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37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

EVIDENCE

CONTENTS

Tuesday, February 19, 2002

0840

The Chair (Ms. Paddy Torsney (Burlington, Lib.))

Mr. Walter Cavalieri (Representative, The Canadian Harm Reduction Network)

0845

0850

0855

The Chair

Dr. David Marsh (Clinical Director for Addiction Medicine, Centre for Addiction and Mental Health)

0900

The Chair

Ms. Koshala Nallanayagam (Hep C Coordinator, Prisoners' HIV/AIDS Support Action Network)

The Chair

Ms. Koshala Nallanayagam

0905

0920

The Chair

Ms. Koshala Nallanayagam

The Chair

Ms. Koshala Nallanayagam

The Chair

Ms. Koshala Nallanayagam

The Chair

0925

Mr. Toby Druce (Program Coordinator, Seaton House)

Mr. Chris Gibson (Program Supervisor, Seaton House)

0930

0935

The Chair

Mr. Glenn Betteridge (Member, Canadian HIV-AIDS Legal Network)

0940

0945

The Chair

0950

Mr. Glenn Betteridge

The Chair

Mr. Randy White (Langley--Abbotsford, Canadian Alliance)

0955

Dr. David Marsh

Mr. Randy White

Dr. David Marsh

Mr. Randy White

The Chair

Mr. Chris Gibson

1000

The Chair

Mr. Toby Druce

The Chair

Dr. David Marsh

1005

The Chair

Dr. David Marsh

Mr. Lee

The Chair

Mr. Lee

Dr. David Marsh

Mr. Lee

The Chair

Mr. Randy White

Mr. Walter Cavalieri

1010

Mr. Randy White

The Chair

Dr. David Marsh

The Chair

Ms. Davies

The Chair

1015

Mr. Walter Cavalieri

The Chair

Mr. Toby Druce

The Chair

Mr. Toby Druce

The Chair

1020

Mr. Chris Gibson

The Chair

Mr. Chris Gibson

The Chair

Mr. Chris Gibson

The Chair

Mr. Chris Gibson

Mr. Toby Druce

1025

The Chair

Ms. Davies

The Chair

Dr. David Marsh

1030

Ms. Davies

Dr. David Marsh

Ms. Davies

The Chair

Dr. David Marsh

1035

The Chair

Mr. Toby Druce

The Chair

Mr. Walter Cavalieri

The Chair

Ms. Koshala Nallanayagam

1040

The Chair

Mr. Glenn Betteridge

The Chair

Mr. Toby Druce

The Chair

Mr. Chris Gibson

1045

The Chair

Dr. David Marsh

The Chair

Ms. Fry

The Chair

Mr. Toby Druce

The Chair

Ms. Koshala Nallanayagam

The Chair

Dr. David Marsh

The Chair

Mr. Walter Cavalieri

The Chair

Mr. Glenn Betteridge

The Chair

Mr. Lee

Mr. Glenn Betteridge

Mr. Lee

Dr. David Marsh

The Chair

Mr. Chris Gibson

The Chair

Ms. Koshala Nallanayagam

The Chair

Mr. Lee

Mr. Toby Druce

The Chair

Dr. David Marsh

The Chair

Mr. Walter Cavalieri

The Chair

Mr. Lee

Mr. Glenn Betteridge

The Chair

Mr. Lee

The Chair

Mr. Toby Druce

Mr. Chris Gibson

The Chair

Dr. David Marsh

Mr. Walter Cavalieri

The Chair

Ms. Koshala Nallanayagam

The Chair

Ms. Koshala Nallanayagam

Mr. Glenn Betteridge

The Chair

Mr. Glenn Betteridge

The Chair

Mr. Glenn Betteridge

The Chair

Mr. Glenn Betteridge

The Chair

Ms. Koshala Nallanayagam

The Chair

Ms. Koshala Nallanayagam

The Chair

Dr. David Marsh

The Chair

Dr. David Marsh

The Chair

Mr. Toby Druce

The Chair

Ms. Davies

Dr. David Marsh

Ms. Davies

Dr. David Marsh

The Chair

Ms. Koshala Nallanayagam

The Chair

Mr. Walter Cavalieri

The Chair

Ms. Koshala Nallanayagam

The Chair

Dr. David Marsh

The Chair

Mr. Glenn Betteridge

The Chair

Mr. Lee

Ms. Koshala Nallanayagam

Mr. Derek Lee

Ms. Koshala Nallanayagam

Mr. Derek Lee

The Chair

Dr. David Marsh

The Chair

Ms. Hedy Fry

The Chair

Dr. David Marsh

The Chair

Dr. David Marsh

Ms. Fry

Dr. David Marsh

The Chair

Mr. Randy White

Dr. David Marsh

Mr. Toby Druce

Mr. Chris Gibson

Mr. Glenn Betteridge

Mr. Walter Cavalieri

Ms. Koshala Nallanayagam

The Chair

Dr. David Marsh

The Chair

Mr. Chris Gibson

The Chair

CANADA

Special Committee on Non-Medical Use of Drugs

NUMBER 024

1st SESSION

37th PARLIAMENT

EVIDENCE

Tuesday, February 19, 2002

[Recorded by Electronic Apparatus]

¾ (0840)

[English]

The Chair (Ms. Paddy Torsney (Burlington, Lib.)): I will now bring this hearing to order.

We are the Special Committee on Non-Medical Use of Drugs. We're here in Toronto as part of our fact-finding tour. So far we've been to Vancouver and Abbotsford. We spent the day yesterday in Toronto and we've heard from witnesses in Ottawa as well--and Montreal, sorry. We did some site visits in Montreal.

I will introduce you to the members of Parliament around the table. Although I'll give you their party affiliations, we're working in a very non-partisan way here. But it is helpful to some people to know who the players are.

My name is Paddy Torsney. I'm the member of Parliament for Burlington. This is Randy White, who is the member of Parliament for Abbotsford, British Columbia, vice-chair of the committee, and a member of the Canadian Alliance. Libby Davies is from Vancouver East and is a New Democratic Party member. Derek Lee is from Scarborough--Rouge River, and Dr. Hedy Fry is from Vancouver Centre. The three of us are all members of the Liberal Party.

With us here this morning are our researchers, Chantal Collin and Marilyn Pilon. Carol Chafe is our clerk. This great team of people behind will make sure your microphones turn on and make sure everything you say will be transmitted to Ottawa and stored in the official record. For those of you who haven't done this before, we try to make it as painless as possible.

With us this morning as witnesses, from the Canadian Harm Reduction Network, we have Walter Cavalieri. Welcome, Walter.

From the Centre for Addiction and Mental Health, we have Dr. David Marsh. Welcome, Dr. Marsh.

From Prisoners with HIV/AIDS Support Action Network, we have Koshala Nallanayagam--welcome--who is the hep C coordinator.

From Seaton House we have Toby Druce, the program coordinator, and Chris Gibson, the program supervisor. Welcome to you both.

From the Canadian HIV-AIDS Legal Network, we have Glenn Betteridge--welcome, Glen--who is a lawyer with that group.

Unless you've decided to do something differently, I'll have you present your information to us in the order I read out your names. If we could, work to roughly ten minutes for everybody. I'll give you a nine-minute warning--the one finger--if you want to look up every so often.

Maybe you can tell me, if you're going to be longer than ten minutes, just how much longer. I don't have written testimony from anyone, so I'm not sure how much longer, but if we keep it to ten, anything you don't cover can be covered in questions and answers, which will come from these guys.

Walter Cavalieri, you're up.

Mr. Walter Cavalieri (Representative, The Canadian Harm Reduction Network): Thank you very much. Thank you for inviting me here. It's a great honour and privilege to talk with you all, and I'm looking forward to it.

I should tell you a bit about myself first. I'm one of the founders of the Canadian Harm Reduction Network, which is a nexus for individuals and organizations dedicated to reducing the social health and economic harms associated with drugs and drug policies in Canada.

I wear a number of other hats. I'm also with the Toronto Harm Reduction Task Force. I'm a researcher at the University of Toronto Faculty of Medicine, where I do qualitative research about AIDS and drug use, with special emphasis at the moment on a multi-city study of crack injection. I'm also a counsellor with students at Ryerson University.

Over time, I've come to know hundreds of people who use drugs. The first I knew were successful working professionals when I was working in theatre for many years. The most dangerous drug there, and the bane of existence for many people, was alcohol. It ruined many a career.

When I went to work in the front lines as a social worker, first with youths and then with adults living on the street, I found that drugs of all sorts were an overwhelming fact of life, and drug-related death a constant companion to my work. It was when I started to develop and deliver AIDS-related education and services that went beyond condoms and basic needle exchange that I became truly aware of the complexity of drug use and how and why people lived with the drugs as they do live with them.

A starting point in the practice of social work is that you have faith in the persons you are working with that they are making the best possible choices they can under the circumstances and with their knowledge.

¾ (0845)

Given the circumstances of people I was meeting on the street, drug use made sense. It ultimately became something to which I could say “Okay, I get that.” But what's the real problem you're dealing with? What is happening? Often you see the drug was genuinely helpful, helping them get by. Often too, when life situations were rectified, the use of drugs would lessen and sometimes even disappear. That's true of even hard drugs like cocaine, heroin, or alcohol.

My current research, as I mentioned, is putting me in close contact with people who inject crack cocaine. I have interviewed them in detail about the practice, and I have observed them actually injecting, so I have a firsthand knowledge of what happens when people use the drug.

It was a surprise to me, I must say, how calming and satisfying crack was to people--mild euphoria, relief from everyday pain and ills, and serenity were prevailing experiences. When you think about it, who living on the street wouldn't pursue that kind of experience, even if it lasted only for a few moments, which is what it does? The effect of crack cocaine is about 15 minutes in duration. Then they return to the reality of their lives. Often these lives are threaded through with depression.

Tales of drug-crazed behaviour notwithstanding--and I know that does sometimes exist--taking a walk or smoking a joint to prolong the good feeling were the predominant activities people pursued after they injected.

So the so-called truths we hear about dangerous drugs, illicit ones, are frequently half truths, or at their worst, treacherous lies and mythologies maintained by those who would support the status quo of prohibition--or sell their broadsheets--no matter what the cost.

There are many reasons people use illicit drugs. Most of the reasons are exactly the same as why people use alcohol, but self-medication is the dominant one we have observed on the street.

The more important question then is why do they use drugs in a harmful way? One reason is economy. People choose to inject drugs over other means of taking them because drugs are expensive, and they are expensive because they are illegal and available only through the black market. Inflated prices make people seek out the most efficient ways to use the drugs, and injecting is much more efficient than smoking. There's more bang for the buck, as they say in the advertising world.

True there are risks to injecting, but by and large, people try as best they can to mitigate those risks. Interestingly, most of the risks could be eliminated entirely if injecting could be carried out in clean, well-lighted places with good, new equipment, and of course if the drugs they were using were of known quality and strength. These are not available, because the drugs are illegal because of our laws. Were they not illegal, most drugs could then be used with at least the same degree of safety as alcohol and tobacco. I am not minimizing the risks or the effects, but most drugs are no worse than alcohol or tobacco.

The point I wish to make is that major contributors to the harms associated with drug use are the laws themselves, as well as the climate of ignorance, apathy, neglect, and fear they have fostered.

Our current laws and the attitudes they cultivate vilify and demonize people who use drugs. Moreover, they create a climate in which it is difficult to discuss drugs honestly. The cumulative effect of this over the years has been to give rise to many falsehoods and myths, both about drugs and the people who use them, especially poor people who use them, and to reduce the person who uses drugs in the public mind from a whole and usual person to a tainted, discounted one. Those are the words of one of our great theorists, Irving Goffman. He says it stigmatizes them.

A further phenomenon is that over time the person internalizes this stigma and actually comes to believe that she or he is tainted. This is quite similar to the experience of homosexuals and people with mental illness. However, in these latter cases, laws have been developed and passed to address this. Over time, the stigma has been lifting, and people are not merely receiving better service and earning respect and understanding, but they are acknowledging and proving their worth. This has yet to happen to people who use drugs, save where drugs and social status intersect.

¾ (0850)

Would that the understanding expressed for Noelle Bush and her family were distributed in the same quantity to the people caught possessing or scamming drugs who happen to live in poverty. It's very much a status issue.

There's also a clash between the laws available and the ability to provide services. Though the harassment that service providers and service users experienced in the earliest days of needle exchange has diminished some, it is not gone. Needle exchange programs have survived and proven themselves, but they're still, in many places, scorned and they certainly are not universal. They should be.

However, fundamental and essential services with proven effectiveness, such as heroin prescription and safe injecting facilities, are still held in abeyance while some people dither and some people die.

This is not an abstract debating point. I see the direct and the indirect harms at ground level, the day-to-day consequences of bad laws, the sickness, the suffering, the deaths. That has changed me considerably.

Though we claim our drug policy is guided by a harm reduction approach, it remains totally committed to prohibition. As a result, Canadian citizens who use illicit drugs are becoming infected with HIV and hepatitis C at rates far higher than members of the general public because of bad laws. They're forced by circumstance into crime and incarceration because of bad laws. They die, and they still die prematurely because of bad laws.

These were never their dreams, just as they are not ours. They were never their vision, never their hope for the future, but it is their future.

The evidence is overwhelming that the so-called war on drugs, one of the longest and costliest social experiments in the history of civilization, has not worked, is not working, and will probably never work, and yet it thrives and it flourishes.

Since this war's inception, drug use has increased. The variety of drugs available has increased. Drug-related crime has increased. Incarceration of people who use drugs has increased.

How, in all good conscience, can one pretend that it constitutes the most prudent and responsible approach?

What's the basis for this belief that it supports a bloated and costly correctional system, that it supports organized crime, that it supports the spread of diseases, that it supports terrorism? Maintaining the status quo on our drug laws is a disservice to our country and its citizens and to all humanity. It merely makes some people feel morally superior.

There is a shift in public opinion. Canada's stand on medical marijuana has received very good press everywhere, particularly in the United States. The Cato Institute, the Fraser Institute, and The Economist magazine all support ending drug prohibition in favour of legalization, with a degree of social control similar to that imposed on alcohol and tobacco. This is a sensible solution, which can be attained over time.

According, once again, to The Economist, zero tolerance laws are falling out of favour, even in their cradle, the United States.

I implore you to be not merely spectators of this transformation. Even if you do not happen to like drug users, think of the impact on their families, and on your families. Think of the health issues that prohibitionist laws are fostering: the spread of hepatitis C and AIDS. Think of the huge burden on your purses and wallets created by the law enforcement and criminal justice systems alone. Recognize your own interests, they are not unworthy, and show leadership.

In the meantime, to begin with, we must stop cowering before the moral agency of the United States. Their drug laws are paragons of disaster. We must, instead, look abroad to Europe and Australia for successful efforts at humane, efficacious, cost-effective, comprehensive harm reduction programming and adapt their ideas and philosophy to our situation. We must immediately enable the legal framework that will permit the initiation of innovative harm reduction measures, such as heroin prescription and safe injecting rooms. They are absolutely necessary and they must become as ubiquitous as the use of drugs themselves.

It's insufficient to establish these programs only in key cities, in the isolation of those cities. Drug use is not merely an urban phenomenon. We must also involve people who use drugs and ensure drug user networks are included in reducing the harms associated with drug use. We must ensure the expansion of effective harm reduction and addictive treatment services across Canada.

¾ (0855)

Finally, let me invite you to come back and go with me to meet some of the people who have been so harmed, both directly and indirectly, by our laws, and to hear firsthand what they have to say. I invite you to come not as prurient observers but as interested fellow citizens of Canada, open to learning. Merely doing this was an experience that changed and focused my life. I thoroughly believe the humanity of these people, with whom I have been working and have come to know quite well, will have a profound effect on you and your deliberations.

Thank you.

The Chair: Thank you, Mr. Cavalieri.

Dr. David Marsh.

Dr. David Marsh (Clinical Director for Addiction Medicine, Centre for Addiction and Mental Health): Madam Chair, members of Parliament, good morning. I'm sorry I don't have a written and prepared brief for you, but I didn't have a lot of time.

I will try to make basically three points this morning. First, drug users are people who make decisions based on complicated motivations, just like anybody else. Whether we're talking about a 14-year-old who's deciding to use cannabis for the first time, a 65-year-old who's deciding to smoke cigarettes after their heart attack, or a 35-year-old who's been injecting heroin daily for 20 years, they're all making decisions day by day about whether or not to use drugs and how to use drugs. And those decisions are influenced by the same range of complicated motivations, coming from their past, from their emotions, and from their present, that we use every day in making decisions.

Related to this is the fact that the drug use may influence these motivations. We know that drugs do have effects on the brain that in certain situations can be reinforcing, which means the person is more likely to use the drug again in the future. For some drugs there is emerging evidence that the drug influences the brain in a way that forces them to be more focused on short-term goals, or on short-term influences as opposed to long-term influences. However, drug use effects on the brain are not the only factor. The user is also going to be influenced by their past experiences and by the environment around them.

The second main point I want to make is that we, as people outside of those drug users, have a limited ability to influence their decisions, whether we're health care providers or public policy-makers. The 14-year-old who is deciding to use cannabis for the first time thus may be influenced to a very limited extent by the fact that cannabis is illegal to possess.

As evidence of that, I would point you to the recent Ontario drug use survey results, which showed that from grade 7 to grade 12, at every year, the lifetime use of cannabis was higher than the lifetime use of cigarettes. I would suggest that this data points to our prohibition against cannabis as having a limited effect in preventing youth from using.

Our centre's official position on cannabis public policy states that the current public policy approach does more harm than good. I know that other people from the centre are going to come speak to you as well, or have already, about this issue.

Because we have a limited ability to influence people's decisions about drug use, and because psychoactive substance use has always been a part of society, I believe it's always going to be a part of society. I think the idea of having complete abstinence across all of society is an unrealistic goal. That includes the assumption that everybody who uses drugs will be in treatment, or that everybody who uses drugs who's in treatment will be able to quickly achieve abstinence.

So we need to take those realities into account when we're planning public policy or planning treatment options. We have to realize that there will be people in treatment who are still going to want to use some drugs.

The last main point I want to make is that since our ability to influence people's decisions is limited, we should try to exercise this influence where it's most likely to be effective, and that means defining which effect we wish to have and then demonstrating the effectiveness of that.

¿ (0900)

I think a key principle of harm reduction is the ability to measure or the importance of measuring the effectiveness of what we do. I submit that this would apply to public policy-makers as much as it does to health care providers or others who offer interventions for drug users.

One example of an intervention that has been evaluated and found effective is needle exchange, which Walter mentioned. People are making decisions about whether or not to inject drugs and how to inject drugs, and if they have clean equipment available, then we know that can help decrease the spread of disease. It is important for needle exchange or needle distribution services to be widely available across the country, including in correctional facilities, where we know people inject drugs.

Another example would be methadone maintenance. I have been very involved over the last six years in the rapid increase in the availability of methadone maintenance in Ontario. In 1995-96 at our centre we had had a methadone program for 30 years, but we had three times as many people waiting to get into treatment as the total our clinic could hold. We had people who were dying of suicides and overdoses or who were intentionally acquiring HIV or becoming pregnant in order to get into treatment. It was a very desperate situation.

Since that time, April of 1996, when the College of Physicians and Surgeons of Ontario became more involved in methadone, we have been able to expand treatment capacity across the province more than tenfold. There is now no waiting list in Toronto, and we're still actively working to make treatment more available in more rural parts of the province.

It goes beyond just making treatment available. It also means making treatment available in a way that is likely to be effective, that's likely to maximize treatment retention, and that involves adequate doses. It is not always the case across the country that when methadone maintenance treatment is provided, it is provided in a way that is based on the best evidence or includes the most effective doses.

Another example of an intervention that can be effective in certain circumstances would be heroin prescription. Just recently the Dutch have released a report of their heroin trials, and it is the most scientifically rigorous evaluation to date of the prescription of heroin. I believe the prescription of heroin is an example of a treatment option that would clearly fit within harm reduction because you're taking someone who is injecting heroin daily and prescribing for them heroin so they can continue to inject heroin daily. But we know from the Swiss experience and the Dutch experience that providing them with clean heroin of a known dose they can inject in a safe environment will prevent drug overdoses and the spread of diseases and will improve their health and their employment. Over time, some of those people in the Swiss experience, in fact many of them, chose to gradually come off heroin or to add methadone and inject less often, so their quality of life was improved.

I will be glad to answer questions about any of those, but I don't have any other formal remarks at this time.

The Chair: Thank you, Dr. Marsh.

Koshala?

Ms. Koshala Nallanayagam (Hep C Coordinator, Prisoners' HIV/AIDS Support Action Network): Hi. None of us had a lot of time to prepare.

The Chair: Let me apologize for that. Unfortunately, the House process is a little difficult for getting travel arrangements and getting notification out, but we do appreciate everyone's effort and knowledge.

Ms. Koshala Nallanayagam: I'm a little nervous because I don't do this every day of my life. I'll first tell you a little bit about PASAN because I don't know if everybody knows about PASAN. It stands for Prisoners' HIV/AIDS Support Action Network. We've been around for more than ten years. Our mandate is to provide education, support, and advocacy to prisoners, ex-prisoners, and also young offenders living with HIV and AIDS and also hepatitis C.

As to the statistics in prisons to do with HIV and hepatitis C, there are ten times more HIV positive people in prisons than in the general population, and hepatitis C is, I believe, at least forty times higher.

¿ (0905)

And there are lots of reasons, as other people have mentioned. A lot of people in prison are there due to drug-related offences, because drug use continues to be criminalized as opposed to being seen as a health issue. Sometimes people use intravenous drugs for the first time when they enter prison. Sometimes they might only have smoked marijuana on the outside. But when they come into the prison system, as far as harm reduction, the way a prisoner might look at it is that it's easier to get away with shooting up than smoking up, because they're more likely to be discovered.

One of the reasons there's a lot of drug use in prisons is because the conditions are intolerable and prisoners resort to taking drugs to maintain their sanity and to prevent themselves from committing suicide.

Obviously HIV and hepatitis C are transmitted through sharing needles, and unprotected sexual intercourse with HIV. But also in prison, tattooing is very popular. There are lots of amazing tattoo artists there. Unfortunately, that equipment is shared as well, which contributes a lot to the transmission of disease, especially to the likes of hepatitis C. Even sharing the ink can transmit the virus, so that causes a lot of people to become hepatitis C positive. Tattooing is still an institutional offence so there are lots of things that could be changed.

PASAN wrote a brief in 1992, “HIV/AIDS in Prison Systems: A Comprehensive Strategy”, and it was presented to the Minister of Correctional Services and the Minister of Health. There are lots of really good recommendations in there around education for prisoners and prison personnel, the distribution of condoms, bleach, needle exchange, and methadone.

Condoms are available now, especially in the federal prisons. However, they might not always be made accessible. Sometimes the prisoners might have to go ask at the health care for condoms, and they are only allowed a maximum of two. Otherwise, again, it's an offence. Bleach, as I'm sure most people know, could be effective in killing the HIV virus, but not hepatitis C, unless, say, a needle that's being used again is cleaned thoroughly and soaked in bleach for ten minutes.

First of all, the kinds of rigs and needles that are used in prisons are used over and over again, and they'd probably melt in the bleach. At this point, one needle can be used for a whole range over a couple of months, so you can just imagine the kinds of infections that are being transmitted. One woman was telling me the story that she got some bleach on her shirt and it didn't even take away the dye or whatever. Obviously it's diluted so much that the effectiveness isn't very good.

¿ (0920)

As far as tattooing goes, we suggested that it be under hobbies or crafts, and that people come in to teach them how to do it properly. It could be done that way, because it is a very popular activity in prison.

In terms of needle exchange, it's the same old thing that was said before needle exchange came into the general community, which is that it's encouraging drug and needle use. But it's happening anyway, and people are being harmed. That's the whole thing around harm reduction, that more and more people are getting infected with diseases. And it's easy for a lot of people to think prisoners are out there--they're not part of our society or community. But indeed they are, and most prisoners do come out, even the so-called lifers. So there is a good reason for us to look after prisoners when they are in prison.

Also, they are supposed to receive the same kind of medical care they would on the outside, which doesn't quite happen. The needle exchange programs in prisons have worked really well in Europe and Australia. There were fears around the guards being hurt, but it hasn't happened. They have not been used as weapons, because this needle is a precious thing to the user. If it's kept in a place where it's visible, it's less harmful to the guards. Now, when they go into a cell to search, they could get pricked by a needle, because they don't know where it could be.

The other thing is methadone. For a prisoner who would like to get on methadone for the first time, it's almost impossible. We continue to work with people to help them access that, because that would be another harm reduction method that could be quite effective. If they're already on methadone, it's easier.

We work with HALCO, and Canadian...the other legal place. I'm sorry, I can't think of the name. A lot of people helped us write the brief in 1992.

I guess what I'm saying on behalf of PASAN and the prisoners is that there are a lot of things that can be done to really reduce the incidence of HIV and hepatitis C, as well as other harmful things. For instance, if a needle is used so many times, it's going to be really hard on the person, and they could get wounds and abscesses.

I think I'm going to stop there.

The Chair: Okay. Can I just ask one question?

You mentioned that prisoners are allowed to have two condoms, and anything more than that is--

Ms. Koshala Nallanayagam: Contraband, yes.

The Chair: How frequently can they get two?

Ms. Koshala Nallanayagam: Oh, probably daily.

But again, it's not consistent. It really depends on the place and the way they're distributed. In some places they're in a central place where it's easy to go and pick up two. But there are other places where you might have to go ask the nurse in health care.

So that's the other thing. Even the distribution of bleach is not consistent.

The Chair: Is it not consistent between federal and provincial prisons, or are you dealing only with federal?

Ms. Koshala Nallanayagam: Both. The provincial institutions have even less in place, and the differences are more marked than in the federal system.

The Chair: Thank you very much.

Now we go to Seaton House.

¿ (0925)

Mr. Toby Druce (Program Coordinator, Seaton House): Thank you. I very much appreciate being invited to come to speak this morning.

My name is Toby Druce. I'm the program coordinator of Seaton House. I'm going to talk a little bit about Seaton House as an institution within the services to homeless people in the city of Toronto. Then I'm going to turn it over to Chris Gibson, who's the program supervisor of a risk reduction program that works primarily with people who are addicted to crack cocaine.

Seaton House is a 690-bed facility. It is for single men. It is directly operated by the City of Toronto. We provide services to approximately 4,000 people a year. We have 690 beds that are certainly filled each evening, and since 1953 a proportion of the clients who use Seaton House have been people who have non-medical drug use issues.

In 1997 we underwent a fairly significant physical renovation to our facility, and as part of the physical renovation we embarked on an attempt to look at who was using the single men's hostel system in the city and at what kinds of physical changes we could make as to how the building operated to accommodate some of the different issues people were presenting themselves with. In the course of our redesign, one of the things we identified was that of the 4,000 people a year who come into Seaton House, approximately 50% use the service for less than a week; then they exit and we don't see them again. Seventy-five percent of all of the people are gone within a month. So we have very high turnover, with people coming in and using the facility for very short-term emergency care.

The impact people who had a drug addiction had on the whole population was significant when we only had two programs. We had a program for older, medically frail men and we had a program for everybody else. In the emergency hostel, which provided services to the bulk of the clients, certainly drug use was an issue. Some of the behaviours around the drug use were perceived to be an issue, and primarily that was from people coming and going from the building. The way we operate our facility, we have a curfew at midnight because a lot of the people who were out looking for drugs or out using drugs were coming and going after midnight and creating conflict around us having a curfew. It wasn't around their behaviours because of their drug use, but there was some conflict with the rules of the facility.

As part of our physical redesign, we wanted to look at how could we provide some different services and try to separate out drug users from the majority of clients who used the facility and who didn't use drugs. We had explored a number of options with the police department here, all of which were quite complicated to implement. We talked at one time about having dogs come in and sniff through people's rooms. That would be very intrusive and is not something that fits in with our philosophy of providing services to people who are homeless. We talked about having paid duty officers on site to lay charges if someone was found in possession of paraphernalia or drugs. But again, people are in our hostel because they're in desperate straits. We don't want to make their life any more difficult because of a small group of clients who have those drug use issues.

The solution the police offered to us was to provide almost a sense of containment.

So within our definition of harm reduction, at the time we started to conceptualize the O'Neill House, our intent was to reduce the harm to everybody who didn't use drugs. It wasn't to reduce the harm to people who did use drugs; it was to try to provide the least degree of exposure we could to some of the issues around the drug use for the 75% of our client group who were in for a very short period of time. So we opened up the O'Neill House program. It's been in operation now for approximately 18 months. It's a 60-bed facility.

That's an overview of Seaton House. I'm going to turn it over to Chris now so he can speak specifically to the issues of harm reduction and the O'Neill House.

Mr. Chris Gibson (Program Supervisor, Seaton House): Thanks very much.

I would like to reiterate a couple of points that were addressed earlier. Walter had touched on the criminalization, and I think, as with any law, it was a reflection of our society's moral stance on drug use. The drug use in and of itself is given a moral dimension; people who use drugs are bad, and that's why there are laws against using drugs.

¿ (0930)

I say that because there are a number of substances and lifestyles that are not criminalized but are equally as dangerous as the use of these criminalized substances. I was looking at some of the questions the committee was attempting to address. The first one that leapt out at me was: “How much does criminalization contribute to the harm associated with drug use?” I would suggest hugely. I think if the point of a law is to provide some disincentive from engaging in a behaviour considered to be harmful to individuals or to the society, that effect is lessened at the point someone has crossed over the line into what is considered to be criminal behaviour. If you have been identified as a criminal through using drugs, it's much easier, having already been labelled a criminal, to continue engaging in criminal behaviour. The disincentive is much weaker.

As Walter mentioned, because most of the drugs that are used are available solely through black market sources, they're incredibly expensive. To support something that is a behaviour that by necessity must be hidden--and to afford it--necessitates engaging in that same black market and in criminal activity, primarily property crimes such as small theft.

For the clients we work with--as Toby mentioned, it's single men--and in the shelter system broadly, being a user of drugs is something there are huge incentives to hide, even though that regular heavy use of drugs may be a contributing factor in an individual's homelessness. Admitting and discussing it openly is discouraged.

Most of the services offered to the homeless are not offered to the homeless drug-using population if they're honest about their drug use. Housing, which is at the best of times very difficult for a homeless person to get, is virtually impossible to get if a homeless person happens to admit using drugs--although if you hid that fact from somebody who was offering housing, you would be considered. So the incentive is to hide the behaviour, to keep it underground, because it's labelled as a criminal issue. Because of things like this, Toby mentioned that the vast majority of our population at Seaton House were there a fairly short period of time.

Another thing we've tended to discover is the longer somebody is in a shelter, the longer they're likely to stay in it. There is a sort of vanishing point after about six or nine months, where getting out becomes incredibly difficult. That's for anybody in that population, whether or not they're using drugs. If they are using drugs, it becomes doubly difficult, because to receive any services that might get them out of that situation, they are first required to go into some kind of drug treatment. Again, if they're open and honest about the use, that's an additional hoop they must jump through before they will receive any kind of service.

The success--and this is anecdotal and coming back from the clients of our program--is that we acknowledge they're drug users. Again, as Walter mentioned, people who are using are using for good reasons. I've never met anybody who started using any drug because they thought it was going to make them homeless, poor, and make them ultimately feel terrible. That's absurd, as I'm sure you would all agree. Drugs create feelings of well-being; that's the reason people use them in the first place.

The approach generally seems to be that to have an opportunity to re-enter mainstream society you must first jump through a number of hoops. When somebody is living in abject poverty and has limited education--in the client group I work with it's people who have extensive histories on the streets, of 10 or 15 years--I think if we're being honest with ourselves, telling a 40-year-old man who has a 20-year history of chronic drug use and maybe a 10-year history of homelessness and less than a high school education that if he stops his drug use tomorrow everything is going to be sunshine and roses is patently absurd. They have no education. They have no work history. They're institutionalized because they haven't even lived independently in a decade.

¿ (0935)

Stopping drug use is going to allow them to wake up every day and be clearly aware of that fact that they have no education, they have nowhere to live, and they have limited prospects, which seem like really good reasons to use drugs.

For us, with the client group we have, who again are people who are chronically homeless, we see homelessness as the primary issue; it's not the drug use. Because drugs are illegal, there are limits to what we in the shelter system, a government-operated shelter, can do. We cannot open a safe using space. Personally, I believe that would be very useful, but it's illegal, and we certainly cannot permit drug use on the property.

What we can do is, in providing the service, take drugs out of the equation. For the clients, for the 60 men we have in our program, it's a given that they're using crack cocaine. We do not demand that they enter any kind of treatment. We have a number of staff who have experienced working in conventional treatment models and who are well connected. If clients choose to pursue that avenue, we don't discourage it. It's about offering people a choice rather than mandating them to enter treatment. The success rates of conventional treatment programs aren't all that high anyway. When someone is forced to go, it's even lower. If someone makes that choice, it has to be a choice they've made and it has to be an avenue they're attempting to pursue.

We have certainly had people who have used our program in the past 18 months who have chosen to cease their drug use. It was because they had an opportunity to address underlying issues, to make connections with the family or to address issues of education or employment. Those are things we target. Those are the issues we're looking at. The drug use is in some ways quite irrelevant to us.

If we want this client group to have a legitimate shot at re-entering society, I think to continue punishing them for drug use is guaranteeing that they never will. They will be chronically interacting with the criminal justice system, they will be chronic users of shelters, and ultimately, as their health begins to suffer, they will be chronic users of emergency services and hospitals, both because they are homeless and because they lack supports within the community.

Given our current strategy of dealing with people who are chronic or heavy users of drugs, my job, as far as I can see, is going to be here for a good long while, certainly beyond the term of my work in it.

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

Our final presenter is from the Canadian HIV-AIDS Legal Network, Glenn Betteridge.

Mr. Glenn Betteridge (Member, Canadian HIV-AIDS Legal Network): Good morning.

First of all, I'd like to thank the committee for extending an invitation to the Legal Network to present today.

Second, I'd just like to clarify that I am a member of the Legal Network but that I am not an employee. I am here today because employees of the network are in Ottawa presenting to a different standing committee. I bring you knowledge about working in a legal clinic in Ontario for people with HIV and AIDS, some of whom are prisoners.

The Legal Network has provided a brief to the committee, 25 copies of which were given to the clerk. This basically outlines the position of the Legal Network and addresses the issue the committee outlined in its request.

Let me just give you a bit of background on the Canadian HIV-AIDS Legal Network. It's a national organization engaged in education, legal and ethical analysis, and policy development. We have 250 members across Canada, about half of whom are community-based organizations with an interest in HIV and AIDS issues. Two main areas of work since the network's inception have been the area of injection drug use and HIV and the area of prisons and HIV.

There are a number of publications, which I will leave with the clerk of the committee for the researchers to mull over, the first of which is HIV/AIDS in Prisons: Final Report, which was written in 1996. This was a comprehensive report and a follow-up to the Expert Committee on AIDS and Prison's report, which was commissioned by the Correctional Service of Canada.

There are a number of fact sheets dealing with HIV and AIDS and hepatitis C in prisons. I will leave those as well.

¿ (0940)

The next major report I would like to leave with the committee is the report Injection Drug Use and HIV/AIDS: Legal and Ethical Issues. This is obviously directly related to the mandate of the committee.

A number of background papers were commissioned for the report, and I will leave copies of those as well. A number of fact sheets were also produced out of the report.

Although the committee probably has it, I am going to leave you with a courtesy copy of Health Canada's Injection Drug Use and HIV/AIDS, which was a response to the Legal Network's report. And in good legal fashion, I'll leave the committee with the response to the response, which hopefully is by no means the final word on this issue.

The network's work in these areas has received international recognition and accolades. Among other things, the United Nations program on HIV/AIDS has listed the activities of the network in its collection of best practices.

The committee is seeking input on a broad range of issues. As I mentioned previously, the focus of the Legal Network's submission will be around two issues: harm reduction and questions concerning injection drug use in Canada, in particular as the issues of harm reduction and injection drug use relate to the transmission of HIV/AIDS and hepatitis C.

Since the early 1990s, Canada has been in the midst of a public health crisis concerning HIV/AIDS and hepatitis C, specifically related to injection drug use. The spread of HIV and other blood-borne infections like hepatitis C among injection drug users in Canada requires serious and immediate attention.

The problems of injection drug use and HIV and hepatitis C infection affect all Canadians in society. However, some populations have been particularly affected or even devastated by injection drug use and the associated harms. These are women drug users, street youth, prisoners, and aboriginal people--basically people who are already in many terms marginalized and facing challenges in their lives above and beyond those related to injection drug use, and who are living with chronic illnesses such as HIV and hepatitis C. And I think the other panel members have brought forth their personal and professional experiences of this devastation.

To date, the Canadian response to the crisis in injection drug use and HIV and hepatitis C has been far from concerted or effective. Much more can and must be done to prevent the further spread of HIV and other infections among injection drug users and provide care, treatment, and support for these people. This is once again picking up on themes expressed by the other panels that more can be done practically within the existing legal regimes to provide for harm reduction measures to prevent the spread.

But equally important is pulling these people back into the fold in terms of making them part of the care, treatment, and support networks that all Canadians should be able to access and that are seen as part of what makes us fundamentally Canadian--equal and universal access to health care services appropriate to our circumstances.

Much more must be done because the current approaches do not withstand ethical scrutiny. This particular point is the subject of a number of background papers to the injection drug use survey.

Why has the response been ineffective to date? One of the main reasons, picking up on Chris's point, is that the drug laws and policies, far from stemming drug use, have contributed to the harms associated with it, in particular the harms associated with drug use in relation to HIV and hepatitis C.

So in these two areas that the Legal Network submissions highlight--harm reduction and injection drug use--in terms of harm reduction, the Legal Network analyses how much criminalization actually contributes to the harm associated with drug use and the need for educational programs.

¿ (0945)

In terms of injection drug use, the submission looks at needle exchange programs, methadone maintenance treatment, clinical trials of heroin prescription, supervised injection facilities, and the specific particularities of those programs as they should operate in correctional facilities.

With the time remaining, I am just going to highlight the recommendations of the submission in two areas, harm reduction and injection drug use. In terms of harm reduction, I'll look at the recommendations related to educational programming. In terms of injection drug use, I'll highlight the recommendations in relation to needle exchange programs.

The recommendations in relation to educational programming are at page 11 of the submission. The first one, recommendation 8, is that federal, provincial, and territorial health officials should provide funding for the development and wide distribution of accurate, unbiased, and non-judgmental information on illegal drugs for health care providers, drug users, and members of the public.

Once again, this recommendation picks up on themes echoed by all the witnesses today, that what we really need is to start from a baseline of honesty and information about drugs, what they are and what harms are associated with them, so that individuals can make choices and Canada as a society can make choices in the way it wants to deal with the problems related to drug use.

Recommendation 9 is that provincial and territorial governments, government agencies, and community-based organizations should develop educational programs based on harm reduction principles.

Recommendation 10 is that provincial and territorial ministries of education and health should undertake an evaluation of school programs on illicit drugs. The theme in that very simple recommendation is that ministries of education and health should work together. I know this is an issue that the standing committee is particularly interested in, the coordination of services. Highlighted throughout the submission to the committee and throughout the injection drug use booklet or study is the point that there needs to be more coordination of effort among various government levels and within the federal and provincial governments--for example, Health Canada working with Correctional Services Canada.

Recommendation 11 is that universities and colleges should ensure that the curricula of health care professionals include accurate, unbiased, and non-judgmental materials, presentations, and discussions about drugs, drug use, and harm reduction approaches to drug use. I think the witnesses you have before you today, it would be fair to say, are miles ahead of many of their colleagues in terms of their perceptions, their education, and the role they take in providing services to injection drug users. I think the vast majority of health care professionals and service professionals still have a prohibitionist mentality firmly ingrained in their practice and the way they practice.

I have less than a minute left, so I will just point you to the recommendations in relation to needle exchange programs, which are at page 15.

Recommendation 12 is that the federal, provincial, territorial, and municipal governments should ensure that needle exchange programs are easily accessible to injection drug users in all parts of Canada.

The next recommendation relates to alleviating or getting rid of the criminal prohibitions around possessing the paraphernalia related to injection drug use and dirty needles, basically needles with traces of controlled drugs and substances.

The final recommendation is that pharmacist associations and other professional care professions should become more involved in needle exchange provision and exchange programs.

I would like to thank you for your time. I will make myself available for questions.

The Chair: Thank you very much, Mr. Betteridge, and thank you for appearing on behalf of the network.

¿ (0950)

Just to clarify one thing, the rest of the network, I guess, is at a standing committee. We're a special committee.

Mr. Glenn Betteridge: Thank you for that clarification.

The Chair: These are just a little outside the normal process--which is a problem at times.

Mr. White, you have ten minutes.

Just to clarify, any of the members of Parliament could ask you a question, and it could be to a specific person. Let's say they ask Mr. Druce a question. If you would also like to comment, just indicate, and I'll keep track of who has indicated. Hopefully, we'll spend around ten minutes per MP.

Mr. White.

Mr. Randy White (Langley--Abbotsford, Canadian Alliance): Thank you. These were good presentations from all of you.

I'd like to ask if any of you are aware how long it would take--and I realize it takes longer for some individuals to become addicted, but how long, approximately, does it take a person who dabbles in heroin, for instance, or crack to be dependent on it? Does anybody know that?

¿ (0955)

Dr. David Marsh: The first part of the response to that is to realize that the majority of people who use psychoactive substances are never dependent on those drugs, the only exception being nicotine. About 80% of people who use nicotine will become dependent on it, but for alcohol, heroin, cannabis, cocaine, most people who use those drugs don't become dependent. For those who do become dependent, they have a variable length of drug use prior to becoming dependent.

Mr. Randy White: That's not what addicts tell me.

Dr. David Marsh: Drug users may not be the most informed as to the epidemiological evidence around the population that they are a part of.

Mr. Randy White: Many of the issues we talk about in regard to this problem with drugs do get down to money, don't they? I was reading here this morning about one of the problems Gordon Campbell is facing in British Columbia right now. He will be tabling a budget with approximately a $4.5 billion deficit. There will be an austerity program. Of course, that means it's very likely that the drug issue would not get funded very much, if at all.

When all governments seem to be wrestling with money, how do you rationalize additional safe shoot-up sites, for instance, rehab centres, and staff to operate them and so on and so forth? It's a difficult situation, and I think you folks who are running that centre probably face the same kinds of cutbacks. How does this go ahead if there is little money for it? Perhaps Chris or Toby could respond.

The Chair: I have Mr. Druce, Mr. Gibson, and Dr. Marsh.

Mr. Chris Gibson: In my case, and this relates to illicit drug users also, initially the program I worked in at Seaton House worked with street alcoholics, the classic stereotype of the homeless person. Because the program was fairly radical in that, these people were supplied with palatable alcohol, which they purchased to substitute non-palatable forms of alcohol they were drinking

À (1000)

It was quite important for us to get the go-ahead to do this to demonstrate some kind of effectiveness for it. We looked quite extensively at the cost of providing service in a conventional manner to that population. I think the same applies to drug users. The costs associated with the current methods with which we interact with the drug-using population are absurdly expensive. For a lot of people who are heavy drug users, the only regular medical contact they get if they're not on a methadone maintenance program is through emergency visits, which are hugely expensive.

Being sent for a psychological assessment as part of a court process is again hugely expensive. Incarceration is more expensive than a shelter bed. A shelter bed is more expensive than having somebody live in independent housing.

The services we're providing now cost a fortune. Anything that might address those issues more efficiently is by necessity going to be cheaper. Opening a health centre that is accessible to drug users is much, much cheaper on the health care system than by default forcing drug users to access their health care primarily through emergency visits, which cost a fortune.

The Chair: Mr. Druce.

Mr. Toby Druce: I first would echo Chris's statements. One of the things my experience at Seaton House and being involved with the O'Neill House would suggest is that one of our big concerns is around the impact drug use has on our community. We obviously operate in a residential neighbourhood, and our local residence association has for a long time been asking for a higher police presence on George Street and on the streets around our shelter because of their perception of the crimes that are associated with people who are homeless and people who are addicted to drugs. Through our work with that group, one of the things we've been able to identify is that the biggest problem our community experiences--obviously outside the community of homeless people--is not drug use; it's the activities that go around the purchasing of drugs.

In terms of having an austerity measure--and it certainly is a concern for us at these times--then what you would want to do is ask, what will provide the best service at the lowest cost? The best service at the lowest cost is then to say that somebody who is using drugs is not a threat to a community. Somebody who is on a street corner engaging in an illegal activity has become involved in criminal acts because of the transaction to purchase the drugs, not because of the drug use. Our approach and certainly our experience has been that when you remove the behaviour of buying or participating in drug use, right away we don't have--all our costs for operating our program directly are much lower.

One of our concerns certainly is the perception that if you took 60 people who are heavily addicted to drugs and put them all into one building, there would be mayhem: there would be a lot more fights and a lot more police involvement. Yet that simply hasn't been the case.

The Chair: Dr. Marsh.

Dr. David Marsh: I think in times of austerity it's more important, but at all times it's important for government to invest its dollars and its resources in areas that are likely to be effective and that are in keeping with the mandate of government to try to ensure a healthy and safe population.

With respect to investments in drug treatment prevention measures or harm reduction measures, I'd just like to mention three things. The first is a study called the CALDATA study, which was done in California by the four largest health maintenance organizations. The economists who did the studies told me that the HMOs commissioned the study because they wanted to de-list addiction treatment and that going into the study their assumption was that addiction treatment was ineffective and they should be able to take it off their list of covered services. In fact, what the study showed was that for every dollar the HMO spent on addiction treatment they saved $7 over the next year in health care costs. So it's good investment to invest in addiction treatment.

Second, I'd like to mention methadone maintenance in Ontario. Ron Wall is a health economist at our centre. He took data from a study of untreated injection opiate users and calculated that in 1992 dollars in Toronto, an untreated injection heroin user cost society about $45,000 per year on average.

À (1005)

Included in that cost was about $5,000 of health care costs. The majority of the costs were related to crime or legal costs, but $5,000 a year were health care costs because these injection heroin users were visiting their physicians on average twice a month. We could provide methadone maintenance for less than $5,000 per month. It would be the same health care dollars, and the other $40,000 a year in crime and legal costs would virtually disappear.

The last thing would be that in terms of investing dollars where they're likely to be effective, approximately 70% of people who are convicted of narcotics-related offences in Canada are convicted of simple possession of cannabis. Where's the evidence that this is effective in any way in terms of prevention or improving the health of society? There are a lot of dollars there that could be reinvested in more effective measures.

Thank you.

The Chair: Dr. Marsh, do you mind asking your colleague, Mr. Wall, for a copy of that study?

Dr. David Marsh: Sure.

Mr. Derek Lee (Scarborough--Rouge River, Lib.): Could I ask for a clarification?

The Chair: Yes, I think there was a mistake on the cost for methadone.

Mr. Derek Lee: Is it $5,000 per month or $5,000 per year?

Dr. David Marsh: Sorry. It's per year, yes.

Mr. Derek Lee: Thank you.

The Chair: It was adding up a little funny.

Mr. White.

Mr. Randy White: I'd like to ask Walter about the priorities and the issue of harm reduction versus what others would say is harm extension, that is, giving an individual heroin as opposed to concentrating on rehabilitation, getting them off heroin, and the idea of a safe injection site versus a rehabilitation centre. For those who aren't closely affiliated with the drug issue, I'm sure they look at these things and say they can understand a rehabilitation centre, but a safe injection site scares them.

Is there a priority, given that there are scarce resources and all that?

This committee has to make recommendations to government, and I'm not suggesting we're going to prioritize a safe injection site versus a rehabilitation centre, but when it comes down to it, the country lacks a cohesive rehabilitation system in all provinces. Is there a priority in those two issues?

Mr. Walter Cavalieri: First of all, I want to address the issue of time extension. I've never heard it. I'm going to think about that a bit.

I don't see the safe injection facilities as harm extension, actually. They're harm reduction, because although people are continuing to use a drug--and mostly in this country it would be an opiate, although cocaine is also very high--the facilities reduce the harm, as I said in my presentation, because the drug is injected in a safe, clean environment.

Prioritizing is a problem. I would love to see a coherent policy across the country for dealing with the use or misuse of drugs. In the meantime, however, I do think that safe injection facilities, because they have a proven success record in Europe, should be given closer attention than they have been...and started out. Treatment, as we provide it now, with the exception of methadone maintenance--and even that has its problems, which even Dr. Marsh will admit--hasn't worked that well.

So for me, a major plus of the safe injection facilities is the opportunity to build a good relationship between staff and a user of the site, with an aim toward helping them deal with the issues in their lives that are supporting their drug use, connecting them to existing services they may not know about or may have had bad experiences with in a way that would be more effective in improving their overall conditions--housing, education, or major issues--so that drug use would normalize and not be seen as the major issue. Then they could get on with their lives. People can and do use drugs and lead very normal and productive lives.

À (1010)

I think that has to be pointed out and realized. The safe injection facilities might provide a way we can help those people who choose to continue to use drugs to contribute to society and feel more whole.

Mr. Randy White: Thank you.

The Chair: Dr. Marsh.

Dr. David Marsh: Thanks. I have heard the concept of harm extension being discussed. I think what you mean by that is if you remove some of the problems with using drugs, people might go on using them longer than if you include the sort of difficulties currently in place. What I'd say in response to that is that it's important to evaluate really the impact of those measures.

For instance, there's an Australian study that looked at injection drug users being released from prison. They're 15 times more likely to die of a fatal overdose in the first two weeks after coming out of prison than they are at any other time during the year. So we could say that putting them in prison is a way of making it really hard for them to go on using drugs, and that might motivate them to stop, but the data suggest it doesn't motivate them to stop and makes it more likely they'll die.

Another study would be the Dutch heroin study I mentioned earlier, the report of which has just become available in the last couple of weeks. I hope the committee will be able to access it. In this study people were randomly assigned to methadone maintenance, which is the best treatment we have for heroin dependence, or methadone maintenance plus a heroin prescription. The people who entered that study had already been on methadone and had the best chance of succeeding, but were continuing to do poorly. In the group that were prescribed heroin, over time their drug use went down.

So it's not the case that prescribing heroin for them will lead to their using heroin longer than they would otherwise.

The Chair: Thank you.

I'll now turn to Ms. Davies for roughly ten minutes.

Ms. Libby Davies (Vancouver East, NDP): Thank you, Paddy.

Maybe we can get the Dutch study, because it sounds very interesting. I know we've had the Swiss one, but you were saying the Dutch one is actually the most scientifically rigorous in terms of evaluating the outcome.

First of all, thank you all for coming today. You've made excellent presentations.

Just to continue along Randy's line of the dollars and cents--the economics--of this issue for a moment, I visited a demonstration safe injection site in Vancouver. Actually, it was on World AIDS Day, December 6, at First United Church right in the downtown east side. The thing that struck me was how simple it was. We're talking about just a small room set up with tables, a public health nurse, a couple of staff who were available. It was so simple and so cost-effective compared with what happens when someone overdoses in a back alley or in a doorway, with the paramedics coming, and going to emergency, and the costs that mount up, that to me it was just common sense that it is an approach we needed to have.

I know, Glenn, you didn't get to that part of your brief, but we talk a lot about the safe injection sites or the NAOMI trials or heroin prescription trials, and I have a sense that, at least at the community level, there's now a fair amount of support, particularly in Vancouver, Toronto, and maybe a few other places. I think sometimes these ideas get held up as too radical--“everybody wants to push this”--but somehow they're separated out and they're not part of a continuum. To me it's very much part of a continuum of services that does include treatment. It's not as though harm reduction is divorced from treatment options as well.

So I'm interested in your impressions as to whether you feel there has been a change even at the community level about the need to open safe injection facilities in Toronto, or the idea of having heroin maintenance trials. If you feel there is community support for it, what do you now consider to be the biggest barrier to actually getting it to happen?

The Chair: I've got Mr. Cavalieri and Mr. Druce so far.

À (1015)

Mr. Walter Cavalieri: One of the things I want to point out, Libby, is that when you look at community, what community do you mean? In the research we've been doing at the U of T, we've interviewed quite a number of people who are using drugs and living on or close to the street--many of whom, by the way, are in methadone programs and still injecting drugs. The people who are using drugs are largely in favour of these, and say they would use them. And that, I think, is very important. It's not something that would simply be imposed upon them but something that they really want. So that piece of the community, in Toronto, favours them.

One of our city councillors, Kyle Rae, has suggested that they should be in all community health centres. I don't think that's necessarily a good idea, because many of them would object to that, and it would be an imposition on them. However, it indicates that there are some people in the political area who are looking at them quite favourably. If you went to the neighbourhood associations, I think they would say no, because they would say no to everything.

One of the things we need to do is discuss this with the general public, inform them of what we mean, and then try to find out how they feel and educate them. There's such a lack of education about all of this, and so much misinformation, that I think one of the projects we have to do is educate the general public. Unfortunately, that takes time and money, which a lot of us don't have. We're just putting our fingers in holes in the dike all of the time.

That's all I want to say about the community at the moment.

The Chair: Thank you.

Mr. Druce.

Mr. Toby Druce: I would say that our experience from working with the residents' associations around our facility demonstrates that they have very significant concerns about the drug trade in their neighbourhood. That's a concern for us, because we provide services to people who use drugs and are a part of that community.

At the first meeting I went to with that association, I certainly thought I was in for a significant struggle. When I started to talk about the work we were doing, they drew a very clear distinction between the work that was done in a publicly operated facility... They said, “Yes, you have 60 drug users. What you guys do is okay; it's just the other drug users who are the problem.” There was somehow a sense that there were two different approaches.

So I think they were quite supportive of anything we were doing that meant that they weren't having to walk through a fair amount of the drug trade, that meant they didn't have to interact with dealers, that meant they didn't have to worry about people vandalizing their cars, that meant they saw a decrease in the number of needles on the street--all of those kinds of things. They didn't know exactly what we were doing, but they were quite supportive of us doing it. They felt there was some accountability there.

Essentially, of course, the same activities going on with our client group were the same ones going on with people who weren't clients of Seaton House, but the presence of somebody to whom they could go and hold accountable for what was being done was for them really important.

So when you can demonstrate that you are accountable for what goes on, I think there's a lot of community support, even within residents' associations, who traditionally haven't been the most supportive of emergency hostels certainly.

For us, it's about putting up more lights in the neighbourhood, patrolling the streets, and doing work with the people who are making a lot of money off the drug trade, encouraging them to at least take that activity to somewhere other than our neighbourhood. Of course, that means some other neighbourhood somewhere is getting all of those people going to them, so there's always the problem of trying to move that around. It's also about working closely with the police.

We don't support illegal activities other than drug use. I mean, we all know that our clients are using drugs, but frankly, we don't have the time, the money, or the energy to try to get them to stop using drugs. But what we do with our client group is say to them, very clearly, if they break any other law, there are consequences to that. If they are supporting their drug habit through shoplifting and they get caught, no one will go to their defence, saying that shoplifting is supported by the fact that they had a drug habit.

So the fact that purchasing drugs is an illegal act forces people into all of these other things. If you can decriminalize that part, then you're eliminating a lot of the things that people who don't work in that field have problems with, which I think would be quite helpful.

The Chair: Before I go to Dr. Marsh, perhaps I can put a pause on Libby's time for a second.

I don't think you actually described O'Neill House. It has 60 beds. People are allowed to use drugs, but are they allowed to use them in the facility? I'm just not clear on that. I don't know if anyone else is.

Mr. Toby Druce: You could come for a visit.

The Chair: We just might have to drop by.

À (1020)

Mr. Chris Gibson: Within the physical structure of Seaton House it is contained within a smaller building at the south end of our complex on two floors. Again, as Toby mentioned, we have a total of 60 beds. All our residents are self-identified as regular users of crack cocaine. Most, I think, would identify themselves as heavy users of crack cocaine.

For the most part they are people who have extensive histories and experience living within the shelter system or other institutional settings, jails primarily, and they have frequently been in and out of them through the course of their lives. People within Seaton House tend to have quite a bit of tenure. I would think most of our clients have been in the hostel system for multiple years.

The Chair: How is it different? Are they allowed to come and go? Is there no curfew? Are they allowed to use drugs on the weekend?

Mr. Chris Gibson: We can't. It's not possible for us to permit them to use drugs. It's an illegal activity, and we're a government-funded and operated body.

Personally, if I could set up an area my client group could use that wasn't on the street, I would be fully supportive of that. We would love to be able to do that. It would reduce the level of use on the street. The comfort level for the client would actually be much higher. They wouldn't need to concern themselves about hiding in somebody's backyard to smoke because they'd be concerned about getting seen by a passing cruiser or something like that. That's the reality of using drugs on the street. When you're homeless, by default you have to use them in public.

The Chair: But, Mr. Gibson, I'm still not clear on how it looks different except that it has 60 beds in a southern facility. Do they have a curfew? Do you have drug suites? How is it different from the regular suite now? I'm not getting that.

Mr. Chris Gibson: We have a curfew. It's much later. We accept the fact that the drug lifestyle means that most of the activity goes on at night. Our curfew is 3 o'clock in the morning. We have a very liberal policy about late passes; by the nature of cocaine use it's often binge-driven for a large percentage of our clients. When they're using quite heavily, they may spend very little time at the shelter. They may touch base in the morning to change clothing. We won't discharge them from the shelter, which is the norm in shelters in the city, where if you aren't occupying your bed at a given time, you're discharged. Then you must go through a re-admission process or face not having a bed for the following night.

We have a lot more latitude around those issues. We've actually found that the vast majority of our clients... since they've been staying in our program, where their drug use is an accepted fact... and that sounds like a very small thing, but within the shelter-using community, it's huge. There are many shelters that will bar admission to anybody who's under the influence of drugs, so to admit that you use them is to risk being ejected from that shelter because of your drug use.

The Chair: Then you can present yourself as obviously high on drugs and still enter?

Mr. Chris Gibson: Yes. Oh, absolutely.

Mr. Toby Druce: You have to be high on drugs, actually, to get in.

We had a problem initially. The possession of paraphernalia or drugs in the main hostel could get you barred for up to six months, but it doesn't for us. We have the opportunity then to say that people whose drug use is making it complicated for them to stay in the emergency hostel and who may have been barred because of their possession or use or because of the fact that they came after curfew and got very frustrated and said something inappropriate to the staff...lots of things can get you kicked out of a shelter. For any of those things we would suspend any kind of judgment around denying somebody service in our facility. Yes, you were in possession of paraphernalia. We're not going to bar you for that. You can't use the emergency hostel. You can come and stay with us. We try to have some more latitude around those things.

We also operate with the drug diversion court, so we set aside some beds for them. We recognize that on average our clients spent ten days in an emergency hostel prior to the opening of the O'Neill House. They now spend anywhere up to 365 days, so that's been really effective for us, being able to provide people with some place they feel connected to and where they will come when they're not incarcerated. It's not the drug use but the activities around getting their drugs that tend to get them into conflict with the law.

We saw that as being a really positive relationship for us, which is to say, if our clients get arrested, we can now advocate for them to go to the drug court, whereupon they get bailed back to us, so we provide them with daily supports.

À (1025)

That was huge, I think, for our clients as well, because oftentimes the moment they really recognize that they need to do something about their drug use is when they're in the back of the cruiser. There are not a lot of options for them at that point. The drug court is now an option--not one that everybody uses, but some clients do make use of it.

The Chair: And we're headed there this afternoon, so that just gives us a bit more context.

I'm sorry, Libby, but I wasn't really understanding how it was different.

Ms. Libby Davies: Can I ask another question?

The Chair: Yes, after Dr. Marsh answers the first one.

You have three more minutes left.

Dr. David Marsh: Since the honourable member for Vancouver East mentioned the NAOMI trial, I will first acknowledge that I've been involved in that group. It's the North American opiate medication initiative, and this month it will be five years since the first meeting we had to plan a heroin prescription trial in North America.

At this point I'm extremely optimistic that a rigorously designed scientific trial of heroin prescription will occur in Canada.

In terms of barriers, there's an economic barrier. When it occurs, it will likely be the most expensive clinical trial that has ever been funded within Canada.

À (1030)

Ms. Libby Davies: [Editor's note: Inaudible]

Dr. David Marsh: We submitted a grant application a year ago to the Canadian Institutes of Health Research, and the budget within that grant was over $8 million for the total trial. A lot of the costs are research-related, so if this were to become a part of the regular treatment armamentarium, it would be cheaper. But it's expensive to do a trial on this.

There also may be other barriers related to the logistics of regulatory approval for actually obtaining the drugs. Since there's no source of heroin within Canada, we have to get import and export permits and things like that.

Ms. Libby Davies: If I could briefly follow up, I want to talk a little about harm reduction. I think people are involved in the field. It's something you don't even think about any more because it's just part of the way you do your work. But it's still a very big debate. Even on this committee there are members who see it as something negative. Could you say a little more about how we need to refocus the whole idea of what treatment is about?

I was very interested to hear you say, David, that at the Centre for Mental Health and Addiction you don't use abstinence now as a sort of golden rule. But I know in a lot of places, if you talk to users, their biggest barrier often in treatment is that the rules are so strenuous you practically have to be clean before you can even get into the program.

It seems there's a shift taking place, but to me the issue is that harm reduction is part of a continuum that includes treatment options. They're not working against each other. The idea of not making abstinence the overall goal is to me something that is very important. I just wonder what your experience is with that, in terms of promoting harm reduction.

The Chair: After Dr. Marsh we'll hear Mr. Druce, Mr. Cavalieri, and Ms. Nallanayagam.

Dr. David Marsh: Thanks. I'll try to be brief. It gives me a chance actually to respond a little to some of the things Walter mentioned earlier around people being on methadone and continuing to inject drugs.

My feeling is that should occur, because it's unrealistic to expect people will stop their drug use immediately upon entering methadone. Once they're on a stable dose, if it's above 75 milligrams, their mortality goes down by 90%. They're going to stay alive. Their crime goes down dramatically early in treatment, but their drug use takes much longer to decline, especially cocaine use.

But our evidence--and I'm sorry, this is unpublished evidence, so I won't be able to give it to the committee in a formal way--shows, in evaluating our program, that of people who've been on methadone for four and a half years or longer, 80% of them are not using opiates or cocaine or benzodiazepines.

À (1035)

So if you keep people in treatment long enough their drug use does go down.

Another way of extending the range of treatment options is to allow people to be on methadone and enter residential treatment facilities. We've been able to successfully do this at the centre so that the 28-day treatment program that used to run at the Don-wood facility prior to the merger, which was very abstinence focused, now accepts people who are on methadone so that they can take methadone while they're in treatment and addressing other drug use.

The Chair: Thank you.

Mr. Druce.

Mr. Toby Druce: Yes, I would say that even amongst the front-line service providers who work in settings where harm reduction is, it's hugely contentious. It's not widely accepted at Seaton House that harm reduction is an appropriate intervention to apply to people who use drugs. It's just that nobody would know what else to do that would be any more effective.

The way we try to explain harm reduction in two of the six programs at Seaton House that operate in a harm reduction approach with new staff, or staff in other programs who have issues around what we do, is we try to explain to them that for us harm reduction is really about doing good social work. It's identifying that drug use is an issue for some clients, but it is by no means their only issue, and that abstinence is a goal for many people, but it is not a requirement to lead a productive life.

There are a great many people who non-medically use drugs who own homes, who have jobs, who maintain stable relationships, who have a relationship with their faith. They maintain all of the things that we would identify with people who don't use drugs as being able to do. They do that and they are drug users.

So we try to enforce that within our organization, because it's not widely accepted there. We say that we're just talking about being good social work providers to this client group, and, yes, ultimately someone may want to stop using drugs. But if they can be successful and use drugs, then more power to them, because a lot of people who don't use drugs who end up in the hostel system don't have great successes.

So it's about being able to manage your life in a way that is not having a negative impact on other people. That's your goal. And if you can do that using drugs or you need to stop using drugs...it's whatever works for you.

The Chair: Mr. Cavalieri.

Mr. Walter Cavalieri: I have two points. First of all, I want to pick up on something Toby said, that harm reduction is really social work. If you take a social work text and take the word “client” and substitute for that “person who uses drugs”, you're doing harm reduction. It's client centered. That's the important thing. And social work teaches us to work with the person where she or he is at. That's harm reduction.

The other point I want to mention is... I want to show you something that a Dutch researcher named Jean-Paul Grund did at a conference I was at when I saw him speak. He took a ballpoint pen and said “Why is this about harm reduction?” And don't say it's because the pen is mightier than the sword, which is true. There were a lot of crazy, kooky answers. Then he took the top of the pen off and blew in it. He said “Notice, air can go through that”. He said “Did you know that when ballpoint pens were first made there wasn't a hole there? They wanted to keep the point dry because the ink would last longer. But kids would swallow these things, be taken to the hospital and die because they could not get air down their throats. You can never stop a kid from putting stuff in his or her mouth, because that's a way of learning, and it's a way of defying the parents too. So they put holes in them to buy time until people could stop, could grow up and grow out of it, could mature out of swallowing things that are dangerous.” That, for me, is harm reduction. It's a way of working with things that won't go away.

The Chair: Now we're all checking our pen sets. Who are the better pen companies?

Thank you. Before I go to you, I have Ms. Nallanayagam.

Ms. Koshala Nallanayagam: As Toby said in regard to harm reduction, not everyone in community service and social services is down with that whole philosophy, but the thing is that abstinence has obviously not worked well for everyone as far as rehabilitation is concerned, and reducing the harm is not just reducing the harm as far the harm the drug does to the person. It's what using the drug could possibly do to the person, like sharing needles and getting infected with HIV and hepatitis C and that sort of thing. If someone is going to use a needle anyway, they're going to increase the risk to themselves and to others by sharing that needle. That is just an example of harm reduction.

À (1040)

I think it is really difficult for people to grasp that. All they're fixated on is addicts taking less of that drug. That's what it's about, but that's not necessarily what it's about. It's everything that has to do with the intake of a drug.

The Chair: Thank you.

Mr. Betteridge.

Mr. Glenn Betteridge: It strikes me that your question fundamentally gets at social perceptions about what harm reduction is and what it isn't, and it gets at overcoming barriers around conceptions and misconceptions. Education is a huge part of the movement towards more rational policies. I think that how Canada has recognized that intravenous drug use is primarily and above all else a health issue...and harm reduction fits into the way we are starting to come around to conceive of health care in terms of not only treating illness and disease at the end point when the symptoms manifest themselves. Most enlightened people now recognize that health promotion and disease prevention are key to providing health care, especially in a universal system such as the one we have, for one principal reason, that it is cost-effective. Harm reduction is in the same way hugely cost-effective. Rather than focusing on abstinence and prohibition, focus on harm reduction. It is cost-effective, it works better, and we have a healthier population. All these things can be said of a health care system that focuses on health promotion and protection. It's more cost-effective, it works better, and you have a healthier population.

Harm reduction fits squarely in with the health care and health promotion and protection model. I think that is the way of selling it. I think it is palatable. I think it is rational. I think it is in keeping with where we as Canadians are in terms of our perceptions and conceptions of health care and where we need to go.

The Chair: Thank you.

I have Mr. Druce again.

Mr. Toby Druce: When I come into contact with people to talk about the work that gets done at Seaton House and about harm reduction, one of the big fears many of them have is the initial impression that what we are doing is just ignoring it, that we are saying we are not going to deal with the problem and therefore everything will be okay. I think the opposite is quite true. In the work we do we have very active discussions with our clients about their drug use, about what the consequences of that are, and about what the impacts are on both themselves and on the neighbourhood in which they live.

It is a very active process, and it's one that engages people much more in talking about their drug use than trying to work and talk about drug use with somebody who has been required for whatever reason to stop using drugs. I find the conversations tend to be more productive and lead to better outcomes.

Across the board, one of the things that as a service provider I feel badly about is that we don't do enough to educate people about what is going on right now. We don't talk enough about what has been done. If you recommend some sort of a national coordinating strategy at the end of all of this, that is one of the things to do. It is to ask, what have people done now that does work? I could tell you right now that what I am doing is working really effectively, but how would I prove that to you? What would you need to know in order to be confident that I wasn't creating an environment in which someone might say, good God, I wouldn't want to go near Seaton House because it is full of active drug users, and everyone is okay with that, and I'd be at risk?

People need to hear that things are getting better, and they need to hear that things are getting better in ways they understand and can measure for themselves. You can say, yes, whatever the issue is, it would say to me that things are better. That's what we need to be addressing, and we're not good at that. We're quite shy.

The Chair: Mr. Gibson.

Mr. Chris Gibson: When talking about harm reduction to other service providers who work in a more traditional abstinence model, I come up against what I think is a common misconception, namely that it is an either/or choice.

À (1045)

We are more than happy to embrace anything that works for any individual, and that includes abstinence.

The client group we worked with were primarily people who were forced to conceal their drug use, to keep it as secret as possible, so they could access services available to homeless people--and those are limited at best anyway. Permitting this client group to be who they are and not punishing them for the fact of their drug use has provided better access to services for them.

I don't have any specific facts before me, but I'm quite comfortable in saying that at their own behest the vast majority of our clients have elected to enter some kind of treatment in the time they've been staying with us. We have not demanded that any of our clients enter treatment. We have not suggested that they must enter treatment to continue using the program. It's been a choice they've made.

To be able to get to the point where they could make a choice they felt was going to be healthier for them--and that's cessation of drug use--they needed to be in an environment where they could even acknowledge that they used drugs in the first place. There are many of our clients who would never have been in a position to access treatment because they weren't in a position to acknowledge that they even used drugs in the first place.

The Chair: Thank you.

The final comment is from Dr. Marsh.

Dr. David Marsh: Thank you. I think it's understandable and perhaps appropriate that the committee is having trouble with the concept of harm reduction. Even amongst people who practise and promote harm reduction there's been ongoing discussion about exactly what harm reduction is.

Eric Single, whose name may be familiar to you, has recently published a paper on that point: what is harm reduction and what isn't? Although I think harm reduction is an important concept, and it would be good if we could find some common definition for it, I'm not sure it's necessary. What's important is for people to realize that drug users are people and that they should be treated like anybody else.

I was doing harm reduction for a few years before I realized it or even knew the term, because when I started practising addiction medicine, I treated my patients the same as I would in family practice. I wouldn't have said to a diabetic who refused to stop eating chocolate, “Go away; don't come back until you're adhering to your diet”. I didn't say to borderline personality patients, “Because you attempted suicide again, I'm going to discharge you from care; you have to be abstinent from that behaviour or else I can't help you”.

As a family physician, you normally work with people around where they are and what's possible for them, and you try to gradually help them decrease the harm. If they keep eating sugar, you add medications to decrease the negative impact of the sugar on their kidneys or their eyes.

I think it's okay to have discussion or discrepancies around how we see harm reduction as long as we continue to look at the full range of possible interventions and evaluate them for effectiveness in order to try to help people where they are.

The Chair: Thank you.

Colleagues, before I turn to Dr. Fry and Mr. Lee, I'm proposing that we have a five-minute step-across-the-hall break. This session is going to go until 11:30, so there's still some good time. If we could really take five minutes, some people will step across the hall to get their fix and other people will step across the hall to....

So I'll suspend.

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The Chair: I will bring this meeting back to order. Mr. White has stepped out for half an hour and will be back.

I will turn now to Dr. Fry.

Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you very much, Madam Chair.

I was going to ask earlier on about the NAOMI project and its status, but I think we went through that, so I won't bother to discuss it.

What I really wanted to ask was a question on the concept of drug courts. Yesterday we heard about the drug court. Some of you, Toby and Chris, have been grassroots folks who have been delivering services to the grassroots. I want to know what your perception of the drug court is. Is it useful, is it cost-effective, is it efficient in achieving outcomes? That is the first question.

The second question is to Koshala, and it is about whether you ever had a response from Corrections Canada on your 1992 submission on what should be done for persons in prison, to deal with harm reduction. This is of great concern to me because I feel that this is a group for which, because of its containment, one could do so much. One could have an opportunity to educate, one could have an opportunity to practise good, solid harm reduction techniques there. Yet I know this is a huge black hole where nothing has happened.

I want to know if you feel there has been any movement, if you have had any response, and if so, what was the response? 1992 is a long time ago, ten years ago.

Those are the two questions I have.

The Chair: Thank you. First, Mr. Gibson? No, Mr. Druce.

Mr. Toby Druce: I think we started off our relationship with the drug court with a great deal of optimism. Our intention was to spend as much time as we could getting our clients who weren't in drug court arrested so that they could go to drug court and be bailed back to us. That would give us some leverage in terms of discussing with them care plans and positive outcomes.

I'm not sure we're there at the moment, and that's our goal. I think it provides people with an option, and I think an option they didn't have before, which I think is really important. I think the Toronto drug court has been really supportive of people who have been trying to make an effort to make changes in their life. I think that's really good.

Systems-wise, I suppose there are communication issues that any two organizations have when they work together. Where we see somebody who's not doing so well and may have behaviours that concern us, they may not concern the court. Or the court may see behaviours that concern them, but we think somebody's making really good progress and we have a difference of opinion about how successful someone's likely to be in their outcome. But I think it's given people an option. As I say, that moment of clarity oftentimes comes for clients after they've been arrested.

We've had some people who certainly would have been low on my list of identifying people who would have successful outcomes, who have been very successful and have been successful through drug court.

The Chair: Thank you.

Ms. Nallanayagam.

Ms. Koshala Nallanayagam: After this came out there was the expert committee. So Corrections did their own study and came up with exactly the same outcomes. Only a couple of things have been implemented, like the condoms and the bleach; however, as I said, it's not always done in the most acceptable manner.

In terms of a lot of our other recommendations, which are page 4 of the brief, as far as doing something about the tattooing or needle exchange, the methadone, all that stuff, it is still taking such a very long time. As you said, it's something that could be done easily, but there are always excuses around that or reasons that don't seem to have been realized in other places where this has taken place.

Ms. Hedy Fry: What are these reasons?

Ms. Koshala Nallanayagam: Around needle exchange, for instance, there's the issue that the needles could be used as weapons and we're condoning an illegal activity. As far as needles being used as weapons is concerned, in the studies that have been done, and actually in the experience of the needle exchanges that have been implemented in the prisons in Europe and Australia, they have not been used as weapons. In fact, as I've said, the conditions have become safer for the guards who are searching cells and the results have been acceptable to the prison personnel as well as to the prisoners.

As for the issue that illegal activities shouldn't be happening inside prisons anyway, as far as illegal drugs are concerned, in fact it is happening. Prisoners manage to get drugs in there in all kinds of creative ways, and they're also brought in by prison personnel as well. So that doesn't really make sense, especially when prisoners are supposed to have the same access to health care inside the prisons as they do on the outside. That is not happening.

Methadone maintenance programs could help a lot, but they're dragging their asses on that one. A lot of prisoners we advocate for would like to be on the methadone maintenance program, but it takes a long time, two years and stuff like that, or until people are shooting up crud into their arteries. It's crazy. People are almost killing themselves before something happens. I know you're probably tired of hearing this, but the rates of HIV and hep C infection are just crazy.

So, yes, as I said, some of them have been implemented in a certain way.... Tattooing, for instance; why can't they make that come under hobby craft? That's still illegal, and consensual sex is illegal in prisons.

So there you go.

The Chair: Thank you.

Dr. Marsh and then Mr. Cavalieri.

Dr. David Marsh: I'll just comment on drug treatment courts. First, I should acknowledge that the treatment provision in the Toronto drug treatment court occurs at our centre, although I'm not personally involved in the program on a day-to-day level.

I think in a structural way drug treatment courts can have a role to play in the continuum of treatment as long as the possession and use of drugs are legal matters that involve the courts. Obviously, if that weren't the case, then there wouldn't be a role for drug treatment courts. I think it's important before implementing drug treatment courts that there be a broad range of voluntarily accessible treatments so you don't have people having easier access to treatment through the legal system, with all the restrictions on their civil liberties that involves, than they have voluntarily entering the health care system.

The Chair: Thank you.

Mr. Cavalieri.

Mr. Walter Cavalieri: Dr. Fry, I want to address the drug treatment courts too. The important thing is that it is one option, and we need a lot of options for people instead of the one-size-fits-all approach, which we have had up until fairly recently.

I want to point out something I picked up at a conference. I'm a conference junkie. I believe it was the head of the American Civil Liberties Union who was equating the treatment of drug users, people who use drugs, to the holocaust, and he then pointed out that for them the drug court was like Schindler. That is a really good analogy. Then he went on to say, but what we really need is an Eisenhower.

A massive change has to take place. As an interim option, they're wonderful, but in the long run, I hope to see them become obsolete and unnecessary.

The Chair: Finally--really finally--Mr. Betteridge.

Mr. Glenn Betteridge: I'd like to comment on your point about prison. The response has been deafening from the Correctional Service of Canada, and they have arguably been quite negligent. The parallels with the blood system are staggering in the sense that it's probably only through litigation that CSC can be made to move. On a small scale, people whose methadone maintenance applications are refused have had successes through litigation in getting methadone, but very few prisoners can actually get access to justice in the sense of being able to litigate.

I don't know whether the members of the committee are aware, but there has been a $25 million suit launched against Correctional Service Canada for wrongful infection with HIV and hepatitis C, negligence in the provision of health care. This is as a result of an inmate who alleges that he was incarcerated, had a history of drug use, asked for methadone maintenance therapy, was refused, and subsequently seroconverted to HIV and hepatitis C. His subsequent treatment has been negligent in terms of provision of HIV antiretroviral therapies. This is currently in the courts. This is a $25 million suit, so it's a pay now or pay later thing in terms of economics.

It's also a moral and ethical issue. As you say, here we have a population and we have relatively inexpensive things that can be done to prevent a public health disaster, and there is no action forthcoming. This is all the more ironic given that it was Correctional Service Canada that funded the Expert Committee on AIDS in Prisons report, which made a number of recommendations to them, which they have virtually ignored.

I personally, and other counsel, continue to go to inquests into the deaths of federal inmates with HIV and are fought tooth and nail trying to bring any harm reduction or systemic issues forward. It's staggering and it's a hidden secret in terms of what the public knows about the administration of correctional systems in Canada.

The Chair: Thank you very much, and thank you, Dr. Fry, for that 11-minute, 18-second round.

Some hon. members: Oh, oh!

Ms. Hedy Fry: Touché.

The Chair: Mr. Lee.

Mr. Derek Lee: Thank you.

This has been a fascinating session this morning. I couldn't help but notice the difference in perspective between what you have generally presented today and what was presented generally by the law enforcement community yesterday. They have quite a different perspective on this. They would refer to this as the illegal drug committee, whereas we would call it the non-medical use of drugs committee. It's just a difference in semantics.

I think it was Mr. Betteridge who said earlier that it was his belief that the majority of your peers in the fields you work in and represent were more prohibitionist than reformist, if I can use the term. Do you all agree that in the fields you work in this might be a political measuring stick? I find the same thing politically. There's great resistance to moving in a reformist direction, in a harm reduction direction. Is it your view that you represent a minority across the full spectrum of service providers, if that's the right term, in the fields you work in?

Mr. Glenn Betteridge: I would say that it's true perhaps amongst lawyers who are members of the bar of Ontario. Do they espouse harm reduction? Well, first off, I think the vast majority of them have no idea what harm reduction is. They see drugs through the lenses of media and any personal experience and exposure they have, which is probably no different from many parliamentarians or the vast majority of Canadians. That's why the educational component, the awareness component, is so crucial to moving in a reformist direction. That is one of the challenges the special committee has identified in its terms of reference.

I think it will be crucial to the success of any practical measures to develop communication strategies to overcome this resistance. Harm reduction and reformist principles at their basis are just good sense. I hesitate to use the term “common sense”, which has been tarnished, but they are good sense in that they are fundamentally rational and ethical principles and they're individually centred. I think these are things that professions and people do understand, the legal profession and the medical profession--ethical principles, responding to individuals' needs as opposed to adopting prohibitionist policies or policies that don't respond to individual client and personal needs and don't accord with professional obligations to do good and not do harm.

Mr. Derek Lee: Madam Chair, I may have to take control of the witnesses here. What is happening, of course, is I will ask a question and many of you would like to jump in. With six of you there who are all very well informed from your different perspectives, I am reluctant to cut anybody off at the knees. But I know Dr. Marsh wanted to say something and I just saw a hand go up.

Could you keep your answer short? My question was that I wanted to establish that it was your view that the majority of your peers were less reformist. If you could just focus on that, Dr. Marsh, I'd appreciate it. Thank you very much.

Dr. David Marsh: I would say that the majority of my peers are employees who work for organizations. I do not think it is the role of every employee in every organization to wander out into the grey areas that we are in right now.

So I think there is an opportunity for a number of us who are comfortable working in areas where there is no direction, in terms of the idea that we could be doing completely the wrong thing and we don't know. We think it is the right thing. We're not sure. To ask everybody else who is involved in the delivery of social services to take those same steps at this time I think is probably asking too much.

So I would say, yes, I agree that probably most of them aren't supportive of what we are doing right now, and I think they need to see whether or not what we are doing is going to be effective before they would then, I would expect, follow.

The Chair: Thank you. I have Mr. Gibson and then Ms. Nallanayagam.

Mr. Chris Gibson: I have a slightly differing viewpoint from Toby. I feel the vast majority of the people whom I have worked with in this field are not opposed but uninformed. I found that almost to a person, everybody who's had an opportunity to work with using these kinds of models, irrespective of their opinion at the onset of the project, by the end of it were fully supportive, even people who have been quite staunch prohibitionists. I think the inescapable question that even the most staunch prohibitionist must face is at what point is that prohibition going to be held to some sort of account? If it hasn't worked thus far, why should I believe it's going to start working now? How is it in any way different from what it was 50 years ago?

The Chair: Ms. Nallanayagam.

Ms. Koshala Nallanayagam: I think most aid service organizations are coming around to the fact that harm reduction makes sense.

As far as being a prison support organization first, we are rather unique. We are unique. We are the only one like us in Canada. So our organization definitely supports it.

The Chair: Thank you. Mr. Lee.

Mr. Derek Lee: This is a short question. I have asked it before and Mr. White has asked it as well.

There exists in Canada, whether you know it or not, what is called a national drug strategy. Is any one of you doing anything in your work that you believe to be a component of the national drug strategy? Just say yes if you think you are. It's okay to say no.

You do. Good. For the record, you may as well describe what it is you do that you believe is a part of the national drug strategy.

Mr. Toby Druce: There are a couple of things about our organization. I think the work we do is directed at the kinds of outcomes that every citizen of Canada is expecting to get from services that are delivered by government. Although we are not federally mandated to do that, I think our contribution is a part of what as a nation we would like to see happen around addressing the issue of drug use.

The Chair: Dr. Marsh.

Dr. David Marsh: I have been involved in Project CREATE, which has helped develop a curriculum for training health care providers in the recognition of substance use disorders and appropriate treatment. Hopefully 30 years from now the answer to your last question will be no, because most physicians haven't been trained and so their attitudes reflect society's and not an informed attitude.

Also, I think the work we've done around expanding access to methadone maintenance across Ontario is in keeping with Canada's drug strategy.

The Chair: Mr. Cavalieri.

Mr. Walter Cavalieri: I think it is done by providing an unbiased education, which we are trying to do with the network and with other organizations, ones whose goals are in keeping with the strategy, and also by giving a voice to people who use drugs. We're in keeping with that because that too is mentioned. So yes, I think we're doing that, and I also want to mention that my organization is funded out of the United States rather than out of Canada.

The Chair: Mr. Lee.

Mr. Derek Lee: I just have a couple of quick questions, or rather one is a perspective.

I'd like to talk about O'Neill House and the fact that it houses approximately 60 people who are addicted to crack cocaine. I assume that most of them don't work or that hardly any of them work, though maybe a few do. Those habits, those addictions, need drugs, so those people during the day are out doing what they have to do to get the drugs. They're not dropping off flyers door to door; they're trying to bankroll something here. This is, I will assume, a source of crime; it's a base for people who must support their habit. I realize that it's not your job to deal with what they do when they leave the place during the day, but I just can't help take note of that. You may wish to comment, but of course you do.

Second, and this question is directed at Mr. Betteridge, if there were to be a safe injection site--there's not much of that going on now--I assume that one would have to sign a waiver or something. Are there waivers signed for needle exchanges when the person comes in, just with a view to preventing lawsuits later? The service provider at the safe injection site or the service provider at the needle exchange is holding out and providing something, which in tort law means mishaps are out there waiting to happen. Is there any legal paperwork associated with safe injection sites or needle exchanges that you're aware of?

And then Mr. Druce wanted to comment on O'Neill House.

Mr. Glenn Betteridge: As far as I know, there's currently no legal paperwork associated with the use of needle exchanges or safe injection drug sites. In tort law you have to have a duty of care before a finding of negligence in the provision of services can be made. Arguably, especially with respect to injection drug sites, you're providing a location for people to come and engage in an activity they would otherwise be engaging in. You are not helping them shoot. It's clear that at the injection drug sites that exist, none of the staff members are actually helping people engage in the behaviour of consuming drugs. They're there to supervise and intervene should that behaviour take the person into a place of danger.

The Chair: Mr. Lee, just on that point, we were thinking that at Dopamine in Montreal they may have had to sign something. We'll check on that for you.

Mr. Derek Lee: All right. I was just curious.

The Chair: Then I have Mr. Druce.

Mr. Toby Druce: I think you're right. It is a big assumption to say that most people are engaged in crime to support their drug habit, certainly amongst our client group. We are quite concerned about what people do when they leave, although we have little control over what they do. But a great deal of effort is spent on trying to do something.

Mr. Chris Gibson: Yes, there's no question. The reason for that seems to be that the drugs are fantastically expensive, and it's not the cost of producing them; it's the cost of using an underground economy to import them into this country from other countries. Simply because it's an underground economy doesn't mean it doesn't follow all the principles of the above-ground economy. There are several points along the way where people are taking their profit, and when it gets to street level, it's incredibly expensive.

Just to be as out there as I possibly can, if it were completely legal, the cost would be much lower and the necessity of committing a crime to acquire your drug of choice wouldn't exist.

I've worked for many years with people who are profoundly alcoholic, and there are very few instances of them committing crimes to support their habit, because the cost of their habit is very low. I think the same would hold true for users of illegal drugs. The fact is that their drug use criminalizes them, and once you're criminalized, you have the entry point to that lifestyle anyway. What's the incentive to leave?

The Chair: Dr. Marsh and then Mr. Cavalieri.

Dr. David Marsh: I have a couple of points to respond to your two questions. First, it may be a valid assumption for the residents of O'Neill House, but it's not a valid assumption for drug users in general that they're not employed. Many drug users are employed.

With respect to the question about waivers, we do operate a needle exchange and distribution service, which includes patients where we have a duty to care. We don't get them to sign waivers. In fact, we feel we're offering them the best quality care available by offering a needle exchange, because there's evidence that it helps prevent them from acquiring diseases. Our goal is to keep them engaged with the health care system, even if they are continuing to commit crimes or to inject drugs, so that over the long term we can help them to decrease the negative consequences or stop those behaviours.

Mr. Walter Cavalieri: In response to both questions, first of all, I ran a needle exchange at a community health centre for eight years and we did not have people sign waivers. Our goal was exactly the same as what Dr. Marsh has mentioned. There was no need for a waiver.

Secondly, I know quite a number of people who have quite heavy drug habits who don't engage in crime, although I must say that most of them do, because of the reasons Chris mentioned. I know people who are not in the O'Neill House and some people who have rather minimal housing arrangements--frequently shacks, under bridges, in ravines, and other places--who support themselves by panhandling, which I suppose is illegal but is certainly benign, or selling the homelessness newspapers. People can do very well with that.

Most people truly don't want to engage in crime, but they're forced to by the circumstance of the costs. The costs are up for the very reasons Chris mentioned: this is illegal.

The Chair: Thank you, Mr. Lee.

I have a couple of questions for Ms. Nallanayagam. Yesterday one of our colleagues was on the Michael Coren Show and was talking about Club Fed and how wonderful our prisons are and how easy it is. You talked about the European model and the Australian model for needle exchanges and what have you. It seems to me, from being on the justice committee in the past as well, that the biggest resistance is actually the workers, in that we need to do something about trying to work with them or trying to educate them on the other models.

What is your group doing to help alleviate that problem and to advertise or communicate to people what is going on, especially in the face of lots of people talking about Club Fed? Why was it successful? What are the methodologies to bring on the workers in Europe and in Australia?

Ms. Koshala Nallanayagam: I think a lot of education was done. There were surveys so that the needs and questions and fears were dealt with.

As I said, the way the needle exchange works, whenever a person enters the system, they're given a needle, whether they need it or not. Also, there's a specific place where the needle is kept in the cell, so that the guards know where it is. Even though there might have been some fears before the needle exchange programs came into place, after that people were pleased about the way things were going, and the fears were no longer there because the needles were not being used as weapons, which was the major concern.

As far as our education is concerned, we tend to go to different organizations to educate around prisons in general: what is offered and what isn't, and what's truly necessary and should be in place. We also advocate on different levels, one on one with health care, and then on systemic levels as well. There's constant debate around why needle exchange is a good idea, why methadone maintenance is a good idea.

So this has been going on, as Glenn said, for a long time. Meanwhile, people are dying. That's really distressing.

The Chair: Do you have any contact directly with the labour organizations for the prisons, federally or provincially?

Ms. Koshala Nallanayagam: Do you mean the unions?

The Chair: Yes.

Ms. Koshala Nallanayagam: I'm not sure, actually.

Glenn, do you think you could answer?

Mr. Glenn Betteridge: I've been to a number of CSC consultations on subjects such as confidentiality and I have never encountered members of the union there, whether they have been invited or not.

I think there's a fundamental gap or a divide between Correctional Services' administration and the union of correctional employees, and this gap has to be bridged. I think it's incumbent upon Correctional Services, and not the community, to bridge that gap. The community can certainly play a role in facilitating and education, but I don't think it's the role of the community to make employees and an employer talk to one another.

The Chair: If you want to get your issue across, you'd better figure out every single way you can. If the resistance to management trying to make some changes is their own relationship with their workers, surely you have to figure out another method to get those workers to agree to what management would like to do, assuming management wants to do that.

Mr. Glenn Betteridge: I would take exception to one point you made, and it's a crucial point: if there's resistance among workers to what management is trying to do. You're assuming that management is trying to do something, i.e. harm reduction. I think that assumption is fundamentally flawed.

Arguably, in a corporate structure, or in a business setting--and I think perhaps where this has been studied most is in the employment equity setting--if the management is not wholeheartedly for employment equity measures and progressive thinking and doesn't sell that, there's no way the rest of the organization will be for it.

Similarly with harm reduction. If the upper administration at CSC doesn't show commitment to these issues, discuss them, and bring them out in the open, I think there's very little hope that the rank and file will see these as viable, important issues. To date, there's been no commitment--

The Chair: But, Mr. Betteridge, you just identified that you've been dealing with management all the time and you're not getting anywhere. Don't you think things ever come from the bottom up? It's your choice, but if you're not happy with the situation, I would think you would be looking at every point of contact to make some change. You and I can disagree about that. I think you're making a mistake if you're not going to bother to work on the one side and you're only going to work on the other where you think they're not even mixing.

Mr. Glenn Betteridge: It's not our position that we haven't bothered in the community; it's a resource issue fundamentally. Frankly, when people in the community get invited to CSC things, they're organizing, they're setting up, they're paying. The brotherhood hasn't approached us. We haven't approached the rank and file because frankly we're too busy dealing with our clients' needs on an individual basis and the infrastructure isn't there to develop the relations.

The Canadian HIV-AIDS Legal Network has undertaken studies and surveys of the union membership to assess their attitudes and opinions on these issues. It's not as if there haven't been efforts made in this direction. But they're starting out with surveying attitudes and opinions and finding out where the blocks are. I didn't mean to give the impression that we're unwilling to enter into this dialogue. I apologize for doing so if I did. It's just that--

The Chair: Can we get a copy of those studies?

Mr. Glenn Betteridge: Sure.

The Chair: Ms. Nallanayagam, and then Dr. Marsh.

Ms. Koshala Nallanayagam: As Glenn said, we, PASAN, are the only organization of its kind in Canada. Now, finally, we have six employees. We accept collect calls from prisoners all over Canada.

As I said, our mandate is to provide advocacy, but also education and support. All our clients are HIV positive and most of them are hepatitis C positive. But we also go out to prisons, jails, and young offender facilities to do programming, to give information about transmission and how to stay healthy with hepatitis C and HIV, if you already have it and so on. So that is a very important part of what we do, the advocacy. But unfortunately, it really has a lot to do with how many people, the personnel, the complement we have, which is really not very much.

We are an Ontario organization now. I think there is talk about going national, but we don't know what that means, because unless we get a lot more staff....

As I said, we do stuff that's national anyway; people look to us to come up with stuff, and we try to be in as many places as possible. It's really tricky because we have over 300 clients, and most of them are inside.

It's difficult because a lot of times we're doing the advocacy around one person not receiving their meds. Confidentiality stuff has a lot to do with what we deal with, such as where someone's status was revealed. Sometimes staff in the prisons do things without really thinking. In one prison everybody knows that on Thursday the primary care doctor comes in. Well, a nurse posted the names of everyone outside on the door so everybody knew that, oh, these people are all HIV positive. Stuff like that happens.

The Chair: Just for clarification, who funds you?

Ms. Koshala Nallanayagam: It's all health funding: Health Canada, the City of Toronto, the AIDS Bureau. A year and three months ago I was hired with funding from Health Canada, the hepatitis C division. We're hoping we'll get funding for the next couple of years, but we haven't heard yet.

The Chair: Thank you.

Dr. Marsh.

Dr. David Marsh: Over the last few years, one of the positive changes that has happened is that in provincial and federal correctional facilities people who enter on methadone are maintained on methadone during their incarceration. I've been involved in training medical staff and other health care staff, and in some of the training sessions we've had wardens and other staff from the correctional facilities. One of the things that bears on this that struck me was that we may assume that people who are in correctional facilities have a right to the same level of health care they would receive otherwise as citizens of Canada. I did not see that as a general working assumption amongst the people from the correctional system, either health care professionals or otherwise.

The Chair: What do you mean by that?

Dr. David Marsh: I mean that in some cases assumptions around confidentiality or access to care were that “these people don't deserve”.

The Chair: Thank you.

And Mr. Druce.

Mr. Toby Druce: We employ 300 people directly. In terms of the struggles we have around getting people at the front-line level to buy into the work that's being done, I would say that what's always struck me is that places that practise good harm reduction, namely good social work, have tended to have very non-hierarchical relationships. The role of our supervisors at Seaton House is to ensure some accountability around the work that gets done, but ultimately the work that's getting done is being done by everybody, and everybody's in that work for the same reasons. The people who practise good harm reduction and end up in harm reduction programs in our facility are people who have demonstrated a desire to explore some areas that aren't clear-cut. There's not a policy and procedure manual for doing this work, and they're comfortable with that.

The union's only concern is that in the event we are engaging in things that are not the norm for all employees in that classification, what happens if something goes wrong? How is that employee going to be responded to?

So you have to really do some groundwork around demonstrating that as an organization you support the principles and you're going to support the people who ultimately have to carry out the work. When you have that kind of buy-in, the sad part is that the front-line employees tend to become so good at what they're doing that they make excellent supervisory candidates and they all get co-opted into management. That's about the only drawback for us.

The Chair: Thank you.

We'll do another short round. Ms. Davies, Ms. Fry, Mr. White, and then Mr. Lee.

Ms. Davies.

Ms. Libby Davies: I have just two quick questions. I'm switching topics slightly, but I think it's related.

All of you have mentioned education. I guess there's education of your own client group and the people you work with, and then there's the issue of broader education. It's come up from time to time, particularly among young people. It seems like the whole field of education is primarily being left to the cops, through these DARE programs and so on. I've always thought it was a contradiction that we had cops out there talking about drug education, when really we should be talking about health promotion and a health message.

I want to ask this of each of you. Do you actually get money for education within your programs? What do you think needs to be done in those terms?

Koshala, in terms of the prison system, we hear all the time this message that it's a luxurious existence, Fed Med and all this. With the reality you presented today, it sounds like there's an incredible amount of harm going on within the institution and that people's health is actually suffering. Is there anything through Corrections Canada that you are able to access and evaluate? What accountability do you find within the system to actually measure what's happening in the system in terms of the health and well-being of human beings, whether they're inmates or not?

Dr. David Marsh: Our organization does get money for prevention and health promotion activities as part of our global hospital budget. An example of this would be the substance abuse program for African Canadian and Caribbean youth, which runs in schools in Toronto. It has a resiliency program where they identify youth at risk and try to build their self-efficacy so they can make better decisions. It isn't a program that focuses on drug education per se.

In fact, the evidence around prevention efforts with youth is that interventions that build their self-efficacy and their decision-making are more effective than interventions like DARE. There is evidence that says schools where the DARE program has been implemented in the U.S. have higher levels of drug use amongst their students than schools where DARE has not been.

Ms. Libby Davies: [Editor's Note: Inaudible] ...information that shows us that in Canada?

Dr. David Marsh: I don't think the drug education offered by the law enforcement staff in Canada has been evaluated rigorously, but it certainly should be.

The Chair: Just on that point, we heard in B.C., and I've heard from police forces, that they're starting to pull back and they're a bit concerned about the DARE program. Some are choosing to go with other models now.

Koshala.

Ms. Koshala Nallanayagam: Right now, actually, two of our staff are doing a project in women's prisons, in the federal prisons. They're doing a huge survey of what is available, what they know about certain things as far as education, knowledge, and that sort of thing. So we have funding to do that.

Yes, we generally do have funding to do education. As I said, we try to go to as many prisons, jails, detention centres, and young offender facilities as possible, and we do educational programs. We have gone into schools as well. Our young offender coordinator does go to young offender facilities, open custody and the ones that are like a prison.

Again, I think that's really necessary, and I think we need more funding and more staff to do it. As you said, if education is coming only from the cops, that's only one perspective.

In terms of harm reduction, I don't think they present that point of view at all, but I think it's necessary, really. I mean, young people are having sex, doing drugs, and all that stuff. It's not as though it isn't happening.

The Chair: Thank you.

Finally, Mr. Cavalieri.

Mr. Walter Cavalieri: Very briefly, the Canadian Harm Reduction Network is funded to do education, and we do about six “educations” a year at conferences. A number of them have been sponsored by the AIDS Bureau here in this province. So far they've all been in Ontario.

We've also educated community groups in rural Ontario when they've invited us. I've been invited back twice to one place, Woodbridge, a tiny town, where they really want to know about harm reduction.

The Toronto Harm Reduction Task Force has been funded by SCPI to do education. They did a survey of community agencies in the Toronto area, and there's a huge demand for harm reduction education. In the coming year that activity will pick up and education will be provided.

In terms of education for youth, the best education I've seen done here in this city is done by TRIP, the Toronto Raver Info Project. I hope you've had a chance to meet these young people who are doing dynamic, effective education at the raves. And not only do they do it at the raves; I've seen to it that they've come to Ryerson twice and to the Ontario College of Art and Design, with which I've had a connection for several years, to educate both the staff and the students. They're incredible.

The Chair: Thank you.

Koshala, one quick point?

Ms. Koshala Nallanayagam: Yes, I forgot to address the Club Fed issue.

Absolutely, the prisons and jails... or most of them. Take the detention centres--the Don Jail, the West Detention Centre, the East Detention Centre. They're terrible places. There are three people to a cell that's made for only one person. There's a double bed, and one person has to sleep on the floor. For our clients, especially the ones who are HIV positive and who already have AIDS, those are terrible conditions for them to survive in--not even stay to healthy, but just to maintain a certain level of health.

I've never seen any of these fancy places. Really, I think it's a huge myth. Again, that's really hurtful to prisoners, because prisons are terrible places.

As I think Toby said, a lot of prison staff have the view that, oh, these people are criminals. They've done terrible things. Why are we worrying so much about them? Why are we so interested in treating them well, keeping them healthy, and educating them? What the hell is all that about?

The Chair: And finally, on this point, Dr. Marsh.

Dr. David Marsh: Madam Chair, I'd also like to comment on Club Fed. I think any member of Parliament or person who believes that's the case should, instead of going to Cuba or the Caribbean next time, make a $2,000 donation to the Government of Canada and go and stay at Club Fed. Then they'll know what it's like.

The Chair: That's a novel approach.

Mr. Betteridge, and then it really is the end of this round.

Mr. Glenn Betteridge: Just as a final point, it may be of some interest to members of the committee that Correctional Services Canada health facilities are not accredited in the same way as any other health facility that you would attend in Canada. There is no oversight or monitoring of Correctional Services Canada health facilities. The only way to call them to comply with professional obligations is through the professional regulatory bodies--for instance, the colleges of physicians and surgeons, or of nurses--or through the court system. The chances of a prisoner actually getting legal aid or having the means to sue for negligent health care are next to nil.

The Chair: Thank you.

Mr. Lee.

Mr. Derek Lee: I had hoped to avoid putting a lot of focus on the Correctional Service of Canada. I see it's a piece of the puzzle, of course, but...

I wanted to direct a question to Ms. Nallanayagam. I got the impression from your earlier answers that you didn't see much methadone maintenance happening in the federal prison system. Is that correct?

Ms. Koshala Nallanayagam: Yes. If someone is already on methadone, if they've been prescribed that on the outside, then it's easier to stay on it, but if someone needs methadone for the first time inside, it's really, really difficult, if not impossible.

Mr. Derek Lee: The only reason I asked that was because the Auditor General's report had focused on spending for treatment programs within CSC, where they spend about $4 million a year on methadone maintenance. At least, the cited example is methadone maintenance; they may do other things. They do use some others, but--

Ms. Koshala Nallanayagam: Yes, if someone is already on it, then it's easier, but it's extremely difficult if they want to go on it for the first time.

Mr. Derek Lee: I'm just trying to determine, Madam Chairman, if we have to shine the light more brightly on the Correctional Service of Canada here on this or not, but there are certainly some questions raised here by the witnesses today.

The Chair: Dr. Marsh wanted to comment on your question before I turn to Dr. Fry.

Dr. David Marsh: Yes. I understand that in terms of the federal corrections system, they have a plan for implementing methadone maintenance in the federal facilities. The first phase was to maintain people who were on methadone prior to incarceration, which has been done. The second phase of initiating treatment has never been implemented, although it's been planned for at least three years now.

I also think that in terms of the Auditor General's report, from my knowledge of what the money is spent on, there are opportunities for people who understand the details of methadone maintenance to help the Correctional Service spend their money more wisely.

The Chair: Thank you.

Dr. Fry.

Ms. Hedy Fry: Thank you, Madam Chair.

I think that, given the high percentage of prisons and correctional facilities where inmates are using drugs, we have to deal with that issue. It's an issue we can't leave out. It's a piece of the puzzle.

What I really wanted to do is just shift focus a little. Yesterday there was a bit of a debate among some persons who presented to the committee on the nature of addiction, whether it was simply just habituation or whether there were pharmacological and physiological components to it.

As a physician, I know there are physiological and pharmacological components to it and it's not simply a habit or habituation thing, one that just demands very good willpower. There is a concept that people who are addicted tend to just have bad willpower and are just really less strong or less worthy people than others.

Now that we have Dr. Marsh here, and because he's an addictionologist, I'd like him to, if he could, briefly give us just a bit deeper understanding of the physiology, pharmacology, and habituation nature of addiction, please.

The Chair: Addictionologist? Is there such a word?

Dr. David Marsh: There is, yes.

Thanks, Dr. Fry.

The Chair: I've learned something extra new.

Dr. David Marsh: The short answer to that is something I mentioned earlier, that drugs that lead to dependence have an effect on the brain that makes it more likely that the person--or in animal experiments the animal--will consume the drug again in the future. It's what we call “reinforcing”.

Some groundbreaking neuroscience research around this actually got started in Canada and continues to be a strong tradition in Canada. Jane Stewart from Concordia University is a world expert in this area. What happens is that when someone consumes heroin, cocaine, nicotine, alcohol, or any drug that can lead to dependence, the common pathway they take is to release dopamine in the nucleus accumbens--an area of the limbic system, sort of the base of the primitive mammal brain--which essentially tells the brain that this drug use is essential for survival. The same type of dopamine release happens when we're hungry and we eat or we're thirsty and we drink water.

So why these drugs cause dependence--in part why they cause dependence--is because of the effect on the brain; they essentially trick the brain into thinking that drug use is an essential behaviour for survival.

Ms. Hedy Fry: Are there some people who have some sort of barrier to the dopamine in the neurotransmitter pathway so that they can be more addicted than other people? There was a concept of that in medicine about five or six or seven years ago.

Dr. David Marsh: There is genetic variability, including variability in the risk of developing substance use disorders. Most of the research around this has been done with alcohol dependence. Probably about 40% of the risk of developing alcohol dependence is determined by genes. It's a multiple gene issue, and some of the genetic risk factors have to do with lower levels of neurotransmitters in certain pathways, related to the reward system.

Ms. Hedy Fry: Thank you.

The Chair: Mr. White, do you have a quick question?

Mr. Randy White: We may have to make a lot of recommendations to the House of Commons for the first time in 30 years. The last time this was studied was the Le Dain Commission in about 1972. So there's a great deal of responsibility on the people here to at least influence the way this is going to go for probably the next two decades, I would say, before they get around to it again.

I would like to ask each one of you to give me what you think is the very highest priority in a recommendation we would make. I'm not asking you to write a report for us, but I want to get a sense from each one of you of what is the one real recommendation in your mind that this committee could put down and go to bat for and really push. I expect they may be different recommendations.

I would like to get into the discussion about Corrections Canada, but it would take you a week at least to convince me that there don't need to be changes there. But I need the recommendations.

Dr. David Marsh: You could recommend that Parliament implement the recommendations of the Le Dain Commission.

Mr. Randy White: That's your answer?

Dr. David Marsh: Yes, that's my answer. The vast majority of the recommendations are still valid and were never implemented, including studying heroin prescription and making methadone maintenance widely available across the country. Needle exchange obviously wasn't in the Le Dain Commission, but he did talk about decriminalization of possession of cannabis. All those are wonderful ideas.

Mr. Toby Druce: I too would focus on the decriminalization of drugs.

The Chair: Of all drugs?

Mr. Toby Druce: Well, I say we should start the process. Start with the ones that will be acceptable at this point. Ultimately, if we can take away the criminal aspect of it, then we can deal with what the issue is.

Mr. Chris Gibson: I would just have to reiterate that I have yet to hear a sound argument for the criminalization of drugs. It makes no logical sense. It's purely a moral stand: it's unethical to use drugs and therefore it is punishable behaviour. It's certainly no worse than a vast number of activities we engage in that are permissible or even encouraged.

Mr. Glenn Betteridge: I'm just going to read from the legal network's summary of recommendations on page 37. It says:

...governments should establish a more constructive alternative to the current legal framework, and provide the research, educational, and social programming required to reduce the harms of drug use.

So basically we recommend a move towards a harm reduction model on all fronts.

Mr. Walter Cavalieri: I cannot disagree with these suggestions at all. I do want to say that the one I would emphasize the most is to explore the option of legalization, employing along with that a degree of social control, as we do with other addictive substances. Certainly the experience of prohibition of alcohol in the past is a clear indicator that it doesn't work and it produces a lot of harms. So let's look at it in terms of other addictive substances.

Ms. Koshala Nallanayagam: In terms of focusing on the prison system, I would suggest the recommendations from the brief that was put out in 1992. But if there's one immediate thing I'd like to suggest, it's needle exchange in prison.

The Chair: Thank you, Mr. White.

Just before we leave, Dr. Marsh, we haven't talked much about prescription drugs.

From what Mr. Druce and Mr. Gibson were talking about regarding decriminalization, I guess I'm making an assumption that you would at least have some controls on the distribution of drugs.

Dr. David Marsh: Oh yes.

The Chair: There are controls on prescription drugs, yet there are clearly people who are abusing them. Perhaps it's more socially acceptable. Could there be a process, beyond distribution of heroin and methadone? Could doctors in good faith prescribe cocaine or crack? Would there be other things they would prescribe instead to people who need that kind of dopamine fix? How would that work?

Dr. David Marsh: There's one study that has just come out recently looking at the prescription of dextroamphetamine orally for injection stimulant users. There's a lot less evidence around prescribing agonists for stimulant dependence than for opiate dependence, but I think it's an area that needs to be researched. There is potential there for treatments.

The Chair: Thank you.

Mr. Gibson and Mr. Druce, we'd have this parallel system of people going to the equivalent of an LCBO or something in our province. Would that satisfy some of the neighbours you work with? We heard from them, but I don't think we asked them that specific question yesterday. You should know they credited you with doing some very good work in the neighbourhood. But there are clearly some challenges still.

Mr. Chris Gibson: Just looking at some of the questions the committee framed in this document I have.... “Prohibition doesn't eliminate drug abuse. Does it at least discourage use among a general population?” I think there is absolutely no way for us to scientifically measure this because there's never been an opportunity for the general population to access these things legally. So there's no comparison.

I think services like ours will continue to be needed. I had stated that I started working with people who were heavy alcohol users and had extensive street histories. That's a legal substance. Now the opportunities to do more radical work around that have been easier for us.

I don't think it would eliminate addiction in society if it were legal, but I don't think you'd see a marked increase in the number of people who are facing dramatic health consequences. In fact, I believe--and I'm not supporting this with any documented evidence--people would be more likely to seek some kind of treatment for overuse of any substance if they weren't facing the prospect of being punished for using that substance in the first place.

The Chair: Thank you, all of you, for your presentations this morning and for the work you do across Canada and in our communities. You're clearly very dedicated, and that makes a huge difference. We wish you well in the work you're doing.

This committee is going to hear from witnesses probably up until about the end of June. If you come across things that are interesting, if there's some late-breaking research or a new program that you have some evaluation of and you want to send that to us, direct it to our clerk, Carol Chaffe. She will make sure it's distributed in both official languages. We can take care of that side of things.

We really do appreciate your time with us today. Hopefully you don't have to calculate billable hours, Mr. Betteridge. We do appreciate your work and wish you well.

Colleagues, we have buses on the lower level to take us to the drug court. If you have any documents that you want shipped back to Ottawa, we can send those back. I can adjourn and then be off the record. Thank you.