Thank you for unanimous consent. I declare this meeting in session.
Welcome everyone. Pursuant to Standing Order 108(2) on the motion adopted Monday, April 16, 2018, the committee is resuming its study of the impacts of methamphetamine abuse in Canada. After our witnesses' testimony, and questions, we will go in camera and discuss the committee report.
Today we have with us, from Victoria, by teleconference, Ms. Lisa Lapointe, Chief Coroner of British Columbia; from Oregon, Katrina Hedberg, State Health Officer of the Oregon Health Authority; and from Vancouver, Dr. Susan Burgess, Clinical Associate Professor, University of British Columbia, from the Vancouver Coastal Health.
You each have 10 minutes to give testimony. In the interest of time, if we're running short I'll give you a one-minute warning when we're at the end of the 10 minutes and we'll go on to each speaker in turn. Then we'll go to our questions.
We'll start now with Ms. Lapointe, for 10 minutes.
I did prepare a slide presentation. Unfortunately, there wasn't time to translate it. Some of you may have it. I'm not going to refer to it greatly because numbers are not very interesting when a person is talking. I'm just going to basically tell you the story of what we're experiencing here in B.C. from the coroner service's perspective.
As you know, B.C. is in the midst of an overdose crisis. We lost 1,500 members of our community last year to overdoses, and we are reporting another 1,500 this year, although that number will increase slightly as more reports come in.
In B.C., we track all illicit overdoses. That is because the vast majority of overdoses are mixed-drug overdoses. It's very rare to find an individual who has died with just one substance on board. Fentanyl, as you know, is involved in 85% of all deaths in British Columbia now. That is predominantly what we're seeing with almost all overdoses. For many years, however, we have tracked other substances as well. I think that's really important.
There has been a lot of focus on opioids and the opioid crisis. In B.C., the only reason we recognized that people were dying at an increased rate of opioid poisoning was that we track all illicit overdoses, and we could see that opioids were starting to have a significant growth pattern. That's really important.
In B.C., more people have died of overdosing in each of the last two years than all motor vehicle accidents, suicides, homicides and prescription drug overdoses combined. Prescription drug overdoses are a very small number of the overdoses in British Columbia. We see fewer than 100 per year. We do not see a pattern in this province related to prescribing. As you know, methamphetamines are an illicit substance. They are primarily purchased on the illicit market. The illicit market is unpredictable and unmanageable.
People talk about drug labs. I don't know if any of you have ever seen a picture of a drug lab. They don't look like any laboratory you've ever seen. They are dirty kitchens and dirty rec rooms. There are cross-contaminated substances. There is no quality control. There is no ability, when purchasing substances in the illicit market, to guarantee dose, quality or even what is in a substance. That's what we think we're seeing now with the increase in methamphetamine deaths.
We have seen an increase in methamphetamine deaths over the last several years. In 2010, this province saw 23 deaths where methamphetamine was detected in post-mortem toxicology testing. In 2017—and we still have 20% of our reports outstanding—we saw 283 methamphetamine-detected deaths.
The reason I report it as “methamphetamine-detected” is that, as I mentioned, most overdoses are mixed-drug overdoses. For example, of 2,042 overdose cases that we have concluded in this province in the last couple of years, illicit fentanyl was detected in 80%. That's not prescribed fentanyl. That's illicit fentanyl purchased on the street. The next most common substance we see is cocaine. Fifty percent of deaths also had cocaine on board. The third most common is methamphetamines/amphetamines. Thirty-one percent of the overdose deaths we investigated had methamphetamine on board.
It's hard to know whether that significant increase, from 11% of the deaths involving methamphetamine in 2010 to 30% in 2017, is because there is more meth being used or because methamphetamine is now contaminated with fentanyl. Virtually every substance in this province is contaminated with fentanyl. We have certainly seen many reports where folks thought they were purchasing methamphetamine/amphetamines, and in fact their may have been some meth—we often find that mix—but there is very likely also fentanyl on board.
That, we believe, is driving the increase in methamphetamine deaths, but it's hard to know. When we arrive at the scene the individual is deceased. These are illicit substances, so they don't leave a record of what they've purchased.
In B.C. the majority of those who die—86%—die indoors and alone, so we don't have anybody to ask what they thought they were buying. Occasionally somebody dies in the company of their friends, and they'll say, “We bought cocaine. We thought we bought ecstasy, and in fact it was contaminated with fentanyl.”
We think it very likely that what people thinks is methamphetamine is methamphetamine, but also contaminated with fentanyl, and that's really driving the increase.
It's great to see the focus on specific substances. It's great to see the focus on opioids, great to see the focus on fentanyl and good to see the focus on methamphetamines. Really, though, what we're seeing is people dying of problematic substance use, and without looking at all the numbers in a broader context, it's really hard to see trends and patterns. We've been very fortunate that we had a database that allowed us to view trends and patterns over time so that we can see, of the number of people who die of illicit substances, what percentage involved opioids and what percentage involved methamphetamine. That's really important.
I remember about two-and-a-half years ago being at a meeting in Ottawa with a number of folks, including CIHI, Health Canada and Statistics Canada, at which there was a strong focus on opioids. I remember mentioning at that time that the prairie provinces were seeing methamphetamine and that maybe we should do a broader review. There was a lot of resistance, a lot of wanting to focus on one thing at a time.
If there's anything I would urge the committee to consider, it is taking a broader perspective. This is a problematic substance use issue. If we have robust infrastructure, robust reporting, robust analysis, then whatever the next substance is that comes to the fore, whether it's MDMA or—who knows what else might be the drug of choice, since it's largely dependent on the source, what's coming into the community and how cheap or expensive it is and how easy it is to get in—then we will be ready to respond to it.
Because I am the chief coroner for B.C., I heartily endorse the Canadian coroner and medical examiner database that is run by Statistics Canada. All coroner and medical examiner offices in the provinces and territories can report into it. Not all services have a robust data collection system, so if there's any opportunity to enhance data collection in the provinces and territories, I think taking it would certainly be beneficial.
Then, of course, the issues surrounding problematic substance use are not confined to one particular substance. We see pain, we see stigmatization, we see marginalization, we see the lack of evidence-based recovery systems and treatment systems and we see criminalization. All of those things serve to work together. If they do not increase the numbers of those dying, they certainly don't work effectively to prevent deaths.
Something else that is, as you may have heard, focused on very much here in B.C. is meaningful measures to address substance use, meaningful measures to reduce harms and meaningful measures to support folks to a full recovery.
In summary, we see an increase in methamphetamine deaths. We have seen an increase, in the last seven years, of 200%. They compose 31% of all illicit drug deaths in B.C. Methamphetamine is on board, but more importantly, in 80% of all illicit deaths fentanyl is on board. We can't say whether, but for fentanyl, the methamphetamine deaths would still be occurring; we don't know. We think it's very likely that fentanyl is driving all of these deaths.
Thank you for the opportunity to talk to you all. I very much appreciate coming after my colleague in British Columbia, because many of the points she brought up are things I wanted to talk about as well.
To start off, one of the really important things to understand is the importance of data. We've been tracking overdose deaths for quite a while. In Oregon we started to see an increase specifically in methamphetamine deaths from the mid-1990s up until 2000. At that time most of our methamphetamine was “cooked”—that's the expression—made locally from Sudafed or pseudoephedrine. At that time there were a number of laws put into place, including that you needed to have identification for purchasing Sudafed, and then it became prescription only. We thus saw a decrease in the local production of methamphetamine, which was good news, and we started to see less use.
At the same time, though, the methamphetamine then began being imported from elsewhere, and while that helped with the meth lab issues around environmental contamination and injuries, our meth use then started to increase again.
I'm an epidemiologist by training and so I like to categorize things and count, but I would also agree with my colleague that many of these deaths involve multi-substance use. If you take apart methamphetamine and then only look at opioids, or if you look at the contamination, or even alcohol.... Many people are polysubstance users and may have chronic medical conditions on top of that. It's therefore a bit hard to say how much of this problem is specific to one drug or specific to another. Again, I would echo the concern about doing a multi-substance use approach.
One thing we've seen in Oregon that I think is a little different from what has been seen in Canada is that we have had in the United States a problem specifically related to prescription opioid overdose. We started to see it in the late 1990s and up through 2000. We were really seeing a lot of opioids being prescribed for pain. People would take them and would die of overdoses from prescription opioids or would use prescription opioids in conjunction with illicit opioids.
Of course, there has been a huge effort in the United States to tamp down on prescribing of opioids for chronic pain, and so we started to see a decline in prescription opioid overdose deaths. At the same time, we are very concerned about heroin deaths and then fentanyl, as another opioid.
In Oregon, for better or worse, we have not yet seen the same problems with fentanyl overdose that other parts of the country have seen. Nonetheless, we've had a very sharp increase in fentanyl deaths from 2016 to now. Again, the incidence is still much lower than that from prescription opioids.
A minute ago I said I don't like to categorize, and I'm categorizing here. It's important to understand that these are polysubstances. There are multiple drugs on board, and because of that we have to see where the interventions can occur.
Looking, then, at what's happening within the health care system, no one is prescribing methamphetamine per se, but they are prescribing stimulant drugs such as Ritalin or Adderall. for ADHD—attention deficit disorder—just as an example. We're saying that we don't want those to be prescribed. At the same time, we're very concerned about illicit use. We need to work within the health care system to look at what's being prescribed.
Many of these patients are chronic pain patients, and so, if we're taking away opioids or other drugs, we want to be sure that people have access to non-pharmaceutical therapies. That's another thing we've been working very hard on within our health care system: to look at what other things might address a person's chronic pain.
We need to support people with medication-assisted treatment and get them into care. Of course, specifically for opioids, naloxone is a rescue drug. We still need to get people into care, even if they're rescued from an overdose. That's a sort of ”death prevention”, if you will, and we really want the upstream substance use prevention to happen as well.
Then getting the data to inform policies is really important.
We in Oregon are quite happy, if you will, that we've started to see progress in prescription opioid overdose deaths. Specifically, we've seen prescribing of opioids decline, and that's by 28% over the last couple of years.
That is going, then, in the right direction: we're working with health care systems. The challenge with some of these other drugs is that while you can look at what's happening in the health care system, you really need to look at what's happening with illicit substances as well.
One of the things we did in Oregon was to pull together a group of stakeholders to help advise us around the prescription opioid overdose and then to broaden that to look at all illicit substances. We called it our opioid initiative, and that included many of the health care partners from the health care system, the prescribers themselves. It also included substance use disorder treatment folks, as well as law enforcement.
It is important to make sure that law enforcement is on board both in terms of the immediate response and when we're talking about the criminal justice system. At least here in the United States, it's important that people who are on treatment for substance use disorder continue that, that if they're in and out of jail or prison, there isn't a sudden stop. We know that one of the riskiest times is when people who are in prison for drug-related causes, or even if it's for something else but they are addicted—and they may get off it while in prison—get discharged or released from prison. They're back into the same environment they left and at an extremely high risk of overdose.
One of the things my colleague from British Columbia did not mention is that many of these people who are using drugs, and who might be injection drug users, are at risk for a number of other adverse health outcomes. We look at overdose, but among people who inject drugs, Oregon has one of the highest rates of death from hepatitis C anywhere in the United States. We see HIV infection related to that. Hospital stays for heart, bone, blood, soft tissue and skin infections are all much higher among injection drug users.
The altered mental status that happens increases the risk of injury. We're of course concerned about pregnant women who use this and what the effects might be on their unborn babies. Recently there have been studies to show that opioids and many of these drugs increase the risk of suicide. We call this a “syndemic”, a number of these various epidemics that are combined. Really, we can't do HIV prevention without considering how many people are injection drug users, and of those, how many are using opioids or methamphetamine and so on.
The challenge for this, of course, is to look at what we would consider the upstream factors: Why are people using these drugs? I mentioned physical pain, but we know a number of these people also have adverse childhood experiences. They're experiencing social problems as well. They have unemployment. They might have problems with housing. We need to look at those upstream factors where we can be more supportive in terms of the community and how these folks can have a number of issues dealt with before they start using drugs. Again, if they have been using drugs, they need not only to be in recovery specifically from substance use disorder but making sure that they have access to housing and employment and those kinds of things so that they aren't necessarily tempted to be using drugs again.
As just very few examples of some of the activities we're doing, we've developed some specific provider training related to a psychosocial approach to pain. That is again broader than just the physical, but understanding that some of the psychological input, how people react to pain, is just as important.
I mentioned the prescribing guidelines. We've done those for opioids. We're considering doing them now for tapering off opioids. That's an important thing. Again, that's done in a compassionate manner.
Another example is harm reduction, things such as needle exchange. I know in British Columbia there are both needle exchanges and supervised injection sites. That's something that's a little controversial in the United States. It's the idea that you want people off drugs, but if people are going to use them, really this harm reduction and death prevention is extremely important.
I mentioned naloxone distribution. One of the other things we're doing is looking at who shows up in an emergency department with an overdose, and can we do a fast track to treatment? Can we have peer support to get those folks into treatment? It's a teachable moment.
I did not prepare an opening statement. I did, however, send a description of our current situation, and I thank the previous speakers for really defining many of the important issues.
I am going to speak as a front-line provider in the inner city of Vancouver, where, essentially, methamphetamines and fentanyl have destabilized all of my patients. We are really left with very little to offer. I'll try to explain that. Certainly all of our patients are multi-drug users. We test routinely when people do present or when we go out to them. They don't even know what they're using most of the time, but rarely do we see cocaine. You have to be very sophisticated in getting cocaine from your dealer nowadays. Everything is crystal, and if you think you're getting crystal, as was described, there is usually fentanyl, and if you think you're getting fentanyl, there is usually crystal.
Multi-drug use is a problem. We have a saturated community. I follow patients with HIV, hepatitis C, COPD and cancer who are all using these substances with a background of trauma and poverty. They're pretty good at surviving, but now, with the introduction of methamphetamine, unfortunately, that is not the case.
While we run around and give people needles and they have safe places to inject, and we work very hard to give them housing and we take their medications to them, increasingly, with the effects of crystal meth, this is becoming more difficult.
People are developing psychiatric effects from this medication that make it really difficult for them, even with the supports we provide, to be successful in treatment of their HIV or their hepatitis C, for which there are very simple treatments now. We can take people their meds every day, and increasingly we're not able to get them into their mouths. It's the same with all the other medical conditions they have. Their condition is exacerbated by the mental illness effects of crystal that we are seeing. This may be in combination with fentanyl. I don't know what the biochemical cause is, other than it's only with the appearance of crystal meth that we're really seeing this in such great depth.
Yesterday I was trying to certify a long-term AIDS patient who did well. He can no longer find words, he is incontinent in his room, and so forth. Unfortunately, when we find people like this with their paranoia, their violence and their hallucinations, which are really increasing, what we have to offer them is limited. It's limited somewhat by the way we approach these symptoms in our patients. They are psychiatrically impaired; however, it is described as a drug-use problem. It is drug-induced psychosis.
This term, unfortunately, in many cases really means that the patient doesn't receive the psychiatric support they need. They go into the emergency department, they sleep it off, they come out, and they're immediately back to where they were. We are looking at a real epidemic here. We call it the elephant in the room. We are constantly dealing with violence and people who are no longer able to engage in care.
I work on the street and I also do palliation, and more and more of my patients are really palliative in terms of the concomitant medical illnesses they are carrying. They are not able to talk to me. They're not able to engage with their support team. They are at risk of overdose. They try to modify things. They take a bit of crystal so that they don't go down with fentanyl. They will frame their drug use by saying, “Dr. Burgess, aren't you glad I don't use cocaine anymore? I just use crystal twice a day.” Unfortunately, those people are becoming more and more psychiatrically impaired.
I'm going to make my remarks short because I'm working at the bottom end of this. What I would like to see is rapid treatment of people when they are psychiatrically so unwell. Without that, everything else falls apart—absolutely everything.
We have a system where psychiatrists are really in charge of a lot of the treatments for psychosis. Depending on their assessment of a situation, they are more or less helpful. In the Downtown Eastside, the inner city area where I work, we have tried to increase the availability of psychiatric services. It's an up and down thing. It's in the middle of being fixed, I hope. The psychiatric issue here is an emergency and we need to be able to help people with this so they can re-engage with the rest of their lives. They are becoming more homeless are kicked out because they're violent. They can't really understand a lot of what's happening around them. They are open to more trauma: running into traffic and not taking their medications.
My population is, as I said, particularly HIV heavy. I'm seeing people who have been stable, with support on HIV and hepatitis C medications, falling off. I have more AIDS patients in the inner city than I had at the height of the epidemic in 1994, 1995 and 1996. From the street, it's a serious illness, this use of crystal meth, but people love it, and people love fentanyl.
While we have now developed an inner city pain program that's specific to the needs of our patients—and that's not including opioid use—as well as mobile ACT teams, assertive mental health teams, we still have a large group of people who are now permanently psychotic. Even if the patients actually appear fairly stable, in conversation, they'll say they're hearing voices and so forth. There's the mild form as well as the very extreme form of people who are totally dehumanized. I would like to see more availability of injectable anti-psychotics for these patients, otherwise I'm accompanying them to either an overdose death or a death from their chronic illnesses, like HIV and hepatitis C. It's really quite an emergency for us and for our population in the inner city.
Thanks for the question. There were actually a couple in there.
One of them is that when we're talking about chronic pain in the United States, we also know—and we have an entirely different health care system than you do—that the amount of opioids being prescribed for pain in the United States is much, much higher than in Europe, for example. So it isn't that opioids are the only answer to chronic pain. In fact, we have to offer other things. It's true for acute pain too. If people come into an emergency department with a broken leg or sprained ankle, certainly things like ice or ibuprofen.... There are a number of other medications that could be used—not prescribing opioids.
A lot of what we're talking about is a change in expectation between a quick response, which is a pill, and something that might take longer. Certainly, physical therapy for chronic pain, for example, takes a lot longer. The idea is that there isn't one size that fits all. We have to look at a variety of things.
In Oregon, of course, we had one of the first medical marijuana programs, along with California, and we recently legalized the retail sale of cannabis or marijuana. It turns out that a lot of people who are buying retail, as you mentioned, aren't doing it just because of the psychoactive effects that they're interested in, but also for pain. They might be buying a salve to use for arthritis, etc.
The problem is, how do we get data on how much people are replacing, if you will? Are you using cannabis instead of opioids? How much? Anecdotally, we know that people say they are trying to taper off opioids and are replacing the treatment with cannabis, but that's just anecdotal.
In my mind, that's clearly an area where we need a lot more data and science. Unfortunately, in the United States, it's very hard to get that because, as you know, cannabis is a schedule I substance at the federal level. In terms of who is using what and what are the long-term effects, we really aren't even allowed to do research protocols related to people in chronic pain if you give some an opioid and others cannabis. That's an area where we really need a lot more data.
I might just add one thing.
Certainly, we have heard police officers here in B.C. say, “We can't arrest ourselves out of this situation.” Our public health folks here in B.C. certainly have the same perspective: As my Oregon colleague mentioned, substance use disorder is a chronic, relapsing disease and a medical approach will make a difference.
From my chair—having been in this type of work for the last 25 years—it's almost impossible to remove the traffickers because it so profitable. You take one off, and because it's so profitable, one, two, three or four more will pop up.
If we can focus on the users, if we can focus on the poor folks who are experiencing this chaotic existence, if we can support them where they are and provide evidence-based treatment when they need it.... Some folks are asking for it and it's just not there. It's certainly not there in any way that they can afford or access. If we can focus on the users instead of the suppliers, it just seems to me that we can be much more effective. We know who they are for the most part. They're in our communities. We're already spending lots of money putting them through courts and jail. If we just repurpose that money, it strikes me that it would, in the long run, be a much better solution.
Thank you very much. I've always been told you never start a presentation or an intervention with an apology, but I do apologize to my colleagues around the table, because I'm subbing in for someone else on this committee, so if I ask any questions that are somewhat redundant and you've covered this ground before, I do apologize for that.
There's a saying, ladies, in politics, that all politics is local. In my case, local means my home riding. As Mr. Lobb indicated with his riding in Ontario, mine is primarily a rural riding. The community of Moose Jaw is the largest city in the riding, with a population of about 38,000 people. I think by anyone's definition, it would not be considered a cosmopolitan centre at the scale of Montreal or Toronto. Nonetheless, according to our mayor, there is a serious meth problem in Moose Jaw.
I'll address my primary question to Dr. Burgess, since you have collected a lot of data. Whether it's meth or a combination of meth and fentanyl, I'm not really sure which, but do you see any commonality in the demographics of drug problems and drug usage across Canada, whether it be age, income, gender or ethnicity? Are there some determinants that we can get some data on to try to make some conclusions that would, we hope, assist the government in finding solutions for this widespread epidemic? I really do think it is an epidemic.
What can we do to try to collect more information than we currently have? I have not heard anyone yet in discussions talk about drug-use problems in small towns with populations of under 5,000 people, for example. What do we need to do to collect the data to assist us and any future government in trying to address this most serious problem?
Thank you for that. I think my colleagues on the panel here are well aware of our need for more data collection in real time, so that we will know exactly what's happening and what the appropriate, if possible, response is to that local condition. I have experience only with Vancouver, as well as the Northwest Territories. One of the issues that may be relevant for us across Canada is what I saw when large numbers of people with mental illnesses were released from large psychiatric hospitals into the community—but not to a lovely community. What were they released into? They were released into the inner city in Vancouver.
These vulnerable people were released into SROs. They were released into drug use. They were introduced to drug use, which, as I described, actually has some psychometric effects on the patients that they enjoyed. Within a month of being released, they were using injection drugs. Within three months, they were HIV-positive.
That was a policy decision. That was not something that those patients sought. How we care for people with vulnerabilities, whether they are psychiatric, trauma or culturally destroyed backgrounds, is really important. I think we need to think about those policies, and their potential effects on vulnerable people, before we make them willy-nilly.
The latest is, “Let's close all the institutions.” Very good point, but what do we replace them with? Currently, in Vancouver, what do we replace our psychiatric care with? It changes monthly. If I'm on the psychiatric ward in St. Paul's Hospital, the psychiatrist will say, “I actually don't know where I'm sending this vulnerable patient now.” They need psychiatric housing. It's changed so much. We need a robust system everywhere, but we need to be careful, and think thoroughly about what our policies are going to do to these vulnerable people.