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37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

EVIDENCE

CONTENTS

Wednesday, February 27, 2002

1530

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

Mr. Nick Hossack (Senior Manager, Addictions Team, First Nations and Inuit Health Branch, Department of Health)

1535

1540

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

1545

Mr. Peter Cooney (Acting Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health)

1550

The Chair

Mr. Peter Cooney

1555

1600

1605

The Chair

Mr. Nick Hossack

The Chair

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. Randy White

The Chair

Mr. White (Langley--Abbotsford)

Ms. Chantal Collin (Committee Researcher)

Mr. Randy White

Mr. Nick Hossack

1610

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. White (Langley--Abbotsford)

Mr. Nick Hossack

Mr. White (Langley--Abbotsford)

The Chair

Mr. Ménard

Mr. Nick Hossack

1615

Mr. Ménard

Mr. Nick Hossack

Mr. Ménard

Mr. Nick Hossack

Mr. Ménard

The Chair

Mr. Nick Hossack

The Chair

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

1620

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

1625

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

The Chair

Ms. Allard

Mr. Nick Hossack

Ms. Allard

The Chair

Mr. White (Langley--Abbotsford)

1630

The Chair

Mr. Ménard

Mr. Nick Hossack

Mr. Réal Ménard

Mr. Nick Hossack

Mr. Ménard

Mr. Nick Hossack

1635

Mr. Ménard

Mr. Nick Hossack

Mr. Ménard

The Chair

Mr. Ménard

Mr. Nick Hossack

Mr. Ménard

Mr. Nick Hossack

Mr. Ménard

The Chair

Mr. Dominic LeBlanc (Beauséjour--Petitcodiac, Lib.)

1640

Mr. Nick Hossack

Mr. Dominic LeBlanc

Mr. Nick Hossack

The Chair

Ms. Fry

1645

Mr. Nick Hossack

Ms. Fry

Mr. Nick Hossack

Ms. Fry

Mr. Nick Hossack

1650

Ms. Fry

Mr. Nick Hossack

Ms. Fry

Mr. Nick Hossack

The Chair

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

1655

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Derek Lee

Mr. Nick Hossack

Mr. Lee

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

1700

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

1705

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

1710

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Mr. Peter Cooney

The Chair

Ms. Fry

1715

The Chair

Mr. Peter Cooney

Ms. Fry

Mr. Peter Cooney

Ms. Fry

Mr. Peter Cooney

1720

Ms. Fry

Mr. Peter Cooney

Ms. Fry

The Chair

Mr. Nick Hossack

The Chair

Mr. Nick Hossack

The Chair

CANADA

Special Committee on Non-Medical Use of Drugs

NUMBER 028

1st SESSION

37th PARLIAMENT

EVIDENCE

Wednesday, February 27, 2002

[Recorded by Electronic Apparatus]

¹ (1530)

[English]

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

We are the Special Committee on Non-Medical Use of Drugs. We have with us today representatives from the Department of Health, Peter Cooney, who is the acting director general, non-insured health benefits, first nations and Inuit health branch, and Nick Hossack, senior manager, addictions team, first nations and Inuit health branch. Gentlemen, we're very happy to have you here, and we're very happy to have so many guests in our audience today.

I think you have a statement for us, and then I think we have some questions for you.

You have a slide show, a deck, as they say.

Mr. Nick Hossack (Senior Manager, Addictions Team, First Nations and Inuit Health Branch, Department of Health): Indeed we do.

I'm pleased to be able to appear before this committee on behalf of the first nations and Inuit health programs branch. I will be presenting information relating to first nations and Inuit addictions programs. My colleague Peter Cooney will be addressing issues you may have relating to the branch's non-insured health benefits policies and programs. It is hoped that between the two of us we will be able to address issues you may have regarding the branch's strenuous efforts to deal with the challenges posed by addictions in first nations and aboriginal communities:

[Translation]

Program for fighting addiction among the First Nations and the Inuit.

[English]

The NNADAP mandate dates back a few years and it currently reads:

To support first nations and Inuit and their communities in establishing and operating programs aimed at arresting and offsetting high levels of alcohol and drug abuse amongst the target population living on reserve and in Inuit communities.

This was obviously developed as a response to what was seen to be a prevalent situation.

The program itself developed from pilot projects that were undertaken in the 1970s, and has now evolved into what is one of the most extensive and recognized programs offered by the first nations and Inuit health programs branch. Surveys and polls consistently rate this program as one of the most popular, and it is viewed as one of the most important. It is composed currently of two major streams. One is the NNADAP program, which deals with alcohol and drug addiction, and then there's the more recently introduced youth solvent addictions program.

NNADAP community and prevention programs were formally introduced in 1982. After a period of development that was supplemented by the national native role model program, which was introduced in 1988. Many people here have probably seen the positive posters this program has produced to encourage substance-free lifestyles. The youth solvent treatment program was introduced in a formal manner in 1994, and was to address an identified problem area.

What I'd like to do is take a look at the program in composite, and then break it down into its two main constituents and take things from there.

Currently, $70 million are spent annually on these programs. At present there are over 700 community-based workers in over 700 communities. This program is the first offered by Health Canada to be entirely run and operated by first nations communities and first nations people. There is currently a network of 57 residential treatment centres, which are capable of serving 846 clients at a time; over 5,000 clients are treated each year. Currently, the completion rate for treatment is 66%, which compares favourably with other jurisdictions. Their recidivism rate is currently running at 30%, again comparable to other jurisdictions.

As for the major achievements of the program, the first and most obvious would be the steady decline in substance abuse that has been visible for some time. Treatment centre accreditation was established in conjunction with the Canadian Council on Health Services Accreditation in February 2000. The network of residential treatment programs will become the first network to have full accreditation in any jurisdiction on this continent.

There has been the establishment and development of national best practices and protocols. The youth solvent treatment program has been used as a model by other countries. Certified training has been established for workers in a number of regions, and plans are under way to extend that to the entire country.

¹ (1535)

[Translation]

Treatment services for hospitalized patients. These services are used by the First Nations and the Inuit. They are adapted to their culture. They are economical and of comparable quality to that of other administrations. They can receive 695 hospital patients and 25 out-patients in a network of 48 centres. Their funding level is $28 million per year.

[English]

Community-based services encompass over 500 community-based programs, with 700 community workers, so it's an extensive program that stretches from coast to coast to coast. It features culturally relevant education and prevention programs, as well as crisis counselling services, which tend to be among the more immediate services that are utilized. There is a system of treatment referrals, as well as post-treatment follow-up, which could also be referred to as after-care. Currently, this program expends $30 million annually.

[Translation]

The program was used by 4,616 clients in 1999-2000. The success rate was 66 percent. The recidivism rate was 30 percent. Forty-three percent of the clients are admitted for alcohol abuse, 20% for drug abuse and 34% for drug and alcohol abuse.

¹ (1540)

[English]

If you take a look at the chart on the following page, you can see that over the past 10 years the pattern of utlization and the pattern of primary substance abuse have changed fairly dramatically. You'll notice that the rates are stabilizing and seem to be reaching a plateau for narcotics, hallucinogens, and other drugs at this time.

If we move to the next chart--

The Chair: I'm sorry, Mr. Hossack, can you just define what you've included in narcotics and what you've included in hallucinogens?

Mr. Nick Hossack: Narcotics would relate to prescription drugs. Hallucinogens would generally refer to the non-prescription drugs.

The Chair: The others are solvents? Are alcohol and tobacco included?

Mr. Nick Hossack: The others could be a variety of different substances. It's a catch-all for non-specified responses. Alcohol is not included, and the statistics on tobacco came a little earlier. Of course, it was indicated that the numbers of people presenting for reasons of alcohol alone was dropping.

With recidivism, you can see that the rate is staying at about 30%. It goes up and down slightly, but overall, 30% seems to be where it's stabilized.

[Translation]

The treatment centres are strategically located in terms of the areas been served. The majority of these centres offer treatment models ranging from 28 days to six weeks. They are culturally adapted and they are specialized centres.

[English]

You can see in the next chart that the national client profile for individuals between the ages of 25 and 34 shows an interesting trend. We're seeing that the number of males in this key target group is dropping, whereas the use of the centres by females in that particular age group has now reached the same level. That, of course, has resulted in a number of changes to the treatment programs themselves.

[Translation]

The treatment program for solvent abuse among young people aims to improve the quality of life and the functional capacities of individuals addicted to solvents. It includes a program for the extension of services which aim to make community workers and families more aware and to ensure follow-up. Thirteen million dollars per year are allotted to this program.

A network of nine treatment centres distributed in each region of Canada, eight of which target young people between 12 and 19 years old and one for young people between 16 and 25 years old. They have a capacity of 114 clients. The treatment cycle is 180 days. The centres work in concert with the communities to optimize the support offered to young people.

Since their creation, the centres have operated at maximum capacity; a minimum of 228 clients are treated each year. The program is recognized internationally and Canada is a world leader. The network will be the first fully accredited network of treatment centres.

Major initiatives. A framework of program renewal was developed in concert with specialists from programs in fighting addictions, from all over Canada, with a view to establishing a clear direction for improving the capacity, specialization and services that are relevant to the clients. The National Native Addiction Partnership Foundation was created and provides for the participation of all the communities and treatment programmes and acts as a leader in the process of change.

¹ (1545)

[English]

Further initiatives would include the first nations and Inuit addictions information system. This system, which has been developed with the assistance of first nations and representatives of treatment and preventive programs across the country, will offer, for the very first time, real-time client booking that will match clients with appropriate treatment centers. It will provide for the capture of data required for client responsive services, and will ensure that the national network of treatment programs and prevention programs can make the changes that are required to provide the services for the clients of today.

This particular program is also part of a first nations health information system, so it's going to operate in conjunction with that major initiative. Prototyping for this system is beginning this summer.

At this point I would like to turn the session over to Peter Cooney to talk about the non-insured health benefits portion of the program.

Mr. Peter Cooney (Acting Director General, Non-Insured Health Benefits, First Nations and Inuit Health Branch, Department of Health): Thank you, Nick.

Madam Chair, I had some specific information in relation to your committee's request regarding prescription drug misuse, but prior to getting into that, I have a few slides to give your committee a feeling for the overall program and let you know where it's positioned in relation to expenditures and the benefits that are delivered.

The program provides a range of health benefits to first nations and Inuit clients that basically supplement provincial and third-party programs. The benefit categories include drugs, and the main components there are prescription drugs, over-the-counter drugs, and medical supplies and equipment. Dental programming includes diagnostic, preventive and restorative services, dentures, oral surgery, and orthodontics. Medical transportation covers that used by patients to reach services that aren't available in the community. Vision care covers eye exams, glasses, and repairs. Payment of provincial health care premiums applies to the provinces of B.C. and Alberta. Co-insurance for deductibles and mental health counselling is also covered.

From reading some of your earlier transcripts, I realized you were interested in costs associated with these, so there is a later slide that breaks down these by category in relation to cost.

To give you a picture of the demographics of the country as a whole, there's a map of Canada that identifies for you where the recipients are located. As you can see, there are just over 700,000 eligible patients under the non-insured health benefits program, and the largest region would be Ontario, with 155,000 people. The smallest would be Yukon, and of course, the Northwest Territories and Atlantic Canada have fairly small numbers as well.

The next slide gives you a breakdown by category, as I mentioned to you earlier, and it tries to give you a picture of where the expenditures occur. Basically, there are three large benefit areas. Pharmacy is just about 40% of the expenditures; it was $228.9 million in the 2000-2001 fiscal year. The second largest area is transportation, which is roughly 30% of the expenditures, and that was just under $183 million last year. Dental is the third largest area, which is just under $110 million, and that's about 20% of the expenditures. So those three areas cover about 90% of the total non-insured expenditures. The other three, being the smaller areas of vision, premiums, and health care, account for about 3% each.

To help us manage the program and to advise us in relation to the program regarding pharmacy benefits, we have what we call a P and T committee, a pharmacy and therapeutics committee, which consists of a number of first nations and Inuit representatives, physicians, and pharmacists, a number of whom are also first nations and Inuit physicians. These folks help us with literature reviews, help us in the areas of adding benefits, deleting benefits, drugs that may no longer be appropriate, and advise us regarding drugs that could or could not be added. We come with specific questions in relation, for example, to drugs that may be abused, and they advise us as to how we can manage those particular areas.

We also have a seat on the PIC, the Pharmaceutical Issues Committee, which helps link the non-insured health benefits program to the provincial drug plans.

¹ (1550)

In the area specifically of prescription drug misuse, the definition is the inappropriate or excessive use of prescription drugs that will adversely affect the health of a patient. It's clearly a problem in all sectors. There is certainly a growing awareness of the problem. I wanted to give your committee members a feeling for the problem in relation to first nations communities as compared to non-aboriginal communities, so I've included a slide on that as well.

It's clearly a serious issue. The program has gone through a number of activities to try to address the issue, and I think we have been successful in part. We're continuing to work on addressing the issue, and I will give you some details on that as well.

It's difficult to get national information. We've gone to CIHI, the basic information system that's used for drug plans. We've also gone to specific provincial drug plans, and we've done some comparison. This is an example whereby your committee can see figures in relation to two drugs that can be abused or misused, the codeine-containing analgesics and the benzodiazepines. A recent comparison of the non-insured program with the B.C. program, because we managed to get some fairly good statistics from the B.C. program, showed that there were fewer clients per year on the non-insured program who received codeine-containing drugs or benzodiazepines than in a fairly comparable provincial program. This isn't a good thing or a bad thing, but I think it does help the committee in positioning where first nations and Inuit patients may be in relation to drug misuse. It should give you a feeling of comfort that the problem is no more rampant in first nations or Inuit communities than it is in the non-aboriginal communities.

The Chair: But how do you get 1,021 per 1,000 in B.C.?

Mr. Peter Cooney: There are more prescriptions than patients. These are average figures. Even the average is higher in that program per patient per annum. We get into the details of that later with specific patients.

We looked at the extent of the problem for NIHB with the utilization of drugs containing codeine to give you and your committee a feeling of where the problem is. We have taken specific drugs over the last year that we knew to be drugs that could be misused and we have put them on what we call maximum allowables. We went to specialist panels, and they recommended a maximum above which there really should be a suspicion of misuse. Using those numbers, we have found that 42 patients out of 700,000 eligible clients would have exceeded the maximum dose of codeine-containing drugs in a three-month period under the non-insured program. To give you a more general feeling of that, 14% of NIHB clients receive the drugs, with one half receiving only one prescription per annum. Clearly, what this indicates is that although there is prescription drug misuse, the numbers are small. Of the clients receiving the drugs 80% received five or fewer prescriptions.

At some point we may want to get into some issues in relation to overall health and illness. As you are aware, the first nations communities tend to be ill and have a higher incidence of very specific diseases when compared to non-first nations communities. For example, diabetes, dental disease, and heart disease tend to be two to three times higher. Arthritis tends to be twice as high.

With the drug utilization review and the stakeholders who are involved in instances of drug misuse, clearly, the first instance would be related directly to the patient, because a patient will initially seek a physician's care to address health concerns. The next person in line would be the physician, because the patient now needs to convince the physician that they need a specific drug, and the physician will prescribe that drug based on what the patient has told them, based on the credibility, whether the physician feels the diagnosis is appropriate. The pharmacist is the third in line in relation to a drug being dispensed. Pharmacists will only dispense and the non-insured health benefits program will only pay for a drug that has been prescribed by a physician. The pharmacist will review the prescription and will determine whether this is appropriate. As I mentioned earlier, the vast majority of them are. Some, however, are not, and we will talk about them later in the presentation.

One of the problems we have run into is the relationship of privacy and access to NIHB benefits. Clearly, patients are entitled to privacy and access to required drugs. What we do in the program is share messages with pharmacists indicating there may be a patient at a pharmacy who is getting a drug that maybe they should not get. There are specific messages that are given to pharmacists, they are called warning messages. If a patient received a specific drug and comes back to get another drug within the same timeframe, a warning message goes to the pharmacist through our system: please check, there may be a problem with this prescription. The pharmacist then determines from the patient if this is appropriate, and in a number of cases will call the physician. It may be appropriate, it may be a similar drug in the same drug class that is being dispensed because the physician couldn't get the patient to respond to the first drug. If there's a problem, we tell the pharmacist not to dispense.

¹ (1555)

What are we doing about this? As I just mentioned, we do provide pharmacists with these warning messages, and we have been doing that since 1997. We do provide client information to regulatory bodies upon request. If a regulating physicians' body asks us for information regarding physicians' prescribing practices, we will give them specific information on the client, but we will not identify the client. We wouldn't say Peter Cooney received x amount of a specific drug, we would say a patient received it. It would be Peter Cooney, but we couldn't share the patient's name with the physicians' body.

Also, as I mentioned to you, through the Pharmacy and Therapeutic Committee, we review drugs that are perhaps being used inappropriately. We had a case recently in Saskatchewan, where a drug that was being used inappropriately and caused considerable problems has now been put on the limited-use listing. A physician will review that claim prior to the pharmacist's dispensing the drug. We have mechanisms within the system for specific drugs, where physicians will review the dispensing.

As Nick mentioned, we also are involved in treatment through community health programs, through NNADAP programs, and we have also been involved in getting prescription drug misuse information to first nations and Inuit groups.

We have done public service announcements, which are shown on the Aboriginal Television Network, regarding prescription drug misuse and the problems it can cause. We continue to run a number of education sessions for first nations. We are coordinating our effort in a fairly major way with private providers, because these are the people who prescribe and dispense under the program. We pay the bill, so we certainly have an element of responsibility, but it is after the physician and the pharmacist have seen the patient. So we are working very closely with physicians' regulatory bodies, with pharmacists' regulatory bodies, and with their associations to get a positive message out and to keep prescription drug misuse to, we hope, a minimum.

I mentioned the override systems pharmacists use. We monitor them very closely, because there are some pharmacists who override a little easily, and that does cause concern. We now have systems in place where we monitor those overrides and call the pharmacist to determine why their number of overrides on certain drugs is far higher than that of other pharmacists. It's basically a check-and-balance issue.

We have introduced the physician prescriber number on the field as a mandatory component. In the past claims could be processed without knowing who the physician was. We now need to know who the physician is, and that allows us to work with the physicians' bodies in identifying physicians who may not be prescribing ideally.

As I mentioned, we've implemented maximum allowable quantities for specific drugs. These actually cut off at a particular maximum, and the pharmacist has to go back to the physician to determine whether, for example, this painkilling drug is genuinely necessary. And it may be, in cases of terminal cancer, in cases of severe illness. There may be a genuine reason for a patient in severe pain not wanting to go onto the mood-altering drugs, preferring codeine-containing analgesics. That's unusual, so the maximum allowable trigger tends to be a very valuable tool in telling us that.

We monitor pharmacists very closely. I gave you an example of the types of things we look for. There are about 19 indicators that we look for in relation to pharmacists' billing, and we do deal with their regulatory bodies where we have concerns.

As I mentioned to you, through our Pharmacy and Therapeutics Committee, we do review drugs specifically that could be misused or abused.

º (1600)

As to the next steps, I brought some information, Madam Chair, for you and your committee on this. We are involved in what we're calling a client consent initiative for the non-insured program. We've discussed this with the public accounts committee, and it is now under way. In fact, this has so far moved along fairly well, and we're about to get into a national roll-out in the next month or two. We are at the moment testing it in a number of communities with first nations who have agreed to come forward.

What we want to do is be able to identify clients by name, so that we can refer that client to a program such as that Mr. Hossack has going in NNADAP programs, and help them. To do that, we need to have their consent, and we are obtaining consent from patients at the moment that their information can be shared, very specifically with professionals, with specific providers, with programs, so that we can actually address in a more proactive manner issues of potential misuse of prescription drugs. We are also increasing our prevention activities, and we are doing that in association with the NNADAP program.

I hope that gave you an overview in relation to the questions that you provided to us from the last committee meeting. In closing, I thank you for asking us here. If this didn't address your specific issues, we'd be happy to try to address them for you now. I have brought with me some annual reports, which I will leave with your committee technical folks. I've also brought with me some material in relation to the consent initiative and the privacy initiative, and I will leave that with your technical people as well.

Thank you, Madam Chair.

º (1605)

The Chair: Before I turn to Mr. White, Mr. Hossack, your hand-out, on page 4, says it's $70 million, there are 700 community-based workers and 700 communities. You've got a network of 57 residential treatment centres, capable of serving 846 clients. On page 6 you say there are 48 centres for 695 in-patients, 25 out-patients, which doesn't add up to 846. On the next page, you've got 500 community programs, with 700 community workers.

Mr. Nick Hossack: I apologize for the confusion. The first slide, which is page 4, talks about the combination of the NNADAP and the YSAC programs, and that's where we have 57 residential treatment centres. On page 6, where it talks about 48 centres, those are specifically NNADAP programs. Page 7 refers specifically to the number of community-based programs. Some first nations have more than one community within their jurisdiction, so that's why there's a difference between 500 and 700. For example, the Peter Ballantyne First Nation would have six separate locations with six programs.

The Chair: Okay.

Mr. White.

Mr. Randy White (Leader of the Opposition in the House of Commons, Canadian Alliance): Thank you, Madam Chair. I apologize to you folks; I was tied up in the House.

I'm sorry I missed, Nick, your presentation, because there are some things you address that perhaps I may have to ask again here. With the drug and alcohol facilities, I'm on the same track as you were. They are fully funded by government, you say, right?

Mr. Nick Hossack: They are funded by various governments. There are different funding mechanisms for different centres. For example, the Round Lake treatment centre in Vernon, British Columbia, receives funding from the federal government, the provincial government, and the Aboriginal Healing Foundation.

Mr. Randy White: Is it fair to say the majority are fully funded by the federal government?

Mr. Nick Hossack: The majority of these centres, absolutely.

Mr. Randy White: I want to ask our researcher how many non-aboriginal treatment facilities are funded by the federal government.

The Chair: We don't have direct responsibility for any.

Mr. Randy White: I know that, but I wonder if there is a way we could find out if federal money is going to other treatment centres.

Ms. Chantal Collin (Committee Researcher): There is some money, but I don't know the numbers exactly.

Mr. Randy White: Then further to that, you mentioned in here that there's an accreditation process. Does that accreditation process certify a certain level of treatment, and does it increase from, perhaps, detox to short-term, intermediate, long-term? What does accreditation do?

Mr. Nick Hossack: The accreditation process, which is operated by the Canadian Council of Health Services Accreditation, is similar to a hospital accreditation process. In fact, the gestation of both programs is the same. What it tries to do is set a series of standards with respect to process and the quality of care the client receives while in the treatment program. There are over 100 pages of standards a centre must meet in order to receive accreditation from that agency.

º (1610)

Mr. Randy White: Would you say, for the lack of any amount of accreditation across this country, it would be a good model to follow?

Mr. Nick Hossack: The accreditation model?

Mr. Randy White: Yes.

Mr. Nick Hossack: I think it's a wonderful model. We're finding that other jurisdictions are, ironically, using first nations accreditors and surveyors to have their centres of this type accredited. So it's a very good model to follow.

Mr. Randy White: I hate the expression, but what would you say the drug of choice is, prescription drugs, alcohol, cocaine, heroin?

Mr. Nick Hossack: It remains alcohol.

Mr. Randy White: Less cocaine and heroin, I would guess.

Mr. Nick Hossack: Absolutely. The majority of cases would involve alcohol.

Mr. Randy White: Okay, that's all for now,

[Translation]

The Chair: Mr. Ménard.

Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ): Thank you.

I am very interested by your presentation and I am very happy with it to the extent that it deals almost totally with the results of your program. However, I would have liked you to have spoken a bit about the causation factors of this program. You touched on this question when you spoke of your mandate. You then spoke of behaviour models. I would you to tell us what are the principle factors that would make us understand why there is a higher level of drug, alcohol and solvent consumption among the aboriginal and First Nation populations.

[English]

Mr. Nick Hossack: There are a number of reasons one can cite with respect to the motivations and the causation factors for the tendencies these programs are meant to address. That's why we have such a wide variety of approaches in treatment. I'll leave a copy of the NNADAP treatment centre summary document for your research people. It goes through the details of what types of approaches the various centres take in attempting to alleviate the difficulties. For example, there is the disease model of treatment, which is used by approximately 20% of the centres. There's a cultural approach that attempts to deal with issues relating to loss of culture, lack of culture, or other cultural issues. There are behavioural models that are employed by some of the centres. So I think the treatment programs try to replicate the variety of causes that result in clients requiring services of this nature.

º (1615)

[Translation]

Mr. Réal Ménard: I'll try to reword my question. I know it is not an easy question, but I would think it unlikely that an organization like yours has no hypothesis or information to share with the committee. After all, when the Laurendeau-Dunton Commission tabled its report--I can never remember if it was in 1967 or 1968--, it said that aboriginals, in terms of the Deprivation Index, were the next-to-last group in Canada. It is not insignificant that 40 years later, aboriginals are in the same worrisome postion. We have all seen the images from Davis Inlet. Even the Prime Minister was moved by it and was worried about it, a few years ago.

The members of the committee went to Toronto and met several drug users there. They explained to us that, on an individual basis, there are many personal triggers that may lead people to take drugs, but each of the witnesses based his analysis on a personal point of view.

You situate the problem at a collective level. It is said that among the aboriginals and the FIrst Nations, there is a problem which is very focussed, which is very specific. This is not the first time that the Health Committee has taken an interest in the First Nations. You will remember that in 1998, there was a special report. The committee went to see the native people. My colleague, Pauline Picard, is the one who went at that time. Do we have any indications of the reasons why this problem is worse among aboriginals than among heterosexual, 35-year old white women with an income of $18,000, for example?

I am trying to get a more systematic and collective understanding of the phenomenon among a group we call aboriginals.

[English]

Mr. Nick Hossack: Looking at the collective tendencies, as you've indicated, one thing we have learned is that our mandate in this particular branch is a mandate for health programming, and for treatment programming specifically. What we found, however, is that for the programming to be effective at all, it's essential to work with all segments of the community to properly allow an individual a chance of success following treatment. For example, there must be economic opportunity for individuals. There must be a sense of worth. There has to be respect within the community. There are a variety of factors that go beyond treatment. Treatment by itself is certainly not going to provide the answers we're all hoping for.

[Translation]

Mr. Réal Ménard: Here is one last, short question.

You spoke of the harm reduction model. Obviously, I haven't come to the conclusion that it is not advocated or priorized in your interventions. Secondly, do you have needle exchange sites? Should we have roughly the same understanding of this type of intervention as that which we have of other populations, such as, for example, addicts who more frequently use injectable drugs?

I am trying to please you, Madame Chair. Mind you, that's not always easy.

[English]

Mr. Nick Hossack: Currently, we do not have needle exchange programs in the treatment centres. As you're probably aware, most of the treatment centres are located in isolated regions of Canada, some accessible only by air. So the preponderance of injection drug use is actually lower than the general population, although in areas that have proximity to urban centers, we're starting to see some changes there.

As for the harm reduction model, I can say that pros and cons are probably as controversial in the first nations community as they are in the community at large. There's ongoing discussion, and sometimes quite vehement discussion, taking place.

[Translation]

Mr. Réal Ménard: I'll come back to it on my second round.

[English]

The Chair: As a supplementary to this question, I'm not sure Mr. Ménard was thinking there would be actual needle exchanges within the treatment centres. Does the first nations and Inuit health program have needle exchanges operating anywhere in the country? For instance, the Province of Ontario mandates that all its public health facilities have needle exchanges.

Mr. Nick Hossack: We're not aware of any.

[Translation]

The Chair: Yes, it is a serious problem.

Mr. Lee.

[English]

Mr. Derek Lee (Scarborough--Rouge River, Lib.): Can I get an idea, statistically or just anecdotally, of how large the problem of solvent abuse is in the client group you work with?

º (1620)

Mr. Nick Hossack: That's a very interesting question. We did a national survey prior to implementing this program, and it was clear that the demand for services was in excess of 200 clients per year. Since the program has been established, all of the centres have operated at 100% capacity, and that's the best gauge. It's a very difficult malady to get an absolute number on. We're generally reliant on numbers of applications for admission.

Mr. Derek Lee: The solvents that would generally be used by the individuals who have developed a dependence, if I can call it that--I stand to be corrected if I'm using not the exactly the right terms--would all be substances that are legal and available, is that correct?

Mr. Nick Hossack: In general terms, yes, although local edicts in particular communities have removed things like model glue from shelves. But generally speaking, you'd be correct.

Mr. Derek Lee: In the client group you work with there are other drugs that are abused or on which people become dependent. Does that list of substances vary substantially from what we see as the abused drugs in urban areas?

Mr. Nick Hossack: It does. Generally, the drugs would tend to mirror more closely specific socio-economic groups and strata, and there tends to be a lag behind what's happening in the urban centres.

Mr. Derek Lee: This is a bit of a stretch, but one of the issues our committee's looking at is whether prohibition helps or hurts or is neutral. You've mentioned that there are some communities of your client group that somehow prohibit certain solvents. Do you have any experience or information that would help us, even on a limited basis, to conclude whether that type of prohibition helps or hurts? For example, in the face of the prohibition, does model glue show up?

Mr. Nick Hossack: You'll often find substitution. So whereas people did at one point use model glue, gasoline becomes more of an issue where it's prohibited. There are a number of communities--and the list would be available from the Department of Indian and Northern Affairs--that actually prohibit the sale of alcohol or the possession of alcohol within those first nations. The experience has been mixed. It has worked well in certain cases, it has resulted in an underground economy of supply in others.

Mr. Derek Lee: To push the analogy a little bit--and I realize I am perhaps hopelessly pushing it--do you have examples of the criminalization or prohibition of these substances giving rise to kind of a black market distribution? You don't have to mention any particular community, but perhaps you have a real life example of an attempt to prohibit a particular substance giving rise to a black market in this substance.

Mr. Nick Hossack: The most graphic examples are provided by some of the northern fly-in communities in Canada, where the chief-in-council has established a policy of prohibition with the connivance and with the assistance of transportation agencies and others. The amount of money spent on alcohol, for example, tends to be the same. It may buy less, but it certainly results in some incredible profits for some of the primary entrepreneurs, if I can use that term, in the process.

º (1625)

Mr. Derek Lee: So this happens even in fly-in communities.

Mr. Nick Hossack: It does.

Mr. Derek Lee: That's sort of like drugs showing up in our prisons,drop-in communities, time-to-go-visit communities.

Mr. Nick Hossack: There are, unfortunately, many examples of that.

Mr. Derek Lee: Yes.

I'll pause there, Madam Chairman.

The Chair: Okay.

Madame Allard.

[Translation]

Ms. Carole-Marie Allard (Laval East, Lib.): Madame Chair, I would like to ask our witnesses how long their program for fighting addiction among the First Nations and the Inuit, has existed? We see that you have an annual budget of $70 million. I would like you to give us an idea of the evolution of this budget over the years. Also, are you able to evaluate the effectiveness in terms of dollar value? Can we say that, the more money we put in, the more effective we are or is the drug problem such that it is uncontrollable anyway? Is it a matter of resources?

[English]

Mr. Nick Hossack: The program, in its current form, has basically been in existence since 1982. As to how the program has grown, I'll leave a copy of two documents that will answer that in painful detail, but to encapsulate the answer, it has grown, but it hasn't grown at the same rate as other programs within the branch.

In respect of efficiency, I think the treatment centres compare favourably in operating costs per client per day with any jurisdiction in Canada, roughly 50% of the per diem costs of a provincially funded treatment program.

Would more money increase the effectiveness? We've been working, actually, with representatives of all the preventive and treatment programs across Canada through an organization known as the National Native Addictions Partnership Foundation. They represent all the first nation programs across the country. What we've tried to do is identify what's changed since the program was originally established and what we need to do to make the changes today's clients are requiring. The type of client has changed. We're seeing different people admitted to the system for different reasons. So clearly, change is required in order to meet those new needs. What we've tried to focus on--and I'll leave a copy of that as well--is the plan itself. We've tried to identify existing funds and to best utilize what's currently in the system before we've turned our attention to other requirements.

So we're still in the initial implementation phases. The answer to your question, I think, will become apparent once we see the kind of success the information system we referred to is able to give us.

Ms. Carole-Marie Allard: I have no more questions.

The Chair: Okay.

Randy, do you have a question before you leave?

Mr. Randy White: No, I'm okay.

º (1630)

The Chair: Réal.

[Translation]

Mr. Réal Ménard: I want to get back to what is very important to our work, that is the issue of the harm reduction model. We could, obviously, name names on this subject, but we aren't going to do that.

First, I want to make sure of the reason why there are no needle exchanges in the various aboriginal communities. It is not because there are no users of that kind of drugs. Is it for cultural reasons or functional reasons?

[English]

Mr. Nick Hossack: There are a number of reasons. The first is that the critical mass required to operate a program of that nature generally doesn't exist in most of the rural and isolated areas. People aren't necessarily opposed to the idea culturally. That has currency in various parts of the country. It's certainly not that.

[Translation]

Mr. Réal Ménard: Earlier on, we took a quick look at the statistics. I'm trying to find them. Finally, in a general way, are you asking us to be optimists or pessimists as to the addictions of very specific segments of the population? I know that the services you offer mainly focus on the 25 to 35-year-olds. If I understood the presentation properly, the core of your users are in that age group. As for the addiction rate and the effects of your policies, are you reasonably optimistic or reasonably pessimistic about the addictions afflicting the aboriginal community?

It's not a trick question. It's a question of general understanding. You know that the committee has already looked at the problem of tobacco addiction and that there have been significant declines in the use of tobacco in some segments of the population. Your policies may also yield results that are just as encouraging for aboriginals.

[English]

Mr. Nick Hossack: I'm very optimistic.The statistics tell us there has been substantial improvement in the rates of alcohol abuse over the years. Where the vigilance is required is in the substitution of other challenges. So whereas for specific age groups, the battle with alcohol is quite successful, if I can put it in those terms, unfortunately, there's a lot of vulnerability for particular age groups and particular segments of the population with other situations. The injectable drug issue you identified earlier would certainly be one cause for concern. It's as if there's a pillow with various hands putting on different levels of pressure. It changes all the time.

[Translation]

Mr. Réal Ménard: Here's one final question. I know that, a few years ago, a very sustained campaign was presented by various intervenors, both in the provinces as well as the federal government, to encourage aboriginals to pursue their education and, in some cases, higher education.

Is there a correlation between the pursuit of education and the absence of alcohol addiction? It's a bit mundane to repeat it but, the committee is often told that there is a link between self-esteem, heath factors, education and the place we fill in society. This link is not perfect. We went to Burlington, to Madame Chair's riding. Obviously, there are middle and upper-class people who use drugs, but we are being once again presented with a marked link between the Deprivation Index and use. Have you noted a link between education and alcohol addiction?

[English]

Mr. Nick Hossack: A number of interesting correlations can be drawn. By and large, the connection between education, participation in the economy, various other factors, and drug use tends to be fairly predictable. When we analysed our data, which go back to the beginnings of the program, we found an interesting statistic that would, at first glance, appear to contradict that particular trend. The recidivism rate actually increases with education up to a certain level, and we were originally quite surprised when we saw that. However, it's not a negative thing. Analysis reveals that because there is a greater expectation of participation in the economy, along with various other factors, there's more appreciation of the value of the kinds of skills the treatment programs offer. So it's more likely that individuals in that situation will avail themselves of opportunities before the difficulty becomes too severe to overcome.

º (1635)

[Translation]

Mr. Réal Ménard: I want to understand properly. It is really very important. The more education people have, the higher the rate of recidivism. Is that really what you said? OK. So, we're not just talking about a few “stoned” university students, during end-of-term parties. That is not what we're talking about. We are talking about people who have already had treatment, who stopped using and then started again. Have I understood you correctly?

[English]

Mr. Nick Hossack: We're talking generally about adults in their thirties in this category.

[Translation]

Mr. Réal Ménard: Understood. May I ask one final question? Go ahead, Madame Chair, but don't take too much time. Leave me a little bit, at least.

[English]

The Chair: That was among people who sought treatment, not among the general population.

[Translation]

Mr. Réal Ménard: We are talking about people who have already had treatment.

Here is my last question. In your presentation, you didn't say much about the issue of marijuana. The problem of this type of drug use doesn't arise in your population. As a program manager, would you be comfortable if the committee recommended the legalization of marijuana use? I am not asking for your personal opinion but rather that of a program manager. Now, if you want to give us your personal opinion, that isn't a problem.

[English]

Mr. Nick Hossack: There is a problem with marijuana, there's no question about that. We are seeing that cases of dual dependency, clients with difficulties with alcohol and with marijuana, are actually increasing. As to the policy issue relating to marijuana, I'm afraid I would leave that to people far more exalted than myself to answer.

[Translation]

Mr. Réal Ménard: As a program manager working in the drug community for several years, you have no idea? The question is obviously going to come up. If we went in the direction of legalization or prohibition, you have no idea of the impact this would have on the management of your programs. You may be a bit reticent regarding this point, but I'm sure you have some idea.

[English]

Mr. Nick Hossack: The context I would put it in is addictions, realities, and patterns within first nations, where it certainly isn't one of the pre-eminent threats at this point. There are other challenges, such as injectable drugs, that I would have more concern with at this point.

[Translation]

Mr. Réal Ménard: Understood. Thank you.

[English]

The Chair: Thank you.

Monsieur LeBlanc.

Mr. Dominic LeBlanc (Beauséjour--Petitcodiac, Lib.): Thank you, Madam Chairman.

I had the chance in January to visit Big Cove, which is the biggest first nations community in New Brunswick, in my constituency. Minister Nault came with me. We spent a very interesting day there, including a considerable amount of time at the health facility on the reserve. The chief, the council, and the professionals working at the health centre there were very complimentary about your department, the branch, and the support they got. I thought you should know that, and we should congratulate you. In Big Cove, at least, you have some friends who are very supportive.

The one thing they said to Minister Nault and me--I appreciate that you're with the Health Department, but they took a chance with Minister Nault there--was that they wanted to try to have more prevention and educational programs, particularly in the schools. We also visited the school at Big Cove. The teachers and the principal of the school told us they were hoping for more attention at an early age--we visited first grade classes and, I think, a fourth grade class. They're concerned that some of these young people, aside from the personal experiences many of them have in their own homes, don't understand the cycle of drug dependency, drug addiction. They see the consequences in a tragic way. The suicide rates in that community are astounding. We met a woman 33 or 34 years old who committed suicide at Christmas and left 12 kids without parents. She had terrible problems with drug addiction and substance abuse. The chief was saying to us it would be good if there was a way these children and friends in their class could understand. They thought that perhaps it was a question of not enough resources or focus on prevention education. Is that something you encounter? It wasn't a criticism, it was more a request or a concern.

º (1640)

Mr. Nick Hossack: I'd like to start by complimenting the fine work done by Brian Augustine and his group at the Big Cove treatment centre. It's probably the most satisfying part of my job to visit people like that who are working so hard in such difficult circumstances. So I really appreciate those comments.

As to prevention and educational programs in schools, there's a lot of competition to get onto the curriculum at any school, and obviously, this program has the same difficulties as any other. However, we have, I think, made some fairly strong inroads in developing programs that can be become modules of various courses within schools, and we're finding that more and more local educational authorities are incorporating those programs into their curricula. So it's something we're aware of. We're not there yet, though, I'll certainly admit that.

Mr. Dominic LeBlanc: Thank you.

In my community, or in New Brunswick as a whole, there are not huge aboriginal populations living off reserve, as there are in some larger cities in other parts of Canada. I appreciate the federal-provincial dynamic with off-reserve aboriginal people, but is your branch working with provincial partners, for example, or local health authorities to try to address some of the particular needs aboriginal people with addiction may have in an off-reserve context? I was in Vancouver and Montreal with this committee before Christmas, and what struck us was, in many cases, the lack of treatment facilities or beds for in-patient care. I can only imagine the situation in an urban context, with a lot of aboriginal people living off-reserve, many of whom have substance abuse problems. Is your department working with city officials or local authorities at all on this?

Mr. Nick Hossack: There is considerable work in that area. I should note that point of residence isn't an impediment to access to treatment. Many of our clients come from urban centres to the national network. I think, once the information system we talked about earlier is up and operational, you'll find that utilization by individuals living in urban centres will actually increase.

The Chair: Ms. Fry.

Ms. Hedy Fry (Vancouver Centre, Lib.): Thank you very much, and I'm really sorry I'm late. I just came back from Vancouver, so I may be asking questions that have already been asked and about things you've already explained in your presentation.

With the question Mr. Ménard asked about recidivism increasing with schooling, which is, for me, a really remarkable piece of information, I really don't think I heard a reason. Have you done any studies to find out why this is happening? It would seem to me that this should, in fact, decline. Recidivism and schooling should be giving people a new lease on life. They should be able to go out there and find a better living for themselves, and therefore not want to go back into drugs, a possibility which, as we know, tends to be exacerbated by street life, homelessness, hopelessness, and all that kind of stuff. So I would like to find out about that first.

The second thing I would like to do is follow up on my colleague Dominic LeBlanc's questions about off-reserve people. You talked a little bit about AIDS, but I haven't seen anything on hepatitis-C in your data. It is said that there was a decrease in the prevalence of HIV and AIDS, and that is not true any more. It has been shown that it's rising again. When you say off-reserve people can have access to treatment, do you mean they have to go back to the reserve to have treatment? I know, coming from Vancouver and having been very closely involved with the Vancouver agreement, that there is very little going on in the city of Vancouver for off-reserve people, and the youth tend to go into the cities, and so they have a huge problem in securing treatment. If you're sending them back to the reserve, that is a very impractical way to deal with them.

I also wanted to know if you've got any kind of relationship between FAS-FAE and substance abuse, given that you said your program has been very successful since 1994. I find the data on substance abuse among aboriginal people not to be in keeping with that statement, but in fact, substance abuse is rampant and getting worse, and it is associated with a high level of morbidity and mortality rates among these groups. So what data do you have to show that this is, in fact, an effective program, given that there are still a lot of people on substances? Davis Inlet showed us that solvent abuse is still high.

º (1645)

Mr. Nick Hossack: With recidivism, this study looked strictly at statistics from individuals who had presented for treatment in the treatment centres across the country, so perhaps I was misleading in saying it is an absolute that one can draw from that particular study. What it shows is that if an individual with a high level of education goes for a course of treatment, their recidivism rate tends to be higher than others.

Ms. Hedy Fry: That could also mean, though, that people with a higher education go for treatment more often than others.

Mr. Nick Hossack: That's right. There are a number of interpretations. We're as fascinated by that apparent dichotomy as you are, and we're following up on that, so we'll hopefully have more information for you on that.

In making any claims of success or program effectiveness, what we have to work with are essentially the statistics the centres gather and compile; this is probably one of the few comprehensive databases of this type anywhere in the world, having been maintained for, I think, 17 years now. We have those statistics, which give us some indicators about each client who enters a treatment program. So those would be the statistics I would be quoting from.

As to whether there is an ongoing mortality, morbidity, of course there is, there's no question.

Ms. Hedy Fry: It's increasing, that was my point.

Mr. Nick Hossack: Again, a number of interpretations are possible. I think there's more of an effort to identify the statistics for the first nations population. We're getting better at capturing those data. So I think we're getting a better and better picture of prevalence and of statistics that would relate to first nations. I'm not sure we've always had that.

º (1650)

Ms. Hedy Fry: You haven't answered about off-reserve access to treatment.

Mr. Nick Hossack: That again tends to follow historical patterns. When the program identified centres for treatment, there was an allocation process that we're still trying to tweak, if I can put it that way. There was an urban centre offering treatment in Toronto, there is an urban centre offering treatment in Winnipeg, Manitoba, currently, but you're absolutely correct, there's an absence in other major centres across the country. The reason most often cited relates to the mandate of the program, which is to provide services to on-reserve first nations and Inuit peoples--however unsatisfactory that answer may be.

Ms. Hedy Fry: It's very unsatisfactory, because I think the fact that people who are using substances move in and out of reserves and into cities over and over means that you're not dealing with the reality of the problem, you're just dealing with the statistical data. Having treatment centres where they are needed is the way you're going to decrease the ability for this to continue.

In the cities of Canada there are aboriginal people, especially in the west, who are the majority of people who are having this problem and are dying, all the hepatitis-C and AIDS victims who are incarcerated in large numbers, who are into prostitution, and as you can see in the city of Vancouver right now, are being murdered, because these are disposable people. Somewhere along the way, for a program to be effective, it has recognize the reality of the problem, not merely the in vitro component of the problem. It has to recognize the in vivo component of the problem if it is really to be effective, if, at the end of the day, it can be said to be the envy of the world. The evaluation, the outcomes are going to decide whether it's the envy of the world or not, not the amount of money thrown at it.

Mr. Nick Hossack: That's absolutely true.

I would note that regardless of what one might think of the current location of treatment centres, they all are heavily patronized, if I can put it that way. So clearly, they're meeting a need where they are. Would it be desirable to have centres elsewhere? I don't think that's deniable. Because of the mandate of our branch, what we've been doing in this area is trying to work with provinces and other service providers to ensure that individuals in urban centres have access to services. As you can probably imagine, that works better in some areas than in others.

The Chair: Mr. Lee.

Mr. Derek Lee: I have about four quick questions here.

Just to confirm, you don't, in any of your programming, have to treat individuals with marijuana dependency, do you?

Mr. Nick Hossack: No.

Mr. Derek Lee: It's not an issue unless it's connected to another substance and you have dual dependency.

Mr. Nick Hossack: That's right.

Mr. Derek Lee: So marijuana by itself is not a problem, at least from your perspective.

Mr. Nick Hossack: For the 5,000-plus who present on an annual basis, with the exception of dual dependencies, you would be correct.

Mr. Derek Lee: Thank you.

Is time a factor in your definition of recidivism? The 30% recidivism rate, is that over a year, over two years, over three years?

Mr. Nick Hossack: Two years.

Mr. Derek Lee: I think that was the timeframe we came across elsewhere.

Mr. Nick Hossack: That's standard.

Mr. Derek Lee: Thank you.

One of the witnesses in Toronto, from the Bellwood Clinic, said they used to get first nations clients, but they don't get them any more, they're not funded anymore, they don't show up any more, they're not referred any more--I'm not too sure which. Can you confirm, from your point of view, that in Toronto there isn't any referral going on to treatment centres?

Mr. Nick Hossack: The general idea is to build capacity within the first nations network of treatment centres, and the referral patterns tend to reflect that tendency.

º (1655)

Mr. Derek Lee: And thus in Toronto....

Mr. Nick Hossack: In Toronto there was actually a first nations operated treatment centre until very recently. I don't think we have the statistics at this point to indicate where the referrals are going right now.

Mr. Derek Lee: All right.

Finally, the prohibition model for certain substances exists across the country and among the communities where your client group is highly present. It's not hurting, is it? Is there an element of the prohibition model that's hurting your work? If there is, say so, if there isn't, then there isn't.

Mr. Nick Hossack: I've never thought of it in those terms. I would have to see what the evidence suggests in that regard. I'm not aware of any impediments.

Mr. Derek Lee: Thank you.

I wanted to get a good handle on the statistics. Your program treats about 5,000 persons per year. How large is the population of your client group across the country? Is it half a million?

Mr. Nick Hossack: It would be between 400,000 and 500,000.

Mr. Derek Lee: So 0.1% or something get treatment. Do you have any idea of how large the eligible treatment group would be? Now 5,000 get treatment. Would the group that might need treatment be 10,000, 20,000? Do you have an idea of that?

Mr. Nick Hossack: I think that would depend on the types of services we were able to provide. That's why I referred earlier to what's basically a renewal of the entire system taking place currently. If you have the services that are required, you can expect to see an increase in interest.

Mr. Derek Lee: Yes.

Thank you.

The Chair: Thank you.

Further to Mr. Lee's question, you said the objective is to build capacity in the aboriginal community. That's great, but are people going without treatment because you don't refer to Bellwood now?

Mr. Nick Hossack: No.

The Chair: Do they have to wait longer for treatment because you won't refer them to Bellwood?

Mr. Nick Hossack: No. Again, it's similar to admission to hospitals in various provinces in Canada. There are different access times depending on one's location. But generally speaking, there is enough capacity within the system to deal with all referrals I am aware of.

The Chair: An aboriginal person who's in a city, though, has to go on reserve. They can't stay in the city of Toronto and get treatment there, because there are no treatment centres in Toronto now.

Mr. Nick Hossack: Well, there are provincial treatment centres, and it's a service--

The Chair: Provincial aboriginal treatment centres?

Mr. Nick Hossack: There are, and the Province of Ontario operates a number of them.

The Chair: In Toronto?

Mr. Nick Hossack: Not in Toronto, but in other parts.

The Chair: So an aboriginal person who is in Toronto, who wants treatment today, where do they go?

Mr. Nick Hossack: If they're applying through our system, they would go to one of our treatment centres.

The Chair: Which would be where?

Mr. Nick Hossack: Which would be in rural Ontario. Six Nations would be the nearest.

The Chair: Then I assume that if they're a parent, perhaps even a single parent, they take their children there and disrupt their family. Or is there something that covers that?

Mr. Nick Hossack: Many centres operate on a family-friendly basis, and there are possibilities of bringing children as well. It depends on the individual system. That's why we're spending so much time and energy trying to develop a system that matches clients and their needs with the types of services that are offered, because not all centres would offer that service.

The Chair: But if I'm an aboriginal person, do I get a choice? If I want to go to Bellwood, do I get to go to Bellwood, or do you tell me, no, I have to develop capacity in the aboriginal community, I don't care if you want that program? Disrupt your family, take your kids out of school.

Mr. Nick Hossack: At this point the non-ensured health benefits policy would come into play. What would that tell us, Peter?

Mr. Peter Cooney: It would be the non-insured policy in relation to transportation to the nearest facility.

The Chair: So you will pay to send me to some place in rural Ontario, send all my kids and everybody, and I guess, pay for schools, but you wouldn't let me go to Bellwood just down the street?

Mr. Peter Cooney: Within NNADAP I would hope there would be some discussion on that, but generally, first nations patients want to go to their own facilities.

Mr. Nick Hossack: That's the clear message we get from the leadership.

The Chair: I would like to be clear on whether it's an actual policy that an aboriginal person cannot choose to go to a place like that. I would like to be clear about what's going on. You don't have to give me that now, but I would like you to get back to the committee.

The second question I have is, what is your cost per person on the 28-day program?

Mr. Nick Hossack: The average is approximately $130 a day.

» (1700)

The Chair: So for the 28 days, what is that?

Mr. Nick Hossack: It is 28 multiplied by 130--I don't have my calculator.

The Chair: One of the things we were very concerned about is the transfer for a 28-day program. In Vancouver it's about $1,000, and yours is $3,640, so it is triple what they pay in Vancouver. It is not that it is a good thing or a bad thing, it's just interesting.

Could we get a rundown of where the centres are, these 57?

Mr. Nick Hossack: Actually, to address cost, our centres are core-funded and they don't charge a per diem. The $1,000 for a 28-day treatment program wouldn't cover the entire cost. There's funding coming from another source, if that's all they're charging.

The Chair: They spend $4.53 a day on food for their patients.

Mr. Nick Hossack: Okay, well, that's impressive.

The Chair: No, actually, they weren't that impressed. They are laying off staff, they've got a serious problem. I'm not saying spending three times as much is better or worse. It's just interesting.

Mr. Nick Hossack: For your information, the average in an urban area would be around $300 a day. That's quite a bit below what you would see.

As to information regarding the location of these treatment centres, it's posted on our Internet site, and there is a description of each of the programs on there.

The Chair: Okay.

How many beds are there in total for children?

Mr. Nick Hossack: That would be 114.

The Chair: Across the whole country?

Mr. Nick Hossack: Yes.

The Chair: It sounds as though it's a little better than in the non-aboriginal population. Do you take non-aboriginal kids in any of the programs?

Mr. Nick Hossack: The centres have discretion, depending on what their situation is with respect to number of clients at any particular time.

The Chair: Are the 114 beds generally full?

Mr. Nick Hossack: Yes.

The Chair: Are there good surveys on drug use among the aboriginal population?

Mr. Nick Hossack: Yes. The Aboriginal Health Survey, which takes place every four years, tries to take a snapshot of what the state of health may be at any given time. It's about the most comprehensive thing I could refer you to.

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The Chair: It's a concern for some people who have appeared before us that the use of drugs, illicit and prescription, is not well understood in the country, because there are very few surveys and very few consistent surveys.

We heard from some witnesses that there's a great concern about the movement of people between off-reserve and on-reserve. It's a good thing for people to be able to move back and forth, but it's spreading AIDS and HIV. For that reason, I'm wondering why you're not either supporting needle exchange programs in urban centres or operating things. I appreciate that some of the communities are remote or whatever, but in the Halton example, with a fairly large geographic area, not as large as Nunavut or something, they'd give needles to 100, knowing they would get those to 10 people, rather than necessarily saying, you only need 10, you get 10. They knew there was an informal distribution system, and at least they were getting clean needles to people. Is there a condom program? Are there programs to try to prevent harm?

Mr. Nick Hossack: There are condom programs in quite a number of locations.

The Chair: But no needle programs?

Mr. Nick Hossack: Generally speaking, no.

The Chair: Is there an attempt to work with some of the people who are working within the aboriginal community in urban settings to try to establish them, so that there is a distribution back and forth?

Mr. Nick Hossack: There is, and I would cite Regina. A number of first nations individuals have returned to their communities with drug injection difficulties, and there is cooperation between the different jurisdictions, the urban and the rural, in that particular circumstance. Wherever that's possible, it's encouraged.

The Chair: But, Mr. Cooney, you're not sending any free needles into those places?

Mr. Peter Cooney: No. The non-insured health benefits program is very specific on the area it covers. It does cover on- and off-reserve, and I've outlined to you the areas it covers. We provide over the counter or prescription medication, so we do provide needles, but in some very specific instances, for example, diabetic patients, and they would be under prescription.

The Chair: Okay.

Can we get some estimates of what you're spending on HIV and AIDS drugs in the aboriginal and first nations communities?

Mr. Peter Cooney: I can certainly get those numbers for you, and there are a number, as you know, of provincial plans that cover HIV cases under their catastrophic illness programs. I will get statistics done by benefit list for you on specifics related to HIV and AIDS.

The Chair: Had Dr. Fry not been delayed by being on a plane, she would have asked you about an initiative. One of the concerns on prescription drugs is that there are doctors who are facilitating some pretty bad habits out there, perhaps out of ignorance, perhaps for other reasons. You've instigated these checks on amounts and things that have signals. In B.C. they have triplicates of prescription forms, and so they get some information. Are you working in some of the different provinces to establish a new kind of prescription drug form?

Mr. Peter Cooney: Yes, we are. Keep in mind that we now look at the prescriber number.

The Chair: Right.

Mr. Peter Cooney: One of the issues we have with non-insured is that we pay the pharmacist, we don't deal directly with the physician at all. Your point is very valid, and what we have been doing is not reimbursing pharmacists unless they now include the physician's prescribing number.

The Chair: So you're tracking that.

Mr. Peter Cooney: That's correct.

The Chair: Okay.

Mr. Peter Cooney: The loop we still need to close on that is the issue associated with coming back to the physicians' licensing bodies and giving them information, which we can do, but only on a nominal basis--

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The Chair: Right, so you're protecting the patient.

Mr. Peter Cooney: --by preserving patient confidentiality, and that's the consent initiative we discussed.

The Chair: We heard in British Columbia extremely disturbing testimony--it was extremely disturbing to me--that pharmacists were actually giving money to methadone patients to bring in their friends, because it's a pretty lucrative business, I guess, dispensing methadone by prescription. It seemed to me a terrible ethical issue that the pharmacists should now be participating in this kind of behaviour, and we haven't had any testimony to the contrary. It didn't seem very responsible behaviour, and it didn't seem there were any initiatives to stop this. Is that a problem you're encountering in other parts of the country, that pharmacists are giving cash to people to bring them in?

Mr. Peter Cooney: Madam Chair, the vast majority of professionals are honest, but there are small numbers, whatever the profession is, who are not honest.

The Chair: Or they're honestly unethical.

Mr. Peter Cooney: That's correct, you've got it.

We are aware of that, and we do track methadone prescriptions, we do monitor. I mentioned to you some of the indicators we use regarding pharmacists' dispensing practices. If we had a specific pharmacist who was over-dispensing in a specific area, that would trigger one of these indicators as the claims were being generated. We have a process in place whereby we review these on what we call provider profiling. If we still have concern, we will move in and do what we call an on-site audit. We do up to 60 on-site audits every year in the area of pharmacy, the same in the area of dental, and 20 in the area of medical supplies and equipment. So we would target those types of pharmacists for on-site audits, and we would refer them to the licensing body, should we realize that there is a genuine problem. What I'm saying is, that pharmacist should get caught.

The Chair: And do you track also by the OTC drugs they're selling?

Mr. Peter Cooney: Yes, we do. Everything under the non-insured health benefits program is paid by prescription. That was one of the slightly less disheartening issues in relation to numbers of prescriptions. The Canadian Institute of Health Information indicates that your average Canadian receives between 9 and 10 prescriptions per annum. Our information indicates that your average first nations patient receives between 9 and 10 prescriptions per annum, and that includes OTCs. And a lot of these people are quite ill, they have diseases and illnesses over and above the Canadian average. So that does lead one to believe that prescription drug misuse, although it is a problem, in all likelihood, is not as great as the issues you've been discussing with Nick.

The Chair: There's been some talk about heroin maintenance programs in different parts of the country, some trials. Is there potential for the aboriginal and first nations community to be included in some of those? How many people are on methadone maintenance, do you know, across the country?

Mr. Peter Cooney: I can get you the numbers under non-insured. One of the reasons that gets a little blurred is that some of the provincial programs cover methadone treatment, but I can certainly get you non-insured methadone numbers. We do have them, and we're involved with them from the perspective of transportation quite a bit too, because it's a regular trip to the pharmacy.

The Chair: But you're not, as far as you're aware, looking at being a participant in any of the heroin maintenance trials?

Mr. Peter Cooney: Not at this point.

The Chair: All right.

I have one comment for you, Mr. Hossack. We've heard some conflicting information about drug education, its value and whether it's done well in a lot of places. I know there are some curriculum issues, but I would hope that when you approach people about developing some of the stuff, it's about good decision-making, it's about risk-taking behaviour, it's about kids getting onto the job site and not knowing their responsibilities in making sure they're kept safe, it's about them choosing to goof around with their friends in difficult circumstances that are likely to lead to injury, it's about choices they're making in careers and everything else, it's about the young offenders stuff, it's about healthy decision-making and healthy lifestyles. Maybe we could get some good models within the aboriginal and first nations communities, examples where it's about good choices people make that are appropriate for their age and for their situation. That's just a personal plea.

Does anybody else have questions?

Hedy.

Ms. Hedy Fry: I'm sorry to belabour this. You seem to spend most of your resources treating on reserve, when we know that people move from on-reserve to off-reserve, and especially on substances, they tend to go off reserve a great deal into the city. How do you fund the treatment programs? Do you fund them on a per capita basis with the number of people who are supposed to be on reserve? Shouldn't that dollar be tracked with a person when they move?

It would seem to me that as a result of that, given, as you already pointed out, the huge nomadic movement that occurs, there should be as many treatment resources in the urban areas as on reserve. You said the decision is only made because the leaders say that's how it should go. Surely, a program that is meant to deal with a public health issue should not be decided on by leaders, but by people who are experts in public health, as to where the resources should be and how they should be targeted to the people.

Has there been any work done on looking at it from that perspective, as opposed to merely saying, you have to come to the reserve to get your treatment? We know the whole nature of a person who's addicted is that from one moment to another, they don't know what their life is going to be like. They're looking for the next fix, and if they can't get that, they're not going to travel x hundred miles, even if you give them a ticket to go, to get treatment. The whole nature of treatment means you have to be where the person needing the treatment is. Has any work been done to evaluate how that could be done differently and better, so that you could probably have better outcomes?

Then I want to ask you a question the chair originally put in about prescription drugs. I'm looking at your data here, and I don't believe anybody can tell me, as a physician who's practised for 23 years, that 907 clients out of 1,000 should be on benzodiazepine. That is an absolutely incredible figure. It doesn't come anywhere near the ordinary population--1,021 prescriptions for 1,000 clients on income assistance for codeine-containing drugs. I just don't understand that. I wonder if these data have allowed you to build a relationship with physician associations to find out why this is so out of whack with what one would expect in a normal population.

Paddy asked you about the triplicate prescription. I'm reading your B.C. statistics here. There's a triplicate prescription for codeine, benzodiazepines, or any narcotics, and a copy is kept by the physician, one by the pharmacist, one goes to the college. You could slip into that tracking, and it's not on a non-nominal basis, it's on a nominal basis. It's a way of ensuring that person isn't triple-, double-, and quadruple-doctoring to get their prescriptions. Has there been any work done on that?

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The Chair: Mr. Cooney.

Mr. Peter Cooney: Thank you, Madam Chair.

Dr. Fry, we did pause on this particular slide. As you know, it's very difficult to find any data out there, particularly national data. So we looked at the non-insured benefits program in relation to the provincial program in B.C. What that reflects is the number of clients who received at least one prescription.

Ms. Hedy Fry: It's still too much for just one.

Mr. Peter Cooney: I appreciate that. You are correct, it is high, but these are average numbers, so you would find much smaller numbers receiving multiple prescriptions. This was done as comparison only.

In relation to your question regarding triplicate prescriptions, you are correct. There are now four good triplicate prescription programs that have been pretty well operational within the four western provinces. Saskatchewan is the latest one, just getting up and running. We're working closely with the colleges in those provinces, particularly in Saskatchewan, because they are just bringing their triplicate prescription program onto an automated basis, and we're actually sharing. Again, it's nominal data at this point, so we're sharing nominal data with the college in Saskatchewan. What they will receive from the pharmacy they can receive by name, because it's under the Saskatchewan legislation, and that can be used in association with our data when we have client consent. So yes, we are working closely with physicians' associations and regulatory bodies.

Ms. Hedy Fry: Thank you.

We've gone around and listened to presentations, and there are some people who are suggesting that you should treat the addict or the person who is abusing substances as a patient who needs public health programs attached to what they do, and you should only deal with a trafficker in a criminal way. What does Health Canada think about that concept?

Mr. Peter Cooney: That is an interesting issue, and it's a good question. As we move through the consent initiative, that's the thing that keeps coming back. We are now testing consent, and then we will be able to use data on a personalized basis with licensing bodies. What we keep getting asked is, why would somebody who is trafficking in or abusing drugs want to give their consent? That is a key question. Why would they give their consent to be tracked?

At the end of the period during which we expect to receive the consents we've allowed a lag time for everyone to sign and to provide their consent. With those who haven't provided consent, it may be because they genuinely were not needing any of the services of the non-insured program. The alternative to that is that they don't want to give their consent. They will become apparent at that point, and that should allow us to deal with the prescription addicts or misusers by referring those to the NNADAP programs, dealing with the NNADAP people to identify those patients.

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Ms. Hedy Fry: On the tracking, I understand, but I still haven't got my answer. I'm sorry to pin you down, but what I'm asking you is, what do you think of the idea of treating the user under public health principles and treating the trafficker as the criminal? We're talking about decriminalizing the use only of substances, so that addicts are not afraid. If they think that if you pick them up, they're going to be thrown into jail, they won't come, but if they felt that they're treated from a public health perspective, that might improve their readiness to come forward. What you think of the principle? It's not whether you're doing it or will do it.

Mr. Peter Cooney: I believe it's a logical principle. We have been asked by the first nations communities that people who are identified not be subject to criminal proceedings as a result, that we treat it as an addiction and an illness, as opposed to treating it in a criminal manner. So there is validity in that.

Ms. Hedy Fry: Thank you.

The Chair: Just before we close the meeting, Mr. Hossack, I'm not sure you answered the question on whether your policy about where people get addictions treatment has been examined strictly on what the leaders told you or on a public health issue analysis. Maybe the leaders have a public health issue.

Mr. Nick Hossack: The answer is in three parts. The first is mandate. The second is utilization of current resources. Current resources are fully utilized and are under extreme pressure as we try to renew the addictions network across the country.

The Chair: Can you say that in plain English?

Mr. Nick Hossack: Every dollar is spoken for, every bed is full. So at this point it's our biggest challenge to keep the capacity we currently have operational where it is. Were it possible to improve the scope and amend the mandate, there could well be some more seamless transitioning, if I can call it that.

The Chair: On behalf of the committee, thank you very much for the work you do every day in a very interesting area of government policy and implementation. Thank you also for coming before us today and for the time you've put into your presentations.

This committee is going to hear witnesses probably until about the end of June, and then we have to write a report for November 2002. I know you have a lot of friends in the audience, and we are looking for input from everybody, as citizens and as people working in a specific issue area. So your insight would be valuable. If you have reports we should read or people we should be meeting with, we would be extremely pleased to have the details. Carol Chafe is our clerk, and she is at snud@parl.gc.ca. I encourage people to communicate with us their ideas. We have plans to go east, and we have plans to go to the middle of the country, to the prairies. So if there are specific people or programs we should see, we'd be very happy to find out about them from you, the good and the bad. We can be honest about this. This committee doesn't really work in a very partisan way, as you've seen. Nobody has the magic wand or the silver bullet. We're here to figure out how to do this better. Clearly, you are spending a fair chunk of money in this area, so we would be happy for your input.

We appreciate your work, and good luck. Thank you.

Colleagues, this meeting is adjourned. We have a meeting tomorrow at 3:30.