Interventions in Committee
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View Wayne Easter Profile
Lib. (PE)
View Wayne Easter Profile
2015-05-26 16:25
You say Statistics Canada was moving in that direction. Why did they stop, and how do we get them back on track so that they do keep that data?
The second question I have, which is for Ms. Hopkins, is what needs to be done? The $25,000 investment for your addictions management information system, to me, seems to be a small number. What needs to be done to implement that system?
Norman Buckley
View Norman Buckley Profile
Norman Buckley
2013-12-09 15:35
Thanks very much for the opportunity to appear today.
My name is Norm Buckley. I'm a professor and chair of the Department of Anesthesia at the Michael G. DeGroote School of Medicine at McMaster University. I also serve as director of the National Pain Centre at McMaster University, an endowed centre with the mission and vision to support best-practice pain management through the dissemination and creation of guidelines for care.
We currently hold the copyright for, and have agreed to disseminate and update, the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain, affectionately called “the Canadian opioid guideline”.
I'm also chair of the Canadian Pain Society's special interest group on education. I co-lead, with Professor David Mock of the University of Toronto's school of dentistry, the Canadian Centre on Substance Abuse implementation group for education as part of the First Do No Harm strategy on the issue of misuse and abuse of prescription medications. During the development of the CCSA strategy, I chaired the expert advisory committee on education.
These affiliations notwithstanding, my appearance here today is not as the representative of any of these organizations. I'm appearing at your request. The leaders of these groups are aware that I will be appearing, but they are not in any way responsible for my opinions or my responses. My dean has some mild anxiety about my appearance here, but he's a very brave individual.
My disclosure statement follows in two parts: fiscal and belief.
From the fiscal standpoint, I'm a physician who derives the largest part of his income from fee-for-service clinical earnings. I receive an administrative stipend as chair of the Department of Anesthesia and earnings for academic activities supported by the Hamilton Academic Health Sciences Organization alternate funding plan. I provide some medical legal opinions and I also engage in consulting through a consulting organization, as well as consulting for two provincial health committees.
I carry out research that is funded by a number of sources, including pharmaceutical companies, although funding from peer review sources, such as the Canadian Institutes of Health Research and the Heart and Stroke Foundation of Ontario, exceeds industry funding substantially. Research funding is on a cost recovery basis, and I do not receive income for carrying out research except through the alternate funding plan. In particular, I do not receive income for research from industry.
I have received speakers' fees from a variety of organizations, including industry, medical, legal, and other professional societies.
Since the problem of finding a solution for prescription drug misuse is complicated by issues to do with belief, clinical perspective, and a variety of other issues, it is probably of greater interest to know my beliefs and my clinical perspective. I come from the position of a clinical practitioner in pain management. My patient population is the patient with acute pain or chronic pain, a problem that continues to be poorly understood and a topic that is very poorly taught and treated in our health care professional training programs. Some of these patients also present with mental health disorders, including mood disorders and addiction.
Given the proportion of Canadian population that suffers now and is likely to suffer in the future with pain, and the impact of that suffering on the health care, social, and economic systems, it is my belief that there must be a dramatic change in the function of the Canadian health care system to provide rapid access to appropriate treatment, including early assessment and treatment, with active intervention and physical rehabilitation and psychological treatment as the situation dictates.
The problem of prescription drug abuse seems to be several different things, perhaps depending upon perspective. Selling of prescription medications or diversion of prescription medications into the recreational or abusive sphere for money strikes me as being theft or fraud, and should be treated as such.
The epidemiology of crime is outside my purview today, so I will not comment upon the magnitude of this element, except to say that law enforcement is the appropriate source of information in this regard. Part of the solution may be found in improving communication between health care providers and law enforcement and improving understanding of each other's goals while recognizing that health care professionals are not the police and law enforcement is not health care. There does need to be collaboration.
Use of prescription medications by the addicted patient to meet the demands of their addiction represents addictive behaviour, which is a medical condition. Again, I'm not an expert in this field, and I will limit my comments on this topic, but medical conditions should be identified as such, and treated appropriately. According to Health Canada, behaviours that represent addiction are present in approximately 10% of the population. Since pain is present in approximately 12% to 20% of the population, depending on the study you look at, one would expect a certain amount of crossover amongst these groups. This creates a complicated clinical situation if an abused medication is otherwise appropriate for a pain condition.
The patient who buys medication on the street or borrows medication from a family member or friend because he or she has an untreated pain problem or an undertreated pain problem seems to represent a failure of appropriate medical care, and it should be treated as such.
Prescribing of medications by physicians is a professional practice issue. When this occurs for inappropriate indications, in inappropriate doses, or in an incautious fashion, which may tacitly permit diversion or abuse, this should be amenable to educational and administrative interventions if the appropriate data-gathering tools are in place and directed interventions are undertaken.
When a physician fails to prescribe when appropriate or fails to offer treatment because he or she does not have the knowledge to treat, this should be addressed by directed educational activity. When patients die because they have combined the prescription medication with other intoxicants, intentionally or by accident, this is a tragedy. When it is the result of inability to gain access to appropriate treatment for mood disorders, addiction, or pain, it is a failure of the health care system, and should be treated as such.
There are several models of successful community interventions to address local cultures of prescription drug abuse and diversion. These have been reported elsewhere, but include Project Lazarus from the United States and a community action in Inverness, Nova Scotia.
Lazarus is a broad-based community intervention, which includes physician practice education, community education about pain and addiction, distribution of narcotic antagonists to make emergency treatment of overdoses in their early state possible, law enforcement involvement to address diversion issues, and availability of pain and addiction treatment programs. This program resulted in a dramatic reduction in unintentional death due to overdose and a reduction in diversion and abuse of prescription medications, while not reducing the prescribing of opioid pain medications for patients requiring these. It is noted in passing that the diversion behaviour seems to have translated itself to neighbouring communities, but this does not in any way negate the demonstration of the effective program.
In Inverness a small medical community undertook to implement a pain-management practice guided by the Canadian opioid guideline and to engage the entire community, including pharmacy, law enforcement, and other health care professionals. The result was a dramatic change in prescribing practice; no loss of capacity to treat patients with pain problems, within the context of the guidelines; and a significant reduction in diversion-related health care interactions and criminal activity.
My own observation, from attending several years of meetings having to do with prescription drug misuse and hearing of interventions that have been undertaken, is that one of the common characteristics of communities facing problems having to do with drug misuse is the disruption of the social fabric of that community, or disruption of the social structures in which the drug-abusing individuals function. Returning communities to a functional state seems to be a necessary element of successfully addressing the problem.
Earlier today I forwarded three editorials by Dr. Mary Lynch, past president of the Canadian Pain Society and co-leader of the Canadian Pain Society's national strategy on pain. My goal is to make the case that improving pain education and establishing an understanding of the appropriate response to patients with pain problems can, to a large extent, address problems of prescription drug misuse by providing care that can limit the inappropriate prescribing of medications that may become diverted and/or abused. If pain is appropriately treated, then the patient who seeks out analgesics because his or her pain is not being treated will no longer need to do so. Addiction is a separate medical problem, which also needs to be addressed through appropriate diagnosis and treatment.
Acute pain typically occurs as a result of the reaction to an injury or a metabolic or inflammatory process. This can occur from a variety of sources, including trauma, surgery, arthritis, metabolic disorders such as diabetes, infections such as shingles, the direct effect of cancer or an effect of surgery, radiotherapy or chemotherapy to treat cancer, peripheral nerve injuries due to trauma, central nervous system injuries due to spinal cord injury or stroke, and a variety of other causes.
A great deal is known about the treatment of acute pain, and effective treatments exist that can significantly reduce pain and support recovery. Some pain resolves spontaneously as the underlying disorder is treated, but some does not. Despite knowledge of the physiology and treatment of pain, it is still the case that within our acute care health systems, patients often experience moderate to severe pain. That is pain that can delay recovery or contribute to additional morbidities such as cardiac events, sleep disturbance, and delayed activation and discharge. This can occur up to 75% of the time following surgery for the first few days. In some patients, up to 30% of them, this can persist for as long as three months or more after surgery.
It is possible to do considerably better than this with appropriate education and implementation of treatment systems. Since poorly treated acute pain is one of the predictors of the development of chronic pain, improved treatment is a necessary goal.
Chronic pain states are in some ways analogous to mental health problems, because they are frequently subjective and not immediately apparent to the external observer. They are even less well understood and treated than acute pain states. Its simplest definition is that it occurs when pain has persisted for more than three months, or after the expected resolution of the triggering injury or illness.
Chronic pain interacts with the underlying psychological makeup of the patient and their social situation, to have a behavioural impact that extends beyond the sphere of physical or biological injury. This relationship is well described by a conceptual model referred to as the biopsychosocial model of pain.
View Dany Morin Profile
Thank you.
The National Advisory Council on Prescription Drug Misuse has established that seniors were the group most at risk for prescription drug abuse. Since the population is aging, that abuse problem will worsen.
My question is for anyone who may have a solution to suggest. What kind of prevention methods do you think could be used with future seniors, so that they don't end up in the same situation as the current generation of the elderly, who are abusing prescription drugs?
Peggi DeGroote
View Peggi DeGroote Profile
Peggi DeGroote
2013-12-09 17:21
This also goes back to the question by Mr. Lizon about appropriate care. If we look at the number of hours that a family physician spends learning about pain while in medical school, it's about three hours in total. Our veterinarians have about 15 hours of pain education. Even though you were told last week that dentists get the same medical training on pharmacological information and that that ought to be good enough, if we look at the number of three hours, it's not at a good standard.
I will suggest that if a family physician doesn't have confidence in what they're doing—through no fault of their own, because we can say that they're not getting good education to begin with—they perhaps don't know even how to do things. My big concern right now for people suffering from pain is that the physicians then will decide not to write prescriptions for opioids, so that people can't even manage their pain. There is a program out of the University of Toronto called the ECHO program, which comes from the University of New Mexico. It is about training front-line family physician workers in pain and addiction. I know this is going forward in Ontario, because we will be one of the hubs for it. I think that kind of thing will help to manage and give confidence to the doctors who are seeing the patients.
Honestly, in lots of cases and through no fault of their own, the doctors don't know what to do.
Donald MacPherson
View Donald MacPherson Profile
Donald MacPherson
2013-12-04 15:42
On the issue of displacement in the U.S., using the combined data from the 2002, 2004, 2008 to 2010 national survey on drug use and health, a recent study has shown that 77% of those reporting both non-medical prescription pain relievers and heroin use in the past year were found to have initiated non-medical use of pain relievers prior to initiating heroin use. Although the discontinuation of one drug cannot account for all transition from non-medical pain relief to heroin use, it may be a significant role.
I'll close by saying what we believe. We will submit a more comprehensive brief in the coming months. It is being translated at the moment.
We feel it's a component of a comprehensive overdose strategy around both illegal opioids and prescription opioids. This is an overlapping public health problem that we have and people move back and forth between both of those markets, and then there are accidental overdose deaths when people are attempting to take medication as prescribed.
We recommend that the federal government adopt a comprehensive approach to overdose prevention and response that includes six key components.
One would be to make naloxone more readily available and cost effective by including it in provincial drug plans and making it available over the counter.
Two would be to scale up community-based and institutional overdose programs training on how to prevent, recognize, and respond to overdose. I just took one of those at the Canadian Students for Sensible Drug Policy conference. It takes about an hour.
Three, would be to scale up overdose training programs for first responders.
Four would be to reduce the barriers to calling 911 during a drug overdose event so that people do not fear police arriving and arresting them for some other drug charge during an overdose event. The Vancouver Police Department has a policy of not routinely responding to overdose calls unless they're asked to by ambulance attendants. This could be expanded to other departments.
Five would be to implement appropriate guidelines for opioid prescription that do not limit access to needed pain medication or result in further discrimination against people who use drugs.
Six would be to increase the timely collection, analysis, and dissemination of data on drug overdose events.
This is probably one of the more important recommendations, because in the literature that I've read, Canada really does need to get much better at monitoring and collecting data so that we can come up with some sound policy decisions based on some sound evidence.
Thank you very much .
Phil Emberley
View Phil Emberley Profile
Phil Emberley
2013-12-02 15:41
Good afternoon.
I'm Dr. Phil Emberley. I'm the director of pharmacy innovation at the Canadian Pharmacists Association and also a practising pharmacist. CPhA represents over 35,000 Canadian pharmacists from coast to coast, practising in community and hospital pharmacies, family practice clinics, industry, and other settings.
I'm joined today by my colleague and peer, Mr. Mark Barnes, who is a pharmacist, owner, and VP of business development and public relations of a pharmacy in Ottawa that provides treatment to patients addicted to opiates. In a couple of minutes, Mark will share with you the services he provides, as well as the impact he has on his clients.
As front-line health professionals, pharmacists see first-hand the devastating impact of prescription drug abuse—in particular, opioid painkillers—as it shatters careers, relationships, and indeed lives. Many patients who become addicted to opioids start them as prescribed therapy for an actual ailment.
Ensuring access to pain medications for patients who have legitimate needs while working to prevent misuse, abuse, and diversion of opioids is a complex balancing act for prescribers and pharmacists. There are no easy answers to mitigating the prescription drug abuse problem in Canada. However, pharmacists can play an important role in helping patients to avoid the pitfalls of prescription drug abuse and in providing treatment for those who are addicted to opiate medications.
But there also remain areas where further work and efforts must be addressed. First and foremost, pharmacists want to do what is best for the health of their patients, and their goal is to steer patients away from harmful situations such as prescription drug abuse. As drug experts, pharmacists fully understand how drugs work and how addictions occur, including the factors that lead to medication abuse and misuse.
In recent years, provincial governments have expanded the professional scope of pharmacists. In most jurisdictions, pharmacists can now provide medication reviews to their patients. A medication review allows pharmacists to become more familiar with a patient's diagnoses, the indication for treatment, and their response to medication.
This service can also be used to flag potentially problematic medication use, as well as to provide an opportunity to better educate patients on how to take their medication safely. For example, stopping some narcotics abruptly can cause harm to patients and even lead to emergency room visits in some cases. Medication reviews are an ideal setting for pharmacists to educate patients on how to safely stop a medication.
The CPhA recommends that all jurisdictions, including the federal government, as a provider of health services, support pharmacist medication review programs.
The Canadian Pharmacists Association is also an accredited provider of continuing education. While there is medical, nursing, and pharmacy training that educates to optimize the prescribing of psychoactive drugs, there is an opportunity to do much more. Health providers need better education in order to weigh the risks and benefits of opioid treatment and in order to educate patients on the safe use of these medications.
Health professionals also need to be able to recognize evidence of and potential for the misuse of these medications. National and inter-professional education programs need to be developed that ensure all health care providers are fully up to date on the current treatment regiments for chronic pain and mental health disorders.
I'll now pass the floor over to Mark, who will describe some of his experiences with patients who have problems with prescription drugs.
View Libby Davies Profile
Thank you very much, Chairperson.
We do have a lot of witnesses today, so thank you for coming.
As we get into this subject more and more, I find myself in a bit of a conundrum. I would certainly agree with Dr. Gerace when he says that it's a complicated issue. It's not necessarily that there's just a black and white answer; there are a number of things that need to be done.
Having now heard from so many witnesses or stakeholders who are involved, whether from a regulatory point of view, a professional point of view, or a practitioner point of view, I'm left wondering where the problem really is. Is it just a leaky vessel that's got so many holes in it that it's sinking? We are hearing from all of you that we have a very serious problem in Canada.
I want to relay an experience that I had a couple of weeks ago at a pharmacy in Vancouver. I went in to get a generic prescription renewed. It wasn't an antidepressant, it wasn't a stimulant, it wasn't an opiate, it was just your run-of-the-mill generic. I was kind of happy when the response was that I couldn't get it renewed, that I had too many days left. They actually counted it out, and I said that I travel a lot and I'm worried about it running out. They said that I had to wait a certain number of days.
The reason I was given did not have anything to do with safety or anything like that—I don't think there were any safety issues—but with insurance coverage. It was the insurance company through our federal plan that wouldn't have reimbursed me unless I met certain timelines. It left me wondering why I got that response when trying to renew a low-level prescription, yet on serious medications where there are serious issues of addiction, you're telling us that there are so many holes—I think that's what you're saying—and that we've got a huge problem.
I'm glad, Ms. Bouchard, that you talked about the monitoring surveillance system and what is going on in the United States. It seems to me that it's something that we have to do in Canada. There has to be some kind of pan-Canadian strategy for a monitoring surveillance system. I wonder if you can tell us a little bit more about how you think that would work.
My second question is for Mr. Barnes. Your front-line experience is very good for us to hear in the two cases that you provided. What struck me about what you said is that you talked about both of them with no judgment. That's good, because I think that for people facing addiction issues there's a stigma, whether they're a street user or whether they're the accountant that you talked about, the guy who was afraid to talk to his wife. From your point of view as a front-line health care professional, how do we deal with the stigma?
You obviously developed a really good relationship with that guy. I don't how rare that is; I would imagine it's somewhat rare. How do we reduce the stigma so that when people run into trouble they can get access to the proper interventions? The system has got to work, but when people do run into trouble, either intentionally or not intentionally, how do we remove the stigma so that we can actually then focus on getting them the proper appropriate interventions without criminalizing or stigmatizing people so they just end up going more and more underground?
Sorry, that's kind of long, but I would just like to get responses on those two things from Ms. Bouchard and Mr. Barnes.
Mark Barnes
View Mark Barnes Profile
Mark Barnes
2013-12-02 16:26
I can definitely understand the drug plan issue. As you're aware, it happens on a daily basis with a day supply, so I can relate to what you're saying. Unfortunately, for addiction it doesn't work, because a patient who is diverting a medication will just pay cash. Unfortunately, the drug plan solution is not there.
You alluded to my approach earlier. It's unique in being a respect-based approach to addiction treatment. I had to evolve that respect myself because, unfortunately, I was a typical health care provider who was a non-believer. My evolution itself, through my patients, taught me that it can work. My respect comes from my experience.
So first, the answer is that respect is from experience, but we can also provide insight. I think there are three answers to your question. The first is about teaching respect at the university level through our students—med students, nursing students, pharmacy students, and dental students. I think that if we make them aware of the problems and teach them a respect-based approach to addiction treatment first...the education is very, very important, I think, as is having educators who have the same approach.
It starts there, but then it also has to continue among our own profession. I also sit on a committee for First Do No Harm, as well as a working committee for treatment teams, and there is no standardized treatment education level among pharmacists, as an example. Every province varies as to what education experience you require to be involved in addiction treatment and prevention, whether it be through the methadone program in Ontario.... I was just in Newfoundland giving a presentation at the university there. We need to have a standardized education system that looks at addiction treatment the same way, with this respect approach. I think that if we work in academia, as well as with our students, it can make a huge difference, and then having standardized or post-schooling training on addiction treatment....
The third thing is that you have to teach people. No matter if it's high blood pressure, when we're treating addiction, it's no different. We've done a phenomenal job with mental health over the last decade in bringing it in from the darkness, from being ashamed and seeing mental health as a character flaw, not really a true illness.
I think we have to use that same approach for addiction treatment. Unfortunately, addiction treatment doesn't go by itself; it's usually a triangle. There's pain, there's addiction, and there's mental health. There's a reason why. As my patients tell me, they didn't wake up in the morning and want to stick a needle in their arm. It's an escape from some reality.
A voice: [Inaudible—Editor]
Mr. Mark Barnes: Yes, exactly. It's an escape from some unfortunate event, even in our own military, with post-traumatic stress, so it's very important that we approach those things with an open mind. As well, what we've done with mental health over the last 10 years has been phenomenal. We don't actually need to ask why there's addiction, but why there's pain.
View Laurie Hawn Profile
Dr. Gerace, you talked about creating a better coordinated and accessible system for, I think it was, educating stakeholders, health care providers, and other stakeholders. What would that look like and what can we learn from somebody else who's done this successfully, because we're not the only country facing these kinds of situations?
Rocco Gerace
View Rocco Gerace Profile
Rocco Gerace
2013-12-02 16:47
Well, I can't speak explicitly for other jurisdictions, but we do know there is a huge need for education. If we look at medical school and the residency curriculum around the management of chronic non-cancer pains, it's woefully lacking. I can't speak for other specialties, but we're simply not doing enough. We've heard about public education, which is critically important, and I would refer you to our report on that issue, which we will leave with you.
In terms of other modalities, I'll just go back for a second. The other problem is that many of these modalities are not insured, and we have a population that is in desperate need of treatment and can't afford it, and the public health system doesn't provide it.
So there is a real need for a comprehensive—and David alluded to that—approach to pain management, and not simply looking at opioids.
Jean Cormier
View Jean Cormier Profile
Jean Cormier
2013-11-18 15:44
Good afternoon, Mr. Chair, and first of all congratulations on your election to the position of chair.
Honourable members of the committee, thank you for inviting the RCMP to participate in these proceedings. I am happy to be here today with my colleague and partners.
I am Inspector Jean Cormier, and I currently hold the position of director of the federal coordination centres within the RCMP's federal policing program at national headquarters. The federal coordination centres provide subject-matter expertise to many of the enforcement initiatives supported by federal statutes.
Today I am accompanied by Corporal Luc Chicoine, who is one of the RCMP's Drug Initiatives National Coordinator at RCMP National Headquarters.
Thank you for the opportunity to say a few words about the RCMP's engagement with this important issue, as well as our relationship with the different partners from the Canadian government involved in addressing the issue of prescription drug abuse.
Prescription drug abuse is a serious problem affecting citizens of our country. The misuse and abuse of prescription drugs has always been present, but recently it has become increasingly prevalent and therefore requires the attention of all of us. Non-medical use of prescription drugs is the third-most prevalent form of drug abuse among Ontario students. Information from Health Canada estimates that it is at 16.7% just behind cannabis at 22% and alcohol at 55%.
The misuse and abuse of prescription drugs has devastating impacts on the citizens of Canada. It is important to note that this issue is felt across all age groups, races, social classes, incomes, ethnic backgrounds and genders. The misuse and abuse of prescription drugs directly affects the Canadian population as a whole, our businesses, communities, and our international reputation.
One of the dangers posed by prescription drug abuse is the false sense of safety users have, as it is prescribed by doctors, manufactured in regulated facilities and provided by pharmacists. However, when these prescription drugs are misused, they come with the same devastating impact as other illicit drugs.
It is important for law enforcement to work collaboratively with domestic and international partners to identify, prevent, and detect the diversion and trafficking of prescription drugs by pursuing those who engage in such activity. The RCMP and other domestic police services are often the first responders to incidents of prescription drug abuse. Education and training of officers is an important step in properly addressing the situation.
We believe that information-sharing between different private and public partners is crucial in addressing this problem.
The National Anti-Drug Strategy promotes a three-pillar approach—prevention, treatment and enforcement. The RCMP is an active participant within the National Anti-Drug Strategy so as to deal with the problems related to prescription drug abuse.
The investigation of abuse or diversion of prescription drugs is complex and challenging. In spite of this, the RCMP in concert with its partners is focused on two of the national anti-drug strategy pillars—prevention and treatment.
All RCMP officers are technically responsible for investigating illicit drug-related activities. We do, however, have officers such as Corporal Chicoine here who have special training in drug investigation who are also considered subject-matter experts. These resources also have a responsibility to investigate illicit activities related to prescription drugs. There are some of these trained resources situated in all provinces and territories across Canada.
Although international cooperation has come a long way in establishing standards to prevent and detect prescription drug abuse, such as the elimination or further restriction of certain prescription drugs, continued effort and a sustained focus must be maintained.
The RCMP believes that everyone has ownership and a role to play in the prevention of prescription drug abuse.
It is our belief that focusing on prevention by raising the level of awareness within our communities, including our health care practitioners, of the misuse and abuse of prescription drugs will assist in conducting successful enforcement action that will suppress criminal activities. The RCMP is committed to efforts to detect and deter prescription drug abuse, which has a negative impact on Canada and the well-being of Canadians.
I thank you and look forward to answering your questions.
View Wayne Marston Profile
Well, the medicinal side is what made me think in terms of that because we were talking about the abuse of prescriptions and medicinal marijuana should, hopefully, be prescribed—I would presume it to be. What brought that to mind is that during the break week, I spoke to two different schools—grades 4 and 5—and because of a particular leader talking about legalizing marijuana these days, I was quite surprised that the grade 4 and 5 students were asking questions about marijuana. It led me to that particular question.
Going a little further, we have information about a report from Public Safety Canada. Mr. Wilks touched on it earlier, about the misuse of drugs. Would you say that enforcement officials—RCMP, municipal officers as well—are receiving enough training to identify the abuse? If not, where would you see it lacking?
Jean Cormier
View Jean Cormier Profile
Jean Cormier
2013-11-18 16:27
I think the officers in general—RCMP, municipal, and provincial police force agencies—are receiving adequate training. But I think it's something that has to be continuous, because you can never receive enough training. It's not because the training they receive is not good, it's simply that there has to be an evergreen program. New officers come online and their training has to continue. New drugs come online and there has to be training in relation to them. So the education of officers has to be a continuous process.
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