The impact of methamphetamine on the prairies has been particularly devastating and certainly increasing year by year. I've provided a breakdown to you of the information on the supply side, the demand demographic that we're seeing with regard to the individuals who are using, the impact with regard to HIV, hepatitis C and IV drug use, keeping in mind that approximately 70% of the HIV that we see in this province is transmitted through IV drug use, driven primarily by opioids but increasingly by the injection of methamphetamine.
The people we have dying from AIDS are those who, in spite of the fact that care is available to them, are typically in psychosocial chaos because of their stimulant use. They can't simply make it to the pharmacy each day if they're on opioid agonist therapy to take their antiretroviral therapy for their HIV, and we lose them. We have a high mortality rate.
There are treatment challenges with regard to methamphetamine that are somewhat unique. Because of the potency of the stimulant, because of how long-lasting it is, it has significant challenges in the acute intoxication phase. At the extreme end, you will see people with psychosis who are very disordered, agitated, paranoid and potentially violent, but certainly many people under the influence take a small amount every day and are chronically impacted by its effects.
Also with regard to the acute treatment is the challenge that it poses in emergency departments when people present there, and the need for a calmer space for intervention if they're psychotic that doesn't necessarily require psychiatric intervention but does require protocols.
Then, of course, there's the phenomenon of sensitization where with increased use, people may be more inclined to have seizures, psychosis or what we call repetitive stereotypical behaviour.
Finally, there are challenges with regards to the stimulant withdrawal, not so much the acute withdrawal, which can indeed be problematic, but more what we call the post-acute withdrawal. Once the substance is out of the body, the problem then is what's happening in the brain in reverting to normal, which can take weeks or months. This is a high relapse period, a time of craving and a time where if there isn't adequate support, they're more likely to relapse. I've provided you with brain scans that show some of the changes that occur there. One could frame it as a form of chemically mediated acquired brain injury when you have a severe addiction.
I think what's important here is looking at what potentially could be a federal role in closing the gaps in care. I don't know if you want me to continue to explore them now or if you would prefer to explore them after others have made their introductory comments.
I think what's important is that we should acknowledge the role of the Health Canada's emergency treatment fund bilateral agreements that have been struck, the funding that we have received within the province and the way that it's been utilized to improve the quality of care to address some of the surge issues that we've seen with methamphetamine. Unfortunately, at a provincial level, it doesn't translate into boots on the ground in terms of health care providers. We have to look to the province for that.
What we do need, though, is to look at ways that people transition. What we have is essentially a chronic disease at a severe level. Our system treats it with episodic acute care, a little bit of detox here and maybe 28 days of treatment there. They're not necessarily well connected; they're disjointed.
I think something that would greatly help us is the federal government being more involved in therapeutic or supportive housing for people who can be housed in a therapeutic community, or supportive community between detox and treatment, and from treatment out into more of a recovery mode. They would have other wraparound services, social services for income support, transition to other housing, education, vocational training and so on, which are not necessarily in the purview of the federal government. We could find ways to target federal funds towards therapeutic housing to close the gaps, because recovery takes one to two years. Episodic acute care is not going to meet that need, but therapeutic housing may very well.
Where can we look for that? Certainly there are a number of ways that we could approach this. Perhaps there are ways to use tax benefits to get the philanthropic sector, the private sector and the public health care sector working together in partnership, in a 4P approach, if you will, so that this money can be used to support programs that normally would not be provided by the health sector alone. That includes housing and wraparound services.
Another way would be looking at how people donate or how philanthropists may come forward with money. Often it's a one-time example of their largesse, but, if there's a social impact that benefits the system of care, which is going to save money in terms of acute care and other health care costs, perhaps that could be recognized in terms of a social impact benefit of charitable donations, which increases the value or has a way of recycling it, so instead of once-only funding, we have a way of continuing to recycle that charitable sector funding.
Housing that's dedicated to this would be helpful. We can do that by enabling developers to dedicate an apartment building to drug and alcohol-free living space with support from the health care sector to create those therapeutic communities we need in order for people to recover.
I think we should also be looking at transitions from where people congregate, such as emergency departments. Rapid access to addiction medicine would help to get them stabilized, back out in the community and connected with community care. That sort of transition is important, but it's often not done efficiently.
The other area of congregation, however, is in our correctional system, in our jails. In Saskatchewan, 70% of the people in provincial corrections are there because of drug and alcohol problems. It's not a therapeutic environment. There are ways that we could enhance drug courts to look at more focused intervention, recognizing that a crime has been committed—or potentially, if they're only on remand—but also recognizing that there are ways that we can use this sector more therapeutically to get to the root cause of the crime and the problems in our community.
Is this something where we can use some diversion from correction money, from penitentiary money, into the health care sector, into the mental health and addiction sector, to increase the services? All too often these are court ordered, but the health care system doesn't have the capacity to deliver in a way that's going to have a sustainable impact over time and is going to prevent re-incarceration.
Finally, one other source would be the proceeds of crime. It's great that it goes to the police, but if this is related to mental health and addiction issues—and the majority of crime is related to mental health and addictions—we need more social work and police teams working in our communities to be more proactive to address some of these issues. We need targeted funding for treatment and intervention, as I described previously.
I'm trying to think of ways that the federal government could be involved in providing targeted funding through taxation, through charitable donations, through housing, through proceeds of crime, which could help us address this significant gap in terms of the continuity of care, the care that goes from harm reduction—which from a treatment perspective, is outreach and engagement—through detox as indicated, into treatment and transitioning on into recovery.
The best way to prevent this intergenerational transmission of addiction is through treatment and helping people to transition to recovery and become productive citizens. It can be done. It's frequently done, but often it's in spite of us, not because of us.
I am Dr. Réjean Thomas. I'm not an expert on addiction, but rather sexual health. I'm going to talk to you about the link between amphetamine addiction and the current epidemic of sexually transmitted infections, or STIs, HIV and hepatitis, particularly in downtown Montreal.
The Clinique médicale l'Actuel has been in existence since 1984. We are located in Montreal's Gay Village. So we have gone through the entire AIDS crisis and seen extraordinary progress.
What I'm seeing in the office today is catastrophic. It's something I didn't see three or five years ago. Increasingly, we have begun to see use of crystal methamphetamine, or crystal meth, in a population that is quite different from Saskatoon, but with the same harmful effects. Our clientele is made up mainly of gay men who don't have substance abuse problems. This population is relatively well-educated and financially comfortable.
Slowly, for all sorts of reasons that are difficult to understand, crystal meth has arrived in the Village. Every day we see at least one, two, three, four or five patients with severe addiction. The problem with this drug is that addiction occurs rapidly. People are losing their jobs. They are businessmen and people between the ages of 16 and 72 who have lost everything and are being thrown out on the street.
This drug also creates a sexual addiction in individuals. We have to work on this double addiction, which makes it difficult to treat these patients. I have very few patients who have managed to get off crystal meth; it's a very long process. When these people in the gay community use detox resources, there is a lack of understanding of this double addiction, which leads to what we're seeing today.
For example, in 1998, there were three syphilis cases for all of Quebec, whereas now there are 1,000 a year. There isn't much AIDS prevention in Canada and Quebec, either. At first, this was most common among gay men, but now, women, some of whom are pregnant, have syphilis. Some children are even born with the disease.
The same is true for hepatitis C. In these groups, there are more and more cases of sexually transmitted hepatitis C, whereas it has always been said that this disease is transmitted more through blood and injections. The epidemic context is quite important, not to mention the human problems Dr. Butt mentioned, the psychoses and all that.
I have provided you with some data. Currently, we have about 2,500 patients with HIV and nearly 3,000 patients who are now taking what is called pre-exposure prophylaxis, or PrEP. It is HIV preventive treatment for gay men who we consider to be at high risk after asking them questions. Nearly 30% of people undergoing this treatment practice “chemsex”, meaning that they have sex under the influence of hard drugs. We aren't talking about cannabis or alcohol, but just hard drugs such as cocaine, GHB or crystal meth. Thirty percent of our customers is huge.
Evidently, you have to ask questions. People don't tell us that right away. Often they are our patients, and we learn this by asking questions. This drug is very insidious. People start smoking a little, like those who used to use cocaine from time to time at one time. Now people become completely dependent quickly, and it destroys their lives.
In addition, 30% of this clientele is under 30 years of age. These people use very strong drugs and earn a very average income. The most commonly used drugs are cocaine, ecstasy, crystal meth and ketamine. Our customers use very strong drugs. These 30% of our patients who practice “chemsex” have many more sexual partners, 34 partners in the past year. They have much more unprotected anal intercourse and are at high risk of contracting an STI after 12 months.
On average, these patients have almost 50% more STIs than people who don't use drugs.
Our data really show that our preventive treatment is aimed at a clientele already at high risk. It must be said that the treatment is very effective. We have no cases of HIV among all these patients. We have seen a reduction of nearly 50% in current HIV cases in the last two years.
We have incredible treatment, but at the same time we have clients with addiction, sexual addiction, STIs and HIV problems. I am talking about clients who are HIV-negative, but we see the same thing with our clients who are HIV-positive.
Sometimes people come in who stop their treatment—they are too unstable—and even do not take PrEP. This has difficult consequences: it is a very heavy clientele for which we have very few resources. We really manage to support these people between us, as doctors and nurses. We work with dependency centres, but their staff are not necessarily familiar with or comfortable with this clientele. There is really a twofold problem. This is what we see in at the Actuel clinic.
I'll try to take 10 minutes, but as I'm sure you'll find out, I talk rather quickly and off the cuff.
In the Sarnia area, we've been experiencing an extensive problem with crystal methamphetamine for close to 30 years. Recently, due to the changes in the structure of how methamphetamine is used, delivered and trafficked, we have come across the delivery of crystal methamphetamine. Prior to that, historically we were an old-school liquid methamphetamine community affected by biker-type methamphetamine from California back in the early days, the fifties and sixties. The problem is that crystal methamphetamine has become stronger, obviously, and more addictive, and it allows different delivery mechanisms that are enticing to certain individuals.
The other thing with the drug that I find makes it attractive in this particular community is that we have a very blue-collar socio-economic makeup, and this is a cost-effective, affordable and easily accessible drug. The issue now is that we're starting to find out that it is easy to manufacture, and also, it is somewhat dramatized, I guess you could call it, or publicized more through commercialism and the Hollywood-type of exposure, which makes the drug more attractive and possibly allows people some peace of mind when they're taking it. For the most part, a lot of them don't even know what it consists of or how it's manufactured. When they hear the word “amphetamine” thrown into something, I think it gives them some sort of an idea that it's a pharmaceutical-grade type of drug that has been around for a long time.
Historically, we know that amphetamine has been around for over 200 years, for other uses and purposes, but certainly not to this extent, and it was never made up of these types of chemical compounds that we're seeing now, which of course are being closely regulated and controlled through amendments to federal acts such as the Controlled Drugs and Substances Act. It controls a lot of these precursors and the chemicals themselves. In particular, pseudoephedrine was a big one we had problems with years ago, but now we're starting to find out that these individuals, through their own entrepreneurial skills or intense fortitude, tend to be able to manufacture the stuff on their own, sometimes in quick and easy quantities that are easily accessible.
These are not just the compounds that we see on a daily basis and are manufactured at a high level though organized labs. These are even the impromptu, unsophisticated uses in the development of crystal methamphetamine by individuals on the street and otherwise. That makes it more attractive to a different socio-economic group, too, and as was alluded to earlier, we see more and more that it's starting to affect a younger generation. Before now, it was reserved to a certain age group, the mid-to-late thirties into the fifties. Now we're seeing people as young as early or late teens wanting to experiment with the drug and quickly realizing that this isn't the type of drug you experiment with because it's so addictive. When they become addicted to this particular drug, they realize there's certainly no point of return for them once they get into the exposure, the symptoms and the side effects of this drug.
Keeping that in mind, this creates a whole new problem, because now we're dealing with other issues. We have our opioid pandemic, so to speak, in our own area here as well as nationally. However, from the standpoint of this city, we've traditionally been a meth community, prior to the opioid crisis evolving in the early 2000s. Still to this day we find out that people are starting to get involved in the crystal methamphetamine trafficking trade, where they're holding drugs out to be crystal methamphetamine but which we later find out test positive for fentanyl. There are things like that, where people are not doing their research and aren't interested in checking their source, so to speak, or attempting to identify the source or mechanism of the drug.
We just had an incident in Ontario close by here where drugs were held out to be crystal methamphetamine and tested positive for fentanyl. As anyone knows, if you have an amphetamine addiction and you throw opioids into the mixture, it's a recipe for disaster and we're definitely going to have overdose issues.
Locally here, we do have overdose issues, not just on opioids but in crystal methamphetamine. We're struggling right now with funding for our own detox rehabilitation housing here. We've been able to open up a seven-bed detox centre statically through our Bluewater Health hospital. However, we've been pushing for a 24-bed delivery system for several years and it seems like it's been caught up in some financial bureaucracy at the federal and the provincial level.
I know the local MP has certainly been an advocate for us and has certainly been pushing for the funding. I think we are going in the right direction here for identifying that crystal methamphetamine addition, methamphetamine addition in general, is very addictive and very volatile. It is a somewhat different scenario when we're dealing with people coming off the addiction or treating the addiction and trying to get them to some sort of realistic future off the drug. What we're having problems with right now is just getting them to some sort of detox program when we suggest to them that they have been seven days free of the drug and to carry on with therapy after that. That is where we're at right now; it's a very similar trend to other drugs that I alluded to.
It sounds like a lot of us are on the same page. The big thing right now is there is a spike in STIs in the community and in the county in general, and a lot of them are relative. One of the big side effects of amphetamine is some of the sexually active side effects that it does cause with the trend of the stimulant. With that in mind, it certainly segues into the fact that there are issues to deal with other than psychosis and the mental health issues we are dealing with as a direct result of the drug. There are also the other side effects that have to do with sexually transmitted infections. This drug is one of the few drugs that encourages sexual behaviour and can stimulate that as a side effect, indirect or otherwise.
From what I've heard so far anyway, we're all on the same page, even if we have different socio-economic backgrounds or different issues relevant to crystal methamphetamine or amphetamine in general, and I'll be interested to hear everyone else's comments.
Good afternoon. Thank you, Mr. Chair and members of the committee, for the opportunity to speak with you today.
As you've heard, my name is Dr. Eileen de Villa and I am the Medical Officer of Health for the City of Toronto. In that capacity I and my organization, Toronto Public Health, serve a population of about 2.8 million people. I am joined today by my colleague Jayne Caldwell. She's a policy development officer in Toronto Public Health and works quite actively in the work we do at Toronto Public Health in respect of drugs and drug use among those who live in our city.
It's my understanding that you have been studying the impacts of methamphetamine use in Canada since November and have heard quite a bit of evidence from a variety of experts on these issues. For the purposes of our remarks today, we will focus largely on Toronto.
As you are aware, just as a little bit of a reminder, methamphetamine is a stimulant, along with other illicit drugs such as powder and crack cocaine and pharmaceutical drugs such as amphetamines. Historically, here in the city of Toronto, we've seen more harms resulting from the use of cocaine, although we can say that methamphetamine use has been increasing and has risen in recent years.
Looking at the impacts of any substance use, methamphetamine included, we need to actually understand why people use drugs and the context in which they use them. Looking at our particular data, I can say that rates of stimulant use are low in the general population, particularly for methamphetamine. The most recent Canadian community health survey data tell us that 4% of Toronto adults have used methamphetamine in their lifetime. The use of cocaine, by contrast, was more frequent, with 2% of Toronto adults having used it in the past year and 9% of Toronto residents indicating that they've tried it at least once in their lifetime.
We know through our practice here that, when people have issues with alcohol and with other drug use, it's often a symptom of much larger issues. For example, the prevalence of substance use is much higher among people who are experiencing homelessness than it is among those in the mainstream population, and this is certainly the case in Toronto. It is, however, important to note that substance use, in and of itself, is not necessarily a cause of homelessness, particularly for most people in Toronto. In fact, last April, when the City of Toronto, with its partners, conducted a count and survey of its homeless populations, only 5% of people surveyed noted addiction or substance use as a reason for their being homeless. Substance use among people who are experiencing homelessness is often associated with unmet health care needs, and over half of the respondents in this survey reported at least one type of health condition. Specifically, it was 57%.
Our harm reduction program in Toronto Public Health provides a range of health services to vulnerable people who use drugs. People can receive nursing care, methadone treatment, care for communicable diseases such as hepatitis C and HIV, and much more. We also operate a supervised injection service, where people can consume pre-obtained drugs under supervision. Between October 1 and December 31 of 2018, there were 9,460 visits to our supervised injection service. The data from the Works, our supervised injection service here in Toronto, show that in about three-quarters of the 9,460 visits to that service, people actually used opioids. ln about one-third of visits, people used amphetamines or methamphetamine, and cocaine stimulants were used 4% of the time, with other drugs being used about 3% of the time.
These data are consistent with a Health Canada survey of Toronto adults who were street-involved and used drugs; some 30% of them reported crystal meth use in the past year. However, crack cocaine use was much more prevalent, used by 75% of those adults. Historically, methamphetamine use in Toronto has been more frequent among street-involved youth. ln a 2013 study, 54% of street youth in Toronto reported using crystal meth.
While each person's motivation is different, some people use stimulants such as methamphetamine for practical reasons, to help them stay awake, to have more energy and to focus on tasks. This is true for people from all walks of life. For example, here in our city, we know that women who are homeless have said that they use crystal meth to stay awake at night because they fear of being vulnerable if they fall asleep. People also use stimulants to boost their confidence, to enhance sociability, as we've heard from other presenters today, and to enhance sexual activities. We've also heard today that crystal meth is sometimes used by gay, bisexual and other men who have sex with men to maximize pleasure and sociability with sex partners. We also know that some people use various drugs, including stimulants, to help them get through opioid withdrawal symptoms.
There is indeed the potential for harm as a result of methamphetamine use. As I am sure this group would know, both those via video conference and those of you in the committee room, our illicit drug supply has become increasingly toxic with potent opioids and many other drugs. Many people are coming to our supervised injection service here is Toronto because of fear of overdose from the current drug supply. In Toronto, for example, there have been occasional reports of opioid overdoses following the use of drugs that the individual believed to be a stimulant.
People also intentionally combine the use of drugs, including stimulants and depressants. They do this for a variety of reasons, including to help modulate the effects of one drug over the other. However, drugs can combine in a person's body and act together to cause severe reactions, and even death. While most accidental deaths are now caused by non-pharmaceutical, illicit fentanyl, in some cases, stimulants are also a contributing cause of death with opioids.
In fact, between May 2017 and March 2018, preliminary coroner's data on accidental deaths caused by fentanyl in Ontario shows that cocaine contributed to just over one-third of these deaths, and methamphetamine contributed to about 14%. In Toronto, however, cocaine contributed to over a half of accidental deaths caused by fentanyl— that's 53%—and methamphetamine contributed to 12% of these deaths.
In fact, in most cases of deaths in Ontario in which stimulants were a cause, other drugs also contributed to the person's death. In preliminary coroner's data for 2017, 90% of deaths in Ontario caused by methamphetamine, and 86% of deaths caused by cocaine also had another substance contributing to the death.
The number of deaths in Ontario where cocaine or methamphetamine either directly caused the death or was one of the drugs causing death has risen sharply. In 2012, 14 deaths across the province included methamphetamine as a cause of death. This number rose to 217 in 2017. And just a reminder, this is preliminary coroner's data. The number of deaths by cocaine toxicity alone or in combination with other drugs also increased during this time period from 142 deaths in 2012 to 587 deaths in 2017. Again, I'll remind you that this is preliminary coroner's data that I am giving you.
Some people struggling with substance use do seek help from treatment programs. For several years in Toronto, crack cocaine has been the most common stimulant for which people sought treatment. While this is still true, the number of treatment admissions for crack cocaine use declined by 4% between 2012 and 2018, from 32% to 27%; and there was a rise in admissions for issues with cocaine powder, from 16% to 23%, and methamphetamine, from 4% to 12%.
In addition to treatment programs, Toronto has other dedicated supports for people who use stimulants. Many harm reduction programs that provide education and supplies for safer drug use have focused efforts on educating people about stimulant overdose.
There are also resources for gay, bisexual and queer men. For example, the AIDS Committee of Toronto has health promotion materials and support groups specifically targeted at these groups of men.
In Toronto's downtown west end, St. Stephen's Community House has a new crystal meth pilot project to support people who frequently use withdrawal management services and hospital emergency departments. In addition to providing case management support and connections with health services, front-line workers are trained in how to support people who use crystal meth.
The Ontario Harm Reduction Network also plays a critical role in this issue. It brings together evidence from cross-sector experts, including people with lived experience, to train people around the province on many issues related to substance use. Last year, it held webinars focused on methamphetamine and was overwhelmed by the demand for these sessions.
Once a year we undertake training for several hours.
We meet with people and members of the community at large through Canadian Mental Health, through addiction services. We go over trends and research data locally about what we're finding in addiction concerns, treatment concerns and admission concerns.
We collaborate on a regular basis on issues of drug concerns: whether we have a specific type of drug problem, some of the side effects caused by the drug, some of the repeat clients we're dealing with and the resources required to deal with them as well as the concerns we have about dealing with them if they're in crisis at the time, whether it's a medical or a physical crisis, a mental health issue, and how we're going to combat that and get them the treatment they need.
We've obviously discovered they don't need to necessarily be in custody if a potential criminal allegation is made, or a criminal scenario. We try to diagnose and facilitate the corrective action to take, whether it's to simply call in a crisis worker from Canadian Mental Health, whether we realize from arriving on scene that the individual is in medical distress, along with their addiction issue. But do they need to go to the hospital? Do we need to get them sent to a medical facility for treatment? Sometimes it's a secondary issue.
I think the big thing is that we need to get on track with educating everybody consistently, and it has to be done at least on an annual basis. We're all on the same page. We extract the resources of all the services available, and we come to a common ground on what we're doing to facilitate the needs of the community.
When we come into contact with these people, they're normally at that stage of their addiction, psychosis or medical issue where they've come to the attention of the public at large, where they're acting out and we have to intervene. It's not necessarily as it was in the past, where it was a law enforcement issue and they just needed to be arrested, handcuffed and taken to the police station.
It may have a role in rural and remote areas that are having problems accessing care, but it still is a capacity issue.
Frequently what we see in more rural and remote areas is a primary role through non-insured health benefits, first nations and Inuit health, and the national native alcohol and drug abuse program, NNADAP, with their counsellors providing that within the community more on site.
I think that the distribution of methamphetamine that we see in the province.... From my understanding we don't see a lot of local labs from our police services. Rather, it seems to be coming from out of province or indeed out of country, coming in from Mexico. The distribution tends to be more in the larger and regional centres rather than farther out into smaller rural and remote communities. This isn't to say that it doesn't get marketed there, doesn't get distributed there, but typically, because of the criminal organizations that are distributing these illicit drugs, they tend to go where the market is.
What we see with methamphetamine is that it seems to be directed toward poorer communities, which is perhaps why we see it more on the plains. Fentanyl is less of an issue in Saskatchewan, where 10% to 15% of our opioid-related deaths are due to fentanyl. The rest are due to prescription opioids, unlike in British Columbia or Alberta. Fentanyl is getting mopped up in those more western provinces when it's coming in from the coast. However, we see an increase in the marketing of methamphetamine.
Part of this is a marketing and distribution issue. To get to your core question, I think there's a role for telehealth, no question, but I think it needs to be targeted to community and resources that are on the ground.
The issues we're having were partially covered in the last question. We have this cycle. We come into contact with an individual, and if there is an allegation of a criminal nature and-or we don't necessarily have a medical issue, and the individual is potentially arrested for a criminal offence, typically they are taken to the police station. Police stations are not suitable for this type of individual. First off, if they have a drug addiction problem and they're high at the time, it's definitely not the right place to be. Or worse, if they're coming down off the high and they're detoxing, it's even more of a medical issue and-or a safety concern. Once they do present in a formal structure for court, whether it be for a bail hearing or simply an uncontested release, unfortunately, with the process in general, whether it be through the ministry of the attorney general's office or the justices of peace, we're finding the individuals back on the street, typically within hours of our arrest.
No matter what the central allegation is, we find that a lot of the time these people are, first off, homeless. They don't even have a place that they call a residence. We would call that “no fixed address”. The next thing is that they're potentially put back on the street again, into the same environment they just came from, where they had just been out potentially committing criminal offences, typically property crimes involving breaking and entering into homes or businesses and-or personal property being stolen or vandalized. They get put right back out on the street again, literally within hours. Typically, they're of no fixed address and are put back onto the street with some quasi-conditions. Within sometimes hours, sometimes days, we're having the same interaction with this individual again, where we have no other recourse. Now they're potentially breaching conditions they've been released under, and we put them back in front of the court system again, potentially for a very minor infraction. But, once again, they haven't reported that they need to go for medical help. They haven't suggested they need medical help. The furthest thing from their mind is the fact that they need to go to some form of detox; nor would they be suitable, potentially, for detox at the time.
From there, they also know that once their detox is complete, they have no other avenue to go to. Even if they go to detox and last out the seven days at the hospital, they're basically shuttled back out onto the street again, and promptly, because we don't have anywhere to send them right away. If we have a referral on a queue to send them to a treatment facility, sometimes that can be days or weeks away, so we're basically just putting them in a holding pattern. We hope they're on their honour system, and they're not going to reuse or reacquaint themselves with what we were trying to detox them from—or any substance for that matter—and hope that they can hold the line until we get them into a facility. The next thing you know, as soon as we open that door and let them out, whether voluntarily or not, they're back at it again. By the time a bed does become available for some sort of treatment, they're not interested; and we have to start over again anyway, because now they'd have to detox.
It's a vicious cycle. It just seems to be a revolving door to which there's no direct answer.
It's very similar to what we've heard elsewhere, where there isn't adequate capacity with regard to accessing detox.
Keep in mind that detox is not treatment; detox is simply the first step. Locally, people have to keep phoning until there's a detox bed available, so they need access to a telephone, and they need to have the persistence and the perseverance to keep on calling until a bed becomes available. For somebody who's struggling with a substance use disorder, if they're craving or they're in withdrawal, they're only going to be doing that for a certain period of time before they go back out and self-medicate, if you will. They'll continue to use to avoid withdrawal.
I think that we set people up by not having a system of care that's evidence based and has continuity from outreach and engagement through various harm reduction strategies when they're prepared, when they want to move on to detox and have a transition there. The gap between detox and different treatment models is variable. In some instances, if people have stable housing, they might be able to go to a day program, and they don't have to go into residential treatment. But by and large with the folks we're talking about today, the psychosocial instability is such that residential treatment is usually preferred. Until their minds are more settled, it's very hard for them to engage in counselling, in the psycho-educational groups, and the intensity of just being present, not to mention some challenges with perhaps literacy skills and the pedagogy of how these things are taught within treatment centres, the ideology.
A host of things may not speak to a person. If the treatment centre is modelled on alcohol, that's not going to resonate with people who are smoking or injecting. They don't see the commonality to it. We need to be very mindful of this and be culturally appropriate, gender appropriate and so on. That sometimes is where supportive housing between detox and treatment can be helpful to help them to further stabilize so that they can engage when they go to a treatment centre. Following treatment, what's a 28-day period for brain rehab? Nowhere near long enough, and some treatment centres will go three months or six months.
I think it has to be client specific, particularly if there's a concurrent mental health problem, trauma or just layers of other issues that need to be addressed until people can get stable enough to get back out into the community and function on a day-by-day basis. This takes time, and that's not how we have provided services. As I mentioned, it's episodic acute care, nowhere near what we need.
In the DSM-5, the psychiatric manual, three months of non-use is early remission. Twelve months of non-use is sustained remission. We don't stop cancer treatment before they even get into early remission, and yet that's all we offer people with addiction. We're not offering them enough, long enough, appropriately client-centred treatment in order to achieve the success we could achieve if we did, and we blame these individuals because they're not able to get better. We don't provide them with a coherent, evidence-based system of care.
Education involves all sectors of society, and one of the challenges we have is, yes, it is important to get that education to the public, particularly with youth, because with some of the potency of these drugs, particularly with illicit fentanyl, they try and they die. They don't have a substance abuse disorder. They're experimenting. They're adolescents. I didn't have a full brain when I was an adolescent. It goes with the state of life.
The point is, we need to be able to provide them with education, but we also need to encourage them to get engaged with other prosocial activities so they are not bored, they have recreational, cultural, artistic, sports and other pursuits. Part of it is also providing other activities to youth. The education is important, as well as the education of the teachers, or whoever is doing this. There might be an interface between the schools and the public health sector, but the education there is important.
There is also that wider level of education. The Canadian Centre on Substance Use and Addiction has done work on infographics and so on for parents to have this conversation with their children so they are better equipped to discuss this around the dinner table.
There is also education with regard to health care professionals, because we have stigma entrenched within the health care system. More can be done there. We are seeing within Corrections sometimes this dynamic tension between correctional staff and therapy staff. More education would be helpful there. People have their roles, but we need to be able to think about ways of breaking down the friction between those roles to have synergy rather than a sense of conflict.
There is also education of health care providers. Some of these individuals are treated very poorly within hospitals, particularly if they have a concurrent mental health and addiction problem. They might go into a mental health facility, and if they slip and use, they are kicked out. If their depression gets worse, if their psychosis gets worse, they get treated. This is not rational health care service. We need to be thinking much more rationally, using the evidence and applying it in improving our systems of care.
That is a fairly broad answer to your question on education.
The situation has changed a lot. In the 1980s and 1990s, it was certainly cocaine, at parties for example, on occasion. We were in no way seeing the addiction we've been seeing in the last three or five years.
After that, there were opioids. In Quebec, we have had needle exchange centres since the early 1990s. We did not see that this increased or encouraged drug use. On the contrary, we have seen a significant decrease in HIV and hepatitis C among people who used the services of these centres.
Then there was a decrease in the number of people using injection drugs in general. People switched to other drugs. For the past five or six years, this has been particularly the case with crystal meth. In my office, it's catastrophic. In my practice, in the gay community in downtown Montreal, this drug is the most damaging, along with the STI epidemic and HIV, diseases that have been mentioned.
We receive testimonials from people who have used crystal meth. They often tell us that, even if they want to stop, it has been so good sexually that they are dependent on it. Some people will rather tell us about their creativity, which is stimulated when they consume it. They wonder how they will ever be able to stop and whether they will be able to do so.
There are resources in hospitals at the emergency hospital centre. Then there are the resources for detoxification. However, there is little expertise for this clientele, which corresponds to a particular group, the one I see in downtown Montreal.