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37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

COMMITTEE EVIDENCE

CONTENTS

Thursday, February 21, 2002

1400

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

1410

1415

Ms. Linda Bell (President, Bellwood Total Health Centre)

1420

1425

The Chair

Mr. Dean Tate (Program Co-ordinator, Salvation Army Harbour Light Centre)

1430

1435

The Chair

Dr. Douglas Gourlay (Pain and Chemical Dependency, Wasser Pain Management Centre, Mount Sinai Hospital Foundation of Toronto)

1440

The Chair

Dr. Frank Evans (Chair, Addictions Medicine Committee, Ontario Medical Association)

1445

1450

1455

The Chair

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

1500

The Chair

Dr. Douglas Gourlay

Mr. Randy White

Dr. Douglas Gourlay

Mr. Randy White

The Chair

Mr. White (Langley--Abbotsford)

1505

Dr. Frank Evans

Mr. Randy White

Ms. Linda Bell

1510

The Chair

Dr. Frank Evans

1515

The Chair

Dr. Douglas Gourlay

1520

The Chair

Mr. Ménard

The Chair

Dr. Frank Evans

The Chair

Dr. Douglas Gourlay

Mr. Ménard

The Chair

Dr. Douglas Gourlay

1525

Mr. Réal Ménard

Dr. Douglas Gourlay

The Chair

Dr. Frank Evans

Mr. Ménard

1530

Dr. Frank Evans

Mr. Réal Ménard

Dr. Frank Evans

The Chair

Dr. Douglas Gourlay

The Chair

Dr. Douglas Gourlay

The Chair

Ms. Linda Bell

1535

The Chair

Ms. Linda Bell

The Chair

Mr. Dean Tate

The Chair

1540

Mr. Lee

The Chair

Dr. Frank Evans

Mr. Lee

Dr. Frank Evans

Mr. Lee

Dr. Douglas Gourlay

Mr. Lee

1545

Dr. Douglas Gourlay

Mr. Lee

The Chair

Dr. Frank Evans

The Chair

Dr. Frank Evans

The Chair

Dr. Douglas Gourlay

1550

The Chair

Mr. Dean Tate

The Chair

Ms. Linda Bell

1555

The Chair

Ms. Fry

1600

Dr. Douglas Gourlay

Ms. Fry

Dr. Douglas Gourlay

1605

The Chair

Dr. Frank Evans

Ms. Fry

Dr. Frank Evans

Ms. Fry

Dr. Frank Evans

Ms. Fry

Dr. Frank Evans

Ms. Fry

Dr. Frank Evans

1610

The Chair

Dr. Frank Evans

The Chair

Ms. Linda Bell

1615

The Chair

Mr. Lee

The Chair

Dr. Douglas Gourlay

1620

Mr. Lee

Dr. Douglas Gourlay

The Chair

Dr. Frank Evans

The Chair

Ms. Linda Bell

The Chair

1635

Mr. Jeff Wilbee (Executive Director, Alcohol and Drug Recovery Association of Ontario)

The Chair

Mr. Jeff Wilbee

1640

1645

The Chair

Mr. Randy White

Mr. Jeff Wilbee

Mr. Randy White

1650

Mr. Jeff Wilbee

Mr. Randy White

Mr. Jeff Wilbee

Mr. Randy White

Mr. Jeff Wilbee

1655

Mr. Randy White

Mr. Jeff Wilbee

Mr. Randy White

The Chair

Mr. Jeff Wilbee

1700

Mr. Ménard

Mr. Jeff Wilbee

Mr. Ménard

The Chair

Ms. Fry

Mr. Jeff Wilbee

1705

Ms. Fry

The Chair

Mr. Lee

Mr. Jeff Wilbee

Mr. Lee

Mr. Jeff Wilbee

Mr. Lee

Mr. Jeff Wilbee

Mr. Lee

1710

Mr. Jeff Wilbee

Mr. Lee

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

1715

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

Mr. Jeff Wilbee

The Chair

1720

Mr. Jeff Wilbee

The Chair

Ms. Chantal Collin (Committee Researcher)

Mr. Jeff Wilbee

The Chair

1725

Mr. Jeff Wilbee

The Chair

CANADA

Special Committee on Non-Medical Use of Drugs

NUMBER 026

1st SESSION

37th PARLIAMENT

COMMITTEE EVIDENCE

Thursday, February 21, 2002

[Recorded by Electronic Apparatus]

¸ (1400)

[English]

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

We are the Special Committee on the Non-Medical Use of Drugs. We've been doing some hearings across Canada, in Montreal, Vancouver, and here in Toronto, as well as in Ottawa. We are a committee struck in May 2001 to consider the factors underlying or relating to the non-medical use of drugs. The committee has been given until November 2002 to report.

We've asked all of you today to come to talk to us about prevention and treatment specifically, although judging from our previous panel things could move off into different areas of your expertise and experience. We're happy to have that as well, but hopefully we'll have some focus on prevention and treatment.

To introduce the members of Parliament who are at the table, I'm Paddy Torsney, the member of Parliament for Burlington and the chair of the committee. Randy White will probably be here; he's the vice-chair, from the Canadian Alliance, and he's from Abbotsford. Réal Ménard is the Bloc Québécois member for Hochelaga--Maisonneuve, which is through the Queen Street East section of Montreal. Derek Lee is a Liberal member from Scarborough--Rouge River, and Dr. Hedy Fry is the Liberal member from Vancouver Centre.

We have other members of the committee who are not here right now, but all this testimony is being recorded, and they will have the benefit of that. While I've given you everybody's political affiliation, we tend to work in a non-partisan manner.

We have with us today as witnesses: from the Bellwood Total Health Centre, Linda Bell, who's the president; from the Salvation Army Harbour Light Centre, Dean Tate, who's the program coordinator; from Mount Sinai Hospital Foundation of Toronto, Dr. Douglas Gourlay, who's with the pain and chemical dependency unit of Wasser Pain Management Centre. Welcome.

And a new addition, colleagues, is Dr. Frank Evans, who's the chair of the addictions medicine committee of the Ontario Medical Association. I know you're a recent addition, and we're very happy to have you with us as well, Dr. Evans.

We may have Nancy Usher come in from the Jean Tweed Centre; if so, we'll just put her on the end.

¸ (1410)

I've spoken about what I hope we'll do today, so I'll cut right to it.

Ms. Bell.

¸ (1415)

Ms. Linda Bell (President, Bellwood Total Health Centre): Thank you, Madam Chairman, honourable members, ladies and gentlemen. I would like to thank you for the opportunity to speak today. I've been waiting for this opportunity for over 31 years, and that's how long I've been working in the field of addiction medicine. My father, Dr. Gordon Bell, opened his first clinic 25 years before me, in 1946.

When my father opened his clinic in 1946, it was out of our house, and addiction research and treatment was virtually an unknown science in Canada. Finding help or hospital care was almost an impossible task, since the medical community simply turned its back on the problem. My father did not. He literally pioneered a new field of medical treatment, learning with his staff on the job, often from the patients themselves and from Alcoholics Anonymous. Their work and successes lead to the founding of the eminent Donwood Institute, the first public hospital for addiction in Canada.

Being at the forefront of an unpopular branch of medicine was not easy. So here we are, in 2002, still fighting for addiction treatment services to be taken seriously by the governments of Ontario and Canada in order to affect what everyone knows is a degrading and destructive, complex biopsychosocial disease. I consider it to be the most significant unresolved public health problem we have today.

There are many kinds of treatment for addictions, ranging from outpatient counselling, harm reduction, residential treatment, and total abstinence. These treatments vary in intensity and focus, depending on the problems of the clients. It is a mistake to consider a dichotomy between harm reduction and total abstinence. Both are on the treatment continuum.

This conflict of views has been destructive for the whole treatment process. I have read the transcripts of the hearings in Abbotsford, British Columbia. It is all relevant, important, and given by very knowledgeable people, but it could have been the testimony of people from Halifax, Toronto, Medicine Hat, or Davis Inlet in Labrador.

This problem is so acute and so all-encompassing across this country, across age groups, nationalities, the rich and the poor, it knows no boundaries. We need serious intervention in the form of research, as they've been doing in the United States, by people like Dr. Robert Dupont.

Dr. Dupont is a practising addiction psychiatrist who was the first director of the National Institute on Drug Abuse, NIDA, serving under Presidents Nixon, Ford, and Carter. He was also the second director of the White House drug abuse prevention office, a position known as the drug czar. He is president of a non-profit organization, the Institute of Behaviour and Health, and professor of psychiatry at Georgetown University School of Medicine in Washington.

You might want to pick up his latest book called The Selfish Brain--Learning From Addiction , which describes in great detail the disease of addiction and how to treat it.

What we need is our own Canadian drug czar to coordinate a military-style attack on this illness; to tackle a multi-billion dollar business that causes major health and social problems. We need a few really qualified people to intervene on the causes of the problems in society and raise the bottom for addicts. Even in the United States, most of the billions of dollars invested by the federal government is funnelled into law enforcement and research rather than treatment and intervention. As your report indicated, 95% of our $450 million goes to law enforcement. This is wrong; this does not work. We in the profession know a lot of things that work, but no one has the final answer.

We need serious research into how to keep people from relapsing and how to keep people from using in the first place. We need to know more about people who become addicted versus the ones who don't--why their brains work differently. This is a brain disease.

Some of this information is out there and some of it is yet to be discovered. We need credentialed professional people, certified addiction medicine specialists, and certified alcohol and drug specialists. We have a shortage.

We need a drug czar. And we need these people to help that drug czar do its job, because as your report shows, we do not have a coordinated effort at the federal or the provincial level.

As I move on, I'm going to talk about treatment and prevalence. Five percent of the adult population are considered to be alcohol dependent. Another 5% are drug dependent. Another 7% have serious gambling problems, and another 20% are living in a marriage or family relationship with one of these problems. That's scandalous. That's 37% of our population coping with this problem.

We're coping with it with 75% of our inmates in jails. They're there for alcohol- and drug-related offences. They're often repeat offenders. Up to 20% to 40% of our hospitals are occupied by people with alcohol- and drug-related health problems in emergency, cardiac, and fracture clinics. They're often repeat admissions.

The cost of dealing with these problems in jails and in hospitals is too expensive. It's much cheaper to treat these people, and there are studies that will show for every dollar invested in treatment, you will realize a benefit of anywhere between $2 to $10. If you want to save money, deal with this problem. Please, deal with this problem right across the board.

We know that treatment works. We've been doing outcome studies for over 25 years. What do we see? We see the same today as we saw 25 years ago. We see 70% reduction in unemployment, 92% employment stabilization, 41% reduction in time off work, 83% reduction in drinking on the job--we don't have that number for drugs--34% reduction in visiting physicians, 45% reduction in hospitalizations, 63% reduction in legal charges, 78% reduction in impaired driving charges, and 66% reduction in suicides. We know that treatment works, and we can help you to make it happen.

If we look at this issue, we have to keep certain things in mind, and that is that although we're talking about the non-medical use of drugs, alcohol is often a gateway to using crack and other illicit drugs. It's also used for coming down from other drugs. It's linked with gambling and tobacco. Let's make sure we tackle the alcohol problem as well as illicit drug abuse. When you separate the non-medical drugs and ignore alcohol, gambling, and smoking, you miss the coordinated response that's needed. They're all compulsive behaviours. They're all addictions. They're a major health problem.

The police I've spoken to recently have observed that the modern drugs are so intensively addictive that we need an intensive response. We have a fabulous resource in Canada and around the world in the form of self-help communities. This is an opportunity for the government. Self-help systems are self-supporting. The more the demand, the larger they grow. It's a powerful influence for treatment and prevention. It's not the only answer, but it's one answer that costs you nothing.

Let's take a look at withdrawal management, where it all starts. Our detox centres were set up under the Liquor Licence Act to stop the revolving door of drunks through the jails--in lieu of charging a person with drunkenness in a public place, the police could take them to detox. The problem is that the detoxes have now become the revolving door. There is no mandate for the detoxes to send people to treatment. There is no housing to send them to after detox, and treatment is not readily available.

The withdrawal management centres today are being asked to take street people without addictions because they also need a roof over their head.

There are two major problems here: the need for treatment facilities and the need for housing. It's being backed up all over the place.

Let's take a look at criminal justice. The courts are now mandating treatment. Probation and parole officers cannot access treatment for their clients. What do they do? Where do they go? Treatment centres say the client does not match their treatment criteria. There are waiting lists. Now we have probation officers who are already overworked, backed up, monitoring a health problem they're not trained to deal with. There are two major needs here: treatment facilities and housing.

¸ (1420)

Addiction is a specialized health problem. It's not a mental illness; it's a brain disease. It causes and is related to a myriad of health and social problems including mental illness. Dual diagnosis, addiction and mental health, has received a lot of attention over the past few years.

It is a problem, yes. But moving treatment dollars from one population in need to help another sub-population in need is inappropriate. The same goes for the focus on women, aboriginals, and ethnic populations. We need the resources to help this problem within each sub-specialty group, and it's cost-effective to do it.

We had the privilege of being designated as the addiction treatment centre for the eastern Arctic for many years. We treated Inuit and members of first nations from across Canada. At one point, one third of our patient population were first nations, and then Health and Welfare Canada mandated in a sweep of somebody's signature that the aboriginals had to be treated in NAADAP centres and many treatment resources, including ours, were no longer available to first nations. If we are to treat all Canadians equally, why do they not have the same resources available? Why are their choices reduced?

I'm going to move to harm reduction. There is a continuum of care required to appropriately tackle these problems. Harm reduction is part of the continuum. It's not a panacea; it's part of the continuum. Let's not get into a battle of one theory versus another; it's not helpful. There is room for everyone. There are some people, however, who are concerned about the government's responsibility when somebody who is addicted is out of control, is given another drug that keeps them addicted. What is the government's responsibility if that individual commits a crime? It's a big risk to be giving out drugs.

We need an incentive to get people working in this profession. Let's learn from the successes of the United States and the mistakes of the United States. Because of private pay, many U.S. physicians from a variety of specialities got involved with addiction medicine and raised the level of care. The mistake in the United States is that managed care has dismantled their system and it's crumbling just like our system. We need to get the mainstream of medicine involved. Without this, the revolving door in the hospitals will continue and the prevention potential will not be realized.

What about research? We have enough research. It's a huge problem. They might not be the latest statistics, but we know we're not doing well, that we can do better, and the know-how is available.

Take a look at prevention, at grassroots education that's measurable. Your organization's non-medical use of drugs directorate had a fabulous program in the 1970s called the Dialogue on Drinking. Where did it go? Let's bring it back and then let's let everybody know what this problem is all about. Let's talk about it. Let's not keep it hidden. It's costing us a fortune. It's destroying our children, it's destroying our families.

There is a decision point for this committee. Does the government want the revenue from the problem or the savings from the solution? Because you make a lot of money from this problem. Alcohol taxes from Ontario alone gave the federal government $391 million, and 95% of $450 million to fight the drug problem goes to law enforcement. Gambling gave the federal government $4.8 billion. There's a lot of money invested in maintaining the system, but where do we want to go?

If in fact the federal government is going to give any additional money to the provinces, such as Elizabeth Witmer has asked for, to move from 14¢ to 18¢ on the dollar, then I ask you to put it with the drug czar in a new approach with measurable outcomes to change things here.

Work with the U.S. We don't have to replicate everything, but they have great resources there. Let's make it happen. There are people in this room who would be happy to make this happen. It's a very exciting time to be here, but I want to tell you I've spoken to an awful lot of people and we haven't really made a lot of progress. You can make a decision, and our country needs your leadership because it's a dog's breakfast in Ottawa and it's a dog's breakfast at the provincial level. We can do better than that.

Thank you very much.

¸ (1425)

The Chair: Thank you very much, Ms. Bell.

Mr. Tate.

Mr. Dean Tate (Program Co-ordinator, Salvation Army Harbour Light Centre): Thank you for the invitation to sit on this panel of four witnesses and to share with your committee on the topic of prevention and treatment.

I've chosen to formulate the main points of this witness around the treatment experiences of the Salvation Army Harbour Light Centre in anticipation that the needs and concerns we experience also reflect the needs and concerns of other treatment facilities, both male and female, in the Toronto region and indeed throughout Canada. Hopefully, they will be relevant to the aims and purposes of the special parliamentary committee.

The Harbour Light Centre is a 70-plus-bed residential facility with a staff of eight trained counsellors, a registered nurse, and an on-site psychiatrist, along with reception, administration, and other appropriate support staff. We have a day program with two counsellors that's just beginning. Under the sponsorship and oversight of the Salvation Army, Harbour Light relies almost exclusively on provincial funding through the Ontario Ministry of Health and Long-Term Care. The population served by this facility is the severely addicted adult male who may or may not suffer concurrently from a diagnosed mental illness.

The program is structured into 12 weeks of treatment designed to educate the client in the nature of recovery from chemical dependency and to train him in a proven process specific to early recognition and prevention of relapse. In the first half of the program the clients learn to process their thoughts, feelings, urges, and actions so as to identify and intervene in situations that put them at risk of returning to alcohol or drug use. In the latter half of the program they learn how to challenge their previous counterproductive patterns of thinking and acting while gaining more effective control in order to constructively manage their feelings and social interactions. Each client attends appropriate self-help groups in the community as part of his residential treatment.

Prior to discharge, each client is required to map out his foreseeable immediate high-risk situations. He solicits a commitment from five significant other persons in his life and contracts for specific interventions they will have to perform when they see evidence he is returning to his old behaviours or lapsing into drug or alcohol use. At this time he signs a renewable three-month contract to attend weekly after-care meetings, and then he relocates for up to 18 months to subsidized housing dedicated to the support of abstinence-based living. He also begins to carry out educational and/or employment plans.

Since April 2001, 86 clients have completed the full 12 weeks of this program, and in that same period of time over 60 clients have completed the initial three months of after-care group attendance. Most of them continue regular involvement in one of the four weekly after-care groups, and there is also a well attended dual diagnosis after-care group. Presently we have 75 clients who are active in our after-care groups who live in “dry” houses within Toronto.

I tell you this in order to underline some needs. The first one we would focus on is supportive housing. There is a need for abstinence-focused subsidized housing that supports the recovery of both men and women. There are often clients on a waiting list for supportive housing. Right now we have 10 waiting at Harbour Light who applied for supportive housing beds two months ago and who are still occupying treatment beds that could be filled by clients on the intake waiting list.

Another item is concurrent disorder beds. There is a need for specialized treatment for chemically dependent clients with concurrent psychiatric diagnoses. During the past 10 years we have attempted to discover what helps the clients and then to develop and refine what we do with them. We've been fortunate to have on-site psychiatric services, which include consultation with the counselling team as well as therapy for the clients. Although concurrent disorder clients represent one in three of our residents, our services have been limited to those who are stable and functional at a fairly high level.

Experienced program and medical staff make it possible for Harbour Light to work with this clientele in a significant and cost-effective manner. This same cost-effectiveness with appropriate funding could extend to the less functional and less stable concurrent disorder clients in our community.

For 14 months in the years 2000 and 2001, selected Harbour Light staff met weekly to plan and design in detail a comprehensive concurrent disorder program to address the needs of concurrent disorder clients at every level of stability and function. Throughout this process the committee was driven especially by their awareness of the need for concurrent disorder treatment strategies related to the homeless population of Toronto. This program is currently shelved because there is no new money within the Ministry of Health for addictions programming.

¸ (1430)

As to program philosophy and prevention, there is a need to devise and promote a simple explanation of chemical dependence that can be applied at every level of child development and adult experience. Prevention is inherently linked to one's understanding of the nature of chemical dependency. Viewing addiction as a biopsychosocial sickness is not uncommon. Many approaches would bring in the spiritual aspect as well, relating spirituality to one's personal values and beliefs and the will to practise them. Indeed, this is often the focus of effective treatment, whether the spiritual aspect is identified in this way or not.

Perhaps the single most effective prevention strategy to offset the use of mood-altering substances would be to demythologize the nature of feelings. One way of doing this might be to promote feelings as a natural, built-in indicator of whether what we're doing and thinking is helping us to achieve what is important to us.

In closing, I would point out what is obvious to all treatment facilities and staff relying on government funding: there simply isn't enough cashflow. No doubt this committee is already aware of the discouraging state of the financial resources available for addiction treatment in this province and city. Hopefully these comments and observations have been of some value in your endeavours.

I've cited three recommendations, just for the purpose of bringing them before you. One is to develop a realistic and objective means of identifying where effective treatment is happening and to support its further development with specific funding. The second is to identify where and how to invest in housing that is dedicated to medium-term support for those in early stages of recovery. The third is to begin a search for a scientific, accurate explanation, one that a normal six-year-old child can understand, of how an addiction emerges in one's experience.

¸ (1435)

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

Dr. Gourlay.

Dr. Douglas Gourlay (Pain and Chemical Dependency, Wasser Pain Management Centre, Mount Sinai Hospital Foundation of Toronto): Thank you, Madam Chairman. I appreciate being invited to speak to the committee, and I certainly concur with the previous speakers on the panel.

I'd just like to tell you a little bit about the work I do. I'm an anesthesiologist who works at the Wasser Pain Management Centre at Mount Sinai, but also at the Centre for Addiction and Mental Health. I'm an anesthesiologist who practises pain and chemical dependency.

I'd like to tell the committee a little bit about the risks of medical management of problems with pharmaceuticals and some of the consequences of underappreciation of addictive disorders. I look at pain and chemical dependency as a continuum, as has been spoken to by other members of the panel.

I think it's important to know there's nothing I can say about pain and addiction that doesn't apply to illegal substances as well as licit substances. It isn't helpful to make the distinction. If anything, in the pain population the diagnosis of addictive disorders is considerably more difficult. If you look at the literature, the context of pain management would say that addiction is so uncommon in legitimate pain as to not even be worth looking for. Some of the literature actually says that the prevalence of addictive disorders in the pain population is less than 0.1%.

There's really nothing about that that makes sense to me, since as you all know from other members who have spoken, the prevalence of addictive disorders in the population at large is not insignificant. Depending on what you look at, it's between 5% and 15%, depending on the demographics and the drugs you speak of. So the thought that a group of people who have a poorly managed medical condition such as pain should somehow have less likelihood of having an addictive disorder makes no sense at all.

Fortunately, we in the fields of addiction medicine and pain management are starting to work together to develop a common nomenclature so that we can describe what we see in a similar way. This way, the individuals who are duly diagnosed with not only addiction and psychiatric illness but addiction and pain management problems can seek a better quality of life through the treatment of both.

I actually have a handout, which I understand the committee will get at some point. Basically, the thesis of it is that pain and chemical dependency, pain and addiction, do coexist.

As I said, the lack of precision in the terminology we use makes it difficult to speak of these problems together in the same room and believe we're talking about the same thing. As a result of that, in the United States there's a committee called the Liaison Committee on Pain and Addiction. That group is comprised of members of the American Society of Addiction Medicine, the American Pain Society, and the American Academy of Pain Medicine. This group got together to resolve the nomenclature problem, the fact that we can talk about addiction and mean completely different things while looking at the same set of data. Many of us believe that is why the apparent discrepancy exists between what we find in terms of prevalence of addictive disorders in the population at large and in the pain subset population.

The first role of the liaison committee was to develop a set of terms. That set of terms includes definitions of addiction, physical dependence, and tolerance. It's important for us as medical practitioners, for you as politicians, and for the public who consume the health care to understand that dependence isn't addiction. Yet dependence is extremely common in the management of pain with opiates. Likewise, as has been said before, addiction is defined as an illness in the brain and it's multifactorial. I think it's important to define these terms in ways that all of us can agree on.

I'm sure the committee has heard from others that addiction is the confluence of the right drug in the right person at the right time. Where only two of those exist, you have a different phenomenon, such as dependency. If anyone in this room were to take opiates for pain management chronically, on discontinuation there would be signs of withdrawal. Those withdrawal signs do not equal addiction.

It's when the individual suffers from the pre-existing risk, the genetic predisposition, in the right setting, such as a chronic pain problem, and they're given the right drug, a drug which reinforces its ongoing use, that we see the phenomenon of addiction. I can assure you that addiction does exist within very legitimate pain management problems. This is the reason I'm at the Centre for Addiction and Mental Health and the Wasser Pain Management Centre.

The Wasser is a tertiary-level pain program. It's multidisciplinary. It involves anesthesiology, neurology, psychiatry, and several allied psychology and other practitioners. The idea is that through several people being involved in an individual's care, a better solution for that person can result.

This is the same approach we take in addiction medicine. As Ms. Bell has told you, no one has one answer to this problem. The answer lies in multiple approaches. In particular in the pain population with addictive disorders, it's extremely difficult to help them identify and treat an addictive disorder. Many don't embrace a 12-step mutual help model. For many who have pain that is responsive to opioids, abstinence isn't an option. It certainly isn't achievable in an individual who seeks benefit through the use of drugs that help their pain problem.

We have to have an improvement in the education of practitioners who look at these problems and who are currently stuck in an either/or model: if you have a real pain problem, the likelihood of there being addiction is not even worth looking for; likewise, if you happen to have an addictive disorder, the only reason you could be asking for drugs for pain is because you have an addiction. This isn't true. So education is needed for doctors who are currently in the system to prescribe wisely medications that are valuable and helpful and to recognize that as pain patients are stigmatized and undertreated, so too are addiction patients. If you can think of a worse situation than having an addictive disorder or a pain problem, I'd suggest to you that the combination of the two really puts you at risk.

I hope you have questions that are on point. Thank you.

¸ (1440)

The Chair: I'm sure we will.

Dr. Evans.

Dr. Frank Evans (Chair, Addictions Medicine Committee, Ontario Medical Association): Thank you.

First, I appreciate the opportunity to be here before the committee. I'm the chairman of the section of addiction medicine of the Ontario Medical Association. That encompasses a number of physicians whose entire practice is addiction medicine or who have a strong interest in addiction medicine and also physicians who are educated and trained in addiction medicine.

I'm fellowship-trained in addiction medicine. I actually went down to the States. I'm what's called ASAM-certified.

I also work at a couple of treatment centres as a full-time consultant. I've been in the field about 10 years. I've seen a number of things in terms of how we handle the treatment of addiction and also the research of addiction in this country.

As I mentioned, I was trained down in the States in this area and I could see some differences upon returning.

I'd like to reveal to the committee that I myself, as a physician, am in recovery. I know a lot of physicians who are in recovery and also work in the field.

I really didn't have time to prepare much for this committee, because it was about 10:30 p.m. when I found out I could come here. In fact you were already here. I wasn't even aware you were coming, and that was an issue that concerned me. I checked with a number of other colleagues, and they weren't even aware of this.

I think it's fantastic that the government is taking a look at this in order to try to improve things; I know everyone is trying to help out in this very difficult area. I just caution the committee, first, to understand--and maybe you've acquired this--that you need a really clear understanding of the nature of this problem. It's a very perplexing medical-mental problem.

Second, you need to understand there are very few problems in medicine where the patient does not want resolution; with this one, they'll fight it. They'll fight the diagnosis, and secondly, even when you propose the treatment, they'll disagree with that. It's rather analogous to a patient coming into my office with a tumour on his arm, and he's in there because of a headache. I point out the tumour on his arm, and he tells me, “No, it's not a tumor; it's a wart.” It's like the alcoholic who comes in and says, “I don't have a problem. They sent me here.”

The first challenge is to get them to understand what they're dealing with. And usually that requires education; they just don't know. Then secondly, when the patient agrees it is a tumour, just like the alcoholic, rather than following a treatment that we suggest, the person proposes he's going to use Oil of Olay cream on it.

So it's a funny area of medicine, where we're really challenged. It's also a disorder in which the person may seek other solutions that will delay or enable or worsen their medical problem.

I respect what Dr. Gourlay does, but delaying in some cases involves people who actually have drug-induced pain disorders. And yes, they will keep seeking opiates from anyone without addressing the issue that their pain is caused by their continuous chemical dependency. We tell them something that seems absolutely paradoxical, which is, “We're going to get rid of your pain by taking you off pain medication.” You can imagine the challenge that is. In fact, I call it doing an exorcism. They'll fight and squeal until the very end and then they'll realize, “My God, I was caught in that.” It's very challenging trying to separate out the two, as Dr. Gourlay mentioned.

You need to be aware that there are also many well-meaning people who wish to help with this problem but lack real knowledge or realistic experience and understanding. I've never seen an area of medicine where there have been so many different people involved who mean well and have so many different ideas. How confusing it can be, and how frustrating.

One of the things a number of physicians who work in the field have noticed is they don't get invited to sessions like this--policy-making. In fact, they actually get excluded. A number of them actually just give up the process of trying to provide their input.

There are many physicians out there working in the field who have frustrations like that. I'll give you an example: drug court. I myself found out about drug court on the last day when they finally put together all their policies. I asked if I could come, and they welcomed me. Then I looked at the list of 60 people and couldn't see one physician on the whole thing.

For heroin addiction in Toronto a committee was put together, and I think only one physician showed up or was invited. But there were a number of other people, again meaning well. And I've talked to colleagues, and some of them have had bad experiences.

¸ (1445)

The other thing, too, is that physicians do not get paid for going to these things. They're self-employed, so they have to sacrifice time and money, whereas a number of other people have actual jobs as directors of facilities, and they can afford to go there. There's sometimes a mismatch.

One final example of that--and this was so paradoxical--is that the Ontario Medical Association informed the Ministry of Health that we now had a section of addiction medicine--physicians who were interested, who were trained. We received a letter from the Ministry of Health saying they were very pleased to hear that; they were very supportive. The next week, the ministry asked people to come together on a committee to organize policies in treatment, research in treatment, in the province. When they finally published the list, out of the 30 people, one person was a physician--who had never really treated people--and the OMA wasn't even notified or invited.

There's some dysfunction that goes on in this whole area, and maybe you pick up on that a little bit--differences of opinion. I think as a family, we need to come together and work together on this. As I said, everyone means well, but maybe we don't all know what the real solutions are. We need to talk, communicate, and interact.

Another thing is, as I mentioned...and I'll speak as a physician at the Humber chemical dependency unit; we're a chemical dependency unit in Toronto. In fact, at one time we were the only medical detox in the entire province. We have four beds for medically detoxing highly addicted people. We even have them coming from other provinces trying to get our beds.

In that facility we utilize techniques that come from the Addiction Research Foundation, but we also use techniques of a 12-step program, because we've found that a lot of the answers seem to come from people who have found the solutions. It's interesting, I notice that when there are policies and plannings, they do not seem to draw upon the people who've found the answers.

There's a huge recovery community out there that can help any government organization guide its way through this difficult quagmire of what is true, what isn't true; what may work, what may not work; what could cause problems, what couldn't. It's quite easy to draw upon the experience of others who've been there. There are many recovering police, lawyers, and politicians who have been on the other side of the fence and have seen what the real world of addiction is like.

I can tell you, there's a big gap between what is printed in textbooks and what the reality is and how challenging it is to deal with. They can help. But it's interesting that, again, they seem to be left out of all of these plannings and policies. They have such wisdom.

I'll give you one last example of that. There's an organization called the International Doctors in Alcoholics Anonymous. What is that? That's an organization of recovering psychiatrists, brain surgeons, orthopedic surgeons, etc., who all had problems with drugs and alcohol. Some of them lived on the street. Some of them did heroin.

The interesting thing with that group is that they found the simple concepts that came from a 12-step program and a recovery population helped them the most. Maybe you're not aware of it, but the actual membership in North America is 6,000 recovering physicians.

I can tell you that the gist of what I hear from them is that they're very frustrated when they look at some of these policies and how risky they are. Methadone can help, but it has to be used by people who know how to use it. Harm reduction can help, but it has to be used by people who know how to use it. If it's put in the hands of those who truly don't understand addiction, they unfortunately can do harm. Everyone is trying to help, but I think we all need to come together and work together. I think the recovery community needs to be involved.

Linda Bell mentioned a drug czar, and I saw in some of your transcripts there was mention of this. If the government wants to really work on this problem, my suggestion would be to make sure you have highly knowledgeable, trained, and “experienced” people--people experienced with working with the reality of what that is.

¸ (1450)

Secondly, I would strongly suggest that half of the people you have involved maybe have a recovery basis. Why? Because they can help you around the knowledge area that is not in the books--what you are dealing with, and some of the pitfalls you could run into. There are so many pitfalls, and so many that have happened with good intentions by others.

Thank you.

¸ (1455)

The Chair: Thank you, Dr. Evans, for coming before us today.

Perhaps I need to clarify something for the benefit of everyone who's interested in this issue. This committee was struck last May. There have been hearings in Ottawa and Vancouver, and we did some site visits in Montreal. We have a website and all the transcripts there for people.

Members of Parliament, through their various contacts with people who are interested in this issue, have recommended a number of people to appear before this committee. There have been some articles in the newspapers. Through a variety of ways, such as networks and what have you, people have either asked to come or we've sought out some people.

You'll notice in our work this week we've divided our panels into the conventional focuses of prevention, rehab, interdiction, and what have you. I'm completely confident in saying absolutely no one has been excluded from appearing before us. We have been beating the bushes to try to get people to come and talk to us about the problem, and we're totally open to hearing from others.

Just as I would expect that you don't speak for all doctors, I certainly don't speak for all prior consultations, or need to make excuses for what they have or haven't done in the past. We're here. We're open. We're trying to find things. Hopefully, as part of this process you'll be telling others in the network to come forward and talk to us. A big part of our consultation has been with people who are very much involved in the community of drugs, recovering and otherwise. So we've been talking to lots of people out there who are dealing with some of these issues first-hand.

Just as you don't think one size fits all, hopefully you won't think a one-size committee fits all, either.

Colleagues, Dr. Gourlay's information has just been circulated.

We'll now turn to questions from the members of Parliament. I propose to have roughly 10-minute rounds. The question will be asked to one of you, perhaps, or it might be a general question. If you're interested in speaking, just give me the signal. Hopefully the questions and the answers will be brief, then I will try to wrap up.

The first questioner will be Mr. White.

Mr. Randy White (Langley--Abbotsford, Canadian Alliance): Thank you, Paddy.

It's interesting that the four of you have shown up at the same time, because some of the questions I have had on my mind for some time you have actually addressed. I can assure you there are people in politics who are closer to the recovery area and this issue than you may realize, sir.

The comment about it being a dog's breakfast I can agree with wholeheartedly. We've heard that right across the country. We know that. That's why this is in the House of Commons. In fact, that's why the motion went to the House last May to get this moving along. I come from British Columbia, and it's one hell of a mess there, I can assure you.

I have a lot of questions in my own mind. Because it is such a mess there are issues like decriminalization, safe injection sites, heroin maintenance, rehabilitation, national education, drug courts, how we deal with our ports and the demographics of all this, needle exchanges, methadone treatments, failure of the drug war, what is the strategy, what is the federal strategy, and does it work--I don't happen to think it does. So there is just a proliferation of issues.

I was going to wait until Derek came in. Derek and I went out to lunch and I said, “Derek, there's one thing I've noticed about the witnesses who have come before us. Most of them aren't doctors but are individuals close to the drug issue, who call their groups clients.” To some extent I'm wondering about how each group seems to have a function, but one doesn't function the same as another group that's supposed to be doing very similar things. For instance, we were told that in one needle exchange, well, we do a one-for-one: we give them a needle and they give us one. Now, another one said, well, we give out a hundred needles and say, give them to your friends. That's quite a difference in needle exchanges, yet those two concepts operate in areas very close to each other.

I'll get to some of my questions. I want to ask both of you doctors--are you all doctors? Two of you are doctors. Are you medical doctors? No. Is it fair to say heroin is a relatively safe drug?

¹ (1500)

The Chair: What I would recommend is asking, can it be under certain conditions?

Dr. Douglas Gourlay: I think it's important for the committee to realize that the drug in and of itself shouldn't be invested with too much power. Certain drugs are more reinforcing than others, and heroin by its nature--it's morphine. It's a derivative of morphine, and it's converted very rapidly in the body into an active drug. It crosses into the brain very quickly, and in that it gives it some increased power in terms of reinforcement and abuse liability. But fundamentally heroin is a painkiller, as is morphine and as are many drugs of abuse. In the right context they're very powerful and they're very useful.

So I think it's important to look at the context, at the setting in which you want to pose that question. In a medical context, heroin is probably no more dangerous than hydromorphone--Dilaudid. In a street sense, heroin is often mixed with many other substances to reduce its potency, and many of the materials that are contained within the heroin that's sold on the street carry a lot of its risk. The drug itself isn't so much the problem as the context in which it's used.

Mr. Randy White: I'll go to you, Dr. Evans, in just a moment. I have a pretty bad back, and I'm running on Robaxisal right now. Now, nobody would say Robaxisal is an unsafe drug. I got this one--it looked as if it was behind the counter--handed to me by somebody in the prescription area. But why wouldn't I take heroin?

Dr. Douglas Gourlay: Well, one of the main problems with addictive disorders is where the locus of control is in terms of the use of the drug. An individual who has no increased risk of drug dependency is unlikely to get into trouble with medically prescribed drugs. What we don't do very well is assess risk. I think that if you go to a doctor and he says, well, you have legitimate pain and you can take anything I prescribe for you with impunity and have no trouble, that's naive. Most doctors who make that statement have no idea how to take a drug and alcohol history.

We know that it's important to understand the risks when we prescribe any medication to a patient. Over-the-counter preparations, medications you can buy from a pharmacist without a doctor's intervention, are not necessarily safe; they have abuse liability. Dextromethorphan--cough syrup--is tremendously abusable, especially in the population who is at risk. Antihistamines are terribly sedating, and many of them have been removed from the counter and taken behind the counter.

In Canada the presence of codeine-containing products makes the monitoring of individuals with addictive disorders, particularly with opioids, very challenging because that drug converts approximately 10% into morphine in the individual.

You have to be careful about investing too much in the drug itself and should focus more on the context in which the drug is used.

Mr. Randy White: Dr. Evans, we have had an individual--I think it was Jamie in Abbotsford--who said she was addicted to marijuana and broke the law to get marijuana.

The Chair: No.

Mr. Randy White: Yes, she did. I know she did. I know her quite well.

In any event, is marijuana a legal issue or is marijuana another subset of all these drugs in there that we shouldn't be playing with?

¹ (1505)

Dr. Frank Evans: Can I go back to the heroin?

Mr. Randy White: Yes.

Dr. Frank Evans: Your question is whether it is safe. What do you mean, physically? I could hook you up to an IV and run heroin in you for the rest of your life at a proper dosage. You'd be fine. You'd probably live as long as you're going to live. The problem with the drug is that you're not going to be the same person. Your family will notice you're different. Your drive, your aspirations, your thinking ability will be part of the risk. And as Dr. Gourlay said, based on circumstances and how you're getting it and what has to be done for it and risks of how you use it and things like that, there's more risk to it. The drug itself is fairly safe. Everything else around it is where the harm comes from.

Is marijuana safe? Personally, I feel it isn't. Would I legalize it? Personally, no. Basically, the message I get from patients who've gotten clean is that when they were using it they thought it was all right. When they get clean and they notice the difference and how many things they've lost, that were not there, that's when they realize the risks and the price they pay for it.

Mr. Randy White: Very good.

Linda, I want to describe to you what has been more or less described to us from different places, and that is the component of harm reduction. I want to know if I've missed something in this. The components are needle exchange; condom distribution; crack pipe distribution; heroin distribution; methadone maintenance; safe shoot-up sites; reformed laws; encouraging a designated driver system for those who smoke marijuana or do other drugs, I guess; explaining the criminal consequences. If you were to describe the components of harm reduction, is that what harm reduction is?

Ms. Linda Bell: That's a great question. I can't give you a definitive answer because I think different people have different ideas. Harm reduction really came into vogue when we had all the attention spilling over onto HIV and AIDS. When that happened, I kept saying, “I'm so tired of hearing about HIV and AIDS. I wish we could just talk about alcohol and drug abuse. Let's talk about what's causing these problems.”

The idea of harm reduction was how to reduce the harm to society. Instead of having a heroin addict who's committing crimes, we're going to give them methadone or we're going to give them safe needles, clean needles, or we're going to give them condoms. It started off with needles and condoms. That was pretty good. But it has really spread all across the board at this particular point. It concerns me because, as Dr. Evans was saying, different people's definitions change. One person's giving out one needle, one's giving out a hundred.

I remember listening to a Dr. Smith from New York talk about needles. I'm going to ask you a question. If I were to walk over to you with a clean needle, would you be able to inject yourself with it?

Mr. Randy White: Before I faint?

Some hon. members: Oh, oh!

Ms. Linda Bell: Chances are no. I couldn't do it either. What happens is that if you're going to be an IV drug user, someone's going to show you how to do it, and chances are they don't have a clean needle in their pocket when they show you how to do it. Part of the subculture has to do with the fact.... You know the blood brother stuff when you were a kid? It's that. There's a subculture there.

I'm not against handing out clean needles. I'm not against handing out condoms. I will give you an example of something that I really think shows what I'm against.

We had a heroin addict who came through our treatment program and was dry and clean and doing very well for six years. He phoned up and he'd had a very short relapse, less than two weeks. He wanted to come back into treatment. We said, yes, he could come back into treatment. In the meantime he and his father went out to a methadone clinic and he phoned back and he said he had decided to go on methadone. That to me is a tragedy. That's an inappropriate assessment. It is not a panacea. This guy is sicker today than he was when he phoned us.

I think there needs to be policies and guidelines. I think there needs to be training. If you're going to have people giving out methadone, they should know what they're dealing with. I think it's turned into a very lucrative business here in Ontario for certain individuals. I think that's a tragedy, because we wanted to stop one problem and in fact maybe we've created another problem.

When you have somebody taking home methadone, putting it in their refrigerator, and then their five-year-old child drinks the orange juice that it's in, and we don't make a big scandal of it.... We have more of a scandal going on up in Ottawa with one of your colleagues about arresting criminals, for goodness sakes, when we're at war in partnership, and we have a child who's dying and we don't talk about that. We don't talk about the heroin addict who was on methadone and went to get another prescription of methadone, and the people there told him he had to take it right there and then. This person didn't tell them he had already had his methadone for the day. He dropped on the floor in the pharmacy.

How do I know that? He's related to a staff member of mine. Did it hit the press? Not a chance.

Harm reduction: I'm concerned about it because I think it's being taken to different types of extremes. I think there is a place for it. I think you need to meet people where they are, whether it's on the street with a needle exchange, or whether it's getting them off heroin and getting them into methadone and then slowly teaching the skills and getting them moving toward a healthier life and hopefully off the methadone. But ask the doctors how easy it is to get them off methadone.

Then it's a start, but let's realize it's a start, not a stop. It's part of a continuum. It's a point of entry.

¹ (1510)

The Chair: Thank you.

Next is Dr. Evans and then Dr. Gourlay.

Dr. Frank Evans: The thing I've learned to understand with harm reduction..... First of all, with abstinence, in the old days of abstinence or no abstinence, it was black and white and there were limited choices, especially dealing with human nature. Harm reduction I think was a breath of fresh air, different approaches to, again, trying to help people.

Sure, with HIV and hepatitis C and AIDS we needed to do something. But the other thing you need to understand about harm reduction is that every harm reduction approach does cause harm. I don't know of any harm reduction approach where it will inflict harm.... And if you propose that to an individual, propose it as a suggestion to a patient, you have to take responsibility for the spinoff harm that may happen in that.

I'll give you an example drink-wise. Say you're trying to advise somebody on how to drink sensibly and you don't have the ability to really separate out whether they are a true alcoholic and would they be safe with this, so you suggest they continue the drinking, and they smash up the car and kill some mother. Who takes responsibility for that? As a physician, I take responsibility for everything I suggest. It's part of our trade.

Methadone can help, but when methadone was proposed my feeling was you'd better watch it. It'll cause harm reduction but it'll cause harm, and I have 100 scenarios where it's caused harm. I have a mother bringing in a 14-year-old who's taken Tylenol number threes for two weeks, getting high on them, and when she stopped she had a bit of a withdrawal. They accidentally walked in somewhere where they were told to see Doctor Such-and-such, and all the doctor knew was methadone. And so the 14-year-old daughter was on methadone and she was hanging around heroin addicts and learning about other opiates. I said there's just no way they should have done that, but that was harm reduction. There are 100 spinoffs that happen with harm reduction.

As for abstinence, I have not really come across any scenario where abstinence kills or causes harm. Abstinence is at the end of the scale, the best harm reduction you can hope to achieve in a person. Can you achieve it in everyone? I don't think so. But again, we have to be cautious about how we do this, and don't think harm reduction is without consequences. It does have consequences to society, to the people themselves, delaying somebody who can't abstain from getting into recovery.

I've had hundreds of cases of people on methadone who came to see me and asked if there was something else. I'd say, yes, there's treatment. Then I asked them if anyone had informed them about that, and they all said no. It's on record; I wrote the college. I gave them all the cases, saying, when you hand out methadone licences to a pile of physicians who are not trained in addiction, they will get caught in all of these traps, and so will their patients. I have case after case after case where I've asked, “Did anyone inform you after six weeks of Percocet that one of the solutions was just to get you off it?” They said no.

¹ (1515)

The Chair: Thank you, Dr. Evans.

Dr. Gourlay.

Dr. Douglas Gourlay: I'd like to respond to and maybe add to what has been said about harm reduction. I think harm reduction gets confused with “no rules”. When I did a fellowship in addiction medicine I remember a senior sociologist describing harm reduction. I said towards the end of the lecture, “It sounds as if harm reduction means we don't care if an individual uses.” He smiled and said, “Exactly; you've got it.” I said, “I've got to tell you, down in our clinic in addiction medicine we care very much if people use.”

As Dr. Evans has said, harm reduction includes abstinence. For me, and when I teach issues around the use of methadone and the management of addictive disorders, I like to suggest that harm reduction means we don't penalize you for failing to meet our schedule on our timeframe. Really, it is a matter of grey. Ultimately, in what we call “the model of change” or the readiness to change, which was proposed a number of years ago, people are at various stages in willingness to identify a problem they have. The pre-contemplative stage could be present around one drug, and there may be action around another--the action phase being “I'm ready to seek treatment”.

The important thing for an addictionist to do in our line of work is to identify where that individual sits and help them move along. Methadone for many people provides a window of time where they're free from the consequences of abstinence, of discontinuing a drug upon which they have become dependent. They don't have to go out and smoke up or they don't have to curl up in a ball because of opiate withdrawal, which would exist for anyone who discontinues an opiate abruptly. It gives them room to make change. But if the only thing you add to an opiate addict is another opiate, in all likelihood you will reduce to a degree some harm but you'll get an opiate addict on another opiate.

I would challenge, in your province, addictionists I've spoken with who have basically said being on methadone equals active addiction. I couldn't quite understand what they meant by that, what the fellow was saying. I realized when I picked up the phone and called him that the type of patient doctors in British Columbia put on methadone are the last-straw patients. They're people who have failed every other attempt. They are the lowest of the low, and they're really people to whom those who feel abstinence is the only answer have said, “Okay, we'll put you on methadone.”

People who are on methadone in that context often aren't doing very well. And yet I have people on methadone who are functioning as lawyers, who are functioning in a high capacity, and the only thing that would remind them they have an addictive disorder is the fact that we take urine specimens from them. They've made changes. They've undergone cognitive behavioural changes. They may have gone into treatment for a problem with cocaine that's concurrent.

What I prescribe to a patient and what comes out in their urine plays a very small part in defining an addictive disorder. In the pain management population who have addictive disorders, it's used despite harm. When the drug is doing more to you than for you and yet you continue to use, there's a good chance there's more going on there than “My back hurts, and therefore I have to take my Robaxisal or my Robaxacet.” The key for me is to assess the individual in toto.

I think you're getting a sense that there is a wide variety of approaches to addiction medicine, and there very clearly is. Many people who espouse a harm reduction position believe abstinence is an excellent form, but it's not achievable for all patients and it isn't achievable on the same timeframe for all patients. Some people need time to process the changes in their life and move forward.

¹ (1520)

The Chair: Dr. Evans, can it wait until the next round?

Dr. Frank Evans:Yes.

The Chair: Thank you.

Réal.

[Translation]

Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ): Thank you. I am somewhat bewildered and disturbed by everything I have heard in the last while, and I am going to try to make sure I understood what you told us correctly.

First of all, I think at least two different points of view have been mentioned, and, as I said, I want to make sure that I understood them correctly. Can the problem of dependency be placed in the category of mental health concerns? Yes or no? I understood that Dr. Evans said yes, and Ms. Bell said no. I just want to make sure that I understood this correctly. Is there a connection between mental health and dependency? Please explain that to us clearly, in pedagogical terms.

The Chair: To whom is the first question directed?

Mr. Réal Ménard:To all those who wish to answer it.

[English]

Dr. Frank Evans: My belief and understanding is it is in mental health. Some people still debate whether or not it is a disease process, but it is in the mental health area.

The Chair: Dr. Gourlay.

Dr. Douglas Gourlay: I agree. It's categorized in the DSM-4 as a mental health issue.

Allan Leshner, who is a key NIDA director, has said it's a brain disease. I think that's trying to encompass both the behavioural element and, as Dr. Evans says, the biological element. So it really contains both.

[Translation]

Mr. Réal Ménard: I ask this question not for speculative reasons, but rather to make sure I understand correctly. Once we acknowledge that drug dependency is related to mental health, we can understand that, to some extent, this problem is beyond the control of individuals. Is that correct?

You even made an important distinction between good and bad dependencies. Some dependencies can be controlled, and others cannot be controlled.

This morning, we talked a great deal about the definition of addiction. We wondered whether or not marijuana should be legalized, and a panel of witnesses told us that there is dependency when individuals become ill if they stop using the drug. There are some physiological signs that they are ill; they become dysfunctional, for example. We were told that people could stop using marijuana easily, without suffering any physiological consequences. This does not create any problems. Perhaps you do not agree on this point, but that is what we heard this morning.

On the basis of your understanding of this problem, would you accept this definition of dependency? You are shaking your head. Is that correct?

[English]

The Chair: Dr. Gourlay.

Dr. Douglas Gourlay: No, I don't.

The distinction you have to make is between dependency and addiction. Dependency is a consequence of a certain type or class of drug that the body becomes reliant upon and, upon discontinuation, exhibits a characteristic pattern of symptoms. For anyone in the room who is dependent on a narcotic, when they discontinue it they will have a runny nose and goose flesh and, in the extreme, diarrhea, nausea, and vomiting. That's a physiological phenomenon. It is not addiction. Virtually everyone who is treated with narcotics for pain will have a degree of physiological dependency. That distinction has to be made.

This is the reason the Liaison Committee on Pain and Addiction, as I said, comprising the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine, crafted these definitions. This very thorny issue of what comprises addiction...in the pain population it's particularly treacherous because many people are going to say, because my back hurts, I must do this. I must drink. I wouldn't drink if I didn't have pain, or I wouldn't do this drug if I didn't have pain. “Use despite harm” is probably a better framework within which to define addiction and compulsion to use. Compulsive use is part of the definition for addiction that helps distinguish it from the dependency everyone who uses opiates will exhibit when they discontinue.

¹ (1525)

[Translation]

Mr. Réal Ménard: That is a very, very important distinction, and we will read your document and keep it for future reference. Does marijuana cause dependency?

[English]

Dr. Douglas Gourlay: As a quick answer to that, yes, there is a dependency associated with marijuana and there is, I believe, an addiction associated with marijuana. One thing the committee should be aware of is the fact that much of the literature around marijuana and even the anecdotes around marijuana are taken from a period of time when marijuana was a much weaker product. One of the concerns we have in the specialty is that as the concentration of the active ingredient in marijuana, tetrahydrocannabinol or THC, increases, the withdrawal phenomenon we see associated with discontinuation increases. I think we're looking at a different drug use now than people were perhaps experiencing in the sixties and the seventies.

Make no mistake, cannabinoids play a role, we believe, in pain management. Personally, I would have difficulty suggesting anyone should smoke something for their health in the year 2002. I find that an awkward position to be in. I'm looking forward to the availability of cannabinoids, the family of active ingredients of marijuana, to be available for use, but as a pharmaceutical product, one we can not so much regulate as quantify. We'll be able to say, when you use this amount for this period of time, this is what we can expect. For me, whether or not there are cannabinoids active in pain management involved, smoking marijuana perhaps carries more harm than benefit.

The Chair: Dr. Evans.

Dr. Frank Evans: I think a simpler way to look at it is that there are two, shall we say, driving processes that can occur whenever any human uses a mood-altering substance: a physical dependence and a psychological dependence. You can use some drugs and you won't experience physical dependence or withdrawal when you back off, but boy, you have a psychological dependence. You try crack cocaine once, and if you have the brain for it, you're hooked, yet if we put you in a clinic and watch what happens after, there's absolutely no physical withdrawal.

Look at sexual addiction. There is no physical withdrawal, but boy, there's a psychological dependence. The person is driven by one of or both physical and psychological dependence. The thing is, the people are all chemically dependent. In other words, their mind is focused on the idea that one way or another, I can't get by life without finding something to make me go up, to make me go down, to make me relax, or to make me speed up. A person who is doing marijuana can't fathom the idea of getting by in life without being numbed out. They're psychologically dependent, but there is a physical dependence--we're understanding that now--with higher concentrations.

[Translation]

Mr. Réal Ménard: But there can be all sorts of dependencies in life. I accept that. Ultimately, being in politics may be a dependency. Some say that politics can be a drug; I often hear that said. But it depends on the physiological repercussions.

For example, earlier you gave the example of a heroin addict who can function for 18 years and not necessarily suffer any negative consequences. It may depend on a person's metabolism. It may depend on the makeup of each individual. You gave the example of sexual dependence—some people have a compulsive need to make love every day. When Parliament tries to set some boundaries, should it be trying to determine the physiological effects of particular drugs on individuals? As parliamentarians, our concern must be public health.

Our colleague, Senator Nolin, has received some studies from the United Kingdom, which show that cannabis does not have many negative consequences, fewer than a glass of red wine every day. As members of Parliament, should the boundaries we set have to do with the physiological effects of drugs on individuals?When there are negative physiological effects, there is an impact on the cost of the health care system. When there is an impact on the cost of the health care system, there is an impact on the country's financial situation in general. And where there is an impact on the financial situation, there is an impact on the country's collective wealth.

As I understand it, neither of you would recommend the decriminalization of marijuana.

¹ (1530)

[English]

Dr. Frank Evans: I do not recommend the legalization of marijuana.

I'll give you another area. You ask yourself, would you like the pilot who flies you back home to be on marijuana? There'll be no physical withdrawal. Would you like your brain surgeon, who's teasing out that artery that may blow, to be doing one joint a day?

[Translation]

Mr. Réal Ménard: So there's a physiological impact on dexterity. In the example you gave, marijuana has a physiological impact on dexterity. If an individual takes marijuana and simply feels happier and enjoys life more, there is no problem, but you would not want a pilot, a surgeon or the Speaker of the House of Commons to take marijuana, because it impairs our ability to make decisions.

[English]

Dr. Frank Evans: Part of the problem with a dependency is that they've paid the price of causing harm to themselves or others by still engaging in the behaviour.

The Chair: Dr. Gourlay.

Dr. Douglas Gourlay: I have problems with the decision the government made to medicalize marijuana, primarily because I think the issues with respect to marijuana, as I see them, are more societal than medical at this time. This is asking a doctor to look at an individual and say that smoking this drug is going to be better for them than not smoking it.

In my experience, I've had no one apply for a medical exemption for marijuana in the context of pain management who hasn't had, on careful examination, a fairly significant marijuana history long preceding the underlying pain problem for which they're now asking for exemption. I think that shouldn't be ignored, because, as I think Dr. Evans is saying, the whole context has to be looked at. We may find cannabinoids, which form the active ingredient in marijuana, plays a vital role in a variety of illnesses, and I'm all for looking at that. The Wasser Pain Management Centre is involved in marijuana study.

But in your analogy between addiction and being a politician, if the consequences of practising as a politician were that you'd lose your family, that you'd lose your liberty, that you'd lose, really, everything you held dear, and yet you continued to do it--

An hon. member: When you're right, you're right.

Dr. Douglas Gourlay: This is not helping you, I understand.

The Chair: You may be describing any number of politicians in the country, but yes.

Dr. Douglas Gourlay: When you continue to do this behaviour despite the fact that it causes you harm, it doesn't matter what comes out in the urine, it doesn't matter whether it's medical or non-medical; it matters what price you pay. I think what we as addictionists are saying is you need to have people help individuals assess that. They need to be able to look at the cost-benefit analysis.

Many people recognize that crack cocaine is destroying their life, but the notion that they stop drinking is out of their framework altogether. And yet we know crack cocaine users are going to continue to have difficulty stopping crack cocaine if they drink, because of a chemical change that occurs when those two drugs form in the body. People don't know that, and if they continue to use despite being aware of it, it's probably not abuse; it's more likely addictive disorder.

The Chair: Mr. Tate or Ms. Bell, do you have any comments on this round?

Ms. Linda Bell: All I would like to say is I think the committee is very privileged to have two physicians sitting here. This is a medical question, and you have two very knowledgeable physicians here addressing it. I have nothing to add.

¹ (1535)

The Chair: What's interesting is that the police thought it was just their issue.

Ms. Linda Bell: From the perspective of the effect of marijuana, I understand where the police are coming from. One of the things the police have said to me is that the problem with guns on our streets today has to do with the illicit drug trade. If we didn't have that, we wouldn't have guns, and we didn't in the 1970s. It's a very complex issue that you people are challenged to deal with, but I think you've heard some very poignant information.

The Chair: Mr. Tate, on this round, do you have anything you want to add? You don't have to have something.

Mr. Dean Tate: The only thoughts I would express would be in reference to mood-altering substances. I find there's one thing that's easy to ignore when we're looking at it from strictly a medical standpoint, and this is not in any way to try to discredit anything from a medical standpoint. When we come to the feeling of the individual, we're moving into a less scientific area in one way, and yet it's a challenge for us to look at it from a scientific standpoint.

Clients who come to us at the Harbour Light Centre basically do so because of the pain they're experiencing in their life, whether it's physical or emotional. They want something different and they don't know how to get it. They want what has been a help in the past and at the same time not to experience the consequences of the pain that help has created for them.

We help them to sort out their circumstances and their experiences. We teach them how to manage their feelings and to make decisions and to a certain extent how to use their feelings, apart from when they're experiencing mood-altering substances, to identify issues so that they can begin to address what is at the heart of their need to use. It doesn't discount the physical dependency. We don't do things that we don't get some kind of benefit from, and the main benefit we get from using mood-altering substances is the relief from some level and some form of pain.

As Dr. Gourlay has pointed out, it is physical pain. Many people who come for help with the physical pain don't have an addiction. They're not prone to addictions.

We teach the clients how to identify and deal with stress in their lives and to use the level of stress they're experiencing as a signal that they need to take action to deal with something, rather than laying it aside, and to find a way to do something that helps them feel as if they're dealing with it and to relieve the pain that comes in a natural way when things are not going the way we would like to see them go and to identify what is the real issue that is involved. We find that what helps them to maintain their recovery is teaching them the skills to do that and of course the need for them not to depend on an external substance. That can work for behaviours as well. It's not necessarily a scientifically proven method in terms of the function of it, but it helps a lot of clients.

The Chair: Thank you.

Mr. Lee.

¹ (1540)

Mr. Derek Lee (Scarborough--Rouge River, Lib.): Thank you.

I would have jumped in a little earlier to ask for clarification, because I felt as if I had taken a double jab to the head during the exchange between Monsieur Ménard, Dr. Gourlay, and Dr. Evans.

I suppose I'm inviting response, but I thought our committee had established a distinction, that there existed a distinction between what we call “decriminalization” and “legalization”. Maybe the thing got a little fuzzed in the translation, but I think we have made a distinction. The question was about decriminalization, and the response that came back was about legalization. If the two doctors don't wish to make a distinction, that's okay; the testimony can stand the way it is.

Second, in responding, Dr. Evans suggested the scenario of an airline pilot smoking marijuana--I presume while flying. I'm inviting some clarification on that, because we don't let pilots drink booze either when they're flying. I didn't think that the analogy was particularly apt, but there may be a perspective you have, Dr. Evans, that makes it quite apt.

Could I invite a response from the two doctors on those two issues.

The Chair: Dr. Evans.

Dr. Frank Evans: True, we don't allow pilots to drink or have alcohol in them, but we've discovered that even if they have no alcohol in them, they can still be incapacitated if they have problems with alcohol. The navy did a study with their carrier pilots--it's a very difficult manoeuvre to land an aircraft--and they found out that if the pilots had had alcohol the night before and had gotten intoxicated, even if they had no alcohol in their system the next morning when they tried to fly, some of them made fatal mistakes.

Cannabis? Again, pilots are not going to smoke on the plane, but in terms of their overall ability, again, all these things are not safe. They are not safe, and there's a price to pay with each one. I don't feel bad about saying to society no, I don't think you should have another choice here. Booze and cigarettes are not--

Mr. Derek Lee: I accept that, but the discussion was in the context of decriminalization or legalization. Alcohol is legal. It's not criminalized. It may be regulated, but it's there, and airline pilots have a responsibility in relation to alcohol, just as they would with any other substance that might affect their performance when they're flying an aircraft.

Dr. Frank Evans: I don't know the validity of this, but I remember somebody saying they had a pilot and an addictionologist together at dinner once, and they said, okay, I'll tell you what. Suppose we had a choice as to what would be legal, that only one or two drugs would be legal in society and the rest would not, and that we looked at them all again. In actual fact, both of them agreed that alcohol would not be legalized. Alcohol just got lucky. It was the first one.

Mr. Derek Lee: Therefore, you're not actually a prohibitionist. You're somewhere in the middle.

Could I ask you to comment on your earlier response, Dr. Gourlay, in not distinguishing between legalization and decriminalization.

Dr. Douglas Gourlay: I think that is an important distinction to make. The penalties associated with the use of a drug like marijuana should reflect the risk that society incurs by the use of that drug. There is a difference for me between legalizing the drug and decriminalizing it. I do support the approach of decriminalizing the use of marijuana.

That doesn't mean I disagree markedly with Dr. Evans in terms of the risk for those people who are at risk of getting into trouble with that drug. People get into trouble with lots of things, including Robaxisal. If you had to pick a drug that wouldn't be allowed on the market today--other than ethanol--it's ASA, because Aspirin--and that's one of the active ingredients in Robaxisal, as opposed to Robaxacet--causes terrible harm and wouldn't be available over the counter. I support decriminalization of the drug, but legalizing it and promoting it as safe is quite another thing.

Mr. Derek Lee: Thank you for that.

I want to get to something bigger than those narrowly focused questions. This afternoon we'd hoped to touch on the issue of prevention and I'm wondering if there are insights, and I'm sure there are.

We certainly want to be able to address that. What more could we do with the money we have and what more could we do if we added new money? What are we doing wrong? The issue is prevention. It's not purely a federal jurisdiction, of course; in fact, it may well be arguably more provincial than federal. But do you have insights you would like to put to us on the issue of prevention of--I hesitate to put a word to it--the illegal use or the non-medical use of drugs? I'm not quite sure how to phrase it in relation to our mandate. Prevention of the abuse of the non-medical use of drugs. How's that?

¹ (1545)

Dr. Douglas Gourlay: The misuse--

Mr. Derek Lee: Anyway, the theme is prevention, and we'd like to hear your thoughts on it.

The Chair: Why don't I start with Dr. Evans and go right across the table, if that's all right with you guys.

Dr. Frank Evans: I totally agree. Prevention is missed and should be highly invested in.

When I trained down in the United States I was at Loma Linda, and basically I trained in preventive medicine. I think in North America we miss that part. We're always looking for the cure versus why don't we just try to prevent.

One of the things you may consider doing is encouraging the recovery base. The more people you have in society who.... In California, it was fascinating. Down in California, you weren't in vogue if you weren't in recovery. Hollywood stars would say, yes, I'm in recovery too, because everyone else was. And it actually fosters a base in society that encourages prevention by maybe not engaging in it or being sensible about it.

So I think again the recovery base is something that can be helpful in this area, but I'm totally supportive of prevention and I don't think we do enough.

The Chair: Can I ask a corollary to that, though?

Ultimately, if a whole bunch of people get better of their own accord we don't have to do anything. There's going to be a bigger base of people who got addicted and got better. Are there any active things you would do to prevent people from even having to get to recovery?

Dr. Frank Evans: I think it might be also approaches. I think prevention is probably going to deal more with the younger population. I question whether the scare tactics work versus just giving them proper information, things like telling them that one in ten of them who engage in alcohol will subtly develop a problem, letting them know what the problem is like and how subtly it comes on.

I don't think I can add much more. I know there are people who are more experienced in this.

The Chair: Thank you, Dr. Evans.

Dr. Gourlay.

Dr. Douglas Gourlay: I think an important part of prevention is education, and the education has to occur at a variety of levels. There needs to be, as Dr. Evans says, education within the schools, and the information isn't effective as scare tactics. People don't respond to that, because it doesn't happen to me, it happens to everybody else. We need, our colleagues need, to have a better understanding about drugs and alcohol and the risk assessment and management of problems.

We had an initiative with the U of T called Project CREATE, and Project CREATE was a website-driven collection of information from medical students, who were called sentinel students, in the five Ontario medical schools to ask them on an ongoing basis what experience they'd had with respect to drugs and alcohol in either identification, epidemiology, treatment, pharmacology, all of these things. The goal in that was to bring together a body of knowledge that could become a curriculum development tool.

The good news is that we got a lot of people in the medical schools, in various branches of medicine, to put to paper what they felt were the key issues that practitioners in their specialty--internal medicine, gynecology, surgery, and so on--should know about drugs and alcohol.

The bad news is that the curriculum in medical school is so tight there's nowhere to put it, and that's a sad thing because drugs and alcohol are not a small part of the presenting complaint of people who go to see their doctor. And pain is even larger. It's the number one complaint that people present with, and if we could separate them and say, you go that way and you go that way, it would be brilliant but we can't.

The only hope we can have is that people in a position of credibility can pass knowledge on that's real and accurate. It's part of what you're involved in; it's part of what we're involved in as educators within the health community. It's part of what we do at all levels. Education plays a key role in prevention.

¹ (1550)

The Chair: Thank you.

Mr. Tate.

Mr. Dean Tate: I think the emphasis I would put, in addition to the other things that have been said, would come back to the ability to make choices in our lives--teaching our kids that.

For example, there are four general areas of life that are very important. We all need to be with people who, we do not doubt, care about us and love us. That gives us something we can't get anywhere else. We all need to be able to look at what we're doing, how we're living our life, and see that it counts and makes an impact on other people. The satisfaction we get from that is very important to us. We need to believe the way we're living our lives is based on choice and that we are actually making choices. When those choices are beneficial to us, great. When they don't accomplish what we want them to, we can reassess and see another direction to go in to achieve what it is we want. And we all need to be doing activities we enjoy.

When these things are happening, the chemistry of our body is healthy. And when we need to deal with painful areas in our life, we have that as a support: not a support to fall back on; a support because it gives us the confidence to actually tackle things. I think that is the key, alongside education, regarding the ways various substances inhibit our ability to understand fully what's going on around us and what our choices are, and short-circuit the natural process we all take for granted. It's there.

So I would emphasize that at the root of effective prevention has to be an understanding and an articulation of how we function as human beings in the first place that takes at least those four areas into account, and how we can ensure we are getting satisfaction from our lives.

We don't get a lot of clients.... We're at the bottom--I'm just talking about a limited experience here--at the Harbour Light. We deal with severely addicted clients, and they don't have those things in their lives. When we learn the history they have, it's easy to see how they got where they are. And it works when we help them begin to rebuild in those areas. I think that would be very important in prevention.

The Chair: Thank you.

Ms. Bell.

Ms. Linda Bell: I think I'm going to go back to a couple of things I said earlier and then expand.

One is that when you talk about the non-medical use of drugs and look at prevention, I would ask you to remember to include alcohol in it, because that's still our biggest problem--and tobacco, and other things.

I'd ask you to think about the fact that treatment is prevention too; it's preventing further problems down the road. Treatment, if it involves families, is touching the families, and the children who come from these families are at high risk. So it touches on the prevention.

But I would say that as long as Canada continues to put its head in the sand and not talk about this problem, it's going to continue. It's a big secret here; we don't talk about it.

You used to talk about it on the Dialogue on Drinking. You had some great ads. Pull out your filing cabinets; use that concept. You don't remember it, I know, but that's the problem. There is some history we could pull on. It used media. We have the CBC, we have cable networks, we have websites. We have ways to get the message out.

We have family members who say they wish they had learned about this ten years ago. We can educate; we have systems to educate. You can educate by talking about it; you can educate by showing positive responses; you can educate people on how to develop a peer group that's going to help you say no and stay away from what's going on.

We don't talk about it here. We need to do that, so that anybody then can start talking about it. Then they can go to their doctor. If their doctor doesn't know anything about addiction--which most of them don't, and you just heard why--maybe they'll refer them to a specialist, because you can say in your message that there are specialists and that they should make sure they find one.

We have to talk about it the way we talk about cancer. We have to inform the public about the amount of money that comes into the government because of this and what the cost is because of this. If you keep the public ignorant, they cannot make informed choices. If you give them the information, they'll make informed choices.

If the federal government says that a charitable organization has to redirect 80% of its receipted donations every year in direct service, I would ask you, why are we at our government level not doing the same thing with the revenues from tobacco, lotteries, and alcohol? Maybe you can't do 80%, but I'll tell you, if you're not doing 50%, who's really in the drug business here?

It's a very serious question, a very challenging question, but if we don't talk about it and the people are not informed.... All sorts of things can roll out if we start to talk about it, and there are more people who know a lot about prevention. But it can start from the House of Commons, and I think whoever starts it in the House of Commons is going to get more votes than they ever thought possible, because there are more people in this country in recovery than you can imagine, and they would get behind it.

Families are suffering from this problem. If you have a family member who's going to work, working for you at the House of Commons, they may not have an alcohol or a drug problem, but they may have a child or a parent who does. When your child phones and says, Mommy is asleep on the floor, how do you focus? If they say, Daddy didn't pick me up, how do you get that brief out?

This is a major problem, one that affects everybody's life. If we can start people talking about the problem, they will reach out for help. But I'll tell you, the help is not available right now, so you need to put money into giving help.

¹ (1555)

The Chair: Thank you very much. And thank you for feeding the political junkies with some self-interest.

Dr. Fry, briefly.

Ms. Hedy Fry (Vancouver Centre, Lib.): I just wanted to say how stimulating your presentations were, all of them.

I also wanted to focus on one question, and that's the one about health promotion. There's a lot of lip service being paid in today's society to health promotion and disease prevention, but we focus that only on tobacco cessation or on some primary things like obesity. Yet the thing that affects and destroys most people's lives is the use of alcohol and the use and misuse of substances. I think this should probably be one of the most important pieces of any kind of health promotion. With the federal government clearly being responsible for health promotion and it having said so, this is obviously a place we need to look.

Now, you've talked a lot about education and prevention, and Derek asked you that question, so I won't go back into that. I just wanted to focus on one thing. Over and over we have seen that in Europe they are looking at the concept of decriminalization. We've looked at Australia and they're decriminalizing. I think we shouldn't talk about legalization, we should talk about decriminalization.

As a physician who didn't learn a single thing in medical school about addiction, I did manage to be lucky enough to chair a council on health promotion in the BCMA. One of the 15 committees in that council was the committee on substance abuse, and I learned a lot then about this issue.

The question I want to ask you, therefore, is--and I agree with you that you don't want to make this decriminalized to the extent that anybody can get it wherever they want, perhaps creating something like liquor control boards so you can just go buy it in the LCBO.... What do you think of the concept that has been floated by some people who have presented to us on--and I know you commented on cannabis--the medicalization of substances as a form of regulation? In other words, the question is, would you create physicians, addictionologists, who would have to be certified and who would then become dispensers of substances to persons who are addicted, habituated or dependent on...?

Is that a reasonable thing to suggest? I don't know. I'm asking you because, for me, the concept of having it freely available bothers me. I'm like you. I don't think marijuana is as simple or as non-troubling as everyone makes it out to be. The whole cognitive impairment thing is a big piece to look at.

What do you think of that concept? That's been the one that some people have suggested to us. Instead of making it readily available in an LCBO, how do you deal with the medicalization of it? I agree with you that one of the things that bothers me very much is that now methadone is available in the pharmacy, which I think is an inappropriate place for it to be available. It should be under an addictionologist who knows how to deal with it, knows how to use it as an appropriate tool. Do you think it could work if one did that as a stop-gap, as a medium-term solution, as opposed to a long-term solution?

º (1600)

Dr. Douglas Gourlay: I should probably disclose to the committee that I'm a methadone prescriber and I'm the chairman of the opiate agonist committee for the American Society of Addiction Medicine, and I'm involved in office-based treatment of opiate dependency with agonists--in other words, methadone and drugs like that--in both Canada and the U.S. I definitely believe the literature supports the use of that drug in the treatment of opiate dependency.

I don't think doctors are particularly good at being regulators, and I agree with Ms. Bell that there are practitioners who inappropriately start individuals on methadone. I'm involved in the development of the guidelines for methadone in Ontario, and I can tell you that the lower limit for the guideline is 18. That doesn't mean that someone younger than 18 can't get on methadone, but what we felt was very important was that if an individual was going to be started on methadone at that age, it should be done by someone with experience and expertise, not only in addiction medicine, but also in adolescent medicine. So the checks and balances are there; it's just difficult to make that happen.

I think when a doctor has an aparent solution in hand there's a tendency.... If the only tool you have is a hammer, everything looks like a nail. If your only treatment for those who are hurting themselves with narcotics is to give them methadone, that's unfortunate, because methadone doctors are not addictionologists.

Methadone doctors are practitioners in Canada--I can speak mostly of Ontario--who understand certain things about the drug that can make it safe or safer, as Dr. Evans would say, to make this drug available to people who might benefit from it. But they are not addictionists, and it's a mistake to imagine that someone who has done an eight-hour course to understand the subtleties, pharmacologically, of the drug methadone, somehow understands the subtleties and the picture around addiction medicine. So I think doctors are very poor regulators.

Ms. Hedy Fry: If you had addictionologists, certified, trained addictionologists, like you and like Dr. Evans, dispense these substances, would you feel that this would be a way to go--in other words, only if it were regulated by those specific types of physicians?

Dr. Douglas Gourlay: We know a lot about the use of methadone as a substitute therapy in opiate addicts. We know a lot about disregulated opiate systems. In certain people, no matter how you slice or dice them, when you discontinue opiates with them, when you put them on antagonists to opiates, they become profoundly dysphoric, their mood changes, and until they're treated with an opiate agonist, like methadone, they're not quite right. Unfortunately, we don't know who everybody is who should be slotted into slot A, slot B, or slot C.

If you took a hundred heroin addicts who were shooters and put them into an abstinence-based treatment program, the number of people after a year who would be abstinent would be extremely low, and the number who were back using would be extremely high. So I think to the credit of the system, even programs like Bellwood, Homewood, and other locations are recognizing that methadone is a tool that can be used to help introduce an individual to the changes that you've heard described here. We know that about methadone, but when you extend that into amphetamines, when you extend that into other stimulants to treat cocaine dependency, we don't know if that's true.

Personally, as an addictionist, I can give the example of something called pseudo-addiction in pain management, where the individual is behaving like an addict, but they're doing it because of inappropriate management of pain. When you appropriately manage that patient's pain with more--and appropriate--drugs, which might include opiates, their behaviour normalizes. They become normal people again.

But addicts, when you add more drugs, generally get worse. We know a lot of things about methadone, but I don't think you can generalize. It isn't as simple as saying of a sedative abuser who is hooked on valium, well, we'll just send him to an experienced, knowledgeable doctor to get him on his daily use of valium. I think it would be selling short the recovery community and the people who need to take advantage of it. Doctors don't make very good regulators, and that's one of the things I think you need to take away.

º (1605)

The Chair: Dr. Evans.

Dr. Frank Evans: I agree with everything Dr. Gourlay said, but I need to ask you: the decriminalization and medicinal use for what?

Ms. Hedy Fry: What they are suggesting in some countries--and this is what we're grappling with here; we don't know if it's a good thing or not--is that heroin, cocaine, and all the substances that are now the licit and illicit drugs be regulated through people with the knowledge of those substances. That would be specialists in addiction medicine, for instance, who would regulate it. You'd have to become, as happened in the U.K., for instance, at one time with heroin, a licensed addict or user and would go to a certified physician who would give you your dose--

Dr. Frank Evans: For your addiction?

Ms. Hedy Fry: Yes--which, as they've said, would decrease the crime rate due to the criminal trafficking of the drug by 60%, would increase the employability of certain addicts by 50%, would decrease diseases and bad needles and all that, through use of needles that involves harm reduction as well. That's the selling point for this suggestion. I'm not saying I buy it or not; I just want to know about it.

Dr. Frank Evans: The selling point for the medicinal--

Ms. Hedy Fry: Decriminalization and medicalization of the drug.

Dr. Frank Evans: Decriminalization of marijuana?

Ms. Hedy Fry: No, of all substances, and medicalizing it.

Dr. Frank Evans: All substances. So basically you turn us into the zoo keeper who just feeds the disease continuously with whatever it wants to eat.

Ms. Hedy Fry: Well, that's the suggestion.

Dr. Frank Evans: Yes, and the idea is we're the ones who'll probably be most cautious about not getting mauled in the process, compared with other physicians.

I agree with Dr. Gourlay. One of the problems with methadone--and I was very concerned when methadone hit the province--is you cannot give licenses out like Smarties to people who are not experienced, because there are going to be all sorts of problems, all sorts of abuse, all sorts of mismanagement.

Sure, if you limit it to addictionists, there's something that.... Oh my God, what a nightmare that would be. I couldn't see the benefits of it. The other thing is, I don't think we have a full feel for the harm in harm reduction and harm cost.

I know a number of people who are on methadone, but their behaviour can still continue because they haven't given it up--not unless they're working with people who know how to work with them while they're on the methadone, and most don't. Most don't. They continue in all the other behaviours, one way or another. That's why you find them: they're on crack and they get arrested again. That's why you find they're selling their methadone. I've had people selling their methadone to buy heroin and use it. It's a mess, and to throw in all of them I think would be a very difficult thing to do.

Treatment of addictive disorders does not simply mean the replacement of a drug. That's the take-home message. The use of a drug in the same class as the one the person is dependent on can play a vital role in an individual getting well, but it's through the other things that go on that the person gets well. We know the number one element in treatment that leads to a good outcome is retention in treatment. We know one of the reasons why methadone programs in the United States do not work as well as they could and why to a degree we're the envy of many in the United States and they emulate our program....

I'm involved in the introduction of methadone into the state of New Hampshire--something called Project NH Remote. This is an initiative to try to make available agonist therapy--methadone--in a state so geographically dispersed you can't have focal locations, as they have in the United States for narcotic treatment.

In the U.S. their prohibitions on drugs are such that there's some value in artificially keeping people low on methadone. If you're going to use methadone to treat people it should be a sensible approach. It should be involving cognitive behavioural therapy, perhaps support groups, or “twelve steps”. Some people fit in very well.

The one thing that's associated with good outcome with methadone is retention in treatment. And people who are artificially held low, as they do in the United States, leave treatment. When they leave treatment they do poorly because when they're connected we're dealing with this readiness-to-change model, with this what's referred to as pre-contemplation, contemplation, action, maintenance, and then relapse.

We're looking at people and helping people move forward through those stages of change. Those stages of change occur in smokers who want to stop smoking, in people who want to change jobs, in people who want to leave relationships. This is a really novel approach. When I was in medical school Prochaska and Declamente hadn't published this paper. Good clinicians seem to know in dealing with a patient where to pitch. You don't take a person who says “I don't have a problem” and recommend they go to the Bellwood Health Centre. On the other hand, for somebody who wants to go to the Bellwood centre, you don't spend half your time uncovering a family history, because they know they have a problem. It's about learning how to approach addiction. The big thing we suffer from is stigma. We suffer stigma as patients and we suffer stigma as people who treat patients with addictive disorders.

It's really helpful to realize that when you punish a person for asking for help you drive people underground. We see this in the impaired health professions in medicine and others. If blowing the whistle on a doctor with a problem with drugs or alcohol is going to ruin their career, you'll get no buy-in from the family who are going to be tremendously disadvantaged by asking for help. And the colleagues are going to say they just don't want to ruin this guy's career.

In reality, treatment may be the beginning of their career, not the end of it.

º (1610)

The Chair: Thank you.

Dr. Evans.

Dr. Frank Evans: If you had physicians, even addictionists, handling that...I use the phrase “exorcism“, but it's true this is a tough field to work in with people who have this condition. If I'm dispensing out everything, and my practice is getting filled up with ones who want to come and keep feeding the disease, that's why you don't find many doctors working in the field. It's a tough field to work in; you'll burn them all out.

Secondly, and Mr. Tate could probably comment on this, the other thing we hear from the people is when you work with them and you really get them to a level of cleanliness they start to wake up. Their brain can function fully in terms of learning some subtleties. They'll describe things to us like this: “After I was clean for two months I started to smell the grass. I had a lump in my throat when I saw my kid playing on the lawn with the ball. Before when I was on Percocet every day, no, I was not here. I was here physically. I could talk to you. I could make good mental decisions, judgments in business, but I was not fully human. The only way I could be fully human was to be actually clean.”

If you start feeding them multiple drugs, you're going to really deny that process in the people.

The Chair: Ms. Bell.

Ms. Linda Bell: It's a huge question you're asking and your committee is trying to undertake. In response to your question, I would ask you to go back to the issues of treatment and prevention. Have we really done as much as we can in the treatment and prevention areas? There's evidence-based treatment that shows treatment works in the correctional system. It works through the Harbour Light program. It works through our program. We know that treatment resources have waiting lists and they're underfunded. The treatment resources in Ontario haven't had an increase in base funding for over ten years. Things are starting to crumble.

If your committee is going to do anything, think of trying to shore up our resources and putting the structure in place to have more of what we have, because we can do a lot more.

You shouldn't have anybody going in and out of a jail without going through a program. You have a captive audience. Goodness gracious, 75% to 90% are there for alcohol and drug-related problems. We need to get the medical profession on board so that nobody goes into a general hospital with an alcohol or drug-related problem and lies in a bed there without being referred to primary treatment or to a specialist. Use your specialist that way.

We need to encourage more physicians to become specialists in addiction medicine. We need to figure out how to do that. We need to recognize it's a specialty area of health care, and the credentialing of addiction counsellors is extremely important. Just because you graduate from university with a social work degree doesn't mean you have an opportunity or you know how to treat this problem.

There are many things you can do. You're talking about the very sensitive issue of decriminalization, and you will have to come to terms with that. But I would plead with you to try to increase and enhance the services.

We treat people from right across this country in our clinic because the resources are not there at home and our program works. Harbour Light treats people from across Canada and out of the country because their program works. There are models of programs that work very well, and the recidivism rate drops in jails and corrections because of treatment linking it to probation and parole.

We can do this. If you want us to help you, we can do this. I'm sure we would all like to help you. I personally feel that Canada is one of the most highly taxed countries in the world, and is also considered to be one of the best countries to live in. I think you can save tax dollars by throwing some money at it, investing in it like any good business would do. You'd save money in the long run and create a better place for Canadians.

º (1615)

The Chair: Thank you, Ms. Bell.

In your presentation there weren't any specifics about how many beds you have, how long the program is, what it costs the patients, and whether you get government support. Do you think you could get something to the committee on that?

Ms. Linda Bell: Absolutely.

The Chair: Okay.

I think there were specifics in your presentation, Mr. Tate.

Mr. Dean Tate: In general terms, yes.

The Chair: Okay. One of the issues in Vancouver was the availability of rehab. It came up earlier in our last panel on rehab, as well, that you three have very few spots and on and on--and just the money they get for some of the programs, what it costs the individual, and what it costs the government. That would also be helpful, of course, because as you say, we're spending an awful lot on incarceration, and if we were to do rehab instead, where would we get?

Mr. Lee, do you still want to find out about the prescription of heroin?

Mr. Derek Lee: Yes, this is my only chance to question two medical experts.

We use methadone to service a heroin addiction, if I can use those terms, as a layman. Wouldn't it be possible to just use heroin instead of methadone, if we're looking at practicality? Why don't we just prescribe heroin instead of methadone?

The Chair: Dr. Gourlay.

Dr. Douglas Gourlay: That's an interesting question, and it's one that's being examined in various countries around the world.

At our centre for addiction and mental health, money has been secured to do a heroin trial, yet we've invested heavily in training and education around the use of methadone as a treatment option for heroin addicts. But it's not about heroin addicts; it's really about addiction. So even if you made methadone available to everyone who might benefit from it, only about half of the people who would benefit potentially, from what we understand about methadone, would actually participate.

Some of the barriers to participation are the structure and regulations around the medical use of methadone. Why would you have people diverting a drug like methadone to a willing population that wants to buy it, when that population can go to a clinic and get it? It doesn't make sense intellectually, and that's the danger, as we think of this in an intellectual fashion.

People want autonomy and control, and going into treatment reduces some of that. So on the notion of going to a heroin trial, if we have control with methadone, I can assure you we're going to have tight control in any kind of medical use of heroin in an addict population. We do not want to become suppliers to the street of the drug heroin.

So if people aren't availing themselves of methadone.... And methadone has abuse potential. It's sold on the streets. It's probably diverted from pain management, which is under a completely different set of regulations--virtually none--as well as from methadone. It's not just through methadone maintenance programs that methadone is becoming available on the street. It's being diverted because there's a market for it.

So I think it's important to study heroin, but I don't think it's a magic answer. If it were, we would have had that a long time ago.

º (1620)

Mr. Derek Lee: Are you aware of any reason that one wouldn't prescribe heroin instead of methadone? Why not? I understand all the things you've mentioned. They are real issues. But we develop methadone to take care of heroin because we're afraid of heroin. Can't we just use the heroin? It's probably cheaper--fewer drug companies involved. I'm just throwing out the idea. Is there a medical reason we can't use heroin instead of methadone?

Dr. Douglas Gourlay: No, no. The short answer is no. And methadone is probably the cheapest narcotic you will find. It's cheap because it's only just recently become sponsored by a Quebec pharmaceutical company, Pharmascience, that brought out the product Metadol. But methadone, used both in treatment of pain management and in treatment of opiate addiction, is a raw chemical that's sold by BDH. It doesn't even have a drug identification number in Canada, which is a real problem when we look at insurability of people who go on methadone. Without a DIN most insurance companies won't cover it. That's been introduced so that doctors don't write prescriptions for paracetamol or vitamin C and other things that people can buy themselves with a product identification number. Yet the drug is as controlled as controlled could be. So it's a cheap drug.

Heroin is infinitely more expensive. This trial is going to be likely the most expensive trial we've ever done, because providing an injection room, safe injections, requires 24-7 nursing. That's part of the trial, and that's expensive.

So methadone is the cheapest narcotic, bar none. The cost of methadone shouldn't be considered.

The Chair: Dr. Evans, then Ms. Bell, and then that's it.

Dr. Frank Evans: I think you have to also look at a couple of other questions here. If you provide an opiate addict with two choices and you put them both on the table, methadone or heroin, which one do you think they'll go for?

Mr. Derek Lee: Heroin.

Dr. Frank Evans: Exactly.

Secondly, if they're using heroin, how will you know they're complying with what you want them to do, versus adding extra heroin because they really like it and you keep tweaking them with it?

Third, yes, there is an illegal market of methadone. I get a number of people who get methadone everywhere. And when you get heroin in there, where there's more motivation.... Again, that's why I say, understand the disease. Understand human beings who have this disease. They'll find ways around it. And again, you're going to be giving it to physicians who maybe don't have the expertise. You're giving them a bigger gun that's a bit more dangerous.

No, I think methadone serves the purpose. And what Dr. Gourlay says is that we understand a lot of aspects about it, but I think throwing in something like that.... I say let the Europeans do it. Sit tight; give it 20 years.

The people are being taken care of with methadone. The heroin is their preference. The cocaine addict, crack addict, does he want amphetamines? No, it's “Give me free crack, and I won't break into your house”. But you'll get more problems with that, one way or another.

The Chair: Okay, Ms. Bell.

Ms. Linda Bell: I think one thing that's important to remember is an awful lot of people who are going to the methadone clinics are not heroin addicts. They may be addicted to prescription narcotics. They may be buying narcotics on the street. So it's not as if you're dealing just with people who are using heroin. Many, many people in those clinics do not have a problem with heroin.

The Chair: This has been yet again a wonderful panel. We've learned a lot of things. You're clearly doing great work in your areas. On behalf of the committee, we thank you for the work you do in our community and in Canada. We appreciate the time you've taken to come before us today, because it does make a difference to our understanding of the situation.

We'll continue to hear from people, probably through the end of June, so if you see a study, hear of something, think of something else, have a friend, or want to talk to us, we would very much like to hear from you. Our e-mail is snud@parl.gc.ca. We can get that for you if you'd like it.

Carol Chafe is our clerk. Any information that comes to her is distributed to all the members. We really do appreciate that, and we wish you continued success in your areas of expertise.

Thank you again.

I'll suspend now, so we can switch witnesses. You're more than welcome to stay to hear our next witnesses.

º (1630)

The Chair: Let me bring everyone back to order. It might be a bit of a challenge.

We are very pleased to have with us this afternoon, from the Alcohol and Drug Recovery Association of Ontario, the executive director, Jeff Wilbee.

Mr. Wilbee, thank you very much for coming before us this afternoon. We have about half an hour with you, and we're hoping that's going to be.... The last half hour turned out to be an hour and 15 minutes. But Réal, I think, has a train, so we're not going to get that far out of line.

I wonder if we could ask you to make an opening statement, or tell us a bit about your work. Why don't we give you a maximum of ten minutes? Does that work?

º (1635)

Mr. Jeff Wilbee (Executive Director, Alcohol and Drug Recovery Association of Ontario): It works very well for me. I'm mindful that at the end of the day, people are looking to get their coffees and get the train, so I talk rapidly and--

The Chair: Self-medicate.

Mr. Jeff Wilbee: Self-medicate, yes.

First of all, Madam Chair and committee members, let me thank you for the opportunity to express some of my views and my organization's views on this very serious discussion around the non-medical use of drugs.

I'm not surprised the hour and a half went by, because I know my colleagues and I know they had some good things to say.

This committee knows the devastation, the cost to individuals and their families, employers, and the very fabric of our society caused by drug addiction.

I'm going to attempt to touch on some of the questions set out in the committee's terms of reference. When given the opportunity, the first thing I did was to try to get an understanding of the terms of reference of the committee and some of concerns you are addressing. I must say from the outset that some of my comments may appear to be mixed messages because of the complexity of the issues and the availability of some of the solutions.

For example, there's growing emphasis on harm reduction interventions. But there are many in the treatment sector whom I know you have heard who feel that although there is value in many of the harm reduction programs for a minority of addicts, the movement is growing too fast, that it's being overused, and that we just don't know enough. Most in this camp would say the treatment has not been adequately funded in this country, at least in the province of Ontario, where I reside. Some of the recommendations of Health Canada's paper Reducing the Harm Associated with Injection Drug Use in Canada need to be monitored closely to assess the outcomes before rushing into full implementation.

I'm an association manager, and on the other side of the argument I also represent those who provide harm reduction programs. Their logic and experience speaks for the need for such programs.

The one fact we must all acknowledge is that no longer is addiction just an individual problem or challenge. Because of the unsafe exchange of needles it has become a serious public health problem. Harm reduction therefore makes sense for this population. This needs to be dealt with, however, in balance with what many would argue is the most ideal intervention: abstinence from all non-medical use of drugs. So the challenge, I guess--and I struggle with it--is that we must find ways to reduce the harm without sending out the message that using drugs is acceptable and that there are no consequences, because clearly there are consequences.

This complex argument is nothing new. A book published on the history of addiction treatment and recovery in America, a book called Slaying the Dragon, records that the argument about abstinence versus harm reduction has been going on since the mid-1970s. I found that rather interesting. Therefore I applaud the work that you're doing here, struggling with this issue that has been around for a long time, within our modern age.

Before going on to attempt to give my perception on some of the issues raised in your terms of reference, it might be helpful to speak to what I think are some of the main deficiencies in our public policies when it comes to addiction.

The reality is that although illegal drug trafficking and non-medical drug use from time to time gets focused in the minds of the public and government policy-makers, on the whole we have not paid enough attention to it. This is particularly true on the treatment and prevention side.

The reason I think I can be so bold as to say this is because in most jurisdictions, addiction services, at least community-based programs, are not always seen as core health services, and there are few regulatory requirements for addiction counsellors. And in my jurisdiction, at least, we are woefully underfunded. It is our hope that this committee's work will rectify some of that.

So whether we're providing treatment based on harm reduction or an abstinence model, we approach this primarily as a health problem, and I believe we have made great strides over the years in terms of matching the people to the proper interventions. Seeing the non-medical use of drugs as much a health issue as it is a criminal justice issue I believe is a major step forward, but we have a basic challenge, in that this may be completely out of sync with the general public's opinion.

I suspect that you're aware of a recent report, as of February 18, conducted by the Leger Marketing group that reported that 79.2% of those surveyed thought taking hard drugs--cocaine, heroin--is immoral. Interesting enough, only 47.5% of those surveyed thought taking soft drugs--marijuana--was immoral, and alcohol abuse rated in the middle at 66.1%.

These are interesting numbers that I believe speak loudly to a core problem: that the public is ill-informed due to the lack of public education. One of the questions the committee has asked in the terms of reference is if there is realistic and honest drug education focused on health and well-being. To my mind, the answer is clearly no. I respectfully suggest that this is where we need to start.

If we as Canadians are going to be serious about reducing the harm of drugs, we must all be involved. There needs to be a massive media campaign, similar to the tobacco strategy, that raises the profile of addictions, explains how people get trapped into usage and dependency, why and how society will benefit from more resources being invested in prevention and treatment programs, and of course the underlying social ills that have been clearly identified as contributing.

Of major concern is usage among our youth, where it all starts. Recent research on substance abuse among Manitoba high school students reported that the average age of first use of alcohol is 13.3 years of age. By the fourth year of high school, 33% were using alcohol once a week or more. In the latest report on Ontario student usage, reporting a return to late 1970s usage, what alarms me is that with large increases in the abuse of solvents, it is not a northern problem any more; it's across the board in this province, at least, and most interestingly, is rising with young females.

There is one thing we know, and that is that most youth will experiment. And we also know that most, having experimented with alcohol and other drugs, will then move on with their lives. Others will get hooked, and they and society will then have to face the issues that are being deliberated by this committee. We also know that, generally, their experimentation does not start with injected drug use, but rather with alcohol, marijuana, and substances such as Ecstasy.

I think a big part of our public education program should be for parents and teachers to learn how to recognize the signs of drug usage and what to do about it. If we can delay the experimentation, recognize that a person is in trouble earlier, and implement the appropriate action, I would suggest we could reduce some of the harm. However, if the view of most parents is, according to this survey, that experimentation is immoral and not a health problem, then I would suggest this may lead to a barrier of denial.

As you are undoubtedly aware, Health Canada has just published a compendium of prevention best practices, entitled Preventing Substance Use Problems Among Young People . If you're not aware of that document--I'm not seeing it--I would certainly suggest that it be given serious consideration in your deliberations and report.

We know from the experience early in the last century in the U.S.A. that prohibition does not work, but we would caution against the wide-open decriminalization of the so-called “hard drugs”.

Yes, obviously in some cases there is a further victimization of soft-drug users through criminalization, and we're also concerned about how effective the drug treatment programs are within our correctional institutions.

º (1640)

This is a tough one for me. I spent about 13 years in that field. We support an equal balanced approach to both harm reduction and abstinence programs inside the walls, as we're suggesting for a free society. Needle exchange and other safe methods will obviously reduce the transmission of disease. But the dilemma you have to struggle with is how can we condone illegal activity within a system that is set up to demonstrate society's disapproval of that activity?

We strongly recommend that we divert more injection drug users from incarceration through the expansion across the country of drug treatment courts. This, in my mind, is the best example of combining health and the criminal justice system, which has demonstrated success.

We further suggest that in major urban areas the expansion be based on the Toronto drug treatment model, and that modifications of the model be utilized in smaller communities. But that is going to take a realignment of resources and a change of attitude, particularly within our criminal justice system.

The basic principles there, of course, are proper selection of the candidates for the program and the weight of the courts, combined with the compassion of health care providers. But in order to expand this effective program, there needs to be an enhancement of the already underfunded and overburdened system.

In the province of Ontario there are long waiting lists. I received a call yesterday from a young man who was desperate and highly emotional. He said “You have to help me”. He went on to tell me that he had been told in his community that it would take 30 days before he could see a counsellor. He said “I can't last that long, I won't be around”. Fortunately, in this case we were able to get him into a detoxification unit in another city; otherwise he would have been perhaps just another statistic.

It's imperative for the federal Minister of Health to convince her provincial counterparts of the need to provide additional funding to enhance treatment. As indicated earlier--and I heard it from the panelists before us--we just don't know enough. So I think we would also support the Canadian Institutes of Health Research creating a research institute dedicated to addictions. The research should also include measuring outcomes of innovative programs, and for that matter, some of the more traditional treatment models, so we understand what works best for whom.

Having made the point that we need to increase addiction prevention and treatment services, I would like to close by emphasizing the need to ensure that those who are providing services have the skills and competencies to meet the ever-increasing clinical challenges.

I am here today representing two organizations. One is the Canadian Addiction Council Certification Board. The other organization is about to launch, with other addiction partners, online training programs for addiction professionals. Both the training and certification of those working with non-medical users of drugs must be given top priority by all jurisdictions in Canada.

Again I thank you for the opportunity to present this formal presentation. Perhaps I'll attempt to clarify what I have confused.

º (1645)

The Chair: Thank you very much for your presentation. I, for one, am happy to see a recommendation to the federal minister.

Mr. White.

Mr. Randy White: Thank you, Paddy.

Were you here, Jeff, when I asked Linda the questions? I think you came in a little later.

Mr. Jeff Wilbee: I came in a little late, which was terribly unfortunate, not for you but for me.

Mr. Randy White: I'm glad you did, because I'm going to ask you the same question. I didn't want you to cheat and get Linda's answer. She was quite an exceptional presenter.

I was in a so-called rehab facility about six months ago, where the person operating it was a former addict. It got funding, but I don't know how. A number of the people working in the place, if they weren't addicts, were very close to being former addicts. The place was a damned mess, poorly organized, dirty, filthy. I was not impressed at all. It wasn't with this committee, I might add, Madam Chair; it was on my own in another place.

On the other hand, I've been in other places that appeared to be very well run that lacked funding. I guess they didn't hit the right people for funding. So one was sort of professional and not doing well in funding, and the other was anything but professional and got funding. The people in these organizations referred to addicts as clients.

When you opened, you mentioned the harm reduction idea may be growing too fast and that kind of thing. It's precisely one of my concerns. I see the harm reduction thing as the hula hoop of the drug industry. It's almost a fad, if I can say it in that way.

What is harm reduction? It's anything you want it to be, if you can get some money, perhaps, and different styles. As long as you call it harm reduction, maybe there's money in it and a way to get things operating.

I would like you to comment on it. Maybe I'm wrong about this. I've seen one heck of a lot of places in my short life in this industry. I'd like you to comment on the observation.

º (1650)

Mr. Jeff Wilbee: I think you have a couple of points I'd like to address.

As we all know, it's always tough to get something into a five or eight-minute timeframe. One of the comments in my presentation is, in most jurisdictions that I'm aware of, many times the kind of program you're seeing needs to be seen as a core health service. That is rightly so, perhaps, not knowing where it is, in what part of the country, or what have you. I know the places of which you speak. Ergo, it means they are funded appropriately.

Funding itself is not the answer. I gather, from your experience, you would suggest here was one that was operated very professionally and was having financial difficulties. The other one did not appear to be operated as professionally as you might like, but maybe it had really good sales in terms of fundraising or something of that nature.

I think it is not the fault particularly of the agencies, or correcting it is not the fault of the agencies, and we'll get rid of the program. I think the whole system needs to be looked at.

I can tell you, in this province, we have just come out with a report. Except for the hospital-based programs, for example, there are no standards or accreditation processes. We've been working on it. My organization developed some accreditation. We recognized four or five years ago that there needed to be accreditation processes. I would expect this.

Let me put it this way. When I had to put my parents in a long-term care facility, one of the toughest things I had to do in my life, I wanted to make sure the accreditation was on the wall. I wanted to know about the competency and certification of the staff who would be looking after my mother and father. If I had to put one of my sons or, God forbid, one of my children in rehab or a treatment centre, I think I should expect the same quality of standard. I think that's what I mean by it not being seen, many times, as a core service.

I've been around a little bit. My experience has been to say yes, there are those who are coming from their own addiction. I know many of them. I had dinner with one last night who has been clean and sober for 35 years, and has reached more addicts in southwestern Ontario than anyone else I know.

Back in the early to late 1960s and 1970, when the recovery homes or rehab homes were being set up, the only people who would be prepared to work in them for the low wages would be those who had something to give. They can be very effective. On the other hand, in 2002 it's not good enough. It's just not good enough. The fact of the matter is I would like to see credentials and certification across the country in all jurisdictions. I ended my presentation talking about it.

Dr. Fry was talking about “addictionologists”. I don't think there are too many of them around with high skills. I would tend to agree with you. It's why we should not rush into the complexities of harm reduction, the decriminalization of some of the drugs, until we have the knowledge, competency, and staff to meet the complexities.

I don't know if I've answered your question.

Mr. Randy White: Yes, you did. It's precisely where I was coming from with the idea of standards and bringing things up to a level playing field.

Could you describe for me the components you think exist in harm reduction? I'll give you an example of safe injection sites. It's one of the things we commonly hear about. It's harm reduction.

Mr. Jeff Wilbee: Yes.

Mr. Randy White: What else is harm reduction?

Mr. Jeff Wilbee: I believe the ultimate harm reduction, of course, is abstinence. I would rather my grandchildren never experiment. If in fact they do experiment and get involved, then I would like whatever is needed to save their lives and to get them off drugs.

Many would say, I guess, we cannot get into a situation where we throw our hands up in despair and say nothing works. We would argue perhaps we have not been serious enough about prevention. I would say early intervention is needed. For most kids, the problems start much earlier than taking the needle out and sticking it in the arm. To me, it's a stop-gap.

I think the first thing is you want to save the lives of those persons who are addicted, and I'll leave that to the physicians, who understand it far better than I. I'm not a clinician. But I would caution that it can be a panacean solution, or it may be seen as that, and again, that's why the caution that we need to go far more slowly. I don't want to come here and say we--

º (1655)

Mr. Randy White: But we're hearing that harm reduction is needle exchange, condom distribution, crack pipe distribution, heroin distribution, methadone maintenance, safe shoot-up sites.

Mr. Jeff Wilbee: Yes. I guess I would personally agree with Dr. Evans when he was saying to let other jurisdictions play around with this before rushing into it here.

Other harm reduction could be controlled drinking. There are programs out there that say okay.... One of the toughest things, of course, is how do you say to a 16- or 17-year-old who obviously has a problem with the legal drug of alcohol--talking about getting into non-medical drugs--that he can never drink again? So I think there are things we can classify as harm reduction, such as controlled drinking and those kinds of responsibilities.

You could press that even further to say it's okay to drink, but just don't get behind the wheel of your car. That's a form of harm reduction. And I know exactly what you're saying in terms of these kinds of methods. I just think they shouldn't be expanded too quickly--piloted, but well researched, so that we're absolutely sure. I think one of the things is how good are we at knowing how to match the patient, the client or the person with difficulty, with the intervention?

Mr. Randy White: Thank you.

The Chair: Thank you, Mr. Wilbee.

Mr. Ménard.

Mr. Jeff Wilbee: That's it in part, but I also think we need to be better at what the outcomes are of the various interventions. So I think if we're going to get involved with expanding harm reduction and shooting galleries and those kinds of things, it should be surrounded with good research on the outcomes here in Canada.

So I guess we would support this. If there are going to be pilot projects, I think we would strongly say--and I'm here to say this from our fields--the government has to make a decision on where it spends its money. We would caution that if we're going to make those kinds of investments without the proper research it's very dangerous.

» (1700)

[Translation]

Mr. Réal Ménard: For example, we have the Canadian Strategy on HIV/AIDS, which was started by the Conservatives in 1989 and continued (phases 1 and 2) by Minister Dingwall and Mr. Allan Rock respectively. There is an evaluation process involved in the distribution of funds under this program. When we talk about a harm reduction strategy, funds can come not only from the federal government, but also from provincial sources. It is in fact probable that most of the organizations you represent in Ontario get most of their funding from the province.

Would you say that the provincial boards or health organizations provide funding without requiring strict evaluation procedures?

[English]

Mr. Jeff Wilbee: I'm saying that in the province of Ontario, certainly the funder, the Ministry of Health here, has concentrated on the fiscal more than quality control. That is being addressed by a provincial committee. In fact, I was involved with a telephone conference call yesterday morning to take a look at those kinds of issues. Until such time as we get that, sir, we're going to have the kinds of situations that your colleague was sharing with us a few minutes earlier.

So yes, it needs to be a full accreditation process, and that includes looking at the competence and skills of those who are providing services. And I'll go back to it again: If I need to put someone in my family into a health-funded program, I would hope that those same standards would be there. In some cases, obviously, as our colleague had indicated, they're not.

[Translation]

Mr. Réal Ménard: I have no further questions.

[English]

The Chair: Thank you.

Madam Hedy Fry.

Ms. Hedy Fry: I think the question of certification is an important one. We heard from the last group who presented to us, especially the two physicians, that it was essential for us to look at how we ensure that not just the people who are dealing with addiction and treatment, etc., are certified, but also that people who are at the first level of intervention--that is, the family practitioner, the nurse, or the emergency room physician--have a certain knowledge of even a simple thing like how to take an addiction history. A lot of physicians we know, without being negative toward the profession, from a lack of information and understanding don't take addiction histories. They manage to give narcotics to people for whom it's like adding a match to a gallon of kerosene.

So how do we get that moving without interfering in the fact that medical schools, as we heard before, don't even have the room in their curriculum right now to add a lot of other essential things? How do you suggest we make that a priority? I agree with you. I think good certification is important so that we have people doing the right things and not literally prolonging the problem. How do you suggest we go about doing that when you would have to intervene with the people who set up a curriculum as well as with the licensing bodies of a lot of these organizations? That's like provincial jurisdiction.

Mr. Jeff Wilbee: I think that's an excellent question. I'd like to start off by saying we have made some strides. I would mention here the American Society of Addiction Medicine. There's also the Canadian Society of Addiction Medicine, which really was inactive here six or seven years ago. So we see more physicians, if not specializing, at least in part of their practice being in this area.

So we have to take a look and say there are some movements. There is some recognition within the Ontario College of Family Physicians of the need for training along these lines.

The Alcohol and Drug Recovery Association and other partners are about to launch some online training for addiction professionals. We received some money from the Office of Learning Technologies of the federal government to do so. Part of that is also to make it easier for physicians, nurses, and addictions counsellors to get training across this country.

I also manage a certification board. I hear from people in Come By Chance, Newfoundland; Barrie, Ontario; and Moose Jaw, Saskatchewan, saying they'd like to get certified but they don't have the time or the resources to drive however many miles it is to get it. I'm talking about non-physicians here. I would suggest that is also true of physicians. So you might want to include in your report some comments directed toward faculties of medicine across the country that they need to take a look at this.

I think we need to continue what we're doing, because there has been some movement with physicians. That really wasn't the case twenty years ago, to the best of my knowledge.

I think we have to put ourselves in other people's shoes, including physicians, who are very busy in their practice. We know, at least where I live, that there is a shortage of physicians. My people deal with those who are addicted or have substance abuse problems--and let's be honest about it, they sometimes can be difficult patients.

So I think we have to keep on doing that. I look to this committee to address that very issue in your report somewhere down the line.

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Ms. Hedy Fry: Thank you.

The Chair: Mr. Lee.

Mr. Derek Lee: Thank you.

In your reply to Mr. Ménard earlier, although I didn't hear all of the exchange, you used the words “very dangerous” when referring to possible harm reduction tactics. I'm just curious as to what is very dangerous. Why would it be regarded as very dangerous when, to my understanding, harm reduction is something less dangerous than what already exists?

Mr. Jeff Wilbee: That was poor communication on my part. That's not what I intended to say. I stated in my presentation that there are those for whom harm reduction is quite appropriate. What I intended to say was that when you start getting into something new, such as controlled shooting galleries, that should be surrounded with some good evaluation. That is what is dangerous, to just go and do something without evaluating it. I wasn't suggesting that harm reduction itself was dangerous.

Mr. Derek Lee: Okay.

Just to play devil's advocate, you're indicating some caution here. So I'm going to ask you right out: why would you be cautious about injecting someone with heroin or letting them inject themselves when they're already injecting themselves with heroin? Why the caution? What fears and risks are you alluding to?

Mr. Jeff Wilbee: The caution is around the system, not individuals. I don't disagree with you. The first thing we need to do is to save people's lives. So that isn't where the caution is. I understand that this committee is taking a look at how the system can operate better. The caution is around how systemically this evolves, as opposed to personally.

I didn't make myself clear in my answer to Mr. Ménard.

Mr. Derek Lee: You're just urging caution when new steps are taken in order to make sure we do it properly.

Mr. Jeff Wilbee: We do that in every other medical area. You have to go through a rather rigorous procedure in order to brings drugs onto the market, and medical procedures are certainly evaluated before they're approved. That's all I'm saying.

Mr. Derek Lee: That's fine. I do understand.

One of our witnesses, who is or was a user of drugs, said that abstinence should not be the theme of treatment. It can be the goal. But in your submission you use the term “abstinence model”, versus other types of models, and I think I know what you're saying. He urged us not to accept abstinence as a model, but that it's always the goal. But the existence of abstinence as the theme of the treatment means that some people who are addicted will simply not be there. They are incapable of achieving the goal; they will admit defeat early. They don't want to admit even to their counsellors.... The counsellor gets wrapped up in the abstinence goal as well, and the counsellor doesn't want to fail. So they think maybe it's better just to call the whole damn thing off--let's not bother trying to get there, because I'm going to fail.

Too much emphasis on abstinence as the model should be avoided--that's what he was suggesting to us. Do you have a comment on that?

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Mr. Jeff Wilbee: I think there is some validity to that, but I'd like to just make the comment that I think it depends on how we intervene.

If that person for whom abstinence doesn't work at this point of their life is being counselled or being helped in a non-residential setting.... It gets a little more complex when you have a residential setting. How then do you have some who are maintaining abstinence with others who have this ability to go on and do harm reduction and use substances to some degree?

We've had one experience where one of the rehabilitation or recovery homes here in downtown Toronto started to use a number of their beds for those who were on methadone. What they found--and I think there's probably good reason for this--was that if there was a small number--three or four in a milieu of twenty or so--it didn't seem to have too many negative impacts. However, once they got higher than that, a larger percentage, it seemed to cause some difficulty with those who were trying to maintain some abstinence. I think there's some validity to that.

I've tried to talk in my opening statement about it. My comments may seem mismatched, but I think somehow we have to get that balanced. We have to have a better understanding of what works best for most, how we can intervene and match the client or patient to the proper intervention. So I don't disagree with what you're saying. There is certainly a lot of truth in it. But I think it's a little more complex than that.

Mr. Derek Lee: Yes, it was really him who was saying that. I was restating it for him. But anyway, thank you. You've been very clear in that answer.

The last question is, how can you help us address prevention, before people get there in the first place?

Mr. Jeff Wilbee: Well, I think in my presentation I very briefly talked about that. I think that's where it starts.

I mean, if kids are starting to experiment in Manitoba on average at 13.3 years of age, that's much earlier. We know there are kids out there starting much earlier than that.

I think that sometimes.... I'm going to say that maybe we have societal denial. Maybe we need to do some education in our educational institutions and what have you. Many times parents are just unaware that their child is part of it. They're too busy, or they're into some denial.

We were doing a kind of prevention community thing a year or so ago, and one of the coaches came up and asked us if we could help him. He was talking about a midget hockey team--you know, age 15. One of the kids got nailed in the corner--there was something wrong with him--and the coaches didn't know that he was high. His son and this other 15-year-old colleague knew, but the coach didn't.

So again, if we're going to make changes, if we're really serious about this, it's going to take some money, number one. But number two is we have to involve everybody. Certainly there are socio-economic contributions to those who.... But you know, I've been involved for a long period of time, and I've known people who come from some pretty good families who've found themselves in these situations.

I started off to say I don't think we've really taken this seriously. If there is a premier who announces something, or there's a tragic death, all of a sudden it's front-page news. We get excited. But this has to be long-term.

I think also--and I know my own organization has looked at research that would indicate this--sometimes we're out there with just the negative messages. So we've started a program called “High on life”, to start talking about, you know, “I need to get high, sir. I don't know about you. I need to feel good about myself.” The difference is what I feel good about.

I think we have to develop that kind of strategy, and it can't be done without resources. It also needs to be evidence-based. I'd also mention that there's a Health Canada document that just came out that I've had a chance to look at. Please, if you haven't seen it, take a look. It looks at best practices, and develops...I think there are nine criteria for best practices. I think it should be given a serious look.

The Chair: Thank you.

I did have a couple of questions for you, Mr. Wilbee. You're a charity and you represent the majority of addiction treatment and recovery programs. How many is that? How many are members?

Mr. Jeff Wilbee: Around 90, and also some private practitioners.

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The Chair: So people pay a certain amount?

Mr. Jeff Wilbee: A small amount, yes. We raise dollars like every other charity.

The Chair: From the general public?

Mr. Jeff Wilbee: Donations, membership fees, those kinds of things. The addictions field is so terribly small and underfunded that membership fees themselves would not sustain us.

The Chair: You're paid a salary?

Mr. Jeff Wilbee: Yes, I am.

The Chair: Do you also run an addiction treatment and recovery program?

Mr. Jeff Wilbee: No, I do not. I'm not a clinician. If some of my questions weren't answered clinically, it's because I'm an association manager.

The Chair: How long have you been doing this work?

Mr. Jeff Wilbee: I've been doing this for nine years. Prior to that I was involved with community corrections with the St. Leonard's Society of Canada. I've been in most of the prisons across this country. I have done some consulting with Corrections Services Canada here provincially. As we know, there's some impact here as well. So that's my experience.

The Chair: If you don't mind, I wonder if we could get some information on what the activities are of Drug Awareness Week, the Tell Someone Program, and the High on Life Initiative.

Mr. Jeff Wilbee: I would love to do that. You don't want to be so bold as to bring that stuff to a committee like this, but if you're interested in it....

The Chair: Be bold.

Mr. Jeff Wilbee: Okay, then I will be bold. You need 25 of them.

The Chair: Those are some innovative programs. Certainly with High on Life, we've been hearing about more people needing some of these kinds of initiatives.

Right now you're trying to establish some guidelines for your members, or formalizing those guidelines within the province of Ontario?

Mr. Jeff Wilbee: Yes. We've developed standards and also have a full accreditation process based on good accreditation principles. They just need to be implemented. That's being looked at here. The Province of Ontario has recognized that. We have a small working group that has just produced a report, and the province has struck a task force to continue looking at accreditation and certification issues in this province.

Last July I had the opportunity to be in the Northwest Territories and meet with the Speaker of the House and the deputy minister and his people. I have the opportunity next week to speak to the Secretary of State for Children and Youth, who of course represents that area. We'll be there to talk about two things. One is, again, around being a core service offering credentialing and accreditation in that jurisdiction. Also I want to bend her ear a little bit about our High on Life prevention program and her role as minister.

I hope that answers the question.

The Chair: One of the things we've been hearing is that there's a shortage of treatment facilities. Secondly, I wasn't kidding when I said I was really happy to see your recommendation on the top of your last page about talking to the minister and encouraging the provinces to set up more treatment facilities, or maybe make them larger or something. There is a real shortage. The other challenge we've heard from people is that when someone is ready to get treatment, sometimes it can't be found, not just because there's a shortage but because people just don't have a clue.

Are there some good inventories that exist? Are there good models of inventories? Let's say a physician was interested in recommending something else but isn't that familiar. How do they find stuff?

Mr. Jeff Wilbee: In this province there is a service called DART, the Drug and Alcohol Registry of Treatment, and that number is well out there. It's a scenario where you can call. It also has a problem gambling hotline. Somewhere down the line, my colleague, Susan Vincent, might also be a good person to address here. In this province, through the Centre for Addiction and Mental Health, we are also setting up a whole information gathering system. It is called the DATIS, the Drug and Alcohol Treatment Information System. Again, that kind of knowledge is not research, but it's democratic data, and it takes a look at that.

So I think there are some good things. I know there are some good things happening in other provinces. I can best speak for this province because this is where I reside. Although I do know something about the other jurisdictions through the certification process, I don't know them very intimately, so I would not just speak to that.

The Chair: Are there other provinces that are ahead on the certification process?

Mr. Jeff Wilbee: The fact of the matter is that we certify people right across the country. This Addiction Intervention Association, which is the addiction.... One of my board members is here to make sure I do the job properly.

The Chair: He's about to write you a note.

Mr. Jeff Wilbee: Yes. We certify people right across the country.

The Chair: Okay, but in this listing--we have it already--one of the things of concern to me is there are different types of programs for different types of people at different stages. It might not work for Bob in this circumstance, and it might work for Jane over here. It's getting that secondary information--it's probably just getting that anywhere--and trying to get at least some kind of description of the program. Is that all included in that information?

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Mr. Jeff Wilbee: Yes, it is. That needs to be up to date so they can gain that information. The CCSA, of course, also has a repository of programs. So we need to get out there.

I'll tell you what's working for us a little bit, and in some ways is a bit of an annoyance. We have some radio commercials out there--it doesn't cost us anything for air time because we're a charity--in about 122 radio stations, a little low-cost television ad, and commercial public service announcements. A young fellow who called me yesterday apparently got our number from the radio.

Again, we don't want to talk about this. As I say, there are flare-ups every once in a while when it comes up, so I think the general public needs to know.

We're also just about to launch a computer portal, again, sort of High on Life program and using journals that the teachers will be able to use. We've done a little bit of field testing on it. It seems to be based on some pretty good literature, in terms of assisting teachers, coaches, and others to first of all recognize....

We have a really serious problem with substance abuse among our elderly. Nobody wants to talk about it too much. We have two small programs in this province. That disturbs me a great deal. That's kind of specialized treatment. They may not be doing heroin and cocaine, but they're in difficulty.

The Chair: When you mix alcohol with some of the prescription drugs--

Mr. Jeff Wilbee: Exactly. One of the things I'm hoping for around this training is to involve the Victorian Order of Nurses, or those doing home care nursing. If the bottle of wine is rolling around on the floor that's easy to see, but do some training so people are a little more astute in recognizing and doing proper intervention.

We have a lot to do, but I think we've done a lot. We need to keep expanding on that. But there's another problem you have, even dealing with kids in school, that we're really concerned about. We did a journaling exercise in a school in Kitchener in this province, and I think there were 28 young grade 9 or 10 females. We did the traditional “drugs are bad”, and all that kind of stuff, and then we had them do a journal for a month. We were then able to bring in not only a coach, but also an expert on youth addictions from Sick Kids. The fact of the matter is four of those girls came forward and said they had a problem. Three of them got help. It would have been extremely dangerous if they had opened up to us and we hadn't had services to provide to them. That really causes me some concern.

In this province we have a lack of residential treatment programs for youth. People open up to you and you can call the DART and find out this information, but the young fellow who called me yesterday would not have lasted 30 days. He was lucky he heard and called, because I could make a phone call and ask for a bit of a favour. That's not the way to build the system.

Like my colleague Linda Bell, I won't apologize for passion here either. We have to take this seriously or we'll be in another committee 15 years from now sitting around talking about the same issues.

The Chair: Let's hope we'll be talking about how successful it's all been.

Chantal Collin wants to ask a question.

Ms. Chantal Collin (Committee Researcher): I have just one question on DART. Doesn't its inventory only include programs that receive some form of provincial funding?

Mr. Jeff Wilbee: Yes, I think you're correct on that. A small number out there are self-supporting.

Ms. Chantal Collin: They are not in the inventory.

Mr. Jeff Wilbee: I have had a couple of calls lately from people wanting to start rehab centres, and the first thing I say is we have to sit down and talk about money. The fact of the matter is there is no provincial money, and if they want to do this, they'd better have some clever ways.

Unfortunately, we may end up with the same situation you were referring to, sir.

The Chair: Thank you very much for coming before us today. We are very pleased you're out there working so hard and are so compassionate. We think it's a good thing, and we wish you well in your work.

Thank you for the time you've taken to share your ideas with us. As you're communicating with your members and others you meet in your day-to-day life, encourage them to participate in our process.

Mr. Jeff Wilbee: I will do that.

The Chair: We'd be very happy to have that.

All the transcripts are available on our website. We have information for people, and we are really encouraging the widest possible number of people to participate, because part of this process is also helping to develop some national consensus on some of the issues.

We wish you well and thank you very much.

» (1725)

Mr. Jeff Wilbee: Again, I thank you for the opportunity.

I will make two promises. One is that we have a pretty sophisticated communication system, and it will be going out there, I suspect, by the end of tomorrow. They knew I was making a presentation here. Second, I'll be sending you 50 packages--25 from each organization. I don't expect you to read them fully, but I would appreciate it if you would just glance at them.

The Chair: That's terrific. Again thank you very much, and thank you to everyone who's been here.

Colleagues, thank you for a great week of hearings and visits.

To our team of technicians, interpreters, and others, thank you very much. I know Randy and all of us have been talking about what great panels we've had and what great research we've had--organization and logistics. So thank you all very much.

We're adjourned.