HESA Committee Report

For example, Health Canada is working with and supporting the Canadian Indigenous Nurses Association to complete a report identifying best practices in enhancing access to culturally appropriate clinical care.

Health Canada is also supporting First Nations partners to implement service delivery models that are grounded in the holistic First Nations vision of health and provide a comprehensive range of high quality, effective and culturally safe health services, including land-based activities.  In some communities this approach is reflected in the provision of problematic prescription drug use programs that have the flexibility of including on the land-based activities alongside methadone or buprenorphine/naloxone opioid replacement therapy/treatment.  

Health Canada will continue to work with partners to ensure treatment and mental health support programs are culturally safe, trauma-informed, and grounded in culture.

Treatment and Prevention Services

Health Canada funded community-based programming provides prevention, intervention, aftercare and follow-up services in the majority of First Nations and Inuit communities across Canada, while residential treatment occurs through the national network of National Native Alcohol and Drug Abuse Program/National Youth Solvent Abuse Program (NNADAP/NYSAP) treatment centres that are operated by First Nations organizations and communities to provide both in- and out-patient services. Central to success are the collaborative approach to programming that blends cultural practice and safety with mainstream treatment approaches, and cultural awareness of the treatment providers.

Health Canada is committed to working with partners to improve access to buprenorphine/naloxone in communities as part of an approved Community-based Opioid dependence program. Health Canada’s Non-Insured Health Benefits (NIHB) Program has been providing coverage for buprenorphine/naloxone as a Limited Use benefit since December 2011.  In fact, the Program was the first plan in Canada to ensure that prescribers can choose the most appropriate treatment option. The Program implemented changes in September 2014 to increase access to buprenorphine/naloxone by expanding criteria under its Limited Use status. There are approximately 3,000 NIHB clients currently approved for buprenorphine/naloxone coverage.

Buprenorphine/naloxone is a controlled substance and poses risks to clients and communities if it is diverted to the illegal market.  In remote or isolated locations, NIHB confirms that supports are in place to safely store, handle and undertake the daily witnessing of buprenorphine/naloxone before coverage is approved.

The NIHB Program also includes any clients receiving coverage for opioid addiction therapy medications in the Prescription Monitoring Program which places additional safety measures on their coverage. Within the NNADAP/NYSAP network of treatment centres, 21 of the 43 treatment centres (49%) accept clients on buprenorphine/naloxone and 14 (33%) accept clients on methadone.

To accommodate the unforeseen realities (e.g. weather delays) of delivering client specific medications to remote First Nation communities, Health Canada added naloxone to the Nursing Station Formulary in 2013 for communities using this drug as part of approved Community-based Opioid Addiction Treatment Programs to make sure there is continuity of treatment. 

Harm Reduction
(Recommendation 7)

Many centres within the network of Health Canada funded treatment centres have existing, or are taking on, harm reduction initiatives. First Nations community-based programs have the flexibility to adapt to the needs of community members accessing a program. Training on how to administer naloxone (by injection or nasal spray) is taking place in multiple regions with community-based workers, treatment centre staff, and individuals connected with friends and family members using opioids.

For remote and isolated communities, injectable naloxone is listed in the Health Canada Nursing Station Formulary as a “must stock” antidote, to reverse the effect of opioid overdose. The injectable naloxone currently available in nursing stations is only administered by trained health professionals such as nurses and physicians to reverse the effect of acute opioid overdose as required. Naloxone in these health facilities is replenished as needed. As an initial effort to provide timely access to at-risk clients and their families, Health Canada is stocking a nasal spray version of naloxone for remote and isolated community through Nursing Stations.

Health Canada is working with existing provincial public health programs under the framework for take-home naloxone injection kits distribution to high risk clients for opioid overdose, as part of their opioid harm reduction strategy.  Nursing stations are involved as an extension of that work (e.g. Alberta take-home naloxone injection kits).

Health Canada’s NIHB provides First Nations and Inuit with coverage for injectable naloxone as an open benefit, which means that clients can obtain naloxone at retail pharmacies at no cost. Coverage for nasal naloxone will also be provided when available for purchase in retail pharmacies.

Health Canada supports First Nations communities in the implementation of a variety of harm reduction initiatives identified as community priorities, such as provision of biohazardous waste containers and needle exchange where appropriate.

Health Human Resources
(Recommendations 25, 27)

Health Canada provides approximately $300M annually on an ongoing basis for community based mental health and addictions programming. In April 2015, Health Canada announced it would provide more than $13M over five years and $3M annually on an ongoing basis to enhance prevention and treatment capacity for problematic prescription drug use within First Nations across Canada. Most funding is provided directly to First Nations communities or partner organizations to deliver health programs and services.

The type of contract arrangements a community can enter into with service providers is largely determined by the type of funding arrangement it has with Health Canada. As of March 31, 2016, 74% of communities have a high degree of autonomy due to their block or flexible funding arrangements. This means that funding is contributed over multiple years and recipients have the ability to re-profile funding as needed.

Health Canada employs primary care nurses in 52 of 79 remote and isolated communities. For the remainder of the communities (27), health services have been transferred to the communities, where the Band is responsible for employing primary care nurses. Although dedicated to primary care services, these nurses play a role in addictions treatment and to support them, guidelines that define the Health Canada nurse’s role in the therapeutic management of opioid dependence have been developed. Other remote and non-remote communities may choose to employ health care providers directly for addictions treatment.

As primary care providers, Health Canada’s nurses can initiate pharmaceuticals that are prescribed by a Nurse Practitioner or Physician and provided by a retail pharmacy in support of addictions treatment as long as it is within provincial regulatory requirements.  However, given the ongoing nature of buprenorphine/naloxone and methadone-reliant treatment, client treatment is initiated by nurses and then typically referred to community-based addictions programming for ongoing observed treatment and support. 

National Native Alcohol and Drug Abuse Program and National Youth Solvent Abuse Program treatment centres offer an array of special programming, with 49% accepting clients on buprenorphine/naloxone. Depending on the treatment centre, treatment cycle length can range from 7 to 180 days. Problematic prescription drug use projects located in communities and treatment centres are demonstrating promising practices with culture as the foundation, community ownership, and collaboration at their core. Many have the flexibility to include the land-based activities in conjunction with methadone or buprenorphine/naloxone treatment.

Health Canada is also working with the First Nations Mental Wellness Continuum Implementation Team to support First Nations partners to develop First Nations service delivery models, including crisis response and prevention as well as land-based healing and wellness programs, which strengthen relationships with the land and traditional culture. These service delivery models will draw upon promising community practices to facilitate their integration into existing mental wellness programming in other communities.

Conclusion

The Government is seized with the urgency of the situation, has taken action, and is committed to continuing to act to address the opioid crisis.  The Federal approach is comprehensive, compassionate, collaborative, and evidence-based. The Canadian Drugs and Substances Strategy, including making naloxone available by non-prescription status, an emergency order to allow easy to use naloxone nasal spray into Canada, approval of five supervised consumption sites, and the introduction of Bill C-37, are concrete steps to protect lives and protect the health of communities. The Government will continue to use all the tools at its disposal to respond to the crisis while being a strong partner and encouraging parallel action from  provinces, territories, municipalities, health care practitioners, law enforcement, and civil society.

Annex I to the Government Response

Joint Statement of Action to Address the Opioid Crisis
November 19, 2016

Canada faces a serious and growing opioid crisis. We see its consequences in the rates of addiction, overdoses, and deaths across the country. This is a complex health and social issue with devastating consequences for individuals, families, and communities.

The response to this crisis needs to be comprehensive, collaborative, compassionate and evidence-based.

On November 18, 2016, we heard a number of perspectives on this crisis: from people who use drugs, from families, healthcare providers, first responders, educators and researchers. Today, we have come together to identify specific actions to address this crisis and publicly commit to taking these actions.

This Joint Statement of Action to Address the Opioid Crisis reflects our combined commitment to act on this crisis. We have agreed to work within our respective areas of responsibility to improve prevention, treatment and harm reduction associated with problematic opioid use through timely, concrete actions that deliver clear results and we commit to reporting on our progress in delivering those results.

As Health Ministers, our focus today is on the important actions being taken by players in the health community. We recognize that this is just the beginning. Much work is already underway separately in the areas of law enforcement, corrections, education and elsewhere. We will invite leaders in these communities to join us as we build on the commitments made today.

The Honourable Jane Philpott
Federal Minister of Health

The Honourable Eric Hoskins
Ontario Minister of Health and Long-Term Care

Our Actions

To achieve this vision, we commit to taking the following specific actions to address the opioid crisis in Canada

Health Canada commits to:

• Providing leadership to address the opioid crisis by working with health professionals, addiction experts, provinces and territories, and other stakeholders, to implement Health Canada's Opioid Action Plan.
• Improving access to buprenorphine/naloxone treatment in rural and remote First Nations communities by taking steps to ensure that the supports are in place to safely store, handle and undertake the daily witnessing of buprenorphine/naloxone.
• Engaging with prescriber colleges and regulatory bodies, as part of the First Nations and Inuit Health Branch's Non-Insured Health Benefits Program, to improve awareness of its Prescription Drug Abuse Strategy and Prescription Monitoring Program.
• Collaborating with the Non-Insured Health Benefits Program and other public drug plans on plan-based prescription drug abuse initiatives to increase innovation and prevent the shifting of costs and problems from one payer to another.
• Supporting a range of tools and harm reduction measures for communities, including supervised consumption sites. This will include: proposing any necessary amendments to the Controlled Drugs and Substances Act to remove any undue barriers introduced through the Respect for Communities Act; continually supporting potential applicants to complete the application process through proactive engagement; and keeping the public up to date on the status of applications that have been submitted to Health Canada, including their stage in the review process.
• By February 2017:
• Publishing a report on Health Canada's Opioid Action Plan and keeping it evergreen by posting regular updates and progress reports; and
• Publishing a report on the Health Portfolio's Prescription Drug Abuse initiatives.
• Implementing Health Canada's Opioid Action Plan, which comprises the following elements:
• Better informing Canadians about the risks of opioids: this includes mandating new warning stickers and patient information sheets for all dispensed opioids; conducting targeted public awareness activities; and disseminating youth prevention tools that reflect best practices.
• Supporting better prescribing practices: this includes continuing to promote best practices and national approaches through the Federal/Provincial/Territorial Prescription Monitoring Program Network; and sharing prescribing practice information obtained from pharmacy inspections with selected Provincial/Territorial regulatory authorities, as appropriate.
• Reducing easy access to unnecessary opioids: this includes adding new contraindications for approved opioids; requiring a prescription for low-dose codeine products; requiring manufacturers to develop and implement risk management plans for high-risk opioids; and providing updated guidance to pharmacies on the handling and destruction of consumer-returned prescription drugs.
• Supporting better treatment options for patients: this includes expediting the review of non-opioid pain relievers; consulting stakeholders on whether the special exemption requirement for methadone prescribers poses undue barriers to access to treatment; implementing the recent regulatory change to enable access to diacetylmorphine (heroin) via Health Canada's Special Access Programme (SAP); accepting applications to SAP for other drug treatments not yet available in Canada and encouraging manufacturers to take the necessary steps to bring those drugs to the Canadian market; and promoting increased access to buprenorphine/naloxone as a first line treatment choice by disseminating the results of the recent Canadian Agency for Drugs and Technologies in Health (CADTH) report, Buprenorphine/Naloxone Versus Methadone for the Treatment of Opioid Dependence: A Review of Comparative Clinical and Cost-Effectiveness and Guidelines.
• Improving the evidence base upon which policy decisions are made: this includes improving data collection and the Canadian evidence base to support drug policy decision making; considering the recommendations from the recent Best Brains Exchange on a National Drug Observatory for Canada; hosting Expert Advisory Panels to advise on scientific elements of the Opioid Action Plan; and publicly reporting on the results of the Health Portfolio's Prescription Drug Abuse initiatives and projects funded through Health Canada's Substance Use and Addiction Program (SUAP).
• Reducing the availability and harms of street drugs: this includes continuing to facilitate increased access to naloxone in line with Health Canada's actions to date (i.e., making it available without a prescription, issuing an emergency Order to allow bulk import of naloxone nasal spray from the United States, and conducting an expedited review to authorize the nasal spray in Canada); publishing regulations to control fentanyl precursors; sharing Health Canada's Drug Analysis Service lab analysis with Provincial/Territorial authorities in a timely manner so they may respond effectively to local drug trends; considering options for controlling pill presses; and educating law enforcement agencies on their ability to investigate and press charges for offenses under the Food and Drugs Act, particularly for the sale of unauthorized drugs that have not yet been controlled under the Controlled Drugs and Substances Act.
• Continuing to implement the Health Portfolio's Prescription Drug Abuse Strategy, which received $44M over five years (2014-2019) to support: increased pharmacy inspections to help reduce the diversion of prescription drugs; enhanced access to prevention and treatment capacity for prescription drug abuse within First Nations communities across Canada; a national marketing campaign aimed at parents and youth; research on new clinical and community-based interventions for preventing and treating prescription drug abuse; a coordinated pan-Canadian approach for the monitoring and surveillance of prescription drugs, including the data reporting standards necessary to establish a national network of coroner's reports to better understand the impact of opioids on death rates in Canada; and the development of evidence-based practices for appropriate prescribing. A key deliverable for March 2017 is an updated Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain and associated training tools for prescribers, for which Health Canada provided funding to McMaster University. Health Canada, through its Substance Use and Addictions Program, is also funding a variety of additional prevention and treatment initiatives across Canada.

The Province of British Columbia commits to:

• Establishing supervised consumption services in locations of high need; BC presented two applications for exemptions in October 2016 and will present four more exemption requests to Health Canada by the end of 2016. BC looks forward to working collaboratively with Health Canada to facilitate timely review of applications to open a minimum of eight new supervised consumption services in 2017.
• Supporting federal efforts to improve the application process for Section 56 exemptions under the Controlled Drugs and Substances Act required to operate supervised consumption services; BC will continue to provide Health Canada with recommendations for areas of the Controlled Drugs and Substances Act, as amended through Bill C-2, that can be substantially modified or eliminated without compromising public health or public safety to facilitate the timely establishment of supervised consumption services in BC and nationally.
• Sharing knowledge about treatments for opioid use disorder that are new and emerging in Canada and supporting the development of a national framework for the provision of injectable opioid agonist therapies.
• Sharing new provincial guidelines for treating opioid use disorder scheduled for release in January 2017, as well as further updates incorporating new treatments later in 2017.
• Encouraging Health Canada to continue its efforts to remove any unnecessary regulatory barriers that prevent or inhibit access to evidence-based pharmacotherapies for the treatment of opioid use disorder. Given BC's current public health emergency and the unprecedented number of preventable overdose deaths, BC appreciates Health Canada's support to date and looks forward to further cooperation to ensure the full spectrum of evidence-based pharmacological treatment options for opioid use disorder (including methadone, buprenorphine/naloxone. long acting injectable naltrexone formulations, long acting buprenorphine implants, injectable hydromorphone, diacetylmorphine, and, in the future, additional safe and effective pharmacological treatments currently in development) are maximally available to health care providers and their patients.
• Supporting the creation of a nationally coordinated surveillance hub providing ongoing active surveillance of illegal and prescribed fatal and non-fatal overdose and other drug-related harms in Canada. During the public health emergency, BC will continue the release of weekly and monthly data tracking illegal drug overdose deaths, the proportion of deaths where fentanyl is detected, non-fatal overdoses requiring emergency service response and/or emergency department care, data disaggregated by age, sex, and region, as well as regular exploration of the contextual factors associated with the current emergency situation. Once the public health emergency is over, BC will continue its work with other provinces/territories and the federal government to generate and share data that helps build a national picture of the harms related to substance use.
• Encouraging Health Canada to create a nationally coordinated process to develop common case definitions for surveillance (for health, coroners, and other drug data), beginning in early 2017.
• Continuing to support the federal government in its exploration of improved scheduling of substances and equipment under the Controlled Drugs and Substances Act and Precursor Control Regulations-including pill presses, sorters, tableting machines and pill dies-to permit monitoring and control of access to non-legitimate users.

BC is in a unique position relative to the rest of Canada. The opioid overdose crisis is a public health emergency in our province - and to address this crisis, we have taken a multi-sectoral and integrated approach, engaging both health and public safety. Recognizing that some of BC's priority actions are not within the purview of the federal Minister of Health, BC respectfully and in a spirit of cooperation and collaboration commits to:

• Continuing to advocate that the federal government support an enhanced RCMP/Canadian Border Services Agency (CBSA) federal partnership and increased federal funding to re-instate federal RCMP resources to interdict the importation and trafficking of illegal opioids such as Fentanyl.
• Encouraging federal counterparts to pursue diplomatic efforts to reduce fentanyl sale and importation to Canada, and supporting Canada to engage in discussions with China with the aim of entering into a bilateral agreement to stem the export of Fentanyl and its analogues. Such an agreement could emulate the USA - China agreement established on Sept 3^rd, 2016:
• China committed to targeting USA-bound exports of substances controlled in the United States, but not in China;
• The USA agreed to increase their exchange of law enforcement and scientific information with a view towards coordinated actions to control substances and chemicals of concern;
• The USA will continue to work with China bilaterally and multilaterally to tighten international scheduling and improve the capacity of states to monitor and analyze illegal synthetic drugs.
• Contributing provincial surveillance data that outlines the magnitude of the fentanyl problem in BC, including the proportion of illegal drug overdose deaths where fentanyl is detected, to inform the national picture, and sharing appropriate information with federal health and enforcement sectors to support an intersectoral and multi-level approach to reducing overdoses and overdose deaths.
• Continuing to report on progress publically every eight weeks during the public health emergency.

Manitoba Health, Seniors and Active Living, Province of Manitoba commits to:

• Improving data collection to better target interventions.
• Expanding access to Manitoba's Provincial Naloxone Distribution Program.
• Improving prescription drug monitoring to prevent prescription drug misuse.
• Providing specialized education for service providers and parents.

The Ministry of Health, Province of New Brunswick commits to:

• By December 2016, completing the roll-out of New Brunswick's Drug Information System (DIS), currently on track.
• Implementing a Prescription Monitoring Program Application that will provide alerts and tools to prescribers and pharmacists in real-time that will support the appropriate prescribing and use of monitored drugs, help prevent harms, and help identify patients who may be at risk of addiction.
• Continuing to collaborate with stakeholders with respect to the distribution of Naloxone kits and the associated necessary training.

The Department of Health and Wellness, Province of Prince Edward Island, commits to:

• Convening focused planning tables of key stakeholders in the coming months to develop targeted initiatives to combat opioid abuse. Areas of focus will include:
• initiating prescription drug monitoring and accountability framework under the Narcotics Safety and Awareness Act
• enhancing opioid surveillance to establish a strong evidentiary base to support decision-making
• collaborating with Justice staff and other officials to develop strategies that target illegal sources of opioids and diversion of prescribed opioids

The Ministry of Health and Community Services, Province of Newfoundland and Labrador commits to:

• By December 31, 2017: Implementing a Provincial Prescription Monitoring Program focused on prescription drugs with high potential for abuse. Specific actions include:
• By December 2016: Establishing the governance structure for the program;
• By January 2017: Implementing of Safe Prescribing Course for Physicians;
• By May 2017: Establishing wide-scale access to patient drug profiles for physicians;
• By May 2017: Implementing a Provincial Pharmacy Network;
• By December 2017: Operationalizing Prescription Monitoring Program database and analytics capacity; and
• Exploring the legislation required to enable the Prescription Monitoring Program.
• Implementing a provincial Take Home Naloxone Kit program to increase capacity for Opioid Overdose response. Specific actions include:
• By December 2016: Collaborating with community partners, regional health authorities, and other government departments in the development of a provincial Take Home Naloxone Kit program;
• By December 2016: Establishing target populations and provincial distribution sites;
• By January 2017: Developing and implementing related training, education and program awareness materials;
• By October 2017: Developing and implementing a program evaluation framework to strengthen the effectiveness of the provincial Take Home Naloxone program; and
• By January 2017: Developing and implementing a multi-faceted opioid overdose awareness and education campaign.
• By March 2017: Initiating coverage of suboxone under special authorization, until an Atlantic Common Drug Review can be completed. Specific actions include:
• By December 2016: Determining updated physician licensure requirements to prescribe suboxone;
• By December 2016: Identifying training/operational requirements for physicians/pharmacists/others working with clients on suboxone;
• By January 2017: Communicating and consulting on the plan with Newfoundland and Labrador Medical Association, Association of Registered Nurses of Newfoundland and Labrador, Prescribers, Pharmacy Association of Newfoundland and Labrador and others as required;
• By February 2017: Finalizing and implementing training and any operational requirements, e.g. revised billing codes; and
• By March 2017: Communicating publicly.

The Ministry of Health and Social Services, Government of the Northwest Territories commits to:

• Establishing a Northwest Territories Opioid Drug Misuse and Overdose Task Force, led by the Northwest Territories Chief Public Health Officer. This task force will develop a comprehensive action plan to respond to the ongoing issues related to opioid drug misuse and overdose and to provide strategic oversight, leadership and coordination on the implementation of initiatives related to opioid drug misuse and overdose.
• As a key action item, developing and implementing of a new public education initiative focusing on enhancing awareness of the dangers of street fentanyl.

The Ministry of Health and Wellness, Province of Nova Scotia commits to:

• By March 2017: Developing detailed actions in the following seven areas:
• Data Collection and Monitoring
• Health Promotion
• Harm Reduction
• Access to Naloxone
• Opioid Addiction treatment
• Enhancing opioid prescribing and pain management
• Justice/Law Enforcement
• Opioid Misuse and Overdose Response Plan Work Groups have been established and will report to the Opioid Misuse and Overdose Response Plan Leadership Team.

The Ministry of Health and Long-Term Care, Province of Ontario commits to:

Implementing Ontario's first comprehensive Opioid strategy to prevent opioid addiction and overdose by enhancing data collection, modernizing prescribing and dispensing practices, and connecting patients with high quality addiction treatment services.

• Modernizing opioid prescribing and monitoring
• Ontario's First-Ever Provincial Overdose Coordinator: Designate Ontario's Chief Medical Officer of Health as Ontario's first-ever Provincial Overdose Coordinator.
• Quality Standards: Develop evidence-based quality standards for health care providers on appropriate opioid prescribing.
• Appropriate Prescribing: Develop new, evidence-based training modules and academic programs that will provide modernized training to all health care providers who prescribe or dispense opioids.
• Patient Education: Improve access to important medication information, including a patient guide, for all patients prescribed opioids to help them better understand the associated risks.
• Practice Reports: Provide reports to physicians that show how their opioid prescribing compares to that of their peers and to best practices.
• Narcotics Monitoring System (NMS): Make NMS data readily available to health care providers, including physicians and pharmacists so they have access to up-to-date dispensed medication information for their patients when making decisions concerning opioid prescribing.
• Overdose Monitoring: Launch a new overdose surveillance and reporting system to support Ontario's Provincial Overdose Coordinator.
• High-Strength Opioids: Beginning January 1, 2017, high- strength formulations of long-acting opioids will be delisted from the Ontario Drug Benefit Formulary.
• Province-wide expansion of the Fentanyl Patch for Patch Program: Beginning October 1, 2016, stricter controls on the prescribing and dispensing of fentanyl patches took effect. Patients are now required to return used fentanyl patches to their pharmacy before more patches can be dispensed.
• Improving the Treatment of Pain
• Investing in the Chronic Pain Network: Invest $17 million annually in multi-disciplinary care teams, including 17 Chronic Pain Clinics across Ontario, to ensure that patients receive timely and appropriate care to help them manage chronic pain.
• Expansion of the Low Back Pain Strategy: Expand access and availability of health care services for more Ontarians who suffer from low back pain. This comprehensive model of care includes a rapid low back pain assessment within an average of two weeks, as well as evidence-based management plans and educational tools to help patients manage pain.
• Chronic Pain Training for Health Care Providers: Expand training and support to primary care providers, including in rural and remote communities, to enable them to safely and effectively treat chronic pain.
• Enhancing addiction supports and harm reduction
• Expanded Access to Naloxone: Expand participation in the Ontario Naloxone Program. Naloxone, an antidote for opioid overdose is now available free of charge for patients and families through pharmacies and eligible organizations.
• Naloxone Kits for At-Risk Inmates: Begin providing naloxone kits free of charge to at-risk inmates at the time of their release from provincial correctional institutions.
• Intranasal Naloxone: Explore providing naloxone in nasal spray form to first responders.
• Expand Access to Suboxone: Effective October 11, 2016, Suboxone is available as a General Benefit on the Ontario Drug Benefit Formulary. Ontario will ensure that access to Suboxone treatment is better integrated into a holistic, primary care approach to opioid addiction treatment.
• Harm Reduction: Develop an evidence-based harm reduction framework, which could include expanding needle exchange programs and supervised injection services which have been demonstrated to save lives and reduce costs within the health care system.
• Health Care Delivery and Primary Care Integration: Enhance integration of comprehensive primary care, mental health and Suboxone/methadone treatment to better support patients with opioid addiction.

The Ministry of Health, Province of Saskatchewan commits to:

• Continuing to provide data and financial support to the College of Physicians and Surgeons of Saskatchewan to operate the Prescription Review Program to reduce the abuse and diversion of opioids.
• Continuing with the provincial Pharmaceutical Information Program to allow authorized health care professionals to electronically view current and past prescriptions of Saskatchewan residents.
• Continuing to support the RxFiles, a Saskatchewan-based academic detailing program that provides ongoing education to health professionals on various aspects of drug therapy, including pain management and prescription misuse.
• Continuing the work initiated in 2015 to provide training and Take Home Naloxone kits at no cost to eligible Saskatchewan residents in collaboration with regional health authorities.
• Working with the provincial coroner's office to ensure the Saskatchewan Ministry of Health has up to date information on the number of opioid overdose deaths, and monitor for regions and populations where risk is increasing.
• Increasing the number of locations across the province that provide the training and distribute Take Home Naloxone kits to individuals at risk of an opioid overdose.
• Working with the Pharmacy Association of Saskatchewan to have Take Home Naloxone kits in retail pharmacies and to ensure that complementary training occurs in these situations.

Accreditation Canada commits to:

• By December 2017:
• Reviewing existing Qmentum medication management standards, including those with respect to identifying, monitoring and addressing opioid misuse, abuse and diversion in light of the Joint Statement of Action to Address the Opioid Crisis.
• Developing a specific standard(s) to incorporate and reflect the language of the Joint Statement of Action to Address the Opioid Crisis.
• Contributing to any potential updates to Abuse and Diversion of Controlled Substances: A Guide for Health Professionals or any other guidelines that may emerge as a result of the Joint Statement of Action to Address the Opioid Crisis and related processes.

Sébastien Audette, President, Global Standards and Programs

The Association of Canadian Faculties of Dentistry commits to:

• By September 2017:
• Teaching every student registered in dentistry programs across all 10 dental schools in Canada to develop the knowledge and skills required to reduce the harms associated with opioids.
• Course outlines for all dentistry students will include the topic of opioid use, prescribing and related harms, and include relevant knowledge and skills evaluations.

Paul Allison, President

The Association of Faculties of Medicine of Canada commits to:

• Continuing to ensure that the accreditation standards for Canada's medical schools include instruction in the diagnosis, prevention, appropriate reporting and treatment of the medical consequences of common societal problems, including the opioid crisis.
• By November 2017: Having faculty experts:
• review opioid educational activities currently in use in its 17 faculties of medicine; and
• create and share a repository of educational products that reflect best
• practice and provide them to all faculties.

Geneviève Moineau, President and Chief Executive Officer

The Association of Faculties of Pharmacy of Canada commits to:

• Conducting an environmental scan to identify faculty experts, best teaching practices and the extent to which current curricula addresses pain management, opioid use and misuse.
• By September 2017: Adapting and disseminating the recommendations of the First Do No Harm: Responding to Canada's Prescription Drug Crisis Strategy "Competencies for health professionals in pain management, drug prescribing, dependence, addiction and abuse" within the curricula for undergraduate levels and continuing professional development of the 10 faculties of pharmacy.

Beth Sproule, Clinician Scientist / Associate Professor,

Leslie Dan Faculty of Pharmacy, University of Toronto
for
Ann Thompson, President

Canada Health Infoway commits to:

• Reducing the harm and costs of opioid-related fraud and misuse with the launch of PrescribeIT(tm) Canada's national e-prescribing service. PrescribeIT's secure electronic transmission will ensure that prescriptions cannot be altered or forged and will provide value-added data to physician regulators, policy makers, and others. This effort will include the following elements:
• By December 2016: Establishing a national medication management stakeholder community where clinical leaders can share information and tools with others across the country to discuss, learn and apply knowledge to promote medication safety practices, leveraging collaborative platform tools.
• By January 2017: Conducting an environmental scan of countries that have adopted electronic prescribing for narcotics and apply the lessons learned to the Canadian context.
• By January 2017: Undertaking research with the Canadian Pharmacists Association and MDBriefcase to better understand the prescribing and dispensing process in Canada.
• By March 2017: Providing education and awareness of legislation and regulations associated with e-prescribing.
• By March 2017: Providing updated national Electronic Medication Reconciliation Toolkit developed in partnership with the Institute for Safe Medication Practices Canada.
• By June 2017: Launching a publicly-available clinical drug list for use by prescribers in collaboration with Health Canada's Health Products and Food Branch.
• By June 2017: Updating e-prescribing standards - both terminology and messages to enable interoperability for the PrescribeIT (e-prescribing service).
• By March 2018: Launching improved analytics feeds in Ontario and Alberta, as the beginning of a staged rollout across the country to provide for narcotics surveillance.

Michael Green, President

The Canadian Agency for Drugs and Technologies in Health commits to:

• By November 2017: Analyzing the international literature to identify best practices and provide evidence-based recommendations, advice and decision support tools that will inform and guide patients, clinicians and policy-makers regarding pain management interventions (drug and non-drug), and the treatment of opioid addiction.

Brian O'Rourke, President and Chief Executive Officer

The Canadian Association of Poison Control Centres commits to:

• Working to establish a Canadian national database of poisonings to improve information about the extent of exposures across Canada. This database offers a unique picture of the number and outcomes of exposures across Canada.
• By March 2017: initiation of upload of anonymized call exposure information to a national hub which can be mined for opioid exposures, as an example. Patterns of use, location mapping, symptoms and outcomes of exposures are possible data elements that could provide an early warning signal of localized increases in poisonings from opioids or other drugs.

Margaret Thompson, President

The Canadian Association of Schools of Nursing commits to:

• By November 2017: Disseminating evidence-based educational resources on opioid use through a communication strategy for nurse educators, registered nurses and nurse practitioners, and students in collaboration with the Canadian Nurses Association.
• Educating nursing faculties on the growing opioid crisis in Canada through a series of blogs, lunch-and-learn webinars, and a dedicated editorial section in our newsletter reaching over 2,000 members. As a result, nursing faculty will have the increased knowledge and support to educate the future generation of nurses about opioid prescribing and the harms associated with opioids.

Cynthia Baker, Executive Director

The Canadian Centre on Substance Abuse commits to:

• On a quarterly basis starting March 2017: reporting on the Joint Statement of Action to Address the Opioid Crisis by communicating regularly with, connecting, monitoring the progress of, and facilitating reporting by all members.
• Starting immediately, working with Health Canada to engage stakeholders and identify new partners with clear accountability for action for reducing the harms associated with opioids and other problematic substance use.
• Providing leadership and guidance to individual and collective efforts, as part of ongoing work related to the First Do No Harm Strategy to address the harms associated with opioids and other psychoactive prescription drugs.
• Promoting the inclusion of the newly developed Competencies for Healthcare Professionals related to Addiction and Pain, in licensing exams and educational programs and curricula.
• By March 2018, assessing the effectiveness of different clinical pathways to improve treatment for youth and older adults in Canada experiencing issues related to opioids and other psychoactive prescription drugs.

The First Do No Harm Executive Council commits to:

• As stewards of the First Do No Harm Strategy, proving ongoing guidance in the coordination, implementation and evaluation of the Strategy's recommendations through quarterly teleconferences.
• Continuing this role of expertise and coordination in the complex areas of problematic substance use.
• For example, in collaboration with McMaster University, contributing to updating the existing Canadian Guidelines for Safe and Effective Use of Opioids for Non-Cancer Pain and contributing to the development of e-tools for prescribers (train-the-trainer modules, face-to-face delivery, tool kits).
• By March 2017: Producing a manuscript examining prescribing patterns for short- and long-acting opioids in Ontario using Institute for Clinical Evaluative Sciences data.
• By November 2017: Promoting the more effective identification and treatment of those addicted to opioids and promoting the resources to address opioid overdose.

Rita Notarandrea, Chief Executive Officer

The Canadian Chiropractic Association commits to:

• By June 2017: Developing evidence‐based professional practice recommendations and guidelines to facilitate the appropriate triage and referral of Canadians suffering from chronic and acute musculoskeletal conditions and reduce reliance on opioids. The recommendations will aim to:
• better understand the burden of pain related to musculoskeletal conditions;
• develop key recommendations for the appropriate role of chiropractic care (in anticipation of similar efforts for other key alternatives to opioids); and
• facilitate dissemination of key recommendations.

Allison Dantas, Chief Executive Officer

The Canadian Council of Registered Nurse Regulators commits to:

• By June 2017: Developing a guidance document for all registered nurse and nurse practitioner regulators that will support the implementation of a consistent, standardized approach to:
• Opioid and controlled substance prescribing for nurse practitioners;
• Education and practice for nurse practitioners with respect to harm reduction, including prescribing suboxone and methadone to reduce the harmful effects of illegal drug use;
• Utilization of electronic pharmacy management e-systems that support medication reconciliation;
• Monitoring of prescribing and quality assurance;
• Entry-level and remedial education on prescribing competencies for nurse practitioners; and
• Entry-level competencies for registered nurses that include ways to support effective pain management and limit potential for abuse amongst patients/clients.

Cynthia Johansen, Registrar and Chief Executive Officer

The Canadian Institute for Health Information commits to:

• As a matter of priority, continuing to contribute to the development of a pan-Canadian prescription opioid surveillance system and to the national evidence base on opioid use and related harms. To that end:
• By November 2017: Developing key metrics on the prevalence, consumption and harms of opioid misuse and to publicly report on an ongoing basis:
• the number of people receiving opioids per 1000 population;
• the number of defined daily doses (DDDs) of opioids per 1000 population;
• the number of hospital admissions due to opioid poisonings; and
• the number of emergency department visits due to opioid poisonings.
• By August 2017: Collaborating with provincial/territorial chief coroners and medical examiners to release recommendations for the investigation and reporting of drug-related deaths. These recommendations will improve the quality of data collection and will increase the Canadian evidence base on the use and harms of opioids.
• By November 2018: Begin to publicly report on an ongoing basis the number of opioid-related deaths.

David O'Toole, President and Chief Executive Officer

The Canadian Institutes of Health Research commits to:

• By November 2017: Working with policy makers on an ongoing basis to ensure they have the research evidence needed to address the issue of opioid addictions and misuse in Canada, including the dissemination of research supported through Canadian Institutes of Health Research funded programs, such as results from the Canadian Research Initiative in Substance Misuse.
• By June 2017: Launching two funding opportunities:
• to support a synthesis grant aiming to review the current literature and increase our knowledge related to the harms associated with opioids in Canada; and
• to support new research projects on gender implications related to opioids.

Jane Aubin, Chief Scientific Officer and Vice-President, Research, Knowledge Translation and Ethics Portfolio

The Canadian Medical Association commits to:

• By December 2017: Disseminating new tools and resources to promote the uptake, use and impact of the updated Canadian Guideline for Opioids in Chronic Non-Cancer Pain, among over 83,000 physicians. This will also include creating a new webpage to host relevant educational resources and updated guidance documents.
• By December 2017: Surveying a sample of its members on the facilitators and barriers to implementation of the new Canadian Guidelines for Opioids in Chronic Non-Cancer Pain, to determine the level of awareness and educational needs of Canadian physicians, as well as identify system issues such as access to pain and addiction treatment options.

Cindy Forbes, Past President
for
Granger Avery, President

The Canadian Medical Protective Association commits to:

• Monitoring and reporting on medical-legal issues and lessons learned related to opioid prescribing by physicians.
• Sharing this analysis with Joint Statement of Action partners and other groups to promote system level changes to improve opioid prescribing and to inform the development of educational offerings across Canada.
• Further enhancing the Canadian Medical Protective Association's educational outreach to increase awareness of appropriate prescribing practices, and reporting on the number of presentations delivered to physicians and stakeholders in 2017.
• In 2017, publishing a short series of evidence-based articles on better prescribing that will be distributed to all 95 thousand Canadian physicians; these will also be made publically available on our web site with other existing publications on this topic.
• Developing and implementing a social media campaign on tips to improve opioid prescribing with a potential reach of many thousand physicians and trainees.

Gordon Wallace, Managing Director, Safe Medical Care

The Canadian Nurses Association commits to:

• By November 2017: Developing and disseminating educational resources related to opioid use for provincial and territorial nursing associations and colleges in collaboration with the Canadian Association of Schools of Nursing. These resources will provide current, evidence-based information to support registered nurses, nurse practitioners, clinical nurse specialists and licenced practical nurses in their practice.

Barb Shellian, President

The Canadian Pharmacists Association commits to:

• By October 2017: Developing a sector-wide strategy in Pharmacy on opioid misuse focused on prevention, control and monitoring and addiction management. This will include maximum dispensed quantities of narcotics, effective pain management, Drug Information System / Electronic Health Record monitoring systems to help reduce diversion, and addiction treatment programs, among others. The strategy will advance education programs, as well as regulatory and practice guidelines.
• Undertaking and promoting pharmacy practice based research in the area of opioid abuse (e.g., addiction management, optimal strategies for managing co-morbidities, innovative and best practice pharmacy approaches, and de-prescribing strategies).
• Producing an environmental scan of Continuing Professional Development programs across the country as they relate to pharmacists to better understand what already exists and to ensure that there is no duplication.
• Continuing to work with Health Canada, Regulatory Authorities and stakeholders towards extending prescribing authority for pharmacists to include medication management of controlled substances.

Alistair Bursey, Chair of Board of Directors

The Canadian Pain Society commits to:

• Supporting the activities of the Joint Statement of Action by acting as a content resource (about pain and its management) to government and partners who are working to reduce harms caused by opioids.
• Working with the joint action members to assure that any strategy that aims to prevent diversion or misuse of opioid analgesics will contain measures to assure that they remain available to those patients who require them for appropriate medical use, and that these individuals are treated compassionately.
• Continuing to emphasize the need for better education for health professionals and patients about appropriate pain care and safe use of opioid analgesics for the treatment of pain.
• Continuing to emphasize the need for better interprofessional multimodal treatment for patients with pain (e.g. physiotherapy, psychotherapy), which may not only reduce opioid requirements, but also potentially mitigate pain and suffering.

Fiona Campbell, President Elect
for Brian Cairns, President

Le Collège des médecins du Québec and l'Ordre des pharmaciens du Québec commit to:

• Mobilising partners to establish an action plan for the safe use of opioids in Quebec.
• Establishing a Prescription Monitoring Program and identifying high-risk prescribers and at-risk patients. Interventions after identifying practices will include targeted professional development and training programs and, if necessary, additional actions under the jurisdiction of professional regulatory associations (inspection visits, formal investigations, or disciplinary processes).
• Promoting the optimal use of opioids and modifying key prescribing practices in hospitals, especially in surgical specialties, to reduce or eliminate the practice of systematically prescribing long-term opioids for post-operative pain management.
• Promoting common curriculum in all four universities for the management of chronic pain and best practices in opioid prescription and pain and addiction management.
• Collaborating with partners to update guidelines and training programs with respect to best practices in the use of opioids and the treatment of pain.

Pauline Gref, Medical Advisor of Executive Officer

The College of Family Physicians of Canada commits to:

• By December 2017: Implementing the Pan-Canadian Collaborative on Education for Improved Opioid Prescribing. Activities include:
• Curating an online repository of Continuing Professional Development courses in opioid prescribing;
• Determining educational needs and knowledge gaps for a variety of audiences, and designing program elements to address them;
• Using Prescription Monitoring Program and other data to assess the impact of specific educational interventions; and
• Evaluating educational approaches for subgroups of prescribers, patient education initiatives, and programs for pain management to refine future approaches based on efficacy.

Jennifer Hall, President

The College of Physicians and Surgeons of Alberta commits to:

• By December 2016: Providing every physician in Alberta who prescribes opioids and/or benzodiazepines in a community setting a comparative prescribing pattern report which includes data plus a list of patients whose doses exceed guidelines.
• By March 2017: Adopting a standard of practice on safe prescribing that will require physicians to prescribe opioids consistent with the latest opioid guidelines.
• By December 2017: Subject to receiving Ethics approval, conducting a randomized control trial to assess the effectiveness of sending physicians their prescribing data along with different educational supports. Physicians will receive their data referenced to the guideline and also to their peers.
• By December 2017: Requiring every physician who prescribes very high-dose opioids (3000 oral morphine equivalents or higher) for chronic non-malignant pain to at least one patient to work closely with a mentor to reduce the dose to the lowest possible dose for the patient.
• By December 2017: Conduct large scale targeted educational interventions using data (audit and feedback) each quarter.

Karen Mazurek, Deputy Registrar

The College of Physicians and Surgeons of British Columbia commits to:

• By March 2017: Forming a Prescription Monitoring Oversight Committee that will receive PharmaNet data and do detailed analysis of that data to deliver customized reports to regulatory Colleges to identify prescribing that may be unsafe.
• By March 2017: Publishing a new Professional Standard and Guideline on PharmaNet Access.

Heidi Oetter, Registrar

The College of Physicians and Surgeons of Ontario commits to:

• By June 2017: Collaborating with the Ontario Ministry of Health and Long-Term Care on the recently released strategy and development of a plan to use Narcotics Monitoring System data held by the Ministry to promote patient safety. This includes:
• identifying possible high risk prescribing and referring to regulatory bodies for follow up; and
• developing a plan to identify low risk prescribing and providing a variety of educational interventions, including tools, that are tailored to individual needs of prescribers.
• By December 2017: Publicly reporting, as permitted by legislation, on the outcomes of the current approach.
• By December 2017: Updating existing policy to reflect revised Canadian Guidelines and Health Quality Ontario Quality Standards (if available).
• Once all physicians have access to narcotics profiles, inclusion of expectation in policy for physicians to check the medication profile prior to prescribing narcotics.
• Using prescribing information (comparative prescribing reports or prescribing data), when available, to inform educational approaches in conjunction with assessment of physician practice.
• Supporting and contributing to a broader strategy to ensure necessary supports are available to patients and other health professionals.

Rocco Gerace, Registrar

The College of Physicians and Surgeons of Newfoundland and Labrador commits to:

• By June 2017: Developing and implementing a new education tool, a Safe-Prescribing Program, which will be mandatory for all new physicians seeking a license to practise medicine in this province for the first time; current practising physicians will be directed to complete the program on the College's instructions.
• This will provide focused instruction on safe and appropriate prescribing practices for opioids, stimulants and benzodiazepines.
• This program will also be extended to other health care provider groups, such as nurse practitioners, dentists and pharmacists.

Linda Inkpen, Registrar

The First Nations Health Authority, Province of British Columbia commits to:

• Preventing overdose-related deaths through promoting awareness and appropriate use of naloxone and awareness of the harms associated with fentanyl and other opioids through Indigenous learning circles.
• Working with partners, design and establish safe consumption sites for First Nations communities in collaboration with Regional Health Authorities.
• Working with partners on the ongoing process of implementing the Declaration on Cultural Safety & Humility throughout the health system.
• Working with the Ministry of Health and the Regional Health Authorities to ensure that the evidence-base on opioid use and related harms, in particular overdose rates, is collected. Once data is received, the First Nations Health Authority can match against the First Nations Client File.

Evan Adams, Chief Medical Officer

Health Quality Ontario commits to:

• Developing quality standards for opioid use disorder and opioid prescribing for pain.
• By September 2017: Distributing drafts of these standards for public feedback.
• Supporting prescribing practices consistent with the quality standards by providing every family physician in the province with a report showing how their opioid prescribing compares to their peers and to best practice.
• Developing a specialized public report on opioid prescribing and opioid-related harm in Ontario.
• Involving people with lived experience in all of these activities.

Anna Greenberg, Vice President, Health System Performance
for
Joshua Tepper, President and Chief Executive Officer

The Institute for Safe Medication Practices Canada together with the Canadian Patient Safety Institute and Patients for Patient Safety Canada commit to:

• By August 2017: Empowering patients to improve knowledge about the use of opioids, the options for non-medication treatment of pain, and the prevention of harm from medications by developing tools for patients and their healthcare providers.
• Tools will include: the questions to ask; the information that helps answer the questions; and a template for non-pharmacological options that can be used during hospital discharge or in primary care.
• Selected hospitals and community pharmacies will provide this information to every patient with an opioid prescription.
• By November 2017: Providing resources for dealing with left-over end-of-life opioid supplies in the home. These resources will include information and procedures addressing improved in-house storage to reduce the risk of accidental harm, information about the safe storage and disposal of medicines, and procedures for the safe disposal of medicines and equipment.

Sylvia Hyland, Vice President and Chief Operating Officer
for
David U, President and Chief Executive Officer Institute for Safety Medications Practices Canada

Chris Power, Chief Executive Officer Canadian Patient Safety Institute and Patients for Patient Safety Canada

The National Association of Pharmacy Regulatory Authorities commits to:

• By November 2017: Developing and implementing a pharmacist-patient communication tool that will provide guidance to pharmacists on how to have difficult conversation with patients regarding opioid use.
• By November 2018: Contributing to national monitoring and surveillance through compiling the extent by which provinces are able to gather data from multiple sources on the doses of opioids, for example, in "morphine equivalents" or another common measure, to possibly correlate national Prescription Monitoring Program data with new national guidelines on watchful doses that are prescribed to patients across all provinces and territories and Canadian Forces Pharmacy Services.

Anjli Acharya, President

The Royal College of Dental Surgeons of Ontario commits to:

• By December 2017: Requesting and reviewing Narcotics Monitoring System data for opioid prescriptions by dentists and dental specialists for the calendar year 2016 and comparing this data to that received for the calendar year 2014 to assess the impact of the Guidelines on the Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice (published in 2015).

David Mock, Professor
for
Irwin Fefergrad, Registrar

The Royal College of Physicians and Surgeons of Canada commits to:

• By March 2017: Engaging experts to develop a Royal College statement of principles on safe opioid prescribing.
• By June 2017: Creating a central e-portal to host educational and practice related reference resources that will be accessible to all Fellows and residents in order to bring a greater focus to the medical and surgical dimensions of safe opioid prescribing.
• Carrying out a communication plan to engage with and disseminate knowledge to Fellows of the Royal College.

Kevin Imrie, President

The Council of Chief Medical Officers of Health commits to:

• Exchanging and disseminating best practices and lessons learned from jurisdictions addressing the opioid crisis.
• Providing evidence-based public health advice to the Public Health Network Council and Conference of Deputy Ministers of Health.
• Providing support and input in the establishment of key metrics for comparable data collection and reporting across Canada.

Robert Strang, Chief Medical Officer of Health for the Province of Nova Scotia
on behalf of
Heather Morrison, Chair, Council of Chief Medical Officers of Health and Chief Public Health Officer for the Province of Prince Edward Island

Annex to the Government Response: Participant List at the November Opioid Conference and Summit