SNUD Committee Meeting

SPECIAL COMMITTEE ON NON-MEDICAL USE OF DRUGS

COMITÉ SPÉCIAL SUR LA CONSOMMATION NON MÉDICALE DE DROGUES OU MÉDICAMENTS

EVIDENCE

[Recorded by Electronic Apparatus]

Monday, December 3, 2001

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[English]

The Chair (Ms. Paddy Torsney (Burlington, Lib.)): I'll call this meeting to order.

On behalf of the committee, we're very pleased to be in Vancouver and that all of you have come, on probably fairly short notice, to present to us today.

We're pleased to have with us from the Kaiser Foundation, Dan Reist; from Prevention Source B.C., Colin Mangham; and from the University of British Columbia, Dr. Mark Tyndall, and Dr. Julian Somers, who's from the Department of Psychiatry. At 9:30 a.m., Dr. Schechter is going to arrive to join you. It's going to be a little squishy down there.

If it's okay with you, we'll go in the order I introduced you. Or have you agreed to something else? Are you okay?

I'll turn it over to you, President Reist.

Mr. Dan Reist (President, Kaiser Foundation): Thank you, Madam Chair, and members of the committee. It's a privilege for us to be able to address you and help you fulfill your mandate in bringing forward recommendations aimed at reducing the dimensions of the problem involved in the non-medical use of drugs in Canada.

It's an important mandate, and the Kaiser Foundation believes we all need to work together to prevent and reduce the harm associated with problem substance use. You have an important role to play in ensuring Canada's drug strategy is an effective tool in achieving this goal.

Promoting a comprehensive and collaborative approach to problem substance use and pressing for the development of the capacity for practical research are some of the most important contributions this committee can make. If we're to effectively prevent and reduce the harm associated with problem substance use, we must adopt a comprehensive model.

Saying this, of course, is not new. We've been saying it for as long as I've been involved in this field. But a comprehensive approach involves much more than a range of services along a particular continuum. This has tended to be what we have offered in the past. Like a single line through a three-dimensional space, this continuum failed to meet the needs of many individuals, families, and communities.

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Furthermore, we as professionals have tended to debate where the survey markers should be placed in plotting this continuum of services. Many of the debates alluded to—or at least some of the debates alluded to—in your terms of reference, and no doubt many of the arguments that will be put before you as a committee, are of this sort. At the Kaiser Foundation we believe we must abandon the notion of a single continuum of services and begin to respond to the three-dimensional world of drug use.

Let me briefly chart for you the three axes that define this space. One is a continuum from services designed simply to save lives, through services designed to stabilize individuals, to those designed to treat and bring healing, and finally to those designed to reintegrate individuals into society.

That continuum or that axis most closely resembles the traditional continuum of services, although even it departs in significant ways. But there's a second axis. It's provided by the theory of stages of change that goes from pre-contemplative, to contemplative, to preparation and action, through to maintenance. These two dimensions are illustrated in the attached chart—which I have brought for you—from the report Weaving Threads Together, produced by a task group appointed by the British Columbia government last winter.

The majority of traditional alcohol and drug services have been targeted toward clients who were in the preparation or action stage relative to change and who were seeking healing or treatment. Pre-contemplative individuals, on the other hand, were often labelled “not treatment ready” and thereby denied service. This was sometimes code for the fact that these individuals were not prepared to embrace abstinence as their goal.

These two dimensions create an intervention map. A comprehensive system must provide services for individuals irrespective of where they are on this map.

A third dimension, the prevention axis, adds another order of complexity to the situation. Prevention has often been interpreted too narrowly to refer to activities designed to prevent or delay the onset of use, particularly among youth. While this is a worthy goal, prevention is much more of a continuum. Prevention is important at many transition points across the lifespan of the individual. Prevention is also about blocking progression from less harmful to more harmful use. Moving from smoking marijuana to injecting heroin, for example, would be one of those areas you would want to block.

Prevention is also about promoting personal development and healthy lifestyles, as well as about the development of policies that address key determinants of health such as housing and economic stability. Prevention should not be isolated from other interventions as if it were something completely different. It is another dimension in the comprehensive approach to problem drug use.

If we are to effectively prevent and reduce the harm associated with problem substance use, we must ensure the provision of service throughout this three-dimensional space. Within this comprehensive system it is essential that service providers respect one another and that clients can access those services they need when they need them. The capacity to evaluate programs and plan services based on evidence is essential to making good policy and program decisions, particular decisions about how to use limited resources in creating this comprehensive model.

Let me offer a word about “harm reduction”. The primary goal of all services should be to prevent and reduce the harm associated with problem substance use. It is not helpful, I believe, when the term “harm reduction” is used as the description of some services at one end of a continuum. While those services are an essential part of a comprehensive model, “harm reduction”—or what we tend to refer to as preventing and reducing harm—ought to be seen as the philosophy that underpins the entire system.

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So I would urge you to press for the building of this kind of complex, yet real, comprehensive system that's needed to address the complexity of problem substance use. I think it's been the oversimplification of the problem and the solutions addressed to it that have led to the repeated failures we've experienced in this field. We need to recognize the complexity and to design a system that reaches out to clients everywhere within that system.

Secondly, the comprehensive services needed to prevent and reduce the harm associated with substance use can best be delivered through a multifaceted service delivery system rather than by a single specialized entity. Since the problems related to problem substance use cross many institutional and sectoral barriers, the only effective response is one involving many systems working collaboratively. The Kaiser Foundation would caution against creating “a single dedicated agency operating independently of other government departments” to administer Canada's drug strategy. This approach is inefficient and ultimately impractical. An example of the failure of this strategy is the attempt in British Columbia to build a single ministry to deal with all issues relating to children.

Other government departments will continue to be and need to be involved in the issues relating to substance abuse. The drug strategy needs to be accompanied by a mechanism for effectively harmonizing policy across these various departments and levels of government.

Two factors are crucial if we're going to harmonize policy. The importance of legitimized leadership cannot be overstated. If Canada's drug strategy is to be effective, the Prime Minister must appoint a national spokesperson and instruct the heads of key departments to work cooperatively under the leadership of that person to harmonize policy relative to substance use issues.

The second factor is no less significant. Mechanisms must be established at the community or regional level that allow various departments and levels of government to work cooperatively in addressing the issues. A task group in British Columbia earlier this year recommended a cluster-based planning process similar, in some respects, to the Oregon benchmarking project or to certain regional development processes.

These models depend on the harmonization of policy and on the capacity to measure outcomes relative to predetermined benchmarks that reflect the interests of the various departments or agencies involved. I would like to suggest that there are models available for this kind of harmonization and collaboration. We simply need to start using them in this field.

The third area I would urge you to take action in is the area of research and evaluation. The Kaiser Foundation supports the committee's observation about “the absolute necessity of having reliable data on which to base the myriad policy decisions necessary for developing and administering a cohesive and viable drug strategy in Canada”. In fact, in the ever-complex relationships between the federal government and the provinces and territories, this could be one of the most important contributions of the federal agency.

Our foundation would point out, however, that we need much more than research into drug use patterns. While this and other epidemiological data are essential to good policy development, no less important is research into best practice and program effectiveness. In order to move toward an evidence-based system, policy-makers, program developers, and funders all need access to quality data.

The mandate of the Institute of Neuroscience, Mental Health and Addiction is extremely broad. The institute is, however, in the process of articulating priorities for addiction research. A research institute dedicated solely to research on addictions may ensure that these priorities are given the attention they require. I'm not sure it's absolutely necessary, however.

However the research capacity is organized, the essential issue is that the research priorities be driven by the needs of the system and avoid narrow interests with limited significance for policy or program development. Again, the limited resources need to be used in such a way as to have the greatest impact on our service delivery capacity. It is for this reason that the B.C. addiction task group, in formulating its recommendation for the development of an addiction centre for excellence in British Columbia, was concerned to emphasize that the centre must be well connected to the field and must avoid becoming an ivory tower institution.

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In conclusion, I would urge the committee to promote a comprehensive system designed to meet the needs of all individuals, families, and communities impacted by problem substance use. We must work to overcome the exclusionary rhetoric that has often characterized the discussion of drug policy.

The Kaiser Foundation urges the committee to call for a collaborative approach and the development of the necessary mechanisms to ensure efficient harmonization of policy across departments and levels of government. Furthermore, the Kaiser Foundation recommends a commitment to a cluster-based planning process at the regional or community level to ensure the effective and efficient provision of services.

Finally, the Kaiser Foundation urges the committee to press for increased research and evaluation capacity that will provide reliable data on which to base those policy and practice decisions necessary for developing and administering a comprehensive and collaborative system to prevent and reduce the harm associated with problem substance use.

Thank you very much for your attention today.

The Chair: Thank you, Mr. Reist.

We'll now hear from Dr. Mangham.

Dr. Colin Mangham (Director, Prevention Source B.C.): I'd like to thank you for the opportunity to participate in this session today. The things you are considering are very important because they could shape Canada's drug strategy and policies in the future.

I will be providing a written brief that offers social and scientific arguments and a warning note about pursuing harm reduction as a driving philosophy beyond the adjunct strategy in support of treatment and supply-and-demand reduction strategies. I say that because this is one of the thorny issues you will be discussing, and I know you'll have many opinions around it. It is one that needs to be resolved in this country. In that brief I will also address in more detail the place for prevention in a national drug response.

But today I would like to direct my opening remarks to the concept and practice of prevention and its place in a national response to drugs.

Prevention can be defined as the aggregate of programs and policies intended to achieve a threefold outcome: to reduce the rate of onset of drug use, to slow or stop the progression of drug use to more harmful patterns, and to reduce the overall level of drug use and abuse in society.

I would like to make four key points about prevention that contribute to the task before you of examining our national drug policies and strategies. First, in any response to drugs, only prevention can reduce the incidence of drug use itself, and it has the most potential for reducing harm. Therefore, it is an absolutely vital component of any drug strategy. All else we do simply addresses the problem after the fact. In this broad context, all other components are really part of prevention. For example, supply reduction holds consumption down by reducing social acceptability and physical availability of drugs. However, prevention, as we commonly refer to it, includes education, social marketing, community action, and other avenues of influence to foster healthy attitudes and choices and to make drug use less popular. Of all components of our drug response, it is the most neglected. Yet it has the most promise for improving the situation regarding drug use and abuse.

Second, prevention is effective. Research on trends in drug use shows clearly that a consistent prevention message contributes significantly to a shift in social norms regarding drug use. For both tobacco and drinking and driving, for example, the incidence has declined substantially in recent decades, approaching a 50% reduction in both cases. This decline corresponds with long periods—years—of consistent prevention efforts. Moreover, today we have considerable evidence that best practice prevention programs and policies can and do create change.

What is lacking in Canada today in prevention regarding illicit drugs is strength within three key factors producing prevention effectiveness. These are the qualities of comprehensiveness, durability, and consistency. Comprehensiveness means that prevention is made up of many messages in many forms. It is not any single program, nor can any single program be expected to have a behavioural impact. If we rely on single programs of any kind to achieve a reduction in drug abuse, we will be disappointed, and critics will make the common but false assumption that prevention does not work.

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The second quality of durability means that to achieve an impact, prevention must be left in place over time. It takes time to effect change, since social norms are a key driver in change. Prevention is most susceptible to the inconsistency produced by failure to implement or by trying to fit it into a political mandate or a pilot project, because the process of prevention is a lengthy one.

The third quality of consistency means that our prevention messages should be clear and consistent and non-contradictory. They have been inconsistent with regard to illicit drugs in recent years, particularly marijuana, or perhaps I should say that they have been consistently absent, because we have certainly let down our guard regarding this substance in particular. The Really Me campaign of the late 1980s was the last federal drug campaign in this country.

Third, prevention works by reducing the overall social acceptability and availability of substances. If we look at alcohol, tobacco, marijuana, and heroin, for example, their consumption falls into rank based roughly on the level of social acceptability and the economic and physical availability of each. Tobacco and alcohol, because they're used much more and by more people, produce greater apparent economic and health costs. This should not be taken to mean that other substances are necessarily less harmful or that they should therefore be treated the same. This process of prevention requires time and is achieved by reaching a threshold level where public opinion and attitudes shift toward support of responsible attitudes and away from use and harmful practices. Lack of prevention messages over time can produce an apparent harmful effect on both consumption and attitudes.

Fourth, prevention must be part of a balanced response to drugs. Prevention, treatment, and reducing the supply of drugs form key pillars in a drug response. Prevention points the way to healthy attitudes and behaviours by increasing individual and collective assets, correcting misinformation, and providing a strong backdrop for other components of a response, including public support for that response. Treatment, if it is adequate, can help drug users to get off drugs, which is ultimately the ethical goal we should have in working with addicted persons.

Harm reduction, a fourth pillar, can form an important bridge to stopping drugs by helping to protect addicted persons from serious harm until such time as adequate treatment and rehabilitation can be effected.

Recently, however, the concept of harm reduction has become somewhat of a buzzword or euphemism for a liberalization of drug policy. Such a policy would devalue prevention and send a wrong message to the most susceptible segments of the population. This certainly has happened wherever such policies have been put in place. This would not be a balanced approach, and we need a balanced approach with all pillars.

Prevention is a vital part of any drug strategy. We must embrace it not just with words, but also with concrete steps to ensure it is put in place adequately, consistently, and with the conviction needed to continue it over the long term. Prevention forms not only the most positive part of any drug strategy, any comprehensive approach to drugs, but it also is the most cost-effective component. I urge the committee to address vigorously the need for strengthening prevention in this country and ensuring that other parts of our national drug response do not work against it.

I welcome your questions. Thank you.

The Chair: Thank you very much, Dr. Mangham.

Next is Dr. Tyndall. For the benefit of committee members, I understand that Dr. Tyndall has to leave at 10.

Dr. Mark Tyndall (Director of Epidemiology, B.C. Centre for Excellence, University of British Columbia): At 10:15.

The Chair: You're flexible.

Dr. Mark Tyndall: Thank you very much for inviting me to speak to the House of Commons Special Committee on Non-Medical Use of Drugs. I consider this to be an extremely important issue, and I congratulate the committee members for taking it on. I'm grateful for this opportunity.

I was selected to speak here this morning as a researcher of injection drug use in the downtown east side of Vancouver and as a physician who treats HIV infection among marginalized groups. I am actually here this morning as a concerned citizen with a sincere conviction that something has gone terribly wrong with our approach to illicit drugs and the people who use them. Although my comments this morning will focus primarily on the situation in Vancouver, the concerns around the harm of illicit drug use are clearly national.

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As a physician, I am confronted daily with the severe health consequences of drug use, from the heroin junkie in withdrawal, to the crack smoker coming off a 72-hour binge, to the battered teenage girl who just had a bad date. There is something terribly wrong. I am convinced that it can't be only the drugs. There is something about our response to drug use that makes a bad situation much worse than it has to be.

For the past two years I have been director of the Vancouver injection drug users study that follows over 1,400 injection drug users who live in Vancouver. In addition to HIV and hepatitis C testing, we collect detailed information regarding sexual behaviours, types of drug use, incarceration, housing, and the utilization of health services. This study was started in 1996 during an explosive outbreak of HIV in Vancouver's downtown east side. Currently, 35% of the study participants are HIV-positive and over 90% are hepatitis C positive.

The vast majority of the participants continue to use injection drugs despite the obvious physical and social consequences. In fact, most have very long histories of substance abuse and often started using drugs to dull the pain of physical abuse, sexual abuse, family breakdown, and mental illness. Tragically, over 10% of the total cohort have already died, half of them due to drug overdose. It is difficult to say how many of these overdoses were actually deliberate.

As the study site is in the downtown east side, over 80% of the participants reside nearby. Few are employed and most are supported through welfare and/or disability insurance and with a fixed housing allowance that essentially locks them into the downtown east side. Over half live in dilapidated single-room hotels, most rely on food banks and other handouts, and the majority are deeply entrenched in the street and drug culture.

Over 70% have been jailed for drug-related activities, and many of the women in the VIDU study rely on prostitution to support their drug habit. Clearly, this community represents society's discarded people, the dispossessed, the marginalized, and, in many cases, those without hope. These people are the victims of society, drugs, and neglect.

It should be stated clearly that the HIV epidemic in Vancouver is driven mainly by injection cocaine use. Although poly-drug use, including heroin, crack cocaine, marijuana, alcohol, and a range of other drugs, is widespread, it is the pattern of injectable cocaine use that poses the highest risk of HIV and hepatitis transmission. Cocaine is also associated with a high incidence of injection-related infections.

Injection cocaine users will often go on intense binges or drug runs that may involve 20, 40, or even more consecutive injections over a short period of time. With each hit the risk of unsafe injection practices or inadvertent needle sharing is amplified. In our study, individuals who are intensive cocaine users are seven times more likely to become HIV infected than those who do not inject cocaine.

It has been alleged that harm-reduction strategies will only encourage current drug users to continue their use and actually entice others to start using drugs. There is absolutely no evidence to support this from the VIDU study or from other cities that have adopted a harm-reduction approach. In fact, the Le Dain commission cited the downtown east side as the drug capital of Canada in 1972, long before harm reduction was even thought of.

From our surveys we see the two major reasons for addicts living in the downtown east side are cheap housing and available drugs. In our most recent survey, there were no participants who said the needle exchange program attracted them to the area, and less than 5% mentioned any other services that brought them or kept them down there.

Although the downtown east side is an obvious and critical target for intervention, the use of injection drugs is rapidly expanding to other parts of the province. In many larger cities and towns, many versions of the downtown east side are being formed. These are of particular concern since many lack even the most basic social and health services to deal with the problem.

First nations communities may be especially vulnerable to the introduction and spread of cocaine and heroin addiction. There are well-grounded concerns that the HIV and hepatitis C epidemics will have a disproportionate impact on first nations people.

Vancouver has been the site of a horrible, natural study in drug use and, more recently, HIV and hepatitis transmission. At international meetings, Vancouver is consistently held up as the place where an explosive HIV epidemic was not prevented. If we continue to be stalled in providing even the most modest services and interventions, we will be known as the city that did nothing when the epidemic occurred.

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It is ironic that we expend most of our efforts and nearly all of our resources on combatting crime, reducing public drug use, restricting prostitution, and treating drug-related illness as we allow the underlying causes of this problem to go largely neglected. The medical costs alone are astounding as we continue to work within a model that provides expensive tertiary care for illnesses that are entirely preventable.

Vancouver and other Canadian cities are not alone in the struggle to reduce the harms associated with illicit drug use. We can look to several European cities that have shown tremendous success in dealing with their drug misuse problems through comprehensive harm-reduction strategies.

Frankfurt, Germany, is perhaps the most high-profile example of a city that transformed a large, open drug scene into a well-managed, controlled, and relatively safe drug-using environment. It should be noted, however, that it did not eliminate the use of illicit drugs.

Although both the addicted and the non-addicted universally recognize that drug use, as seen in the downtown east side, is both unsustainable and deadly, abstinence can only be realized through long-term service provisions implemented in a comprehensive fashion.

Throughout the debate, one thing is clear to all: something needs to change. It is in everybody's best interest to move on, especially those addicted. Contrary to popular belief, the vast majority of drug users would rather be doing something else. These people are not ambassadors for more drug use.

Too often, drug users are portrayed as self-indulgent, morally corrupt, and generally responsible for the social and economic problems of our urban centres. Such scapegoating is entirely counterproductive and clouds the real issue. Specifically, drug use is primarily a public health issue and should be approached with prevention and treatment.

From the merchant who wants to run a business, to the seniors' group who want safe streets, to the provincial government trying to balance health budgets, to the political activists who demand social justice, to the police who want to reduce crime, to the street-involved person who has just witnessed a friend's overdose, the status quo is not an option. It must be made clear to all groups who are impacted by drug use that a harm-reduction approach in no way promotes or legitimizes the use of drugs but rather is a rational approach that will benefit us all.

Within eight blocks of this hotel, we have Canada's most impoverished neighbourhood, perhaps the densest concentration of injection drug addicts in the world, and HIV rates that are comparable to South Africa's. Do people really need more convincing that change is needed? I cannot think of one single intervention that could make the situation worse than it already is.

This debate has gone on a long time. Policy-makers must make some bold moves, now. Anything short of this is irresponsible and, in my view, reprehensible.

There are a number of specific steps that are required. Many can be found in reports and recommendations that have previously been written and repeatedly articulated. These include increased public education and prevention programs, expansion of detox and treatment facilities, alternatives to jail sentences, establishment of safe injection rooms, enhanced needle distribution, more choice in drug substitution therapies, improved methadone services, innovative programs for cocaine addition, and the delivery of HIV and hepatitis C treatments. It is not a lack of ideas that perpetuates the epidemic but a lack of political will and leadership.

Whether motivated by vested self-interest, by genuine compassion or something in between, we must move forward on these issues. Lives are being ruined, HIV is spreading, cities are deteriorating, and young people are dying as this tiresome debate rages on.

Canadians have an excellent opportunity to show global leadership through a balanced, humane, and enlightened approach to illicit drug use that will ultimately improve the health and well-being of our society. Municipal, provincial, and federal governments must understand that the social and economic consequences of doing nothing about illicit drug use cannot be imagined.

Thank you.

The Chair: Thank you, Dr. Tyndall.

I now call on Dr. Somers.

Dr. Julian Somers (Department of Psychiatry, University of British Columbia): Thank you.

I'm very grateful for the opportunity to speak to the special committee this morning. I did learn of this opportunity very recently, so I'll keep my prepared comments quite brief and hope I can add more in the context of discussion and questions.

I'd like to begin by echoing a couple of points that have already been raised. One that I think is of the utmost importance is that the prevalence of illicit substance use is very much a reflection of broad themes of social disintegration and that the practice of substance abuse, dependence or addiction is not a reflection of the self-interest of the substance-using individual. If anything, their self-interest lies in overcoming the harmfulness associated with their substance use. I believe the onus is very much on us to be exploring ways to provide opportunities for those individuals to advance their self-interest.

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I'll speak to three specific issues that were raised in the discussion document in question circulated by the special committee, addressing issues of research, the role of public involvement and public dialogue, and harm reduction.

A number of questions were posed, asking whether the current status of our data and research knowledge is adequate for informed policy decision-making. Like any self-respecting psychologist, my answer is yes and no.

The yes part is probably the more important. I think there are failings in our existing data sets across the country. Provincial regulation of matters having to do with health and substance use in large measure ensures that there are differences in standards of data collection and data management. The better integration of our data sets would undoubtedly be an asset. However, I think the greater problem is that the research knowledge we do have is not effectively utilized.

There is an immense history regarding substance use and the factors that influence substance use, and there are vast amounts of data concerning the prevention, effective treatment, and moving forward in public policy relating to substance use from other countries that I think are available for us to take advantage of. The challenge is, how do we best learn from the lessons that have been gleaned elsewhere?

This really leads to the matter of public involvement, and the examples that come readily to mind from other countries, from Switzerland, Germany, the Netherlands, England, and elsewhere, are all relevant. But one factor that I think is often obscured in looking at those examples is their evolution in those countries.

The Swiss, for example, considered and defeated numerous referenda having to do with substance use legislation and reforms to substance use policies prior to eventually adopting what to the rest of the world appeared to be fairly radical measures. While all the attention is turned to the radicalness of these measures, I think the process of public involvement, public discussion, and consideration of alternatives is a huge factor contributing to the ultimate success and tolerance for errors as reforms are introduced to the policies and practices regarding substance use.

We are making some steps here. Meetings such as this are just the sort of thing that I believe contribute to a better informed public, but a great deal more is needed.

Mr. Reist introduced the stages-of-change model, which is widely consulted in the context of substance use treatment, recognizing that many individuals begin a journey of change without actively considering making any changes, and then move through a number of stages, often resulting in a relapse to use, whereupon they begin this cycle of change once again.

I think that model can be applied to the public, so that members of communities, members of families, who are themselves directly affected by substance use, are brought into the consideration of particular changes, changes such as introducing safe injection sites into their communities, such as the redirection of substance users into mental health or drug courts. At the outset, in numerous constituencies, they are very skeptical as to whether these types of measures are going to have any kind of effective impact, or they are more concerned that they'll have some destructive impact.

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I think the experience gleaned through carefully introducing these measures, and again in terms of data, the careful evaluation of those strategies as they are implemented, is vital. Institutes such as CIHR, which, as is noted, have addictions within the mandate of one of its institutes, are not ideally positioned to be providing these types of data that are not only of importance to legislators but crucially are of importance to the individuals directly affected by changes. This type of program evaluation, as it's often called, notoriously receives short shrift in budgets and in planning of programs.

Again, in our experience, in introducing changes in the area of substance use, policies ensuring that this type of research is done credibly are absolutely vital in relation to ensuring that the public is well informed and is actually strategically brought into the fold. This relates to my last point, which concerns the matter of harm reduction.

I agree with Mr. Reist and Dr. Mangham that harm reduction ought best be considered a description of a philosophy and not something more akin to a trademark of professional interveners, that harm reduction needs to be considered as part of a continuum of care, something that shared societally is part of a continuum of caring. But the experiences, again, we have had by introducing the measures that are currently before committees such as this to better address the needs of substance users are really a starting point for responding to those needs.

Around methadone, for example, the literature, which appears not to be consulted, around our current methadone planning is that methadone is really a doorway into treatment for many individuals, but the effectiveness of methadone programs appears to be linked very much to the involvement of counselling services and other steps of care that can be appended to a methadone treatment program, such as work preparedness, housing needs, and addressing other types of family and social services needs. The effectiveness of methadone treatment on its own, disjointed from that broader continuum, appears to be much more questionable.

That continuum of services, which really is the rightful place of professional treatment providers, I would hope would begin to merge seamlessly with other community agencies and the roles of families and employers. Through that process, as the continuum of care shifts from professional agencies and providers into the other more stable structures of our communities, such as families, I would hope that—this is the point I began with—substance use, as a reflection of social disintegration, can ultimately be repaired and that what can be achieved through this kind of continuum is a process of social reintegration. But I don't think it's any less complicated than the complete continuum I've attempted to allude to.

Thank you.

The Chair: Thank you, Dr. Somers, and thanks for appearing on short notice as well.

We now have some time for questions. We have roughly 40 minutes, so I will start with Mr. White. Why don't we do seven-minute rounds and we can come back and have a three-minute round quickly.

Mr. Randy White (Langley—Abbotsford, Canadian Alliance): Thank you, Madam Chair, and thank you all for coming this morning. You come at it from different but similar perspectives.

I want to ask you about a couple of comments you made. Dr. Tyndall, you said the debate has gone on far too long, and I would agree with that. We are still talking about trying to understand the situation, when it's gone on for 20 years in this country.

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One of you made the comment that the downtown east side is a bit of a tourist site. I would suggest it is a very large tourist site; unfortunately, people want to go there to look, but we don't seem to have the wherewithal to fix it.

I would like to ask each of you to get down to the nub of the issue, as far as the federal government goes, whichever government that is, and consistently throughout the years. What is the primary role and the secondary role of the federal government? That's my first question. I only have seven minutes, so if you can just kind of give me that in brief; I have a few other questions here I want to get into.

Maybe, Colin, you can give me what you think are the primary and secondary roles for the federal government at this time.

Dr. Colin Mangham: The primary role of the federal government is to provide the leadership and set the direction. If there's going to be leadership in this country, I think the federal government is more stable in providing that leadership than provincial governments, particularly here in B.C. where we have quite a see-saw. Most of the time is spent by the government undoing what the previous government did. So in setting that policy direction, the very first step is to decide what we want to accomplish with regard to drugs in this country.

Different countries have gone about it differently. In Europe, which I've been quite interested in of late, we have some very different approaches, but at least they're clear. For example, Sweden has a simple statement that it should not be easy to use drugs. They've gone from a harm-reduction-driven program right back to a restrictive policy. In other countries, there is very clear direction.

I think the federal government here really needs to ensure an open debate and discussion. I like what Dr. Somers said about the need for public discussion. This is too important to leave to the work of a committee or individual people with an interest in presenting.

That's my response to that. Thank you.

Mr. Randy White: Dan.

Mr. Dan Reist: I think it's really important, in addressing addictions, that we don't simply look at the problem and the solution as being something we make up from discrete building blocks. That has tended to be the approach in the past: add this kind of program and that kind of program and start throwing things together into this mishmash of bits.

The federal government can model, in their own approach to this issue, a comprehensive and collaborative approach. They can start showing how to bring together the agencies and departments that are impacted by substance use issues and begin to harmonize policy and engage the provinces and territories in that collaborative process. It's a leadership role, a modelling role, about how to approach this in a collaborative, comprehensive way. I think that's the first and foremost thing the federal government can do.

In terms of actual delivery of things, the federal government has some important levers through Health Canada—the research capacity and the ability to bring together a body of knowledge and then assess that knowledge in the Canadian context. Then that whole area of research and support to the delivery mechanisms will be created, hopefully not just at provincial levels, but right at regional community levels, so it provides the support mechanisms the service delivery system needs.

Dr. Mark Tyndall: I see the federal government's main role as not creating unnecessary obstacles for things to change. A lot of change is going to come through grassroots efforts, and they're already happening. The federal government really has a role in making that path a little easier and clearer for people, and not setting large agendas from the top down and hoping their policies will be taken up by these groups.

Vancouver is a good example where very strong community commitment and ideas are really held back because of bureaucracy. It may not be federal, in many instances. But if the governments could really clear the way to let these things happen....

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A really small proportion of the population is actually impacted directly by illicit drug use. Although it has major societal implications, if you were to do a survey of all Canadians about illicit drug use, most of the opposition would come about...people who are impacted are not very well-informed. So the very well-informed people have great ideas, and the federal government needs to allow them to move forward.

Secondly, I believe these interventions we put in place need to have proper evaluation, and that requires funding. The government plays a role in that also.

The Chair: Thank you.

Dr. Somers.

Dr. Julian Somers: One function that's quite important is providing, for the benefit of Canadians, some sense of the overarching context within which we are to understand substance use. In other countries, substance use and addictions are collapsed in a ministry with concurrent responsibility for sport. I just introduce that as an example of a method at the federal level for introducing a context that in that case relates substance use to wellness, on some type of implicit continuum. That's one function, and I think it's a very important function.

Another, to echo Dr. Tyndall's comment, is that a comprehensive framework for evaluation of our efforts needs to be overseen. In order to unite the energies and activities that are undertaken in various regions of the country, it seems most sensibly to be a federal responsibility.

Third, and underpinning maybe both aspects of the formula—the metaphoric framework and the evaluation—is having a longstanding relationship with trusted advisers who can speak from the research literature. That may already exist within the auspices of Health Canada, I don't know.

I work in a unit that has had a longstanding advisory relationship with the provincial government in B.C. One thing I've learned is that the quality of the data we have to draw upon is really only a part of our effectiveness. A much larger part, at times, is our ability to cultivate a trusting relationship reciprocally between our unit—the researchers, the applied researchers—and individuals in government. Having that type of dialogue, which may take a visible form in a national spokesperson, raised in the discussion material would be a vital underpinning to the success of the federal government, in both the framework and evaluation areas.

The Chair: Thank you, Dr. Somers.

Sorry, you'll have to come back in the second round. It's already almost nine minutes.

Ms. Davies.

Ms. Libby Davies (Vancouver East, NDP): First of all, thank you very much for coming today. I'm glad the committee is here in Vancouver.

I guess I just want to start by saying that I kind of share the sense of frustration, after so many reports. The VIDU study has been very important in really illuminating the reality of what's gone on in Vancouver. But there have been so many reports. I have them all stacked up on my desk, from John Miller's report, to reports from the health boards, and the national reports. It seems to me they all say the same thing. There was also the one from the Kaiser Foundation that went to the B.C. government just a few months ago.

There is a sense of frustration because we're still debating what we mean by harm reduction. I kind of wish we could throw all that language out and just focus on what we know needs to be done.

From that point of view, I think Mark made a very important point that the initiative has really come from the grassroots. The so-called experts in the bureaucracy have defended the status quo, in many ways. People at the local level have really shown us where the status quo isn't working.

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In that regard, I know on Saturday the safe injection site demonstration room was set up in First United Church. It's waiting to happen. It's actually something that is relatively easy to do. It's a very low intervention. At this point, what do you now see as the obstacle to doing this? That's one question.

Secondly, to Dan, you mentioned the report that went to the provincial government, Weaving Threads Together, and on the back page you put your model of the continuum, which I think is a very good, comprehensive approach. Where does that fit now?

With the previous government, it was adopted, if I remember correctly. I have no idea where it's at now. I don't know whether you have any idea of whether it's still in the works or whether that has fallen off the table. This is part of the problem, right? We have elected representatives who have a political agenda, so the issue just keeps churning around and around.

Maybe you could answer those questions.

The Chair: Who would like to go first?

Dr. Mark Tyndall: If I could address the safe injection site issue, I think that has become a very hot topic both in Vancouver and internationally. At international harm reduction conferences, there are whole segments dealing just with safe injection sites.

I think in certain situations they can really cut down on overdose deaths and unsafe injection practices. That has been shown for us already. It has been implemented already in other countries. So it's not a really bold step. We know it works.

In a situation as desperate as the downtown east side, where there's a large proportion of people injecting by dumpsters, I think having a place to go is just a reasonable, humane approach to dealing with their acute problems.

Outside of a comprehensive approach, though, it's certainly an important avenue to engage people. So for the young person who's brought in off the street, if the option is to go to jail or go to a safe injection room where they can be engaged in further care and directed to further services, and hopefully treatment and detox when they're ready for that, I think that is a crucial element.

What's holding that up is I think, again, just bureaucracy. I don't think there's a lot of opposition in the community to the idea, actually. I think the municipal government, the mayor, has come out in support, the research community is supportive, and the community is very supportive. So I think it should happen, and it probably will happen soon. I don't know really what barriers should exist right now.

There are even the legal barriers. Maybe the government has some role in ensuring that when a demonstration project is open in Vancouver, there are special leniencies or changes that will allow people not to be arrested in those situations. But I think they should just go ahead.

The Chair: Dr. Reist, and then Dr. Mangham.

Mr. Dan Reist: You ask about the situation of the recommendations from the Weaving Threads Together report, which were adopted by the previous provincial government. Then, of course, as you understand, there was an election and the government changed.

During the process of preparing that report, we were aware that the government would change; it didn't take a lot of special sight into the future. So we had worked with the existing provincial government with the understanding that we would be briefing the then opposition throughout that process, which went forward.

After the election, as you probably understand, the responsibility for addiction services was moved from the Ministry of Children and Family Development to the Ministry of Health Services. The current Minister of Health Services has, on the floor of the provincial legislature, referred to the report and expressed his support of its recommendations. So there's no opposition within the current political situation—in fact, seemingly support for implementing the recommendations.

The problem is that in reorganizing and restructuring ministries as massively as the ministries in British Columbia were restructured, it has been very difficult to get on with implementation. So where it sits right now is support for the recommendations, but no implementation plan to actually act on them. We continue to press for that. It's anybody's guess as to how quickly that will move forward.

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The Chair: Ms. Davies, you have thirty seconds.

Ms. Libby Davies: Do you have any update on what's happening to the clinical trials for heroin maintenance? Are there any new developments in that regard?

Dr. Mark Tyndall: I thought Martin Schechter would be here. I'm not aware of any new developments other than that it has been a proposal to the CIHR and they're still working out potential for funding. But a site hasn't been sorted out and staff haven't been hired. I can't really say anything more than that right now.

Ms. Libby Davies: Is this going to be on a national basis as opposed to Vancouver alone? Is that your understanding?

Dr. Mark Tyndall: Yes, it would be a Montreal-Toronto-Vancouver initiative.

The Chair: Thank you, and thank you for keeping within the time limit.

Mr. Owen, are we in your riding or Ms. Davies'? Neither?

Mr. Stephen Owen (Vancouver Quadra, Lib.): Neither. It's Hedy Fry's. But it affects us all, I can assure you.

Thank you all for being here. I feel that we're, if not insulting you, at least depriving ourselves of greater opportunities, given the expertise you represent, all of you, when we have only such a short time. Let me pose a few questions, one to each of you at least, from your presentations.

Mr. Reist, you seem to be describing the need for a complex matrix administrative model, a decision-making and implementation model. I agree entirely, if that's what you're suggesting—all levels of government, plus community groups, and law enforcement and everyone.

Against that identification of need, I'm wondering how you measure the Vancouver agreement, either in its conceptual form or the way it seems to be rolling out, or the potential for it to roll out. In terms of your identification of the need of data, I'm wondering how you are seeing programs like VIDUS as long-term, longitudinal data collection processes and whether that's the type of thing we need more of.

I was interested in your description of the three-dimensional model, too, on your chart of intervention stages, as well as stages of change. You introduced the prevention as a third dimension, which seems to make a lot of sense.

Dr. Mangham, in your addressing of the prevention issue, I was a little confused as to whether, when you talked about the balance of pillars, you were really only talking about three pillars and were leaving harm reduction out. As well, with respect to your focus on prevention, I'm wondering whether you agreed with Mr. Reist's idea of the prevention being in fact a third dimension that would be appropriate at any of the other stages so that it was not just a preliminary or upfront model.

Dr. Tyndall, I was very taken by your identification of the much broader causes of addiction, and, to follow a particular thread, whether it's young, impoverished, aboriginal women who come to the downtown east side and really fall prey to abuse, physical and sexual abuse, to drug addiction, to street prostitution, and whether it's really the intravenous drug use that is the problem or whether that's just a contributing cause in the whole range of social issues.

When we look to other countries and other areas where there has been success or failure that we might learn from, we tend to look to the European experiences. But in listening to you, it seemed to me that the African experiences are even more relevant in the sense of migrant populations from impoverished native villages, often involving young women, men coming back and forth, women being pushed into prostitution through poverty, being abused because of their weak position in society, and then coming out of despair addicted, and perhaps going to HIV and hepatitis C out of social causes more than drug-related dependency.

Dr. Somers, related to that, where Dr. Mangham seemed to be describing a three-pillar approach, you seem to be describing a five-pillar approach, with social justice issues being the fifth. This really relates to Dr. Tyndall's points. It seems to me that unless we take a five-pillar approach and maybe take the social justice one as the first approach, we're never going to deal with the specific question we're putting, which is the despair arising from the non-medical use of drugs.

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Anyway, those are a few questions for each of you, and I think you have about 30 seconds left from my seven minutes. Dominic has given me his time.

The Chair: We'll have Mr. Reist first.

Mr. Dan Reist: You asked about several issues that related to my comments. First of all, you asked about the Vancouver agreement, and I would argue that the Vancouver agreement is in fact a good model of cluster-based planning at the regional community level, with one exception. It is that the absence of legitimized leadership in that agreement from both the federal government and the provincial government has hindered the progress of that agreement.

Compare the effectiveness of the Vancouver agreement, just from the provincial side, to the effectiveness of the provincial government in bringing together a vast, complex array of services to deal with the problem in Gold River, for example. There the premier clearly identified a deputy minister as the lead role and ordered his ministers in a variety of other services to cooperate with that person. That agreement moved ahead very effectively and very quickly.

When you compare that to the Vancouver agreement and the absence of that kind of legitimized leadership, you begin to see the problems. I think the federal government and the provincial government have been remiss in terms of legitimizing their leaders in that agreement. That needs to happen for it to be effective.

If you compare that also with Oregon, where benchmarking across multi-levels of government and multi-departments has been reasonably effective, again, it is with that kind of legitimized leadership driven by the governor of the state, so—

Mr. Stephen Owen: Just so we understand, with the Oregon model you're talking about their land-use planning model, their sustainability model?

Mr. Dan Reist: No, I'm talking about their social planning initiatives around dealing with social planning.

Mr. Stephen Owen: They started with a land-use planning model, and it sounds as if they're using the same one.

Mr. Dan Reist: They use the same model for just about everything. It's very effective. There are some lessons to be learned from that, but I'm not suggesting that you can simply transplant it completely.

Second, you asked about research, and I applaud the work of the VIDUS group. What I'm suggesting is that we need much more of that, and we need a more comprehensive approach to how we deal with research and evaluation in all aspects of addiction services. That's one good example. Unfortunately, we don't have too many of them.

Concerning the prevention dimension, I really am concerned that sometimes the pillar discussion—insofar as I understand what it's trying to say—tends to treat things as independent, discrete entities. I believe that we have to get away from this notion of discrete entities—programs that are prevention, programs that are treatment, issues that are enforcement, issues that are harm reduction, or whatever—and begin to see that there are multi-dimensional aspects of everything we do. Then all programs will be dealing with prevention to a degree, and they could be dealing with treatment. It's just a matter of focus along these various continuums rather than discrete entities.

The Chair: Thank you.

Dr. Mangham.

Dr. Colin Mangham: I'll respond to the two questions. First of all, I see the social justice as very important but not as a pillar or a background to everything. It's a constant struggle and a constant thing, and it really isn't simply a part of a response to any single thing, so it's beyond a pillar. It's the backdrop against which other things have to take place.

Also, I come from a very different world. I think you hear disparate opinions, but what you have to remember is that I deal with the general population and with children. I picture a child in bed with a teddy bear as my driver of a national drug policy. What do I want that child to grow up in? What would I like this country to do that would help that child?

Meanwhile, another person could be in a whole different world and might ask, what do we need to do at the corner of Main and Hastings? It's an entirely different mindset and an entirely different world.

The harm-reduction pillar—or the harm-reduction component or thread—becomes extremely important there. I'm saying it's not the national driver. It is the exception that is needed to address the serious issue that's at the bottom of that barrel—I don't want to use that term—or rather, where the severe problems are most manifest in disenfranchised populations.

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I'm looking at the whole and saying, if we use that approach, it's not going to work out here; it's going to take us in a direction we may not want for that child with the teddy bear.

Second, as to prevention, my only concern is a pragmatic concern—and I've said it to Dan—where time and time again everyone at the table says yes, we should do prevention and we should make it important, whether it's a third dimension or however we want to say it. The problem is—and it's coming more from an educational background—that the perfectly integrated, elegant, beautiful, seamless curriculum in a school, for example, is often a non-curriculum. It winds up that nobody does it because everybody is sort of supposed to do it. It becomes lost.

Prevention cannot become lost again. If one thing comes out of this, it tends to be that everybody says.... It's the second sentence in national drug strategy prevention, but look at your dollars and look at the programs, and you'll find that it's not there. That's why I would be a little concerned about getting too integrated to where.... We're being driven by less than 2% of the population, less than 10% in the case of marijuana. A six-block area or whatever of a city cannot drive a national drug policy. We have to have different public policies for addressing different needs. That's the flexibility we need.

The Chair: Thank you.

Dr. Tyndall.

Dr. Mark Tyndall: I'd agree with that; it's very important to separate a hardened, ghettoized drug situation in Vancouver from a national drug policy if we don't want our kids being cocaine and heroin addicts. I think that clearly, the distilled determinant of how people get down there in the first place has to be high on our agenda to try to prevent that cycle from recurring.

I have the option as a clinician to ask people in detail about how they got there. Most people have horrible stories, and there are good reasons why they turned to substance abuse. For the people we're dealing with, those in a downtown area in Vancouver, how they got there is certainly very important. To try to stem the cycle is also very important, and the first nations community has to be high on our list.

Along with that, with respect to getting out of the situation, you're dealing with people with incredible baggage. Not only are they now addicted to drugs, they might be HIV-positive, they probably have a criminal record, and they've been alienated from their families. To think we're going to put any intervention in place that is all of a sudden going to have them living in suburbia with a nine-to-five job is a fairly inappropriate expectation.

For some people we want to reduce their harm and make their living in Canada as comfortable as possible, which is our role as a caring society. But to have expectations that somehow with the right intervention we will just clear up the whole problem so everybody is an upstanding citizen, just as we all want everybody to be, is a fairly inappropriate expectation, I think. HIV and hepatitis C have put a whole new slant on it, and now we have people who are sick and dying because of their drug use.

The Chair: Thank you, Dr. Tyndall.

Dr. Somers.

Dr. Julian Somers: Thank you.

I would argue that however many pillars it may seem prudent to adopt, they should all be given visibility in a national strategy. I think we all agree that multiple dimensions and consideration of multiple determinants of substance use and pathways away from substance use problems are important.

Whatever final number we were to agree to or the government was to agree to, I think it's important to advance visibly on all of them at once. We have seen—and this has been our experience thus far—that fitful progress, that is, fighting off the problem timidly and using components of effective treatments, actually does everyone a disservice, because those efforts do not succeed. The net result is a loss of confidence in all constituencies, those who provide services, those who receive them, and the public who observe this entire transaction.

I don't know from a strategic perspective whether the courts and police present in any way and in some communities a more receptive audience in which to proceed. I'm really referring here to the magnitude of steps that can be taken, in either enforcement, prevention, or any of the single pillars.

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I also wanted to emphasize that those pillars, and the advancement of the strategy, should not leave the impression that substance use is in any way confined to a particular subset of afflicted individuals. Obviously, injection drug use and the spread of infectious disease is a huge concern for us, but the numbers that you're already familiar with attest that, if we're looking at the burden of illness and the burden borne by the public, by far the greater concern lies with the inappropriate use of licit substances.

Again, that goes back to the notion of a continuum. Somehow, wherever we start visibly, I think we need to anticipate not conveying an inaccurate or skewed message to the public about what substance use and/or addiction entail. We have the big picture in our sights. I feel this is important, even if we are to address a particular constituency. I refer back to my comments about the process of reintegration. We all have to be a part of this, and that's a theme that everyone on this side of the table has emphasized today.

The Chair: Thank you, Dr. Somers.

I'm not sure, Dr. Tyndall, if you're going to be with us, but....

Dr. Mark Tyndall: Actually, there's a treatment conference going on here. I can leave the....

The Chair: That would be great. Also—and I'll save myself saying this to all of you—if you think of other things that you would have liked to have said to us, you're very encouraged to send those to us afterwards. So if there's something that you've thought of afterwards, Dr. Tyndall, let us know.

I'll now go to Mr. White for a couple of minutes.

Mr. Randy White: Madam Chair, we're talking to some experts here who have seen the worst in Canada, perhaps the worst in North America or even in the world. But I don't come from Vancouver and a lot of members of Parliament don't.

It used to be that when we were in high school, a parent would say, “Look how well my child is doing. They're in grade 10, grade 9, and they're getting through high school. Wow, what a bright future.” Today, most parents typically say, “My child is in high school. I hope they can get out of there without being drug addicted and abused”, and so on and so forth. Things have changed in high schools.

A short time ago we had virtually no prostitutes in the Fraser Valley area, in particular Abbotsford, which was a quiet little city. At last count, we had over 40 prostitutes in the community, which is a sign of addiction, of course.

We have the worst prison in the country for a reputation of drugs in the community. We have significant growth in addiction in youth, in schools. I was just recently talking to a young fellow who was voted the most likely to succeed. He was in a rehabilitation centre, a long way down from where he came.

It was mentioned here that there's perhaps not a lot of opposition for safe injection sites or this concept of harm reduction. I can assure you there is. We shouldn't underestimate that; it's very strong in my community. In fact, in my community, where all these things are going on, quite frankly, there's a lot of opposition to needle exchanges. They're fighting over that now, and even other minor things that you may consider just commonplace here.

What we need is a national drug strategy that works not just on the street but all over the country. It's difficult to convince people where I come from that you should deal with it the same way you do in the downtown east side, I can assure you.

I'm wondering if any of you would recommend something different in Vancouver than you would in the Fraser Valley or any other area like that. They're all over the country. We're talking about the worst here. In our community, drugs are the worst, but they're not as bad as they are with the concentrated group in the downtown east side. If you had a national drug strategy that worked at the street level, is there something that would be better for an area I just described as opposed to the real urban area we're talking about? That's my question.

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The Chair: He left you not a lot of time.

Mr. Reist.

Mr. Dan Reist: I would really like to respond to that last question. It seems to me that the model put forward by the addiction task group in Weaving Threads Together addresses exactly that. If we think we can come up with a strategy, meaning a model of services that should be delivered in every community across this country, we will waste our time for years to come.

What we need to do is develop a strategy that allows communities to address the issues they face and to do that without putting artificial barriers in their way and without choking off the resources they need to address those things. That's why the collaborative model, which brings together the players that need to be involved across the health and social infrastructure, has to come together at the community level and sort out what priorities this community has. What are the issues we need to address? How can we most effectively impact addiction issues in our community? Those will vary from community to community, depending on the situation you face. I think it's important that we have a system that is responsive to individual communities.

I wanted to make one other point about your earlier comment in setting the stage for our understanding. There are many tragic stories. You've heard them; we've all heard them. We know people who are involved in tragic patterns in their lives. But I think we have to be really careful about the “hell in a handbasket” message the media likes to pick up. The little evidence we do have would show that the actual pattern of the level of drug use and drug addiction has not changed significantly in the last number of years. It has not changed significantly from the days when I was in high school. Certain things have changed, and the media attention to the issue has definitely changed.

I think we need to promote in this country media attention to some of the good stories about our kids in high school. There are a lot of really good things developing. I see kids in high school, my own children and their friends, who have been involved in some things that I wish I could have been involved in. There are some really great opportunities being given to them to develop leadership and so forth. So I think we need to promote those things as well. That's not to minimize in any way.... I'd be the last one to minimize the problems related to addiction, but I think we just need to balance that out and really be clear that there are a lot of good things happening too.

The Chair: Ms. Davies.

Ms. Libby Davies: Thank you.

It seems that everybody does agree that the status quo is not working. In thinking about what some of the barriers and obstacles are to change, one of the things that I've come to is that really the stigmatization of injection drug users in particular has been a huge barrier. It's been really easy to marginalize people and reinforce this law enforcement approach. Yet the more you get into the issue, you realize it is a much broader problem. Is there a way to break down some of those stereotypes?

One of the most interesting things that's happened in Vancouver is that a group like From Grief to Action, which is actually middle-class parents on the west side, I think in Mr. Owen's riding, linked up with VANDU members in the downtown east side because they actually saw that they had an incredible amount of stuff in common. Yet the stereotypes about drug users, partly because of what the media does, are so directed to a criminal element, people on the street. It seems to me that's been one of the biggest barriers to overcome. I just wonder if you have any thoughts about that in terms of how we deal with the stigma.

The Chair: Who would like to answer? Dr. Somers is thinking about it.

Dr. Mangham, did you want to speak?

Dr. Colin Mangham: Well, in dealing with stereotypes, one of the big issues is that whatever the media makes of something, that is what happens, and we glom in on that.

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I think in our overall approach we probably continue to make a serious mistake by focusing on the very worst of the problem and drawing a lot of attention to that, rather than looking at it from a broader perspective and focusing on the fact that the incidence is relatively small. The problem is large, but the incidence is relatively small.

I don't know how to deal with those stereotypes, other than to rely on human compassion and the idea—which I agree with—that people are not disposable and we shouldn't treat them as disposable, or as recidivist. We should be doing everything we can to help them.

The Chair: Thank you, Dr. Mangham.

Dr. Somers.

Dr. Julian Somers: To be very blunt about it, courage is called for in combating stigma and in addressing unique community needs, and I would actually look to the federal government to appoint such a courageous individual or group of individuals who could, on behalf of the drug users we're talking about, remind all of us that they are us. We've gone over this turf that this is a multiply determined, social set of circumstances. We're all connected. So these people are us.

The communities, as Dr. Tyndall commented, are coming up with their own solutions, and that's right. That will give rise, community by community, to a different look, a different feel, precisely because the process of reintegration has to call upon the resources, the willingness to give, of the individuals in those communities. And the capability, resources, and needs are going to vary. They have varied elsewhere.

So as I said, it would be appointing such a courageous individual to come into communities to assert what the research literature, what our experiences, tell us ought, prudently, to be effective, and to assure everyone that there will be a careful evaluation.

I'll interject here. I'd be concerned if the process of evaluation were co-opted by or leaned too heavily on CIHR or other nationally funded research organizations. Those research organizations are charged with supporting basic investigator-driven research, and this is not that type of research. This is evaluation of social policy. It just tempts all kinds of very difficult issues to attempt to meld those too closely together.

I think the audience we're talking about needs a champion—I guess that's another way of putting it—and that champion would have a huge opportunity to overcome stigma and facilitate change.

The Chair: Thank you, Dr. Somers.

Mr. Reist, did you have a quick comment?

Mr. Dan Reist: Well, as I've been listening here, I thought it rather interesting that yesterday was the first Sunday of Advent. If you were in church yesterday, you might have heard an ancient text about turning swords into ploughshares, and a reminder of that great statue in front of the United Nations building.

What struck me about that is that the image in the ancient text, of course, was from a time when metal was extremely precious, so when you wanted to dispose of a piece of metal, you didn't simply throw it away, you turned it into something else. I think in our society we've tended to view life as divided into good and bad, and we are to value the good and throw away the bad. In fact, what we are to do is transform things, and I think it's that process of transformation we need to take into problems like substance abuse, even the most extreme cases, like the downtown east side. We need to transform that community, not throw it away.

The Chair: Thank you, Mr. Reist.

Final comments are for Mr. Owen.

Mr. Stephen Owen: Thank you.

We've covered a wide range of issues this morning, and I thank you for it.

One we haven't touched on, and maybe it goes to Dr. Somers' research in particular, is the intersection of mental health issues with drug addiction. Perhaps I could just put the question to you, Dr. Somers.

How complicit is the institutionalization and the betrayal—because while everyone supported the philosophy, we never put the resources into the community-living side of it to give it even a chance of success—in the failed implementation of the sound philosophy of community living? How does that failure play into the despair, particularly of the downtown east side, and what lessons can we learn from that?

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The Chair: Dr. Somers.

Dr. Julian Somers: It plays directly into what we're observing in the prevalence of concurrent substance use and mental illness among people living in the most impoverished circumstances.

I suppose there are many lessons.

The one that leaps to mind is that mental illness, like many other vulnerabilities that individuals can suffer from, including economic vulnerabilities and vulnerabilities by virtue of the circumstances of their upbringing, is conspicuously contributing to the most desperate instances of substance abuse. It's one of many contributing factors, risk factors.

So that's one, and it's a reminder that this is typically not a function solely of an organic vulnerability, but, as has been mentioned, is mostly determined.

Other implications or lessons are that the process of reintegration, if that's what we're aspiring toward, needs very much to integrate concurrent services. I would add mental health services to those that are intended to specifically address concurrent substance use problems. And I wouldn't stop there. I would include and move further in the direction of housing and employment, and the other range of services we've all discussed.

If one needed to prioritize, I would certainly put concurrent attention to the management of mental illness and substance use as, in almost all instances, one of the earliest steps, one of the earliest phases of intervention.

As I'm sure you're all aware, the concurrent provision of services is quite rare. One of the questions you posed is whether adequate intervention and treatment services are available in the area of substance use. Most clearly they are not. If one were to go about systematically overcoming that shortfall, I think you would be well served to see the ready integration of mental health services as very much a part of what needs to be implemented.

The Chair: Thank you, and to all our panellists, thank you very much. It was a great way for the committee to kick off the day, actually the week, looking at the situation here in Vancouver and British Columbia.

We really appreciate the time and effort you put into your presentations and in giving us the best of your thoughts. If you do have anything else, please, we encourage you to communicate with the chair of our committee, who will make sure everything is translated and distributed. We really appreciate your efforts.

Thank you very much, Mr. Reist, Dr. Mangham, and Dr. Somers. We wish you lots of good luck with the work you are doing.

We'll suspend until about a quarter to eleven.

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• 1053

The Chair: I call the meeting back to order.

We have with us our second panel of the day. It includes a couple of people who were going to be on the first panel.

We are the Special Committee on the Non-Medical Use of Drugs and we are here to get great advice from people in Vancouver. In our second panel we're very pleased to have with us Larry Campbell, the former chief coroner of B.C. We have Fred McMahon, who's the director of the Social Affairs Centre with the Fraser Institute, and we have Professor Bruce Alexander from the Department of Psychology at Simon Fraser.

As a carry-over from our first panel, we also have Dr. Martin Schechter, head of epidemiology and biostatistics at UBC, and Dr. Michael O'Shaughnessy, VP of research, director, Centre of Excellence in HIV/AIDS, and a big media star after last week—I saw you everywhere.

Welcome to our committee. If it's okay with everybody, unless you've made some other prior agreement, we'll go in the order I introduced you.

If we can keep the presentations tighter, then we have more time for questions and answers. Everyone is welcome to send us anything else to elaborate on their contribution after the committee is finished, but we will start now with Larry Campbell.

Mr. Larry Campbell (Individual Presentation): I want to thank you for allowing me to appear before you today. The panel is quite awesome in that I'm the only one here who probably doesn't have an official designation other than a long-ago MBA.

I come from a unique perspective. My life has sort of travelled the gambit. I was in the RCMP originally, in fact on the drug squad for six years here in Vancouver and doing some undercover work. I progressed from that side over onto the side of, in some circles, darkness. I was a Vancouver coroner for approximately 16 years, give or take a couple, before I became the chief coroner. So I was there and watched as the drug deaths started rising and in fact went through the roof. We thought 1993 was bad. It dipped a bit in 1994, then it continued on after that.

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I think it's interesting to also note that I have a rural background, in that I go back to Saskatchewan every year to plant and to harvest. I listened to Mr. White, and he's quite right. In Dubuc, Saskatchewan, they're really not too sure what a drug addict looks like, so this is not a big deal in rural Saskatchewan. However, when I go to the big cities of Regina and Saskatoon, there are obviously major problems that need to be dealt with. In fact, in certain areas they remind me very much of the downtown east side. It may only be a very small percentage of the population that is touched by this disease, but the resources and the costs to society are so disproportionate that we simply cannot ignore it any more.

One of the things to cause me the most difficulty is that the conversation surrounding what we should do about this disease process has polarized between those people who believe in pure abstinence and those who have gone to what's considered, perhaps, the more radical route of harm reduction. In fact, abstinence is an integral part of harm reduction. Abstinence is at one end of the continuum of care. What we have to start with is the understanding that this is a health problem, not a criminal problem. If we understand that, then we recognize that any time you have a disease, in many cases there is a continuum of care that goes from one side to the other.

My suggestion is that in the perfect world, abstinence would be what we would want. Of course, we want that. We don't want people to be sick. But in the real context, people get sick and people become addicted, and therefore we have to understand that the continuum of care runs from abstinence, just say no, 12 steps, over to the other side, which may even be heroin maintenance. And the number of people who actual utilize these two poles are probably in the minority. Most of the other people are going to fit within the middle of this continuum of care.

I'd like to acknowledge Mark Haden from Addiction Services. He gave me most of what I'm going to tell you today.

Harm reduction, from my point of view, appears to be the best solution. Harm reduction asks the question, how do we reduce the harm to individuals and society, given the fact that some individuals will become addicted? We currently already use harm reduction for many issues. Cars kill people; therefore, we have safe driving courses, seat belts, stop signs, speed limits.

Eric Single, in a paper from 1999, actually examined three definitions of harm reduction. The first is “that which applies to individuals who continue to use drugs”; the second is an all-inclusive definition, which includes “all addiction services as all programs want to reduce harm”; and the third, “those programs which can be demonstrated empirically to reduce harm to users in the larger society”.

Within that context, we've entered into the Vancouver agreement at all levels of government. Anybody who has lived in Vancouver will know that this was not an easy process, that this took courage on many fronts, and that even still, to this point, is not universally accepted within the Vancouver community.

“Just say no to drugs” does not stop people from using them. And what do we offer people who end up being addicted? Most services are for people who want to stop. We need a range of services that are client-centred for people at each stage of the use. In order to engage addicts, we must meet them where they are. So I agree with some of the things that were said this morning by the panel, that while we need a national strategy, it has to be community based. The community has to be allowed to decide how they're going to approach it, because one size definitely does not fit all in this case.

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I don't want to go into all the lessons from Europe and the Swiss study and all the rest of it, but I do want to comment about safe injection sites. For me, this was one of the most difficult areas to come to. I moved from “No, I'm not going there”, to studying it very carefully and looking at all of the circumstances and moving to the point where I say “This has to be considered part of the treatment; this has to be part of the continuum”.

We know there are safe injection sites in Spain, Germany, Switzerland, the Netherlands, and Australia. I don't think I need to go into what's in there, but so far the studies evaluating these have shown that overdose deaths decrease; there's a reduced sharing of needles; there's a reduced number of needles left in public, which is of great concern here in Vancouver; there's reduced participation in unsafe sex; there are declining HIV injection rates; drug use in the IDU population goes down; and expropriated public space is returned. Again, in Vancouver this is a huge issue. You're driving through downtown Vancouver and you end up at a drug market, right smack in the middle of downtown.

In Europe, that is referred to as a nuisance. In Canada, it is referred to as a criminal event. Crime is reduced; public nuisance is reduced as the open drug scenes are closed; and contacts with the users, social integration referrals, etc., are easier than contact at other services like needle exchanges, as users relax and are not taking care of business.

One of the problems we have is that people who are drug addicts, who are suffering from this mental condition, don't live like you and me. There is no safe place. Life is one big scramble. On top of the addiction, they're malnourished, they may be HIV-positive, they have all of the heps, and life is one big scramble. This is not a bunch of people sitting around recreationally getting stoned. They will crank anywhere, as you've seen on the news. We need to give them some place where they can do it safely, where we can make sure they aren't dying, and where we can make sure the needles, etc., are clean.

We had a symposium here on safe fixing facilities. It was looking at the legal aspects of safe injection sites. I can tell you right now I'd open one tomorrow, because I don't think it's illegal. Just opening that site is not illegal. Now, if the police want to come into that site, there will be all kinds of people who will be using drugs. That's illegal. They can do what they want there, but there's nothing they can do to me. That was the conclusion we found.

Another thing that's interesting with safe injection sites is that after safe fixing sites have been open for a number of years, the average age of the users goes up. If we can keep these people alive and healthy until they're 40, they usually stop using. It's this idea that it's the youth who are all using; the fact is it's not. It's simply that they don't get to be very old because of all of the other things that are going on around them.

I want to throw one thing in here that I found very interesting. In England, they did a study. In England, of course, the physicians were not limited in what they could prescribe up until 1965. After that there were specific clinics that dealt with addicts.

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A Dr. John Marks took over a clinic that was prescribing heroin with the intention of closing it. He evaluated it and found that patients were free of AIDS—he expected 15% to 20%—in good health, and most were employed. The local police tracked 100 of its patients and found a 94% drop in theft, burglary, and property crimes. The most significant finding was that convictions for illegal possession in the community dropped immediately after the clinic opened.

Marks concluded that the demand curve for drugs is U-shaped. If drugs or alcohol are too freely available or if they are prohibited, you increase consumption. The bottom of the U appears to be drugs available on prescription.

I know you'll be discussing the economics, so I won't go into that.

Specifically, for Vancouver, what would harm reduction mean? It would mean more methadone and lower-threshold methadone, for example, methadone plus; no urine tests; increased accessibility; prescribing heroin, cocaine, and amphetamines, which again is at the far end of this continuum; more needle exchanges; safe injection sites; less stigma; more detox and treatment options; more preventative programs; and selective non-enforcement of laws.

As to harm reduction implications for treatment, abstinence is only one of the goals. Cutting down and using less dangerous drugs or methods are legitimate goals; more focus on improving social, vocational functioning; increased attention to normalization or social integration; relapse would not mean treatment failure; and the need to provide for services for users who want to continue using. At some point, they are going to want to stop, but there are those who are going to continue using it.

I want to make a differentiation here. There are some groups that say using drugs is their right as a Canadian citizen. I do not support that, and I do not understand it. You cannot have this as a medical condition and also have it as a life condition, as a social condition. I do not agree with that. But I do recognize that there will be people who cannot be cured of this illness, and those people will have to be maintained on the drug.

I believe there's a place for enforcement. I don't think there's going to be a magic wand that we wave around here where all of a sudden everything is going to go away, but harm reduction has implications for enforcement. The harm of marginalization of drug users needs to be understood and acted upon.

I think in Vancouver, for the most part, there is a will and a goal to do that on the part of the police. Enforcement staff need to adopt the public health vision of drug abuse and form linkages with the public health service. Enforcement pertaining to illegal drugs needs to be focused on crimes of force, such as violence, break and enters, and so on; fraud, for example, money laundering; and public safety concerns from drug use, the needles that are left out in the public, and driving while impaired. Individual drug use is not an enforcement concern, as this needs to be dealt with as a public health problem, using the tools of prevention and treatment.

I sometimes have some difficulty understanding why it's so difficult for people to understand that one size does not fit all. If I were suffering from cancer and I went to a doctor who said, “Look, we have ten different treatments that can be used here, but I'm only allowing you to use one and I'm not sure what the success rate will be on it”, the doctor would be before the College of Physicians and Surgeons faster than your head would spin. Yet when we take a look at this other disease that's killing people, that's costing us billions of dollars, we don't seem to be able to come to grips with the fact that there is a continuum of care. As long as we ignore that, we're going to continue having the deaths, and we're going to continue having the diseases that are associated with it. I'm going to continue meeting with the mothers and fathers and the sisters and brothers of these people.

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These people who have this addiction are not castoffs. They are not throwaways. For some reason, whatever it is, they found themselves with this disease, and I don't think we should be in a position to stigmatize them for having it. So I hope that at least in my lifetime we'll be able to see some form of treatment, some way of helping these people out of it, and some way of helping society to rid itself of the nuisance.

Thank you.

The Chair: Thank you very much, Mr. Campbell.

Mr. McMahon.

Mr. Fred McMahon (Director, Social Affairs Centre, Fraser Institute): Thank you very much.

Several months ago the Fraser Institute released an e-book called Sensible Solutions to the Urban Drug Problem. That came out of my department. I'm grateful to you for inviting me to speak here today.

As I mentioned to your staff, and they've passed it on to you, I'm a generalist rather than a specialist in this area. So I'll take a generalist overview.

For about the past 50 to 75 years, western nations have been involved in a disastrous policy experiment. That disastrous policy experiment was making recreational drugs illegal. Prior to that period in time, recreational drugs were not illegal and were more or less freely available.

An amusing book review in The Economist this week notes that even the arch-puritan Gladstone took opium before speaking in the House of Commons—in fact, a drug called, if I pronounce it correctly, laudanum. In fact, according to this article, you could virtually judge the professional relationships between various cabinet ministers by the number of drops they needed to take before meeting each other. You could almost rate cabinet ministers that way today.

About 75 years ago our policy towards these drugs changed dramatically. They were made illegal. Then, from that, the war on drugs was launched. That war on drugs now involves police forces, paramilitary forces, military forces, and governments around the world. Talk about mission creep.

We've created a very serious worldwide anti-drug industry here, but what have we accomplished? Just about nothing as far as the war on drugs goes. As far as obtaining them, they're pretty much freely available for anybody who so wishes. I could walk down to Gastown now and get just about any drug I wanted. Mind you, I might want a change of clothes to get a good price on those drugs on the street, but other than that, they are freely available.

Most of the problems that we now associate with drugs or the war on drugs come not from the drugs themselves, but from the mere fact of their illegality: the crimes committed to support drug habits; the use of dirty needles; criminalizing a whole segment of the population. These are not problems that emerge from the actual use of drugs. These are problems that emerge from their illegality.

The problems we create in Canada and the United States are small potatoes compared to the real horrors that are created in drug-exporting countries, where civil wars or low-level civil wars, battles between various groups, and corruption seeping all the way through these governments—and it's not just Colombia; it has affected any number of other governments—are a real tragedy. It is time we rethought the drug policy from top to bottom.

I'm going to stake out a fairly radical position or a fairly radical question here. What would be the impact if we just made drugs legal, as they used to be? Granted, working through the U-shaped curve that Mr. Campbell just spoke about, the inconvenience of getting them was high. I don't think there's much evidence that would create a splurge of drug use, but it might bring it in and under control and reduce the secondary harm from the fact of drugs being illegal. It's hard to experiment here. It's particularly hard to experiment because if you hold a closed experiment, say legalizing drugs, people will come from everywhere to try them out and become part of that subculture.

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Perhaps the best example we have is the Netherlands, where marijuana has been effectively legal for some time, and legally legal for about eight months now. Marijuana use in the Netherlands is roughly at the European average—a touch above, but not significantly above. I suspect that would happen as well if hard drugs were legalized across the board. You would see some uptick, but not a huge amount, and if the inconvenience level were appropriately calibrated at the bottom of the U-curve, you might in the long run see a drop-off.

Let me put this to you. We economists are very interested in incentives. Right now you've created a system where there are immense incentives to people involved in the drug trade to recruit new drug users. That's where their profits come from. That's how they stay in business at the bottom of the pile. The drug policy has created massive incentives for people to build criminal gangs, organize criminal networks, and hook a new generation of young drug users. All this would disappear if drugs were made legal but hard to get under a legal system, which could be arranged.

Then the question comes, could we do that, and would the events of September 11 have an impact on it? Probably our only room to manoeuvre in Canada would be in various harm-reduction policies and perhaps legalization or decriminalization of marijuana.

Clearly, the United States would not tolerate what it would see as a drug haven north of the border. We'd have increasing border problems if we went much beyond that. But we would have some room to manoeuvre in appropriate policies, like the harm-reduction policies for harder drugs, and perhaps all the way through to at least decriminalization of marijuana.

My remarks have been brief, and I'll just quickly sum up now. As noted, our policy toward drugs is relatively recent. Society did not fall apart at the hinges when Gladstone spoke to Parliament slightly stoned. It did not fall apart when King George IV decided he needed 100 drops of laudanum just to tolerate his foreign minister's presence.

There is very little reason to believe drug use would take off dramatically under a change in regime. But there are lots of reasons to believe that the secondary harm of drug usage could be significantly reduced.

Thank you.

The Chair: Thank you, Mr. McMahon.

Professor Alexander.

Professor Bruce Alexander (Department of Psychology, Simon Fraser University): Ladies and gentlemen, I'm honoured by the committee's invitation to be here, and I hope the members and especially my own MP, Libby Davies, will accept my compliments for their courage in taking on the perilously complex problem of non-medical use of drugs in this public format. Please also accept my heartfelt wishes that your efforts will achieve great success.

When I received the terms of reference from the committee, I noted that there were no less than 42 weighty questions in it. Each question by its nature calls for an answer based on extensive documentation and analysis. I then realized that the committee must have meant to express enormous confidence in its witnesses by inviting each of us to address the 42 questions in a 10-minute speech, obviously assuming we would need less than 15 seconds to dispose of each of them.

However, I publicly confess that I cannot measure up to this challenge, and I will restrict my comments therefore to the single question of centralizing political power over addictive drugs in an office of Canada's drug strategy, a possibility that is given some prominence in the terms of reference.

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I will also jump directly to my conclusions on this question. Although there is a great deal of documentation behind each of them, the conclusions I will submit are based on three decades of research, teaching, and clinical practice on addiction. Some of the documentation is reviewed in the article that is attached to the written form of this presentation.

My first and main conclusion, I respectfully submit, is that further centralization of political power over drugs in any form of an office of Canada's drug strategy would be counterproductive. Therefore, I will propose a different sort of centralization that I believe would be beneficial.

I believe the committee has now fully experienced the maddening decentralization of philosophy in this area. There are many passionately held but diametrically opposed views and statistical demonstrations among the courageous and well-informed people who struggle bravely every day to try to ameliorate the problem of drug addiction.

On the one hand, these differences of opinion are embarrassing, inasmuch as they make it impossible for Canada to identify itself with a single coherent strategy. On the other hand, these same differences are the greatest strength we have. An addict who cannot be helped within the aegis of one philosophy may well be helped within another.

In Vancouver there is widespread agreement that we need all four of the so-called pillars of drug policy—policing, prevention, treatment, and harm reduction—despite the dramatic confrontations that sometimes arise between the champions of each. The role of the federal government, in my view, is not to impose a single philosophy in our response to drug addiction, but to make sure there is room for all views to flourish wherever they have any success, however incoherent the whole may become.

Although it would be counterproductive to impose a centralized philosophical coherence, I think the committee must also recognize the hard fact that each of the pillars has a very long, well-documented history, both alone and in combination, which shows that not one of them, nor even a well-coordinated combination of them, offers any real prospects for substantially reducing the tragic problem of drug addiction. Nor is there any reason to think that new drug legislation, useful and compassionate as it will probably be, will be any more successful than past legislation in substantially reducing this problem.

Thus, the question of centralization of power leads directly to a more fundamental question. Why have our best methods, carried out by intelligent, compassionate practitioners and parliamentarians, failed to solve this problem over a century of effort?

I submit that this failure has occurred because for political and historical reasons we have not seen the full extent of the addiction problem that bedevils us. Drug addiction, as the committee's terms of reference point out, continually jumps out of the boundaries that are imposed on it. It is not merely a problem of injecting drugs, nor is it merely a problem of hard drugs used in a variety of ways, nor is it merely a problem of drugs used outside of medical practice.

We now know that serious addiction to medically prescribed drugs, alcohol, tobacco, and marijuana can have the same tragic and sometimes lethal consequences and the same causal dynamics as serious addiction to heroin and cocaine injection. But even if we include prescription drugs, alcohol, tobacco, and marijuana within our boundary for addiction, the boundary remains artificially narrow.

Serious addictions to gambling, shopping, food, etc., can have the same tragic and sometimes lethal consequences, and the same causal dynamics as drug addictions, although like drug use these practices are usually carried out in ways that are harmless and beneficial. Non-drug addictions are both equally tragic and far more prevalent than the problem of drug addictions.

Please do not imagine that in saying this I'm trivializing the doleful problems of Vancouver's downtown east side, where I have worked for many years. Incidentally, I always drive through there when I'm going to give a talk downtown because I want it to be in mind. But come with me one day for a walk further along Hastings Street, beyond the downtown east side in either direction, and I will show you a multitude of addictions that, though perhaps better concealed, are every bit as tragic and intractable.

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I've done a great deal of public speaking on the topic of addiction in British Columbia and elsewhere in Canada during the past three years following the publication of my article on the globalization of addiction. In these travels, I have learned, to my great surprise, that we Canadians are closer to a consensus now than we have been in the entire 30 years that I have worked in this field. I respectfully submit to the committee that most ordinary Canadians now understand, perhaps better than some professionals in the field, that addiction, in the most general sense of the word, is close to an epidemic problem in Canada and that it is not, fundamentally, a drug problem. Because it is not fundamentally a drug problem, Canadians, sad to say, have no high hopes that an adequate solution can come from further modifications of drug policies or drug legislation. This is not to say of course that modifications should not be made. Improvements are always desirable.

I further submit to the committee that most Canadians understand what causes the rising tide of addiction they see around them. They know that people lock themselves into addictive lifestyles when they cannot construct an adequate way to live within mainstream normal society. They know that it is becoming more and more difficult to construct an adequate lifestyle within mainstream society as people become more mobile, families more fragile, jobs more insecure and anonymous, and even our status as a sovereign and indissoluble Canadian nation becomes vague.

Addiction encroaches upon Canadian society because it can fill a void in each person, and these voids are growing ever larger. Addiction will increase no matter how much our drug policies and drug laws are improved. Therefore, I humbly request of the committee that in your report to Parliament you recommend a different kind of centralization than that of an empowered office of Canada's drug strategy. I ask that you report to Parliament that the power to do something about drug addiction does lie within its hands, but only when it acts beyond the artificial boundary of non-medical use of drugs. Drug addiction and all other forms of addiction will not decline until Canadian society finds a way to provide stability, security, and, above all, a coherent culture for our children and grandchildren.

As a single illustration, among many, of good work in this direction that Parliament has the power to implement, I will mention the federal government's current struggle, along with the B.C. government, to finally resolve, in a culturally sensitive way, the native land claims that have caused so much instability, insecurity, and incoherence for native people of British Columbia, and ultimately so much addiction. I think you, the committee, should ask Parliament that this same resolve to protect essential aspects of culture be concentrated in all its legislative work. When I speak to parents' groups, I tell them that the way for them to prevent addiction in their children is to find somehow the means to be good parents in bad times.

Years ago, when I started saying this, most parents objected, saying their children can be protected from addiction by more drug education and more police in the schools. But now that we have tried massive drug education and more police in the schools, those parents understand what I mean by this, and many more agree.

In a similar way, I hope I can today turn to Canada's Parliament, not as parents, of course, but as neighbours, elected to exercise power on behalf of my children and my grandchildren. I hope that my country's parliamentarians will understand that their role in combatting addiction is trying still harder to govern well in the interests of all the people, remembering always that people need a secure place in a society that they respect much more than they need increasing GDP, freer trade, and prominence in the international power game.

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It is within this centralization of Canadian resolve on the need for a more sustaining cultural base, I submit to you, that a realistic approach to the non-medical use of drugs and all the problems that are associated with it can indeed be achieved at the parliamentary level.

Thank you.

The Chair: Thank you, Professor Alexander. I'll now turn to Dr. Martin Schechter.

Dr. Martin Schechter (Head of Epidemiology and Biostatistics, University of British Columbia): Thank you very much for the invitation to appear and for accommodating scheduling problems. I also want to congratulate the committee for taking on this incredibly complex and challenging problem, and I also wish you the best of luck in your work.

I thought I would maybe take a personal view, the way Larry Campbell did, about how I came to this issue, and that's through HIV. So I think I will focus my remarks on the issue of HIV and drug use. Although we know that the problems associated with drug addiction are myriad, I'll concentrate on those for now.

I began working on HIV in 1983 at the very earliest stage of the epidemic, and at that time the issue of HIV in injection drug users was not a significant problem in Canada. Our epidemic in the earliest phases was primarily in men who have sex with men.

Over the course of the next ten years, the world saw a number of devastating outbreaks of HIV among injection drug users. And when I talk about an explosive outbreak, I'm referring to a situation where a community or a population can go from having a prevalence of HIV of 1% or 2% to 30% or 40% in the space of a year. That is what I refer to as an explosive epidemic.

Through the 1980s and early 1990s, explosive epidemics in injection drug users were seen in Edinburgh, Milan, Bangkok, New York City, Manipur, India, and more recently Odessa in Ukraine and in a number of centres around the world. We worried in Canada about the situation of injection drug users, and we had numerous discussions and warnings to governments about the potential. Our worst fears were realized when the city of Vancouver entered that hall of infamy as one of the cities to witness one of the most explosive outbreaks of HIV in injection drug users that has ever been witnessed. I'm referring to the downtown east side of Vancouver and the years, 1996, 1997, and 1998.

I know Dr. Tyndall, one of our staff, was here this morning, and I hope I'm not repeating some of what he said, but we now know that approximately 40% of injection drug users in that area have HIV infection and 90% of them have hepatitis C infection, which means that the overwhelming majority of people with HIV are co-infected with hepatitis C. That makes the treatment issues associated with both infections infinitely more complicated, because our use of drugs is compromised by the presence of both infections.

I should say as well that we've now seen smaller explosive outbreaks of injection drug users in Ottawa. Recently, in the newly independent states of the former Soviet Union, China, India, and Indonesia, there are now ongoing explosive outbreaks among injection drug users.

So I come to this situation of addiction through that lens, and in my other life I work as a physician epidemiologist whose job is to look at medical evidence. As I began to look at the issue of addiction and its treatment, it became clear to me that the current armamentarium of treatments for people with opiate addiction is very inadequate based on the medical literature.

I had the opportunity over the past two years to be part of a working group of North American addiction specialists who educated me as to where we stand. The situation for opiate addiction is that we have one therapy that is effective, called methadone. When studies are done that compare methadone with no treatment, it's clear that it does provide benefit to some people with opiate addiction.

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The problem, however, is that it is also clear that methadone will not work for a significant number of people who are addicted to heroin and opiates. That is absolutely clear from the medical literature. Therefore, I believe that those people who would say that methadone is all we need to conquer this problem within the pillar of treatment are overstating the case. To use Larry Campbell's analogy, it would be like me saying that currently we can treat 30% or 40% of people with cancer. There's a significant number of people who will not be cured by our current chemotherapies, but let's stop and not look for any future therapy or do any more research. That is clearly an indefensible position.

So I would argue from the point of view of medical research and treatment that we urgently need to look at alternative treatments. Those that are currently of interest are the medical prescription of heroin and the medical prescription of other drugs. I believe this should be investigated scientifically. We should not say outright that it is not going to work, nor should we immediately embrace those kinds of treatments without adequate study.

There are encouraging results from other parts of the world that suggest that alternative strategies, such as the medical prescription of heroin, can be effective additions to methadone, particularly for those people who have failed methadone therapy and for whom we have no alternatives to offer. That subgroup tends to be the group that gives rise to the greatest number of public problems associated with opiate addiction. Therefore, reaching them and getting them into therapy and in contact with the health care system and all kinds of ancillary services that you can bring to them once you have them in contact with you could reap enormous benefits on the social side.

I also speak as someone who lives in Vancouver and is tired of having his car broken into and his house robbed.

I agree with Professor Alexander that public opinion has changed in this country. I think people are tired of the downtown east side and are embarrassed by this blight. It's an affront to what we believe is valuable in Canadian society. Like them, I believe we have to look at alternatives and to think in new ways in order to affect the problem.

The final thing I want to say is that within the context of HIV there's something that people often forget. HIV causes AIDS. If you don't get HIV, you do not get AIDS. Therefore, every time you prevent a case of HIV infection, you absolutely prevent a case of AIDS. Unlike other illnesses, we have a disease that is essentially 100% preventable, and that's AIDS. Every time we prevent a case of HIV infection, we save $200,000 of downstream medical care costs. Each year in Canada about 4,000 people are becoming infected with HIV, half of whom are injection drug users. So the mortgage on our children at the present time for HIV is $800 million per year, $400 million of which is for injection drug users who have HIV infection. Therefore, if not for sound social policy but for economic policy, it's absolutely critical that we try to prevent every single case of HIV infection, because the benefits economically and socially are enormous.

Thank you.

The Chair: Thank you, Dr. Schechter.

Finally, we'll hear from Dr. O'Shaughnessy.

Dr. Michael O'Shaughnessy (Vice-President, Research; Director, Centre of Excellence in HIV/AIDS, University of British Columbia): Thank you for this opportunity to speak today.

Martin mentioned the lens through which he sees things. I would like to remind everyone that this weekend the star of Through a Blue Lens died of a drug overdose. We had worked with this woman a number of times, but she was just not able to continue to resist injecting drugs, and she died this weekend.

I come to this from a different perspective. Martin and I are trying to stay tough and ensure that a heroin trial happens. You may wonder why anybody would want to do that. I can tell you that there is a lot of heat about this very issue of a heroin trial.

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I do it for a number of reasons. One is that in the summer and fall of 1997, 2,500 people in the downtown east side acquired HIV. We're all going to die, but they're going to die from HIV. About 9,000 people got hepatitis C in the same year. Of those people, 3,000 are going to die. So in one summer our policies helped generate an outbreak that will cause 5,500 additional deaths. In fact, when you look at the downtown east side, life expectancy is declining. It is one of the few places in the country where you can experience that.

As we said, I represent the Centre of Excellence in HIV/AIDS, and we provide all the drugs for all the positive people. If you just think, my program now costs $10,000 a person. So if we're looking at treating 2,500 additional people times $10,000, that's an enormous amount of money. Mind you, I think if we have to focus on the monetary side, we've lost something in the equation where we don't think about people.

Martin and I spoke to the caucus of a government, and this person, who represented a rural area, came to me and said, “I wouldn't have listened to you guys before, but my daughter is down there. She's on the street, so I'm going to listen to what you say.” We're talking about a lot of folks. This situation is replicated across Canada.

This is a federal committee. Besides helping to shape policy, I think you need to look at the drug policies for populations you specifically look after. In my view, the problem with addictions in the aboriginal community is astounding. With regard to what will happen in the aboriginal community with HIV and hepatitis C, the federal government needs to step up to the plate and say, we need to look at how we're going to address these problems. When the aboriginal leadership addresses this issue, it will be a factor in all treaty talks, because these are very expensive illnesses to treat. They're going to say, wait a minute, you're giving us self-government but somebody needs to look after these issues.

One of the things I heard is, what's the answer? I think Larry Campbell framed it well in saying there really is no answer. I think that's correct. There is no answer.

As a scientist, and that's what I am, I always look at problems and say, if I apply ingenious or good methods, where does it end up? That's where we're at today on a heroin prescription trial.

I have seen the disaster. Twenty percent of all the acute care patients who come into our hospital have addictions. What are we going to do, just let that number roll up? I can tell you now that the treatments are not that effective. We see the same people day in and day out. They come in; they go into, say, psychiatry; three months later they're out; and four months later they're back in. They come into the medical wards with endocarditis or HIV. They come in, are discharged, and come back in.

So for me, as a practical person, it's time to break the mould and look at some of these innovations. Try a heroin trial, because the status quo is not acceptable. We have one person a week die of HIV in our hospital. But with the natural history of the disease in the IDUs, we're going to go back to where it was when I came ten years ago, where we'll have a person a day die in my hospital from HIV, and they'll almost all be addicts.

Thank you.

The Chair: Thank you, Dr. O'Shaughnessy.

Thank you to all of you for some pretty compelling testimony.

We will now go to a round of questions. The question may be directed to somebody in particular, but if anyone else is interested, you could give me a signal and I'll make sure you get on. We'll try to keep the questions short so that there are lots of opportunities for answers.

• 1145

Mr. White, for seven minutes.

Mr. Randy White: I don't know. I'm getting depressed, guys. I read the original national drug strategy, a document that was put out by the Conservatives in 1989, I think it was, and I looked at the national drug strategy that was put out by the current government, which is very similar to the one the Conservatives had done. After looking at them both, I asked myself this question: Is this drug strategy working? Does anybody even know that it exists? What tangible things can I do with this document to convince myself it's working? I have yet to find anything tangible about it, to tell you the truth.

Someone said before you that it's really not getting worse. The level of addiction is staying the same. You couldn't convince my communities of Abbotsford and Langley of that for sure.

The question I'm seeking in all of this is, what does a federal government do to replace a current strategy that doesn't appear to be working? In fact, I've taken that strategy across the country in various places and people didn't even really know it existed.

People here often talk about DTES as being the worse case, and I would agree with that. However, Walley is bad now. My communities of Langley and Abbotsford are bad. I was saying before you arrived that we heard the other night that we now have 40 prostitutes in Abbotsford, which never had any before, quite frankly. But in Abbotsford and Langley you can't talk about needle exchanges or safe injection sites. That just doesn't wash.

So I'm at a loss here. I'm trying to figure out, just as you seem to be, how this really works. What is a tangible drug strategy that could work?

Here are some of the suggestions I have so far. We have the primary role to provide leadership, set direction, model a comprehensive collaborative approach, don't create obstacles, no large bureaucratic agendas, and provide an overall policy and concept. Ironically enough, nobody said give us more money—yet.

Help me out here on this thing. I tend to be probably the more conservative type here, but I'm open on this. I'm at a loss as to a national strategy. What can a federal government do that would pick up on your presentation so that we can say, finally, we're getting somewhere with this thing? What is it?

The Chair: Mr. Campbell has indicated he wanted to speak, and I think Dr. Schechter moved up to the table.

Mr. Larry Campbell: In 1976 I opened the drug section in Langley, British Columbia. I can tell you there have always been drugs in Langley. Walley has always had major problems. I lived in Abbotsford and Abbotsford had problems then. There were prostitutes in Abbotsford in those years. They probably weren't as recognizable as they are now.

The fact of the matter is that no society, no community, is safe from this. Abbotsford was the sleepy little town, but things change. Populations change.

So I have two answers to your question of what you should do. The first answer is be brave. That's the first answer. None of this stuff we're talking about here is mainstream, although it's becoming much more so. I can remember going to speak and having somebody in the audience tell me that people who were drug addicted liked it and deserved it. Now I think that has changed.

Secondly, my suggestion to you is to learn by the successes and don't move yourself into a position of failure. If Abbotsford and Langley want to fight things that are successful such as safe needle exchanges, that's fine. They're going to pay the consequences of it, and down the road eventually the community will recognize this. But they will pay the consequences of it. There's simply no doubt about it. Don't try those things that aren't successful. That's the beauty of where we are now. We can look around. But by simply ignoring it or by simply going on faith-based abstinence, Langley and Abbotsford will experience exactly the same things that have happened here in Vancouver. If we did not have a needle exchange in Vancouver, I shudder to think what would have happened—the catastrophic events that Marty talked about. It would just have been unbelievable.

• 1150

So be brave and go out there and try the things that we know work. Needle exchanges cause addicts like garbage causes flies.

The Chair: Dr. Schechter.

Dr. Martin Schechter: I would just add one quick comment. I have seen a sea change in public opinion in Vancouver. Obviously you know your constituents better than any of us, but I would predict that this change will spread, because I have seen in my career the attitudes towards injection drug use and our approach move 180 degrees among suburbanites in Vancouver, outside the downtown east side. People can see that our current strategy is not working. I therefore predict with some educational work people will change their minds on this issue.

I don't know about the details of strategies, but heuristically if you look at Canada as a nation, our current strategy is based on the criminal justice system. So, to your big question, what's the one thing we can do, my answer is that through whatever means parliamentarians have, we must change our approach to this problem from where the major thrust is criminal justice to a health-based approach. If that can be the overarching principle of the national response, I think we'll move ahead.

The Chair: Thank you.

I have Professor Alexander, Mr. McMahon, and Dr. O'Shaughnessy.

Prof. Bruce Alexander: Your question really speaks to me, partly because I'm contemplating my own retirement from the university. I've grown old in this business, and I've seen so much intelligence focused on answering that question over the last 30 years. I think it is now obvious—at least it's obvious to me—that there is no answer to that question, as long as it's framed that way. The reason there's no answer is that the frame for the question doesn't work. If we say, how do we solve the problem of drug abuse, we're lost. I think if you look carefully at what's being written, people agree on that. They say, well, we can ameliorate it a little bit, but we can't solve it. The reason we can't solve it is because it's the wrong frame to put around it.

What I tried to say in my own talk is that if we reframe that issue and look at the larger problem of addiction and the kinds of failures that are so widely experienced by so many people now, then we can deal with it. Then it's quite clear that the government does have a role in providing a better kind of cultural sustenance for the people in our culture. Of course, that's what the government is doing anyway. But what it says is that government must go back to fundamentals. It must do that better and that anything short of that is bound to be a band-aid. There's nothing wrong with band-aids. There are many people who are very good at providing very good band-aids, and they're very important and it must be done. But if the larger question is asked, then I think it can only be answered by being reframed in that way.

The Chair: Thank you.

Mr. McMahon.

Mr. Fred McMahon: I think one of the reasons for your confusion is that the question is usually framed inside the box of a failed policy. We've known that this policy has failed for 20 or 30 years now, and there's been this constant idea that if we had more resources.... As you noted, that's at a stall now; nobody's asking for more money. Well, if it's not resources, then we'll tweak this or we'll tweak that or we'll tweak the other thing.

• 1155

One of our key problems, which I mentioned earlier, is that this policy—and I'm talking outside the box now—has in effect caused the government to indirectly hire an army of talented recruiters to go out there and form criminal networks and recruit new addicts to spread the problem. The people at this table, other than myself, have all been on the front line fighting it. Well, we've put out some people on the front line fighting it, but the other side is immensely wealthier, has immensely more people on the ground, and can go out and find those new recruits. Until we deal with that problem, all this other stuff is going to be tinkering on the side.

You mentioned that you come from the conservative side of the spectrum. Any number of conservative thinkers have come to the conclusion that our drug policy shouldn't be tinkered with; it should be dramatically changed. Milton Friedman, William F. Buckley—there's a long list there. We need to fire that army of recruiters and deal with it in some of the ways we did in the past. That's a dramatic rethink, but I think we should start down that road.

The Chair: Thank you.

Dr. O'Shaughnessy.

Dr. Michael O'Shaughnessy: As the federal government deliberates what to do, you need to develop a process of accountability with your partners. I'll give a good example of that. We talked about needle exchange in Abbotsford, and I'll use it where I live.

I live in Maple Ridge. We have no needle exchange. The council says we have no addicts, so we have no needle exchange. So our addicts in Maple Ridge travel into Vancouver, the hot zone. They go in there, buy their drugs, share their drugs, get infected, and come home. Why? Because everybody is in such denial over needle exchange. All you have to do is go to Chilliwack to see how many needles are given out there. That's a pretty rural, religious community, and I can tell you there's a big demand.

Whatever the federal government does, you need to not let your partners off. When the province says it's not going to encourage communities to have needle exchange, it's going to be helter skelter. That's what's happening. We've done a paper where we saw the distribution of HIV along the sky train. The reason is that people were coming into the downtown east side for services.

So truly the federal government needs to take a leadership role. You need your partners to shake their heads and say, “What are the policies causing?” Certainly needle exchange was a simple one. Decriminalization and all those other things are bigger issues, but there are some fundamental issues where some levels of government have been able to get away with not doing anything. In my view, that just increased the harms.

The Chair: Thank you, Dr. O'Shaughnessy.

Ms. Davies, you have a theoretical seven minutes.

Ms. Libby Davies: Yes, you have the clock, not me.

First of all, thank you very much for coming. You guys are a real powerhouse of testimony this morning, and I kind of wish you could follow us across the country.

I actually want to begin by going back to a meeting I had with you, Dr. Schechter, after I was first elected. You might remember; it was in my office with Bud Osborne. What you told me then was that, given what we know about the Krever commission and what happened to Canada's blood supply—the issue of public consciousness, of public disclosure, of knowledge about what was happening—if we failed to act as a federal government, or any other person in a place of authority, it would be criminally negligent. I think those were your words. It was something that really stuck with me. I told you I would go back to the House of Commons and raise it with the Minister of Health, which I did do, and he kind of slipped off it.

• 1200

But it's a very fundamental point. When we have a consciousness about what has actually happened in terms of a failure of public policy, what are the consequences if we fail to act in terms of the positions we hold?

This is to all of you. Do you feel we've actually made progress in getting beyond denial in terms of people in positions of authority? If we have, there is a debate about whether our response has to be national or whether it can be more local. I put this more specifically in terms of the heroin prescription trials. As you know, I've supported that very much, and I support the idea that it should be national. But I'm also worried; if we can't get support across the country, what do we do?

Today we've heard quite a lot of evidence from people saying that we should actually focus this from a community basis and what we know within the local community. If we're ready to move, we should move. I wonder how that sits in terms of where we might go regarding safe injection sites and heroin prescription trials. If we're ready to go in Vancouver, I don't want to see any holdup to that while we're trying to get Toronto or Montreal or wherever else. Do you generally advocate that we should move on that basis, or are you still feeling it has to be a kind of national initiative?

Dr. Martin Schechter: Actually, Dr. O'Shaughnessy and I wrote an intentionally provocative piece in the Canadian Medical Association Journal called “Krever 2008”. It basically said that I was a member of the Krever commission, a committee of theirs, so I knew the work they did.

When I was doing that, it struck me that many people were called to account for knowingly distributing blood products that were tainted and for not doing the utmost. If you have a community where a politician says they will not have a needle exchange, knowing the evidence on what needle exchange can do for HIV infection.... I saw a clear parallel in how that person ought to be called to account in much the same way that administrators were called to account by the Krever commission. So it was just a provocative piece.

Your other question is a complicated one, because we are sort of on the interface between science and practice. When we're talking about trials and experiments, one of the fundamental questions people will ask is whether a trial done in Vancouver will work in Toronto and Montreal. Right now, for example, the Swiss and the Dutch are doing trials, and people in North America who are opposed are saying that doesn't establish the fact that it will work in our setting. So part of the reason for doing it in multiple centres is for that kind of generalizability issue.

Referring to the specific case of the heroin trial, Toronto and Montreal are ready to go. There is nothing stopping us other than a few requirements to go through. Toronto and Montreal are ready to go, and so is Vancouver. The issue right now is funding. So there's not any kind of impediment to us going on a three-province basis—I guess you wouldn't call it national—other than the funding issue.

Ms. Libby Davies: Where was that funding...? Is that through the protocol that was set up? I forget what it's called.

Dr. Martin Schechter: NAOMI. Yes.

Mr. Larry Campbell: I don't know that we should speak of success or failure, but rather whether we are moving along. Certainly one of the things that Dr. O'Shaughnessy said is important is that if you're in denial in Surrey, which they are, then there's no way of gauging the magnitude of the problem.

I can tell you that probably somewhere around 40% of the people who died in Vancouver didn't live in Vancouver. They came from New Westminster, they came from Surrey, they came from North Van, Abbotsford. They came into this location because it's a drug market and there really is no risk. As I said, it's not a recreational drug, so they don't sit and watch the hockey game while they crank. They find an alley, they crank, and they die.

• 1205

One of the things we have to do—and I agree with Dr. Schechter very much—centres on the fact that it does no good for Vancouver to be enlightened if the communities around it are in denial. It simply won't work. Whether it's a success or a failure, I don't know. There are areas where that has been successful, but that's what I found as chief coroner. When you go out and speak to these municipalities, their reaction is, it's all Vancouver; it's all the downtown east side. Yet that's not true.

The Chair: Thank you.

Ms. Davies.

Ms. Libby Davies: I support that, but I just feel this urgency, a sense that we have to get on with it. I hear what you say about the national trials, but when we come to safe injection sites, we had the demonstration set up on Saturday. It was very powerful because it really showed how a low-threshold intervention can still be very effective.

If we're ready to go there and no one else is, I just wonder how you see this. Should we be pushing ahead there and at least providing some impact in the community that is worst hit? I would like other neighbourhoods or even other municipalities to participate in that, but if it means waiting another year or two—we've waited so long already—how do you feel about that?

The Chair: Dr. Schechter.

Dr. Martin Schechter: I think I'd make a distinction between the need to do a heroin trial on a multi-centre basis and the evaluation of safe injection sites. I think you're absolutely right. A safer injection site is very contextual, and the kinds of analyses one would look at in terms of evaluating it are different from what we do with multi-centre medical trials, where we're looking at clinical outcomes in individual people. With safe injection sites we're going to look at impacts on neighbourhoods and the effects on people who use the sites, and I don't see any reason that can't be done locally. I'd distinguish between the two.

The Chair: Mr. Campbell.

Mr. Larry Campbell: One of the things I'm expressly interested in with the safe injection facilities is the statistics as to who is using it. That's going to be incredibly interesting because we're going to be able to then gather data that says, here's where these people live. Then we'll be able to go forward on that. Again, we've waited way too long as it is. People are dying out there, and they don't have to. They simply don't have to.

We should go ahead on it. The argument is, well, they're all going to come to Vancouver. Hello...? They're all coming to Vancouver already, and it's not going to change. But now we can at least say to these other communities that statistically this is what's happening. They have to understand that.

The Chair: Dr. Schechter.

Dr. Martin Schechter: If I could, I'll just add one point that is critically important, and it has to do with this theme of the honey-pot effect that keeps coming up. People will say, well, we can't open this kind of service because drug addicts will come to this community. That's been an excuse that's been used over and over again in lots of different jurisdictions.

We have a study in Vancouver that Dr. Tyndall talked about this morning. We asked the people in the VIDU study, 1,500 injection drug users who come from all over the lower mainland, why do you come to the downtown east side? Is it because of the needle exchange? Is it because of services? Is it because of any of those things? It was never because of those things. They come there because the drugs are there, and that's the only reason.

I say this to any jurisdiction that says they can't offer this service because addicts will move to their community because of it: there's no scientific evidence whatsoever to support that.

The Chair: Thank you.

Can I just ask a secondary question to Ms. Davies'?

Is part of the issue the fact that you're concerned that if these outlying communities don't do anything in, for instance, your case, Dr. O'Shaughnessy, you will move the population into an area where they then lose the rest of the supports they might have? Are you concerned that as a result it will perhaps be harder for them to be reintegrated or to move into a different phase of life? Is that also part of the concern, that everyone is coming away from their support networks into some other area, or not?

Dr. Michael O'Shaughnessy: There are a couple of layers of answers to your question. One of the things is, if you don't provide, say, needle exchange in Maple Ridge, where I live, do you know what will happen? They'll reuse the needles. They'll share. If we don't provide drug treatment, for instance, the methadone clinic, how are you going to get people off the drug? I agree with Martin and Larry; the big attraction in the downtown east side is, where else can you go buy some points of heroin for 10 bucks? It's in the downtown east side, so they go there for that.

• 1210

But at the same time, when the rural communities or less central communities don't provide the service, you're denying these folks a way out. If they want to use the needle exchange, that means they have to go into the hot zone, which is crazy. Most times, do you know what happens? They don't access the service because as addicts they say, give me the service now. If you can't put them in care or whatever, then they're just going to continue to do what they do. The window is pretty small.

The Chair: Mr. Campbell.

Dr. Larry Campbell: They're coming back to your community, and they're spreading the disease within your community. For instance, if I lived in Abbotsford, I'd probably still go downtown to score my drugs, but if there were a safe needle exchange in Abbotsford, what I would do is go and exchange my needle. It would cost me nothing. I would go downtown to score and crank, but I'm still going back to my community. I'm still going back to Abbotsford. As Michael says, it's there; it's just there to be used. If I don't have it, at some point I'm not going to care, and I'm going to share the needle.

The Chair: Dr. Schechter.

Dr. Martin Schechter: From a health point of view, if you're, say, the health officer in Abbotsford, where the prevalence of HIV among drug users is maybe 1%, 2%, or 3%, the last thing you want drug users in Abbotsford to do is go down and share in the downtown east side, where the prevalence is 40%. You want to have the services available there, for example, a safe injection site, that will allow that. Otherwise, they're going to come down, get infected, and go back. That's how this epidemic spreads out from urban centres.

The Chair: Mr. McMahon.

Mr. Fred McMahon: I just have a quick question. What is the use of a prohibition policy if anybody can jump on the Sky Train, go down to east Vancouver, and pick up supplies? In fact, you find this in every major city in Canada, and to some extent it worsens the problem because what you're doing is drawing addicts into such a drug ghetto, as well as creating the recruiters. Again, what is the point of a policy of prohibition if you can hop on a Sky Train, a bus, or whatever and pick up whatever drugs you want?

The Chair: Mr. Owen, please.

Mr. Stephen Owen: Thank you. Thank you all for being here, and in particular or in a greater way, thank you for all the important work you've done in our community.

I have a few observations and questions. Vince Cain, John Miller, Larry Campbell, and Terry Blythe, pillars of our community from the health side as well as the enforcement side, have all been saying in a very forceful way for over a decade that our current approach isn't working. Maybe public attitudes are changing in Vancouver—and the discussion around the Vancouver agreement indicates that they are—but they haven't changed in the broader society. Part of our role is to get your message out more effectively, and I hope we can do that.

The consequence of getting the message out will be the acceptance in our broader community across the country of the need for these types of services. Also, beyond the triage aspect of the downtown east side, we're going to share the response in a more effective way. You've partly answered this already, but how do we get that message out?

Mr. McMahon, interestingly enough, about eight years ago I read a Fraser Institute article that made the economic argument, the one you've made, in the most exhaustive way against the war on drugs policy. To Gladstone's assertion that he would die either at the gallows or of venereal disease, Disraeli answered, “That would depend on whether I embraced your principles or your mistress.”

• 1215

Some hon. members: Oh, oh!

Mr. Stephen Owen: Well, we can perhaps add “or whether I indulged in your laudanum”.

My question for you relates to organized crime—an accurate description of it, being a source of a lot of this problem. The problem with organized crime is that it resides constantly just at the other side of whatever policy line we draw. Simply by liberalizing the soft drug approach, we will have that concentration just on the other side of where we draw that line. That's true in prostitution, in drug policy, in guns, and most things.

So an economic question doesn't help us with the organized crime or enterprise crime problem. Does it just shift upstream their involvement in the drug trade?

Professor Alexander, you say if we have a centralized objective it should be for coherence. I agree with that. I wonder what your opinion is on the Vancouver agreement as a model for coherence that can draw on local experience and reality in a way. Is that something we can duplicate, at least as a process model, across the country?

Dr. Schechter, your discussion was focused—and I know your experience is much broader than this—on the intravenous drug users as the object of your specific work in the downtown east side. To what extent is that the driving problem of HIV and hepatitis C spread, or is it one of the stops along the way of social conditions, of poverty, gender imbalance, mental illness, and then a basic unhealthy situation in the downtown east side?

You bring up the issue of aboriginal victims of the disease. It seems to me the prevalence rates you're describing very much mimic the prevalence rates in Africa, which would suggest this is not unique, that the pandemic over there isn't something different from what we have here but something quite similar, and that should guide our approach to it.

In that regard, Dr. O'Shaughnessy, I'm interested in the approach of the federal government towards aboriginal health. I wonder if we're mimicking the African experience of poverty and gender imbalance and transience more than anything. Are we finding and are we looking in Canada at the rural aboriginal situation? We know that prevalence rates are enormous in the downtown east side. Are we getting the transient moving from impoverished native rural community to urban centres in Winnipeg and Vancouver, and is that cycle spreading it in rural situations?

The Chair: On the first issue, of organized crime, I've got Messrs McMahon and Campbell. Then we'll go to the coherence one, and we've got Alexander, and then Schechter. And I think we have Campbell and O'Shaughnessy on the drug users and unhealthy aboriginals.

Mr. McMahon.

Mr. Fred McMahon: With that list of questions, I guess we can close the doors for the rest of the afternoon.

Some hon. members: Oh, oh!

Mr. Fred McMahon: As for organized crime, you simply want to cut off as much territory as you can to them; therefore, the more you bring within the legal realm, the less territory there is. For instance, if we did prohibition again, you would open up more territory to legalized crime. You would have an increase in crime gangs and social pathologies that come from that. That said, if we legalized all drugs tomorrow, it would take a long time to wind down those criminal gangs, as it took a long time.... In fact, the criminal gangs that grew up during the prohibition period have never been wound down, but they have been dramatically reduced and their influence cut back.

• 1220

You simply want to limit the territory, as much as you can, that's available to organized crime to make a profit from.

As for the economic losses that go with this, they are virtually unimaginable, because there's the direct cost of policing—some estimates put it at around $2 billion—and we have no idea how much is taken out of the economy because of lives ruined, because of the war on drugs, the recruitment, and so on. Many people could exist and be healthy members of the workforce, if the stuff were legal, at a low level of addiction—and have help to get themselves off it. There's an immense problem there.

The social problems and secondary crime that come out of the war on drugs again represent an astronomical sum, but nobody knows what it is. Then, finally, there are some really good entrepreneurs over on the other side of the street. They would benefit our economy immensely. It was a good thing that Joe Kennedy stopped being a rum runner and started working on the legitimate side of the street. Sam Bronfman did pretty well. We have a number of entrepreneurs over on that side of the street who could be contributing to the economy.

So the economic costs of this war on drugs are astronomical, and in my opinion incalculable, although economists, as always, will come up with answers to incalculable questions.

The Chair: Thank you.

I think Mr. Campbell wanted to comment on this one as well.

Mr. Larry Campbell: I have to draw the line at working with those entrepreneurs on the other side.

I'm afraid I don't agree with decriminalization. I understand exactly what's being said here, but if we can't get needle exchanges, I think it's going to be a huge leap. Sometimes I wake up in the middle of the night just realizing that I'm on the same side as the Fraser Institute and I like that; I really like that.

I think you're going to hear from the enforcement side, obviously, and I have to tell you that interdiction and all the rest of it, while important, is not a significant factor in the criminal world, especially when it comes to drugs. We have a waterfront here that has no police force now, and coming in through there it's just like a huge, huge pipe—I can guarantee you that. If I am the entrepreneur, I can go overseas—and I can tell you right now, as a result of the war against Afghanistan, get ready, because this is going to crank right up again.

One of the reasons we see such a huge increase in the amount of drugs is because they're good farmers. There's a glut on the market, and anybody can get it. If I'm a good entrepreneur, I hire four mules, send them over to pick up the drugs, and if one of them gets through, I'm making a million. And you know what? I don't care about those mules. I don't care about them and I don't care about the $3,000 I gave them to carry the suitcase.

The criminal element will simply go and find something else. Mr. Owen's right; they're always just on the other side. If I'm a police officer, they don't have to ever play by my rules, and they never play by rules. If I play by their rules, then suddenly I'm sharing a cell with them somewhere. I'm sure the police will get into that part of it.

The other thing you will hear is that marijuana is a gateway drug. That's garbage. If marijuana were a gateway drug, three-quarters of the Canadian population would be addicts. It's not a gateway drug. The gateways to addiction are poverty, unemployment, homelessness, and, surprisingly enough—something that people don't think of—ostracism; people who don't fit within the mould. They haven't been abused, but they don't fit within the mould. Because of that, they go where people will accept them. That's all I have to say.

The Chair: Thank you.

Professor Alexander.

Prof. Bruce Alexander: I think the Vancouver agreement is a marvellous achievement—an incredible achievement, really, if you have some sense of how much work went into bringing it into place. Some of its main architects are here and I think they deserve tons of credit for being involved in it.

• 1225

In my opinion, this is also the answer to Libby Davies' question earlier, “Have we made progress?” The answer is yes, at the city level we've made tremendous progress. I think the answer is no, at the federal level, we haven't made progress. That's because.... Well, I won't repeat my whole story but I'll tell an anecdote, if I may, to perhaps illustrate what I mean.

If we go back 125 years or so and look at Vancouver, it was all native people, of course, 150 years ago. I'm not going to do a noble savage routine here. These were ordinary human beings and they had complicated lives with lots of problems. They had slaves, lots of wars, and they had insanity—all kinds of problems. They didn't have addiction. They had none of that, as far as I can find out, and I've checked very hard to find this out. They didn't have it.

They then ran into a federal policy, of a sort, and these same people went to the point at which they have very close to 100% addiction and the federal government is now, in its wisdom, doing a lot to try to restore some of what is lost. Obviously, these people can't go back to the pre-civilized condition in which they lived—they can't do that—but something of what was there can be restored. Some sense of culture can be restored, and I think the federal and provincial governments are working sensitively and very hard to do this right now.

I think the realization that goes into that work needs to go into everything the federal government does. I think only when that happens will the federal government be playing its role, not only in dealing with the kind of addiction we're talking about in the downtown east side, but in a much larger expanse of addiction and malaise that surrounds us as well.

The Chair: Thank you.

Dr. Schechter.

Dr. Martin Schechter: I think the comment was an excellent one about the sort of social determinants of this entire problem. The point is well taken. The needle—HIV or an overdose—is just the final common pathway of a whole host of social situations, and you raised some. We know from our study, VIDUS, that there's a tremendous amount of history of sexual abuse of these people in the past. In the aboriginal community, you can question the role of residential schooling in the current situation, and on and on.

As Larry pointed out, these people are not injecting in an alley and watching the hockey game while they feel good. These are people who are self-medicating because of a whole host of antecedent problems. Quite rightly, if we don't address those through other means, we will be facing more and more addicted people down the line.

I focused on HIV and the final common pathways because there's a principle in emergency medicine that says if you have a patient who is bleeding, whose heart has stopped and who isn't breathing, you deal with their airway first. Why do you do that? Because that's the thing that's going to kill them the quickest, and then you turn your attention to the bleeding and the heart.

Similarly, what we have here are people who have broken lives, and the goal is to stabilize them before irreversible harm happens, like HIV, hepatitis C, or an overdose. Then, hopefully, there can be other services and things to address the underlying problems that are really the source.

You are right. All our policies that are creating these kinds of lives have to be addressed at the same time. Gender imbalance, power imbalance, abuse, are all part of the milieu.

The Chair: Dr. O'Shaughnessy.

Dr. Michael O'Shaughnessy: You asked a question about the aboriginal community. It's interesting because earlier Martin alluded to the Krever commission. The Krever commission was held because 1,100 people who received blood products got HIV.

We're now talking about something much larger than that, even in the downtown east side. But in the aboriginal community, one of the difficulties with approaching HIV and drug addiction is the split responsibility. When you work with the community, you can see the fissures, because governments tend to think, go on reserve, do my job, then go off reserve. But what we see in the downtown east side is a recycling, from the city to their ancestral home, for a break. Many of them leave the downtown east side and what they do is get sorted out, they get off drugs, kind of recover, get their health back a little, and then come back to Vancouver. So there's this recycling.

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However, the programs are discrete. We have a federal program here and maybe no program there—maybe a provincial program—but when it comes to what the federal government should be doing, it should be driving toward talking to each other.

With the problems of addictions, starting with alcohol, then drugs, and then HIV in there, I think this community is in for a catastrophic event. Part of it is that the members of the community who have addictions don't come forward because they're ostracized. I know that personally. We have a place in the interior, and people with HIV, native people, will come to talk to me because they can't talk to anybody on their reserve. So there is a real leadership role for the federal government here, because there are too many fissures between the programs.

The Chair: Mr. Owen, do you have any final comments?

Mr. Stephen Owen: No, that's fine. I got a lot of important information on the record, thank you.

The Chair: Thank you, gentlemen. You've certainly given us lots of food for thought and the benefit of years of experience, and we really are encouraged by all of the mandate you've given us.

Thank you very much. We do wish you the very best at the work you're doing here in Vancouver, and hopefully across the country in the case of Dr. Schechter and Dr. O'Shaughnessy.

Thank you very much, Mr. Owen, for being with us this morning. It's been great to have your expertise as well.

Again, if anybody has anything they want to send to us following this meeting or as a result of something they read about this week, please send it to the clerk and she will make sure it's distributed to everybody in both official languages.

We will adjourn until 2 p.m., and then we'll have another panel.