and relationships and understandings of some of the other systems…. Every system has its own laws and rules and all of those kinds of things. So it’s navigating that, I think, that we could probably do a better job of too.

S. Bond (Deputy Chair): Thank you, Elder Robinson, for starting us off in a good way today. We appreciate it. Thank you for the teamwork that you use.

Today, for me, this…. One of the themes that has emerged as we’ve been meeting is that people tend to — I’m not suggesting it’s right — assume that the opioid crisis and overdose death issue is…. The images attached to that are the Downtown Eastside.

What we know is that it’s happening everywhere, and, in fact, it’s actually a crisis of many people using alone, many who live in rural and urban communities, rural communities that are disconnected from services. I think the thing in your slide presentation that is something we need to remember is the growing gap between First Nations and other B.C. residents when it comes to the number of people that die.

I say that all from the perspective of how do you take the things that you’ve learned about connection with Elders…? I thought the study you did was incredible, the impact of connection with Elders when it comes to addiction and overdose. How do we take what’s going on at Kílala Lelum and help people across the province? Is your situation so unique to the Downtown Eastside, or are there teachings and lessons that we need to make sure that, particularly, other First Nations know — that there is support and all of the things that you’ve shared today?

Can we replicate it? Can we learn from it? The thing that I find so tragic is that for First Nations women in particular, the numbers are staggering, not just in the Downtown Eastside but across our province. Construction workers who work in northern parts of this province.

We’ve learned from you today. What can we take from what you do to help others across the province?

D. Tu: This is a great Leah question.

L. Walker: I don’t know if I can actually answer that question.

I know that communities are trying to do that work, and it’s a matter of scale. You might be having 300 members of that nation that might be there. Of course, not only members of that community are there. There might be, in other places….

I know Carrier-Sekani, for example, and I know of other sites that have Indigenous models, which means it’s holistic. We’re not just looking at the physical. We’re looking at the emotional, mental, spiritual. We’re looking at all of it. They’re providing those kinds of services for the community at large, and I think, as a society, that’s what we’re missing. Not to say it all happens in a medical clinic, but I do think some of that occurs.

I also know that what we’re doing…. We’re working to go back, to allow the people that we work with — to give them access to culture, not only through our Elders but through the programming. We have a canoe, for example. We’re working on going back to the teachings.

I think that work…. It’s hard to measure that work. It’s almost intangible. When you ask for metrics, Sonia, it’s very hard to measure that. But I think that work is really important.

[10:15 a.m.]

I don’t know. I don’t know if that answers it well enough.

B. Robinson: You know, I’ve been going out and doing a lot of teaching about culture, and I always say: “Oh, I love yogurt, because they say yogurt’s got culture.” But that word is just a word. It’s a word that can’t touch what it truly means to us here.

We’re looking at getting another van, a ten-passenger van, to be able to bring some of our members out onto the land. These are some of the things that can make a big difference. We brought one out when we were at Vancouver…. It was Native Health at that time. We brought some out there, with the Elders and everything like that. I turned around, and here was this grown man, and he was just in tears. He said: “It’s been so long since I’ve been out in nature.”

I can’t say it enough, to have a governing body say that Indigenous people have rights. And we’re still fighting for it. This report, In Plain Sight…. She said it herself. This doesn’t have teeth. All it is, is just a report. Some of the teachings…. It was a lot of the doctors and nurses, and I said: “You are a part of the system. You can make a difference to change it. But then it’s up to you.”

It’s an understanding that yes, we can all make that difference, all of us. It’s in that understanding that we’re all in it together, all of us, no matter what. That’s what we’re here for. That’s what we’re trying to make a difference to. It’s all the ones that we’re here to try and make a difference for. Yes, it is.

I always talk about when we go across Canada and we attend every single ceremony that we have across Canada. It may be done in a different way, but it all means the same thing. It all means the same thing. I’m so honoured to be here. I always say that I’m honoured to be here to try and make a difference, but I’m sad that I’m here, because this has been going on for so long.

I thank you for listening.

D. Tu: Just to answer, in part, your question, I’ll just add to that. There’s nothing that we do that couldn’t be done in a different context. It takes a couple of things. It takes a commitment to transform the way you’re doing your work, because it is a different way of working. It’s a team-based model, which we know…

L. Walker: …doesn’t exist everywhere.

D. Tu: A commitment to transform, a commitment to actually partner and make ideologic and conceptual space for other health systems, such as Indigenous medicines. There needs to be an openness and a willingness to work. Then it needs resources. It is a more resource-intensive health system when it’s done right.

Sonia, just your metric. You have a glaringly obvious hardest outcome of mortality sitting in front of you as a metric, and you can get a denominator out of a population very easily. I could tell you. Especially, it’s so easy in a more remote zone, where you actually have a captured population. You can look year to year: how are we impacting deaths by unintentional overdose? That’s a fantastic mechanism for how well people are connecting to a health system, how well those other systems are using….

I don’t think you need to struggle to find some surrogates of belonging when you have a great, hard outcome that you’re already measuring. You just need to actually carve off your denominator, then make your intervention in that zone and then monitor. If it’s not working, then do something different. That’s pretty straightforward.

This is not a unique recipe, what we’re doing. We’re just…

L. Walker: …committed.

D. Tu: Yeah, we’re committed. We said we were going down this path, and then we’re just accessing ways that people have been looking after each other for thousands of years. It’s not something so….

[10:20 a.m.]

L. Walker: We have an opportunity to do something different. It’s beautiful to be able to have it led by Elders and proper teachings.

B. Robinson: One doctor asked what the barriers are for our people to access medical. This one doctor said: “Oh, I took a plane to get there, and I took a helicopter to get to the community.” I said that’s one of the barriers, but then I said that we have our own ways of healing, but they’re not recognized. It’s in that understanding that if we didn’t have our own ways of healing, we wouldn’t still be here. It’s in that understanding of that.

S. Bond (Deputy Chair): I just want to quickly say thank you for sharing the story of Mrs. J. I will remember that. I know we all will around this table. It puts a face to the…. Thank you for that.

N. Sharma (Chair): I’m going to try to get my question in before we have to switch up to the next panel.

I join the committee in just thanking you for teaching us about how you’re showing up for people and building connections. I think we’ve had an interesting journey to think about people like yourselves that are on the front line of separating people from the toxic supply and the learnings that you’re doing when you’re in that space. That’s really illuminating, I think, to everybody here.

My questions are kind of in that realm. Is the work that you’re doing on the forefront of this? Do you have peers outside of B.C. that you can learn from when it comes to helping to figure out how you compete with the illicit supply? Is it just responding to the community? Where are you getting that kind of best practice and how it’s showing up and that?

D. Tu: There are lots of networks out there, but our contexts…. It’s always going to be a local context, wherever you’re practising. We have a strong network in the Vancouver inner city. We networked with other Indigenous partners and also non-Indigenous health care providers. Christy and I talk every few weeks. Dan…. There are about six or seven leaders within the different health centres that we talk to, and we share guidelines.

We actually have…. Because we’ve got to protect our­selves from our own college, we try to standardize and harmonize our approaches. So it does take networks of providers, but they’re local networks. Those are ones that I find helpful.

Again, the rules change so much, province to province, in terms of what you’re able to do and not do that you need that local environment. I think we’re fortunate that we have a pretty cohesive medical community to work with in that regard on the prescriber end.

L. Walker: And the Indigenous community, we work on connecting as well. Sharing knowledge with each other and sharing best practices and growing. We feel fortunate that we can…. We’ve modelled after certain models in Alaska that we toured, as well as in Toronto.

I think we’re fortunate. We’re creating our own unique response to the members that we are serving where we’re located. There are aspects that can be replicated elsewhere, but it is very much community-specific.

N. Sharma (Chair): I think one of the things we’ve also learned is that there’s a relentless growth in the toxicity of the supply and that you’re trying to keep up with it in terms of responding to the people that you’re helping. It kind of blows all of our minds when we think about the doses that you’re competing with, so it struck me when you said the “safer supply,” because it’s hard to match it.

How do you do that? How do you show up? It sounds like there are a lot of things within those decision-making…. Like what’s available to supplement what’s out there. I think there’s probably a big answer, but what’s the framework that you’re trying to use in your favour that’s blocking you? Is it the federal drug control laws? I just want to understand that.

[10:25 a.m.]

D. Tu: In terms of how…? On a very narrow, prescriber, individual level, we have 30 years of knowledge around injectable opiate agonist use. One of the safest things I can do is actually have someone witnessed in front of me. I’ve got my whole resuscitation kit beside me. “Let’s take this dose. I know I can resuscitate you if you go down with this. We’ll watch you for 15 minutes, and if not, you’re fine.” So actually, it’s way safer for me to prescribe an injectable opiate in my clinic than it is to actually…. “Here’s a prescription. Go take this at home and see what happens.”

There are health systems to kind of check — the barriers, the right products, how to scale this beyond those that are coming into a clinic. We can care for about six to ten people in that way in our health service, because they’re coming in two to three times a day and we’re also looking after 1,400 other people with kids and families and elders and everything else. So I think it’s capacity.

L. Walker: Yeah. We don’t have the capacity to take much more.

D. Tu: We can show an exemplar. “This can be beneficial, for Mrs. J.,” for example. I’d love to come back to you next year and say: “Yeah, this is where she’s at now. We found something that actually helped her to turn a corner.”

N. Sharma (Chair): So it’s like a product of scale issue that you’re….

D. Tu: There is a product in scale, and then there’s a system. We’re not close to a regulated…. We’re not going to prescribe our way out of this. There needs to be a non-prescriber model to have a population-level impact. We can improve our health system, and we can improve it for those numbers that touch….

That would be a good thing, good to improve the way we’re caring for people with substance use disorder, because it’s been poorly done historically. So if we come out of this with a better system of care, great, but that’s not sufficient.

L. Walker: It can’t be the only way. The pressure on the care providers is too high, and there are too many. I see the burden.

B. Robinson: Our Elders — they help the staff too.

L. Walker: A lot.

N. Sharma (Chair): Well, I just want to, on behalf of the committee, thank you for the work that you do, showing up for people every day in a really meaningful and spiritual way that fills the connections in community.

I think I’m speaking on behalf of everybody that we learned a lot from you today, and we just appreciate your time and everything you’re learning on the front line to teach us. Thank you.

L. Walker: Thank you for your work. It’s much appreciated.

B. Robinson: You’re welcome to come and visit us.

N. Sharma (Chair): We have time for a short bathroom break until 10:30, when we’ll try to start.

The committee recessed from 10:27 a.m. to 10:34 a.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome back, everybody. We’re moving on to our next presenters.

Next we have the group from Together We Can. We have Alex Lekei, program and business development coordinator, and Steven Hall, community relations team lead.

I’m going to pass it over to you. We all have your slides. You have about 20 minutes, and you’ll see there’s a little timer with some lights over there. Then, after that, we will have about 40 minutes for discussion. I know a lot of people usually have questions, and we can dig deeper into your presentation.

Over to you.

TOGETHER WE CAN

A. Lekei: Absolutely. Thank you so much. First off, we would like to be able to say thank you. It’s an incredible honour and privilege to be able to discuss these very important matters with folks that can empower change within our communities.

[10:35 a.m.]

We’d also like to acknowledge that we are on the unceded territories of the Musqueam, Squamish and Tsleil-Waututh Nations. If you’ve already done a land acknowledgment, we just wanted to start off with that.

We also understand the privilege to be able to talk about these topics from a cisgendered, Caucasian point of view. We understand and appreciate that. We also have a lens from recovery, working within a treatment facility, and we view the topics today from that lens. So we understand the privilege and/or the perceived bias that could come up, but what we want to be able to do is be able to present an unbiased and also solution-focused conversation around the systems of care that we have for our organizations and other health care models.

We’re going to be talking today mainly around the topics that you have put in front of you — the terms of reference. We want to be able to sort of zoom out and then zoom back in at a variety of different health measures. We’re going to look at some case studies that we have within Together We Can — folks that have accessed safe supply and also harm reduction models, as well as other systems of care — and then some feedback that they have given us, and then some reference recommendations from our team.

My own journey through recovery. I’m a person in recovery. I’m also a person in recovery that has worked in health care for 15-plus years. I began as a young person working as a youth counsellor, as a leadership counsellor, as someone who travelled in different places of the world to impact change.

Then along the way, addiction sort of blindsided me. I never thought that I’d go down that path. I didn’t think that I would go down the path from homelessness to a thriving, amazing career impacting change. But that’s part of my story. It’s where it took me, and I acknowledge it.

I actually celebrate it today, and I know that most folks that have been in my shoes or even the folks that I work with on the front lines have those possibilities. I am someone who is extremely passionate about people recovering and healing pain and finding systems of care and navigating the systems that we have in place. So that’s a little bit about myself.

Together We Can is part of my journey, and we have a mandate to be able to help folks improve their quality of life, have holistic measures of care and help people have a substance-free moment in their lives. We embrace and we know there are so many different models of care, and we embrace harm reduction models. We embrace folks that are going to access safe supply. We embrace different opioid replacement therapies.

I think that’s something that not many people know when they go to an “abstinence-based centre.” Our model is that every model is embraced. We have a full medical team. We have exemplary service that we can provide folks.

Today’s vision is to be able to provide more of a message of how we can work together. It’s in our name, Together We Can, and I think more of that needs to happen within our pillars of health and the people that we work with — not only that but within the higher systems of government to be able to help people navigate the systems. It’s a systemic issue. It’s an intergenerational issue. It is something that I think is larger than all of us. It’s a global issue. So that’s like zooming out and zooming in on many of the different issues we have.

That’s a little bit about myself.

Steven, do you want to share a little bit about your journey?

S. Hall: Yeah, thank you.

My name is Steven Hall. I, too, am in recovery from alcohol and drug addiction. I lived in the West Kootenays for the majority of my addiction, my active use. So I also bring that perspective of the rural communities, as well, in the province and the access to resources and things of that nature, which I’ll speak about briefly here today.

But yes, over the last almost four years…. I came out to this area for treatment through Together We Can, and the organization has given me many opportunities to volunteer, get back into the community and get back into regular work. So today I’m employed by the organization that I went through.

Like Alex had said, it brings a certain passion. I bring a certain passion to my work in trying to help other people who are on their first day trying to get clean off of substances — for them to know that out of our 100 staff, there’s 95 percent of us that are in recovery, so we give that lived experience. We’re able to meet them where they’re at and to help alleviate some of the concerns.

[10:40 a.m.]

My primary role with Together We Can is community relations. A big part of that is trying to build partnerships in collaboration with other organizations and service providers here in the city as well as throughout the province — and, most recently, interprovincial. We are trying to open discussion and discourse with other organizations out there that have the same goal. In our recommendations, we’ll speak a bit more about that as well.

I’m really pleased to be here and thank you guys for the invite and holding this forum.

A. Lekei: That’s great. Thanks so much, Steven, for sharing that.

I’d like to open up part of the conversation, around that this is about improving people’s quality of life and working together — again, in our name. I think for so long there have been so many divided systems of care. Oh, gosh. I’m not sure when the four pillars of health for substance use had come out. When it first came out, I was so excited about the different changes that could be made.

Through that, I found that again, there was a disproportionate, unlevel seat within the pillars. We have harm reduction, prevention, treatment and recovery, and en­forcement. I think there have been waves through government change that is evoking something different. However, I think there needs to be more. There can be more. The conversations could be more.

Our lens is when people do access safe supply, what happens next? I think that is the biggest thing. It’s like harm reduction or, what we like to be able to say, relieving pain. The language about harm reduction is so stigmatizing. But we have this relieving pain, and then we have the other pillars. What we aim to say is: “Let’s improve the conversation to bring people to a place where they’re given opportunities to have all.”

Our initial brainstorm, when we got together and we got the email from this — we can share some of that. COVID-19 has brought isolation. Conversation around the street level decreased. Outreach decreased. People accessing safe supply and quality of life decreased through COVID-19. I think we’ve all been impacted — myself, my partner, everyone in my life. It was a decrease in everything. I live my life. I see the privilege in what I get to do. What about the folks that don’t or don’t even know yet? That’s the part that just pulls at my heartstrings in terms of the initial things that we want to talk about.

How do traditional harm reduction models intersect with treatment options, and what does that mean? What does treatment mean for everyone? It’s different. So I think unravelling the language we use as health care providers is so important. There’s us versus them. There’s such a level of change that needs to and can happen, but we need more.

The Portugal model, which I’m sure you all have heard, the decriminalization that just happened…. It all is incredible. The movements and changes are fantastic. But what happens now? What happens when somebody has…? I guess I’ll say pass — okay to under 2.5 grams. “Fantastic. These are some options.” I know that’s the legislation. Things are mandated to be presented. But then what? In the other models, it’s like: “These are the options. You get to pick this, this or this, and we will follow up.” Our systems of care follow up. That is something that we need to look at, in my respect.

I know everybody has the presentation in front of them, so what I did is I actually looked at themes of a UBC study in terms of the public supply within addictive drugs and rapid review. I have a hard copy here. I can send an electronic copy as well. It’s 30 pages. If you feel like you want to have a really good read, you can definitely go through that and read it.

The things that came from safe supply in Canada was that there is a need…. It had a range of medication options. It’s accessible. Locations were needed, flexible dosing conditions, flexible goals. The common theme in the first portion, the quotes that I took directly from it…. They suggest that there are benefits to it. I absolutely agree. There are, 100 percent.

Another theme, as we go down, is that there is no mention of evidence-based interventions that impact people’s homelessness, nothing through the whole thing. In contrast, safe supply appears many different times. But how is that defined? I heard a member up here talking about it being prescribed. Then what? There is not enough of a health system in place to be able to monitor what could happen afterwards to improve someone’s quality of life.

Next, down the list: what are the benefits of public supply? What happens next? Most people advocate for it, and then they don’t define what it is.

[10:45 a.m.]

I think more information needs to come. On social exclusion and marginalized folks, the studies were done in populations where we have very vulnerable people. That’s a section in Vancouver, I could say. What about the rest of Vancouver, B.C. and Canada? People are forgotten about in all of the rest of the areas. How do we, again, improve the systems of care?

Just let that portion sink in. There are so many studies that are completed, in terms of the reduction models and a public safe supply. What about the other quality-of-life pieces? Again, I think those are some things where, if we want to impact change, going forward with it is to have more conversations with folks to improve the health care in other areas.

Some of the conversations in the case notes that we have with clients…. You have it in front of you. I’ll just bump down to client A. There’s a new customer being created when safe supply is introduced. It does not meet the fix of the person that is looking for it. So they take it, and they sell it to other folks at SFU. I have heard that so many different times. The client conversations…. Again, it doesn’t meet what they want, their “fix” — if I use that stigmatizing label. So they look for other ways and other means. Is this improving, or is it creating new crime?

Why do I mention this? Again, I’ve gone through a lens of improving people’s quality of life, but to hammer it home, the pillars of health care are out of balance. If we want to impact change…. People are going to use substances. They are going to access safe supply. Then what?

Within the recommendations that my colleague is going to go through, and then we have a conversation afterwards, I look forward to so many different conversations that happen now and invite conversations afterwards. The door is open for any one of you to contact any one of us to have more conversation.

With that, Steven.

S. Hall: Thank you very much, Alex. I appreciate that.

We did look at the four pillars, as it has been described for a number of years now. We’re making our recommendations based on that and on where the pillars are out of balance. On the first page, after the “Call to Action” section there, is where our recommendations begin.

Basically, what you see on this page is that we’re looking to hold space for further discourse and conversation with stakeholders and service providers in the community. My colleague Alex had mentioned an us-versus-them mentality. That’s very strong when it comes to service providers, I think, in the city of Vancouver as well as just throughout the entire province, it’s: “We’re doing it this way; they’re doing it that way.”

It’s important that we have an opportunity — and a mediator, I suppose — so we can start facilitating conversations about how we can look at this as a rounded service that includes harm reduction, safe supply, decriminalization, treatment and also aftercare, which is very important too. That aftercare piece is housing. There’s a whole bunch of different pieces there.

On our second page, this one would be the treatment and recovery pillar. That’s where we can really make some recommendations. What we’re looking at here is an increase in outreach services from the organizations that already have the infrastructure.

As I mentioned, we’re 100 employees strong. We have 40 volunteers, people who went through our program as well. We have a lot of people, but they’re very busy. That said, we have people on the ground here in the city of Vancouver that have the training and have the life experience to be peer support, to go out there and speak to people who are going to be using safe supply and to talk to them about other options as well.

Our intention wouldn’t be to force recovery or abstinence on anybody, but again, we field a lot of phone calls from the detox centres and the shelters here in the city of Vancouver, from individuals who are looking to get into treatment to stop using substances. There’s a very short window of opportunity there with that.

If we have better access to outreach and support through organizations like Together We Can, I believe that we’ll be better able to serve those people who are looking for a different type of service as well, meet them where they’re at and offer them solutions that they’re looking for.

One of the other big recommendations…. Currently the Ministry of Social Development pays a $45 per diem for us to have a client in our care. Out of that $45 a day, we have to, as an organization, feed, house, take people to appointments. There’s 24-hour care, a master’s-level therapist. We have a medical clinic.

[10:50 a.m.]

That $45 a day does not go far in the city of Vancouver — I think anywhere in the country, especially the city of Vancouver. If you look at Alberta, they’ve just increased their per diem.

So what we would see there is that right now most organizations are sitting at a 90-day wait-list for people who are trying to seek drug treatment. A lot of people are dying that are on that wait-list, the reason being because organizations simply cannot afford to bring them in. They’re actually paying money in order to serve these people.

When we’re looking at the increased collaboration, as well, when it comes to the Downtown Eastside, this is not just a local or provincial issue. This is a federal issue. It’s important that we take a look and speak with our federal counterparts to look at this as a nationwide issue and get support from all levels of government.

A majority of the people in the Downtown Eastside are not actually from Vancouver. A lot of people come here because of the weather, because it’s easier to live down here while you’re in that state of mind — and a lack of services.

I had mentioned I’m from a rural area. There is no treatment centre in Trail, B.C., or Fruitvale, B.C., where I’m from, a town of 1,200 people. The closest centre is Kelowna. I was asked to go to that centre, personally. I would have gone to the centre with people I used with, so I opted to come up to Vancouver to distance myself geographically without leaving the province. Together We Can, as an organization, serves people from all over the country for that very reason.

One of the things we’re also looking at here is no longer waiting for the crisis for intervention. That’s one thing primarily with mental health. One of the things we’ve noticed is that people are actually finally able to receive psychiatry, proper interventions, when it has become a crisis, instead of when they’re asking for help initially. So it’s important.

The other fellow that was speaking up here about systems of care and the health care system that we have…. The hospitals are not the…. The emergency room is not the best place for mental health and substance use patients to be. I work very closely with the clients, and we’ve taken them to Burnaby General, for instance. “Let’s just go to zone 5. Stay there for the night.” Then they release us back to our care while they’re still in a state of mind that is not beneficial for recovery. The environment is not beneficial for their own safety.

One thing we’re looking at too is detox beds and availability. There is a serious lack of those, especially in the city of Vancouver. I’m not too sure about up north, things of that nature. I know in the West Kootenays, they opened a new facility — I think it was a 13-bed facility — a few years ago, but that, again, is only 13 beds. Together We Can, on average, sees 1,200 clients a year, and a majority of those people need to access detox in order to come into our services.

The other piece here — I’m going to talk about enforcement really quickly; I’m going to get through the recommendations quickly — is again, in mental health and substance use, the addict is not a criminal issue. We’re asking our police force, which is ill-equipped and not properly trained…. It’s not the officers’ fault. They’re not equipped and trained to deal with the issues that are presenting now.

It would be important that we look at outreach teams. Again, I spoke about that outreach piece where we can go and have these professionals who are able to deal with mental health and substance use as it is, in real time, in real life.

And, of course, safe and suitable community housing. If you look at a majority of our detox beds, they are in the Downtown Eastside. So somebody is in detox for a few days, and they are released back into the Downtown Eastside — or discharged, sorry, not released. So what we’re looking at is some geographic distance in between where they’re using and where they’re attempting to stop using, or where they’re in the thick of it, if you will.

Moving into the prevention aspect, obviously, we just went through COVID-19. We did see that there was a large amount of money that could be spent in order to prop up our economy on a national level — federal, provincial, as well as municipal. Some of that funding could really go towards this health crisis, this crisis that we’ve had in the province since 2016.

In the recent report from the coroner’s inquest, a lot of the recommendations that were made in that inquest are the same recommendations that were made in 2017. It’s basically a carbon copy. We’ve now paid for two inquests to get the same answer, but there are no solutions being put forward, it seems like, which you could clearly see in the press release of that information as well.

I’m going to go over a little bit of time. I’m sorry. I’m almost done.

By putting ourselves in a position where we can actually start to use those recommendations and work together again as community stakeholders, different service providers, and looking at what the recommendations are of that service, then, most certainly, I think, we can start to see some changes.

[10:55 a.m.]

The other thing, too, is family programming. Addiction does not only just impact the addict; it also impacts the family. Together We Can offers a free family course. There is nothing government-funded. We take the family members in. We teach them about education and boundaries, a whole bunch of different topics. It’s a free service we offer to, actually, the whole community — offering types of prevention support like that, too, where we can educate people on what addiction actually is and how to support somebody in addiction.

Finally, the province of British Columbia has several commercials out. We’ve seen the campaigns where they’re bringing a face to what an addict is. You know, this is a mom, a daughter, a worker — things of that nature.

But that’s all it’s doing — showing what an addict potentially looks like. It’s not showing solution. It’s not showing hope. It’s just showing everybody this is what an addict…. It’s not just the people in the Downtown Eastside, which is very important. But taking those preventative measures and that public broadcasting message and expanding it, as these are the types of services that are available to your family members, would be very important.

Sorry for going over time. I appreciate you guys letting me continue.

N. Sharma (Chair): Okay. We’ll go to questions and answers.

S. Chant: Right back at the beginning, you spoke that you’re doing intraprovincial work with other provinces and, in fact, working across Canada in a lot of ways. Are there other organizations that are doing the type of work you’re doing, or are you acting as mentors for other organizations?

S. Hall: There are a number of organizations that are doing the same type of work we’re doing. Interprovincially we have started to build a partnership with Walking As One. It’s an Indigenous-based healing partnership that’s out of Winnipeg. They are trying to talk about safe supply and open discourse and things like that. So that’s where we’re beginning right now — and into our Indigenous population throughout Canada.

Together We Can has the All My Relations program, which is an Indigenous healing program. It’s cultural-based. It’s led by Elders and knowledge-keepers from the community, as well as First Nations or Indigenous individuals, counsellors and things of that nature.

In the province here we have actually been working with some smaller treatment centres to share our best practices. One of them that we’ve been working with is up in Powell River. There’s a number of scattered smaller centres throughout. We also partner with a number of centres here in the city to help, again, with best practices.

Together We Can is one of the largest organizations. We house 300 people — so as we’re sitting here speaking right now, there are 300 people that are not using substances — and then our 100 staff and our 40 volunteers, so there’s a community of almost 500 people. We like to offer our services and that knowledge and resources to centres out there that maybe only have two full-time staff members. We’re lucky. We have 100.

S. Furstenau: Thanks very much for the presentation — really informative and interesting. Several weeks back we heard from the chief coroner, and she said to the committee that B.C. currently has no evidence-based treatment plan, treatment programs.

I think it would be really helpful for us to hear about how you are looking at your results, what the evidence and data is that you are using. Also, I think, to give us a bit more of a picture of the funding, where is your funding coming from? You’re a society, so I’d be interested in that. But really to respond to what the chief coroner has said about treatment programs in B.C.

A. Lekei: Absolutely, and thank you for asking that question. This is something that as an addictions counsellor who has…. I worked as an addictions counsellor for approximately six years and then a youth counsellor for about 15 years, working within harm reduction models. For a coroner’s report to say that there’s no evidence-based treatment programs is something where I have to take a step back and say: “But there is.”

When we look back to when injectable ORTs were introduced in 1968, they talked about heroin users and crime going down, and they did prove that through harm reduction and ORTs, people could improve their quality of life and that they could make change in their life.

So 1968 and 2022 — there is so much time that’s in between that has been spent on evidence-based models through the government that has given a disproportionate, I believe, evidence being swayed in one direction.

[11:00 a.m.]

It’s about time that the coroners and also the systems of care come in to say there is plenty of evidence stating that people’s quality of life and “success” is being modelled within recovery systems. But what they do is they look at abstinence. I’ll use that word. That’s a stigmatizing word. People using no substance or improving their life have success every day, but how do we track that?

At Together We Can, we have a number of different systems through our computer system that we have. It’s called FYI. We have all of the different tracking markers that are in place. I believe that there needs to be governmentwide and/or systems to be able to work on to be able to track people’s success rate. The reason why they can say “there may not be evidence base” is that sometimes it’s hard to track.

However, what do people deem as success? What do people deem as improving quality of life? If we’re going with an us-and-them model, again, you can say: “Oh, there are no evidence-based treatments.” That “evidence-based” word is slightly triggering to me, because I go: “Okay, how are you marking that? What markers are you going and putting into place?” More time, effort and money needs to be spent on how we track and work with folks and what markers they deem as being success.

We have different, let’s say, forms that we have that say: “How is your quality of life increased?” We put those markers down. “Before you came in, out of a marker of 1 being poor and 10 being fantastic, where was your life when you first came in?” Okay. Most of the time it’s a 1 or a 2. And as they leave, it goes up incrementally.

We have markers that also state: “Which areas of your life were you lacking in? What groups did you go to? Did you go to codependency group? Did you go to strength-building group? Did you go to a stress-management group? Did you go here after taking that group? Where do you feel your knowledge and your life have improved?” Those are all trackable measurables within place.

There is a very outdated model that’s in place from 1968 stating, okay…. That’s just one of the reports that I put into place.

I hope that helps with some of that. There are so many models. It’s, again, in our name: Together We Can. We implore and hope that the public and the government can get on board to say: “Our pillars are out of play.” Please, please give some sort of support to the folks that are on the front lines seeing people’s lives improve so much every day, even when they use substance.

However, what happens if they decide not to use substance for a period of time, and/or opiate replacement therapy in a harm reduction model for two years? Yes, that’s harm reduction, absolutely. But those are treatment models. Those are lifestyle models that are being changed.

Again, it’s the us versus them. It’s systems saying, the coroner saying that there is no evidence. However, let’s stand up and say: “There’s so much evidence.” Please, these are the markers that you could use in the government place.

I’ll leave it at that. As you can hear….

S. Hall: May I add to that, if that’s okay?

A. Lekei: Absolutely.

S. Hall: I really like that you touched on it. What is success? Am I a success today? If I fail tomorrow, at three years clean…? If I use tomorrow, am I now a failure? Is that what I’ll be labelled as? So what is success?

That’s where we need to open that discourse again with all of the stakeholders. What is successful? Is it people not dying? Yes. That is successful. If you look at Together We Can, again, we have 300 clients that are alive right now. So that’s success.

Again, sitting down and figuring out what those markers are is important. You had mentioned funding as well. The best place an organization like Together We Can can get that information is through after-care programs.

Now, when it comes to funding, like I’d mentioned, we receive a very small amount for those who are on ministry. We rely heavily on people and family members to pay for themselves, or their unions or insurance companies and things like that, in order to keep the organization afloat but also to subsidize those beds for people who do not have access to that type of funding.

One of the worst parts, though, is that a lot of the times we’re met with families who have to take out loans to put their child through treatment so they can help fund their child’s treatment or family member’s treatment, and then what are we supposed to do? That funds the treatment.

Together We Can, right now, of our own volition and our own strategic planning, is building an after-care program where we can follow somebody’s journey better and track that information. Again, that’s through our own funding.

[11:05 a.m.]

It’s going to take a number of years, because a majority of the funding is being spent on what our primary purpose is, and that is to get people into beds — hopefully, they stay for the full 90 days — for a 60- to 90-day treatment, feed them, do all those things I had mentioned earlier. That’s where the majority of our funding goes.

If we’re able to access better funding and, again, resources and have those conversations about the metrics…. If we’re going from ’68 to ’22, that’s 50 years. Hopefully we can get this done in 25 or 30 or less. I would like it done tomorrow, but that’s not going to happen. I think if we start seeing everybody take that collaborative effort and really look at treatment centres and recovery as a model of care, we’ll be able to grab those metrics. We’ll be able to follow people’s journeys. We’ll be able to break the stigma of people who are in recovery as well.

We’ve gone for zoning for houses so that we can have a treatment centre or a first stage, and we’ve been met with a lot of backlash from the community. That’s that we’re moving criminals into the neighbourhood or there are needles everywhere. We were ready to go through zoning with the city of Vancouver, and then they bought the Super 8 Hotel on Kingsway and Victoria — I think it was the Super 8 — and turned it into supportive housing. We experienced a backlash because of that. Again, it’s a lot of stigma.

Opening that conversation through funding programs such as Together We Can and a bunch of organizations out there, and having those conversations, we’re going to really be able to actually stop asking what an evidence-based practice is and actually have the evidence. Right now it is just a question. We need to actually figure out how we are going to look at it so that we find that evidence.

T. Halford: On your website, it’s 16 beds subsidized by the Ministry of Social Development. Is that separate from the per diem?

S. Hall: No, that is…. So 10 percent of the beds are subsidized by MSD.

T. Halford: And the per diem is?

S. Hall: It’s $45 a day.

T. Halford: Do you know how much an MLA per diem is?

S. Hall: I do not.

T. Halford: It’s $61.

R. Leonard: We raised it, if you’re going to get political.

T. Halford: I’m not getting political.

N. Sharma (Chair): Let’s just stick to the questions and answers.

Go ahead, Trevor.

T. Halford: Sorry about that.

So it’s $45 per diem. That is to encompass your entire day there?

S. Hall: Yeah, your 24-hour care.

T. Halford: That is if you’re a client?

S. Hall: Yeah.

T. Halford: So if I’m not a client, then there’s no per diem.

S. Hall: Mm-hmm.

T. Halford: And that is strictly to the family to fund.

S. Hall: Yeah. For instance, we had a client come in. He was asked by the Ministry of Social Development to sell his truck and tools to pay for his treatment. Then he has no access to work once he’s done his 60 to 90 days of treatment.

So the organization Together We Can has actually created the all together fund. That’s what it’s called. It’s through private donations and corporate donations. We’ve been successfully able to put over 21 people through treatment at no charge or a subsidized charge that were not eligible for funding.

When we look at that, we are again asking people from the community, who are already paying their property tax, who are putting money into this government, to continue to fund services that should be readily available.

A. Lekei: If I can just add some clarity to numbers. We have approximately 80 clients that are in primary treatment. Then we have second stage and/or sober living and/or safe living outside of that. So we have approximately 220 folks that are living in safe housing through Together We Can. That per diem is paid for the approximately 80 folks that are in treatment for primary treatment. That’s where we get the number in terms of the percentage of the people that come through.

R. Leonard: I’ll apologize for my side comments, Madam Chair and our guests.

Lots of questions in my mind. You’re abstinence-based. It sounds like you’re male-centric in terms of your clients.

I just had a quick look at your website. It says you have certified counsellors. I’m wondering how you are certified. Does your program go through accreditation? If you’re getting funding, are those recovery beds or treatment beds? All those kinds of questions about just who you are.

[11:10 a.m.]

I want to acknowledge that…. I know it’s a word we don’t want to use, “abstinence-based.” But it’s safe space for a lot of people who want to detoxify their lives, and I think that that’s an important element in this whole conversation. To me, it’s just part of that continuum of care. Everybody’s journey is different. I want to acknowledge that.

I’d like to find out a little bit more about who you are and how you operate. Are you faith-based? Are you connected to AA? Just who are you? I got your personal stuff, but now I want to know about the organization.

A. Lekei: Absolutely. Let me tell you more about that.

My accreditation is through the CCAC, the Canadian addictions counselling federation. I’m certified through their governing board. That’s my designation. I’m also a registered care aide. I’ve worked within health care as a registered youth counsellor as well. Our counsellors are all required to have that certification.

We also have registered clinical counsellors that work with us, neurofeedback counsellors that work with us. Our staff are all accredited and have certification with the client base that we work through.

We view recovery through a multitude of lenses. Steven made reference to our All My Relations program. We also have a biopsychosocial program called Solid Ground. We have another program called Elevate. So they’re different divisions within Together We Can that offer amazing services to the diverse group of individuals that are through this whole world that we live in.

Together We Can operates from a holistic and client-centred point of view. We also have a trauma-informed lens that moves clients through a 12-step-based model. That is something that is traditionally where a lot of folks will find some clarity within their recovery.

We aim to be able to open up everyone’s minds and their hearts and the healing that happens. On the front lines, sometimes people will say: “Oh, you need to stop drinking? Great. You can go to AA.” But the information isn’t out there. They don’t know until they come to Together We Can recovery and treatment and education centre, where we have large groups that are able to learn more about what addiction really is.

Most of the time it’s how do we heal the pain that is within? How do we improve our systems of care to be able to say…? “Huh. You can heal in this way. You can heal in this way. You can be having individual counselling. You can have group therapy. You can have process therapy. You can have neurofeedback.” Our aim is to be able to provide so many levels of care in multiple umbrellas to multiple folks.

I hope that answers some of your questions.

S. Hall: If I can add to it, too, if you don’t mind, really quick.

Yes, we are 12-step-based. The other unique thing, I think, about Together We Can, though, is that we have a large fleet of vans as well. People go out to meetings throughout the community. A lot of our clients will also attend Refuge Recovery, which is a Buddha space. There’s a SMART Recovery model that we’re introducing, and it’s becoming more popular within our community as well.

Together We Can as a whole, though…. We are, again, one of the luckier centres. We offer, also, a medical centre. We have two physicians, a registered nurse that works with us, a dietitian. We have personal trainers. All those professionals — dietitian, red seal chefs. All those things.

The reason why we’ve been…. Over the last two years, actually, throughout COVID, we’ve really been enhancing those services so that our clients and our residents…. When they come through Together We Can and by the time they leave, they’ve learned healthy physical skills, healthy eating. They have access to job-training opportunities. A variety of different life skills is important.

For most people that come into recovery, they don’t carry the same…. They don’t have the same development and life skills. I’ve worked with a 19-year-old client. This is always one that comes to mind. His chore was to help out with house laundry. He wasn’t doing the laundry. So I went to talk to him. I said: “Well, what’s going on?” He said: “I don’t know how to use the laundry machine. I don’t know how to use the washer.”

I didn’t even think about that as a worker. I taught him how to use the washer and dryer, and it gave him a sense of accomplishment and confidence, something as simple as that. He wanted to take on bigger tasks and help out more around the house and be more involved simply from learning how to use a washer.

Those are the types of services we’re offering there as well.

[11:15 a.m.]

R. Leonard: Just a quick follow-up. I like what you’re talking about — tracking markers and what success is.

What we’re sitting here today about are the overdose deaths. We have heard many times about people being in recovery and abstinent, getting out. My first visitor through my door, as an MLA, was a father who was grieving. After having been through a program, the first day out, died on the jobsite.

What is your success rate, in terms of people graduating from your program and staying alive?

A. Lekei: That’s a very heavy question.

R. Leonard: That’s why we’re here. It’s heavy.

A. Lekei: Yeah, absolutely. I can speak to a little bit, and I think Steven will probably speak to that as well.

This is something, as someone who has worked in the recovery and health care field for 15 years in recovery-based and then all the rest in youth care…. For me, in the beginning, to say what success is…. Coming out of college and university, it was: “What’s the data? What are the stats? Tell me, please, what those things are.”

I don’t look at it like that. I could sit here and spin a number at you and say that 80 percent of the people that complete our program have an increased quality of life and stay alive. I don’t have a tracking number, mainly because — hey, guess what — we don’t have the funding to track people. That’s your question.

Our aftercare program, which we so desperately…. In every single model of care not only in recovery centres but in the medical systems of care ends right when they finish accessing services.

I can’t tell you a number, in terms of the success rate. I can also say — as the eternal optimist and working with folks as a counsellor for many years — that it’s 100 percent. Everyone who leaves has improved their quality of life in one shape, way or form.

It’s so unfortunate to hear when people leave and they use a substance for the first time. Because of the toxicity of the drug supply, it’s absolutely horrific to hear that.

There are so many other avenues or questions that need to come afterwards, when you say somebody leaves and then they pass away. They weren’t using harm reduction models, or they maybe stopped using their opiate replacement therapy. They came off…. We don’t put parameters on what people have to do.

I hope that this is all sort of answering the questions that you have for yourself.

R. Leonard: Somewhat. You started off by speaking about…. Everything on the table is…. You embrace.

It’s not a challenge. I just want to acknowledge that that is a part of the picture that we’re looking at.

A. Lekei: Absolutely, I 100 percent hear you and acknowledge it. It’s very hard to hear.

S. Hall: Yeah, if I could add to that too.

Part of my position is contacting family members. Their child or loved one has left Together We Can, and they’ve passed away in the community, for instance. One of my positions [audio interrupted] phone and offer them grief and loss support, which is another program we offer. I speak with the moms, and I speak with the dads and the family members that have just recently lost somebody and offer as much support as we can.

You are right. People don’t just leave, and not everybody stays clean. With addiction, there is relapse; there is death. What our goal is…. Again, I’ve met people who have come through treatment five, ten times. It takes them that tenth time to get it. So we don’t want to close down on any opportunity for them to try and try again.

Yes, the reality is that some people are going to leave treatment. Some people are going to leave detox, through Vancouver Coastal Health, and they are going to overdose and pass away. Some people are going to be using safe supply, and they’re going to overdose and pass away. It’s something…. Believe me, I’ve buried a number of my own sponsees since being in recovery — and friends. It’s not something that I look forward to. It’s on my Facebook feed every single day.

It’s not unique, I don’t think, just to treatment and recovery. I think it’s a very broad issue.

N. Sharma (Chair): I have a question for you. Thanks for your presentation.

It really seems like you’re talking about building up a system of care across the province. We’ve been meeting with many people, at this stage, that talk about that system.

[11:20 a.m.]

We actually were presented with…. I think it was Vancouver Coastal or somebody that developed what could be a treatment and recovery model — not just treatment and recovery but also harm reduction and the whole gambit of services that could be applied to all the province. How you make sure that each region of the province has that kind of network of things…. I hear you saying that harm reduction, safe supply are part of that, along with recovery.

You also said in there the us-and-them thing, and I just don’t understand that. I don’t understand how that shows up for you. I don’t understand what that conflict is or what that means, in general, in terms of the us versus them. So I just would love to have more of an explanation of what you mean by that.

A. Lekei: Yeah, absolutely. I can speak to my part. As an addictions counsellor, I’ve had a lot of folks sitting across from me saying that when they access harm reduction…. It was really easy for them to access harm reduction methods: safe supply, needles, clean substance. However, it was very difficult for them to access services like counselling, like extended health, like housing — like: “How am I going to improve my quality of life?” — and even after they make a decision to enter “treatment,” how hard it was.

So there is, again, the us-and-them model in terms of there is a lot of funding for traditional harm reduction, and there is not a lot of funding, because of the lack of evidence-based models, for treatment and recovery.

Ronna-Rae, you had indicated before, regarding somebody leaving treatment and then passing away. That’s something that is heavy on my heart, but again, it’s the us versus them. If they go to treatment, they might pass away because they’re not accessing harm reduction or they’ve come off of traditional opioid replacement therapy, etc.

It sort of puts a divide to say, “You pick one or the other,” with the harm reduction teams and the traditional treatment models, in terms of medical models, not necessarily working together. The us versus them comes to clients, vulnerable people having to choose: “Which one should I do? Which one should I access?”

So most of the time, it’s like: “I can access this one because it’s the easiest one.” Then other folks are saying it doesn’t work because people die afterwards, but again, that’s a line that’s being drawn. It works in every way, and that’s where it’s sort of coming together — Vancouver Coastal Health, recovery centres, accredited treatment centres being able to offer all of the systems in care.

Does that help you understand?

N. Sharma (Chair): Yeah, thanks. I think I understand it a little bit better now.

I guess another, maybe, follow-up question I have for you is that we’ve been learning a lot about just the toxicity of the current drug supply. We talked about the different ways that people are dying. How has that changed your recovery or response to people that come to your services to match that kind of toxicity and the doses that people seem to be taking and that kind of thing?

S. Hall: Again, over the last two years…. Actually, I’m going to speak about COVID-19 again real quick. One of the biggest impacts we’ve seen is obviously the increase in benzodiazepines in the supply, so we’re no longer able to Narcan people — or use naloxone — as effectively as we have been in the past.

One of the things we were really noticing, too, was when the CERB payments came out, for instance. All of a sudden, the CERB payment would come out, and then we would stop getting phone calls from people. Then when the money ran out, they would start calling us again and asking to get in.

But the urgency in their message increased a lot, like: “I need to get in. It’s really bad out here. It’s really bad out here.” These individuals that are trying to recover from addiction are watching their friends drop around them — people dropping around them.

So our response to that is…. We’re trying to get people in as quickly as we can and trying to keep them off the waiting list as best as we can, but again, we’re sitting at…. All the treatment centres are sitting at a huge wait-list. At one point, they wanted us to stop doing our own referrals and have to go through a whole other process through Access Central and the CAIT referral, and it created all this bureaucracy and red tape.

[11:25 a.m.]

The biggest response though, again, is when we’re just trying to keep that community open and letting people know: “Hey, if you do relapse, you need to contact us. You need to come back as quickly as you can, and we’re going to try and get you in as quickly as we can.” But the second somebody leaves a bed, it’s filled. We don’t have enough space. It would be beautiful if we could have 1,000 beds, but those would be full too.

Again, an internal response has obviously been trying to saddle the horses, if you will, and start speaking to bodies like yourselves, start speaking to other organizations out there. We need to find a solution to this. It’s getting to be too much of a crisis right now.

A. Lekei: If I can just add one other aspect. On our medical team, we have two physicians right now and a number of different care staff that are in place. The response…. There’s traditionally a lot of…. When people see our treatment and recovery, it means: “Oh, we’re not going to maybe give opiate replacement therapy” or “We require you to be off of that.” Together We Can’s response is: “We absolutely want you to be on something that’s going to help save your life.”

Our physician would work tirelessly more with systems of care for…. I don’t want to speak on the organization’s behalf by saying safe supply. However, we have had microdosing of a certain substance, to be able to improve people’s quality of life. That is an introduction of safe supply to be able to improve people’s lives. Our physician would embrace the opportunity, if funding came into place, to be able to introduce more models like that within our treatment services.

We encourage folks to be on ORTs. We encourage people to be on medications. The neutral response from a counsellor’s state is: “I will not let somebody know whether I approve or disapprove. I approve.” It’s up to the physician that we’re working with to be able to help navigate the system with the person that’s in front of them, to say: “This is okay.”

Again, you spoke to the us-versus-them mentality. Some folks that I work with are absolutely afraid to be on opiate replacement therapy, because they feel like they’re going to be on a ball and chain. Some folks don’t want to even say that they’re on opiate replacement therapy, because they feel like they’re going to be shamed by other people within the community saying: “You’re not sober enough.”

I think it’s up to us to say: “You are absolutely at a place where you’re making change in your life. Whatever is working in terms of your relationship with the physician that’s in front of you, please do that.”

Together We Can is embracing that and wants to do more of that. I know that if the systems were in place, we would embrace it. At least, I believe that we would. There has been a lot of conversations with the physicians that are there.

So that’s, again, one of our responses to it. It’s how do we improve? How do we introduce this to be able to save people’s lives, especially in response to COVID-19, where we have a variety of different substances — and different substances that are coming into place to change and also save people’s lives?

N. Sharma (Chair): Sonia, I think you had…. This is the last question before we wrap.

S. Furstenau: Just a follow-up, because I noted what you said in response to my question — that we need a governmentwide system for tracking people. Can you elaborate a bit more on what you would see as how government could implement it and what that system could look like? That’s, I think, one of the things that we need to be thinking about.

A. Lekei: Oh, absolutely. We are regulated by Vancouver Coastal Health. It’s exciting to hear that Vancouver Coastal Health would have a system in place to be able to track and to have markers for that. I’m not a tech wizard. I will never claim to be one, so I don’t necessarily know what that would look like on that side. However, having Vancouver Coastal Health, along with ourselves and other care providers, to be able to say: “What could we put in place…?” I don’t know what that would look like.

However, I would like, as a counsellor, to see more questions in there, like: how has your quality of life improved? What have you learned about yourself? What systems do you have in place for your aftercare? What systems do you have in place for increasing your safe home and having safety within your life? Systems that actually help people receive housing afterwards. I know B.C. Housing does an incredible job, but questions like that need to be in and quantified with a governing body like Vancouver Coastal Health.

[11:30 a.m.]

If we had something that was a system within the regulated treatment centres where we could track those markers, we would be able to evoke and make change. So in, hopefully, 30 years, when we’re having more conversations about something else, we can say: “This works, and this is why.”

Again, I’m going to speak to the us versus them. It’s like there’s so much evidence that’s put in place in terms of why one system will work. Why, maybe, other people might question another not working is that we just need some more assistance to be able to create that, to say it does work.

S. Hall: I think, too, if I could add on to that, it would be important to determine who’s going to be collecting the data and how the data going is to be looked at. Is it going to be the Minister of Health? You know, things of that nature, but also the own internal dialogue at the government level. We’ve had an official recently quoted in the news — I’m not going to get political — that people cannot recover from opiate addiction. We had another health care worker in the Interior say in the news that “treatment does not work.”

That, unfortunately, is some of the rhetoric and perspective that’s in our own government, so it would be important, again, to really look at…. We need to bring everybody to the table and really look at what information, what metrics we are trying to gather. Look what we did with PharmaNet. We could look at who’s filling their prescriptions early and things of that nature.

There are systems out there that have been built that could be, obviously, customized and used to track this same information. Is it going to be us collecting the information and submitting it to the Health Ministry? How are we going to look at that?

Again, it would take conversation and what the metrics are and what do we need to do, but also really sitting down with the people who are the stakeholders and the people who are going to be in charge of leading that to make sure that we all have the same language and that we all have a similar perspective on what it is we’re trying to achieve.

N. Sharma (Chair): Okay. On behalf of the committee, I just want to thank you for your time in coming and helping us learn about the work that you do and your perspective on this really challenging issue. We really appreciate it, and all the best to you.

We are recessing until one. Lunch is right there for everyone.

The committee recessed from 11:32 a.m. to 1 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): Welcome. Thanks for coming. We’re now going to get back to our work today.

You are one of a few panels that we’re having today that are on experts on substance use and research. I just want to welcome, on behalf of the committee — there are some on the phone here — Dr. Aaron Shapiro from the B.C. Centre on Substance Use, and Dr. Sandrine Mérette, B.C. Provincial Toxicology Centre. We’re really looking forward to learning from you today. We have your materials on our computers here.

I’ll just pass it over to you. We have about 20 minutes for the presentation and 40 minutes for discussion afterwards.

A. Shapiro: Just a correction. We actually both work at the B.C. Provincial Toxicology Centre.

N. Sharma (Chair): Sorry. Thanks for correcting me. My notes said something else, but there you go.

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

PROVINCIAL TOXICOLOGY CENTRE

A. Shapiro: I’d like to thank the committee for inviting us to present today.

Before we start, we’d like to just acknowledge with gratitude that we live, work and play on the traditional, ancestral and unceded territories of the Coast Salish people, including the Musqueam, Squamish and Tsleil-Waututh Nations.

We do work at the Provincial Toxicology Cenrangertre, which is housed within the B.C. Centre for Disease Control. We are the laboratory that performs forensic testing for the B.C. and Yukon Coroners Services, toxicology research in the form of characterizing the illicit drug supply and also surveillance of drugs that may be circulating within the population. We also serve as the reference laboratory for clinical testing within the province.

Before we continue, does everyone have a copy of our…? Okay, wonderful.

On slide 4, I’ve included a publication from the U.S. Centers for Disease Control and Prevention that characterized the unprecedented death toll caused by opioid toxicity in three distinct waves. You’ll see, in a sort of teal colour, that the first wave is characterized by the rise in prescription opioids, specifically oxycodone. That lasted until around 2010, when it transitioned to heroin. A lot of that had to do with some of the financial incentives from Purdue Pharma to try to push a new product called OxyNEO that didn’t really make it onto the market for a variety of reasons.

Heroin persisted in the illicit drug supply for a few years until we started to see that it was tapering off and largely being replaced with a drug called fentanyl. You can see that when fentanyl started to show up in this data set, the number of deaths really started to rise. The numbers are quite alarming.

It’s important to note that the substance…. I just wanted to put that in the context of the fact that substance use has been part of the human experience for millennia. People have used and abused opioids for a long time. It’s not a new phenomenon. But what’s really changed in recent years is the toxic nature of the illicit supply. We didn’t see, up until 2013, that many deaths from illicit opioid use, but there were a lot of people using them in the interim or prior to that.

I also wanted to mention that I’m responsible for reviewing and reporting all drug-related deaths in B.C. to the B.C. Coroners Service. I’ve been doing that for about five years now. From reading case histories, I’ve noticed that there are people dying who come from all walks of life, and they take drugs for all sorts of reasons. There are some who would have benefited from treatment, some who would have benefited from a lot of treatment and then some who just used recreationally and probably didn’t need any treatment.

What’s common with the vast majority of these deaths, however, is that they could have been prevented if the dose and the contents of their drugs were known. We find that most of the time, people are just using as they normally would, whether it be a daily use or occasional. They just don’t know what they have in their drug. That’s unfortunately what leads to their demise.

Today I’d like to talk about how drugs are made, how the illicit market is evolving and how our laboratory detects and responds to the ever-changing drug supply. During my talk, I just wanted you to consider the following three points.

[1:05 p.m.]

The first is that fentanyl is a cheaper and more profitable drug than heroin. The second is that fentanyl provides a less desirable user experience than heroin. The third is that clandestine labs are experimenting with new drugs and combinations in an attempt to make a cheap and desirable alternative to heroin.

On slide 6, I provide the analogy that chemistry is like LEGO. With LEGO, it’s possible to build a simple structure using standard blocks, but you can also build more complex structures using these specialized kits. The big difference is that the generic blocks are cheap and they’re easy to come by. The specialized kits cost more and are more difficult to find. Similar with chemistry, you can use basic, generic chemicals to make certain drugs, but there are other drugs, like heroin, that are just too complex to be produced with your regular chemistry, and instead, you have to seek other means of getting the starting materials.

In the case of heroin, it’s derived from morphine, which comes from a plant, which makes it expensive. Fentanyl is just a bunch of chemicals put together that are very cheap. On slide 7, I’ve provided one of the many pathways to synthesize fentanyl. I’ve colour coded all the different molecules. You can see how they really just come together. It’s basically just attaching one molecule to the other to form this end product of fentanyl.

On slide 8, I just put together, basically, a shopping list of what we would pay if we were to go to our commercial suppliers to buy these chemicals. You can see that for a cost of less than $1,200, we can produce enough fentanyl to yield a street value of $40,000. That’s when we pay extra for good quality starting materials from commercial suppliers.

If you go directly to a source that produces in bulk that may or may not need to have the same regulatory requirements, that profit margin can be much, much higher. We’re looking at a 40 times profit margin when you do things conservatively, and if you scale up, it’s quite a bit higher.

In contrast, on slide 9, heroin is produced from morphine, which is found in poppy plants. Cultivation of the plants can be very expensive, especially when it’s done in a clandestine manner. So you’re growing vast fields of poppy, and that leaves producers vulnerable to detection by government and competition. That can lead to loss of their crop. Assuming that they’re successful enough to harvest their entire crop, they still have to isolate the morphine using certain chemical methods and then turn that morphine into heroin, which is another chemical step.

I bring this up to show the scale of work required. You can also think of the transportation costs associated with moving products from places where you could maybe get away with growing vast fields of plants, in contrast to something that you can do in a kitchen pot — basically mixing a few chemicals together. Fentanyl is just far more profitable than heroin ever could be.

To add to that, on slide 10, I provide a picture of two vials — one that contains heroin and one that contains fentanyl. The amount in there represents a typical dose for the two drugs. What you can see from the picture is that the amount of fentanyl required is very low compared to that of heroin. This is because fentanyl is about 50 to 100 times as potent as heroin.

With fentanyl being much cheaper to produce and the potential for it to go up to 100 times farther than the same amount of heroin, it’s not surprising why producers have moved away from heroin and started to move to fentanyl.

But as you can see on slide 11, the introduction of fentanyl, similar to what I showed with the U.S. CDC figure…. This is B.C.-specific data. Slide 11 shows that the introduction of fentanyl coincided with a dramatic increase in the number of deaths. We did see that annual number decrease in 2019, which I think is mostly a result of harm reduction efforts that were put into place. We know that it didn’t fix the problem. It kept people alive. We know this because the number of ambulance calls in that period was higher than it had ever been prior to that.

[1:10 p.m.]

It shows that harm reduction is effective in keeping people alive, but again, it doesn’t deal with the underlying problem. Sure enough, we know that because in 2020, when the COVID pandemic was declared, we saw that the number of deaths really skyrocketed.

I just bring this up again to stress that while the issues surrounding drug use are complex and multifaceted, the reason why people are dying is because of the toxic nature of the drug supply. They don’t know what they’re taking or how much they’re taking. And in my opinion, I don’t think you can address any of the other issues with treatment and prevention if you don’t deal with this one issue of an unpredictable and unregulated drug supply.

I’ve been listening to some of the transcripts from previous presenters, and I know that there’s been some confusion or uncertainty regarding the movement of drugs and how the pandemic affected it, so I included a link to a report by the DEA, the U.S. Drug Enforcement Agency. It was published in January of 2020, but it reflects the environment in 2019.

What they mentioned was that in May of 2019, when the Chinese government put a stop to production of fentanyl in China for export, these manufacturers in China started to send the precursors to various countries, including Canada. I don’t think that there’s been much of a change in terms of production because of COVID. I think it happened before that, and what we’re seeing now is really just caused by an exacerbation of a dire situation brought on by the pandemic.

I just wanted to also mention…. I don’t have data to support it, but I’ve had anecdotal conversations with folks from border enforcement who have suggested that the restrictions and border closures brought on by the COVID pandemic did not have an impact on freight and mail delivery. In fact, there’s some suggestion that because of concerns with supply chain, it might have been easier to transport substances across the borders, at least from a freight perspective, not from individuals travelling and smuggling in drugs. I just wanted to put that out there.

I wanted to sort of shift a little bit to how I think the illicit market is evolving. There’s been messaging lately about how the drug supply is getting increasingly toxic, and the reason for it is because, as I mentioned before, heroin provides a better user experience than fentanyl, and drug producers are experimenting with ways to provide a similar experience to heroin without raising their costs.

When I say that heroin is a better user experience than fentanyl, what I mean…. There’s a number of reasons why, and the first is…. On slide 16, I have some figures of the metabolic pathways for both heroin, or diacetylmorphine, and fentanyl. You can see on the top here that diacetylmorphine is metabolized to a number of metabolites, including morphine and M6G, or morphine-​6-​glucuronide.

These are all active drugs. So while taking heroin can give an initial rush that’s fairly short-lived, you still have these active molecules in the body that allow for the drug to continue to give some opioid effect, which means that you’re not going to a withdrawal very quickly. In contrast, fentanyl, which is also active, just gets metabolized to an inactive metabolite, norfentanyl. So you’re left with a situation where you go from an active drug to an inactive drug very quickly. It’s a very short duration of effect.

With a shorter duration of effect comes a need for more frequent dosing, and I think that’s why we see this dose escalation and subsequent tolerance as a result of it. Slide 17 shows that there’s an increase in the number of deaths where extreme concentrations of fentanyl are detected.

[1:15 p.m.]

This is from the B.C. Coroners Service monthly report, but I’ve put it into, I think, a more user-friendly version in slide 18, where you can just see the…. Unfortunately, my trend line didn’t show up, but you can see that the concentration of fentanyl over time is increasing. It suggests that there’s…. This need for rapid dosing leads to an escalation and can have some pretty disastrous consequences as a re­sult.

Perhaps the most alarming issue — in my opinion, at least — is that with repeated dosing is the increased risk of taking a toxic dose. You’ll recall from an earlier slide that the amount of fentanyl required for a typical dose is miniscule compared to that of heroin.

To disguise that fentanyl is being used, drug dealers will often add a bulking agent. Slide 19 shows a random distribution of bulking agent with drug. On the left, you can see that heroin, in dark blue, is well dispersed throughout. However, on the right, you can see that there is very little fentanyl mixed in with a large amount of bulking agent, and if not mixed properly, you can have regions of the sample that have no active drug and others with dangerously high or even fatal doses.

Part of the problem here is that mixing powders is very difficult and requires specialized equipment that pharmaceutical companies use. But most drug dealers don’t have access to that equipment, and instead they often use things like the Magic Bullet, which is designed for mixing liquids and does a very poor job at mixing powders.

I also just wanted to mention, on slide 20, that there was a case report that was published for an adverse reaction that happened at Insite, in the Downtown Eastside. It was a person who had muscle rigidity as a result of taking in fentanyl. So that’s an additional side effect. It’s a known side effect of fentanyl that doesn’t exist with heroin, and it really complicates medical intervention.

As a result, producers have been looking for ways — I think, at least — for finding alternatives to fentanyl that can give that heroin-like effect without some of the negative aspects that I just discussed. On slide 21, I mention that there are a number of fentanyl analogues that have been circulating that I’ve listed, and slide 22 has other opioids that have been detected.

It’s important to note that while some of these drugs, like meperidine, have approved therapeutic uses, the two on the ends have never been approved, and it’s possibly because of concerns about side effects. We’ve detected several analogues of etodesnitazene, which is the one on the right, and U-47700, on the left, over the past few years. Those drugs seem to be in decline now.

The latest trend, though, is the introduction of benzodiazepines in the opioid supply, as shown on slide 23. The addition of benzodiazepines is particularly problematic for a few reasons. The first is that benzodiazepines can produce greater toxicity when mixed with opioids. The second is that naloxone doesn’t work on benzodiazepines, which can really complicate medical intervention. The third is that withdrawal symptoms from benzodiazepines can be very difficult to manage and can even be fatal.

The final question, then, is: how do we detect novel drugs and respond to the ever-changing market? On slide 25, we have a typical output from our high-resolution mass spectrometer. Using this technique, we have the ability to look for known drugs and search back through data files as new drugs are identified.

What I mean by that, by means of an example, is about a year ago we were alerted that a new benzodiazepine known as bromazolam was detected in the United States. Using this technique, we were able to go back through our data and identify additional cases with bromazolam dating back to January of 2021. So it’s a very powerful technique for not just identifying drugs that are known, but it also gives us the ability to look for them after the fact.

On slide 26, we have data from all the drugs that we’ve detected since this method began being used in July of 2020. There’s a lot of data here, but I just wanted to highlight that we’re seeing a lot of different drugs. The four most relevant ones are a fentanyl analogue known as fluorofentanyl, as well as three benzodiazepine analogues — ezitolam, flubromazolam and flualprazolam.

[1:20 p.m.]

When new drugs are identified, we’re able to share this information with our colleagues at the provincial level through the BCCDC and towardtheheart.com, at the national level through Toxicovigilance Canada and at the international level through the U.N. Office on Drugs and Crime.

In summary, drugs can be produced either synthetically or can be extracted from a biological source such as a plant. Fully synthetic drugs are generally much cheaper to produce in a clandestine lab than plant-derived drugs, but the current offering of synthetic drugs is not providing the same quality of product that can be found with heroin. I suspect that the goal of the current evolution in the illicit drug supply is to identify a new drug that can produce the same effects as heroin, while keeping manufacturing costs low. Unfortunately, it seems that people who are using drugs are being used as guinea pigs in this process.

People have been using opioids for millennia for a variety of reasons. The key difference today is that the rate of death has increased at unprecedent levels. While treatment and prevention strategies are important to help curb this drug toxicity crisis, providing low-barrier access to a safer supply of regulated diacetylmorphine will go a long way to decrease the number of deaths associated with opioid use and will give more individuals the opportunity to seek treatment programs if they so choose.

Finally, I’d like to mention that our laboratory is working hard to support monitoring and characterization of the illicit drug supply through identification of new drugs and combinations, providing consultation support on the significance of these new drugs, engaging in dialogue nationally and internationally, and alerting public health when a new or emerging threat is detected. However, most of our work is performed in our spare time. We are hoping to get additional resources in the future to support more proactive and timely identification and characterization of the drug supply to better meet the needs of the province.

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

N. Sharma (Chair): Great. We’re going to switch to discussion now.

T. Halford: Thanks for that presentation. It was pretty enlightening. I think it was in 2021 that the government of Saskatchewan put forward 30 locations, I think, where you could get testing strips. The testing strips don’t show you…. They’re not foolproof or anything like that. They don’t show you the amount of fentanyl or other compounds, but they do seem to be somewhat effective.

Have you guys looked at how that’s going in Saskatchewan, how that was rolled out, or if that could be of use here? Obviously, there’s no guarantee with it. But it is a tool, right? I’m thinking about some of the users in my demographic that may not present that they’re using, but if they were able to see that there were traces of fentanyl in the drug they’re about to consume, they may have second thoughts on that.

So just if you guys are aware of how that’s going in Saskatchewan. If you’re not, that’s okay. But just any thoughts on those testing strips or if they could be used in B.C.

A. Shapiro: I’m not familiar with the drug-checking programs in Saskatchewan, but I know that in B.C., we’ve had similar programs for quite some time now. There’s a group within the BCCDC that has evaluated the effectiveness of drug strips, particularly for fentanyl, in people’s decision to use or not use drugs.

In the past, it has been found that for drugs like heroin, if people buy heroin and there’s a mixture of heroin with fentanyl and they find that there’s fentanyl in there, they would taper their dose a little bit. So they’d start with a small amount, and then they’d work their way up once they were convinced that it wasn’t a fatal dose that they were receiving.

I think the drug market has changed quite a bit since then, though, in that we never detect heroin anymore. It’s pretty much gone from the drug supply. It used to be a mixture of the two. Then we saw a slow escalation of fentanyl, with a decline in heroin.

There’s no more heroin in the illicit supply, as far as we can tell. So having a test strip that tells you that you have fentanyl doesn’t seem like it adds much at this point. It would certainly be of use to people who are just using stimulants and who don’t want to have fentanyl in their drug supply. But for people who are purchasing a drug for the intent of basically using an opioid, if they find fentanyl, I don’t think it gives them much additional information at this point.

[1:25 p.m.]

P. Alexis: I wish some days that I were a chemist and that I could understand this or pronounce some of the names that you did. I’m amazed. Thank you for that.

I have a couple of questions for clarity. I have to hear it again, because that’s how I work. You said, in slide 4, that…. I believe it was in 2010 where we saw the rise in heroin. There was another factor that you made reference to about a drug that failed technically. Could you explain this? I didn’t know this, so I need to understand this.

A. Shapiro: I think the proliferation of oxycodone in that first wave was really brought on, in part at least, by marketing by Purdue Pharma, who had this formulation of oxycodone called OxyContin that was a slow-release tablet that would deliver a small amount of drug to the person over a course of eight or 12 hours, I think it was. A time-released drug.

They said that this was a way to get people away from addictive behaviours of abusing large amounts in small bursts of time. This way, they can deal with their withdrawal symptoms by taking one tablet and getting the drug constantly given to them.

What ended up happening, however, is that people started seeing that there was a drug with up to 80 milligrams of oxycodone in it that if you crush up and you snort, you can get all 80 milligrams immediately. That’s probably what led to a slight increase in abuse and death.

I’m speculating here, but the patent for OxyContin was coming up. I think it was due to expire around 2015, and Purdue starting lobbying various governments to say: “This is a big problem. We need to come up with a solution to keep people from smashing up these tablets and abusing them, so here’s our new product, called OxyNEO, that has special technology which keeps you from crushing it.” Basically, if you crush it up, it makes these jagged shards of the drug, which can be very unpleasant to snort.

I think that they pushed that on a lot of governments. I know the Health Minister at the time in Ontario even wrote a letter in support of it to try to deal with some of the concerns with abuse of OxyContin, the crushable one. It gained some traction, but at the same time, there was some debate about whether or not that should be used.

In the meantime, though, while they were trying to take OxyContin off the shelves and trying to push OxyNEO, there were people who had these strong addictions to opioids that weren’t able to meet their need anymore. I think that’s why a lot of them turned to heroin.

Then, sure enough, in around 2013-2014, we started to see the emergence of these little green tablets. They’re usually the picture that they show of fentanyl in media. It says 80 on one side and CDN on the other side. That’s the generic version of OxyContin that existed prior to it. I think that’s what people were flocking to because they liked that so much.

It’s an interesting situation or environment, where you have some people interfering for their own personal or financial gains. You have a drug that’s incredibly addictive. It did not play out well, and it seems to be getting worse now.

P. Alexis: I have another question. I want clarity on the slide that deals with the imports from China that we — I, anyway — had thought….

It’s different information than what I had assumed — that, through COVID, borders were closed, and therefore, we were producing home-grown fentanyl, which was highly potent and was killing more people. You’re saying that that’s not necessarily the case, that it was just as easy to be mailed from China through the COVID epidemic.

[1:30 p.m.]

Is that correct? That’s what I’m thinking that I heard, but I want to double-check that that’s what I was hearing.

A. Shapiro: The report that I give a link to on that slide shows that there was a flow of precursor drugs well before the pandemic. In the summer of 2019, that was already happening. With the precursors moving into Canada, there was domestic production.

I don’t have any direct data to support that it was not more difficult for drugs to get in with the COVID restrictions, but I have heard anecdotally from members of the Border Services Agency that drugs were still getting in just fine. They suggested that it was probably because of staffing shortages and a real need to get supply chain into the country.

Again, that’s sort of outside of my area, and that’s just anecdotal information that I received.

P. Alexis: And there’s nowhere that we have to prove this?

A. Shapiro: I’m hoping that the Border Services Agency would be able to corroborate that, but I don’t know.

R. Leonard: There’s lots of new perspective here that you’re bringing forward, which is great.

I don’t know how I should say this. When you talked about the OxyContin training…. My mother was in her 80s and was given OxyContin. At one point, I could see the withdrawal issues that were happening, and the doctors were wanting to taper her off — blah, blah, blah — and she was saying: “I’m 82 years old. I don’t care if I die an addict.” She just wanted to not feel pain.

I get that it’s…. You’re talking about the chemistry piece of it, but it’s also that human piece that is involved in what keeps people married to the drugs. It just sort of really came back to me just now as you were talking, so I thank you. It tells me partly what’s motivating my interest in this subject.

You talked about what Pam was just talking about — that the precursors are coming in. My understanding was that what we were seeing was that when it’s being manufactured in people’s homes or whatever, the quality is going down. Is that what your toxicology examination is demonstrating? As opposed to when it came from China, from manufacturing plants — that there was a certain quality control. I’m just looking at what the arguments could be around controlling it more in terms of the production.

A. Shapiro: I think the facilities in China that were producing and probably are still producing some of the fentanyl were probably better quality or better at producing the product than someone doing it in their kitchen. At the same time, what they would ship would be 100-percent-pure fentanyl, which needs to be cut down and processed before it can go to the end-user.

I think that adulteration or cutting process is what’s really concerning. When someone makes it in their kitchen, they’ll probably get a lower yield of it. So they won’t be as efficient with it. But we’re not…. We don’t really have the ability to look for some of the…. We don’t look for some of the products that remain, so we can’t say how efficient they are with it.

The big concern is really just how it’s processed once it’s made — how much drug gets put into each individual dose, what else is being thrown into it, such as benzodiazepines, other cutting agents. Regardless of where the fentanyl itself is being produced, a lot of that is still happening, has always been happening in Canada and continues to this day.

[1:35 p.m.]

S. Mérette: If I may add, there is some data from the drug analytical services that actually shows that for some fentanyl that is available on the street, you can have up to seven different compounds in your mixture. It’s anything from…. I don’t think we’ve actually ever seen pure fentanyl. But it can have up to seven, eight, nine different compounds. They are bulking agents, so they are benzodiazepines. They are pretty, I would say, toxic compounds, like xylazine, which is a veterinary product, or lidocaine.

S. Furstenau: Thanks so much for the presentation and the information. I think that it’s definitely the most technical we’ve had.

Dr. Shapiro, your comments at the end, that the unregulated illicit supply…. The goal, you think, is to kind of approximate the experience of heroin. You said that drug users are basically guinea pigs in the experiment. Just to put a finer point on that, the lack of access to a regulated safe supply means that humans in B.C. are subject to experiment by an illicit drug market. Would you agree that’s what you’re…?

A. Shapiro: Yes. We can tell that there are experimental batches. We see that the majority of people who die, at least from illicit drugs, tend to have…. We see a pretty standard pattern of fentanyl, usually with a low amount of a benzodiazepine present in there. But then we start seeing some samples that have fluorofentanyl or some other fentanyl analogue or one of the nitazene drugs mixed in with one or multiple other sedatives — a benzodiazepine, a veterinary sedative. Who knows what else.

The fact that you have your typical situation and then you have a very small subset of these weird and exotic combinations suggests that this is just someone trying out something on a select, unlucky few.

S. Furstenau: Can you give us some insight into what the bulking agents are and what kind of other materials are being found in the drug supply?

A. Shapiro: Yeah. I mean, they can be anything, really. Anything that looks like a powder that would mimic the appearance of a drug could be used. Some of the bulking agents that are used will mimic some of the effects of the drug.

With fentanyl, we’re seeing xylazine show up, because it’s also a sedative. With cocaine, we see a lot more lidocaine, because it gives that same numbing, if you put it on your tongue, as cocaine would. It also metabolizes to…. Sorry, I’m thinking of another drug. But there’s another one that metabolizes to another stimulant. So you get….

S. Mérette: Levamisole.

A. Shapiro: Levamisole. That’s it.

So you tend to get things that either have similar effects that are easier to get or just a bulking agent that can make something look bigger and maybe give the appearance.

We see a lot of caffeine pills, for whatever reason, mixed in with fentanyl. I think it’s just because they’re easy to come by, and they come in different colours. Some drug dealers, I’ve been told, like to identify their different drugs by what colour they are. If they can use purple caffeine pills for the fentanyl, they know that’s fentanyl. If they use green, something else to mix in with a different drug, then they know what they’re dealing with.

But it’s completely unregulated, and it’s up to the person who adulterates it to really decide what they want to put in.

N. Sharma (Chair): Okay. I have a few questions. It was really interesting that you were talking about the whole idea that people are trying to simulate the impact of heroin, which is a better user experience. We’ve been learning a lot from people that are on the front line of treating people with addictions.

[1:40 p.m.]

They’ve talked about the kind of seeking behaviour for fentanyl that gets higher and higher doses. You explained that pretty clearly, about how that shows up — also learning that there’s actually no heroin in the drug supply anymore. Now it’s all the synthetic opioids.

So when we’re talking about replacement therapy…. When people go on those programs, we’re also learning that the kinds of, I guess, heroin replacement drugs that are being used — so the hydromorphone and all those things that substitute — sometimes don’t have the same potency of fentanyl, so they don’t work. I’m just a bit confused about that mix. If the goal is to simulate the heroin experience, how fentanyl has kind of…. How do you replace it? It sounds like only with different forms of powdered fentanyl, from the user experience.

You’re the first one that has explained this idea that the synthetics are trying to simulate heroin, but they seem to have just taken over the whole market. So what would be a replacement therapy? How do you…? I guess I’m trying to understand that, from the user end.

A. Shapiro: I think it’s a challenge because we have…. There was a client survey that was done as part of a harm reduction venture through the BCCDC. They found that most people that they interviewed said they’d prefer heroin to fentanyl, but a large number said that they actively seek fentanyl. Some said that they actively seek benzodia­zepines with their fentanyl.

I think there’s a lot playing into that, from a pharmacological perspective. One is that the people who are seeking fentanyl are probably looking for a very intense rush immediately and don’t think about the downstream — “This won’t last very long; we’ll have to get more of it” — or they have such a high tolerance to opioids that they can have what would be enough to kill a dozen people, and it wouldn’t give them the same kinds of effects, because their bodies have become so used to the drug that it just doesn’t work anymore.

On the flip side, when we deal with withdrawal symptoms…. You basically feel awful, to the point where it can be life-threatening, with some of these withdrawal symptoms. So people will seek out whatever they can to treat them. I think that’s why we have people who are seeking benzodiazepines now. They have withdrawal from taking in benzodiazepines. Whether they wanted to or not, they were exposed to those drugs over a period of time. Now when they don’t have them…. Even if they just take fentanyl, if they don’t have the benzodiazepine in there to supplement it, they go into a benzo withdrawal.

So it’s interesting to hear about people’s experiences, what they want and what the rationale is for it, whether it’s conscious or not.

N. Sharma (Chair): I have another question related to what people die from. It was interesting. You were talking about how when they add the bulking agents — I like that diagram that kind of circles off — you just don’t know what you’re getting, because it’s not necessarily a homogenous mixture.

Can you help my understanding of…? At the end of the day, are they dying from too much fentanyl via that unmixed dose? So they randomly will get…. Is it the fentanyl that’s still the major cause of death in these overdoses, or is it just a mix of all the bulking agents they might get? I just want to know, when you’re looking at that, what that would be.

A. Shapiro: It’s a tough one to answer, because we can only really interpret based on what we find. We look for fentanyl. We tend not to look at all the different bulking agents. But for the bulking agents that we do look at, we tend to see…. More often than not we’ll see a large amount of fentanyl with a very small amount of bulking agent present. So in my opinion, it seems like the majority of these cases are just cases where people took too much fentanyl at the time.

The caveat to that is that with the influx of benzodiazepines, there have been some theories about something else going on. It’s basically that when someone has a combination of benzodiazepines with fentanyl and they appear to have overdosed or they show toxicity, a first responder can go over and give them naloxone to reverse that opioid effect.

[1:45 p.m.]

If they just had an opioid in their system, then it’s pretty typical that they would just wake up — take a deep breath in and wake up. But if they have a benzodiazepine on board, they don’t wake up. So there’s no…. They’re okay, and they’re breathing, but there’s no visual cue to the first responder to say: “You’ve given enough naloxone.”

I’ve heard anecdotally that there are cases where people are using a lot of naloxone, too much naloxone, and the concern there is that it’s making the withdrawal from opioids worse. That’s causing people to go back and just try to get as much opioid in their system as possible. We don’t really know what the circumstances are — if it was a first-time use, and then they used too much at that time, or how many cases exist where too much naloxone was provided and it led to an emergency situation of trying to get as much opioid to counteract the withdrawal symptoms.

N. Sharma (Chair): I see. I actually have one more question.

You also were talking about the idea that if people knew what was in their drugs, it would change behaviour. I’m just curious about the science behind that. Have we proven that? Do we know that that’s a key factor in intervening — that if somebody has drugs in their hands and they know what’s in it, it changes behaviour? Is that a key intervention? I’m just curious what supports that and where that comes from.

A. Shapiro: That’s a bit outside my area of expertise. I think there have been studies to look into the psychology of drug use. From my perspective, if someone wants to use a drug and they know how much they took last time….

If you had tablets that you got from your pharmacist and your plan was just to use recreationally, you know that one tablet is five milligrams, and if you wanted a better effect, then you’d take two tablets the next day. If you wanted an even better effect, you’d take three the next day. You wouldn’t go from taking one tablet to taking an empty pill, and you wouldn’t go from taking one tablet to taking 20 pills.

I think that’s the big issue. People don’t know how much they’re taking in from time to time. So even if they wanted to take more, or less, it’s really difficult to gauge how much is in there when you don’t know the purity of your drug.

S. Mérette: It’s also that they don’t know exactly the composition of the mixture they are using. I mean, they could, basically, be only wanting to use fentanyl. The problem is that they don’t necessarily know that it’s just fentanyl. It’s going to be fentanyl with something else, because fentanyl is so potent that it’s always cut with something, and the something is not known.

P. Alexis: I just wanted to follow up. We heard from the first responders — I’ve heard it anecdotally for years — that sometimes the first responders will come back and treat the same person, maybe twice or three times in a single day.

Is one of the reasons, then, for what you referred to just a minute ago, with the benzodiazepine that doesn’t react well to the naloxone…? Therefore, they’re looking for more opioids to get them out of pain type of thing. So they’re taking more drug, then, and that’s the reason?

A. Shapiro: It could be the reason. When a person is given naloxone, even if it’s just for fentanyl, it basically blocks the effects of fentanyl.

P. Alexis: Okay. So regardless of fentanyl or benzodiazepine, there would still be the same effect, technically — the same impact?

A. Shapiro: The same impact on the opioid side of things. Basically, if someone is experiencing a high from an opioid and they’re given naloxone, that high is gone. So people might go back and get more opioid to resume the high. They might be put into a withdrawal situation, where they start getting very sick from not having any opioid in their system, and that might drive them to it. There are a few different reasons why that could happen.

[1:50 p.m.]

P. Alexis: I have one quick question about the benzo, if I could. You talked about muscle rigidity as being a side effect — is that correct? — of taking the benzo.

A. Shapiro: Of fentanyl.

P. Alexis: I had it written down beside the benzo, but that’s not so?

A. Shapiro: That’s an issue with fentanyl. It doesn’t exist with heroin.

P. Alexis: Got it. Okay. So it exists with fentanyl.

Is this muscle rigidity a permanent thing, or is this just a very temporary thing?

A. Shapiro: It’s a temporary issue. It can affect someone’s ability to breathe. There are, I guess, two different issues there. One is…. If they’re still conscious but they can’t breathe, then that puts them in an emergency situation. The other is…. If they are unconscious and they need to be intubated…. When their muscles seize up, it’s really hard to get a tube in.

P. Alexis: How do the first responders do it, then? How do they know?

A. Shapiro: I’m not sure. I know that it makes it more complicated for them.

R. Leonard: I guess the question that I have is…. You talked, at the end of your presentation, about needing resources to have a quicker analysis and to be able to keep chasing what’s going on, on the street.

To me, there’s this question around…. People can come back for more and more, and they need higher and higher doses. Is there a point that somebody could die, with this incremental…? Does the drug eventually kill you if you have too much of it? Or could you go to one million micrograms? Is there a limit?

A. Shapiro: That’s a good question. I don’t know.

There are a number of different mechanisms in which tolerance occurs. Some of them affect the movement of drugs. Some of them affect how the drug interacts with the body. In theory, you could probably get to a ceiling effect where no tolerance can help you. I think the bigger concern is…. When you get into these really high doses, your risk of getting something that’s a little bit off, with an unregulated supply, goes up quite a bit.

It’s not so much that people take too much, enough to kill anyone in the world. They’re used to a certain dose. Then if they take something that’s quite a bit higher than what they’re used to, that’s when they run into problems. As you start to increase and increase the dose, that risk of getting to a point where you have a really, really high dose for you goes up quite substantially.

R. Leonard: I guess I’m speaking within the theoretical notion of a safe supply, if we were able to turn on the switch and there was safe supply. Theoretically, somebody who’s seeking a high isn’t just seeking maintenance. They’re going to go back to ask for more, right? I’m just curious if that could be a future concern.

A. Shapiro: We saw, even with a safer illicit supply…. When people were abusing prescription drugs, there were still deaths. People die from all kinds of drugs all the time. It’s just that the magnitude of deaths that occur from fentanyl is just so much higher.

It’s not to say that these are safe alternatives. Heroin is not a safe drug by any stretch of the imagination. But when it’s a regulated supply of it, it is safer than it would be to just basically play Russian roulette with fentanyl.

S. Mérette: What I’d like to add, as well, is…. When you have a regulated supply, you have a clean drug. It’s not a drug that is cut with things that you don’t know about. So at least you know that the drug that is being administered to your patient is safe.

N. Sharma (Chair): Just as a follow-up for my understanding. The graph that you showed about the tolerance levels of fentanyl…. Even with a safe supply, that’s a factor of fentanyl. Your tolerance makes it so your dose is always going to be going up to get the same effect.

[1:55 p.m.]

A. Shapiro: Right. I think the difference, though, with fentanyl and heroin is that because heroin lasts for almost a whole day…. I think a lot of people would be contented to use heroin once, maybe twice, a day, whereas fentanyl they have to take constantly, every few hours. With more dosing comes more tolerance. That tolerance curve will go up but not to the same extent or not at the same rate as it seems to be doing now.

N. Sharma (Chair): I see.

I think those were all the questions that I saw from the committee. I just want to thank you for your time and expertise and for answering really specific, detailed questions and adding a different chemistry lens to the whole discussion that we’re having. It was really appreciated. Thanks for your work as well.

A. Shapiro: It was my pleasure. Thank you.

The committee recessed from 1:56 p.m. to 2:01 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): On to the next item on our agenda. I just want to welcome the Harm Reduction Nurses Association, as represented by Corey Ranger, here today.

Welcome, Corey, on behalf of the committee. You will have about 20 minutes to present. We all have your slides on our screens here, so we can follow along that way. Then afterwards we’ll have about 40 minutes for question and answer.

I’ll pass it over to you.

Briefings on
Drug Toxicity and Overdoses

HARM REDUCTION NURSES ASSOCIATION

C. Ranger: Okay. Just to get started off, I want to thank everyone for inviting me here today. I’ve provided you with a whole bunch of resources, ranging from the Victoria SAFER initiatives practice brief to the safe supply checklist from the Canadian Institute for Substance Use Research to CAPUD’s safe supply concept documents and a few other resources I’ve made just specifically for today’s occasion.

I also included the elusive ethics analysis commissioned by the province. This is one that is rarely referenced, hard to find. It specifically delves into some of the so-called moral dilemmas of safe supply, so I encourage everyone to have a peek at that.

Lastly, I’ve provided you with a PDF of the slide deck. You don’t have to follow along if you don’t want to. I’ll be as engaging as possible, but there is good reference information there.

Before we get into today’s presentations, I’d like to acknowledge that colonization and the institutional oppressors that continue to permeate in our society have exacted profound and devastating harms to Indigenous people, who have been forcibly displaced from their homes. There is a link between colonization and what we’re here to discuss today — namely, ending the war on drugs, which is, in itself, a tool of racism and colonization in this country.

I’m a white settler on unceded, stolen lands. I live at the intersections of the Quw’utsun’ Tribes and Malahat First Nation. I do work with individuals and organizations across all of Turtle Island, and I’m grateful to be here today.

I also want to acknowledge the incredible amount of work done by people with lived and living experience of criminalized drug use who have borne the greatest risk in order to innovate during this toxic drug supply crisis. Without them doing the work and taking the risks, I wouldn’t be here today, and none of the work that we have done so far would exist.

My name is Corey Ranger. I am a registered nurse. I started my career in harm reduction in Edmonton’s downtown core working with people who were experiencing homelessness and who were either HIV or hep C infected or co-infected with both viruses. I remember the difficult days before the introduction of benzo-dope. I remember the days before fentanyl and fentanyl analogues killing my clients, friends and family in droves.

Since then, I’ve been responsible for implementing HIV programming, naloxone programming, supervised consumption services and, most recently, safe supply programming. I’m the former clinical nurse lead of AVI health and community services Victoria SAFER initiative, which is a flexible and harm reduction model for pharmaceutical alternatives to the toxic drug supply.

At present, I’m a consultant and project manager and educator working at all levels of government and with the public to address toxic and harmful drug policy. I’m also the president of the Harm Reduction Nurses Association.

I’m here today as a subject matter expert and clinician who has seen firsthand the evolution of the mass poisoning public health emergency, the collateral impacts of COVID-19 on the toxic and volatile drug supply, and I can speak candidly to the successes, opportunities, challenges and barriers of a medical safe supply.

[2:05 p.m.]

It is my intention today to share those learnings and offer my recommendations for priority policy and legislative change, funding allocation and underserved populations, who are in the greatest need of urgent attention from this committee. I’m also here today in solidarity with drug user organizations and people who use drugs, to help uplift and affirm their voices. They are the true experts.

I have no biases to declare. I’m not being financially compensated to be here with you today, and I have no conflicts of interest to declare.

I’d like to get us started in a good way. To do so, I’m going to take a very small amount of time offering a bit of a framing exercise. Hopefully, as this committee navigates the host of upcoming presenters, you can go back to this exercise and make sure you’re vetting recommendations through a harm-reduction lens.

Take a moment to think about what harm reduction means to you. Understand that a superficial comprehension of harm reduction means that you view the term as a series of services like needle distribution and naloxone programming. Now understand that these services are simply how harm reduction is utilized at times.

At its core, harm reduction is a guiding philosophy of practice, a means to inform public policy and a way to repair historic harms enacted by colonization. When you zoom out, you understand that the term “harm reduction” has often been co-opted, but you also have to understand that harm reduction is a cornerstone of human rights.

Harm reduction has different theoretical perspectives. You can look at harm reduction from a public health perspective, and from that regard, it’s about acknowledging risks and that people have the right to choose. Knowing this, we implement policy and programs to reduce the likelihood and severity of that risk: things like supervised consumption services, condom distribution — the how of harm reduction.

If you zoom out more, you’ll see harm reduction from the perspective of a rights-based movement centred on agency of choice. In this regard, we are further upstream, targeting the root causes of these harms. Here we understand that drugs are not inherently dangerous, but we make them dangerous through prohibitive policy.

If you take a different approach, and you look at the perspective of Indigenous peoples, harm reduction often does not refer to drug use at all. Rather, the goal of harm reduction is to reduce the harms of colonization. We’re oftentimes reducing the harms of our own laws and policies, and that is not often very pragmatic. Even the federal exemption process is an amendment, an asterisk to our own laws. But rather than acknowledging the colossal failure of the Controlled Drugs and Substances Act, we provide exemptions and half measures.

Harm reduction is based on values, which in turn inform our principles. I’m not going to share all of the principles with you today, but I will highlight two specific ones to keep in mind as we discuss safe supply. These principles that I’ll talk to you about today were adapted from the national coalition of harm reduction and Harm Reduction International and have been informed by people with lived and living experience of criminalized drug use.

The first is No. 6: options for prevention, care and treatment must be evidence-based, accessible and non-coercive. This is critical as we discuss B.C.’s current approaches to the toxic drug supply. There is a problematic trend with this government whereby an over-emphasis on treatment and superficial narrative of stigma is the driving factor, whereas the truth is that people use drugs for many reasons and that many people who use drugs do not need or want treatment. Those who are seeking treatment deserve options that are not solely contingent on abstinence as the primary goal.

The other principle is principle 7: people who use drugs must be involved in designing, implementing and evaluating programs and policies that serve them. There’s a fatal and habitual error in drug policy, which typically stems from a lack of taking the lead from people who use drugs.

I applaud this committee’s efforts to correct that trend but also issue a caution as you move forward. As you hear from advocates, experts and, most importantly, from people who use drugs, there must be a concerted and transparent effort to follow through on their recommendations. Failure to do so will fray an already threadbare relationship.

I’ve provided a summary of statistics. I’m sure everybody is very familiar with how bad the toxic drug poisoning crisis is, so I won’t go into that. But there are two specific stats that I’d like to highlight for the purpose of today’s presentation. The first is that 84 percent of illegal drug toxicity deaths occurred inside, with 57 percent in private residences. The next is that the detection rate of benzodiazepines has rapidly increased from 15 percent in July of 2020 to 45 percent of samples in April of 2022. We’ll go back to that.

When the global pandemic first took hold in B.C., I was working as a project manager for BCcampus in the Ministry of Mental Health and Addictions. I was asked by a number of organizations to assist in preparing COVID-19 protocols for low-barrier shelters and harm reduction services.

As March dragged on, we started to see the collateral impacts of COVID-19 on those at risk of toxic drug death. Moving from macro to micro, we saw the closures of borders, disrupting drug supply. We saw reduced capacity, restriction and outright closure of services across the province. Then, on the micro level, we saw individuals being told to shelter in place, to isolate and to socially distance.

[2:10 p.m.]

When you combine an increasingly volatile and unpredictable drug supply with a reduction in life-saving services and more people using in isolation, you have the perfect storm for devastation.

In Victoria, the sudden reduction in available services immediately resulted in a surge of people experiencing homelessness. The city of Victoria directed those to shelter in place at Topaz Park. This was a first-of-its-kind, state-run homeless encampment and happened to be ground zero for Victoria’s introduction to benzo-dope, the next phase of our public health emergency.

On April 22 of 2020, we saw the drug supply shift right in front of us. People started overdosing all around us. We had nine overdoses that day, and two people were found dead in their tents. On April 26, that following Sunday, we had seven overdoses in a matter of one hour.

We had one individual, who was only 18 years old and had never used an opiate before, use what they thought was crystal meth but actually ended up being fentanyl, and she had a heart overdose requiring full resuscitation. She ended up dying seven months later of an overdose, alone in a hotel room.

This also marked the introduction of B.C.’s risk mitigation guidance documents, and if you want to talk to someone who understands the fatal flaws of the RMG documents, I’m the right person. The very first days that these guidance documents were released, there was a sense that we finally had a tool that would help people use safely.

I started contacting physicians to collect a list of willing prescribers and worked with a handful to complete intakes and get people started on hydromorphone tablets. In the first week, we started 35 individuals on RMG prescriptions. By the end of that week, we also saw the fatal flaws there were with this document.

First, RMG was framed incorrectly as a COVID-19 mitigation tool. The belief was that if people were going to get sick with COVID, they would need to isolate. They wouldn’t be able to access their drugs, so we would provide them with a small amount of their drugs so that they wouldn’t experience withdrawal. By that approach, risk mitigation guidance became a tool of addiction medicine meant to stave off withdrawal, but it also failed to acknowledge why people use drugs.

People who were able to access RMG prescribing, in many instances, were also forced to start treatment through OAT. They were given short prescription lengths and substantial follow-up requirements, including urine drug screening and arbitrary dose reductions.

What’s more, with a prescriber-driven model, patients were subjected to gatekeeping by their general practitioners. We had one individual who was unable to access his safe supply because their only known doctor was an addiction medicine doctor at a treatment facility, and when we called him up, he laughed at us and said he was an addiction medicine doctor and not a Dilaudid doctor.

Even more importantly, risk mitigation guidance was wrongfully marketed as a tool for people heavily en­trenched in daily fentanyl use. In that essence, we were giving the wrong people the wrong drug. As a nurse, I know my rights of med administration. We can look at that a little bit more.

I’ve provided you with a graphic that compares the relative morphine equivalency strength of RMG prescribing to what people are actually taking from the illegal supply. When you look at what we’re offering people through RMG, you can see how clearly it did not have the impact that we were hoping for.

The average dose or prescription is 12 tablets of eight milligrams of Dilaudid provided daily. That works out to a morphine equivalency of 384 milligrams in a day. When people are using around five points of opioids in a day — that’s 0.5 of a gram or half of a gram — that’s the morphine equivalency of 1,950 to 7,400 milligrams of morphine. So it’s a small fraction of what people are actually using.

Then you see the introduction of benzo-dope, and you see the synergistic effect of benzos on opioids. You can tell that 12 tablets of eight milligrams of Dilaudid is nothing in comparison to what we actually need.

Moreover, we provided options that weren’t smokable, and most people in B.C. smoke their drugs. Actually, the majority of people who are dying by overdose in B.C. are people who smoke their drugs. Hydromorphone tablets are not smokeable. So now we have the wrong drugs, the wrong doses to the wrong people in the wrong route of consumption, delivered through a system that is paternalistic and high-barrier for people.

In July of 2020, AVI Health and Community Services received a federal funding grant to develop, implement and evaluate a flexible model for pharmaceutical alternatives to the toxic drug supply. We were given ten months to do this at the peak of the pandemic, and we delivered. We started by using the existing RMG guidance documents, developing a prescriber network and starting clinical services immediately. We also wanted to do right by doing consultation with people who use drugs, so we partnered with the Canadian Institute for Substance Use Research and SOLID Outreach in order to complete a design engagement and concept-mapping exercise.

Within the first ten months, we rewrote the RMG documents, increased doses, removed many but not all of the barriers and added oxycodone to our prescribing practices, because people are able to smoke oxycodone more easily than they are hydromorphone. When we received our funding extension, we moved quickly to open a clinic. We started prescribing fentanyl options, including fentanyl patches, dissolvable fentanyl pills and an injectable sufentanil program. As we continued to build out our program, we saw the benefits and limitations of a medical model, even one that pushes the medical model to be more accessible.

[2:15 p.m.]

When we talk about flexibility, it isn’t just a buzz term. Health Canada actually breaks down medicalized safe supply into three categories: traditional, enhanced and flexible. If you look at the flexible category on the slides I’ve provided, they’re intended to be low threshold, harm reduction and public health–informed and embedded within primary care services.

The benefits to this approach at SAFER were so incredibly clear. The majority of participants reported reduced harms from the illegal supply, including a reduction in overdose. They also reported improved connections to health and social services, reduced reliance on the street economy and improved wounds and infections. That work happened in spite of medical barriers and continues to require heavy support for the prescriber team, which is under constant scrutiny from the regulatory college and their colleagues.

The Victoria SAFER initiative lives at the uncomfortable intersections of harm reduction and addiction medicine. From a systemic perspective, precarious funding models and pilot studies cause more harm. In addition to fighting the toxic drug supply, we also fought the uncertainty of sustainable funding and the ethical dilemma of starting someone on an intervention that we might not know we can keep them on for a prolonged period of time.

What we learned from the concept-mapping exercise and dedicating the necessary time and energy into meaningful consultation from people who use drugs is that people wanted the right drug and the right doses for them. They wanted drugs that were strong enough to compete with the illegal market. People wanted a safe supply and services that were accessible to them. They wanted drugs that were made available without jumping through hoops and shouldn’t be limited to seven-day prescriptions.

They wanted to be trusted by their doctor, and they wanted doctors who understood what they were taking. They wanted to be able to have access to peers or people with lived and living experience in order to bridge that trust with the health care system. They wanted something that helped them function by their own standards, not by the standards of the provider.

For those picking up on a thread, many of these requests are actually very difficult to uplift through a heavily medicalized model. Addiction medicine unto itself is steeped in paternalism, believing that you know better than your patient and that your patient is almost undoubtedly lying to you, a system that invalidates patient self-reporting due to mistrust and instead leans on objective measures limited to urine drug screening and treatment adherence.

The truth is that programs like Victoria SAFER are vital. We need them in every major municipality, and we need more support for the ones that are already operational. That support includes sustainable funding. Funding has to go directly from the province to grassroot community organizations, primarily the ones run and staffed by people with lived and living experience. Funnelling money through health authorities is a black hole where the outputs are ineffective or non-existent.

At Victoria SAFER, we were scheduled to open our clinic doors in June of 2021. We renovated, licensed, staffed and opened our doors in a 30-day turnaround, with our first participants starting a fentanyl product on June 2. At the same time, Vancouver Island Health Authority was scheduled to open an injectable opioid agonist therapy program in June of 2021. To this day, that program has still not started.

What we really need to understand is that medicalized safe supply represents only one small fraction of the models needed to see true progress out of this six-year public health emergency. I provided you with a graphic called “The Safe Supply Continuum,” and it illustrates the unexplored and underinvested options that now require our utmost attention. While medicalized options are beneficial, we know that they have significant capacity issues and that they remain very high barrier, particularly for people who would not set foot through the doors of a harm reduction service.

We need to move away from looking for the panacea of safe supply. Countless times I see our leaders saying things like: “There’s no one-size-fits-all approach here.” That’s actually not true. The secret answer is options — a continuum of options that honours and affirms the many reasons why people who use drugs…. We need a system where no matter what stage you are in your drug use, there’s an option that meets your needs and is accessible.

De-medicalizing safe supply is a journey, not a destination, and the unexplored options include public health models and regulated models. Options that fall under drug policy reform include compassion clubs, co-ops and retail dispensaries. We need these, and we also know that these are going to take a long time to address because of legislative barriers.

I know there are groups that will be speaking to you about those models, so I’m going to stay in my own lane and share a different model with immense potential to address gaps in our system. Let’s call this the safe supply and go back to RMG.

Note that I didn’t say safe supply or RMG was a failure. I said that it was marketed to the wrong audience. There’s a harmful narrative out there that RMG is in safe supply, but the truth is that safe supply is in the eye of the beholder, and it is whatever the person accessing it deems it to be.

Risk mitigation guidance was marketed wrongfully. What does that mean? Going back to our stats, 84 percent of deaths occurred indoors, with 57 percent in private residences. Seventy-six percent of those dying are men, and 73 percent of them are age 30 to 59, young men living alone at home, working in the trades.

[2:20 p.m.]

These are young men who would not step foot through the doors of a harm reduction service. They aren’t going to tell their doctor. They’re very likely using in episodic or recreational patterns, which is actually riskier because of peaks and valleys in their tolerances. They are people who are actually seeking hydromorphone tablets or oxycodone tablets.

If I’m speaking like this, like I know this population intimately, it’s because I do. I’ve lost people I love who went to buy pills, and instead, what they got was powered fentanyl pressed into tablets. If we could find a way to reach this demographic, we could actually see a shift in deaths.

Today I’m proposing the tablet overdose prevention prescribing program, or TOPP program. This is a public health response which leans on decision support tools and removes individual prescriber gatekeeping. This seems daunting and requires your help. It requires legislative change and bold leadership.

When I worked in the STI clinic as a registered nurse early in my career, we used decision support tools and never required an individual prescriber to get people the antibiotics they need. There were agreed-upon protocols that could be utilized and enacted through a public health order. We have the models already to do this type of work.

When we talk about nicotine replacement therapy, which is a safe supply for tobacco…. At one point in time, it required an individual doctor’s prescription in order to get it. That made no sense. Now you can go to a pharmacy. The pharmacist completes a short assessment with you, and you fall under a category which provides you with nicotine replacement therapy. You make the choice of how much you want.

We can mimic these pathways using decision support tools. I’ve written one. There’s a high-level description in your slides; however, there’s a more detailed version available upon request.

To make this happen, we would need to see the use of emergency powers to de-schedule certain drugs, create new pharmaceutical categories, an amendment to the pharmacy and pharmacy operations act and a provincial health order authorizing the use of decision support tools. Remember, we have done this before. We have done this with naloxone as well.

At one point in time, naloxone was a schedule I drug. It didn’t make sense. I needed a doctor to prescribe it before I could give it to someone. We managed to find a way to get through that. We used our ability to critically think and used the urgency that we had before us.

This is a regulated drug store model, an intermediary between fully de-medicalized approaches and where we are right now. It’s a vital transition piece.

To close, I’m going to offer you my recommendations. We need urgent, visible support and upscaling of non-medical co-ops, compassion clubs and additional de-medicalized options for safer supply. We need to expand access to existing medical options, with an emphasis on flexible models for safer supply.

We need to challenge individual prescriber gatekeeping and hold regulatory bodies accountable for their delayed implementation. We need to develop, implement and evaluate a public health model, like the one I’ve shown you today, for the provision of pharmaceutical alternatives. We need to urgently address priority underserved populations, including people who smoke their drugs, people who use their drugs episodically and recreationally and the youth.

It should be noted that there are no options for the youth for safe supply. Many of them are buying what they think is benzodiazepine or Xanax and, actually, dying by fentanyl. Those numbers are on the rise.

Thank you very much for your time today. I’m happy to take questions.

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

P. Alexis: I just want to pick up on that last thing. You said that if we could figure out how we could prevent young people, especially in the categories that you outlined, how to save them, then we’d be much further ahead.

What are your thoughts about that particular demographic? That’s the demographic that my community is most impacted by.

C. Ranger: It’s really awful. I’ve worked with a number of youth who have just been disqualified from being able to access any services simply because of their age. The result is that many of them are incredibly opioid naive, and they’re not actually seeking opioids.

There needs to be a movement towards acceptability for harm reduction services for youth. Right now that is still a grey area that many are trepidatious to actually venture down. There needs to be more support for harm reduction organizations to open the door for youth without being subjected to, potentially, being reported and other concerns that can happen through that.

S. Furstenau: Thanks, Corey. Can you paint a picture for us? If we just keep going, business as usual, and don’t make changes, what is that going to look like?

C. Ranger: Absolutely. I also want to applaud the steps we’ve taken towards decriminalization. I think there are very big pieces starting to move forward; however, without properly supplanting the illegal and toxic drug supply, decriminalization will not pose any potential to eliminate toxic drug deaths in B.C.

[2:25 p.m.]

As it stands right now, we are being outpaced by the illegal drug supply. When you see what people are dealing with now…. In the last two years, I’ve responded to 76 overdoses, and only 12 of them were indoors. All of the rest of them were outside — in tents, in parkades, in alleyways.

The benzodiazepine contamination that is happening in drugs is making even overdose responses incredibly challenging. We have people who are able to be roused but continue to fall asleep and desat, and we have to monitor them for six to eight hours.

It’s predatory now. The worst drugs show up on cheque day, when people get their money. What happens is…. People are also subjected to lateral violence. They have amnesic effects. They don’t know where their stuff is, and they end up having their property stolen from them. They experience a number of harms in addition to being at risk of an overdose death.

If we continue down the current pathway, which is not a pathway towards an accessible regulated safe supply, we will see more people dying. We will continue to see innovation from the illegal supply, wherein more harms that we can’t respond to will continue to arise.

S. Furstenau: Our previous presentation — you’re talking to it a little bit right now — was that the drug-using population in B.C. is being used as guinea pigs for developing new forms of drugs. The piece that we often also don’t talk about is…. When we get the numbers of people who die every month, 161, we don’t hear about the people who survive.

Can you talk to us a little bit about the harms that happen for people who are poisoned but don’t die? What is the cumulative impact of that?

C. Ranger: Absolutely. Those individuals typically don’t show up in the data. What’s actually happening to them is prolonged anoxic brain injuries, hypoxic brain injuries. Even if they’re not dying, they are experiencing the synergistic effect of a sedative plus an opioid, which is a central nervous system depressant, and they’re not breathing adequately.

Oftentimes, when they’re under the supervision of an overdose prevention worker or a nurse, they’re on supplemental oxygen. However, most of them aren’t. This is happening at their homes. This is happening in isolated areas, where they’re not being found.

What that leads to is long-term harms that we’re not even going to see for decades to come, likely. But we see early, already, some of the harms starting to develop, especially with people who are at the intersections of poverty and homelessness and overdose, wherein they are consistently assaulted by others. They are victims of theft, or they’re victims of police brutality. They don’t even know what happened.

I have people who show up sometimes, and they have hospital bands on their arms. I point at it, and I say: “What happened here?” They say: “Oh, I had no idea. I don’t know. I just blacked out for the last 24 hours.” It’s a revolving door where, over time, we’re seeing them deteriorate. They’re still not getting the help that they need, or they’re not getting access to a regulated supply that would actually prompt them to use something other than what is harming them right now.

S. Bond (Deputy Chair): Thank you for being here. I appreciate that.

Tell us a little bit about your designation as a harm reduction nurse. How many of you are there? You’re a registered nurse. Are there other nurses who, by virtue of where they work…? Is that how they become a harm reduction nurse? Is there a designation? I’m just interested in how you fit in the health care system.

C. Ranger: Absolutely. I’m a community health nurse, a public health nurse. I’m an acute care nurse. Sometimes I’m an emergency nurse. My background is working in the operating room and acute care. Luckily, I’m very good at maintaining airways, which has proved beneficial working in overdose prevention sites.

A harm reduction nurse can be a nurse working in any health care setting. Our members, across the country, are people who do work in emergency departments and interact with people who use drugs, or people who work in community and home care or who do street outreach.

As I’ve said, harm reduction is a philosophy of practice that can be adopted in any care setting. Typically speaking, our membership comes from people who are working in supervised consumption services, overdose prevention services or low-barrier street clinics. However, it’s not a limiting factor.

[2:30 p.m.]

S. Bond (Deputy Chair): I’m interested in your comment. I was thinking about how I talk about this issue. I’m probably one of the people who said it isn’t one-size-fits-all. I was interested in your comment about how there is an answer; it’s called options. I guess perhaps we’re saying the same thing, just in a different way.

I think what I worry about is that…. You work in Victoria. I live in Prince George. When I think about the people who live around me, the differing geographic issues, all of the things that they’re facing…. So maybe just explain to me a little bit more about the whole concept of….

Language matters, and I certainly have said that. So I’m interested in your response to that. Tell me a little bit about the options part of it and how you see the work you’re doing in Victoria. How does that replicate itself? How can we look at that across the province?

C. Ranger: Absolutely. I mean, at least you didn’t say there’s no silver bullet, because people who use drugs aren’t werewolves. So we can move past that piece.

Solutions that are actually going to be effective have to be grounded in that local community. So what works in the Downtown Eastside or works in Victoria’s core may not necessarily work in other communities. I actually would say that there have been some harms attempting to just carbon-copy, transcribe programs in large urban areas into other areas that aren’t ready for them or maybe aren’t, perhaps, resourced well enough in order to fully support them.

So any of these programs and services are…. It’s really important that there is extensive municipal consultation, that there’s community consultation, that there are opportunities to embed local cultural practices, particularly with Indigenous communities. There are different priorities.

When I talk about options, what we have to understand is that of the 3,600 — I believe that was the last estimate — number of British Columbians who had accessed a “safe supply,” the primary amount of those people were in Vancouver’s Downtown Eastside and in Victoria. When you go out into rural and remote locations, that accessibility is completely disparate.

So if we were to create a continuum of options, we could look into things like virtual networks so people can connect with a doctor through an online portal. If we utilize decision support tools, then we could use pharmacies and other locations that could end up becoming dispensaries or sites where you do intakes. Then if we support non-medical options like co-ops and compassion clubs, you give the opportunity for local communities to make their own solutions.

If we open the door from a legislative process, then people can create their own models that are born within that community and reflect the resources and needs and priorities that that community has. As it stands right now, we’re very urban-centred. If you look at the per capita death rates in some of the other health authorities, we need to shift that right away.

R. Leonard: At one point, you mentioned how you applaud taking that step around decriminalization, but without safer supply, we’re not going anywhere fast. Given that criminal law is not in the purview of the province…. It’s the federal government. There’s lots of discussion around decriminalization and the amounts. We asked for more — got less. But as certain sectors support that amount, some would rather not see it at all.

I’m curious. Just on that one train, around decriminalization as a first step, where do you see moving forward with that towards it? Compassion clubs, co-ops and all of that…. In my mind, it requires legalization. But maybe not. So just on decriminalization.

C. Ranger: Further movements towards demedicalized safe supply is contingent on proper decriminalization and legalization and regulation of substances, and a lot of that does fall under the purview of the federal government. However, there are emergency measures that can be taken from a provincial standpoint in order to move the needle forward at a bit of a quicker rate.

[2:35 p.m.]

One of the biggest flaws currently with the proposed decriminalization is that it has a short duration time frame on it. It’s expected to conclude after three years. Anything that is viewed as a pilot…. If you look at something that does have a short time frame attached to it, it gives the air of impermanence.

With that, then, we can say that we tried this thing, even though we didn’t try it as fulsomely as we could have, even though it wasn’t done in a way that fully honours and affirms what people who use drugs have asked for. If it doesn’t have the impact that is hoped, then it can be taken away as well.

So I think that we really need to push back on the federal government in terms of the thresholds, in terms of the timeline. If we acknowledge that decriminalization is needed, why is it only happening in January? How come it isn’t happening right now? If we’ve acknowledged that decriminalization is needed, then we need to continue to push forward on a regulated supply, because if all substances aren’t available in a regulated format, then people will continue to die.

N. Sharma (Chair): Thanks, Corey. I have some questions. First, I just want to thank you for your very thoughtful and detailed not only submissions but your presentation. It obviously comes from a lot of passion and expertise. It’s really coming through.

I have some questions about the non-medical. We learned that there’s a pilot going on that has achieved an exemption from the controlled substance use act to do a co-op. I’m blanking on which health authority is running it. I’m just curious if you’ve heard of that and if you have any thoughts on that?

One thing that we’re learning, and I think it’s really becoming clear, is that B.C. is really full of a lot of not only experts but people at the forefront of drug policy and helping think of new ways of addressing the crisis. I see you as one of them, with the harm reduction nurses that are out there trying to figure it out with solutions. I just wanted to know if you have had experience with or are part of these non-medical co-op pilots that are going on or have heard about it?

C. Ranger: I can’t speak specifically to the one that you may be referencing, no. However, as I’ve stated, all options need to be on the table. As it stands right now, we only have medical options, and then within the realm of medical options, we’ve got very traditional, high-barrier options like OAT clinics, or injectable opioid agonist therapy clinics. We’ve started to push into a flexible category with things like the Victoria SAFER initiative.

Outside of that, there’s been a lack of willpower from the federal government to support non-medical options. If there is a co-op that’s achieved exemption, I would say that it would behoove this committee to fully support it, to visibly support it and to try to support other communities and health authorities to start to operationalize similar versions. We’re not going to know until we start to see them happening, but at our current pace, we’re not having the impact we need to.

N. Sharma (Chair): Just kind of a little bit of a follow-up question, and then we’ll go to Sonia.

As somebody who is a health care professional and has seen the front lines of some of this work and what works and what doesn’t, it’s super useful to hear your perspective on things.

We were just learning about the toxicity of the supply from a chemical perspective and how brutal it is, not only for the level of addiction — that the dosage required keeps on going up with the fentanyl that’s required — but also how deadly it can be just in the mixing and all of what we’re seeing on the streets. It just seems like a constant challenge to try to figure out how to keep up with that while you’re keeping people safe.

Do you see a health care professional’s role, even if it’s in a regulated model like you’re proposing…? I wonder what you see, especially from the nurse professionals that are there on the front lines. What’s your role in the bigger administration of it to make sure that it’s done in a safe way — that we know that people are getting what they need to stay alive but not being killed by the toxicity of everything? Do you see an ever-expanding role, or are you thinking that the growth should be in a non-medical model without health care professionals?

I’m just wondering about that from your perspective, as somebody that’s a nurse.

[2:40 p.m.]

C. Ranger: Absolutely. As a nurse who works in harm reduction, I know that my place is alongside people who use drugs, not leading them or not forcing them along the continuum. However, I know that there is always going to be a cohort of people who do need medicalized options.

The people who access the services at the Victoria SAFER initiative — over 90 percent of them are connected to staff who are called systems navigators. Those systems navigators are getting people their birth certificate, their ID, their income assistance. The nurses are dealing with complex wounds. We’re dealing with chronic health issues. People are experiencing ongoing homelessness and a myriad of health concerns. They do benefit from a more medically structured environment — much like how we’ll always need supervised consumption services, to some degree.

However, when we step outside of the medical options, nurses will still play a role, because we need to be able to support people along that continuum. If they find themselves accessing a non-medical option but start to experience health concerns, they need to be able to access a different service that will be able to support them.

So that’s what I mean about options needing to be available. There will always be some degree of a need to support, through a medical perspective, people who use drugs. But that has to be their choice, and that has to be something that they’re wanting to engage in. If they’re not, there need to be options — that they don’t have to jump through medical hoops. Those don’t exist right now.

N. Sharma (Chair): Thanks for that clarity.

S. Furstenau: I think the fact that we need systems navigators to help people access what should be systems that serve people is an indication of the systems not functioning in the way that they should be.

C. Ranger: Absolutely.

S. Furstenau: You made a comment about pilot models causing more harm. Can you elaborate on that and how to navigate this place that we’re at?

We, as you say, need the political capacity to move us forward, but that’s not the easiest thing to achieve. That’s part of the work that we’re doing here. But the pilots are an avenue that…. Often decision-makers, policy-makers, politicians will say: “Well, we can do that, because it’s not as risky as saying we’re making the permanent change.”

You just indicated that the co-op pilot would be a good idea. So how do you balance the potential harm of pilots with the need to actually use them as a policy lever to move things forward?

C. Ranger: Yeah. I mean, organizations need to know that they have sustainable funding. They need to know that their funding isn’t going to be pulled out from underneath them as soon as an election happens and ideology changes.

There have been harms recorded in the past with iOAT programs and their pilot studies — their funding running out and then not having good transition options for people who are on a novel intervention. The result is they get forced back onto an option that didn’t work for them in the past, and then they end up experiencing overdose or other harms related to that. You can look at the NAOMI and SALOME trials from Crosstown Clinic as an example. They certainly learned their lesson, but there were people who were irreparably harmed from the process of that initial pilot ending.

So people need to know that there is sustainable funding. Even the Victoria SAFER initiative being given ten months of funding initially…. Within the first three months, we were already planning disposition plans for patients in case our funding got pulled. How were we going to get them to a different doctor and make sure that their prescription stayed intact? It prevents innovation from happening. It prevents you from being able to build on services.

It also prevents you from being nimble and flexible and adapting to community trends and issues. At the Victoria SAFER initiative, in the first ten months, we were working exclusively through an outreach model. We didn’t have a clinic. Within the first three months, we had people with accessibility issues who weren’t able to make it to the pharmacy every single day. So within a week, we created a med delivery team, and we brought the medications to them.

We had an increased risk for overdose death in one of the parks where people were camping, so over the weekend we set up an unsanctioned overdose prevention site. We embedded a nurse within that site to do intakes for safe supply. None of that exists if you can’t be flexible, and you can’t be flexible if you don’t think your funding is going to last. You set people up for failure, and you set people up for harms in the long run.

So there needs to be a change to the funding model. Maybe pilot studies isn’t the right way to look at it. But we don’t need to study much more anyways, because we have the evidence before us. We have what people who use drugs have been asking for, for over a decade. We know what the harms are for medicalized safe supply. We know what the harms are from not providing a regulated safe supply to people.

[2:45 p.m.]

We need to be a bit bolder and really put the power into the hands of drug user organizations. They’ve been the ones who have opened consumption sites and overdose prevention sites without permission. They’ve been the ones who started distributing naloxone before it was legal. They were the ones distributing needles before it was legal. They can do the work. They understand the communities. They have the relationships. They need the money and the trust from people in power.

S. Bond (Deputy Chair): When it comes to RMG, you obviously…. You called it flawed. We’ve had discussion previous to this about it. Is it salvageable? Is there a future for it, and how should it be adapted?

I think there was relief to know that people who had been receiving support would continue. Once the COVID situation started to diminish, the concern was: what happens now? As we learned, it was designed to deal with COVID mitigation. Really, that’s what it was. So is it salvageable? Does it work in a different context?

C. Ranger: It’s salvageable if it can be adapted to the point where it removes individual-prescriber gatekeeping, which is why I proposed the public health model for it, which would be through medical health officers’ orders, public health orders so that people can use a protocolized and standardized, agreed-upon-decision support tool. You’d present to this provider. You’d go through the tool. You’re provided this option without having to subject yourself to what one prescriber’s perspective on a safe supply may or may not be.

If we can do that, then…. Like I said, it was just marketed to the wrong people. The primary amount of RMG prescriptions went to people who wanted fentanyl or wanted diacetylmorphine, prescription heroin. But there’s a large number of people who seek tablets, seek hydromorphone, seek morphine tablets or seek oxycodone tablets and don’t particularly use a large amount for recreational purposes. None of them have even been targeted or are offered this option for prescribing. It is salvageable, but it will require a shift in how we do things and an intentional divorcing of the mitigation of COVID.

P. Alexis: Corey, you know so much. You strike me as just…. As soon as we ask questions, it’s just like — boom. Have you been part of committees or forums that are looking for solutions in the past? You have so much to offer and so much experience, I think, with what needs to be done. I’m just curious as to how you’ve participated in the past. This is a really good opportunity for us, but….

C. Ranger: I championed for the National Safer Supply Community of Practice. I’ve been on B.C.’s nurse prescribing implementation and education committee. Then I’m a member of a number of different committees that talk about de-medicalized options and imagining safe supply through different models.

Primarily, I get my information from people who use drugs. Working at the Victoria SAFER initiative — I don’t work there anymore; I left there three weeks ago — I’d spend most of my time talking to people after they had used their safe supply or talking to people when they came in after having an overdose and being revived by paramedics, and hearing from them.

So my goal today, as a white service provider talking about an inherently racist and colonial drug policy flaw that we have is to just uplift those voices and to try to make sure that they get a venue to be heard, because they’re the ones who have the solutions. I’m just taking their lead.

N. Sharma (Chair): Corey, I want to thank you for coming today and for all the things that you’ve given us to look upon, too, and the details that you’ve provided. It’s really useful. Thanks for the work you do. Safe travels back to Victoria.

Our next panel is at 3:30. So we have a bit of a break now.

The committee recessed from 2:49 p.m. to 3:41 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): It’s a great pleasure to welcome our next speakers today. They’re from VANDU, Vancouver Area Network of Drug Users. We have Brittany Graham, Dave Hamm and Kevin Yake.

Welcome. Nice to meet you. You will have about 20 minutes to present, and then we’ll have 40 minutes to just kind of have a good dialogue. We all have your slides that you sent to us on our screens in front of us so we can follow along.

I’ll pass it over to you.

B. Graham: Does anyone want to start?

K. Yake: Could we do a quick go-round to see your names and that?

N. Sharma (Chair): Sure, yeah. Of course. Sorry about that.

My name is Niki Sharma. I’m the MLA for Vancouver-Hastings and the Chair.

S. Bond (Deputy Chair): Hi. I’m Shirley Bond, and I’m the Deputy Chair. I live in Prince George and represent Prince George–Valemount.

T. Halford: Hi. I’m Trevor Halford. I’m the B.C. Liberal MLA for Surrey–White Rock.

S. Furstenau: Sonia Furstenau. I’m the MLA for Cowichan Valley.

R. Leonard: I’m Ronna-Rae Leonard. I represent Courtenay-Comox on Vancouver Island.

P. Alexis: I’m Pam Alexis, and I represent Abbotsford and Mission.

N. Sharma (Chair): We have Doug on the phone with us.

Doug, do you want to introduce yourself?

D. Routley: I’m Doug Routley from Nanaimo–North Cowichan. It’s nice to hear you again. I think you came to address our Police Act review.

VANCOUVER AREA NETWORK OF DRUG USERS

D. Hamm: I’m Dave Hamm. I’ve been a member of the board of directors at VANDU for about 12 years now. I’ve been involved in the mayor’s task force on the drug overdose crisis, I think when it first started back in…. Almost seven years ago now, it’s getting on. That’s who I am.

K. Yake: My name is Kevin Yake. I’m vice-president, right now, at VANDU. I’ve been the vice-president for five or six years, on the board for 13 and involved in a lot of different groups in and outside of VANDU and the Downtown Eastside.

I’m Six Nations Mohawk. It’s an honour to be out here with the tribes and whatnot doing this work…. It’s quite eye-opening. I like it.

B. Graham: I’m Brittany. I’m the current executive director of VANDU, but I’ve been a longtime community organizer. It’s actually been my tenth-year anniversary a couple of weeks ago. Everyone who comes to VANDU gets sucked into the love of VANDU and stays for a very long time.

[3:45 p.m.]

I think that kind of goes into the first couple of slides of our presentation, where we give you an overview of some of the stuff the drug users have been doing in our communities for a long time and, I think, is a big part of why the overdose crisis has been as minimal as it has been.

For over 25 years, people at VANDU have been convening together and creating opportunities to discuss what’s happening in their day-to-day lives. That allows people to have friendships and colleagueship that allow them to create conversations around harm reduction at the individual level and conversations of individual harm reduction that’s no longer working and needs to go beyond that to the system-level harm reduction.

These are just some of the things that VANDU has worked on there. We could have gone through 20 pages of this. But for example, one-to-one needle exchange…. That was how things were done for a very long time. You had to hand in a needle to get a needle. And we have one of the highest rates of HIV in the world, let alone Canada.

There are a lot of things that are policy…. People who use drugs are seeing that this is not right. This is not helpful. We need something better, and we have to push and advocate for those changes for a really long time before the actual policies change. We’re seeing that now in the actual overdose crisis.

Do you guys have anything you want…?

D. Hamm: Yeah. We have Insite. That was due to VANDU advocating for a legal injection facility by actually having several unsanctioned facilities over the course of time. There was a need, so we stepped in. Laws, sometimes, maybe, should be just guidelines. When there becomes definite evidence of health-related things, there has to be a change. We can’t be stuck in policy all the time. “Oh, this is the policy. This is the policy.” No, if it doesn’t work, then you have to adjust it to the situation.

That being said, we created a manifesto about drug user rights. It’s inspired other groups all around the world, actually, to form their own drug user groups. We advocated for naloxone way before it was even thought about being here. We ended up at a conference in Holland, I think it was, and there was some naloxone there, and we got some of that. We started using it in the community, and we were the ones that brought it back to Vancouver Coastal Health as being something that needed to be done. Now that’s done.

We always had an unsanctioned injection site. Once it became public knowledge…. Well, we didn’t care that it became public knowledge. We wanted it to become public knowledge, because we wanted to show that by having a peer-led initiative of having a safe injection site…. Just one site is not enough. The extent it went to was a really big model, whereas sometimes it needs to be smaller models — in smaller communities, obviously, but even within the city here. Smaller neighborhoods need to have a smaller kind of program.

We were asked to shut down. Not asked, actually — told to shut down, because the funders found out about it. Then, two years later, they asked us to get one going in 24 hours. Once again, we were ahead of the curve. We’ve always been on the cutting edge, because we deal with issues that are practical and on the street — that are happening right then.

That’s why Vancouver Coastal Health has given us the core funding that we have, to make sure that they get all the information they need — very current and very specific to different initiatives that need to be done. That’s been our role as educators and harm reduction specialists in the neighborhood.

B. Graham: I think the big thing to point out here is that, like when Dave was talking about them telling us to close our unofficial injection facility, that happened in 2014. That was when we were already seeing an overdose crisis in the Downtown Eastside, but because of policy, that was created at a higher level where injection facilities were not sanctioned, and you had to have about 26 categories filled out and paperwork at the levels beyond VCH. They were forced into telling us that they would take our funding away.

[3:50 p.m.]

These are just examples of: you need to listen to people who use drugs. The best way to do that is to actually support the financial creation and sustainment of drug user groups across the province. If you go to pages 2 and 3, you’ll actually see some breakdown of the numbers around the OERC, the overdose emergency response centre. When that was created, there was, I think, $608 million — that’s what I’ve been able to find on a site — for the first five years of that new department. Of that, only $3.3 million went directly to drug user groups.

There are other moneys that went to honorariums and stipends to have people who use drugs on committees, etc. But having one person from one group on a committee quite often is tokenizing and, beyond that, actually doesn’t really reflect the needs of that community. It reflects that person and their experiences. It’s really great to have those places — we don’t want those taken away — but we need more support in these communities.

When you take that $3 million and break it down to the three-year thing, it was about $1 million per year for all drug user groups in the province. The first year we had about five that identified as a drug user group and fit the category. In year 3, which just finished, there were 16 to 30 that would fit the category, depending on who you would speak to.

If all 30 got money, that would have been $33,000 per group. Most of these groups can’t get money from their health authorities, because their health authorities are not necessarily supportive. Most other funding sources do not apply to them. So we really see a place for the province to allot more funds to the peer provincial network or a different stream in which we can have sustainable funding for these drug user groups.

As well, it’s using your authority with the other health authorities to ensure that when they do get money for public health funding, they do allot a certain percent of it to specific drug user groups and whatever that means. So there’s autonomy in the group. There are people who are current or former illicit drug users within the formation, and the governance structures are able to make their own decisions. Those things can all be figured out later on, but at this point, there’s not enough money going to these groups.

From VANDU’s perspective, our history is a lot of work from our actual membership. But we also had some support from our actual health authority. VCH has been someone who has helped us in moments, and other times we’ve been the thorn in their side. But from the beginning, they’ve had a core funding for us, and it has been about $250,000.

That, I believe, is the bare minimum to allow organizations to not have to start and then be forced into making these decisions on whether they can continue to have a space, etc. — all those things. I personally believe it is one of the biggest things that could be changing right now that would be helpful.

D. Hamm: Also, the other health authorities in other regions need to get on board with Vancouver Coastal Health and Vancouver Island Health Authority, who have supported SOLID and, I think, a couple of other groups on the Island, too. We need to see that provincially, I believe. We need to have that kind of directive by the B.C. health, the Ministry of Health to the different health authorities that they must start doing that. That should be a mandate with part of their funds. Ultimately, too, the beginning line on the….

I just wanted to make sure that people understood that the reason that drug users need to be ultimately involved in their own liberation is because the most profound need to establish such a network of people who use drugs arises from the fact that no group of oppressed people ever attained liberation without the involvement of those directly affected by this oppression — that meaning that we know what’s going on with us and what’s happening out there and how the illicit supply is now tainted and unsafe. There needs to be some kind of way that we can do things in a different manner.

When alcohol prohibition was involved, the government took over and started doing a safe supply of alcohol and then putting it out through different distribution branches and that. This is a similar situation where the government needs to step in.

[3:55 p.m.]

I applaud B.C. that they wanted to get involved in the part of decriminalizing, but it was a very small measure that didn’t really have any relevant effect. It’s not going to have any relevant effect on actually what’s going to happen out there with people, because it’s going to actually criminalize more people. It’s going to give the police more powers to actually just keep stopping people all the time. If you happen to be over a threshold, then you’re now criminalized.

Our survey showed that we probably have about 70 percent of our membership that would probably now be subject to criminalized prosecution if these thresholds were put in place.

B. Graham: Yeah, that’s a good example of having drug users coming together and having their own groups. You can actually have more say in what’s happening in the higher level.

The example we give on page 4 is around what’s happening on the ground in most municipalities right now. We’ve heard from three or four different organizations in different areas — the Interior, Nanaimo, Surrey. Those are the three different health regions — and yes, Fraser Health. Those regions have had drug user groups try to open. There are zoning issues. There are business licence issues. There are bylaw issues that are being used to force people out in the not-in-my-backyard way.

If you guys were able to connect with drug users on a more regular basis, we would be able to have these discussions and say, “Use your overdose crisis authority to start working on these things and getting the municipalities to stop being in the way of harm reduction services,” because these services are life-saving. They’re public health, and health is a right. The Ministry of Health and the Ministry of Mental Health and Addictions have a right to tell those municipalities that they are not allowed to stand in the way.

We have more detail on this, but we don’t have a ton of time. If you want more information, we’ve worked with Pivot on these slides. They can fill in the gaps around that kind of stuff.

D. Hamm: An example is that the Lookout Society has been given funding to actually open up OPSs in the Fraser Health region. They cannot find anywhere that they can open that up. Two years they’ve had this money, so for two years, people out there have not had access to a place to inject safely and be monitored and, perhaps, have their lives saved.

Any deaths out there — attribute that to the municipalities being almost criminally responsible for not allowing a health initiative into their community, which then puts it back on the B.C. government and the Health Ministry. They should be monitoring and finding out what these different municipalities are doing, creating bad zoning laws and things like that. Basically, the government should be monitoring and intervening on these practices that are being done all across the province right now.

B. Graham: We only have five more minutes, so I think we’ve got to hustle a bit. I think the big thing to point out here, if we look to slide 5 — and then we can kind of pick where we want to go — is you can see that there was a 15 percent of samples to a 43 percent of samples in 2022, so a two-year difference, of benzos jumping massively in the drugs that are being checked.

In those two years, there has been very little that has happened around benzos. For example, detox in Vancouver — there are three of them. Two of them do not accept people who are on benzos or test positive for benzos because they don’t have the staffing to look after people in detox in those places. They need more care, similar to alcohol. So there’s only one detox in Vancouver that accepts people who use alcohol and benzos.

This is the time to make these changes. The government is very slow and is not making these changes quick enough. If you had more connection to drug users, we would know this quicker, these changes could be made quicker — more staffing at these places, more training at these places; and we wouldn’t be fielding calls at VANDU where people are asking us how they can get into detox when there’s already a four- to five-week wait. That’s just for people who want to detox, let alone everything else.

D. Hamm: Yeah. We understand that because there is not enough capability, the people would be at risk if they were put into those places too. It’s not a matter of that we’re saying: “Oh, you’re not allowing people in there. That’s a bad thing.” It’s a matter of…. As she said, it’s training.

We need to make sure that people know the people that are in these detoxes can work with these people on benzos, because it’s a very life-threatening thing. Even in the hospital, when they’re withdrawing on benzos there, it’s a very touchy matter. It’s a very heavy concern whether they’re going to survive or not, even. It’s worse than alcohol and that.

[4:00 p.m.]

B. Graham: I think the big thing we should focus on for the rest of it is that safe supply is a big issue right now. I think it comes in twofold. There are the prescription models that are out there and everything else. We have both. I think BCAPOM…. You’re speaking with them tomorrow. They can really speak to you a lot more about the prescription model.

Basically, there have been groups like the B.C. Association of People on Opioid Maintenance that have said for years that we should be able to have carries. When people have been on methadone for 20 years and they can’t carry their drugs every day…. How demeaning is that? How ridiculous is that? Would you go into your doctor every day to get your birth control? No. It’s patronizing. They can speak more to the details of all the things that they would like changed there, but ultimately, there are things that need to be changed in the safe supply system.

When we come to what has happened in the coroner’s report, which I think led to these conversations…. That safe supply model will always have gatekeepers at the colleges for pharmacists, the colleges for physicians.

There are things that the B.C. government could be doing to enforce changes. That will take time, and that system will not adapt quick enough for where we are with the toxic supply. We need other models.

VANDU and DULF, the Drug Users Liberation Front, have created a compassion club from a community-led model. We’ve applied for exemption 56 from the federal government, which I know is not the deciding factor here. They’ve actually said that they’re going to unofficially reject it at this point. The two main reasons are…. It’s illegal. We are buying drugs from…. DULF is buying drugs from the dark web and having them checked by three or four different services, boxing them up and letting people know what they are.

In their decision, they said that it was harmful to Canadians. We feel like that decision continues to keep coming back to us — that engaging in the illegal market is harmful to Canadians. It doesn’t show where we are right now. People are buying drugs. They don’t know what’s in them. We have no idea how to protect people.

In our own organization of people who are long-term harm reductionists, who understand the risks of things, who do everything they can to protect themselves, we have had a massive amount of loss in the last three years. It is unfathomable how many people who you wouldn’t expect to die from an overdose have. The drugs are that toxic.

We need to stop thinking about engaging in the illicit market as something that’s going to harm Canadians. We’re already harming them by ignoring that.

D. Hamm: The tainted supply is a big thing, right? People that aren’t even opiate users are being caught up in this because of there being cross-contamination, perhaps, at the dealer level, where they’re not cleaning their scales off properly or whatever. Then there’s some fentanyl that goes along with the rock. People smoke their rock, and they’re getting fentanyl in their rock. Then they’re OD’ing and that.

That’s an example of why we want to be able to test our drugs for our members. We want to make sure that they are getting a safe supply. We’re doing it the way we’re doing it now because we have no other choice. If the government was involved in regulating a safe supply for us, we would more than happily help them distribute that and get that out there in a meaningful manner that is not going to impact the community, except in a good way.

It’s not going to be everybody on the streets accessing this. It’s going to be a members’ club. Everything is going to be…. Our model, if you have actually seen it, is very well put out there. It is actually done in a way that there can be data collected from that to show how effective it will be and then can be used as a model everywhere else in the province and in Canada.

B. Graham: Yeah. All of this was in our exemption 56. They didn’t even take meetings with us. We pushed several times to have conversations.

When we got a response back…. The second reason was that we had no confirmed legal supply chain for our compassion club. The actual letter that we received was basically putting the onus on VANDU and small organizations like us to create a supply chain with pharmaceutical organizations. That really should be the job of the federal government, the municipal governments and the provincial governments. Somehow they’re trying to push it off on us.

It feels like this has continued to happen at the provincial level as well. Fair Price Pharma is an example. For years, people have been saying Fair Price Pharma is the next generation of where we need to go. No heroin has been given out from Fair Price Pharma in this whole time that they’ve been doing their thing.

[4:05 p.m.]

D. Hamm: They have access too.

B. Graham: They have the means to do it. If we could have a place…. We’re not saying that we should be opening stores, and every person in the world should be getting drugs. We think that there needs to be a better system so that people can actually access the safe supply.

At this point, the testing services in the Downtown Eastside are not sufficient. There are three machines. They rotate around. They get broken very easily. They test only very specific things. It’s the wavelengths of whether it looks like meth or whether it looks like fentanyl. It’s very user dependent. I have to know what I’m looking at, as the person. Beyond that, it doesn’t test for very little amounts of things.

D. Hamm: Under 5 percent.

B. Graham: Yes. With carfentanil or fentanyl, little amounts can kill someone. So you need the test strips on top of that and other…. There’s no sure way, other than us creating a safe supply.

D. Hamm: I know we’re over. I would….

N. Sharma (Chair): I just want to say…. Go ahead if you want to take a couple more minutes.

D. Hamm: Okay. I just wanted to get to the page with all the crosses and where our friend Dean Wilson is sitting there. That was from 1997. That year there were 1,000 crosses set up on there. Those aren’t just crosses. Those are people. Every single cross there is a person, right?

If we were to do this today, there would be over 10,000 crosses on that field right now. That is 10,000 people — not just crosses, not just the representation of how bad things are. Each and every cross is a person.

B. Graham: I can say, as an employer of people who use drugs, people coming every day, when their friends and their family are disappearing…. It is like a war zone. It feels urgent. It feels scary.

Almost every day there is somebody in the neighbourhood that goes missing or passes away. When you hear things like: “Oh, they died of COVID….” People are actually mildly relieved that it wasn’t an overdose. That is a horrible place to be in.

I think really reiterating that these are human beings and that these are people we love is really important. I’m glad we’re having this committee right now, but I’m sad that it’s seven years later. I know, personally, over 60 people that have passed away. I don’t use drugs. I can’t imagine what it would be like to have those losses and also be using drugs and scared that it might be me next.

D. Hamm: Canadian drug policy has created a death sentence for people now, basically. By not addressing the issues properly, they’ve made it so people are just…. It’s like a lottery. You don’t know who it’s going to be next.

Interjection.

D. Hamm: Yeah. They’re fentanylities. That is right.

The moment of silence page. These are all very dear people, my partner being one, Charise, on the bottom left-hand corner there, at 40 years old. That’s much too young to be falling victim to this.

B. Graham: All of these people are people that have died in the last three years or four years and have all had overdose-related or health-related things that could have been preventable. They were all people who knew harm reduction, knew what they were supposed to be doing, tried to do their best. The system failed them.

N. Sharma (Chair): Thank you so much for your presentation. I just want to acknowledge that 60 people is a lot, the death toll and the losses that you’ve spoken about today. I know all of us are hearing these stories, but they’re very personal to you. I just wanted to say sorry for your losses.

We’ll do questions and answers. We’ll just take the Qs from the committee, if anybody has any.

R. Leonard: It’s hard to open your mouth and speak.

You talked about the Fair Price Pharma. I’m sorry. I don’t know that system. Maybe you could describe it a little bit more for me.

B. Graham: Sure. They’re a not-for-profit organization. Perry Kendall is a part of that group. They are looking to get heroin, at cost, to people within the system. They’ve been working, I think, for the last four years. I’m not the expert on Fair Price Pharma.

[4:10 p.m.]

They basically have been saying, for three or four years, that if we get 200 people on a list, sign up their names, we can get heroin to people. As they’ve been saying that, there has been no heroin that’s gotten out because there are way more complexities to the system.

We’ve gotten to the point where a lot of the people four years ago who would have done well on heroin are now mostly using fentanyl because that’s what’s in most of the drugs now, and their tolerance is higher than what heroin would do.

We’re not moving quick enough. We’ve been saying, “Oh, should we do heroin or not?” Now we’re at this point where it might not…. It’s the preferred option for most people. But at this point, they actually can’t go on that because it would hurt them in the interim. It’s not strong enough and they would probably go into withdrawal.

D. Hamm: Yeah. There’s a generation of people that have never experienced heroin. When they hear the term “down,” they think they’re doing heroin. It’s always fentanyl for them now. We have people now that are being prescribed…. I know people that have patches, time-released patches all over their back, just for them to be able to maintain a level of not being dope sick, as they call it, and having withdrawal symptoms.

B. Graham: I’ve heard a nurse say once that this person didn’t have enough skin for the amount of patches that person would need for the fentanyl patch.

I don’t know if you’re speaking with Christy Sutherland?

A Voice: Yes.

B. Graham: Okay. There are people at VANDU that want to be a part of her program. She was saying that they were unprepared for how high the potency of street fentanyl is compared to pharmaceutical fentanyl.

When people are being titrated onto their program, it actually…. They thought it would about 1,000 micrograms, but it’s actually 5,000. So that wait-list is going to be longer because they don’t have as much production, because they thought all these things. It slows everything down. Instead of that ten-person program becoming 20 or 30, it’s going to stay ten for awhile because they assumed it wasn’t that strong. But everything is stronger than we expect right now.

D. Hamm: The supply, which started being tainted slowly…. So heroin was preferred out there, and people were doing that. Then fentanyl became slowly, slowly pushed into, became introduced into the street drug system, and now basically you cannot find heroin out there at all. Most people now, if you said you can get free heroin, clean heroin, safe heroin, would go: “Well, that’s not good enough.”

We’re kind of at a point now of asking people if we could start introducing it into the fentanyl and start doing a reverse thing maybe. Maybe we could somehow work it out that way that people would be lessening their dependency on fentanyl.

Once again, like the kids have said, the fentanyl on the street is stronger. Even having a medicalized model is not working out right now too. Just because all this time has gone on and the fentanyl has just gotten stronger…. People’s addictions…. They’ve gotten tolerances and built up to it, so the response that’s always by the people that put out the drug is to increase the potency. That makes it even more lethal. People that don’t have any tolerance at all are so susceptible. It’s an instantaneous thing.

I have personal experience. Being a cocaine user, not an opiate user, I personally have been fooled by a substance, thinking it was something else from what I thought it was. Only by a good luck situation, I guess you would call it, where I noticed the person that had done it before me, just as I was about to do mine, was going into an overdose.

I didn’t quite do enough to get myself into a bad overdose, but I had to help them out as quick as I could before they became a fatality, and then people came along and helped me out after that too. I never did go into an overdose, but the potential was there if I had taken even just a bit more of what I was doing at that time.

That’s what’s happening to people.

B. Graham: Those are really good examples of old-school ways in which drug users would do harm reduction for eons, like: “Low and slow” and “Use with someone else.” Kind of piggyback off someone, where someone would use first and then you would use second if there’s only two of you.

But those things don’t work very well when the drugs are really strong, so the things that people have done for 20, 30, 50 years are no longer effective, because the drugs they’re using are just so potent and toxic.

[4:15 p.m.]

N. Sharma (Chair): Can you tell us a little bit about…? In your slides, you talk about a couple of things that I’d love to know more about. One is: what does a compassion club look like? How does it operate? What are the benefits and that kind of thing? The other one is that you talk a little bit, in your slides, about the College of Physicians and the medicalized model and the kinds of complications with that. I’d love to learn.

D. Hamm: I don’t know if people are familiar with the…. In the beginning, with marijuana, there was the Compassion Club. It has been around for years and years. I don’t know if people are familiar with that model. That’s more or less how we were going to be shaping our model but just using different substances — that being that it’s a members-only place and people pooling their resources, perhaps, to get a supply of what’s needed at a lower cost, and things like that.

B. Graham: We also have a very specific structure at VANDU, and we encourage other drug user groups to do that. We’re a democratically led organization. We have an annual general meeting. We have those members elect our board, and most of our decisions go through our board. We make subcommittees, and those subcommittees work on things.

We have been doing some safe supply events in our activism in the last two years, with the Drug Users Liberation Front. That group was doing it out of necessity at the moment. They were seeing a lot of people dying, and they said: “We want to get clean drugs to people now.” They were using VANDU — the front of VANDU, the side of VANDU — to be a place for people to come.

So we said, “Well, if you’re going to be using our location and our name, we need to be involved in this,” and went through the VANDU processes of how we do things. The DULF model has a very specific, probably, 40-page document of how they procure things, how they test things and how it would go out to the compassion club — possible places.

VANDU right now would be a pilot. We’re trying to apply for exemptions so that we could have that pilot program. In the last six months, we’ve had a committee, through our VANDU board and with one of our interns, to help us figure out what that compassion club model would look like and to speak to a lot of the stuff that Dave was saying. Do you have to already be a member of VANDU? We have an age requirement for VANDU. You’ve got to be over 18 to be a member.

Would we be covering the costs of those drugs? That would be very expensive. What are the costs of drugs? What would we ask for people to put in it? So we have created a 20- to 25-page document on the VANDU specifics of what it would like in-house. It’s very well-thought-out — what we would want to do.

We also would like to do it as a research project and have been working with Thomas Kerr at the B.C. Centre on Substance Use. He has been helping us figure out what the control versus involved in the actual study. He runs the Vancouver injection drug users study, VIDUS, which is one of the longest studies in the world on people who use drugs.

We know how to do things. It’s just that now we’re in this legal kerfuffle, I guess, where we can’t really get out of it. We got a letter from the federal government saying: “We’re planning to reject you. You have 14 days to respond to this letter.”

We sent a letter back, basically so that we could get into judicial review with them of all the things that we had and all their questions, etc., and said we’d like a response in 14 days. We got it in six weeks, saying nothing, just: “Sorry. You can’t get a meeting with the minister. You can talk to the director of whatever.”

We don’t get the same level of face time or respect with most politicians as other organizations like the BCCSU or BCCDC, despite most of the programs coming from those places being originally created and sustained by people who use drugs in VANDU or other drug user groups. There’s this ongoing stigma in the political system of patronizing people who use drugs and working with the researchers instead of the actual drug users.

[4:20 p.m.]

For the OAT stuff, I think the slide where it has a harm reduction client survey in B.C…. This was from a presentation that BCCDC did on their 2018 survey. So it’s a little out of date, but honestly, it’s the exact same information that’s been coming out for 20 years.

When people have difficulty getting…. You’ve probably heard lots of people are getting offered OAT. People are going to be in the system getting methadone, Suboxone — all those things. Six months later most of those people are not on the program. Why are they not on the program? These are typically the things. Kevin has been a long-term methadone user, and for example, his clinic….

Your hours are quite short at your clinic. You have to be there every day.

Quite often, they’ll make you do piss tests to ensure that there’s nothing else in your system, and if there is, they may have a punitive part of the program where they would reduce your prescription. For example, if you don’t show up for your prescription for three days in a row, they would cut you off of methadone and start you back at the beginning. Even during the pandemic, a lot of pharmacists and doctors were hesitant to give people carries, despite them being on the same drug for ten, 15 years.

Those are some of the bigger issues, but people have been saying that for decades, and when it’s brought up to government officials, there’s a lot of: “Well, that’s in the purview of the colleges.” But realistically, the health officer can start telling the colleges: “These are not guidance material. These are policies. You need to start changing your behaviours, because what you’re doing is stigmatizing, and it doesn’t actually follow research.”

There is no research that getting someone in every day is helpful, and quite often, there are kickbacks related to these pharmacies. So if you come in every day, some of these pharmacies will pay you to come in every day, or they get paid for you to come in every day.

D. Hamm: Yeah. Every time they witness, they get seven bucks or something. I forget what it is. They want people to come in every day. Then they end up…. My roommate, he gets $100 for his scrip. He gets 30 days that he has to go get his thing, so he gets whatever amount that works into a day back from the pharmacy that he goes to.

People need money out there, so they’re going to go along with that. They’re going to more or less protect those people, even though maybe it’s not a very ethical thing to be doing. But this is a way they’ve found how to keep making more money at it, too.

B. Graham: Yeah. Those are loopholes that I think you could look into. We’re not the experts on that. BCAPOM would be the group to talk about that, because they’re people that have been on opioid maintenance programs for eons.

D. Hamm: Speaking about the piss testing, it’s so…. When they give out punitive measures, a lot of the time, they’re not even testing…. They’re testing for substances that aren’t even part of the program that they’re in, the methadone program or whatever. They may test positive for cocaine or crystal meth or something, and they’re still given punitive measures about their opiate addiction.

B. Graham: For example, I just heard from one of our board members who has been on hydromorphone the last couple of months. Dilaudid is the big name of it. He was piss tested a couple of weeks ago, and he had no hydromorphone in his system because, honestly, he prefers fentanyl at this point. It isn’t good enough, so he doesn’t use it that often.

Because of that, they cut him off of his scrip. But there’s no fentanyl program for him to go into, so now he can’t even…. He was diverting some of it, but it was to buy the stuff that was useful [audio interrupted]. But instead, the doctor has no purview to say: “This is clearly not working for you. How do we move you to a drug that is useful for you?” There’s nothing there for that person.

So now he’s out of scrip, he has no money, and he still is heavily reliant on fentanyl and still has to figure out a way to get that so that he doesn’t feel like crap every day.

D. Hamm: Meanwhile, the Dilaudid went to people that actually needed them, because they can’t have… For whatever reason, they’re not getting access to a substance that they need because of whatever situation it is — not having a doctor, not being able to maintain because they’re living on the street. They’re homeless, and in order to get to an appointment, they have to leave their stuff, and their stuff gets stolen and things like that.

There are so many mitigating factors in why people have a hard time with the opiate-assisted treatments and that too. The medical model isn’t always going to be the one that’s going to work. That’s where we step in and try and bring you the facts and show you the things that actually will work and have been working.

[4:25 p.m.]

I was hired by the CDDC to be an ethical substance peer navigator, meaning I was hired by them at 20 bucks an hour to go out and get good, clean, safe drugs for people that were attending their conference. So I was hired by the government to actually…. More or less.

B. Graham: Well, an honorarium.

D. Hamm: Yeah, an honorarium — okay. But basically. That’s my way of helping my community and my friends and other members of our group. I make sure I get a good, clean substance. I get it checked. I make it myself. I make sure that there’s nothing in there that’s going to be harmful to anybody, and then I provide that to people in the community.

That being said, I’m not too worried about it being a bad thing, because it’s saving lives. If that’s the bottom line, the way it has to be done out there, there’s a bunch of us that are doing that now — making sure that that happens. Then with the DULF program, we’ve even expanded it even more, applying it to other substances.

B. Graham: The one thing we should mention about the OAT before we move on is that the issues we’re speaking about here in Vancouver are ten times worse in other parts of the province. So in Vancouver, if you don’t like your pharmacist, there’s a pharmacist down the block. If you don’t like that person, you can go somewhere else. It’s not easy to move those systems, but you can.

When you’re living in a small town like Vernon, there’s one person that prescribes two towns over, so you need to go to that town to get your prescription. When they’re asking you to go daily, because they do that across the province, you’re driving every day to get your prescription. Sometimes the doctors are actually punitive to the person, where they’re like: “Oh, you’re driving yourself? You’re not supposed to be driving when you’re on methadone.” They’ll actually report the person to licences and have their licence revoked.

So it is insane how horrible it is in rural places. It just should be mentioned that whatever we say here is tenfold worse in other places.

S. Furstenau: Thanks for the presentation and all the information. It’s really valuable.

We’ve heard a lot about the fentanyl tolerance levels. I’m just curious about, say, the difference between heroin and fentanyl. Is it that…? So what is leading to these higher amounts of fentanyl that people are using? Is it the nature of fentanyl — that your tolerance grows just as you use? Or is it because of the way that it’s being mixed or given to people?

K. Yake: All of it. All of that. Fentanyl is…. There are different grades of fentanyl, like there’s carfentanil. Some are very, very strong. There are tons of people playing chemist — drug dealers getting certain supplies and putting it all together, making their down, as it were. Some of the…. With the benzos, they’re putting that in a lot more and more, because there’s competition out there. So if you’ve got something that’s a little bit stronger than that guy’s, you get more customers. That’s what it’s about. It’s about money and stuff.

But it’s about…. Yeah, there are different grades of fentanyl that are very strong, and there are people that aren’t very educated on how they’re mixing them.

D. Hamm: It’s a man-made thing too. It’s not a natural substance like heroin and morphine and things like that.

B. Graham: It’s not slow-release.

D. Hamm: Yeah, well…. The different analogues…. What happens is that the analogues become…. People just get used to them. So then they end up taking that analogue and mixing it with another analogue.

We’ve seen so many different types of fentanyl come out there and the effects on people. It’s wild how certain ones will…. People will react in a totally bizarre manner, and then some people go: “Well, it’s like being high on pot or something.” You know what I mean?

Fentanyl is so able to be manipulated by whoever the people are that are processing it and changing it all the time. That’s where the toxicity comes in. As he said, people are becoming homemade chemists, and they’re not knowing exactly what the amounts are and that too.

[4:30 p.m.]

Because of people needing to always have something maybe a little stronger, it’s kind of strange and sad in a way that when they hear about people OD’ing, they go: “Oh, where did they get that?” They want to get some of it. Because it’s so….

B. Graham: They think their tolerance is at that level.

D. Hamm: They think their tolerance is going to be fine and stuff like that, and they want to be able to get something that can work for them.

B. Graham: I think a good thing to point out is that we did a quick survey during the decrim era of 2021, where the city was putting in their threshold amounts. We did a bunch of questions with our membership. We had about 160 people complete that. We asked people how long a certain amount of grams would last people. We asked for two grams of opioids, and people said about 25 minutes was how long the high would last.

When we speak to people who used heroin, like one of our longtime members…. His name is Garth Mullins. He does the Crackdown podcast. You’ll probably see him tomorrow with BCAPOM. He used to use heroin 20 years ago.

He said: “I could basically have a full-time job before. I could do my drugs in the morning, and I could make it about five or six hours. Then I would do my drugs again, and I would make it through the evening. I could function in society how I wanted to function. If I had to do drugs every 25 minutes to feel the high that I wanted to feel, I would not be able to do the work that I do today.” He’s on his own journey of an OAT and all that kind of stuff.

It’s a different world now in how quick it is and how hard it comes down. I think it comes down to…. If you’re drinking and you think you’re drinking a 5 percent beer, but it’s actually an 8 percent beer, and it hits you harder, but you do it every day, eventually you are used to an 8 percent.

If you have dependence on something, that difference of 5 percent makes a huge difference. But we know that it’s a difference of 5 percent, so you can measure that, where we literally have no idea what the potency difference is.

K. Yake: Yeah, I’ve used for close to 40 years. I’ve done heroin for a lot of years. I was functioning. I was thought of as a functioning addict. I worked. I worked on the pipeline, heavy equipment operator. I was a chef in restaurants and stuff like that. I could function. I could go out, same as she was explaining about the usage, just in the morning and maybe sometimes in the afternoon and the next day.

Today there are a lot of people using, even longtime users, but because that’s what’s there, the fentanyl is in all of what they get. A lot of young people don’t know how to use properly. They haven’t got the education yet, so they’re overdoing it. A whole lot of young people are dying — ODing or dying. It’s sad.

I used for 40 years. I never OD’d. I never even came close to it. I’ve been high before, quite high, when I wasn’t working. But I OD’d about four months ago. I thought to myself…. When I get up in the morning, I’ll do a fix, injection. I’ll do a fix down, just to get going, to get to work, to get going to do what I have to do. When I OD’d, I was at friend’s place. It was lucky, because otherwise, I’d be at home by myself, and I wouldn’t be here today.

Since then, I quit injecting. I smoke a little bit, but I’m quite…. What I get, the supply I get, where I get it and what’s in it — a lot of people don’t have patience for that. They’re down on the street. Your friend or whoever you go to hasn’t got it. They’re going to just grab it from the next person. It’s Russian roulette, you know.

D. Hamm: We really need to expand the drug testing availability. That’s really a big, big issue that needs to be looked at, I believe, in keeping people safe. I mean, they just don’t have the time. When you’re sick like that, when you have those kinds of withdrawal symptoms going on, you just want to feel better.

I mean, I don’t know personally, because I’m not an addict that way. But my partner, she was, and I understand. Basically, every day I had to go to the clinic. It was like me being on methadone too. Every day we had to go to the clinic together. I might as well have been doing it also, myself. Yeah, the idea….

[4:35 p.m.]

B. Graham: His partner was like a supervisor at VANDU and supervised multiple people on shift, including…. The same with Kevin here. He’s also a supervisor and has responsibilities, has a job, etc. If we weren’t as flexible as we are at VANDU, a lot of people wouldn’t be able to have their jobs, because they would be at clinics all the time, in the middle of their shifts, and they would lose their jobs.

This is a big part of it. It’s not just about getting people to not overdose; it’s about allowing people to have lives. If people can actually have jobs and volunteer experiences and see their children or their families and not be stuck to the golden handcuffs of getting safe supply or OAT or whatever it is, it allows them to have parts of their lives they want to have, on top of being someone who uses drugs. Quite often, the amount of drugs you use goes down, because you have other crap to do.

D. Hamm: So some education for people on how to use the machines. People in the community, like ourselves at VANDU, would be a big step in helping to make sure that there’s safe supply.

What we do is we have meetings. We make sure that people are learning all the time about what’s going on out there. If they knew that they could come, they might stop and not do their drugs before. Take five minutes, go to VANDU, get it tested, and make sure it’s okay. Then use our OPS to do their drugs and make sure that they’re safe, also, and that too. It’s a double thing there. We make sure that the drugs are safe and that they can use it safely.

That’s why drug-user groups and organizations are so vital to a community, because there needs to be a way for people to have access to a safe supply. If it’s not safe, then it’s like: “Wow. Okay. What are we…?” It gives them an option. It’s like: “Okay. Well, I’m going to use it anyways, and I’m only going to use this much.” Well, then we have the OPS there. We can be there and monitor them and make sure that they’re going to be safe and things like that.

We have the luxury down here, in the Lower Mainland, of having had 24 years, now, of doing what we’ve been doing, making sure that we can keep our members safe. But we want to make sure that everyone is safe in the province and in the country. Any stuff that we can do that shows the good work and the real ways to deal with these issues, we need to expand that and make sure that it’s available to lots of people, to everybody.

S. Bond (Deputy Chair): Thank you very much for being here today.

I’m very sorry, Dave, about the loss of your partner. I know what that feels like, having lost mine.

Kevin, thank you for sharing your story about your life and the work that you’ve done.

Dave, you might have answered my question. I was going to ask you about drug testing and how important that is. At VANDU, you have the capability, or you don’t?

D. Hamm: No, we don’t.

S. Bond (Deputy Chair): Okay. That’s one of your recommendations, then, to us: having the option to test your drugs, whether you’re at VANDU or whether you’re in Smithers, B.C., is something that would make a difference. Is that…?

D. Hamm: Yes, it would.

B. Graham: It would. But I think it’s also an in-between measure. We have to stop doing band-aid solutions at this point. Those things would be helpful, but they would only be helpful in the hours we would have it. Those machines break on a regular basis and need to be repaired. You need to train people to look at them. So there’s a lot of stuff to get that in place.

I think that those things, we should be doing. But really, if we could focus on the systems of getting safe drugs without having to force people to do that system as the only…. If we put all our time and energy into that right now, it won’t save us.

It’s the same thing with the overdose crisis. If we had had injection facilities earlier, like the one VANDU had to close in 2014, we would have been able, in multiple places, to slow down this overdose crisis. We were already in the midst of it when we started opening overdose prevention services.

Those became band-aid solutions. That was the only thing most organizations were doing at that point, where you basically were paying us to watch people in their very last moments, instead of doing any of the steps to get them safer drugs, to change the system in which their drugs are taken away by the enforcement — those sorts of things.

Drug checking is really important, and we definitely could use more of those services. But it’s a distraction to the bigger issue, I think. In small communities, it would be very hard to have people coming in to test their drugs.

[4:40 p.m.]

S. Bond (Deputy Chair): I really appreciate that feedback, because my concern is that it takes a while, as you know — far too long, in your mind, I’m sure — to make the kinds of policy shifts and changes that are necessary. In the meantime, what on earth do we do to help people?

I guess in my mind — and maybe inaccurately so — I see it as not either-or but both. The struggle that I think we’re facing and feeling is: what are the most specific things we can do now, and how do we then build the system around that? I really appreciate that feedback, because I don’t want it to sound like I think it’s the ultimate answer, but is there a role for it in a person?

B. Graham: Definitely. It should be a prong, but I wouldn’t put it in the top five of things, personally.

D. Hamm: Right. And funding of drug-user groups — high, high on the list.

B. Graham: It’s because you need those networks of people. If you were going to go…. For example, right now there is some money that came from the province to get managed-alcohol programs moving and shaking in Vancouver Coastal. They wanted to move them into rural places, and a lot of those places didn’t have the harm reduction around alcohol at that point yet. They have to do a lot of education and growth and movement with those communities to get to the managed-alcohol part.

We’re at that place with drug-user groups as well. We don’t have specific places in small-town Vernon in which drug users can be in the same room and use drugs. They can’t even…. At this point, the municipalities are actually giving tickets for trying to have injections. They’re saying: “This is not a real injection facility, and you can’t,” where e-OPSs have been said, by Bonnie Henry, to be a part of the OPS and bylaw exemption thing.

It should be allowed to have OPSs in those places, but they’re coming up against all of these things. Until we create the system to allow people to come together…. At VANDU, if we were given a machine now, we would be able to find the people to train and get people to do all that, and get into that system. But if you tried to do it in a small town, it would take a very long time, because they don’t have the network, the trust or those sorts of things. Focusing on the growing of us is important.

P. Alexis: There’s a similar question with respect to the other health authorities that have not approved harm reduction sites. I just wanted to know about what some of the conditions are that are necessary to approve such a site, like physical things. Does it have to be close to a hospital? Does it have to be in a centre where there are other services? Does it have to be on a bus line? Are there a lot of layers?

B. Graham: To make it work?

P. Alexis: Yes.

B. Graham: I think that usually, you should tap into the drug users that are in that neighbourhood, because they’ll know where people hang out. For example, in the Downtown Eastside, it’s pretty common knowledge that if something is on this side of the ten blocks, and something is on this side, there are very few people that go to both services. People don’t go ten blocks away. It’s not a huge thing. That’s how things are developed here. When you have six OPSs in a ten-block radius, you’re like: “Why? That makes no sense.”

Well, it’s because we have a huge population of people who use drugs, and people don’t walk ten blocks. That makes sense for here, while in a small town they would say…. For example, where the Surrey group was set up — it was called SNUDU — they were set up near McDonald’s, I think, on 156 Street or somewhere around there, because that McDonald’s actually had harm reduction services in their place. They would be like, “Here are all the supplies you need,” because people were coming in and using their bathrooms so much. So it made sense to set up close by there.

In the end, they got a bylaw office…. The bylaws were pushing the landlord to take away their lease. It ended up…. There’s a court case that came from it. You can speak to Pivot about it — they would know more details — but basically, they got kicked out of their space, related to municipality stuff.

D. Hamm: So right there, the Ministry of Health needs to be aware of these situations. I’d start looking at municipalities, looking at what they’re doing when it comes to zoning and bylaws and different things that are stopping the Ministry of Health from actually having their mandate. What they’re saying needs to be done is not being done. They’re illegally circumventing the people from being able to use a space.

[4:45 p.m.]

It just speaks more of the province being more engaged with drug users in every area. Where you see high levels of overdose, okay, there’s a real need there. There are probably drug users there that have information that you need, and more than likely, there probably could be a space.

When I think about the Fraser Valley, for two years there’s been money for Lookout and somebody else to put in these OPSs, and they have not been able to because of no access to a space.

The health authority should be able to just go: “Hey, wait a minute. There’s a space. Maybe they have access to a space of their own.” You know, maybe they can use some…. There could be community centres that have a room where at least they can come and have a meeting and stuff like that, right? Maybe there’s a medical facility nearby that would also be a great place to put in an OPS. I mean, they had OPSs up at St. Paul’s, outside the hospital.

B. Graham: I think, also, there is a network of drug users in every city. They just haven’t been mobilized into a group. I think there are people we can help. We can figure those things out. But we know…. During the pandemic, when they got that $3 million, we went from five groups in this province to about 16 that we would consider to be drug user groups that are autonomous or working to their own autonomy. That’s a huge improvement, where people are able to go to their group and talk and share information and decide on things together.

I’ve worked at VANDU for ten years, and I know my shit. I can make a decision as to what I think will happen in a meeting, etc., and it will go completely different because I’m not part of the group. I am working with the group. So, really, I don’t know the day-to-day thoughts and processes of what people are trying to do. That’s the biggest thing here: tapping into that knowledge and using that knowledge to move forward.

N. Sharma (Chair): I just have a final question, and then we’ve got to wrap up. Thank you for helping us — as I go a little bit over here.

Interjections.

N. Sharma (Chair): No, I think we’ve all really enjoyed the conversation, and we started a little bit later.

One of the things that I find really great about this, what we’re learning and through the reaction to the stories that you’ve provided…. The beginning of all of the interventions that came from VANDU and people that were using, and one of them was naloxone — that was something that you kind of…. There’s that push-and-pull between policy and grass roots that develops it. We’ve seen this graph quite a few times about the numbers going down right before COVID, that less people were dying, and then there’s just this spike after that.

I really would love to hear your response to this in that context, which is that…. It sounds like what we’re learning is that the toxicity of the drug supply has just really shot up there. Some people have come before us and said: “We don’t know what safe supply is.” It could be safer supply, but there’s also…. Like, what is that?

I want to know from this kind of grass roots that’s coming up with solutions: how do you get people on something that is going to be safe? In the context of fentanyl being so…. It sounds brutal in a lot of ways. What does that look like? I’d love to know.

K. Yake: I used to say that the spike during COVID…. We’re educating people to not use alone and to always be with somebody, and then COVID started, and they’re saying to distance yourself and stay home.

It sounded like they were looking at COVID and thought there’s a more important thing than people dying from drug overdoses, whether there was or wasn’t, but that’s what was happening. But we’re educating some people to not use them, and people knew that. Then COVID, like I said….

D. Hamm: There’s a demographic of the people that were…. There were males between a certain age. I believe it was in their 20s to 49 or something like that. Basically, these were people that had been let down by their medical provider.

A lot of them were construction workers or people like that that had received injuries, and then they were getting pain medication. Then they were cut off their pain medication, and they had to go drug seeking. They ended up finding a street solution, and because of stigma and things like that, they would not want their family, their employer, anybody to know that they’re now having to use an illicit supply.

[4:50 p.m.]

Meanwhile, it’s woefully misguided of the medical people to not have a tapering program or something for these people. They became one of the higher statistics in the overdose and that. It’s not just the street drug user that’s being affected by this.

The lady that started Moms Stop The Harm…. My partner and I were the very first people she talked to right after her son died at SFU over here. It was a really powerful conversation we had. From that, she just took it and…. I felt so privileged, actually, that we had a chance to help somebody get an understanding of what really the problem is.

She’s standing up and getting all the other folks that have lost their children to this process. It’s not that they’re street-involved drug users. There are people in everybody’s family. I’m sure almost everybody here has somebody that has been affected by this or they know somebody that’s a close friend or family that has somehow been touched by this crisis.

B. Graham: Going back to what Kevin was saying, one of the things you could point to during COVID is there were policies that were created that stigmatized poverty, which continues to happen with almost everything. For example, the SROs in the Downtown Eastside implemented guest policies in which people weren’t allowed to have guests because of social isolation. That makes sense in that context, but actually a lot of those places already had guest policies, where if you were a known drinker or a partier, they wouldn’t allow you to have people. So that doesn’t let you have a safe space in your room.

I guess going to a safe injection site would be the next place. Most of the places limited their hours or limited their space. VANDU is one of those places. We were told we had to have more space in between our tables. So our six-person went down to a four-person. Even then we were really pushing it. That’s one of the things there. There are less places and less spaces for people to use in injection facilities or OPS’s.

The other thing in the Downtown Eastside…. Oppenheimer Park was not open for the first year and a half of the overdose crisis. It opened last July. The one park space in the Downtown Eastside that people could go to was not open for people to go to. Every avenue of places where people could congregate was taken away from them. Because they’re poor and in a poor neighbourhood, these things don’t matter to the general public. That is a big part of it, when we see things happening on the ground, and we say these things are not okay. They’re demoralizing, and they’re derogatory — whatever you want to say.

Most of the time it falls on deaf ears, because people think we’re complaining. But realistically, every other park in the city — 23 parks — were allowed to have drinking in them. Yet the park in the neighbourhood here wasn’t even open.

We have to think about these things as beyond the actual…. If we got better drugs, yes, people would be doing better. When you don’t allow people…. Even now, there are buildings that still have guest policies that are carried over from COVID. People are using these as ways to…. Obviously, when people have friends over and that kind of stuff, it makes things more complicated in your buildings. So the building managers make decisions that are easier for them instead of what’s best for the residents, and they treat people like children.

D. Hamm: You’re basically taking away the rights of people under the Residential Tenancy Act also. That’s the thing. This supportive housing has been listed in the Residential Tenancy Act. Anytime that they make you sign a contract there that relates your housing to the programs that are being provided, if you don’t fall into line, you could be at risk of losing your housing. It’s an illegal contract.

Right at this time — I don’t know how or why — there’s lobbying being done right now to change in the legislation right now about supportive housing being taken out of the RTA. The only reason they’re doing that is because they realize now….

In 2020, it was put into there specifically, because it was a grey area, everybody said. Specifically, supportive housing was part of the RTA. Now they’re saying that they want to get out of that. You know what I mean? There is no provision in the RTA for any opting out of any part of it at all. If you’re in the Residential Tenancy Act, all those things apply.

[4:55 p.m.]

These places like Atira and all that are trying to use the fact that they’re supporting these people in what they think are productive ways to affect their housing, so there have been a lot of people evicted illegally also. So that’s another thing we’re working on.

I just want to show you how it works when it comes down to people’s dignity of having a space and a home. That is the biggest thing that works against everything that we try to do when it comes down to harm reduction a lot of the time.

B. Graham: I think, to bring it to the end of this, the overdose crisis was declared, and it gives the B.C. government more powers to make more decisions. I think, ultimately, a lot of the decisions that are being made are sort of in the moment — how do we do things right now? — instead of thinking about it further down the line, where it’s like: we need a safer supply, and we need to think about that now and move it further.

Beyond that, we need to think about how housing is being affected here. Because you have created this crisis language, you can have more conversations between departments — the Ministry of Health and the Ministry of Housing. This is the opportunity to actually streamline these things and figure out what these inequities are that are leading to a bigger crisis.

These things have been happening for decades. The only reason it’s so bad now is because the drugs are horrible. All of the other things were already happening, and we need to address those things to actually have long-term changes. If we can use this crisis language that you have created in the government to actually streamline those and use it to have more conversations interdepartmental-wide, that would make things a lot better for us. I think we’re constantly saying things into the ether, and we don’t know if it’s really affecting anything.

Even the OERC. They want to have only conversations with us through CAI, which is Community Action Initiative, about the $3 million. We’re saying: “We don’t want to talk about this $3 million anymore. Give us more money, because more drug users need more money. You have 16 groups of people who use drugs across the province, and you’re not using us to talk about the actual issues that we’re seeing in our province.”

We’ve probably had 50 hours of Zoom calls to talk about that $1 million in the last year, and it’s such a waste of resources. All of those times could have been a place to get a direct pipeline from people who use drugs to the government to say: “These are the things that are wrong for us.” You guys can take that back and say: “These are the top four things we can work on now, and these are the things that are just impossible right now, etc.”

We understand that not everything can happen in one year, but the resources that are going to supporting drug users are inefficient right now and are not enough. We could be having all those conversations with the OERC and the Ministry of Mental Health and Addictions and the Ministry of Health in a much more productive way than talking about the same $1 million over and over again.

D. Hamm: That $608 million was from the federal government, right?

B. Graham: Yes.

N. Sharma (Chair): I’m sorry to say we’re coming up on time for other presenters.

D. Hamm: We could go on and on. But we have people coming tomorrow that will keep….

N. Sharma (Chair): Yeah. I just wanted to say, on behalf of the committee, thank you so much for coming and telling us your stories, what you’re seeing and all the really very clear policy recommendations that you’ve put forward today. Thanks for all your work.

D. Hamm: In the spirit of that, let’s get together some more then.

N. Sharma (Chair): There you go. Definitely. Thank you.

Do you want to take a few minutes to get yourself…? We’ll maybe start at 5:05.

The committee recessed from 4:59 p.m. to 5:08 p.m.

[N. Sharma in the chair.]

N. Sharma (Chair): It’s my job, on behalf of the committee, to welcome our final guest of the day. That’s Guy Felicella — welcome — harm reduction advocate and peer clinical advisor.

We really appreciate you giving your time and expertise with us today. We’ll have about 20 minutes for you to present, and then 40 minutes of discussion. As you could tell from the last presenter, we’re really a committee that likes to dig deep in discussion, so we’ll leave enough time for that.

We have our slides here. We’ll let you go ahead.

GUY FELICELLA

G. Felicella: Awesome. Thanks, everybody.

I want to acknowledge that I’m grateful to be joining from the traditional, ancestral, unceded territories of the Musqueam, Squamish and Tsleil-Waututh First Nations.

I also want to acknowledge that the ongoing criminalization, institutionalization and discrimination against people who use drugs disproportionately impacts and harms Indigenous people. Ending drug-related harms means ending colonialism.

Just for a little bit of history, for me, I struggled im­mensely with many different challenges as a kid — undiagnosed ADHD, trauma and abuse as a young person. This led to me to cope with using substances. I didn’t grow up in poverty, but poverty found me. Addiction or substance use disorders can create that as well.

[5:10 p.m.]

My history began at 12 years old with being criminalized for using substances. Nobody thought to ask deeper, like: why the drugs? They didn’t care. I was just a criminal for using them. That was the first encounter with stigma in my life, obviously — being in juvenile detention at 14 years old for one year for carrying drugs, selling drugs to, really, numb pain. I never was a social user, but I was a user that used to numb himself.

So I found myself, at a very early age, as a teenager, in the Downtown Eastside of Vancouver, where I felt a sense of belonging. What I could notice down there…. I could see people struggling with pain. I’ve been brought back to life six times. I’ve survived decades of being homeless. I’ve also survived the first dueling public health emergency, which was the HIV/AIDS crisis and the first overdose crisis in the 1990s.

We’ve never changed from then. We never addressed the overdose crisis then, so what we’re seeing is a repeat of history again. I saw the same eerily familiar circumstances happen when COVID-19 hit the public. Every resource went into surviving and doing whatever we could to get out of COVID, and we let people die again, senselessly. The amount of death that I’ve witnessed in my life is astronomical.

What I’ve seen with the drug supply today is that it has gotten increasingly worse as each day goes by. It’s that unpredictable. Anybody that uses drugs…. You get one mistake. Sadly, naloxone only works when somebody’s there. But we’ve created the stigma in these policies, through our policies. This created the stigma which drives people to use alone.

I also want to represent to you that one-fifth of the employed workers in this province that die of a drug overdose are construction workers. These are people in all communities. This is not a poverty issue. The thing is, yes, people use substances in poverty, but it’s in every community. The alarming amount of people who are dying in our community is just egregious and unacceptable.

I struggle with the trauma from the past. I have to pay for trauma therapy. It’s not covered under MSP. Rooted in addiction, it’s led by…. Ninety percent of the people who do struggle with addiction have some related forms of trauma or undiagnosed learning disabilities, yet we charge people $150 an hour to go see a trauma therapist. So people who need trauma therapy don’t even get to go through the door. Instead, we just focus on getting people off substances. We don’t focus on what the pain is that got you there.

For me, being a person that’s been in recovery for almost a decade right now, it seemed that people were trying to keep me trapped in a system that continues to punish you. So when I was trying to get off drugs, the drugs that were given to me…. I ask every one of you here. If you needed some drugs — something to function through life, whatever it is, for pain or pain management — but I made you go to a pharmacy two, three times a day…? You create another prison around people.

We wonder why our methadone services are very hard. It’s not the drugs. It’s often what we do, to make people go through to get those substances. We basically show people: “If you use drugs, we don’t trust you.”

The picture with me on the slide with the students with their hands up…. I asked those students: “How many of you have been impacted by the overdose crisis?” Those are the hands that went up. One hand would be too much. Kids are already feeling the stigma of our society because of how we view people who use substances.

I had a youth come up to me after my last school talk. He said: “Thank you for saying that drug users aren’t bad people.” He said: “My dad died of a drug overdose in 2020. I don’t share that with people. I say he died of a brain aneurysm.” He said: “My dad wasn’t a bad person. He just had bad circumstances, but he loved me. He was my dad. He cared about me. He did the best he could.” This kid is walking with that stigma, that shame. He’s 16 years old.

The amount of stories that I hear from doing my high school talks with kids is just astronomical. We’ve passed this on to another generation that’s going to have to deal with it — struggle with it and deal with the pain and the trauma. We’ve failed people. We’re failing our youth. We’re failing the people who use substances. We’ve created this. Our policies have created a divide towards the context of reality for people.

We need to tell people the truth about substances — like, the realities of substances. Give people the information. If telling people not to use them worked, then why didn’t it? Why doesn’t it stop people from experimenting? It doesn’t. We have to change our approach. Our approach is really…. Like, take it from a guy that was down here in the ’80s. Harm reduction wasn’t even a word then. I watched it become implemented from the very beginning stages.

[5:15 p.m.]

I was a person who was incarcerated for just carrying drug paraphernalia. That’s not even the drugs. I spent nine months in prison for carrying syringes in a wrapper. Can you imagine? We constantly…. Once you get in that criminalized system, it’s very challenging to get out.

Hospitalizations in the 12 months prior to death in British Columbia…. We’re not just failing young people, but we fail all people who use drugs. People are dying after they’ve “been helped.” More than a quarter of people who died had been in the hospital. People are dying after a relapse or following a release from a treatment centre.

So going to treatment to get off drugs doesn’t always guarantee that people will stop using substances. But if people do use again, their risk is extremely high. The risk of people dying — in the hospitalization slide — from being released from incarceration or from treatment is astronomical. It’s so high. Our systems fail people precisely when we should be supporting people.

Data from Bowdan showed the retention of treatment is declining for methadone, Suboxone and iOAT. As I shared briefly, in the beginning, it’s because even when somebody wants to change, we put them to go to a clinic. We basically chain them to, now, pharmaceutical substances.

One of the biggest things that I’ve noticed, too, with the medicalized approached, with offering people safer supplies is that for some that get it, great. But it still puts the barriers of the system in place, where you have to go repeatedly to a pharmacy. Sometimes it’s daily witness. It becomes extremely challenging to move forward.

In rural communities — I’ve been in Fort Nelson, Fort St. John — it just doesn’t exist out there. They don’t do it. They have a doctor that flies in once a month to offer methadone. If you’re not there, too bad — suffer. What kind of society have we become where we’ve just lost the ability to care outside of ourselves to see that people are dying and struggling? People want help. They can’t get it.

Then another challenge with the illicit drug supply being so toxic is…. Try to get into a detox with the benzos in the supply. It now becomes a medicalized detox. Anybody that has benzos cannot go to a regular detox. You have to be monitored by a nurse. You have to see a doctor, because you can die from benzos.

Benzos in the supply chain have created another barrier for people to access support. Now they go through a medical detox. But then after the medical detox, if you don’t have $30,000 to pay for treatment and you’re on an income assistance file, then it becomes a wait-list.

Our wait-lists have changed and become death lists. People are waiting to go, but they can’t go. You go through the systems of care once or twice. It’s so dehumanizing and defeating, and we wonder why people don’t try it again. It’s not people that are failing; it’s the system that fails the people. We have to change that system.

I say this often — that it was easier for me to access treatment and detox and recovery in the ’90s than it is today in 2020. What I mean by that is all those barriers that I talked about. But the one barrier that now puts that big challenge is the benzos in the supply chain. I will tell you this — that I witnessed it change and change and change. What’s next that’s going to get added? Because something will…. It’ll be added in, and then what are we going to do?

The question is: why aren’t people retaining on treatment? For me, from a guy that tried treatment over 15 times, you know how I got it? I was finally diagnosed with ADD. Then it blew my mind, because the person said to me: “I don’t think your problem is the drugs. I think there is a reason why you use them the way you do.”

I never heard that before in my life. I just started to cry, because I’d always carried the shame that there was something wrong with me. Why couldn’t I do it like everybody else says they do it? I couldn’t do it like you, because I couldn’t learn like you.

In school, I was called hyperdifficult and hard to manage. I was put in a cubicle. I was shamed that I couldn’t learn like everybody else. Back then, too, they hit you in school. They were allowed to hit you. So you deal with all this trauma and this pain, and then you have to live your life after it. It was too painful.

The comforting thing for me is — I always say this: if people go through what a lot of people go through, you’d understand why we used drugs or why we use drugs. The hardest thing that I’ve ever had to do was get off the drugs. That took a journey of 31 years.

People would say: “You overdosed once. Why wouldn’t that be enough?” It’s because I tried to get off drugs, but the pain of the past was just too unbearable to deal with without them. Until I was developed in those coping mechanisms and skills, through trauma therapy, through out-patient programs…. We don’t even have out-patient programs. We want to throw people in in-patient programs.

People associate treatment in our society with prison. I could do good in prison too. I’ve been to prison a lot of my life. I was very successful in prison. I didn’t use substances.

[5:20 p.m.]

I’d get out. It couldn’t translate into life. I was very successful in a structured program for three months. Unfortunately, that didn’t translate into a good life. So the retention rate is really all these other circumstances — that we force people to go five, six or whatever times a week to go to a facility. You eventually become defeated doing that. You can’t get a job, can’t look for housing.

One of the things after treatment that’s a big thing is that nobody has a place to go to after. Our best excuse is, “Here’s a shelter,” or: “Here’s a shelter. White-knuckle it after we’ve gotten you through detox in 80 days. Make sure you don’t use for the next six weeks, because that’s the wait-list to get into treatment.” How do we tell that to people? If I had a heart attack, I’d go through systems of care immediately. If I have a drug addiction or a drug problem, there’s a wait-list, and a long one.

On slide 7, as you can see from the coroner’s service, the toxicology reports, there’s no margin of error. The drug supply has become more dangerous and unpredictable. In less than six years, heroin isn’t even in the supply chain anymore. There is no heroin anymore. It’s fentanyl. Now it becomes increasingly harder to use the medications that used to help people get off heroin or get methadone or get heroin.

If you look at the models in Switzerland, they’ve become extremely successful. In Switzerland, at the Arud clinic there, they give carries twice a week. People come in two times a week to pick up their substances. It’s widely successful. It didn’t make more people use heroin.

We always talk about diversion. You know, diversion, diversion. Let me tell you something. Diversion has happened since the 1970s. People divert substances because if they don’t work or…. Would you take them? If something doesn’t work for us, why would we take them? We would take what works for us. It becomes more challenging.

Fentanyl has really taken over, and the concentrations, as you’ve seen across the province, have gotten extremely high. Vancouver used to have the highest concentrations, where up north used to have the lowest concentrations. Now the north has the same concentrations that are in Vancouver but has the lack of services. That’s why you see the most deaths are happening out there, because they lack the services to support people that use substances out there.

People get one mistake with this, and that’s it. Gone. We’re gone. These are people.

On what a continuum of care should look like: baton passing. A relay race. Harm reduction. Recovery. Running systems of care. Running on the same team. You have the option of moving from recovery. If you wanted to go back, if you were going back, there should be a pass-off to go back to harm reduction. We shouldn’t let people just: “That’s it. You’re done. Go.” No.

We need to do more at making sure people have access to services, because if somebody’s going to use substances, they’re at such an extreme risk. Harm reduction, safer supply, treatment and recovery all working together to meet the needs of people wherever they’re at — it’s so important.

I wouldn’t be here if harm reduction didn’t exist. My kids wouldn’t be alive. I wouldn’t have the life that I have today, so I understand that we need both working together. People deserve to have a life instead of being trapped. People don’t have to wait weeks to access a treatment centre.

Many places in B.C. don’t have harm reduction services to make sure that people will stay alive while they’re waiting. There are so many people that I talk to throughout not just Downtown Vancouver. People phone me, email me or cross the country asking to access services in London, Ontario; Toronto; Ottawa; Vancouver; and Alberta. The amount of people I hear from — their stories of a family member or a friend struggling with a substance use disorder…. People are getting frustrated that nothing is being done to support people.

I listen to so many people who’ve lost a loved one. I’ve listen to so many kids in a high school talk to me about how they don’t have their parents anymore. They’re in foster care now. It’s just truly tragic.

That relay race that I talk about so often is the important aspect of having the full spectrum. Listen, you can’t support…. I don’t support harm reduction over recovery, and I don’t support recovery over harm reduction. I support helping people. You don’t get that confused. You are in a position to understand that you have to support people. It’s not and/or. It’s both. But it’s the people that we’re here to support, not anything else beyond that.

[5:25 p.m.]

When I took an oath to public service, I said: “I’m going to help people.” I’m not going to get that confused. If we get that confused, then we can get politics on one side or ideologies or our own beliefs. I don’t blame people in our society for how they view things. But I do blame you for not educating yourselves on the policies and procedures that were implemented from the past. Read up on it, to get yourself informed and to understand that those policies still exist today. Those policies were built in racism. We still have them in place, and we wonder why people don’t change.

We need a strong government response. You know, the second-to-last slide shows just how much money we spend: opioid use disorder treatment, $152 million. Everybody says that we don’t put enough into the recovery services. Well, if you look, there’s $133 million into that. There’s only $45 million going into overdose prevention.

But look at this. Mental health supports for children and youth is only $97 million; eating disorder care and suicide prevention is $8 million; early psychosis intervention is $53 million; and First Nations Health Authority is $14 million. You know what we do? We spend the bare minimum and expect maximum results. Then we wonder why nothing changes.

We do need strong government support from all of you, from all of your positions. That includes empowering the OERC to lead the work to make recommendations that aren’t always politically favourable. That needs to happen. The right thing to do is to keep people alive, because nobody gets another chance. When I look at my kids or when I look at other people, friends that have gone through a similar journey as mine, and I see them with their kids, then I see the magic that they were supported. With my kids — for them, when I stare at them, I’m amazed that I’m alive.

I’m grateful, honestly, to have the opportunity to always be there, to learn. Don’t waste mistakes. That’s what we can’t do. We have to learn from our mistakes, because our mistakes are what…. We can’t keep saying we’re sorry. “Sorry” just means we’re going to do it again. We have to learn from the mistakes of the past to change the future. I will tell you this: more and more youth are going to die; more and more people are going to die. It’s going to go up; it’s not going to go down.

The drug supply is never going to go back. We’re never going to defeat or change that supply that organized crime has going. That’ll never go away. It’ll always be there. They’re very efficient in swallowing anything that anyone throws at them. They’ve been doing it forever. They can’t be stopped.

We waste billions a year in trying to keep drugs out of the country. Yet we spend billions trying to reduce the harms of those drugs, through what has happened to people with medical, health, HIV, hep C…. With all the money that goes into this, this is a massive industry. What we really have to do is to help support people and give them the opportunity that I had, instead of burying people. Sadly, that continues to happen every single day.

In closing, I want to remind you that between five and six people have already died today in this province. To me, that’s unacceptable. In ten years, there were about 220 to 250 deaths a year. That has changed, and now it’s 2,200. It’s ten times more, in just seven short years.

Any questions? I’m happy to answer. I hope this just inspires people, too.

N. Sharma (Chair): Thanks, Guy. We have hands going up.

T. Halford: I’ve got a bunch, so I’ll ask one, and then I’ll come back. This is a good way to cap the day. I think we’re on Facebook together. I’m sure you, with other MLAs, are on Facebook. I’ve seen pictures of your kids. Obviously, you’re a very proud dad, as you should be.

[5:30 p.m.]

One of the things that I don’t think we talk enough about, ever, even when I was growing up, is prevention. Some kids don’t have those people to have those conversations. What are we not doing in this province, on the prevention side, that we should be doing to get at them early and get them educated?

I’ll come back to the other ones after everybody, but that’s…. How are you talking to your kids? How would you talk to my kids? I’ve got two boys in grades 8 and 9. How would you talk to them? How do we have those conversations, and are we having enough of those conversations?

G. Felicella: We’re not having any of those conversations.

One of the things, as parents…. You have to remember this. It’s okay to say: “I don’t know how to have the conversation.” Being a parent is being able to have humility, as well, and to say: “Hey, I don’t even know where to begin.”

One of the things that I always educate, when I’m talking to youth or I’m talking to parents, is…. We have to inform people on the realities, but we also have to inform people that not everybody who uses these substances has an addiction either. We can’t go, right away, that anybody who uses illicit drugs has a drug addiction. That would be the same as me assuming that anybody walking to a liquor store has a problem with alcohol. It’s not the case.

When it does become a problem, or if it does become a problem, then what? Usually, what happens is…. We haven’t had those early conversations, and by the time we’ve found out, we freak out, light the house on fire. We’re like: “Oh my god. I’ve got to get this kid into treatment.” Then what we do is….

We start forcing the issue. What forcing does is…. It changes the direction of your relationship with your child. They don’t want to trust you anymore. They couldn’t come to you anyway, for whatever reason that is, and it’s because…. Sometimes, often, how you view substance use as a person, or how you may view poverty, will have a tremendous impact on your children and how they’ll view things. If they ever do struggle, they won’t use you as a resource because they know how you are.

One of the things is…. You don’t need a PowerPoint presentation to ask any kid in grade 8: “Hey, do you know that we’re actually in a public health emergency for the overdose crisis?” Engage them. Let them talk a bit. Most kids would be like: “Oh yeah. How many people are…? I heard it’s like….” They’ll say some number, probably way over the number, and you’ll be like: “Actually, five people die every day.” They’re just like: “Yeah, man, that’s….”

One of the things, too, where I educate kids in high schools…. I’m never there to tell them not to use drugs. I always say…. I don’t tell any kids to use drugs. However, if they are using, I definitely want to educate them on how to use them safer and what drugs they’re using. You have to have that trust. I’m not there to tell them not to do something. As a parent, you could tell them: “I’m honestly very worried about the circumstances of what you could be growing up in.”

There’s experimental drug use. Even with the best parenting, kids are going to go with their peers. No matter what you’ve done…. They’re going to follow their peers, no matter what. Social acceptance for youth? Come on, right? That’s the biggest thing in a child’s life, to be accepted by their peers. I wasn’t accepted as a kid growing up. I was accepted by gang members. It doesn’t matter what they were doing to me or grooming me. What mattered was that acceptance. That’s what our kids look for. So to have a safe place to talk….

Sometimes parents call me. They’ve found that their child is smoking marijuana, and the first thing I just say is: “Hey, it’s not fentanyl.” Then they’re like: “Oh god. What if it is?” I’m like: “Well, you know what? Chances are…. Kids experiment. Why don’t you have the conversation?”

You have those conversations, and then they start to talk about it. They feel comfortable talking about it. They have to be able to trust you.

You know what? It’s not just being a parent. It’s trying to be their best friend. That’s probably the best advice I ever give a parent. Your friend talks to you about their struggles. You’re going to give them advice. If your child comes to talk about struggles — let’s say they are using substances — you’re going to give them some advice. This is the time that you…. We don’t freak out. When you do that, it does hinder your relationship.

[5:35 p.m.]

You can repair it. Even if you’ve gone past that and your child’s already using drugs, you know what you can say? You can go back and apologize and say: “Look, I just really love you. I’m really worried, and I don’t know what the heck to say or do. I just want you to know that. Please come to me and talk to me and let me know.” Then start there. You’ve got to start. And we don’t. We don’t start in the high schools. We don’t start at home.

You know what it is? Parents like to blame the school, and the school likes to blame the parents. Well, actually, I always say this to the parents: “They’re your kids.” But the school system needs to do a lot more.

S. Furstenau: Thanks, Guy. In your own story, your undiagnosed ADHD is a significant part of, as you say, what (1) got you on the track of using drugs but (2) helped you get off of it — finally understanding. I’ve heard you talk about this before.

You’ve also worked a lot with youth and young people, and you go and talk to schools. Can you give us some insight into…? You just said the schools blame the parents; the parents blame the schools.

Schools are a public institution. They are a provincial responsibility. What do we need to see implemented into schools to make sure that no child comes through with an undiagnosed issue like ADHD or many others, and how do we make sure that there’s an equity of access to information and education that we should expect kids to have?

G. Felicella: Well, even when I started doing school talks four or five years ago, people would say to me: “You will never be able to talk about harm reduction in the school system, because that would be encouraging substance use.” I remember telling that individual, when I went into the very first school: “They only bring me in once. Maybe it helps one person. I really don’t care what the school board says.”

I went in. We talked about basically my whole history for an hour, and there was a lineup of kids after who came and talked to me. The teachers were in tears. People were in tears. They were motivated by the story. I always say this with kids. That’s what kids relate to. They relate to people’s stories. I go in, and I just say a bunch of stories to the kids. Then the kids start relating to their own struggles.

Listen, I’ll tell you something right now. Other than the substances, or before the substances, there’s a lot of anxiety and depression and other stuff that’s going on and that’s brewing inside of kids. I’ve had so many kids reach out on my social media and call and say: “Does the anxiety ever go away?” When you hear that from a young kid struggling with the pressures of life…. I always say: “Maybe it doesn’t, but we find a way to cope with it in a healthier way.” That’s what we don’t teach.

When you don’t know how to cope, when you don’t understand or you’ve never been taught how to cope, especially with how their family life is…. There’s a story behind a person. For all those people we see in the Downtown Eastside, there’s a story. They were a child. The system failed them. Guess what. Now we’ve just discarded them as disposable. It’s so true, and it’s so heartbreaking.

The importance of sharing stories with youth. The importance of going in, people who have experienced it. Kids say that to me. It’s like: “I’d rather listen to Guy than have law enforcement come in here and tell me that I’m going to be arrested for using substances or tell me that this is what the drugs do.”

I don’t share graphic details of my drug use with kids. I just share the story. I also share the story behind all that, what I didn’t know. I wasn’t aware of what I was going through. Everybody just said: “It’s the drugs. You’ve got to stop the drugs.” “If this guy gets off the drugs, his life’s going to get better.”

A lot of those times at schools…. There are some great schools doing some great things, as well, some of the alternative programs. These kids are using substances. They’re treated with…. I ask any kid in the alternative school that’s using substances: “Which school do you like better, that one or this one?” They’re all like: “Oh, this one.” It’s because over there it was a constant barrage of either being suspended….

We just punish people. You get caught vaping at the school; you get suspended. So people have to go off the property. We do that with substances as well. We tell people: “No, you can’t do it here. You’ve got to go hide and do it.” That reinforces what people do later on in life, when you’re already shamed early.

[5:40 p.m.]

I’m not suggesting that there should be a spot, but we shouldn’t be telling kids…. I always tell kids this: “Can you try to go through the school day without using?” A lot them say: “Yeah, I could try that.” But you have to have that conversation and say that so people have communication.

Kids in schools use substances. I was glad to hear on the news the other day that they’re finally doing naloxone training. Well, just to let you know, we’ve been doing it for years in the school system.

Definitely, it was brought in, obviously, to the Delta school district, which was a highly conservative place for someone to go into the school system. They’ve just flipped it — a total 360, or 180. We go in there and do community forum talks talking about substances, trying to change the conversation to end the stigma that’s behind it so that youth have the ability to reach out to their support and counsellors. Definitely, we need to share those stories, because kids are struggling, and they don’t know how to let it out.

S. Bond (Deputy Chair): Thank you very much. We’ve obviously heard your story and watched you on television and elsewhere, so we appreciate you being here today.

On one hand, you say that people get one mistake. That’s so true. It’s every parents’ nightmare. We’ve all seen the stories of the 14-year-old kid in the playground who was pressured by his friends. I remember thinking: that could be my grandson. So how do we…?

You’ve shared in the two questions that you’ve been asked about how we have to change our approach. We’ve heard over and over again that there are underlying reasons that people use, and we really need to talk about that. But how do we start talking about the risks? If you are struggling with whatever it is, as you say, there are healthy ways to try to cope with that. But there is a gap. We don’t talk about this publicly — about the fact that there is risk in doing drugs and, frankly, you might die.

I understand where we’re at. Our work is to try to figure out how we’re going to stop people from dying. But I very passionately believe that there has to be something on the front end somewhere, where we find a way…. I get that “drugs are bad” may not be the message that works, but we have to have those conversations early so that we’re not just getting the coroner’s report every month.

We hear so little in our presentations about prevention or how you talk about this in a way that is realistic. You can die. Tell me what you think about that, because that will be an important part of where we end up. From my perspective, that will matter to me a great deal.

G. Felicella: A lot of the time, the kids…. I talk to the kids. The majority of kids are not using fentanyl. However, they are using Xanax, Ecstasy or molly, and that could possibly, potentially contain fentanyl.

One of the things the kids say to me is this. I say this to them, and they say this to me. I say: “If you could check your substances to know what was in it, and it did contain fentanyl, would you take it?” “No. But if I don’t know, I’m taking it.” That’s dangerous, so I try to say to them as well….

When you do these talks in schools, you start to build a relationship with a lot of the kids. One of the things I always say to kids is…. A lot of them are smoking the two regulated drugs — marijuana, and drinking alcohol. These are regulated. There are a bunch of them who go to concerts or raves, but what they like about going there now is that they can test their substances there.

So one of the things I often encourage youth, because they always ask me…. “Well, why I don’t to go to the Downtown Eastside to get my drugs tested.” I’m like: “Yeah, you should.” In some communities, there is a place where youth can access those services, but it’s very limited. Basically, it’s maybe a couple of hours in this community centre and that’s it. So definitely that.

Kids are very smart as well. You know, when you have those open conversations…. I talk about the risks. I talk about my life with kids. They relate to the story. It makes them think.

[5:45 p.m.]

I share my story to help people think and reach out. I always say, like, hey…. The sad part in our reality now is that first-time substance use can result in death. Intermittent substance use can result in death, and using daily can result in death. It’s gotten that unpredictable.

Even when you’re 16 years old…. A lot of the times, too, where I educate kids who are using the hard substances is that I’ve gotten them hooked up with a doctor. You don’t have to have parental consent at 16 to go see a doctor and tell your doctor that you want to get on opioid replacement therapy. I’ve gotten a few kids to talk to their case manager teams. They even know this. You’ve got to give the information that people understand. Whether you’re 16 or 30, you should know the resources that exist. We don’t give people that. It’s kind of like we have them there, but we don’t want to tell people what’s there.

This kid. I’ll tell you something. He came downtown, sold a Walkman. He wanted Ecstasy. He got fentanyl. He overdosed at the Stadium SkyTrain. Transit Police brought him back to life. I went to do a school talk at the school. I won’t mention the school. He was diagnosed with ADD. The story resonated that I told the class of my own struggles.

The teacher called me. When I started talking to the teacher, she started to cry. She said: “He’s just so similar to you. I talk to him, but it doesn’t connect with him how dangerous it is.” I’m like: “Oh yeah. People used to say that to me.” I’d nod my head like I knew what you were talking about, but I knew nothing.

Anyway, I went and talked to him. He got on Suboxone. His whole life changed. They didn’t even know that they could do that. He went to a doctor. They gave a prescription. Even when I was talking to him, he was like: “This stuff is amazing. I take one pill a day, and I show up at school and I’m not so hell-bent to do the street drugs anymore.” We have to allow kids the understanding and awareness. That’s just one story. There are many.

I always talk about the risks. I always talk about how I never chose to be on the Downtown Eastside. I never chose to be homeless. The pain drove me there, and the substances were a way to cope with that until I figured it all out, when somebody diagnosed me and gave me all the awareness of who I am as a person, why I use drugs the way I do, the buried trauma that I wouldn’t talk about.

You have to remember. When I went to trauma therapy, I was still using substances. The therapist said to me: “I really don’t care what you’re using. I’m trying to help you learn new ways to cope.” Lo and behold, after nine months of doing therapy, I was able to put the pieces together to figure out how to address the addiction. I haven’t used drugs in almost a decade.

When you give people the resources to be supported, especially…. Listen. People who use drugs — there’s always a risk now. People who have an addiction…. I’ll tell you what that is. That’s pain, that painful story behind there. We just have to do better. I do it all. I talk about the whole aspect of it. Kids don’t just get a talk where I’m going in and talking to everybody to get this, get that. I talk about the full spectrum that needs to be done. Kids relate to that.

P. Alexis: What are your suggestions with respect to reducing stigma? In particular, conservative populations who would maybe hear you and say: “Oh my goodness. He’s going to encourage children to actually do drugs. This is unacceptable.” How do we get people to think differently?

G. Felicella: Again, it goes to awareness, understanding where drug policy was rooted. It started here with the Opium Act in downtown Vancouver, basically. You know what I mean? Rooted in racism. We talked about that. We can’t allow that to continue going on in our society — just, you can’t.

Even when I looked on the federal policy of the overdose crisis in the federal election, and I saw racism…. The overdose crisis didn’t even make the list, but I wasn’t surprised that racism was like 1 percent, and I was like: “Yeah, no kidding.” Because what it is, is that people lack the ability to see outside themselves to understand. They’re just like: “We’re all in for ourselves, trying to get….” It’s really challenging.

[5:50 p.m.]

Stigma was actually created by the government. That’s where it started. That’s the product of laws and policies that are in place that punish people for…. We’re trying to undo 100 years of prohibition. What it’s done is…. Look, we didn’t learn from prohibiting alcohol. We didn’t learn. We thought: “This will stop people from drinking. We’ll just punish them.”

Look at what…. Switzerland had the same problem as the Downtown Eastside. It was called Needle Park, in the ’90s. You know what they said? “Oh, this ain’t happening. We’ll come with enforcement.” It tripled. Then you know what they said? “The hell with this. Give them heroin.” Lo and behold, they gave them heroin, and the park is, like, beautiful. People go to their clinic. They pick up their supply. It’s in the heart of the finance industry in Switzerland — like, some gorgeous bank where people go in to pick up their prescriptions.

It didn’t encourage…. Listen. Crime down; home thefts down 98 percent; opioid-related crimes down, I think, 86 percent; HIV and hep C non-existent. It totally changed…. They were looked upon as the laughingstock of the universe in the ’90s, but they don’t look so bad now. It doesn’t encourage people. It’s kind of like….

What encourages people to use is not being able to get it. That kind of makes people go: “Oh.” But if heroin was regulated in this province…. Now we’ve let it go so long where we just have such a bigger issue. I mean with fentanyl, it’s just so unfortunate.

I think one thing is that a government campaign on making you aware of stigma…. I think we need to get more into the communities to talk about it instead of putting it on a commercial, because I can just change the channel, which probably a lot of people just do. You need to be out there speaking about it in communities.

I did a talk, and I’ll tell you, the kids couldn’t even look me in the eye. The dad came up to me and said: “I want to tell you something, Guy.” These were his exact words: “There’s only one thing I hate more than junkies. It’s the people that created naloxone.” This is the truth, though. This is how people…. This is how it goes. I heard that, but I watched the kids’ demeanour. I didn’t even feel angry; I just felt really sad. That’s what goes on in our society behind closed doors. That’s how people view it.

T. Halford: You mentioned trauma therapy. Where would you be right now if you weren’t accessing trauma therapy?

G. Felicella: Dead. I’d be dead. I went to an outpatient program ten years ago, and I tell you…. The case worker was on maternity leave, so the maternity leave person that came in to take over for a year was a trauma therapist. By sheer the stars aligning…. I had access to this five days a week.

Not only that, this person really helped me understand me. When I started to understand me, I started to put the pieces together, and my life started to change. Then I realized my relationship with those drugs. Those drugs saved my life at 12 years old, because I wanted to end my life, but those same drugs that once saved my life were now trying to end it. That’s what happens when we forget what people are dealing with.

Once that got addressed, I realized…. It’s almost like you become so comfortable with a friend and knowing that that friend is no good for you anymore. They’ve been there through everything in your life, and now you have to say goodbye.

The hardest thing for me to ever do was to say goodbye to that friend that never judged me, that took away the pain, that made me feel like I belonged. I didn’t care what society was going to say. Sure, I shrugged it off. I went into my own little war of isolation. But what was said to me [audio interrupted] hurt. That hurt me inside, and I withdrew. When I started to understand and put it together, I was like: “I don’t need you anymore.” And I let it go.

[5:55 p.m.]

After that, I even went to trauma therapy. I still go. I said to my therapist…. She’s amazing. I just said to her: “I can’t come. I can’t come as much anymore. It’s just too much money.”

You know what she said to me? “Guy, you know what? I’m going to put you on a sliding scale.” I looked at her, and I was like: “Either I’m still really messed up or you really do care.” She laughed, and she just said: “No. You’ve done some amazing work, and I just want to continue this work.” Instead of paying $150 an hour, it’s $80, so I can do two sessions a month.

The important thing about trauma therapy is what…. In Australia, they have 13 sessions a year. You can access 13 sessions. If we could give people in our society access to just 13 throughout the year…. I’m talking everybody. Give them access to 13 therapy sessions a year.

The important part of going to trauma therapy is the beginning stages. You need to go a little bit heavy in the beginning — like, a couple times a month, at least. I would suggest if you could go every week…. But you go bang that out for six months. It becomes somewhat of a maintenance program after. But we need to give that to people.

Even any therapist that I’ve ever talked to, they were like: “Guy, I wish people didn’t have to pay. I wish I could bill MSP.” We do it for everything else. Let’s spend…. Listen, if we want to really help…. We have a mental health, trauma, anxiety crisis on our hands. Don’t keep scapegoating the drugs. You’re scapegoating the drugs by saying: “It’s always the drugs.” Now take the drugs out of the equation. Why are people using the substances the way they do?

S. Furstenau: I know the story, but I’m hoping you can share, in your story, the moment of human compassion and kindness that really made a difference. I think that that’s also so critical in this conversation.

G. Felicella: Yeah. February 18, 2013. Booth 5 at the supervised injection site — dead, gone. I think it took the nurse seven minutes for me to come around, ten minutes for me to even kind of really open my eyes. When I opened my eyes, she was crying. I looked at her, and the first thing I said was: “Why are you crying?” She said: “Because I care.” I just lost it. I started to cry.

I remember that physically, mentally and cognitively I was tremendously slower. I couldn’t speak like I can speak now. I had to focus to walk. I told her: “I don’t want to do this anymore.” She said: “I know.” I said: “I haven’t wanted to do this in a long time, but I don’t know how to stop.” Boom — that sequence of events, which happened on compassionate grounds.

On the top of the supervised injection site is a detox floor. They don’t just take people in there. You have to go through a process. But they said: “If we let Guy leave, he’s not going to be here tomorrow.” They took me upstairs. That was February 18.

I managed to get out of the Downtown Eastside of Vancouver with one set of clothes on my back and a welfare cheque, and with nothing, I went to a transitional house in Surrey, trying to piece my life together. I got involved with an out-patient program. At that time, it was called drug court. I didn’t like having to be punished to go get services, but that’s the reality. When people try to access services and they can’t, it’s like: “Well, I’ll just go break the law. Maybe they’ll help me then.” That started it.

I think, now, looking back, it was a month later that…. March 17 is the last day that I ever used illicit drugs, then I went on a methadone maintenance program and got enrolled in this out-patient program, where I went every day, five days a week, and went through groups and trauma therapy counselling.

Then after nine months, I said: “I don’t want to be on methadone anymore.” I walked into my doctor’s office, and I said: “I’m going to stop that too.” She just looked at me like: “Wow. Okay. Well, how do you want to do it?” I said, “I want to switch to Suboxone,” and I did. I had boxes of Suboxone, and I tapered myself. I didn’t care what any doctor would say to me. I didn’t care what people were going to say anymore. I’ve heard all my life: “I can’t do this.” I heard all my life: “I’ll never amount to anything.”

[6:00 p.m.]

My wife will be the first one to tell you: “Don’t tell him he can’t do anything, please. He’s just so driven. He just won’t stop.” Really, my drive is to make sure that we actually change as people and really just have some empathy and some compassion.

Down in the Downtown Eastside, where you see the streets like that, pointing fingers — that’s poverty. That’s not addressing poverty for decades. That’s not a drug crisis; that’s a poverty crisis. There’s no housing; there’s no place to go. We look at what it has become. But if you don’t address poverty, guess what. If you look in Los Angeles….

I’ve been to it all — the Mission district in San Francisco, downtown L.A. It’s like, when you don’t address poverty, guess what. People will result to what they need to do to support themselves in poverty, which will come with gangs, crime, drugs, property crime, all of it. That’s not addressing poverty, and sadly today, the drug supply has just got to where it is that it’s just killing people.

I have witnessed, in my life, so many people gone. In my therapy, I’ve dealt with the past of my childhood. I haven’t been able to deal with the grief and loss from all the people, because it’s 161. It’s 184. It’s 150.

Remember before, when it was 90, when it was 75? Now we’ve just become emotionally void. It’s a number. It’s people. And I’ll tell you, the amount of people that are impacted by it…. It has a triggering effect on all of us.

We have to do better with making sure that people have access to harm reduction services but also have options of treatment and recovery. If we can do that…. Gone are the days where it’s and/or. We have to support both.

Really, if you look at it, you want to support people, because if you do that, I tell you that we can change this. We really can.

N. Sharma (Chair): I have the honour, on behalf of the committee, to thank you so much — not only for the work you do but sharing what is a really powerful and impactful story that you tell about resilience and all the things that you learned to get you on your path that you’re now teaching younger people. Thank you so much for that.

It’s been really a great way to end the day, engaging with you. We wish you all the best.

G. Felicella: Thanks for having me, guys. Just make some changes.

N. Sharma (Chair): A motion to adjourn.

Motion approved.

The committee adjourned at 6:03 p.m.