Hansard Blues
Select Standing Committee on
Health
Draft Report of Proceedings
The committee met at 1:06 p.m.
[N. Sharma in the chair.]
N. Sharma (Chair): Welcome, everybody.
I want to start by acknowledging we're on the traditional territory of the Musqueam, Squamish and Tsleil-Waututh people. We think about that, and I invite everybody to, as we conduct this work.
I want to welcome you as our first panel guest members for today. We have Sharnelle Jenkins-Thompson, manager of community outreach at West Coast LEAF, and Hawkfeather Peterson, coordinator at PACK B.C., which is part of West Coast LEAF.
Thank you so much for coming. We're really excited to learn from you today.
My name is Niki Sharma. I'm the Chair and the MLA for Vancouver-Hastings. I'm just going to go around so we can all introduce ourselves.
P. Alexis: Pam Alexis, MLA for Abbotsford-Mission.
S. Chant: Susie Chant, MLA, North Vancouver–Seymour.
R. Leonard: Ronna-Rae Leonard, MLA for Courtenay-Comox.
D. Routley: Doug Routley, from Nanaimo–North Cowichan.
M. Starchuk: Good afternoon. Mike Starchuk, MLA, Surrey-Cloverdale.
S. Furstenau: Sonia Furstenau, MLA for Cowichan Valley.
T. Halford: Trevor Halford, MLA for Surrey–White Rock.
N. Sharma (Chair): We have our Deputy Chair on the phone.
Go ahead, Shirley.
S. Bond (Deputy Chair): Hi, I'm Shirley Bond. I'm the MLA for Prince George–Valemount. Today I'm actually in Prince George. Sorry not to be there in person.
N. Sharma (Chair): Okay. You'll have about 15 minutes to present and then 45 minutes for questions and discussion afterwards. So over to you.
Briefings on
Drug Toxicity and Overdoses
WEST COAST LEAF,
PACK B.C.
S. Jenkins-Thompson: Great. Okay. My name is Sharnelle Jenkins-Thompson. My pronouns are she, her, hers. As shared, I'm the manager of community outreach at West Coast LEAF.
A little bit about West Coast LEAF. We are a legal non-profit. Our focus is on justice, and our work is provincewide.
We are based on the unceded homelands of the Musqueam, Squamish and Tsleil-Waututh.
We come to this topic today with a real focus on the impact of child welfare or, otherwise, what we call, in our work, family policing and the overdose crisis and gender-based discrimination.
I'll pass it to Hawkfeather. PACK is a separate organization that we partner with quite closely.
H. Peterson: Hi, I'm Hawkfeather Peterson. My pronouns are they, them. I am a project coordinator with PACK, which stands for Parents Advocating Collectively for Kin. It is a peer-based organization, which means that the leaders in that organization are all people with lived or living experience, particularly mothers or birthing parents.
We're coming today, like Sharnelle said, to talk about the injustices that impact, specifically, mothers and birthing parents in regards to the overdose crisis. I told Sharnelle earlier: "Be prepared. I might cry." So I'm just going to say that right now too. It's such a sensitive topic to me that I do tend to tear up sometimes. Bear with me if I do.
I want to address a little bit about how…. We were invited to come to talk about the systems and services guiding the government's response to the overdose crisis. One of those systems is largely identified as peer engagement.
It's one of the pathways forward that has been identified since early days. It's been really lacking, and it's something that really is crucial to make sure that this work is done in a way that is ethical and really touches the needs. So I just want to really strongly advocate for stronger peer engagement.
Sorry. Like I said, this is such an emotional topic for me that it's a little hard for me to even stick to notes. I really want to acknowledge that the injustices we're seeing here really predominantly impact Indigenous mothers and birthing parents. There's not a lot of acknowledgement of how people of colour are treated in the child welfare system. We've recently started using the term "family policing" over "child welfare" because it's not necessarily in the welfare of our children to be put into the system.
I'm here representing parents and myself as a non-binary parent and someone with lived experience as a substance user. I'm here to represent all those things — and hopefully, I don't know, change some hearts and minds.
S. Jenkins-Thompson: Just to expand on what Hawkfeather is sharing, we are talking about the system known as child welfare and child protection in the points that we're making, but we've intentionally shifted our language to use the language of family policing.
This is based in some legal scholarship and other research in the work that really talks about how the system is more focused on surveillance, regulation and punishment of parents, and some communities are more predominantly impacted. In B.C., we see that with Indigenous families, in particular.
We're focusing our presentation today around the intersections of these systems, because even the system itself…. The MCFD, in a report published by the Representative for Children and Youth in 2018, identified that social records reported that of the caregivers they interact with, 70 percent use substances. So it's a huge issue that largely has not been addressed in the responses and the overlaps, which we're going to get into three points about today.
H. Peterson: In 2021, Meaghan Thumath and others put out a report that just really clearly identified that apprehending a child increases a mother or birthing parent's risk of death of overdose dramatically, particularly for Indigenous mothers and birthing parents.
Something that had to be highlighted there was that historically that was sort of celebrated in a strange sort of way because it validated the removal of the child. But, really, what this report went on to explore was that it's not that removing the child was necessary, and we're proving that by seeing this poor person overdose and die, but, really, that it's such a traumatic event, of course it's going to increase their risk of overdose death.
To us in the community, that didn't really need a report to say it, but unfortunately it needed a report to validate that that's the reality –– that having your child taken will absolutely increase your risk of death.
Research has shown over and over again that substance use does not necessarily impact how you parent. There is no evidence that shows that substance use hinders parenting. It's just really an outdated…. It's a stereotype, really. It's like a misinformed colonial, racist view, and people rely on it very heavily still, and it's just not what evidence is showing. It's not at all what research has shown.
Apprehension is…. I don't know if you've ever seen a child apprehended. It's profoundly traumatic. You see, I'm already starting to tear up. It's just absolutely devastating, for people that are involved, to have a child taken. It destabilizes your well-being. If we're looking at improving the lives and well-being of substance users, I don't see how that work can be done without looking at the well-being of mothers and birthing parents. We've just been completely ignored from the dialogue since day one.
So I'm really hoping that that's going to be considered and that the stigma that comes along with scrutinizing mothers that do drugs will be re-examined and will take an evidence-based approach to do so.
S. Jenkins-Thompson: Much of our current response to parents who use substances is an approach to surveillance and mandatory reporting and punishment. We cannot emphasize that enough — that that is entrenched in the policy and legislation. Nothing in the guidelines or recommendations for health authorities that rolled out safer supply acknowledged or addressed protections for mothers or birthing parents who use drugs.
This acknowledgment was flagged before these policies were rolled out, but they did not come through. It was not addressed, which is hugely problematic. We see that we have these two systems operating in silos, so the health system, the mental health and addictions approach, and then what's outlined in the Child, Family and Community Service Act, where we look at things like mandatory reporting. So when people suspect neglect, abuse and things like that, it triggers an automatic response to MCFD, which then opens up that surveillance piece.
We can see how these things like the Good Samaritan Act and safer supply guidelines are not considering how things like mandatory reporting are interwoven and creating huge barriers to accessing things like safer supply. There has absolutely been situations where mothers or birthing parents have been seeking safer supply, and they have been reported through the CFCSA.
You can imagine. Research has, again, found what we all know in community. When we have these systems of surveillance and regulation for mothers who use criminalized drugs — and we have these stigmas and biases that Hawkfeather is emphasizing, which paint them as irresponsible or unfit — people will avoid systems of support if they know the risk is too high that they may be separated from their children.
We know, again, that this directly over-impacts Indigenous, Black and poor mothers in this system. We see how things like involuntary drug testing, forced treatment, incarceration, sterilization of mothers are just far too high of a risk when we do not have guidance about how we're going to avoid these approaches of removal.
We know, again, to just really drive that home, that child welfare policies, or family policing policies, rely on norms that view poor and racialized women who use drugs as inherently unfit to parent. This is where we see things about seeing substance use automatically needing to trigger responses to MCFD or DAAs, delegated Aboriginal agencies, where they are ill-equipped to respond and meet the needs beyond removing children or rely on these stereotypes to guide their actions.
We know, again, from research, that children who are separated from their parents have far worse health outcomes than children who are not. We see that children who are in the system and are forcibly separated…. It causes emotional, psychological and physical harm not only to the mothers, who are often already ignored, but also to children. They have poorer outcomes when this is the approach that we take.
Research has found…. The RCY — again, in 2018 — found that MCFD has unsatisfactory policies, training and implementation of evidence-based practice in supporting families with caregivers who engage in substance use. We can see how that…. Having those two systems in silos, if we think about health and we think about family policing or child welfare, there's just a huge gap between them.
We currently have an approach that creates a system of terror and alienation for families. We have to address these policy barriers like mandatory reporting, the Good Samaritan Act and safer supply guidelines across these ministries moving forward.
H. Peterson: I'm sure everyone here knows…. We just recently heard that the government was escalating the government's response to the overdose crisis. I think it's pretty vital that we have to plainly acknowledge that if we're going to escalate a response or have an appropriate response, it has to include all the factors. This is something that has been absolutely neglected. We're losing people constantly because of it.
The coroner's report the first year into the crisis flagged that detox actually increased people's risk of death. Yet here we have a system where you have no choice, and it's taken out of your hands, and it's absolutely enforced in a way that is punitive. You lose your children if you don't follow these recommendations that are wilfully putting your life at risk.
Aside from safer supply guidelines not taking into account our needs, the Good Samaritan Act doesn't take into account our needs. There are so many barriers to care, like Sharnelle just brought up. People don't know that we have a narrative of parenting.
Our stories around parenting always come with the gleeful pictures at the park of a dad or a mom, and it's always celebrating recovery or abstinence. It's very heavily abstinence-based, but there are so many of us that have parented successfully alongside of being substance users. In fact, for many of us, we couldn't have parented successfully if we weren't substance users, because it was a part of our well-being.
That story has been completely erased because of the barriers to care that come with sharing our stories. That's not even on here. Sorry. I just went down a rabbit hole. But it's the reality that people need to make these life-or-death decisions, and they can't factor in all the voices and all the stories, because our stories put us at risk. Sharing our stories is life-threatening to us. I don't even know how people do make these decisions when you can't factor in all the voices and all the experiences that people have.
Harm reduction is really the cornerstone of overdose prevention and response, and harm reduction is not a factor in family policing. There's no education around it. There are no policies that we can find that have anything to do with it. When we go, hand in hand, to support a parent who is fighting to get their children back, there's no room for harm reduction. Every aspect of that journey is just increasing the risk of harm. Every single corner we turn is more risk for someone that's just desperately trying to be well and whole.
Again, I totally went off the rails here, but I just really hope that people are willing to hear our narratives, that we create some safe spaces to share them and that'll be a factor in decisions that have to do with whether we live or die.
S. Jenkins-Thompson: I think I would just add that we need responses that are not based in punishment. They're not punitive. We cannot be dangling people's children over them and trying to push them, even to partake in harm reduction. We cannot have that as the equation. We need responses that are grounded in gender-specific and culturally specific harm reduction, and we need them to be community-based and peer-led. That is going to be essential for supporting families and children.
I think I would just add, again, to the piece of…. We need this looked at across ministries. We need this looked at across legislation. We need to remove barriers like mandatory reporting. We need MCFD to not have harm reduction as a lip service. We need to fully embed that and understand that.
H. Peterson: I think we're getting pretty close to closing. I just sort of implore people to explore their own biases here. It's inherent that most people still envision a mother or a birthing parent that uses drugs…. It comes with some pretty extreme biases.
In our overdose response, we're really hoping that it's going to be evidence-based practice and that we're going to really stick to the best practices here that say that we're striving towards reducing stigma in British Columbia. That means exploring our views beyond misconceptions and outdated racist laws and policies and really just making and holding space for people's truth. Whether it makes people uncomfortable or not, the truth is that you can be a drug user and a good parent.
N. Sharma (Chair): Thank you very much. I'll just take the questions.
Susie, your hand was up.
S. Chant: Hi, there. Thank you for your presentation. I appreciate that it comes from the heart.
My question…. You've referenced the Good Samaritan Act several times. I'd just like to understand what component of the Good Samaritan Act is applicable in this context, please.
H Peterson: In this context, if I am with a peer and they overdose, I am protected — to call the police — from being arrested. I'm not protected from having my children apprehended. There are no provisions in place to protect people from having ambulances, paramedics, ERs or police reporting you to MCFD. So you risk having your children taken if you call to report an overdose.
S. Chant: Okay. I'm just trying to make sure this is clear. If I'm a parent and I have overdosed, then I'm at risk, seriously, to lose, have my kids….
H. Peterson: Yes, absolutely.
S. Chant: But if I'm a person that is helping an overdosed person, is there something…?
H. Peterson: Then you can still lose your kids, because you're fraternizing with drug users.
S. Chant: So as a person that's trying to help, I then come under scrutiny.
H. Peterson: Yes, absolutely.
S. Chant: Oh, terrific.
H. Peterson: Also, I would just say, as a substance user, I have told my partner not to call 911 if I overdose, because I don't want my kids to be taken.
S. Chant: Okay, thank you.
S. Furstenau: Thank you for the presentation. I really appreciate it. I have witnessed an apprehension — it was definitely traumatizing, enormously — and then have worked with the mom. Her children are back, but what you described — the punitive, policing approach — we have seen and heard from parents, over and over again, in our office and have tried very hard to work with the community on presenting alternatives. I really appreciate that you're bringing this really critical piece.
We've heard about the child welfare system and the outcomes for children that are in that system. Can you speak a little bit more to that and to what appears to be a double standard of parenting that exists? The birth parents exist under one standard, but once a child is in the system, the expectations of the parenting that is happening are very different. I'm wondering if you can elaborate on that for us.
S. Jenkins-Thompson: Sure, yeah. I think with that, the research that comes to mind — if we think, again, going back to that evidence base — is the Cedar project, which has tracked outcomes for children and youth in care across health and well-being, the social determinants of health.
What they've found, across the board in all areas of the social determinants of health, is that children in care have poorer outcomes than their peers who are not in care. That includes things like homelessness. We know that children and youth who've been in foster care are wildly overrepresented in substance use. We know they're wildly overrepresented in entrenched poverty. It's pretty much every measure. You will see worse outcomes for children and youth.
Is there anything you'd add?
H. Peterson: I always do think that it's sadly fascinating that you can lose your children for being low-income, and then people can be paid the amount of money you could have had to keep your children healthy and happy, but they've been removed to make sure that their needs are met. I support parents all the time, and the reason they were apprehended was financially based.
I'm supporting a mom right now whose kids were apprehended because the B.C. Housing that she was put into is mouldy. They didn't want the kids in the mouldy house. So they take the kids out and then give the foster parents enough money to rent a better place, which she could have just rented a better place with.
It doesn't make any…. There's no logic to it, as far as I can see. If we know that kids are better off with their parents and we know that we can afford to support parents to raise children appropriately, why can't it be the parents? That just doesn't make any sense to me.
S. Furstenau: I'm wondering if you could get us a copy of the Cedar project report that you've referenced.
S. Jenkins-Thompson: Sure, yeah. They have multiple….
M. Starchuk: Thank you for your presentation. I think that in some cases it's an honour to shed a tear in a group setting like this.
Susie, you asked the one question that I had there, and Sonia, the Cedar project was down at the bottom of the list.
Somewhere in between, there was mention of no policy for harm reduction. You kind of intimated that your children are removed, and then it's kind of like: "Go get yourself clean and sober, and you'll get your kids back." They're dangling a carrot that most people cannot ever achieve. Your comments about being able to survive if there is the world of harm reduction….
I'd like to…. I'm not sure if it was Sharnelle, that you had referred to harm reduction as simple lip service.
S. Jenkins-Thompson: Yeah. I think, in looking at their policies — which we had to FOI to find — in their approaches to substance use, through MCFD, "harm reduction" is a passing line. Then, immediately, the rest of the policy talks about how to do drug testing of parents. It says: "MCFD believes in harm reduction."
Then there's nothing in there about what it actually means in practice, how you do safety planning for that, none of those pieces. The practical pieces that are outlined are how you do urine drug testing. That's what they have as what guides them, for front-line workers. If you're a front-line worker, that's a huge thing to try and unpack and understand.
H. Peterson: Can I also just really highlight what Sharnelle just said — that West Coast LEAF had to FOI MCFD to access their policies?
As a peer-based organization, we can't ourselves look up the policies that affect our lives. I can't say to the peers that I'm supporting and working with: "These are the rules, and these are the expectations that MCFD has of you as a parent." I have no ability to do that. I can't access their policies unless I politely ask West Coast LEAF and they lovingly share them with us, because they FOI'd the policies. They're not available to the public.
N. Sharma (Chair): Okay. Thanks for sharing so much. It's been really interesting to learn from you. I know this is an emotional topic, so I really appreciate that you brought that into the room. It's important for us to hear that too.
I guess I had two questions. One is that you mentioned research that was about, basically, drug use and parenting. Can you send that to us? I'd love to know more about that and read that. I don't know where it is or where it lands, but I think that would be useful for us to take a look at.
S. Jenkins-Thompson: Yeah. I would mention that in that topic, we're very fortunate, in B.C., to have Dr. Susan Boyd from UVic, who has done extensive research on that topic. We can definitely share what West Coast LEAF has used in that area for sure and share that. And then, of course, the Megan Thumath article that you talked about.
H. Peterson: And of course our lived and living experience of parenting and raising healthy, beautiful children.
N. Sharma (Chair): I guess that ties into my second question. Hawkfeather, I was really interested to know what PACK BC does, like where you get in there.
H. Peterson: I realize I didn't say that.
N. Sharma (Chair): No, it's okay. That's what the discussion is about. I'd really love to know how you intervene, who your group community is, what you see while you're doing that and a little bit more into that.
H. Peterson: Yeah, definitely. We started as the women's committee for B.C.-Yukon Association of Drug War Survivors. Pretty much immediately it was flagged that if we had to look at gender-based violence, what was affecting female substance users and non-binary substance users the most was child apprehension. So this project was born out of that.
What PACK does is we started creating a train-the-trainer educational piece so that existing peer support workers in British Columbia can increase their capacity and education around supporting mothers and birthing parents who are risking apprehension and engaging with MCFD. We've created various modules, and those are just getting wrapped up now. The next stage is to provide training where we'll bring in those people.
Now, immediately upon exploring this project and doing it, instantly we started hearing from parents that needed support. We had not trained anyone yet, so we had to take up the cause of doing activism and advocacy one-on-one, which has really slowed the rest of the work. I was shocked how immediately people somehow…. I don't even know how they knew that we were doing this work, but we started hearing from mothers, within a day of announcing our project, that needed someone to come on calls for MCFD.
We've provided respite care for children. We've provided funding for respite care in areas that are away from Vancouver. We go on calls. We help people create safer drug use plans, and we help connect them with peer-based organizations in their communities. Mostly we're about increasing capacity around advocacy.
S. Chant: Where does your funding come from?
H. Peterson: For PACK?
S. Chant: Yep.
H. Peterson: SUAP. We receive federal funding.
S. Chant: Federal funding?
H. Peterson: Yes. We receive federal funding. We also receive a lot of funding from the women's foundation here in B.C. Originally, our funding was through B.C.-Yukon, but since we started initiating the project, we've been getting our own grants.
S. Chant: Very good. Thank you.
D. Routley: Thanks very much for caring about the people that you're working with and your kids. Could you speak to how you feel stigma and acknowledgment of harm reduction in the lives of parents would be affected by an expansion of safe supply? Do you perceive that that would help destigmatize because it's a de facto acceptance that people are…?
H. Peterson: I can tell you that when the initial dual-risk mitigation guidelines came out, I went immediately to my physician. I was on methadone. I went to my physician and said: "I have to admit, I actually still use." You aren't supposed to tell your doctor that. I asked about safe supply, and his immediate response was: "We better call MCFD."
I'm hoping that as more education is provided for care providers, it will lower stigma, and that as people are accessing safe, regulated supplies rather than illicit supplies, it becomes recognized that we are really taking medicine. That's what it is to me. It's medicine that helps me be stable and well and whole. It's just illegal medicine.
Right now I access safe, regulated medicine, and I'm hoping that that is how it will be perceived the more it rolls out and the more people access it. That's my hope.
P. Alexis: Thank you so much. I've learned so much. I have issues hearing you, and I apologize if this has come up. Have you sat with MCFD and explained to them the issues as a result of apprehension and all of that? Where are they in all of this?
S. Jenkins-Thompson: West Coast LEAF has not specifically sat on this policy. I can say we have talked to them about their policies around gender-based violence, which actually, when we've looked at those policies, are quite good in terms of how they developed them. They developed them with gender-based violence experts and things like that. But when we've spoken to them to talk about the issue between policy and practice, there's a huge gap between their own researchers, their own policy developers and what front-line practice is like and how front-line practice is addressed.
Again, I can't speak to that. We haven't had this conversation with them. But in just drawing on our past experiences, there was a huge issue to talk about: "Well, what does implementation actually look like?" There are huge issues happening with implementation.
Again, they don't have a policy that meaningfully addresses harm reduction that we've been able to find or get access to, so I can't speak to that piece.
I don't know if you want to speak….
H. Peterson: Well, I can say that I've been a member of the provincial perinatal substance use project since its origins, so I've been at the table talking about perinatal substance use with MCFD as a stakeholder. It's kind of a fascinating dichotomy.
I know that right now MCFD is promoting that they are updating their policies. We haven't, however, been able to access a conversation with them very readily. I do think that that's fairly problematic. Now is the time, if they're updating their policies, for them to be hearing from the drug user community and from parents — pregnant or parenting — that use drugs.
We do talk to MCFD a lot in the context of one on one while we're supporting parents. But the really frustrating part of it is that there is no oversight that we can really find, so you never know what you're going to get. If I support three parents in one day, it's going to be dramatically different. I'll have one social worker who just strongly, personally believes in harm reduction and might not have her kids ripped away. Then the next person maybe had a cousin that did meth in high school and had a bad experience and takes those kids like that, right? As far as we can tell, there's no real cohesive way to ensure that parents can have some valid expectations of their rights around parenting.
So we do have one-on-one engagement, but no, when it comes to direct engagement with the leadership, it's actually really hard to get their ear to talk about these things. It would be really nice.
P. Alexis: Can I just ask a follow up? You said in the presentation that you couldn't access the policies from MCFD. So this is what you're referring to, then: you haven't had an opportunity to meet with the leadership to go over policy. Is that what you were referring to in your presentation?
H. Peterson: We've presented a couple of different times and extended invitations and such to hear what we have to say on urine drug screening or different subjects related to the subject of substance using parents. Yeah, it just sort of feels like a shut door, just to put it plainly.
S. Jenkins-Thompson: We actually mean their guiding policies and protocols. Only about half are publicly available in terms of their responses, what guides their actions — only about half. West Coast LEAF had to FOI the remaining policies.
S. Furstenau: Just further to this, because I think it's a really important conversation to be having, there was recently a Representative for Children and Youth report on practice standard audits of MCFD. In some cases — well, in a lot of cases — they weren't even meeting 50 percent. In some cases, it was like 5 percent of meeting their own practice standards.
I think it's really important to point out that even if the policies exist or the practice standards exist, if those aren't met, there appears to be no real consequence and no expectation of consistency of the application of those standards or those practices. Then nothing happens after that. So I do think that it's really critical. I'm just trying to hit this home with our experience as well.
Again, it comes back to, Hawkfeather, your point about the standards that a parent is being held to, and that one mistake leads to an apprehension…
H. Peterson: Or stereotypes lead to apprehension.
S. Furstenau: …and stereotypes and poverty — all of these things. So I think it's really critical that this conversation is happening. I think maybe we should be inviting MCFD back to have these conversations.
I just wanted to come back to more of the evidence-based piece. If either of you can talk to programs like Sheway, where mothers and babies are kept together, and the outcomes and what the evidence tells us about that, as opposed to removal or apprehension.
H. Peterson: I would love to. I work with B.C. Women's. A lot of their policies….
They just recently updated their policies on rooming-in for mothers that have had a child that's previously been probably diagnosed with neonatal abstinence syndrome. We now really widely recognize that a lot of those diagnoses were made from stigma. The criteria for diagnosing neonatal abstinence syndrome include crying and shivering, things that all newborns do. So a lot of those diagnoses were pretty exaggerated, and a lot of the treatments were pretty harmful.
The new recommendation that came from Dr. Abrahams, and all the wonderful work they do there, is to treat babies completely normally. It speaks volumes, because most people still believe this is some horrendous epidemic that's harming these beautiful little babies, but really, the recommendation is to no longer medicate these babies. It's to hug them and hold them and keep them with their mothers. That's the literal recommendation to deal with babies that come in for substance using parents.
To me, that just says that so much of the evidence…. They really know what they're talking about. They see it all the time. The work there is so much about protecting that mother-child dyad, but we see it all the time where we'll have parents that come in to Sheway. They check all the boxes. They'll go to FIR, and they'll do all the things they're supposed to do. Then they….
I had a couple that I was supporting that had their baby apprehended at the ferry terminal headed home. Because we don't do birth alerts anymore, they waited for them to leave and then took the baby at the ferry terminal. But the evidence now is really trying to debunk a lot of these myths that are so prevalent. I really, honestly believe that if you polled the general populace about substance use, 98 percent of what you'd get back would be bullshit. I think it would be based in movies and media and stereotypes and biases that people have.
When we really look at the evidence, it's grossly showing us that these babies are best served by being cuddled and loved and staying with their parents, who love them the most and want to take the best care of them. That's what the evidence is showing.
S. Jenkins-Thompson: I think I would just add two things to that. These programs make a huge difference, right? They are meeting people where they're at. They're non-judgmental, but it still means that you're placed on MCFD's radar.
So when you and your children age out, you already have a flag of someone who's been identified as a substance user. When you lose this support, this early childhood support, and a report is made — maybe your child has missed school — that file follows you. You don't get access to that wraparound support, but you've been already identified. We can even think about some of the issues with some of these voluntary programs and supports where it's still creating a situation where you're seen to be at risk.
So that was one piece that I wanted to share. The other piece I would think about is…. We talked about, within the act, mandatory reporting. But the other thing we haven't talked about is the least disruptive measures. That is in the act — that parents should have access to least disruptive…. And "least disruptive" means children with their parents, children with their family, children with their communities.
One of the things that I've been really appreciative of to Sheway and some of the learning that they've shared with our team is that it's not necessarily consistency that we want. We want creativity. We want that each family's least disruptive is unique and different. That could be access to safer supply. That could be things like harm reduction. That could be moving towards shifting their substance use. But it needs to be specific, and it needs to be least disruptive to their lives.
One thing that I've always appreciated from Sheway is that they've also talked about how sometimes least disruptive doesn't mean parenting 365-24-7. Sometimes it means access to a wider kinship network for respite and support so you can plan and, as PACK was talking about, create these safer-use plans.
H. Peterson: Can I add one more thing? I also think that when we're talking about substance use, a lot of people equate all substance use with what they see, which is really chaotic or problematic substance use. What ends up creating systems where people end up in chaotic use are these barriers to care and these systems that are just not meant to support. They're meant to harm. They really are punitive. They're abstinence-based. They're punitive.
When we're talking about being able to parent and be a substance user, that's pretty hard if you're a chaotic substance user. So we're looking at supportive measures to make sure that people can have safety plans and a wider network of support. But they can't do that if they can't admit they're drug users, right? It's this vicious circle, this catch-22 where the mom loses every time, and the loss is death. That's the reality right now.
N. Sharma (Chair): Thank you. One final question from me, and then I think that's it. We're learning a lot about just how crazy the toxicity is with a lot of the substances. I know, through your work, you have a really unique perspective about where you show up for people in their lives. I just wanted to know: what have you seen on the front line with the toxicity changes of the drugs? What kinds of best practices do you think come in to save lives? Definitely, not taking kids away sounds like one of the clear recommendations. And then what else would you say in that category of helping to save people from this toxic…?
H. Peterson: If you look back at peer engagement, it started long before the overdose crisis was declared. If you even go back to reports VANDU did in 2010 and stuff, we've never shied away from saying it's safe supply and it's decrim. Those are the two solutions to regulating a safe drug supply for people so that they aren't risking death.
Unfortunately, in the midst of this crisis, those things haven't been rolled out in a way that has been the best for a lot of folks. But we're still hoping that those things are going to reflect the needs of the drug user community and actually save lives. That's the hope: that we're moving towards those being more widely accepted and some changes in some of the policies around it.
Those really are…. Those have always been…. Harm reduction, decrim, safe supply — those are our rally cries. Those are the answers, and they always have been.
N. Sharma (Chair): Great. Well, on behalf of the committee, I just want to thank you for coming here and for helping us learn from you — what you're seeing and what your experience is and what you're advocating for. It's been really useful, I think, for all of us. So thank you so much for that.
Okay. Our next guest is at two, so we have about ten minutes for people to go to the washroom.
The committee recessed from 1:50 p.m. to 2:01 p.m.
[N. Sharma in the chair.]
N. Sharma (Chair): I want to welcome you, Steve Mathias. Thanks for coming here today from the Foundry. I'll just do a quick introduction of who you see before you, then I'll pass it over to you. You have about 15 minutes, and there will be about 45 minutes afterwards for discussion. I don't know if we tracked down your presentation, if we all have it yet.
We do? Okay. It would have just been updated in your meeting materials.
So my name is Niki Sharma. I'm the MLA for Vancouver-Hastings and the Chair. Nice to meet you.
Maybe I'll go to the phone first. We have our Deputy Chair, Shirley, on the phone.
S. Bond (Deputy Chair): It's Shirley Bond. I'm the MLA for Prince George–Valemount, and I'm actually in Prince George today.
T. Halford: I'm Trevor Halford, MLA Surrey–White Rock.
S. Furstenau: Sonia Furstenau, MLA for Cowichan Valley.
M. Starchuk: Mike Starchuk, MLA for Surrey-Cloverdale.
D. Routley: Doug Routley, Nanaimo–North Cowichan.
R. Leonard: Ronna-Rae Leonard, Courtenay-Comox.
S. Chant: Susie Chant, North Vancouver–Seymour.
P. Alexis: Pam Alexis, MLA for Abbotsford-Mission.
N. Sharma (Chair): Over to you.
FOUNDRY
S. Mathias: Great. Thank you very much for the opportunity to present today. My name is Steve Mathias. I'm a child and adolescent psychiatrist. I'm also a diplomat of the American Board of Addiction Medicine.
I'm also here as the executive director of Foundry, and I just want to honour that I have no conflicts of interest to declare other than the fact that I'm an unabashed fan of what we're doing at Foundry. So I have a bit of a conflict of interest there, I guess.
I just wanted to acknowledge the traditional and stolen lands on which we hold these meetings.
I also acknowledge, with immense gratitude, the thousands of young people, their caregivers and Elders who have trusted me over these past three decades with their wisdom and by sharing their lessons learned with me and my colleagues. Many of these people are no longer with us and have fallen due to the toxic drug supply.
In my presentation today — I know that you've heard from a number of presentations already, sharing general statistics and key recommendations — I really want to focus on our work at Foundry and on our work with youth and young adults and bring to your attention some new pieces of discussion that you may have heard less about. I also want to acknowledge that this is an area that I think provides an important opportunity not only to transform the lives of youth across British Columbia but to have sustained, long-term impacts on overdose crises and future substance use crises.
The reason I bring this to your attention is that this is not the first, second or third time that I've presented at tables such as these. In 1993, when the HIV crisis was really at its peak in terms of seroconversion rates, I was an immunology student at UBC. I went into studying microbiology and HIV and immediately understood, obviously, that the social determinants of health were playing a significant role in what we were seeing.
By 2003, ten years later, I was a new resident, and I was working at a detox centre in Vancouver, where we started to hear about this new drug called crystal methamphetamine. We had never seen anything like crystal meth. I'd worked with folks who had crack cocaine and heroin addiction. But crystal methamphetamine was something that completely overtook an individual and, in many cases, as we found out later on, really created almost a zombie-like kind of quality of life, where, just from one day to the next, the real goal of their existence was to find crystal methamphetamine.
It was in 2013, ten years later, that, as a young psychiatrist, I presented at the Wosk Centre about the Downtown Eastside. I was asked what we could do to improve the outcomes that we were seeing in the Downtown Eastside. My comment then — and what really is my comment today — was that so much of what we're seeing is avoidable and preventable if we would just have invested upstream and we had done the work with primary prevention, the work that we knew was possible.
In 2013, that was my comment. In 2022, it's my comment again. A lot of what we're seeing is avoidable and preventable. What I think I have today, which I didn't have as much in 2013, is very strong evidence around the types of programs that we could implement in British Columbia so that we shift the conversation, shift towards wellness and shift towards supporting young people much earlier in their journeys.
Why youth? Looking at a slide from a study by Schwartz…. This just recently came out. This is an international study looking at the onset of mental health and substance use conditions. Fifty percent of all mental health onset is before the age of 14, and 70 to 75 percent by the age of 24. Seventy percent of all substance use issues will arise by the age of 19 or 20.
Our opportunity to intercede or interject does not happen at 25, 30, 35. It happens at the ages of eight and ten and 12. This is really the area that we need to think about investing in when it comes to working with the population at risk in this province.
When you look at the slide, it really outlines the average age of onset. The average age of substance use onset is not in the 20s. It's in the mid-teens. In fact, many of the young people that I see started using substances at the age of eight and ten. Last week my daughter was on a WhatsApp channel with 350 grade 9s who were all invited to a party at someone's house, at 14 years old. And 350 kids showed up for that party. That is where it starts, and I think that's really where we need to think about interceding.
Based on the estimates that we have in this province, between 180,000 to 250,000 young people between the ages of 12 to 24, in any given year, need mental health or substance use supports. The age of onset for mental health and substance use disorders peaks at the age of 14½ for mental health and 19½ for substance use.
When we look at folks presenting in hospital emergency rooms with opioid use disorders, the vast majority have presented in the 20 years preceding that with mental health or substance use concerns. This is a graph, which you see here, that was from Vancouver Coastal Health. The vast majority, again, presenting in the ten to 15 years prior to presenting to the emergency room with opioid use disorders.
As you all know, unfortunately, overdose due to a toxic drug supply is an unprecedented youth health crisis and now represents the third leading cause of death in young people under the age of 19 and the leading cause of death at the age of 19 to 39. Suicide and overdose deaths for those under the age of 19 have gone up every year since 2019. Obviously, this past year was the highest for both overdoses and suicides.
Who are the young people most associated with opioid use disorders? We actually know this. So opioid use disorders are actually preventable. We have a very good sense of the profile that we need to look for.
In young people, they tend to initiate substances earlier, a full year before other substances. They use more substances, seven to eight substances versus four. They use substances at a higher frequency. They have more co-occurring mental health concerns, particularly depression and anxiety. They have more trauma. They tend to be not employed and in education or training. They have challenges with the social determinants of health. We know this from this group.
At Foundry, we address stigma as much as we can, but it remains a serious challenge for youth around substance use. A significant majority of youth do not identify substance use as a primary concern upon accessing our services. They come in for other reasons, and it's only when we screen them for substance use that we learn that there's an issue. So the stigma is alive.
One population of interest, though, which I think we need to highlight is young men. Between the ages of 11 and 15, adolescent males and females have similar health care engagement rates. Yet between the ages of 16 and 30, adolescent males are three times less likely to engage in health care services. Across Foundry centres, only 29 percent of our youth attending identify as male. It's significantly lower.
Problematic substance use is also higher among adolescent boys and young men than their female counterparts. In Canada, men are three times more likely to experience substance use issues than women. But ask yourself: are we targeting young men for support? I would argue that much of our health care and much of our counselling resources are targeting young women, and I think it's something that we really need to have an open, honest conversation about.
From January to April 2022, 76 percent of those dying from overdose were male. In 2021, 78 percent were male. We really need a call for focused development of policy, theory and evaluation of targeted interventions for this population. We may very well need gender-synchronized service models to work with our young men, particularly our racialized young men.
The call to action, though, is decades old. The United States Surgeon General's report, 1999, the Commission on the Future of Health Care in Canada, 2002, the World Health Organization's mental health action plan 2013-20 all identified key issues that we raise today. But the one that I bring people's attention back to is A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver in 2001, by my friend Donald MacPherson.
In this report, Donald wrote:
"The problem with many programs now in place," and this in reference to prevention programs, "is that they are not evidence-based, and ineffective methods are still widely used.
"As well intentioned as they are, the programs that do exist are often poorly coordinated, under-resourced and scattered among education, social services, law enforcement, health promotion and drug prevention agencies. They often lack clear objectives and specific targets. Rivalry among service providers is seen as an obstacle. In addition, there has been a dire lack of funding for primary prevention programs across the province. Primary prevention with substance misuse is a major part of every official regional health plan and is a key element of the Vancouver agreement. Yet there are currently no provincial or regional prevention plans or goals in place.
"Even the most successful programs often fall short of their goals, either because the goals are unrealistic or because the programs are targeted to the wrong group of individuals."
This is still the case 21 years later. This is what I think we have an opportunity to change.
Early investment in youth makes sense. Study after study has shown return on investment of anywhere from $2 to $10 based on early intervention.
So who are we seeing at Foundry? As you probably are aware, we have 12 centres open, and we have a virtual care service in place. Our youth access our services for mental health, physical health, sexual health as well as walk-in counselling. Substance use tends to be accessed by about 6.6 percent of our population. I wish it was more. Many of our young people who come in for walk-in counselling also speak to their substance use issues.
But the real need, though, in young people, as they have identified over and over again, is that we need to increase their awareness and have balanced, early education about substance use and opioid use. We need to have increased awareness and education about services, increase the availability of a continuum of youth-oriented service options, provide services that emphasize ease of access and youth autonomy, implement a harm reduction approach, provide respectful and responsive service providers, and make changes at systems and policy levels. There are studies out there that talk about what young people have identified the need as being.
We attempt as much as possible at our Foundry centres to offer harm reduction supplies, supports for individuals as well as group substance use counselling. We also have opioid agonist therapy and intensive case management in some of our centres.
But the need is broad, and with the funding that we have, it's difficult to fill the gaps. We try to, but a lot of our young people coming in are coming in for service for the first time, having said that they would have accessed services earlier if they'd known about them. It's challenging to support the sheer volume of young people that we have coming through the door.
One in about eight, so about 14 percent, of our young people actually qualify for full substance use disorder when they walk in through the door on screening, meaning that they've had withdrawal symptoms in the last month from the substances they use. This is on 7,000 young people who we ran through a health survey. These are huge numbers when you think about the young people and the severity of their substance use by the time they come to us.
So 82 percent are reporting high levels of distress, 50 percent report having suicidal ideation, 76 percent report their mental health as fair or poor and 33 percent would not have sought help had Foundry not existed.
I'm just going to move forward. As you all know, the impact of COVID is something that has seen our numbers increase even further, with a need for supports continuing to rise and a huge unmet need. We must respond earlier and target known system gaps. I have some opportunities and recommendations.
There are some recommendations that come out of the Stanford-Lancet Commission on the Opioid Crisis in 2022. One of the areas that they really harp on is the need for integrated, evidence-based systems for the care of substance use disorders and that these should be developed and supported financially on a permanent basis.
We have promising early intervention programs, such as PreVenture, which has very strong evidence. It's a program that was developed in Montreal. It's a program that screens grade 8s, broadly. Then for those at risk, it runs them through two workshops, 90 minutes each, with significant reductions in drinking and binge drinking at a three-year follow-up, a more than 40 percent decrease in substance use and substance use harms, a 25 percent decrease in transitioning to mental health problems and decreased rates of peer victimization and bullying.
We also have Strengthening Families as another initiative that's been shown to have significant outcomes in reducing child depression, increasing child social skills and decreasing overt and covert aggression.
Finally, the model that I would really bring everyone's attention to is the Icelandic prevention model. If there has ever been a graph that has been burned into the back of my eyes, it's the one that you can see there, showing a decrease in binge drinking, daily smoking and cannabis over the course of almost 20 years in Iceland.
This is something that transpired around the country. Calgary is now doing this, as are hundreds of other communities in Europe. This is a model that really brings communities together and acknowledges that families, municipalities and schools have a role to play to identify targets for substance use in their young people and to work together to have the goal of reduced substance use be a community-driven goal.
This is a model that I think that we really need to consider, in conjunction with growth of our integrated youth service model, making sure that we have clinics and centres available in our communities where young people can access all the services that they need, whether it's mental health, substance use, primary care or social determinants of health. This is something that we certainly have been proponents of.
We've been blessed by a bipartisan support for the Foundry model. We have 23 centres that have been approved for this province. But when we do mathematical modelling, we really feel that there's a need for 55 of these centres across the province, in conjunction with primary prevention models, as I've mentioned earlier.
Now, I see that I'm out of time. I'm happy to take a break there. I know I've got more information. I do think that there are some key policy gaps that exist. The absence of a homelessness strategy for young people is one. Certainly, the opportunity to fully integrate youth mental health into primary care networks and into health care would be another area of focus.
I'm happy to pause. I'm sorry. I know there's a lot of information there.
N. Sharma (Chair): Lots comes up during discussion with this group, so we'll start with that.
Any questions?
T. Halford: Thanks, Steve, for your presentation. I'll probably have more questions, but I'll start with one, and then I'll maybe circle through after.
In terms of mental health support for our youth, this is something that's existed for decades in terms of a problem of access and, actually, a problem of affordability.
When you're talking about integrating mental health supports, I always look at the idea of my son falling off his bike, two years ago. I had him in emergency. He got an X-ray within an hour, casted. We were out of there within about three hours. The next day he met with the ortho. The next week we were in rehab — right? — for his wrist. That support would not exist if there was a severe mental health issue that he was experiencing, and that is a massive problem.
You talk about integrating into the primary care network. Can you expand on that? I know it's a bit of a loaded question but just what your thinking is there.
S. Mathias: We continue to have a model of care in the child and youth area, or the youth area, where primary care is separate from those health services. It's very difficult for family doctors or nurse practitioners in the community to feel like they're supported by folks who provide services for child and youth mental health. It is a very different department. It's a different branch. Those services exist in other places with their own separate pathways of access.
If you were to enter a hospital setting, then you would be seeing hospital emergency room physicians and psychiatrists. You wouldn't be seeing, necessarily, folks that are involved in the child and youth mental health service. That siloing exists still today.
S. Furstenau: Thanks so much. There's a lot in here that's really valuable, I think.
Just on your points around evidence-based. So evidence-based prevention programs. The graph from the Icelandic prevention model looks like evidence to me.
Can you elaborate on what we would need to do in B.C. to make sure that prevention is evidence-based, and how would we ensure that that's happening?
Then just with the Icelandic prevention model, how are they delivering that? Is that in every school? Is it in every community?
Just those two points.
S. Mathias: Sure. Thank you. I'm sorry. It is a lot of information, but I've been saving up.
One of the challenges right now, for instance, with prevention programs is…. We understand there's a key role for schools to play. There's been a lot of work led by the Ministry of Education in terms of presenting options to school districts, in terms of the type of work they could do.
The issue is that the school districts are already overwhelmed. This is not their area of expertise. They are absolutely swamped with young people who are struggling. They are swamped with staff that are struggling. They are swamped with parents that are struggling. We have given them a framework, and we've given them options.
The ability to actually implement what is primary prevention is incredibly challenging when you think about what is involved. Primary prevention, by definition, is meant to be a lighter touch than intervention but more broad, right? It's something that you want to be able to implement across your school, across your school district. You need a lot of folks with a light touch to support that. There just isn't the capacity to do it.
Our approach — and I think we can have opinions about whether it's the right approach or not — has been to really put the onus on the school district to implement. What that also means is….
We don't collect data. We're not able to collect data on the effectiveness of that work because it's not in any framework to do the data collection. It's really left to the schools to implement on their own. It's also up to them to then decide whether or not they've been successful. We all know that that's really difficult to do. You don't have a way of measuring that success.
I think that we need a certain level of centralized support to do primary prevention, whether it's Stronger Families or whether it's PreVenture or even something like the Iceland model.
Now, the Iceland model is really interesting. Obviously, Iceland is a country of about 300,000 people. So it's not…. There are some challenges when you start to put it into a province the size of B.C. It's community-based. What they do is…. They work with schools. They work with parents.
Folks really come to an agreement around what should be expected from parents and schools in terms of behaviour that would best support their young people. In other words, as a parent, you sign a contract saying you're not going to be intoxicated in front of your children. As a parent, you sign a contract that says you are going to attempt to have a certain curfew for your young people so they're not out at night, and you're not going to support them to have open-alcohol parties on a Friday night.
Schools also work with municipalities to expand access to sports, to expand access to the arts and to coordinate with each other to design policy that allows youth to participate in those sports and the arts so that they have after-school activities. They try to lower the barriers to access to those, because they know that youth who have a purpose are far less likely to get into trouble.
It's actually quite remarkable. For those of you who are…. If any of you are soccer fans, Iceland qualified for the World Cup as a soccer nation 20 years after implementing this. It's one of the stories that went under the radar, in terms of how it was possible that a country the size of 300,000 people could compete against France, a soccer powerhouse. This was one of the reasons why. It's because they had so many kids who were involved in soccer as part of this program.
S. Bond (Deputy Chair): I really appreciate the presentation, which is focused on prevention and early intervention.
I did send a note to Artour. I think we need to learn more about the programs, particularly PreVenture. I see that Foundry did partner with the North Vancouver school district to pilot a project. It would be interesting to hear how that is working.
I just wanted to agree with you in terms of resources.
The presentation that you've given us talks a lot about a school-based emphasis. That's where kids are. As we've been hearing from different organizations, there have been calls to scale up early intervention, school-based education, etc. One of the suggestions was related to providing more specialized counselling and having those specialists available at schools. As you point out, teachers and counsellors and administrators…. Their plates are full and overflowing.
Would you support a call for more specialized counselling services being on site in school districts across the province? And perhaps just a brief comment on the North Vancouver school district pilot project.
S. Mathias: Thank you, MLA Bond. I appreciate your questions.
Absolutely. I think that when we look at…. I had a conversation with a school counsellor friend of mine, who is a registered clinical counsellor and has gone back. He noted that in his counselling class at UBC, I think a group of 50 or 60 folks, four were men. Four were men.
I really think we need to review who is in the sector helping our young men. They are struggling with a lack of role models at times. I think they're struggling to connect with the current system. I'll say, even with Foundry, I think we need to adjust. We need to have a course correction at some point to try to support young men, teenage boys, at an earlier age. We know that a lot of these young folks can be identified in grade 6, grade 7.
I have conversations with parents all the time, at that age, and they're struggling. You know that this is going to be a challenge for them.
We can make a difference at that age. I think that relationship-building…. When you think about how the system works currently, we wait until the problem is so bad that the parents feel like they need to take them to a clinic, or they're identified as being a problem. Often they're kicked out of school or suspended or struggling to even attend classes. By then, so much of the damage has been done. So much of the damage has been done. When that happens, they often don't have a relationship with someone that they trust who can help them.
I think that this is…. Something that we really need to think about is whether or not we can have counsellors in place who can start supporting young people in grade 6 and in grade 7 and follow them through so that they're there for them when they're struggling.
They're there to keep them in school and to ensure that there's trust so that when the young person really does realize that they need help, they trust that the person who has been guiding them for the last year or two years is going to support them. There are some real benefits to that strategy.
In our work with North Vancouver schools, we found that with the PreVenture program, there was overwhelming support from school teachers and counsellors, as well as from parents, to sign off on having their children screened for at-risk traits. We know historically, from PreVenture, that when we do that kind of screening, about 40 percent of young people will be found to have at-risk traits, whether it's anxiety, depression, impulsivity or novelty-seeking.
When we did this with the North Van school district, we actually found that close to 60 percent of young people were positive for the types of traits that could be at-risk traits for substance use. We are just now in the process of offering the intervention, so we'll gain a lot of information from that.
There are challenges, because the counsellors who are working with us are overworked at times. We will know, in the next few months, how many youth who screen positive and were invited to follow-ups actually attended, and we'll get a better sense of what those outcomes are in about six months.
R. Leonard: Thanks very much for presenting. Foundry is growing all across British Columbia, and it's an opportunity for people in community to find out what's available, so I appreciate you coming here to present today.
I guess the question that I have is around the data collection piece. Sonia brought up the issue around how you do evidence-based prevention, how you determine what kinds of programs are going to be most effective and valuable. Foundry has been around for a while now, and I'm just wondering if you can share with us a little bit around the issue of mental health and substance use and the success rate of Foundry and what the approach is, in terms of ability to collect data.
I know that my community is the second pilot around integrated school-based teams, and one of the first challenges in many things, when we try to get out of silos, is data sharing and being able to have those conversations. Over to you.
S. Mathias: There's a lot to unpack there. Because we were faced with the challenge of collecting data from multiple services, we had to come in with our own data platform and our data collection platform for Foundry to succeed and collect the new data that you see here, for instance.
There are still some partners that, I think…. We're not at full data sharing quite yet. There are some partners that aren't prepared to share data. So that's something that we continue to work on. We understand that those are some of the challenges.
I think what we are seeing with our group that I think is really encouraging is that a significant portion of young people who are coming through our door — I believe it's 30 percent — had not sought any help from anyone in the year prior to coming in. So they're seeing this as the best place for them to come. They often…. I think it's about 35 percent that say that they would have gone nowhere if it hadn't been for Foundry. So they're using this as a place instead of a walk-in clinic or instead of an emergency room.
We do see a decrease in distress levels when our young people come through. Our challenge with this work, like anything else, is to actually say definitively that this young person feels better a year later because they came into Foundry. We can tell you two weeks later that they feel better, but it's very difficult to know that it was three months or six months or nine months later, just like it's really difficult to know when you come into an emergency room if you feel better because of that visit, because there are so many other things that can happen.
I think what we are basing this on is really the evidence that's been and the call for action that goes back 20, 25 years for improved integration, for improved communication between services, for the ability for young people, just like adults, to be able to access their services in one place with short wait times.
I think that those are the metrics that we're using right now. What we hope to show, in time, are similar outcomes to, say, some of these other models that are used. That requires population data, and it's going to take time to develop that database.
N. Sharma (Chair): I have a question. You talked a little bit about targeting young men, and how programs we develop don't do that as effectively as they could. I also notice that you're in a pretty significant period of expansion right now. At some point, you'll have almost the same amount as you have right now that are running. So you're doubling in size.
I just was curious about the thinking that we have now on what you're learning about where we need to go — how to address who is dying, with the crisis right now and your expansion, and what you'll be thinking about when you do that. Will you be changing any of your thinking on that?
S. Mathias: One of the big shifts for us is to try to really engage those young people upstream. That drop-off at the age of 16, as I highlighted, for young men is something where, if we can engage them when they're between 12 and 15 — if we can get parents to bring their kids in, or if they can come through the door before then — our hope is that they won't drop off at the age of 16, because there will have been a trust that was established with Foundry.
That's really what we're hearing, that there isn't the trust when they start having trouble at 17 or 18, because they just haven't been engaged up to that point. Can we engage them? Can we have campaigns? We will be launching a fairly significant Foundry campaign in the fall. We're also refreshing and adding significantly more content for substance use on our website, so that we can be more of a source of truth for young people when they're looking for that information.
I think ultimately, it's that relationship-building, and it's working with schools to identify young people much earlier than we've been able to do. This was a lesson learned for us, and it continues to be as we work through this. We know that between the ages of 16 and 21, Foundry is a trusted brand, but how do we become a trusted brand for the ages of 12 to 15? That's really the challenge that lies ahead.
Going back to your question, MLA Leonard, if we can get to those young people and support those young people at a much younger age, then our outcomes should be stronger still than with them coming in at 16. There was a time when I thought: "Hey, if we can get 16 to 21 through the door, this is great." Now, just with what we're seeing, we know we have to get even earlier than that.
S. Chant: How is Foundry at data sharing? If we were looking for data from Foundry, would it be fairly readily accessible? Do you have the same challenges in sharing data with others as…?
S. Mathias: Well, we have been working on a data governance structure that allows for greater data sharing. When government does come to us with requests, then we do work with government to share data and to show, to explain, the data that we have. We are certainly very much aware of OCAP rules around data sharing. So we tend to not stratify based on culture, but we will have big data shared, like we have today.
S. Bond (Deputy Chair): I just want to do a follow-up, and then one other question. On the North Van situation, I think that when you look at a program like PreVenture, it's one thing to identify significant students who have a risk profile.
My concern about that is — and I think it's important, and we need to learn more about it — how on earth you provide that number of children and young people with the support they need. Certainly, schools are not equipped to do that at the moment. I just make that point, that I appreciate the program. I'm very interested in it. Obviously, the staff do the screening, but then we need the provision of support for those students — especially with a high number like 60 percent.
My question is related to the focus group that is referenced in the presentation that was done with opioid-using youth.
I think one of the things that we've also been learning is that there needs to be some discussion, earlier, about substance use. One of the recommendations from the young people that were surveyed was increasing awareness and balanced early education about substance use.
Do you have a better sense of what that looks like? I think hearing today, for example, that our target group needs to move down fairly substantively in terms of their age…. Was there a follow-up done that looked at what type of awareness, what a balanced early education looked like? I would hope that it includes the risk side of substance use and what the potential risks are when you begin using.
Could you just speak to that, if you are able?
S. Mathias: I just want to go back to your point around the North Shore PreVenture initiative. The first phase is the screening, and the second phase is the actual intervention groups. There are two 90-minute interventions where youth who have screened positive are brought in, and they actually work through a curriculum or a skills group that has been shown to be effective at decreasing their risk long term, So the outcomes….
The reason that this is really important to highlight is that PreVenture has recognized that there are different traits that put people at risk for different substances or different issues. For instance, if you have struggled with depression or, say, anxiety, your risk is for depressants, so your risk is going to be for alcohol. If your risk, though, is with impulsivity, you're going to be at greater risk for cocaine or for stimulants.
Your need to understand your challenge is going to then lead you to being in a group specifically to help you with combatting your anxious trait or combatting your impulsive trait. They're stratified that way, and I think that that's why it's been found to be so effective.
Currently, our focus is on resilience and resilience-building, but what we fail to recognize is that most young people are comfortable with understanding that their risk is, "I'm an anxious kid," or that their risk is: "I tend to be impulsive, and I make decisions sometimes off the cuff." They are comfortable with that, and what we're not doing right now is sitting down with them and saying: "Okay, if you know that your impulsivity is a problem or an issue, or it's a struggle, or it's a risk, here is something you can do to cope with your impulsivity." That's what PreVenture does.
Similarly, if you're feeling anxious, and anxiety is going to lead you, potentially, to problematic substance use, it does allow you then to find ways to combat your anxiety. The body of evidence around PreVenture is that it's very effective in what's called targeted intervention or targeted prevention.
To your second point, young people, when they're asked about having earlier information…. As a parent, I look for it. Where are my young people learning about substance use? I have a 15-year-old daughter who tells me that her information comes from TikTok.
I'm just going to have that land for a second. Her father is leading a pretty important kind of thing here around mental health in B.C., and she's using TikTok to learn about her mental health. So when I sit down with her and I try to understand that, her comment is: "Well, right now the information we have is not digestible for a 14- or 15-year-old." We need to find a better way to communicate. So we happen to have a TikTok study looking at what the content is like on TikTok to see whether or not it's valid or whether or not kids should be looking at TikTok for that.
But to your point, MLA Bond, the young people have said: "Look, we want the straight-up goods earlier. We don't want to be discovering what this drug does late. We don't want to be discovering what alcohol does late. We want to know when we're 12, when we're 13, when we're 14. We want to be able to ask questions. We want to know why people are using. We want to know what benefits some people feel. But we also want to know what the long-term negative impact is so that we can make those decisions for ourselves."
I think that that's…. What they highlight is that when something is illegal, when something is vilified, or when young people hear that something is bad, it actually leads them to it. That's kind of a natural thing for a lot of young people.
The more disclosure we can make, the more clarity we can have around substance use — both the risks and the benefits — the more young people will trust us and are more likely to follow our lead on these substances. We're not doing any of that right now. We're trying to hide it from them.
N. Sharma (Chair): Any other questions, colleagues? Okay. I have one, actually.
I just would love to know a little bit more about, from your perspective and the youth that you serve, how the toxic drug supply has hit. In your slides, I see a lot of substance use or problematic substance use as a term. But I'm just curious how much of what you are seeing is related to, kind of, fentanyl and carfentanil — the things that are leading to death in a lot of circumstances, unfortunately, for the youth that you serve. What's the interaction there?
S. Mathias: I first learned that we were having problems with this in 2016. I was providing psychiatric services to — I always get this wrong — the Crossing, I think. In B.C., it's now Ashnola. It's a treatment centre for young people. It was a 17-year-old young man, and I had asked, basically, as I ask everyone: "How were you supporting yourself financially through your substance use concerns?" He said: "I was cooking fentanyl." I kind of took a step back and said: "Well, how is that possible? Fentanyl is a pharmaceutical. How were you doing this?" He said: "Well, I was working with a gang, and we were making it in a bathtub."
It was shortly thereafter that we started seeing these overdoses. Everyone kept reporting them as high-potency heroin, but we already knew what it was. We'd been told by the young people. Young people are the canaries in the mine shaft. They really are. When it comes to any new drug on the street, they'll tell you about it before anyone else will, before the public health officer. It was six months before public health actually announced that there was a problem when we went back.
The young people started to experiment with it. They moved to it very quickly. The kids that struggled with it the most were those who were using methamphetamine and then mixing it with fentanyl. When Minister Darcy and I met for the first time, about five minutes in I said: "You know, I really appreciate that we have an interest here in the opioid use, the opioid epidemic, but this started with methamphetamine. All of our supply channels were established with methamphetamine."
The young people who had been using methamphetamine for three, four, six years switched to fentanyl. It was a quick switch. It's a drug that has just unbelievably strong effects, and in a way that I had never seen before, even with methamphetamine. I just had never seen young people gravitate towards a drug the way they did with fentanyl.
Early on, I lost, I think, two or three young people who thought they were using something else and died from their overdose. Then I started losing young people who knew they were using fentanyl and were going through the yo-yoing, as they called it, with Narcan, where they would go deep, and then someone would resuscitate them with Narcan. Then they would eventually pass.
I think the young people that…. The experience that was most upsetting were the young people who had started methadone and, for whatever reason, had missed their dose on a Sunday because the pharmacy was only open an hour or had just a bit of chaos in their life and weren't able to pick their dose. They had developed reverse tolerance so quickly that when they used fentanyl the next time, they overdosed and died. That was always the most heart-wrenching, because those were the young people who wanted to get away from it and just…. Like everyone else, you have your slips, but that slip was deadly.
I've also had friends lose children because they thought they were using something else. I think the difficulty is that part of normal child development is to experiment. Right now we're at a stage where, as parents, we have to discourage our kids from experimenting. It's the first time in my life where I advise adults and parents to discourage their kids from experimenting unless they're buying it in a store, because there's no way they know what they're using.
I had parents whose child came home from college, and they called me up. They said: "He has a cocaine problem. What should we do?" I said: "Get a Narcan kit." You might think you've got cocaine, but that's not…. That shocked them into action.
This is why I think the Iceland model, for me, is something we have to have strong consideration for. When you don't have any real safe supply or when you're talking years away from being able to get to a place where you have true safe supply, you need to find another way of decreasing the risk. Prevention is, to me, something that we…. It's just been sitting there for us. We need to really think about it.
N. Sharma (Chair): Thank you very much. Anything else, Members?
Okay, then, it's my job on behalf of the committee to thank you so much for coming in and for the work that you do and for the number of years you've been doing it on the front lines of, it sounds like, more than one crisis when it comes to the youth over the years. Thank you so much for that. We appreciate the information and everything you've given us and also all the things you've helped us learn. Thanks a lot, Steve.
We have our next presentation at three, so that gives us about another ten minutes.
The committee recessed from 2:52 p.m. to 3:05 p.m.
[N. Sharma in the chair.]
N. Sharma (Chair): We'll go back on the record.
On behalf of the committee, Shannon Turner, I want to welcome you, from the Public Health Association of B.C. We have all your materials on our SharePoint, on our screens out here.
My name is Niki Sharma. I'm the Chair of the Health Committee, MLA for Vancouver-Hastings. Nice to meet you. I'll just do a quick round of intros.
Go ahead, Shirley, our Deputy Chair.
S. Bond (Deputy Chair): Thanks so much, Niki. Hi, I'm Shirley Bond, the MLA for Prince George, and I'm actually in Prince George today.
T. Halford: Trevor Halford, MLA for Surrey–White Rock.
S. Furstenau: Sonia Furstenau, MLA for Cowichan Valley.
M. Starchuk: Mike Starchuk, from Surrey-Cloverdale.
D. Routley: Doug Routley, Nanaimo–North Cowichan.
R. Leonard: I'm Ronna-Rae Leonard, MLA for Courtenay-Comox.
S. Chant: I'm Susie Chant, MLA, North Vancouver–Seymour.
P. Alexis: Pam Alexis, MLA, Abbotsford-Mission.
N. Sharma (Chair): So, Shannon, you have 15 minutes for the presentation, and then we'll have the rest of the time, 45, for a good discussion. We look forward to learning from you.
Go ahead.
PUBLIC HEALTH ASSOCIATION OF B.C.
S. Turner: Thank you for reaching out to the Public Health Association of British Columbia about this compelling and challenging issue.
I want to start by acknowledging that we're on the unceded territory of the Musqueam, Squamish and Tsleil-Waututh Nations, and I'm here with gratitude to be able to live, work, and play in such a beautiful part of the world.
Before we get into our story and the experience of the overdose crisis, I wanted to highlight a couple of things. My research has focused primarily on complex adaptive systems, so I wanted to bring to your attention the challenges that are in front of any government confronting an epidemic like this. This is what we would classify as a wicked problem. It's multi-pronged. It's ever changing. There are many, many influences. It's not simply resolved. It can take a long time to evaluate solutions, and by the time you've evaluated that solution, the situation on the ground has changed underneath you.
In public health and in health promotion, we're very comfortable with working with uncertainty, and we're very comfortable with being in complex situations. However, this has tested our mettle, primarily because of the staggering loss of life. I just wanted to clarify why it's been so difficult to find an easy pathway forward to resolve our difficulties and why it's been so important to look at other jurisdictions, at solutions from the grey literature and also at evidence arising from the folks who are living with the issue.
I'm not going to go on and on about the difference between a wicked problem and a tame problem, but I think if you take a look at the table in my notes, you'll see that that's exactly what we're dealing with. Substance-related harms are incredibly complex and are a public health problem that cannot be addressed through quick fixes. I speak to you about this because it's very easy for folks who are outside the system and outside the health system to say: "Why don't they just do this?"
Intensely committed health service staff, public health staff, providers on the street — we just heard from a fabulous man —are using absolutely everything in their toolkit to try to come to terms with this challenge. I come to you today with a significant degree of humility around what we're confronting collectively.
I wanted to place things in context for you. I'm sure you've been talking about this topic over the last few hours. Some of this may be repetitive, so I will move through it reasonably quickly so we can get to recommendations and questions. However, as a scientist and evidence-based public health practitioner, I always want to make sure that you have the context, because addressing a situation out of context means pretty significant failure when you're examining recommendations.
One of the things that we've heard from the folks who are doing incredible work on research on substance use is that the perspectives that we bring to the challenge influence the solutions we choose. If we are medicalizing a problem without dealing with the community-based context or the upstream challenges that people are facing, we're going to make a mistake. What we need to do is focus on human beings rather than pathology. That is coming from a person with a health background and a systems background.
Let me begin by acknowledging the extraordinary efforts that have been made already, from health services, from harm reduction and peer support providers, from legislators and decision-makers, examining innovative solutions and crafting new thresholds associated with decriminalization.
I can say to you, as a public health practitioner and as a citizen of British Columbia, how proud I've been of the governments of B.C. for leading the way on compassionate care for folks who use drugs. We did that with our supervised injection sites. We were early into that. We set the bar for the rest of the country. We taught Toronto. We taught Toronto how to do things.
B.C. is having…. Obviously, we have a profoundly difficult situation in front of us. We are experiencing staggering losses, and therefore, we need to be at the forefront of solutions.
A little bit about the context and the 7,000 deaths. The fact that we have had a twindemic…. With COVID, it's really had an impact on the way things have gone. I think that British Columbia, in particular…. While we may have done quite well with COVID, we haven't done very well with the opioid crisis. So it's very, very challenging for us when we examine all of the efforts that have been made.
I've quoted the coroner's report here. You've probably all seen this incredible spike in deaths. I think one of the things that's important to note about our history is that we were actually doing pretty well before the pandemic hit. That just put things into total disarray.
We are also observing the incredible impact on men. Of course, you are probably very familiar with the fact that it's mid-life males who are alone and using alone who are at greatest risk, with the exception of Indigenous women, who are on equal par with their male counterparts for being at risk.
What I ask about that, as a public health provider, is: what's going on with social connection? What's going on with how we treat isolation? What are we doing to meet the social-emotional needs of this constituency? Frankly, the literature on social isolation is very limited to seniors. We don't understand mid-life isolation. We don't understand why we have alienated young men. We don't understand why we've got folks who are working and there's nothing left for them at the end of the day.
We have to look at the larger context. We have to look at all of the conditions that influence these outcomes — child poverty, economic and racial segregation, unaffordable housing, stagnant wages and weak social supports for parents and caregivers.
Now, this is mission-critical, from the public health perspective. Public health works best at early identification and early intervention. We are the go-to upstream people in the system. We want to do population-level interventions that protect the population long term, both from communicable disease and chronic disease and from mental health and addiction issues.
We know how to do that. We know that where we provide strong supports for parents in early childhood development, where we provide good support for the identification of issues like speech-language pathologies, hearing difficulties, where we create safety nets for children so that they can make great social relationships and, again, experience connection….
Public health uses a model called the socioecological model. It is a model about relationships. When you talk about the relationship of the individual to their family, their family to the community and the community to the society as a whole…. It's in those relationships where we intervene. Our job is to ensure that people experience supportive relationships. Supportive relationships mean that folks do not turn to substance use, because their needs, emotionally and socially, are being met.
When a child has good self-regulation and knows how to manage their emotions and can make connections and can speak clearly or hear what their friends are saying or be supported by sign language or other instruments and tools…. We intervene early enough. We make sure that that child's experience and their early child development are not thwarted.
The other thing we do is…. We support the creation of safe households. Most of the kids who end up on the street involved in the consumption of substances have left unsafe housing. So what are we doing for violence prevention? What are we doing with the epidemic of domestic violence that was experienced during COVID in this country?
We have to tackle every single one of those upstream opportunities in order to create nurturing, safe and healthy communities. That means a whole-of-government approach. That means healthy public policy that has universal programs that make sure kids don't fall through the cracks.
The substance use issues that emerge when people reach adulthood and are isolated and alone and have nothing but a paycheque to look forward to…. That is our failure as a society and as a community.
That's the big speech from Public Health on all of the challenges that are in front of us.
Let's look at some of the contributing factors that have led us to this situation. We have, of course, a justice system where drug possession is a criminal offence. We have an increasingly toxic drug supply. We heard about folks making their own drugs. We've successfully stopped some of the international traffic. Now we have a fill-in-the-gap solution, which is leading to greater risk for our citizens. We've got socioeconomic inequalities.
I have to say this, as a public health professional, a person who has been working in public health and health promotion — internationally, nationally and regionally — for over 40 years. What happened to public health in the last 15 to 20 years was a complete erosion of public health infrastructure — the home nursing programs, the school nurses. All of those safety nets that were in place, where we could say: "Joe is struggling. Okay. Have him go down and talk to the nurse." We disbanded a lot of those things.
This is not just in British Columbia. This is across the country. There is a massive report, which has just been produced by the chief medical health officer of Canada, describing the erosion of the infrastructure. We have no search capacity. How do we respond when there is a crisis like this, when we barely have the staff to do…?
The tasks have been…. We used to have 21 core functions in public health. They've been whittled down and whittled down. This is not to say that I don't appreciate and respect the work that public health is doing. They're doing incredible work. But if we invest upstream in prevention and take care of all those things I described earlier, we don't find ourselves in the situation where we have an overburdened acute care system. There are generational impacts for decisions like that.
Let me just acknowledge, also, some of the government actions that have been taken. It's in your notes. We have the Good Samaritan Drug Overdose Act, which, of course, is protection for citizens who are intervening. We have a federal exemption from the Controlled Drugs and Substances Act for B.C., to be enacted on January 31, 2023, a hugely progressive step — again, not enough — the development of an overdose emergency response centre and increased funding for overdose prevention and response programs.
What I have to say about that is…. We've heard from people with lived experiences that some of our sites and some of our programs which are non-smoking mean that folks who are smoking and inhaling are not going to get the services they need.
Again, we're doing lots of things, but we're not doing them to the level they need to be done to actually intervene and save lives.
I'm sure that you've heard a lot about where we were pre-COVID and where we are now. We were starting to get a handle on things. But of course, it blew up with the pandemic and the amount of social isolation that was necessary to save the community as a whole pre-vaccine.
I serve as the chair of the WHO vaccine safety network. So I can tell you. I've been intensely involved in the vaccine response and in dealing with information and misinformation. The challenges around getting information out to people that is accurate, that people are ready to consume and hear…. It's an extraordinary new challenge that we're facing.
One of the things we have to do in response to this is not only provide services, but we have to provide information about those services that are consumable. They are gold seal. People know that they haven't been tampered with. We have to work on that. That's a whole other issue but an associated and aligned issue in terms of our capacity to respond.
The committee asked to talk about COVID-19 impacts. There is going to be a really wonderful report, which PHABC has been involved in producing with the Community Action Initiative and folks who deliver services and supports to people who use drugs. It has a number of recommendations. I've highlighted some of them in here, but one of the biggest things that has been identified is the threats associated with the current drug supply.
I was listening to the prior speaker, and that was a blessing. I wasn't really sure what I was supposed to do — come in or stay in the hall. There were no seats out there, so I just came in. I hope that was all right.
The fact of the matter is…. When people are on a pathway to recovery and then can't get access to the services they need….
There are recommendations about non-prescriber access in my notes. I really encourage you to look at anything that can be done to pilot and create opportunities for those steps to be taken. They will save lives, and they'll save lives today. There's nothing more important you could do, as a legislator, than to save a life. It's the most amazing opportunity.
One of the challenges I said about this wicked problem is that it's constantly adaptive. When we look at adaptive systems, the only thing that works in complex adaptive systems solutions is where actors, individual actors or organizations, have agency to operate according to a set of principles that lead to constructive global improvements.
You don't top-down direct, by policy, every single decision. What you do is take principles and support actors to deploy those principles, to make good decisions at the front line or in the face of what they're dealing with. That's what leads to what we call emergent outcomes, which are positive outcomes, hopefully, where people are solving problems at the local level, applying principles that you can acknowledge and honour and support and taking charge of their situation within their neighbourhoods and communities.
Is that 20 seconds?
N. Sharma (Chair): Please continue. That's fine.
S. Turner: Let me get to the recommendations, then. What I would say is that there are some systemic recommendations.
I can't stress enough the importance of upstream investment in public health, because you rebuild your foundation, and that gives you surge capacity. It allows you to reply. It means that the acute care sector is not sucking every penny out of the health system. You're actually preventing disease. You're preventing communicable disease spread, chronic disease, and you're enhancing people's opportunities to live to their full potential.
We are protecting air, water and land systems. We're protecting populations. We're protecting the food supply. All of these things are mission critical when it comes to any kind of public health threat. You have to have infrastructure to do that. We're recommending and calling for a 6 percent investment in public health infrastructure.
May I say that when I started my career, the Select Standing Committee on Health made a recommendation for a 10 percent investment in public health. That was 25 years ago, under a completely different government. It was never followed up on.
We're not even asking for 10 percent. We're asking for 6 percent. Right now, we're probably at 3 percent. Some other jurisdictions are at 1 percent. We spend a huge amount of money on health services, but not proportionately where we could be.
Health systems redesign. That means that we're looking a culturally appropriate and low-barrier access to prevention and treatment options for people who use drugs.
Investment and expansion of mental health programs to support upstream interventions designed to support resilient youth. We're very interested in supporting the social listening program around youth mental health. I've been very engaged with Amanda Todd's mother, Carol Todd. I guess you all are aware that the trial is going on right now for the perpetrator — cyberbullying, vicious, vicious. If we'd had effective mental health support programs, Amanda would probably still be with us. We could have dealt with the digital environment more effectively. We're learning from those things.
What I'm saying to you is that youth mental health is vulnerable. They're so vulnerable. We need to create buffers and protections for them that don't remove their agency but bring them into a space where they have literacy, a sense of purpose and a sense of active direction for where they want to go, and to support them if they are victimized.
Implementation of non-prescriber models for safe supply. What I'd like to say here is that there is work ahead for physicians in British Columbia. This is an area where we respect and admire the incredible work and service that has gone on, but there is stigma for drug users. You will hear this from people with lived experience. You'll hear about structural violence going into health services, feeling unseen, feeling invisible, feeling denigrated, not getting the help you need.
We've got some work ahead in partnership within the health system to make sure that public health providers, primary health providers and primary care providers are practising compassionate, sensitive care. We need to strengthen our requirements around that, I think.
Finally, I just want to say that we need to be grounded in Indigenous rights and reconciliation principles because the impacts of colonization have led people to the edge of an abyss, in some cases. We need to create a safety net to bring them back.
There are some recommendations here from the overdose response community. Is the committee hearing from members of the community as well? Great. I've listed them here. I think the most important thing I could say about this is that apart from safe supply and decriminalization, which are clearly opportunities for government to act, support for peers and peer engagement is critical. There are a lot of providers who are working actively with us.
I can tell you that I held the file for harm reduction. I served as a director of public health. We've supported conferences and sessions for people who use drugs. The burden for caregivers and the sense of anxiety when you are trying to keep people alive 24-7, never knowing what's coming in the door — it's such an overwhelming challenge, not only for the people who use but for the people who love them and care for them. Anything we can do to sustain our workforce and to support them as they carry out this work would be deeply appreciated.
I have met some of you before. It is a privilege to be with you today. I'm open to any questions. I'm sorry for talking longer than I should have, but that's me. I'm Irish. What can I say.
N. Sharma (Chair): Thank you, Shannon.
D. Routley: Thanks very much. It's much appreciated, a great presentation. You mentioned the pre-pandemic decline, and some of that can be attributed to safe supply. One of the terms of reference of the committee is to expand and increase safe supply.
First of all, I would like to hear your thoughts on that, on how we can help people understand why that is so important as an immediate step, but you referred to other supports, like the social determinants of health, investments in complex care housing and that sort of thing. Whether you think that those elements had time to improve the outcomes and if you have faith in that approach…. Obviously, we have to do the immediate, emergency steps, but are those the subsequent medium-term steps we should take?
S. Turner: Well, first of all, yay. I'm thrilled to hear it. I have some colleagues that work on this file, and I do appreciate how complex it is just to even ask the question.
I would also suggest that if government is going to take…. First of all, I think the public is profoundly sympathetic. I think we've lost so many. They know, and there are friends, children and their sisters and fathers. So I think the public is probably further ahead than we think they are on this and would just like us to get on with it. However, that doesn't mean we don't need a really powerful and important communications strategy around this.
One of the things we know about communications strategies is that you don't have to predict the outcome. For example, when we were doing seat belts, they did a special campaign in advance of announcing seat-belt legislation, and that campaign was a dummy flying headfirst into the windshield. They just ran that: "This is your head at 30 miles an hour, or at 70 miles and hour." By the time the seat-belt legislation came, everybody said: "Great. Let's get on it."
So there are ways to manage communication to the population in general that create and build support for what is very needed. That, I think, is one of the things I would say.
As I said in my notes, there are immediate, mid-term and long-term solutions. We arrived at a social safety net that was in peril. We had not federal housing program for more than a decade. We had deinstitutionalization, which was supposed to lead to closer-to-home care. Unfortunately, the infrastructure supports for Closer to Home were not implemented. So we had people who had never lived independently finding themselves without shelter.
We also have a climate where people can live outside year-round. That's different than 40-below wind-chill factors. So we have some in-migration, for which we need to, as Canadians, take care of each other and talk to our other Premiers about how to do shared responses around these things.
Anyway, I absolutely believe that we will be naive if we do not expect this problem to be at least a decade in the resolution. It's going to take intensive, mindful, evaluative steps. Rebuilding the infrastructure that was destroyed over the course of a decade is going to take a decade to return. Housing, shelter, food security, social supports, mental health supports, reinforcement for our workforce, which is shattered and exhausted from the dual burdens of the pandemic and the opioid crisis — each of those elements needs attention and care. We also need to recruit more people into public health and into physician care.
The Ontario Public Health Association has done a fantastic job with supporting certification for immigrant physicians. I'm very happy to talk to government about that. We could work with them on the program they've implemented, because we have shortages.
I don't want to keep going, but I thank you, Doug. I think you're right on the money with what you're suggesting in terms of multi-pronged. The problem is multi-pronged, and the response has to be multi-pronged.
S. Furstenau: Thanks, Shannon.
This is just a clarification. When you say 6 percent for public health, can you tell us 6 percent of the budget, 6 percent of GDP, 6 percent of what?
S. Turner: It's supposed to be 6 percent of the health care budget. We would like to have 6 percent now, because health care is basically the budget. These days it takes up so much of the budget and wrongly so.
That's another argument for 6 percent investment in public health, because we need to redirect resources. We need to tighten the belt around the acute care sector. They'll slaughter me for this, but I'm going to be frank. They will consume every penny that you give them, because the need is great. I want my father to have the care he needs, and I want my mother to have the care she needs. But I also want my children to have the programs they need, and that generation needs support.
We have an aging population. The collar has moved up — 85 plus. We are going to consume more and more complex care resources. Those are difficult choices. But if we continue to do that without doing this, we're never going to get into an equal balance in the scale.
So what I'm suggesting is not 10 percent, which was recommended over 20 years ago, but 6 percent of the health care budget so that we can recreate and rebuild public health infrastructure and then gradually produce a healthier population, which is the plan.
R. Leonard: First of all, thank you. I appreciate it.
I was having a text conversation with my niece this morning, and we were talking about how pervasive the deaths are. I think you're entirely accurate that there's a lot more public sentiment supportive of doing something drastic, because it's impacting everybody.
Six percent of the health care budget for public health — where does the 6 percent come from? Does it break down into something very substantial, like the building blocks, the LEGO blocks?
S. Turner: Yeah. To be fair, public health departments know very well to spend what they get. They make do with very little, and they do amazing things. Our farm to schools program, for example, was one of the smallest investments in the province. We're still going ten years later, and we've had extraordinary results.
However, I would suggest that because of the erosion of public health services in Canada overall — and again, there are many reports that reflect what I'm sharing with you — the 6 percent is the minimum investment from the health care budget to go towards investment in public health nursing, for example. We weren't seeing increases in public health nursing FTEs. In fact, we were seeing nursing FTEs moved into other functions in the health system.
This is a pet peeve of mine, if I may be candid with you. When CEOs of health authorities do not understand public health core competencies, do not understand population-level interventions, do not understand the value gained from those early upstream interventions and you have somebody who needs an OR nurse now, you're going to carve that budget off. It's always going to be an emergency. I understand that. I'd probably make the same crisis decision.
So I think we need to ring-fence funding so the acute sector has its fund and operates within that budget and we protect community-based services like long-term care and public health so that those services are not constantly being eroded in order to continue to meet a need that can never be fully satisfied.
We have public health nursing, speech-language pathology, audiology. We have community nutritionists who can help long-term care facilities, for example, plan local, sustainable meal programs. We have hygienists who can go in and support seniors to do community-based care for dental health. There are so many aspects of public health.
R. Leonard: It's big.
S. Turner: I hope that answers your question. Does it? Feel free to follow up with me.
R. Leonard: Well, 6 percent just feels like a number less than 10 percent. But I'm guessing that you have….
S. Turner: Currently, expenditure on public health sits around 3 percent in most health authorities, and that is not doing the job that needs to be done. There are many, many jobs that are unmet and many programs that are not being resourced appropriately.
At 3 percent, even when we had ring-fence funding from the federal government some few years ago, the CEOs at the health authority were asked what it was spent on. "Oh, it was all spent on prevention." Suddenly, everything was prevention, and it wasn't. It actually wasn't.
So we have to have it very carefully scrutinized. If we make this investment, there have to be clear metrics and accounts for the memorandums of understanding that go between the health authorities and the government, saying: "These are the population health outcomes we expect to see with this investment." That will create accountability around how the dollars are spent and utilized.
M. Starchuk: Inside of your report — on page 16, I guess it is — you talked about, in 2019, the downward trend that was identified. Then the year terms are…. Unfortunately, in 2020, there were things that were in play or not in play….
S. Turner: Sorry. We couldn't hear anything that you said.
M. Starchuk: I get that a lot.
In 2019, a downward trend was identified. Then, in your report, it makes reference to…. In 2020, the pandemic undid much of the groundwork that was laid. Then you identify closures of this, social isolation.
Now that we've kind of semi-normalized to the pandemic, what do you predict seeing, based on the knowledge of where we were going in 2019 and how we upset that apple cart? Now we're kind of back on track to getting these things opened. Can you speculate? I think you can speculate.
S. Turner: Yeah. I feel that the goalposts have moved. What we did before was working, to some degree. Then we had the pandemic, but the goalposts had moved. As I mentioned, the smoking inhalation of substances means that a lot of the things that we were using for people who inject drugs don't apply.
We've lost so many people. I think we're going to…. With that, we also have a population that has been actually traumatized and is re-emerging with some degree of trepidation from the pandemic. We've got a general population that is still trying to figure things out. There's a bit of collective trauma in the air, I guess, is the way that I would put it.
Even when we are making outreach and making engagement, it's happening in a different sociopsychological setting. In that setting, trust is less. People are more isolationist. We are not as connected.
So I think we need to find ways to create connection as soon as we can. We need to figure out what we're going to do about sites around smoking. That, along with incredible support for people with lived experience and peer-to-peer programming and non-prescribed use, will help us, I think, shift things.
It is, again, as I said, complex. Of course, I'm also actively praying every single day to see some healing, and I think we could all do that. I think that sending love out into the world is a good thing.
M. Starchuk: I agree.
N. Sharma (Chair): I have a question. You mentioned the expansion of non-prescriber safe supply. I guess I have two questions. One is: what do you see as the role of prescribed safe supply and what the challenges are that exist or don't exist using that model? Then what do you see in communities as a non-prescribed model for safe supply?
S. Turner: Great question. There's a continuum along that, so it's not a singular solution in terms of what could be.
You heard our prior speaker talk about the inability of someone to get to the pharmacy where they were going to get their safe supply and then taking advantage of something that was available on the street because they couldn't get in. Those issues are life-threatening. It's a very coercive model. I know that there are physicians who are kind of, frankly, abandoning it and doing their own thing, and they're under the radar.
Like we've had to do with some other very challenging health circumstances, I think we have to create some safety nets for people who are operating on the edge here, trying to keep people alive and putting their own professional security, safety and futures at risk because they want to meet the needs of their clients in a way that they know is vital. We've got to have more conversations about this and, I think, more public conversations about this. I think there's an opportunity to have some dialogues that the public can tune into that explore and explain what those models look like so we can create support for them.
What I think could happen…. Let me just say that there are people who are so much more informed about this than I am. I will share with you what I see based on my administrative experience, but I think there will be other speakers you'll have who will be much more helpful to you with this question.
So a model whereby individuals can…. We know that there's somebody who has got safe product and that we can go to them and get support from them. That's, basically, the simplest way to describe it. They should be folks who have attachment to wraparound services. They should be folks who can do referrals. One of the things we learned with supervised injection sites was that the site was secondary to the services people got to move forward.
I've read letters from folks who were supported through supervised injection and are now drug-free and who have felt that it was life-saving for them because it was a place where they could make referrals. I think the wraparound — this is not just making something easily available and not doing any follow-ups. I think that's also very important to stress.
The other thing I would say is that we know who does a really good job of this in the province, and they're the people that we want to be working with. We need to manage that thoughtfully.
Finally, I think it would be really great to have a conversation with Doctors of B.C. and look at Doctors of B.C. as a potential partner in hosting a program where they provide supports to non-prescribers. Yeah. In other words, I can do this function, but I've got a clinical backup.
I hope that's helpful.
N. Sharma (Chair): That is helpful. Thank you.
P. Alexis: Can you give me an example where public health is functioning as it should with respect to a different province, different country or anything that we can look at?
S. Turner: Well, there are so many examples from around the globe for different things. As a chair of the VSN, I've worked with countries that are undertaking massive population health issues in terms of poverty, food insecurity, yet they're still managing to get out and immunize their people. They're travelling up bicycle paths and stuff. So there is something about the collective spirit of the community that is addressing the challenge that is, I think, the tipping point to success.
You can look at high-income countries, middle- and lower-income countries. I heard Iceland mentioned earlier. Iceland has done a very good job, but Iceland has had a much smaller problem than we've had. Let's be clear: our problem is significant and profound, and it is complex. It's a wicked problem. Also, community engagement and levels of community engagement in Iceland are more typically experienced. When you're making comparisons, again, context is everything.
I don't mean to take anything away from the successful programming. We do go out and look at that program that worked really well and bring it home and try it. But I will say that, for example, even in countries where they have very strong social safety nets, they don't always have agreement on what the right public health policy is and how to respond to a challenge or a threat.
We saw a lot of diversity in the response to the pandemic. Canada has actually done better in terms of responding to the pandemic. Where I look at our response and my concerns about it has to do with how we support low- and middle-income countries and address global inequalities around access. But that is, again, another stream.
One of the things I would like to stress is that…. I did a lot of work in Sweden, probably 20, 25 years ago, as a consultant on health-promoting schools. Their social safety net was extraordinary. Here's an example. The buses bent over. They kneeled down so the seniors could get on. I thought: "Wow, there is no more powerful structural message than a bus that literally kneels over so that a senior can get on."
Their hot meal programs — another passion of mine — in their schools, which the elders came to…. They really invested in community. Where you have good infrastructure, good programs, balanced by community investment….
Now, our association has just looked at food insecurity through the pandemic. We looked particularly at rural-remote. We see that there are a significant number of NGOs and small organizations meeting needs who are not seen as part of our system. There's a lot of intelligence we don't hold right now. One of our jobs is to develop that intelligence, to figure out, on the community side, who's doing what.
The communities filled in the gaps in a lot of ways. It's not resulting in equitable, even, access to what every child should have or what every senior should have or what every mid-life male who's alone working on a blue-collar shift should have. It's very, very mixed. The consequence of that is that we have more vulnerable populations in different places.
Again, I think that a great partnership between civil society, government and the NGO sector can lead to some really robust solutions. I have seen that in other countries, related to different public health issues — traffic safety, for example. Mexico turned around their traffic deaths in one generation, dropped them like 60 percent.
I work with the global Violence Prevention Alliance. We've seen 50 percent reductions in violence in certain cities with the right programs. These are cities that are fraught with gang warfare, illicit drug trade, profoundly violent, and we've been able to impact them.
There is evidence-based…. Things are preventable. We have to make the upstream investment. It doesn't matter how wicked the problem is. If you do the right things upstream, you prevent harm, and you prevent human suffering. That, of course, should be our objective if we're trying to create and grow a healthy society, a healthy democracy.
P. Alexis: There were lessons learned with the pandemic and how we rolled out this massive vaccination program and how we educated people. Tell me about the lessons learned and how we can apply them to the crisis that we're in.
S. Turner: There were a lot of lessons learned, most of which, sadly, are about the gaps. We went online and did an online engagement with citizens of British Columbia about three weeks into the pandemic. What we were hearing from seniors, who were frightened…. They couldn't go to the grocery store. They couldn't leave their partner. The kinds of challenges that people had were overwhelming. We saw the food insecurity issues.
I think federally, Canada did some amazing things to preserve and protect the population and to keep people in their homes that had homes. But we have a lot of people who are on the edge of losing all the time. So I think there are lessons there about, perhaps, a living wage and basic income, because it made a significant difference.
I think there are lessons learned around the infrastructure and capacity and the burden on our health care system and what we need to do. I was involved in a dialogue during the pandemic about persons with disabilities. This is an embargoed conversation. Can I share it? No? That's okay, then. I'll leave it.
I'll simply say that there are ways to navigate very challenging circumstances with transparency and trust and to create supportive conditions for people, but you have to be an honest broker. I think we learned that we had to find ways to trust each other and to work across sectors.
We saw food producers finding food and getting it to food banks. We saw the province responding to incredible food insecurity needs by finding massive amounts of money for Food Banks B.C. and the United Way. This was gratefully received, and we're now examining it to see how we can do this in a better way so that we have sustainable food supplies and dignified food access and grow food. So there are all kinds of things like that that we have learned.
I have to say I feel very blessed to be both in B.C. and in Canada, because that's not what I was hearing globally, the work that we were doing. India, for example — just devastating losses. We are deeply privileged. We're a higher-income country. There is no reason we shouldn't be applying the lessons from the pandemic to everything we do, in terms of community-based social safety and support, because it was our community and NGO sector that really stepped in.
I guess the other thing I would say, in terms of lessons of the pandemic, is how much we need each other and how much we can trust and rely on each other. When we work collectively, we can move mountains. I saw pharmacists showing up. Across the board: "How can I help?" I had retired people contacting me, saying: "Can I come in? Is there anything we can do?"
I guess the thing is that it's much harder for people who are stigmatized to receive that level of support and nurturance and care, and it should not matter. When it's your mom and your dad and your grandma, everybody's like: "Yes, let's…." But when it's someone who's been living on the street, who's got an underlying mental health condition, who's self-medicating with substances because they have not had the right institutional supports, it's harder for people to create a safety net around them.
Even though the public wants this dealt with, and even though the public is aware that there are many children of their friends and that type of thing, the folks that are really, really vulnerable are the ones that it's…. They're often…. I've seen headlines: "Junkies." Just so, so unhelpful.
What I think we need to do is have compassionate language, a conversation about compassionate language with the media and make sure that when we're describing people who use drugs, we're doing so in a way that's non-stigmatizing, and we educate our publics about that so that we are creating safety for those people to get the help they need.
I think that the pandemic…. We had marginalized folks in the pandemic. The province and the federal government got folks who were on reserve and status folks vaccinated very quickly, which was good, because there wasn't the infrastructure on the reserve. They would not have survived.
Many, many lessons. I think our emergency response and emergency preparedness plans need work. All of the health authorities, we need an investment there as well. So lots, lots more to talk about with that, but thank you.
P. Alexis: It's been a real pleasure speaking to you and hearing you speak. I was mayor through the pandemic, and it was a really difficult time for the community because those marginalized people who we tried to take care of were shunned by the rest of society, and it was an extremely difficult time.
One of the biggest issues that we had, and you addressed it earlier in your presentation, was misinformation. In fact, it remained the biggest problem. How do you see the misinformation conversation fitting into what we're tackling now?
S. Turner: Well, there are different audiences, and there are different problems with different audiences. We heard earlier about TikTok. We're very involved, actually, in looking at social media as a mechanism for health promotion, and that's what my doctoral research is on. We're really interested in looking at social listening for youth mental health, actually.
They're going to their own neighbourhood online, which is not always a nice neighbourhood. There can be lots of garbage that happens there — bullying, etc., that I mentioned earlier — but also misinformation. We're trying to put in — and what we need to do collectively is put in — what we call a pro-social dose of positive information. Teach digital literacy. Support kids to have a sense of agency about what they consume and how…. In fact, we have to do this for the general public too.
It's amazing the stuff that people will share with me that they think is fact because it has a number in it and it came across their desk. It's like: "Oh my." Heavens to Betsy.
I think there are some larger questions for us sociologically around the Internet and Internet use that we have to answer. However, very active participation in the digital ecology. Recognize that it is out there. It is a major threat to health and well-being from a number of perspectives. It's also a major opportunity for promoting health and well-being. Like a car — you've got to be safe when you drive it. Same thing. But I also think….
We've seen all kinds of incredible social supports online. I've seen children disclose that they're doing self-harm and getting all kinds of support back from sites like CDC Atlanta, for example: "We're sorry you cut yourself, honey. We're right here for you. Give us a call. Here's our number. We've got people standing by right now ready to help you."
People tend to disclose online in a way that they don't in person. It's a unique environment, and it's also an environment that creates incredible vulnerability and, for predators, like the fellow who targeted Amanda, just an endless field of opportunity. So we need to buffer our children and protect our children and teach them how to manage that.
I believe there's an opportunity for us to certify information –– for example, the vaccine safety network. We have a certification seal that says: "This is accurate vaccine information. It's accurate intelligence. It's been vetted. You can rely on this site." I think we need to have approved sites, and we need youth peers to produce content. That's what we're doing with our Immunize B.C. project. We have youth engaged in peer education. We can have…. Sadly, there's a dark web, and there's lots of stuff around the illicit drug trade and lots of seduction, so that's one monitoring surveillance function that has to happen.
In the mainstream, there's work to be done, surrounding people with supports and links and contacts and connections and also curating. If somebody says something online that looks like they might have some suicidal ideation, there's a notification that goes out, and there's a contact and outreach. The big sites are doing that now.
I've had the privilege of working with Pinterest, Facebook, YouTube at the global level around how we manage the flow of information, for vaccine information, and getting them to optimize search engines so that accurate information is placed at the top of the list. We've been involved in a lot of projects with that.
We've been doing social listening with really advanced tools so we can tell…. I'm giving this example to you because it's what's possible. We can tell that this particular organization is responsible for 90 percent of the vaccine misinformation. They are lying, they are producing fake videos, and they are trying to sell supplements, basically.
I think there are going to be changes to international law and order around some of those things, but we've been in a tsunami of information explosion, and we're now trying to rise to the surface and figure out where we need to put in protections. I honestly think that digital literacy, pro-social content, accurate information, search engine optimization are some very straightforward steps we can take to start to tackle some of these questions.
N. Sharma (Chair): Shannon, on behalf of the committee, I just want to thank you so much. Not only your passion but your compassion was pretty clear in your presentation, and I just want to thank you for all the work that you do. We appreciate you helping us learn from you today.
S. Turner: Thank you so much for asking and for being so open, and I honour and appreciate your service to our public. It's a big deal to do what you do. It's not for the faint of heart. I know it's exhausting, and you have very long days. So we do hold you in the light.
N. Sharma (Chair): Okay. The committee will recess until 4:30.
The committee recessed from 3:59 p.m. to 4:27 p.m.
[N. Sharma in the chair.]
N. Sharma (Chair): Welcome.
Next up, just for the record, we have the College of Physicians and Surgeons of B.C., Heidi Oetter, registrar and chief executive officer; B.C. College of Nurses and Midwives, Cynthia Johansen, registrar and chief executive officer; College of Pharmacists of B.C., Suzanne Solven, registrar and chief executive officer.
We just want to welcome you.
My name is Niki Sharma. I'm the MLA for Vancouver-Hastings. We'll do a round of introductions, and I'll start over here.
Go ahead, Trevor.
T. Halford: Trevor Halford, MLA, Surrey–White Rock.
S. Furstenau: Sonia Furstenau, MLA for Cowichan Valley.
M. Starchuk: Mike Starchuk, MLA for Surrey-Cloverdale.
D. Routley: I'm Doug Routley, Nanaimo–North Cowichan.
R. Leonard: Ronna-Rae Leonard, MLA for Courtenay-Comox.
S. Chant: Susie Chant, MLA, North Vancouver–Seymour.
P. Alexis: Pam Alexis, MLA for Abbotsford-Mission.
N. Sharma (Chair): You each have about 15 minutes to present, and we have the materials that you've sent us, in front of us. Then afterwards, we have about 45 minutes for questions and discussion.
I don't know who wants to go first, but I'll let you decide.
C. Johansen: We're actually going to present together if that's all right. We're coordinated.
H. Oetter: We don't even need 45 minutes to do that.
Briefings on
Drug Toxicity and Overdoses
Panel 1 – Professional
Health Associations
B.C. COLLEGE OF NURSES AND MIDWIVES,
COLLEGE OF PHYSICIANS
AND SURGEONS OF B.C.,
COLLEGE OF PHARMACISTS OF B.C.
C. Johansen: We're actually hoping we can present some information and answer, hopefully, some questions in advance but then really have a bit of a dialogue.
First, thank you for inviting us.
We want to acknowledge that this meeting is taking place on the unceded and traditional territory of the Coast Salish peoples, including the Musqueam, Tsleil-Waututh and Squamish Nations, whose historical relationships with this land continue to this day.
We also want to take just a moment to acknowledge the devastating toll that the illicit drug toxicity crisis has had on our communities, our family, our friends. All three colleges stand together to express our grief at the loss, just an overwhelming loss, of life. We just want to start there, acknowledging that this is a crisis.
Who we are. We are the three regulatory bodies. Nursing and midwifery have about 67,000 practitioners in our province. Physicians and surgeons are 14,500, half of which make up the family physicians that interact with the communities. For pharmacists and pharmacy technicians, there are about 9,900. As well, Suzanne's college oversees about 1,500 retail pharmacies. It's a substantive number of individuals, who make up more than the majority of the health care system in our province.
A little bit about what we do. We exist under the Health Professions Act. I hope that you all are somewhat familiar with the Health Professions Act. I know that there are a million pieces of legislation, but this one really does outline the authority for regulating health practitioners in our province.
That piece of legislation gives the colleges authority over licensing, or what we often call registration; complaints and discipline, so responding to complaints but then taking action when there's evidence of harm; quality assurance, which takes different forms, depending on the college that's operating the program, but usually includes peer reviews, continuing competence or professional development requirements. We set the standards for practice to enhance quality of practice and reduce incompetent, impaired and unethical practice. We set the standards for professional ethics.
We work collaboratively with government, with regulators, health authorities and educators, to do our work — again, not in a silo at all — and we promote and enhance interprofessional collaborative practice, which is exactly why we're presenting today. This issue is something that all three colleges have a role in, and we like to operate together, wherever possible.
I'm going to turn it over to Heidi.
H. Oetter: Thanks, Cynthia.
The message I really want to start with is that we don't regulate the system. We do regulate individual practitioners, and we do hold them to account and, as Cynthia mentioned, standards for entry to practice, registration. We know that the structure and funding of the health care system is probably a solution for dealing with the illicit-opioid crisis, but those aren't really within our purview.
We know that access to health care providers in this province is a challenge, and it's not just a challenge in rural, remote communities. You can't pick up a newspaper or read online news without hearing about problems accessing either a nurse practitioner or a family physician, who remain an incredibly important first contact for the health care system.
Even though our numbers of new registrants coming in are increasing each year, it's just not enough to keep up with what the province really needs in terms of access. We give out licences to practise, but with that, we don't say, "Oh, and you must go work in Prince Rupert," or: "You must work in Victoria." People are kind of free to work where they work.
Another important aspect of what we don't do is that we don't do the development and implementation of clinical practice guidelines. As Cynthia mentioned, we have a very important role in setting professional and ethical standards for registrants but not in whether you use 250 milligrams of amoxil or initiate this type of surgical procedure. We're not clinical experts; we're regulatory experts.
We also do not administer the Canada Health Act or the Medicare Protection Act. Both of those are very important statutes around access to publicly funded, publicly administered health care services. We know that within the addiction community, many services are privately paid, and that puts it beyond reach for many, many citizens in British Columbia.
We don't do clinical research or innovation, and we very much welcome the creation and the continuance of the B.C. Centre on Substance Use in British Columbia, which started in 2017.
We do not deal with the federal-provincial legislation, and I think that we exist within a prescribing model for safer supply. My colleague Suzanne from the College of Pharmacists is going to talk a bit more about that.
On the physician side of the house, most of the community care in this province is by physicians working in a private practice model in a community setting. It's a fee-for-service model predominantly, and we know that model of care is not well indicated with acute care services or with mental health services.
Just by way of background, it's been a long time since I was in clinical practice, but I did have 18 years of practice working out in the Coquitlam–New Westminster area, and those were concerns then. I was part of the department of psychiatry at Royal Columbian Hospital, and it was always a challenge to find people to move from community to hospital and back out again. We just haven't been able to crack that nut, unfortunately.
So I just want to acknowledge that there aren't enough providers, whether they're nurse practitioners or family physicians in this province, to meet the health care needs, and there's certainly a maldistribution of those individuals.
What do we observe today? Well, you saw on the news that the B.C. government just settled with Purdue Pharma –– $150 million. That was really due to the commercialization of the provision of prescribed opioids in what I would say is the 1990s, 2000s, 2010s. That's certainly when I was involved with the methadone program at the college. That was then. This is now, and that's not the problem that we are dealing with.
Illicit drugs are now made synthetically. They're cheap to produce, and they're just easy to ship around the world. We know that people dying from illicit drug consumption frequently are occasional users and do not meet the diagnosis of an individual with a substance use disorder of opioids.
It's not just the opioids that are potentially contaminated with fentanyl, carfentanil. We know that illicit stimulant medication –– crystal meth, methamphetamines –– may also be contaminated with illicit drugs, now including the whole benzodiazepine precursors. There's no way to reverse those overdoses. They're just really, truly toxic.
The other problem we observe is that the treatment for people who suffer from substance use disorder or substance use disorder plus a mental health condition frequently need resources that are well beyond what can be provided by a family physician or a nurse practitioner. There are personal challenges, social challenges, social work, psychiatry, occupational therapy, vocational therapy. There's really a broad range of supports.
I just really want to say that I don't think this is about prescribing our way out of this current crisis. We really need to think about what the supports are that people really need to be able to meet their basic Maslow's triangle needs of life and then work from there.
We see a lot of successful actions out there. The first I want to talk about is the take-home naloxone. I want to publicly acknowledge and thank Dr. Jane Buxton for the work that she did in innovating the model of take-home naloxone throughout the province. For those of you who don't know, Jane just retired.
Drug testing kits. We know that raves and parties will continue to be a place where people go to gather socially, and we think that they are an important tool so that those people who do use illicit substances can at least be testing them and making sure they know what they may or may not be getting in advance.
We know that harm reduction strategies — including overdose prevention sites, supervised injection sites and needle exchanges — are very important and need to be continued, supported and funded in this province.
We just want to acknowledge that there are lots of good medical interventions out there by a range of practitioners. It's not just physicians. It's nurse practitioners, physicians, nurses, pharmacists and registered psychiatric nurses who are out there doing opioid antagonist therapy as well as opioid agonist therapy and the injectable opioid agonist therapy. So there is lots of good work happening out there, but obviously, the needs of B.C. citizens are not being met.
We know that scalability is an issue. Opioid agonist treatment programs are highly resource-intensive and expensive. Ideally, practitioners really need to be working in teams of health care providers. So mental health supports, addiction supports, social workers, psychiatrists, occupational therapy people. Those models are very scarce around the province, and they certainly are not well spread around the province.
Again, I just want to emphasize that, on the physician side of the house, anyway, the current fee-for-service model does not support family physicians doing this type of work. Solutions for that really ought to be discussed with the Doctors of B.C. and the Ministry of Health.
Back to you, Cynthia.
C. Johansen: We're going to talk a little bit about what each of the three colleges has been doing over the past few years, just to give some context to some of the suggestions and recommendations that we've prepared for you.
I'm actually going to turn it back to Heidi first. She's going to talk about what the College of Physicians and Surgeons has been doing.
H. Oetter: Thanks, Cynthia.
Historically, the B.C. College of Physicians and Surgeons used to run the methadone program in British Columbia. We did so up until 2017. That's when the B.C. Centre on Substance Use was created at Providence Health Care. They took over the running of that program.
We continue to have a very close working relationship with the B.C. Centre on Substance Use. We continue to be very involved in supporting physicians in understanding that resource as an educational resource as well as their clinical practice guidelines.
Our college has participated in both death review panels conducted by the B.C. Coroners Service, and we have sent out messages to the profession regarding safer supply. I've brought copies of those publications that went out to the physicians so that you can have them here.
Basically, we have said that if you have the training and experience to be doing safer supply, we are not a barrier to doing that. We really tried to amplify the messages of the Ministry of Mental Health and Addictions as well as the Ministry of Health.
We do not expect neurosurgeons to be doing this kind of work. It is really, predominantly, within the purview of family physicians. I want to share that our understanding of the post-graduate training programs around Canada, particularly in British Columbia, is that doing addiction medicine is considered a core competency for any family physician graduating from a training program here in British Columbia.
It's page 13 of the handout that we gave you. I've listed the numbers, as a point in time, of the professionally active registrants in this province from 2020 through 2022. You can see that while we still don't have enough doctors in the province, we continue to register a record number of new physicians each year. Numbers are growing, matching the increasing number of graduates coming out of UBC as well as the fact that British Columbia is really quite successful at stealing physicians from other provinces.
I've got the numbers of family physicians. In 2020, it was 6,720. In 2021, it was 6,943. In 2022, it was 7,229.
We then asked, on renewal of their licence, if they were prescribing opioid agonist treatment. That would be methadone, Suboxone and slow-release oral morphine.
If we say…. Mostly, this is done by family physicians. I'm doing a disservice to the colleagues who are psychiatrists and internists who are doing some of this work. We see roughly about 30 percent of family physicians, based on a self-report, saying that they're doing Suboxone, methadone or slow-release oral morphine.
The reason we were asking this question is…. The B.C. Centre on Substance Use — graduating all of these people — was saying: "Where are they? Are they doing this work or not?"
This is self-reported data. I don't know how valid and reliable it is. I just want to make the point here that while it's not enough, it is encouraging. People are out there doing this work despite what we see as some of the structure and funding barriers to that.
Last year we asked the question: are you prescribing safer supply? I'm pleased to report — again, based on self-reported data — that 1,607…. About 69 percent of the people doing opioid agonist therapy also said that they were doing safer supply. Again, not enough. It certainly, I think, goes at least some way to saying we are seeing an uptake within the physician community.
Back to you, Cynthia.
C. Johansen: Thanks, Heidi.
In terms of the B.C. College of Nurses and Midwives, similar to Heidi, we've been quite engaged with different ministries, with all the health authorities, with BCCSU to really think about: how do we implement strategies for nursing, particularly, not so much midwifery, to really engage in system solutions? We've done a number, including things like setting standards, limits and conditions and providing guidance and advice to nurse practitioners, in particular, who do safe supply prescribing.
I do want to take just a moment, though, to talk a little bit more about the registered nursing and registered psychiatric nursing group. That's a more recent change. Nurse practitioners have been able to prescribe and treat opioid use disorder since about 2017. So it's been some time.
In September 2020, the provincial health officer, Dr. Bonnie Henry, reached out to the college to see how we could work with her office to identify an approach to allowing registered nurses, initially, to prescribe Suboxone. In the conversation, we agreed that, absolutely, this could be done, and let's add registered psychiatric nurses as well. Given the practice environment and their connection to different parts of community, it made sense.
We worked with her office, and we developed, with her, an emergency order. Currently Suboxone prescribing is happening by RNs and RPNs but under an emergency provincial health officer order. The reason we went that route was….
Our intention is to make it permanent, to work with government to make it permanent. However, in terms of doing it very quickly, the provincial health officer order was faster than trying to change our bylaws and our standards and our regulation, which does take months. I'm proud of the fact that we got there so quickly.
Work continues to build this into a permanent change. We're looking at making it a certified practice designation for registered nurses and registered psychiatric nurses. Again, it will require — and we already are — working with the Ministry of Health to change the regulation for nurses and to build bylaws, a registration category in our bylaws. I know it sounds very bureaucratic, but it requires public posting time and consultation with the broad range of community partners.
We're happy to be able to have evidence to say the temporary provincial health officer order has worked. Now we can make a permanent change.
In terms of the actual numbers of individuals who have taken the additional education as a registered nurse or registered psychiatric nurse to prescribe, it's only about 120 so far. So a very small uptake.
I do want to pause here and just take a moment to acknowledge that our nurses are burned out. Certainly, taking additional education or whatever it might be to extend their practice to these other vulnerable populations takes time and takes effort.
I think that's going to be…. One of the challenges for any recommendation that comes forward is having the people to do the work. You need faculty to teach. You need people to learn. Then you need practice environments to support. All of that takes people.
We've been working quite collaboratively with Heidi's college and with Suzanne's college around other opportunities for RN and RPN OAT prescribing to extend to other medications. However, as Heidi pointed out earlier in her presentation, we're not clinical experts at the B.C. College of Nurses and Midwives. So our direction on extending or expanding prescribing rights for registered psychiatric nurses and registered nurses will come from those clinical experts, like BCCSU.
We rely on them heavily to provide us that guidance and that advice, because they have the scientific evidence to back up a change that we can make. We're open to more change, for sure, but it has to come from those clinical experts with evidence behind it.
I'm going to turn it over now to Suzanne, who's going to talk a little bit about the College of Pharmacists.
S. Solven: Thanks so much, Cynthia.
I just wanted to say that the College of Pharmacists of B.C. has been proactively working since 2007 with our health system partners to address, as quickly as we could, emerging issues, and these first were around methadone maintenance treatment and what we were hearing from the patients with lived experiences about unsafe and inadequate pharmacy care at that time.
So there was a lot of work done, and that's really evolved over the years. Now we've been working on the change for the illicit drug crisis.
We continue on this work, with our partners, as a priority to keep British Columbians safe. I can say that our team at the college has been meeting regularly with the various Ministries of Health, Ministry of Mental Health and Addictions, our college partners, our colleagues in the communities. I also would like to acknowledge that with the pandemic, the pharmacist community is also experiencing and acknowledging burnout. So again, that's another challenge for us, as we work on these things and potentially look at expanded scope and what that looks like in the business community and their workplace environments.
The college was also a participant in the B.C. Coroners Service death review panel in 2021.
In your package, I did provide a backgrounder document on the work that the college has done to date, but in case you didn't have a chance to review — because I understand you've got a lot of information to go through — I just wanted to highlight a couple of those changes that we've worked on over the past several years that we think probably had the potential of the greatest impact to patient care to reduce drug-related harm.
In 2011, we introduced, for the first time, standards around methadone maintenance treatment. This was to ensure safe and consistent care for patients. At that time, all pharmacists were required to take training, and the goal was to reduce the risk and improve the patient outcomes.
In 2016, our college board was actually the first in Canada to remove naloxone completely from the drug schedule regulation, which basically means that the drug no longer was scheduled, meaning it no longer required a prescription, and there was no requirements for storage as well. As I'm sure you are all aware, this provided much greater accessibility to prevent opioid overdoses. This has been significant as part of the strategies.
In 2018, our board approved a new opioid agonist treatment policy, and that was to support the treatment options that came out in, at that time, the new BCCSU guideline for the clinical management of opioid use disorder.
This was the change where Suboxone, or buprenorphine naloxone, was now recommended as first-line therapy over methadone maintenance treatment. So the guideline was updated to reflect those changes in care, and also to continue, though, with the guidelines around MMT for those patients that could not use Suboxone.
In 2019, working with our partners — and there were many; it's outlined in the background document — the college introduced new opioid agonist treatment training requirements. This was really aimed at reducing stigma and expanding pharmacists' knowledge in this area to address one of the issues that's come out through other recommendations around making sure that health care providers are trained and understand this is a substance use disorder and really aimed at decreasing that stigma, and also making sure that they were up to date on the clinical care and the clinical guidelines from the BCCSU.
So 96 percent of community pharmacists and 67 percent of community pharmacy technicians did take the training. This was mandatory training and continues to be mandatory training for any pharmacy and their staff who wish to dispense this [audio interrupted].
In 2020, as the pandemic was at the height, as I'm sure you know, Health Canada made changes to the Controlled Drugs and Substances Act. It's referred to as section 56 exemptions. But the college acted really quickly to introduce changes and temporary authorization to the delivery requirements for opioid agonist treatment to maintain patient access to controlled substances for medical treatments during the pandemic.
I know from your previous presentations that you are aware of safer supply, but we just wanted to note here that it's a harm reduction strategy based upon prescribing pharmaceutical drugs, such as opioids, stimulants and benzodiazepines as a safer alternative to toxic, illicit drugs.
In 2021, policy changes were made so that pharmacists and prescribers entered a note into PharmaNet. This is the provincial prescription database. So every prescription dispensed in community pharmacies gets entered into PharmaNet. At the time of prescribing and dispensing, prescribers and pharmacists put a notation to identify that this is a…. They call it a safer accessor, SA. There's a code that they put in. This was recommended by the Ministry of Mental Health and Addictions and the Ministry of Health in their document called Access to Prescribed Safer Supply in British Columbia: Policy Direction.
This notation — I just want to make sure you know — is for internal purposes only. So it does not label in any way the substance use disorder patients or stigmatize them in any way, but it's a way for the ministries, both of them, to do monitoring and evaluation to determine what the prescribing patterns are and do further research and determine what would be next steps forward.
What about current realities? Well, as noted from previous presentations that you've had, this is a very complex public health emergency. We're going to touch only on a few of the current realities from our perspectives.
As colleges, we do worry about drug diversion. The drugs we are talking about are dangerous and powerful, as prescription and as illicit drugs, but prescription drugs are dangerous and powerful as well. If they're used correctly, through safer supply, they can help people with substance use disorders. But if diverted or used incorrectly, these drugs do have the potential to cause significant harm, and the complexities of that balance need to be considered in your recommendations.
Safer supply for opioids is easier, but pharmaceutical options for stimulants are not as easy. The death review panel report in 2022 identified that three-quarters of the decedents had more than one illicit substance detected, and this included stimulants. There is really no well-proven maintenance treatment for stimulants as you have for opioids, and there's no antidote comparable to naloxone for stimulant overdoses.
It gets to some of the recommendations we're going to talk about, but there is going to be no one-size-fits-all. There are different patient populations, different groups of people, and we have to consider that as you think about recommendations.
There has been a reasonable uptake of those prescribing OAT to offer safer supply, as Heidi talked to you about earlier, with 69 percent of those physicians who are OAT prescribers having prescribed safer supply. This does contradict some anecdotes that we've heard — that nobody is doing this work and that there is no data to support that.
The risk of overdose is real, as we know, and is seen by the death review panel report numbers, and solutions need to be diverse. Different solutions are definitely needed for those with significant opioid use disorder, for those who are occasional users and for those who have a stimulant use disorder who may be exposed to fentanyl as a contaminant.
The colleges are committed to continuing to work with our partners to find short- and longer-term solutions that we are able to influence and those where we can facilitate change ourselves.
In the short term, we offer some solutions that can enhance access to opioid agonist treatment, where timeliness to care is critical and could be the difference between life and death. This includes ensuring that all our partners continue to engage with Health Canada to ensure, at the very least, that they continue the Controlled Drugs and Substances Act section 56 exemptions.
The exemptions do have an expiry. I'm not sure if people are aware, but they have an expiry of 2026, or it also indicates that Health Canada can replace them sooner. So this is not something that's permanent, and we all need to engage with Health Canada to let them know the value that these exemptions have provided. They do allow easier access to prescribing of narcotics. Where, before, a written prescription was required, now narcotics can be prescribed verbally.
They do provide more options of who can transport or deliver narcotics. I know this has been a concern raised as a barrier, and it has historically been a barrier, because the federal requirements consider it trafficking if you don't have authority to deliver and transport narcotics.
In addition, by utilizing pharmacists' existing knowledge, skills and abilities, for example
In addition, by utilizing, for example, pharmacists' existing knowledge, skills and abilities and their broader availability across the province than other health care providers, patients can start treatment sooner or continue their therapy when they are unable to access their physician or their nurse practitioner.
This aligns with the recommendations from the Ministry of Mental Health and Addictions that recommended to explore expanded scopes of practice for a range of other health care practitioners. As we've heard, there's a shortage; they're burnt out. We need to utilize the knowledge, skills and training that these health care practitioners have received in order to utilize them completely.
The examples noted on the slide would require a change by our college board and the provincial government to the pharmacists' scope of practice and practice standards, but these are changes, if the partners agree, that can be developed very quickly and implemented with, as Cynthia talked about, the usual things that we need to go through with public posting and those kinds of procedures.
Longer term, as colleges we went back and reread the 2017 B.C. coroners service death review panel and noted there are still recommendations to be implemented. There were three separate recommendations which looked at the province regulating and overseeing treatment and recovery programs in facilities, evidence-based quality care and the outcomes that make sure they're closely monitored and evaluated — again, for research and evaluation to feed back and loop back into what's working.
Strengthening primary care in the province. As Heidi indicated, you don't have to go very far to read about and hear stories and patients' lived experiences about the shortage of primary care providers in the province and lack of access to care. How can we possibly address this illicit drug crisis without primary care as the infrastructure to support the work that we're all doing?
Better integration of primary care services — our private sector that we've talked about in physicians and pharmacy, with the health authorities and the public sector. This all leads to providing wraparound service to people in the community doing this work.
Now I'm going to pass it over to Cynthia.
C. Johansen: The three registrars have talked a lot about the things that we're doing right now and some recommendations for the committee to consider, like the death review panels' recommendations and getting to them when the system can.
For the three of us, I think our reflection to you is that there's a lot of focus on substance use disorder, but that's not the only issue here when it comes to safe supply and illicit drug use. There are different categories of individuals who are being harmed by these drugs, and certainly, the medical model or the model that our practitioners engage with can deal well with substance use disorder. But in terms of the one-time user situation, or an accidental use, that's more challenging, and coming up with a medical model for that will be very difficult.
I think, for the three of us, we really did focus our presentation on substance use disorder today and those interventions that could work well or are working well. But we recognize that to even do better than what we've talked about today, ministries and government as an entirety need to think about how we create the space for wraparound services that are just not focused solely on health and health care but look at what's happening in education, what's happening with our social work supports. Heidi mentioned vocational supports, individuals who are struggling with financial needs or financial worries. It kind of compounds.
We would recommend, certainly, that the committee think about how government can come up with a plan that is across the board. We thought about: do we have a suggestion for when that might have worked well? The one that came to mind was around medical assistance in dying, oddly.
There was a lot of work done across government in a variety of ministries to bring that particular change into being. It took a lot of coordination amongst a number of different…. Not only the colleges but the health authorities, Vital Statistics, coroner's office. It was a significant effort.
We changed criminal code, federally. We changed regulations, provincially. Similar to some of the things we talked about today, in terms of that big-scale change, having that coordinated function really helped.
Each health authority has a medical assistance and dying coordination person or office. That, again, helps to facilitate and navigate for patients, for families, for communities, different practitioners, how they're engaging in all of the different wraparound services that they need in their end-of-life decision-making and end-of-life care. It's not the same, obviously, but there are flavours from that experience that, on reflection, we think could well apply here to solving some of the challenges with the opioid crisis.
I think that wraps our presentation. We're hoping very much we can have your questions and some dialogue.
N. Sharma (Chair): Okay. Thanks so much.
I have a list here. We've got Doug and then Susie.
Go ahead, Doug.
D. Routley: Thanks very much.
Of course, one of our terms of reference is to expand safer supply.
S. Chant: Talk to the mic.
D. Routley: Am I doing it again? Sorry. Pardon me.
One of the terms of reference is for us to expand safer supply and, in doing that, try to do that within the current models that are envisioned. Part of the problem is, of course, persuading more practitioners to be willing to participate.
What would you offer as suggestions as to how we could approach that challenge?
H. Oetter: Have you met with the Doctors of B.C.?
D. Routley: No, we haven't. Not yet.
H. Oetter: The Doctors of B.C., at the end of the day, advocate for physicians. It's not my role to advocate for physicians. It's to give them a licence.
In my mind, this goes to the root of the problem, which is that the way the health care system is structured and funded doesn't support physicians doing safer supply in a private physician's office in — you name your place — downtown Kelowna, Terrace, wherever.
This is really…. It's complex work, and it needs to be delivered by teams. I don't come here with solutions for that, but I do think that the way the system is structured and funded has to be looked at. That's really a conversation that has to occur with the Doctors of B.C.
D. Routley: Thank you.
C. Johansen: I would echo Heidi's commentary. It is really challenging when you have a primary care approach. You have fee-for-service in one side of the office and funding coming from, say, a health authority or government grant in another. Making that all work is very challenging.
Looking at how you create the space for testing out new models, piloting something, looking at it, building the evidence around how it can be done across a team…. When we talk about teams, we're not talking just about our three groups. We're really talking about social work and occupational therapy and all those other pieces where individuals need to intersect with a broad range of practitioners to get the kind of service that will help them be well.
S. Solven: I would just like to comment, too, from the pharmacy side.
I know there are lots of conversations already that are occurring between government…. The B.C. Pharmacy Association is the advocacy body for pharmacy. The college is looped into some of those.
Increasing practitioners, in the past, has really focused around providing, as we talked about, some of the education pieces that we've done — really helping them understand — and then the models around reimbursement and how that works within the community models, which is not the college's purview but between the association and government.
We support that by providing or mandating or encouraging education, whatever it happens to be, and creating the standards around what the appropriate care is and allowing them the flexibility where they need to have flexibility. In the past, that has created more opportunities for more health care providers in pharmacy to want to do this work. They're being educated. They're giving the proper standards. Then the reimbursement models, between government and the association, have sorted that out.
S. Chant: Thank you for your presentation. I really appreciate this…. I'm going to say overview. We've been seeing all sorts of layers, and this is a different layer again. So thank you.
Three parts to the question. First off, the safer alternative notation that the prescribers were doing — how compliant was that? Were they regularly compliant on that, or did it get missed half the time, or what are we…? Any ideas on that? To put SA on things….
C. Johansen: I don't know if it was…. It's like self-reported, basically.
H. Oetter: Yeah. Our numbers about who say they're doing it are just self-reported. And are we seeing routine use of the safer supply code on the prescriptions? Don't know. Because, in all honesty, it's not an area that we've put our minds to.
S. Solven: We don't have access to it. That would be the ministry that would….
S. Chant: Okay. That would be very interesting to me. Because one of the things that we've heard from other places is concern about losing one's licence, registration, whatever word you want to use, getting audited, and those kinds of words that were coming through, and it seems to me that if it had the SA, then that would reduce that concern, because one would look at it with different eyes.
The other part of the question, or additional piece, is that a while back we went from methadone to Methadose, and it sounds to me like, at that time, it was a fairly arbitrary decision.
Were the colleges involved in that decision, or did it just come down?
H. Oetter: Suzanne is closer to this than me.
S. Solven: Yeah, I can answer that. There were a lot of problems at the time, and that's why I say we were involved since 2007, because there were a lot of concerns raised by patients around methadone being…. Because it was compounded. The pharmacy compounded it.
S. Chant: Yeah, I know. I'm a nurse. I understand.
S. Solven: There were lots of complaints about the methadone being watered down and other, kind of, practice-related concerns. We'd been dealing with that for a number of years. That's why we came up with the guidelines and then the policy later on, and then a company came out with this standardized product, which…. Actually, the rules around compounds are that if a branded product is available, then pharmacy shouldn't be compounding it unless there's a short supply, because now you have quality assurance and manufacturing quality and all of those pieces that are regulated by Health Canada.
There are compounding standards. I don't want to imply that there aren't compounding standards that pharmacy have to meet. Those have all actually recently been updated. But, given the concerns that we were hearing, we worked, our [audio interrupted] worked, together with the Ministry of Health. So the Ministry of Health PharmaCare program determined what they cover and what they don't cover, and they had made the decision that they were going to move to the Methadose, as opposed to the compounded product, because they were also aware of the concerns raised by patients in relation to the compounded product.
We had then struck a working group. The College of Physicians and Surgeons, our college, the ministry and patients were actually invited. The Vancouver Area Network of Drug Users and B.C. people on methadone were invited and participated….
Interjection.
S. Solven: BCAPOM. Thank you. They were invited to the table and participated, and we had to change the guidelines around things, and we were very concerned, because it went from one milligram per male to ten milligrams per male. So we were very concerned about potential overdoses and making sure that everybody was educated.
We communicated with the prescribers, the pharmacists and the patients. A lot of work was done around it. So from my perspective and the college's perspective, it was not an arbitrary decision. There was a lot of work and thought that went into that.
S. Chant: Thank you. I appreciate it.
P. Alexis: Thank you so much. I just have a question about the self-reporting on the graph that you provided with the positions. Thirty-two percent in 2022 indicated that they were prescribing the opioid treatment.
Did they at all…? Or did you look at the information with respect to geography?
H. Oetter: We did not. It was really to provide, at least on an aggregate basis, back to BCCSU to give them an idea. You know, if you're training this many people, this is what people say they're doing.
Are there opportunities to do deeper dives on that? The answer is yes, but that wouldn't be us. And I think that is absolutely the kind of thing that could be done by researchers. Just so you know…. Do you guys provide your data to Pop Data?
A Voice: Yes.
H. Oetter: Yeah. We all provide data, and it's managed by Pop Data out at UBC. They've got the ability to link business addresses with prescribing data behind a firewall for doing those kinds of research projects. B.C.'s actually…. If you think of all the provinces in Canada, B.C. is the best situated to link, through the e-health record, provincial health data for research purposes. Those things are there.
I just always say, however, that sometimes doctors give us a business address as being in downtown Vancouver when, in fact, their work is a two-week locum in Bella Bella and then a two-week locum up in Terrace and then a two-week locum in Fort St. John.
We have been pushing the Ministry of Health and the Doctors of B.C. to bring in the concept of a location code so that every unique area where you do your work in the province would have a unique location code identified to that, because we think that would be an additional enhancement. Fee-for-service billing data comes in, and it says — I don't know — that I put an IUD in.
But wouldn't it be nice to actually know what that location was? We don't want to see that data. We want the government to be able to access that data, because I think it's those kinds of nuances that should help the Ministry of Health for health planning purposes.
The other important aspect of that is for what we call look-backs. There are times when a test has turned out to be less than accurate, and it's been on a more systemic, wide…. The doctors will get a piece of paper saying: "You ordered a particular test on Mrs. Smith, and we have reason to need it." They'll say, "Well, where did I see Mrs. Smith?" because, again, the current model for working is that people rarely work in just one office exclusively. They're going to work in multiple sites, so being able to link back to the appropriate electronic health record would be really helpful.
But I think that those kinds of granular details to our health care system data…. They're close, but they just require…. Again, it would be some investments and some programming to get unique location codes.
P. Alexis: The reason why I ask this is because so much of our data is broken down by health authority. We did have all the health authorities come to present, and we learned that not everybody is doing exactly the same thing. Some things are emphasized. Some things are not. We are not standardized as far as what we can offer. So that's another issue.
But this would help — to have the data from the physicians so that we would be able to ensure that all the areas in British Columbia are served to the same level. So thank you for that.
R. Leonard: Gosh, there are so many things.
Well, I know that you've probably heard some of the criticisms that have been levied your way around what you need to do, and you've told us what you do and what you don't do.
I guess the question that I have is: where do you fit in working with the Doctors of B.C., which you have raised, the folks who are casting criticisms around what you should or should not be doing? Where should they be going then? If it's not you, where?
And I have some follow-ups.
H. Oetter: I appreciate that when things don't work, the college does become a convenient source to put complaints towards, and I get it. How come we don't have more family doctors? We do what we can within our regulatory framework to do that.
One of the successful things that we launched in partnership with the Doctors of B.C., the Ministry of Health and health authorities was the practice-ready assessment program. That assesses about…. I hope I get my numbers right, but I think it's about 60 physicians a year who are internationally educated, who come from jurisdictions in the world where their training is not recognized as being substantially equivalent for the purposes of a paper review.
That program has been incredibly successful in identifying family physicians who come through. They then go on the provisional register and, from that, then go on and get all of their Canadian qualifications and get advanced to the full register. But it's a drop in the bucket for the number of physicians that we see coming in.
We can proudly report the number of new family physicians coming in every year, but they don't all do full-service family practice. Many choose to limit their practice to doing, for instance, just maternity care, just palliative care or just hospital-based work.
We have a good working relationship with the Doctors of B.C. I frequently get invited to joint standing committees to look at things. As an example, we modified our virtual care standards to permit a more permissive approach to prescribing opioids, as a consequence of COVID-19. But we cannot make up for what is a primary care system in crisis. Sorry to be rather blunt about that.
R. Leonard: Oh, gosh, there are just so many questions that I have around this.
We are moving towards team-based care with the primary care centres, the primary care networks, etc. We're hearing that young, new doctors are choosing not to go to fee-for-service, that they don't want to be working in that model. We are making some movement that way.
I guess the question, then, is: if we're moving that way, what can the college do to help accelerate that so that we can see more of that team-based approach that will provide the kind of care that we're not getting right now, because we're seeing all of these deaths?
H. Oetter: Yeah. I think back to the days when I used to run the methadone program at the college. I went out and actually personally met with every health authority to say: "Would you please do more team-based care?" In those days, in Vancouver, you had Three Bridges. You had all of those.
R. Leonard: And Evergreen.
H. Oetter: Yeah. Then meanwhile, like in Fraser Health, not so many, right?
We can do those kinds of advocacy things. I get together with the faculty of medicine quarterly, with my senior team. We can certainly talk about the importance of encouraging graduates to go into that work. But when you're fundamentally short the number of bodies you need to get the work done, people can be quite picky, if I can use that word. They can pick and choose what they do.
I know it from my days working at Royal Columbian Hospital. To find somebody who's prepared to take on the tough, complex work of doing longitudinal care for people with schizophrenia, people who suffer from bipolar affective disorder…. It's complex work.
I think you're going to have to actually use a combination of some carrots to get the people to do complex work, plus, probably, some sticks on the other side to discourage a certain type of work. But it's not my role to talk about the funding of the health care system. With deference, we really do have to leave it to the Doctors of B.C. and the Ministry of Health.
Cynthia and I talk about team-based care all the time. We don't not talk about team-based care. The days of nursing assistants, physician assistants…. I mean, every single solution is on the table as far as we're concerned when it comes to licensing and registering qualified professionals.
Supervised practice, delegation. There are days we actually don't like to use the words "supervised" and "delegated." It's been…. We've had some…. But how far can you extend the workforce without then compromising the care that's provided to the patient at the other end?
I'm not infrequently asked by mayors in small towns of British Columbia: "Surely, a poorly qualified practitioner is better than no practitioner?" We don't take that position. We would rather be making sure that the people coming in the front door are competent, ethical and professional individuals. But we are open to looking at new models of health care. If that requires some different regulatory responses, we're all in.
M. Starchuk: Thank you for your presentation.
I'm kind of focused on the current state of those that are prescribing and that it has been a stagnant number of 32 percent over the last couple of years. You're talking about the 1,607 that are OAT prescribers. I'm more curious: how do the percentages work? Or do you know?
You had mentioned that there were 120 nurses that are out there that are prescribing. Is their work that they do in a ratio compared to what the family doctors are?
C. Johansen: Well, the family doctors are doing way more — way, way more.
With nursing, there are about 800 nurse practitioners in the province, and they have a similar prescriptive authority as physicians. But of course, I don't have the same self-reported data that Heidi has. We didn't ask at registration renewal this past year: how many of you are prescribing methadone, OAT? We could, absolutely, ask that question of our nurse practitioners and get a read, but my guess would be a similar statistic. That would be my guess.
With the registered nurses and registered psychiatric nursing group, that's a very new change for them to extend their practice, to go beyond their traditional scope. They take a program, of course, of study at the B.C. Centre on Substance Use. Once they've completed it, they can prescribe Suboxone in a very limited capacity.
Again, individuals who would add that to their practice, add that to their resume…. It's a small number right now. We'd love to see it extended and expanded, but if they're not connected with that patient cohort to begin with, they're not likely to take it and then hope to find a job. It makes sense, because they're working in a particular care environment, where having that will be an addition to their practice.
Again, when we come back to that conversation about team-based care, you've got all these different practitioners who have variations on a theme in terms of what they can do within their scopes. Really, being able to take a step back, the funding is a big problem. But if you take that back off the table, and you just say: "How would we design a system to meet the needs of these patients and then fund that…?"
Right now, we're always trying to — square peg, round hole — fix this, tweak that. If you really took a step back and said: "Okay, this is what the patient needs. How do we build the supports and services around them and then fund it?" I know that's a really hard recommendation to make, because it's a really complex system.
However, I do think that when we think about the questions that we're all getting — "Why not this?" — it's like these little, tiny changes here and there. We need to maybe look at it from a more systemic perspective.
I'm not sure that's particularly helpful in answering your question.
M. Starchuk: No, it is. You would think that at a time when a person enters into, maybe, an ER or something else like that, and you have the nurse that has the ability to do that right there on the spot, sometimes that's what it takes to make it safer for the patient.
C. Johansen: Absolutely.
S. Furstenau: Just further to what's been raised and reflecting some of the things we've heard over the last couple of months, particularly around access to a safer supply prescription model, phrases like being handcuffed to the pharmacy, the amount of control that's exerted…. When you say, Cynthia, "a system to meet the needs of the patients," that's not what we're hearing.
That is not currently what's happening for people — being knocked out of the program if you miss three days and then having to go back and start from zero again with no way to bridge that, the reality being that the other supply is very available, right? It is there. There is no problem accessing the illicit and very poisonous, deadly supply right now. But the barriers to accessing safe supply are enormous and have become …. From what we've heard, for a lot of people, it's just not meeting their needs.
I'm wondering if any or all of you want to reflect on that kind of feedback that we've gotten, particularly, Suzanne, around the pharmacy piece, where people are paying a fee every time. They have no choice but to go, maybe several times a day. That fee is a barrier, the ability to have no carries. The kind of paternalistic sort of system that exists, which is not about empowering or trusting or any of those things….
It is a very controlling world that people are choosing to step into because they want do what they can, but then they hit barrier after barrier. I'm interested in your comments and reflections on what we've been hearing about that.
S. Solven: Thanks for the great question. As we were preparing for this, I was looking through some of the presentations by other people that you've had and noted a lot of those comments and looked into some of those things. I think a lot of it is historical, how the system was set up.
In actual fact, although it appears that it's the College of Pharmacists that actually set up the barriers, a lot of them are not. We don't actually have requirements for daily dispensing. That is not a regulatory requirement. We follow the BCCSU guidelines, which require witness for the first dose of methadone and Suboxone. But beyond that, there are no requirements for the daily witness, daily dispensing pieces.
That may be a matter of…. The payment piece is strictly outside of the college. That's probably between PharmaCare and the Pharmacy Association. The fee — if a pharmacist does dispense, they get a fee for that day, but the payment's determined by the ministry on how they're going to fund those programs. Again, that's not within our purview.
One of the other barriers that I was reading about related to the…. I kind of touched on it when I talked about the section 56 exemptions. It was around the delivery piece. That is or was a requirement through the Controlled Drugs and Substances Act. That was a federal requirement, as I mentioned, because it's very strict in that CDSA or narcotic regulations around who can…. They consider it transporting, when we talk about delivering drugs to individuals or to health centres and those kinds of thing where nurse practitioners are. Before the section 56 exemption, it was very limited in who could actually transport drugs.
From our college perspective, we cannot under-regulate what Health Canada regulates through the CDSA or the narcotic regulations. We can add to that, and in some cases, we have. Our college is going back and looking at where the instances are where we have regulated above what Health Canada required. Some of those have already been removed with those section 56 exemptions allowing other individuals to deliver and make it more accessible to people.
We're continuing to look. In fact, at our September board meeting, we'll be looking at…. We still have a requirement for our controlled prescription form that requires the original to be faxed. That will be going to our board in September to remove that. That's something we can quickly remove. That's more of an administrative barrier, but still, to somebody's comment earlier around pharmacists concerned that if they don't get that copy, then, in fact, the college might come down on them in, in audit or something, we want to give them assurance around those kinds of pieces.
There are some historical barriers. I think some things have been removed. Some things the college does not own. That would be Health Canada or the province, around funding and those things. In other areas where we can make change, our board is very committed to doing whatever they need to do to remove some of those historical barriers.
Again, working with the partners so that we make sure there are no unintended consequences, but that we do it in a safe way, but recognizing…. You know, you talk about paternalistic. We recognize that we need to move beyond that. As long as we still have some…. We're ensuring that there are no unintended consequences, as we talked about, because these are powerful, dangerous drugs. We want to deal with the people who need to get access for the treatment, but we don't want diversion.
We are looking at all of these things that you just talked about.
H. Oetter: If I could just add the importance of meeting the patients where they're at is a truism, but we already have emergency departments now in British Columbia that are not open 24-7. I just don't know how we close that gap. I'm sorry. I don't have a solution. But we're already hearing from a sort of spent workforce that they can do this much but not that much.
That becomes a huge barrier, and it's going to be particularly bad in those communities that are under-resourced and family physician offices. When I hear stories about people having to line up at the walk-in clinic and wait six hours to be seen, whose needs are being met? The people who are mobile, have the ability to stand on two legs for a long period of time.
I don't want to be shouting that there's a crisis, but until we get some of those really basic things covered, I just don't know how people seeking assistance for these kinds of really complex health issues are going to find enough doors open for them to get care.
S. Furstenau: If I can just follow up on that. The other thing we've heard a lot, particularly from experts and clinicians and others — and, really, Heidi, your point just now — is about how the system isn't coping where we're at, but we keep hearing about the need for a non-prescriber model. Maybe if you could give us some insight into your thoughts on a non-prescriber model and what that could look like, recognizing….
I agree, Suzanne. These are powerful, dangerous drugs, but we're hearing that there's no way the prescriber model is going to meet the crisis that we're in. So what does a non-prescriber model look like?
H. Oetter: That would look like some kind of federal legislative change, and then that wouldn't involve us. It would be that simple. We don't know what oversight of a non-prescriber model would look like, but we know that the biggest barrier for that is that –– am I correct? –– under existing federal legislation in Canada, only a prescriber model exists.
People have said to us, "Well, what about this? What about that?" and we say, "Hey, those look like really good ideas, but that doesn't engage us." We're not a barrier to that, but the minute it looks like it's a prescriber model, then we're going to have to give people licences and make sure that they're qualified for that licence and do the quality assurance work and respond to complaints and all of that.
N. Sharma (Chair): I have some questions. First of all, I really think…. It surprised me, and I wonder if it surprised all the committee members, that there aren't rules about oversight of the OAT program.
Suzanne, you mentioned that you only need to witness once and that the rest of it…. It's very different from what we've heard from a lot of people. So I find that, just as a comment, really, really interesting.
Then my question is: why is that still happening, then, if it's not something that is set out by the college? The thing that we often hear –– and I think this is a question, maybe, to the College of Physicians and Surgeons –– is that people are scared. They may want to do something, but they're scared about what the colleges are going to do if they actually do it. So it's really your chance to say….
I mean, I'm glad you sent a letter out, Heidi, to physicians, but it's really a great opportunity now to say the things you're saying, which is: "We are not going to be that source of punishment for you if you're saving lives in a way that…." Anyway, I'm just really surprised that that's still happening.
The other question I had –– I have more, but I'll go back in line after this one –– is: do you consult drug user groups when you're thinking about these plans or policies or the impacts of some of these programs? We've learned so much from the drug user groups that have come, about the impact of the fentanyl patches or how it's working, and also some of the doctors on the front line that are trying….
In a lot of ways, we have safe supply. We just don't have safe supply that matches the toxicity of the street supply right now. There's a mismatch going on, because the things that are provided in the scale are just not enough for the crisis. So I was wondering if that's part of your process, to talk to the drug user groups, and then what do we need to get to that level of safe supply?
H. Oetter: That's a BCCSU issue. It's not ours. We are not in the service delivery business. We say to doctors: "Follow clinical practice guidelines, whatever that is." So that is really…. We look to them as the experts to do that.
Have I heard that physicians will require people to either inject on site or consume on site or witness doses and things like that? Yes, but at the end of the day, I think those are treatment decisions of those practitioners. I'm not going to sit at 669 Howe Street and second-guess the clinical decisions of people out in the field doing that work.
Whether it's a fentanyl patch program or a powdered fentanyl exchange, there are people out there doing innovative work. I know that. As I said, the College of Physicians and Surgeons has a very close working relationship with BCCSU, but we don't set those clinical practice guidelines. We're here to help in that sense of "how can we be helpful." But we really rely on the clinical experts to do the innovations, to do the evaluation.
We would have some bare minimum expectations that…. I talk to physicians, not infrequently: "I'm going to do this. Is this okay?" Then I have to phone my colleague Suzanne and say: "Okay. If they do this, does this offend any of the pharmacy drug scheduling things?" Then I have to ask myself: "Well, are they selling drugs to their patients?" Physicians are not allowed to sell drugs to their patients. They have to direct them to a pharmacy, unless they can come up with a good reason why.
That's the level that we deal with, whereas if somebody says they're going to be doing this, and they're going to do this in their office, we then ask them to check with BCCSU. Is it research ethics board–approved? If it's actually truly innovative — with a big-I Innovative — there are some expectations about a good, informed consent discussion with their patient. The more experimental it is, the more important that informed consent discussion is. It needs to be well documented. This is a very vulnerable group of patients, so we want to make sure that they're getting top drawer when it comes to ethics and professionalism.
That's really the extent of whether somebody is giving their patients fentanyl powder or if they're going to buying the new heroin that's going to be coming in — apparently really soon. Did you get Martin Schechter's email about their pharmacy making heroin available? Yes. That's going to be available soon, too. I can send you the email if you like.
N. Sharma (Chair): I just was wondering, Suzanne, if you could maybe…. Do you consult drug users when it comes to the practices and the ways that things are rolling out, and your work with the board to change rules? Is that something that's part of the process?
S. Solven: Yes, it has been. Historically, as I mentioned, when we were working on all the methadone maintenance treatment issues, it was actually in consultation with the users. It was brought to our attention — the extent of the issues — and that got all that work started. That's continued.
As we need to…. We've built relationships with those groups over the years. So yes, we do. We actively reach out to our partners as we develop these kinds of things, because we can't do it without them. We need to understand: "Is this going to work for them? Are there unintended consequences?"
We do actively reach out and consult.
D. Routley: Two things. We heard from some practitioners that stigma can create what was described as lateral violence — practitioner against practitioner, or organization against organization. Do any of you in the colleges consider that you have a role in reducing that stigma and addressing that issue? That would be one question.
Then the other is that fee for service has its limitations, but there are a lot of visits per doctor. As we switch to a new model, the presumption is that there would be more complex issues dealt with and more time could be taken, which would then result in a commensurate higher demand for numbers of doctors. If we had all the money in the world, we still couldn't make more doctors faster.
Have you done any work to examine what these new models…? What implications might they have in your work to register more doctors — whether it will increase the demand?
H. Oetter: No, because, again, we don't regulate the health system. There's an entire group of population health and study at UBC that I think could probably give you some perspectives on evaluating, if you like, the value for money for various models of health care delivery. But no. That's really not our bailiwick.
D. Routley: Just to clarify, I don't mean the design of the program. But have you considered what implications it might have, should there be these changes? Has there been any consideration?
H. Oetter: No.
D. Routley: Then the other would be on the stigma and lateral violence issue.
H. Oetter: We have a practice standard that physicians, surgeons and podiatric surgeons are expected to be in compliance with, and that's about access to medical care without discrimination. Obviously, with the release of Mary Ellen Turpel-Lafond's report, it has put a real spotlight on that.
Our two colleges have just released a practice standard about the importance and expectation of delivering culturally safe, humble care at the point of care, free of racism. There's certainly a big spotlight on discrimination, and if we hear that patients are being refused care because they're too complex, we don't look at those very favourably at all, and those are vigorously investigated.
R. Leonard: Just following up on that, I'm not sure if I'm getting…. We heard about this lateral violence, which is doctors pressuring other doctors who are prescribers. I'm assuming, in your piece under regulation and ethics, that this is something that….
H. Oetter: You have to play well with others.
R. Leonard: Yeah.
H. Oetter: Yes. In the health authority setting, they have, obviously, WorkSafeBC expectations around bullying and harassment and zero tolerance for that, and the CMA Code of Ethics and Professionalism that we point to makes it very clear that bullying and harassment are unethical behaviours. Again, allegations would be vigorously investigated.
R. Leonard: Okay. In other words, doctors who experience it should be turning to you.
That wasn't actually my question. My question was around education, that there's a role that you may be able to be playing in terms of reducing stigma, which you talked about, in terms of Doug's question. What is in place now?
We're sitting here today because of the illicit drug supply deaths, and part of the challenge has to do with accessing safe supply. But the other piece of it is that stigma piece. I'm just curious what exactly the colleges can be doing or are doing, particularly now, to help with that. We've heard a lot of criticism around stigma amongst the professions that you represent.
C. Johansen: We have a role, to some extent, because we set the entry-level competency — what is required to be a nurse, a pharmacist, a doctor.
I'll speak just for nursing specifically. The competencies are quite extensive, and they involve everything from anti-discrimination, anti-racism, cultural safe care, no lateral violence. All of those things are encapsulated in the expectations of an entering nurse. Those standards are set by the college. So if you're going to have a nursing program in this province, we need to see that you are educating the individuals in your program to these competencies. Then we test for it on the entry-to-practice exam.
However, when things start to happen in practice, our way of managing that is through the complaints process. The pre-emptive approach we can do, certainly, through our quality…. Again, I'll speak from the nursing perspective and midwifery as well. The quality assurance program that the college runs — we do ask for peer feedback, anonymous peer feedback for every registrant on a pretty regular basis. I think it's every five years.
Peers can provide feedback anonymously about how they're experiencing their relationship — their working relationship, peer-to-peer relationship — with that particular practitioner. That's one way we can receive that feedback and then offer encouragement, advice, recommendations to deal with it through education.
In terms of the college setting an expectation around anti-stigma education, we would do that through a variety of opportunities rather than just ask everybody to, for example, take a course that we've created. We don't set up courses. We're not educators, but we can influence education, for sure.
I hope that helps.
R. Leonard: Yeah, with the quality. I think it's important for the public to hear this.
S. Solven: I was just going to comment. I had mentioned it previously. In 2019, working together with the Ministry of Health, the Ministry of Mental Health and Addictions, ourselves, BCCSU and the B.C. Pharmacy Association…. There actually was a program developed which the pharmacy association delivered to the registrants. We required it.
A large component of that was looking at addressing stigma in this area. That was identified as a specific need in our pharmacist, pharmacy technician population as we started to roll out and enhance the work in this area.
The things that you've already heard from the other colleges around our standards, our code of ethics, the professionalism…. We have the same things, but we did specifically support and mandate a mandatory course, which was delivered through the pharmacy association, in this particular case, in 2019. That course is still valid for any pharmacy that delivers substance use disorder treatment for their patients. Their pharmacists and technicians have to take the program.
R. Leonard: Okay. Thank you.
H. Oetter: I just sent to Artour the email I got from Perry Kendall and Martin Schechter about heroin.
N. Sharma (Chair): Okay.
Any other questions, colleagues?
R. Leonard: Earlier you talked about the maldistribution. I'm curious how you know that, the distribution of….
H. Oetter: I think every mayor in small town B.C. has me on speed-dial.
We know that the physicians that we recruit…. I shouldn't say we "recruit." They come in through this PRA program. We do follow them over time. Many of them are in rural, isolated, remote communities in British Columbia, but they don't necessarily stay there. That's just a given. It's not unusual for people, once they get their full credentials and some mobility, to then move to, sadly, Toronto.
I don't know if you know this, but 99 positions for family practice training this year went unfilled. Now, the good news is that British Columbia filled all of their spots for family medicine residency. It was Alberta, Ontario and, mostly, Quebec where the positions went unfunded.
There's a real need to have family medicine, which is what I did for a living — it kind of pains me — be considered as a viable, acceptable career option. Sadly, medical graduates seem to not want to do that.
Make no mistake. Being a rural primary care or family physician is probably the toughest job in the whole world. I know that the ministry has put so many supports in, particularly post-COVID — real-time virtual support services. They've really stepped up. They support, by the way, the nurse practitioners working in rural, remote communities as well. But we just can't seem to do enough to get people to develop the stickiness to stay in some place like — I'm making it up — north overshoe for a career.
N. Sharma (Chair): On behalf of the committee, I want to thank you for coming here and helping us learn your perspective on this crisis, which is affecting so many people in the province. We have all your materials. If there's anything else you want to send, please send them to Artour, like you've already done, and we'll take a look.
We need a motion to adjourn.
Sonia, Susie.
The committee adjourned at 5:55 p.m.
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