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37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

EVIDENCE

CONTENTS

Thursday, April 18, 2002

0905

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

0915

Mr. John Graham (Executive Director, Charles J. Andrew Youth Restoration Centre)

The Chair

Mr. Shaun Black (Pharmacologist, Central Region, Nova Scotia Drug Dependency Services, Department of Health, Government of Nova Scotia)

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

Mr. White (Langley—Abbotsford)

0920

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

0930

An hon. member

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

Mr. Randy White

Mr. Shaun Black

0935

The Chair

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

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

The Chair

Mr. Randy White

Mr. Shaun Black

0940

Mr. Randy White

Mr. Shaun Black

The Chair

An hon. member

The Chair

Mr. Shaun Black

0945

Mr. Sorenson

Mr. Shaun Black

Mr. Randy White

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

0950

The Chair

Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ)

The Chair

1000

Mr. John Graham

1025

Ms. Cindy MacIsaac (Program Director, Direction 180)

Mr. White (Langley--Abbotsford)

1030

The Chair

Ms. Cindy MacIsaac

Mr. Randy White

The Chair

Mr. Randy White

The Chair

Mr. Randy White

The Chair

Mr. Réal Ménard

Mr. Shaun Black

1035

Mr. Réal Ménard

Mr. Shaun Black

Mr. Ménard

Mr. Shaun Black

Mr. Réal Ménard

The Chair

1040

Mr. Shaun Black

Mr. Ménard

The Chair

Mr. Ménard

Mr. Shaun Black

The Chair

Ms. Hedy Fry (Vancouver Centre, Lib.)

1045

The Chair

Ms. Cindy MacIsaac

The Chair

Ms. Hedy Fry

Ms. Cindy MacIsaac

Ms. Hedy Fry

Mr. Shaun Black

The Chair

Mr. John Graham

1050

Ms. Hedy Fry

Mr. John Graham

Ms. Hedy Fry

Mr. John Graham

The Chair

Mr. Kevin Sorenson

The Chair

Mr. John Graham

1055

The Chair

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Mr. Kevin Sorenson

The Chair

Mr. Kevin Sorenson

Mr. Shaun Black

The Chair

Mr. Kevin Sorenson

The Chair

Mr. Kevin Sorenson

The Chair

Mr. Kevin Sorenson

Mr. Shaun Black

The Chair

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Ms. Cindy MacIsaac

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

Ms. Cindy MacIsaac

Mr. Kevin Sorenson

Mr. Shaun Black

The Chair

Mr. John Graham

Mr. Kevin Sorenson

The Chair

Mr. Kevin Sorenson

The Chair

Mr. Derek Lee

1105

Ms. Cindy MacIsaac

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

Ms. Cindy MacIsaac

1110

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

The Chair

Mr. Derek Lee

The Chair

Mr. Shaun Black

Mr. Derek Lee

Mr. Shaun Black

1115

Mr. Derek Lee

The Chair

Mr. Derek Lee

The Chair

Mr. Derek Lee

The Chair

Mr. Derek Lee

Mr. Shaun Black

The Chair

Mr. Shaun Black

1120

Mr. Derek Lee

Mr. Shaun Black

The Chair

Mr. Derek Lee

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Réal Ménard

The Chair

1125

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Derek Lee

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

1130

The Chair

Mr. Shaun Black

Mr. Kevin Sorenson

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

The Chair

Mr. Shaun Black

Mr. Kevin Sorenson

The Chair

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

Ms. Cindy MacIsaac

Mr. Derek Lee

The Chair

Ms. Cindy MacIsaac

Mr. Derek Lee

1135

The Chair

Ms. Cindy MacIsaac

The Chair

Ms. Cindy MacIsaac

The Chair

Mr. John Graham

The Chair

Ms. Cindy MacIsaac

1140

The Chair

Mr. Shaun Black

The Chair

Mr. John Graham

The Chair

CANADA

Special Committee on Non-Medical Use of Drugs

NUMBER 037

1st SESSION

37th PARLIAMENT

EVIDENCE

Thursday, April 18, 2002

[Recorded by Electronic Apparatus]

¿ (0905)

[English]

The Chair (Ms. Paddy Torsney (Burlington, Lib.)): Good morning. I'll call this meeting to order and welcome our guests.

We are the Special Committee on Non-Medical Use of Drugs. This committee was struck in May 2001, with a mandate to review the situation in Canada and come up with some recommendations.

We're very pleased to be here in Halifax. We've had some great panels this week, both here in Halifax and in P.E.I.

From the Charles J. Andrew Youth Restoration Centre, we're very pleased to have John Graham, who is the executive director. From the Nova Scotia Department of Health, we have Shaun Black, a pharmacologist who is working on drug dependency in the central region. And from Direction 180, we have Cindy MacIsaac, the program director.

Welcome to all of you. I think you've had a chance to meet some of the people at this table, but let me just review them for you.

I'm Paddy Torsney. I'm the member of Parliament for Burlington, Ontario, just outside of Toronto, and I'm chairing the committee.

Randy White is the vice-chair of the committee, and he's a Canadian Alliance member from Langley--Abbotsford, which is about an hour from Vancouver. Kevin Sorenson is a Canadian Alliance member from Crowfoot, in central Alberta. Réal Ménard is a Bloc Québécois member from a part of Montreal known as Hochelaga--Maisonneuve. Derek Lee is a Liberal from Scarborough--Rouge River, part of Toronto. And Dominic LeBlanc is from the New Brunswick riding of Beauséjour--Petitcodiac, and he is also a Liberal.

Marilyn Pilon and Chantal Collin are our researchers, whom you may have spoken to.

Carol Chafe, whom you have definitely spoken to, is our clerk. If you do have further information, ideas, witnesses or people, or other things we should hear about, you should send that information to her and she will distribute it to us.

And there's a great team behind us that keeps everything functioning—for starters, they request that we do not touch the microphones—and makes everything available in both official languages.

We're also very pleased to have Dr. Hedy Fry on the committee. She is from Vancouver Centre.

There are also other members of Parliament who are members of this committee but are not at this table. They do get all the information, though, because the records are being kept electronically—and that information will be available to you and your friends as well.

So why don't I start in the order in which I introduced you? We'll allow about ten minutes per presentation. I'll give you a signal indicating when you're at eight minutes, and if you're really going on, I'll give you the “time's up” signal. If you can keep to ten minutes, it gives us more of a chance for questions and answers from here. And we're scheduled to go until approximately eleven o'clock.

Mr. Graham.

¿ (0915)

Mr. John Graham (Executive Director, Charles J. Andrew Youth Restoration Centre): Shaun is actually ready to go here, and then we're going to do a shift afterwards.

The Chair: Perfect.

Mr. Black, you're up.

Mr. Shaun Black (Pharmacologist, Central Region, Nova Scotia Drug Dependency Services, Department of Health, Government of Nova Scotia): Good morning, everyone. My name is Shaun Black. As you know, I'm a pharmacologist for Drug Dependency Services.

What I'd like to do this morning is essentially look at the drug use frequency reports from across the province of Nova Scotia; look at population health and its impact upon addiction; and then spend a very brief moment of time talking about nicotine, caffeine, marijuana, Ecstasy, and the date-rape drugs used to facilitate sexual assault, flunitrazepam and gamma hydroxybutyrate, or GHB.

This statistical information is from across the province for the calendar year January 2001 to December 2001, for alcohol, nicotine, cannabis, benzodiazepine, cocaine, and opiate use. The red bars are males, and the teal bars are females, in terms of the percent of reported use by individuals accessing services from across the province.

As you would expect at a drug dependency or addiction service agency, alcohol is the most common of all the reported drugs, followed by nicotine. Within the addiction field, the role of the prevention and treatment initiatives is starting to now focus a lot more on cigarettes and nicotine and their use by our adolescent and adult populations.

Cannabis is also certainly one of the more frequently reported of all the drugs. Benzoates and opiates of the prescription nature usually fall fourth and fifth. And here in the Maritimes, there's certainly a cocaine supply both in a hydrochloride and the free-base form.

The Chair: I'm sorry to interrupt, Mr. Black, but is OH alcohol?

Mr. Shaun Black: Yes, sorry. I'm a chemist by trade.

To remind everyone what we're talking about when we talk about a population health approach, it's an approach that looks at the entire population or at population groups, and it looks at inequities among those groups. Fundamental to this is the concept of determinants of health. Our organization has looked at using a population health approach to look at alcohol here within the central region.

What you see here is a breakdown of the demographics of the population base. If you're not familiar with Halifax, Halifax is broken down into health boards. There are seven community health boards in the Capital Health District. This panel gives you the relative percentages of those populations in those seven areas.

The Halifax peninsula is where we're sitting right now. I could provide a lot more information, but it's not the greatest part of the population. Across the water is the Dartmouth side. The Southeastern Shore area goes down to that coast. The West Hants area is toward Windsor. And the fastest growing area in the Capital Health District is really the Cobequid area. It has almost a quarter of the population, a significant amount of which is young families and adolescents. So from a population health base, adolescent treatment is something we'd like to look towards.

The Chair: And whereabouts would that be?

Mr. Shaun Black: That would be out towards Sackville, probably about twenty minutes from here. If you were on the road at all this morning, the great majority of people you would have seen were coming in from the Sackville area to work here in the inner city.

So we use a population health approach—and again, I don't mean to bore anyone with demographics. This graph takes the individual seven health boards I just showed to you, and, on the left-hand axis, it shows mean family income, as well as those individuals of 15 years of age or greater and their educational level. What we feel is important, especially from a determinants of health perspective, is to look at the educational and mean family incomes, because they relate oftentimes to drug and alcohol use.

This is the way our organization believes we can focus on certain demographics within the area in order to focus our resources and our staffing. If you just look at one particular area, even in West Hants, the red bar follows along with the actual grade levels that the people in that particular area have, while the yellow bars are the mean family incomes. So we've used these things to target some of our services.

Our goal is in a draft form right now. If we want to look simply at alcohol, as you saw in our slide on drug use frequency, alcohol is the most commonly reported of all the drugs. Quite often, we forget about that. Even when you talk about intravenous drug users, the primary drug or primary problem is alcohol. The greatest risks go up with alcohol, so I don't think we can forget it. If we look at a broad draft proposal on this, it would be to reduce the negative consequences of alcohol use in the Capital Health District.

The way in which we envision looking at this is illustrated in two panels here. The top panel is called a health risk continuum. It's something that was developed by the World Health Organization, and our organization added on the black part, which would be the premature deaths often associated with a lot of drug and alcohol use. We see the continuum going from optimal health or no drug use, all the way down to death, with harmful involvement being based upon low, medium, and high use. In the way we like to use this, we can actually look at a particular area of the Capital Health District and define some of the population problems that may occur in that area. We can do it for adolescents, for adults, or for seniors. It's a nice way to model things.

The bottom panel shows the response categories for that. For example, if we look at something right in the medium of harmful involvement, that would be the specialized treatment that our organization would offer. That would be withdrawal management services and adolescent programs. In this particular model, we can conceptualize where the problems may be and how we can target our resources and actual staffing to address those particular things. What we like to think is that we can move people toward the left of the panel.

The Chair: I'm sorry, but what's “Tx”?

Mr. Shaun Black: Treatment.

The Chair: Oh, treatment.

Mr. Shaun Black: Again, the top panel would be a demographic one, an aid to help you visualize how the population looks, and the bottom part would be the resources you would use or the programming you would use to target those particular issues, with the primary goal being to move people to the left of the continuum at the top.

We can do quite a lot with this. This is in a conceptual frame for us right at the moment. We've done it with our staff, and this is a guiding principle for our organization. And again, it's based upon the World Health Organization model.

If we are indeed looking at the goal of reducing the negative consequences, this again is in draft form, but it would be an example of what we'd want to be able to measure if we were able to implement such an approach. Certainly, addiction services by themselves would not be able to do this, but part of what population health is all about is partnering.

If we're looking at high-level harmful involvement with drugs and alcohol, one of the things we would want to be able to look at would be ER admissions—the emergency rooms—and hospital discharges related to alcohol abuse. So this is a way in which we can measure whether or not our approach over the long term is having any significant impact. On the other hand, we may want to look at fetal alcohol effect or fetal alcohol syndrome as another approach. We believe these are ways in which we have to look at outcomes. We can have the approach, but if we can't measure what we're doing, there will be a flaw there.

As I said, nicotine certainly is a drug our organization is looking at. Pharmacologically, there's no other drug out there like nicotine. It works presynaptically and post-synaptically to cause dopamine release. Dopamine is the primary reward neurotransmitter in our brain. When people take in a puff of a cigarette, not only do they bring in nicotine, they bring in dopamine.

Nicotine and alcohol addiction are very comparable. In terms of their use, there are a lot of correlations between both of them. Within our population, what we see is a high prevalence of people who use alcohol and also smoke. Alcohol and nicotine cause a lot of health problems in and of themselves, but when you combine the two of them, the problems grow exponentially.

The medications used to treat nicotine addiction would include over-the-counter nicotine replacement agents designed to deliver nicotine in slower and lower amounts. There are nicotine replacement agents that aren't available in Canada right now—they come as a nasal spray and an inhaler—and there is the anti-depressant medication bupropion, or Zyban. Fundamentally, these medications deliver nicotine in a much slower way, and they allow the body to have nicotine in steadier states than it would have it with tobacco.

The slide I was just talking about shows the correlation between people who use alcohol and cigarettes. There's quite a correlation between the two of them. We see two to three times a greater rate of smoking amongst people who use alcohol; the smoking rates are upwards of 80 percent within our population. Smokers who abuse alcohol are seen as much less likely to give up their cigarettes. From just a detoxification point of view, it does appear that smoking relapse often results in a readmission to the withdrawal unit itself. So I think we need to look at nicotine.

Turning to cocaine, cocaine pharmacology is absolutely fascinating. Cocaine affects dopamine, which, again, is a reward neurotransmitter. Part of the non-medicinal use of drugs also has to look to the pharmacology.

What normally happens in our brains is that dopamine is released, it binds to dopamine receptors, and it gives us pleasure. On a hot day, if you have a drink of water, you get an intrinsic sense of pleasure. What cocaine does is block the re-uptake of dopamine. In the particular model that you see here, the blue dots, which are the dopamine molecules, now start to flood the gaps in our brain to give us pleasure.

One of the biggest problems that we have right now is the pharmacological treatment of cocaine addicts, the ability to give treatment to them. Oftentimes when they come into withdrawal management services, we can look after the signs and symptoms during the first week, but the mental health components of cocaine—irritability, depression, anxiety, panic, and cravings—come back. We really have no pharmacological tools to deal with those things right now. In our detox, cocaine is the second-most widely reported of all the drugs, next to alcohol.

Mr. Randy White (Langley—Abbotsford, Canadian Alliance): Could we go back over the last two slides?

¿ (0920)

The Chair: Would you mind going through those last two slides again? No one has shown us a slide like this. You're the first, and it's quite fascinating.

And I won't take it out of your time. Don't worry.

Mr. Shaun Black: The top left-hand panel shows the brain. In the brain, there are neurotransmitters called dopamines, and they are the reward neurotransmitters in our brain. They are represented by blue dots in this panel. When dopamines are actually released, they bind to something called dopamine receptors, so there is specificity there. You get pleasure when that happens, and then the re-uptake pump takes the dopamines back up to its storage site. This happens in our brain every millisecond. It's happening all the time.

Cocaine has such an incredible pleasure behind it because it works on the chemicals in our brain that give us natural pleasure. That's why I use the analogy of water on a hot day. Food, water, and sex all have pleasure behind them and are driven by the reward centre in our brain. Unfortunately, what cocaine does is block the re-uptake mechanism that takes the dopamine back up into its storage site. What happens now is that the pleasure centre of the brain is flooded with dopamine, and that gives you pleasure. Most cocaine addicts will tell you about the incredible pleasure they get from the drug. This shows the neurochemical level of that.

We don't have any pharmaco-therapeutic medications right at the moment to help out with the craving, the irritability, the depression, and the anhedonia that go along with cocaine's acute withdrawal phase. Within our detox, coke is the second-most widely reported of all the drugs that we have.

Does that make sense? It's diagrammatic, but the primary point is that for most of the drugs for which people come into a detox, we pharmacologically substitute a drug for the one they're using, we stabilize them, and then we take them off of it. With cocaine, the treatment style is much different. One of the problems is that after they've been detoxified, they don't come back for treatment. You can well imagine what it must be like to be irritable, panicky, depressed, and having no pleasure anymore. That can be alleviated by using cocaine again, and that's one of the biggest problems with cocaine use.

The Chair: And in that picture, is that little cap with the yellow—

Mr. Shaun Black: Yes, that's cocaine. It has blocked—

The Chair: Is it going to go back up into—

Mr. Shaun Black: The dopamine will not. The cocaine doesn't go up. The cocaine actually blocks the dopamine.

In the long term, what happens is that you change the model around. Within cocaine addiction, that's why there are mental health issues around depression and anxiety. They're commonplace because you change the neurochemistry. That's often the fundamental behind some disease states within a mental health perspective.

Turning to methadone and opiates, we have no heroin in Atlantic Canada. These are examples of Pacific Rim heroin, which is usually white, and Mexican brown heroin, which is really quite cheap. From an Atlantic Canada perspective, we always worry about drugs coming up the Eastern Seaboard. You may realize that we have about 4,000 kilometres of often unprotected seaboard here. Drugs come in, are dropped off on the shore, but then go on to Upper Canada. Oftentimes, they can then come back after that. In other words, we're a drop-off spot for them, but we don't really use very many of them.

Our problem in Atlantic Canada is prescription opiates. I've sat on some committees from across Canada. I think you all realize that Montreal, Toronto, and Vancouver have quite a different dynamic around intravenous drug use with respect to opiates when compared to the rest of Canada, where it is a prescription opiate problem, with Hydromorphone/Dilaudid, morphine, and MS Contin being the big culprits, and OxyContin certainly coming into the mix now.

This points out the dynamic between the effects of using an opiate versus the withdrawal from it. Withdrawal is just the exact opposite of the effect. When you use an opiate, your body temperature and blood pressure go up, you get a flushing sensation in your skin, your pupils constrict, and you experience constipation and a decrease in your respiration and sex drive, as well as muscle relaxation, nods, stupors, analgesia, and euphoria. When you go into withdrawal, you get the exact opposite. Unfortunately, what happens with opiate addiction is that users get themselves into a cycle that goes from use to withdrawal to use to withdrawal, because the effect of the drug only lasts for four to six hours.

You can well imagine that you can feel good for four to six hours, but when the drug wears off, your body temperature and blood pressure go down, you get gooseflesh, the hairs on your arms turning up, tearing, a runny nose, diarrhea versus constipation, a decrease in breathing, spontaneous orgasms versus a decrease in libido, and breathlessness and twitching. I imagine you've heard the expression “kicking the habit”. This is where that comes from. There's an autonomic discharge in the brain when you come off an opiate, and you start to twitch. That's where “kicking the habit” came from, because you can see that in opium withdrawal. And you also suffer from insomnia instead of sleepiness, and pain, depression, and anxiety.

All of the withdrawal side can be alleviated by putting the drug back in, so people get themselves into that cycle of use to withdrawal to use to withdrawal. And if they're IV-ing the drug, the health consequences go up dramatically.

In the Maritimes, there are two ways in which we're seeing people coming for methadone right now—and this is in the far right-hand corner of the slide. There's an opiate stream in which drugs are being put in intravenously or orally. Intravenously, we have no heroin here, but there is Hydromorphone/Dilaudin and MS Contin orally. We don't really see many problems here from an IV perspective.

Pharmaco-therapeutically, we have methadone. We don't use buprenorphine morphine here, but it has received its notice of compliance. And LAAM is a long-acting methadone or heroin substitute that has been talked about in the literature, but which I don't believe is a trial we should be trying in the Maritimes, at least at the present time.

¿ (0930)

An hon. member: You're going too fast for the translation. It's like an opiate too, eh?

The Chair: Take a deep breath.

Mr. Shaun Black: I'm trying to go slowly.

The Chair: It's always a little more difficult when it involves technical terms.

Mr. Shaun Black: Okay.

Looking at the left-hand panel, opiates are usually prescriptions in the Maritimes. What usually happens is that the opiate can be brought in orally, which we imagine can be done with all pills. You swallow one, but that doesn't necessarily mean a pill is brought in orally. That's irrelevant. So pills can be....

Perhaps you can help me out here from another perspective, but there's no rocket science here in terms of taking a pill or grinding it up, drawing it through a filter, and getting it into an injectable form. That's what happens with two prescription medications here, Dilaudid, which is hydromorphone, and MS Contin, which is morphine sulphate and is a long-acting morphine. So although the pills come out orally, that doesn't mean that's how they're going to be used.

One treatment approach that can be used for someone who is using intravenously is to now substitute another drug for the one they're IV-ing. There are a lot of expressions for IV-ing a drug, but one of the substitutes would be methadone. The body recognizes methadone just like any other opiate, so you substitute it for the one they're abusing. Does that make sense? If I'm using Dilaudid and I'm injecting myself four or five or six times a day, you can give me methadone once a day, although I'm oversimplifying the role of methadone here.

Mr. Randy White: Could you just cover that part about the methadone again, please?

Mr. Shaun Black: Sure.

In the bottom left-hand corner, this particular diagram shows that prescription opiates aren't always being used orally. In the Maritimes, as well as across Canada, prescriptions can be used intravenously. When drugs can be used intravenously and you want to look at a way to substitute another drug for them, you have four options.

The first option that we know about in Canada would be methadone. It's a long-acting opiate that works for 24 hours. If I'm an IV opiate user who has been doing it four or five times a day, then you can put me on methadone once a day. That would be one part of the treatment strategy, because all you've done for me is give me a long-acting substitute for the drug I was using. You've done nothing for my addiction. So there's the opiate side.

Across Canada, sir, you were mentioning the report from 1972, which talked about heroin. They didn't realize cocaine IV-ing was coming out, and it's a huge problem right now within the injection drug use world. When a lot of us think about IV drugs, we think of opiates, but we're missing a big culprit here, that culprit being cocaine. There are two forms to cocaine: a hydrochloride that you can snort through your nose or can inject, and a freebase form that can be smoked. Crack cocaine is freebase cocaine. What is happening is that people are either taking their hydrochloride, which they can inject, or are actually converting their freebase form of crack cocaine to hydrochloride and are injecting cocaine. At times, they're even injecting opiates with it.

Has anyone been around long enough to remember speedballs? Speedballs are heroin and cocaine. Speedballs in the Maritimes are prescription opiates and coke. When people then come from methadone...let me give you a particular example. I'm using cocaine and opiates, and you put me on methadone to substitute for the opiate I'm using. Once I'm on it and I'm stable, which drug do you think I'm testing positive for now? Cocaine.

It raises a significant policy, procedural, program, and community argument about positive cocaine urinalysis while on methadone. It also raises it another level in terms of the role and importance of urine testing while you're on methadone. And I've said all this to point out that you should please not think IV opiate use involves opiates only.

The second-most important point here is that, oftentimes when people get themselves into problems with IV-ing a drug, alcohol is the thing they used first. Alcohol is freely available. We take big risks when we drink. I think it's important to realize that.

I like this pace. I'm breathing and I'm stopping.

An hon. member: Oh, oh!

¿ (0935)

The Chair: Are there any questions about that? Derek.

Mr. Derek Lee (Scarborough--Rouge River, Lib.): This witness is absolutely not getting away from this slide until he explains this grouping.

Mr. Shaun Black: I always worry when someone gets a pen going.

Mr. Derek Lee: That's right, because I'm making notes.

The bottom left-hand corner of your slide shows methadone, buprenorphine, LAAM, and heroin. Could you please explain that grouping?

Mr. Shaun Black: The grouping in the left-hand corner is primarily a grouping of drugs that can be substituted for the IV opiates they're using. They're all opiates.

Mr. Derek Lee: It doesn't substitute for the cocaine?

Mr. Shaun Black: No.

Mr. Derek Lee: But it does for the opiates?

Mr. Shaun Black: It does for the opiates only. That's why—

Mr. Derek Lee: Do you regard all of those to be reasonably substitutable?

Mr. Shaun Black: They substitute pharmacologically because the body will recognize them as opiates. They would work at the same the receptors.

The benefits of substitution—or what you would look for in a drug—would be oral activity and a long half-life, so that you give it once a day and don't have to give it on multiple levels.

The buprenorphine is a mixed agonist–antagonist, but we'll get to the importance of that sometime later. People have suggested that you can't overdose on buprenorphine, because at higher doses it works as an antagonist, which would stop its effects.

LAAM is a drug currently being studied in the States. Methadone is delivered once a day. LAAM can be delivered every other day, so there are some benefits to that.

And then there are other things that go across the world on heroin substitution. If I'm a heroin user and you've tried me on methadone but it has failed, the next step may be substituting heroin for it. I've got pure heroin, a needle. It's another approach, but I'm not suggesting in any way that it's correct. I'm just pointing out the pharmacology. It makes sense, because they're all opiates. But their beauty is in the length of time that they work.

Mr. Derek Lee: Well, we have to deal with the correctness issue, but thank you very much for pointing that out.

The Chair: Thank you, Mr. Lee.

Mr. White has a quick question.

Mr. Randy White: This is actually all very interesting. I'm trying to tie in those two pictorial slides that you showed us with this one here.

If you only had to take methadone once for a 24-hour period as opposed to coke or heroin three, four, or six times a day, I take it the difference would be the high that you would get, from what you're describing here.

Mr. Shaun Black: The primary difference is that there are a number of highs that would go with an opiate. One could be just using the needle itself. Maybe my colleague here can talk about that, but there's a relationship that addicts have with their needles.

If the half-life is short with heroin or Dilaudid, you are putting the drug in four, five, and six times a day, but you're not putting it in safely. You're not a medical practitioner as an addict, so you're missing your veins and you're scarring your veins. On a very fundamental level, if I'm taking a drug four, five, and six times a day and I'm using dirty needles and I'm not sure how I'm doing it, when that's compared to taking a drug once a day in an oral format, on that level I would conclude that once a day in the latter particular format is the way to go.

That's a very superficial answer, but we could spend months talking about methadone addiction.

Does that answer your question, sir?

¿ (0940)

Mr. Randy White: I'll get back to it. I won't take up your time.

Mr. Shaun Black: The other stream here is someone...the reality now is that, when we offer methadone within our agency, people are coming not only on opiates, but also on benzodiazepine, cocaine, marijuana, and alcohol. So the opiate picture is really quite complex.

Am I taking time from my colleagues here, Madam Chair?

The Chair: No, I'll make sure they have enough time. Yours is probably the most technical presentation we've had in all of our hearings, so we're spending a little more time with you than we normally would. Clearly I've let the clock go, but I think my colleagues are in agreement that this is technically very interesting.

An hon. member: And we want to stay.

The Chair: Marijuana.

Mr. Shaun Black: The science of marijuana is growing by leaps and bounds. What this slide shows is THC, which is the active ingredient in marijuana, tetrahydrocannabinol. It's a 473-amino-acid chain, and there is a receptor, a part of the brain that the THC binds to when a person smokes marijuana. We know that now. We know how to actually structurally resemble the receptor itself.

To give you and idea of what receptors are, think of the concept of a lock and key. A key can be a drug or a key can be a neurotransmitter, and the receptor is the lock. The key goes into the lock and the door opens. THC goes into a THC receptor and you get an effect. And we know the receptor now.

We know where these receptors are. There are two types of cannabis receptors, a CB1 and a CB2. The CB1 receptor is widely distributed throughout the entire brain, in the hippocampus, the cortex—the top part of your brain—the cerebellum, and the ganglia right in the middle. As a technical term here—it's not important—we know that when cannabis goes into the body, the receptor, the G-protein, couples with adenylate cyclase. We believe that when someone uses THC, they're inhibiting the release of neurochemicals in their brain called acetylcholine, noradrenalin, and glutamate.

What is intrinsically very important about the chemical or neurotransmitter glutamate is that it's responsible for memory. This is technical, but when I ask you what the short-term effects of cannabis are, it is in the literature that short-term memory is impaired. That's well known. From my point of view, I can tell you why it's impaired. I can tell you where the receptors are and what chemicals in the brain it is working at. No longer is the science not understood; we know why that's happening. So when we look at cannabis use by our youth and their short-term memory is impaired, we have a problem here.

A second thing is important. Another set of receptors called CB2s are involved in our neurological responses. They may be responsible for the amino-suppressant effects of cannabis and marijuana. Medicinally, this is important to talk about. When people talk about the medicinal uses of marijuana and are telling you about an increase in their appetite, that they're going to eat, and that this is going to be a good thing, I will counter with the fact that they may actually be suppressing their immune system. Although you may be eating, you could be compromising your immune system, so I think this is the important one to look at. The other part of this is not as important.

Let's drop the pharmacology and get down to what's really important. There's a take-away message here. I have here a Nova Scotia student drug use survey that has been conducted over a three-year period of time. The bottom panel shows alcohol, nicotine, cannabis, and LSD use. The Y-axis shows the percentage of reported use in Nova Scotia by students in grades 12, 10, 9, and 7, so it collapses all of them. In terms of identification, 1991 is in blue, 1996 is in teal, 1998 is in red, and another one is going on right now.

Across the board for alcohol, nicotine, cannabis, and LSD use from 1991 to 1998, the reported use by our grades 7, 9, 10, and 12 students for cannabis, as well as nicotine and alcohol, was going up. I therefore think it's very important that we look at this when we talk about marijuana and the uses of it, because as it becomes more available...supply and demand are all interlinked.

All I'm trying to point out here is that we know the pharmacology and the negative consequences of marijuana. Amongst our students, cannabis is singularly the one drug most of them report. I come from addiction services, where we have an adolescent program. The primary drug of abuse there is marijuana.

So all I'm suggesting is that we know the pharmacology, that there's a lot of work ahead, and that we're looking at issues related to it.

¿ (0945)

Mr. Kevin Sorenson (Crowfoot, Canadian Alliance): Would that be regular use?

Mr. Shaun Black: This is reported use. It could be once or it could be that they're using it every day. It's what the students reported, and it asked about use within the past year.

Mr. Shaun Black: Oh, yes, thank you for that. They have been over the years.

Dr. Christiane Poulin, from Dalhousie University, is the epidemiologist responsible for this survey. Another one is going on right now and will give us four years of it. It's running here in Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland, so it can get all the Atlantic provinces involved.

Mr. Randy White: What about short-term memory? How short is short-term?

Mr. Shaun Black: Can I go off the record for a second on short-term memory?

Mr. Kevin Sorenson: Are you impaired for one day, two days, three days?

Mr. Shaun Black: We don't know the answer to that one at the moment.

The Chair: That was a very good question, by the way, Randy.

Mr. Shaun Black: Yes, it was.

I'm at the end now. Again, though, my colleagues can put things into perspective.

On ecstasy, as we know, it's all across the newspapers, so I think it's important to talk about it. The dynamic in Atlantic Canada is really no different from the dynamic in the rest of Canada. When we talk about ecstasy...is that a familiar name?

The Chair: Yes.

Mr. Shaun Black: If you want more information on ecstasy, I'd advise going to the Web. It's not rocket science. That's where the pictures I'm showing you are from.

In the top panel, you see baby or candy ravers. There's a whole dynamic in terms of the dress code that goes on at raves. The soother in the young woman's...no, I'll call her a girl. Jaw-clenching is one of the most common things that happen with a stimulant.

Ecstasy's long name—and I'll do this one slowly—is methylenedioxymethamphetamine, and MDMA is the acronym for it. For those of you at the table who have been to the drug world and have thought about it, methamphetamine is ice, crank, or crystal. It's a long-acting stimulant, which is essentially what the drug ecstasy is.

In the bottom panel is a picture of a rave. I'll ask you to look at the young woman's back in the bottom right-hand corner of the photo. That's sweat. That's what happens at a rave or in these particular areas. With a drug that is a stimulant, it causes you to sweat, causes your body temperature to go up, and causes your heart rate to go up. When your body temperature and heart rate go up, you're at a risk for seizure and cardiovascular collapse.

In this particular picture here, they look like sardines to me. Raves are not held in well-ventilated areas and areas that let everyone know where they are. They're held in warehouses, off the record, usually between the hours of midnight and six or seven o'clock in the morning, with an age demographic of 13- and 14-year-old girls and 25-year-old guys.

Raves are places where people dance. I'm not suggesting in any way that all of the people are using drugs while they're there. But a 13- or a 14-year-old girl—I'm not being condescending; I'm not a parent, so I don't have that right—between the hours of midnight and eight o'clock in the morning is going to be much different from a 25-year-old guy. That's just another way to look at things.

This is a slide showing the brain, but it's not one of those “This is your brain on drugs” things. In the left-hand panel is a PET scan—it has a long name again, that being positron emission tomography—that can actually label serotonin transporters. The pharmacology is not important here. What is important is to look at the colours.

In the right-hand panel is a scan of a former ecstasy user who has been using for a year and a half and has had eighty separate reports of using ecstasy itself. The lavender actually labels serotonin parts of the brain. Serotonin is a chemical in our brain that affects mood, behaviour, sleep, and appetite. In the left-hand panel, in the brain of the person who is normal, there seems to be a lot more labelling of their serotonin pathways. What science is suggesting is that ecstasy seems to have a detrimental effect on serotonin. A lot of our anti-depressant medications are called selective serotonin re-uptake inhibitors. They have an effect on serotonin. In this particular model in the former ecstasy user, three weeks after the last hit, the serotonin pathways appear to be destroyed. The clinical significance of this has yet to be determined.

This is a worry around ecstasy as well—and maybe my colleagues here can talk a bit about this—because it's not just happening to a few people who are using.

I'll finish off with something about our adolescent program. This last slide presents a research study that shows three separate panels. The left-hand panel is the cortex of your brain, or the higher learning part of the brain that sits up on top. This shows labelled serotonin in monkeys. Two weeks after ecstasy use, what was labelled as serotonin looks like it's not there as much. The serotonin component of the brain has virtually disappeared.

In the study, they allowed other monkeys to continue for seven more years without any ecstasy. If you compare the far right-hand panel with the far left-hand one, there's quite a difference in terms of what is being labelled or being diagrammed in the serotonin in their brains.

Again, the science is not well understood in terms of its clinical significance. I'm not here to scare anyone, because our organization takes a great deal of pride in knowing what we're talking about. However, this has to be an issue that we look at because serotonin is a mood-altering chemical.

I'll end off with the following. Adolescents who have used ecstasy put a little bit of pharmacology together. From the literature and from what people talk about, adolescents know ecstasy destroys serotonin. They use ecstasy on the weekend, and the drug that they think about using on Monday morning is Prozac. They want to use Prozac because they know Prozac is linked to depression and that Prozac affects serotonin.

In terms of what they're exposed to, the adolescents of today are a lot smarter than you and I were. It doesn't mean they're any more intelligent. They just have a lot more information. Physiologically, they develop in the same way, and psychologically it's the same. They just have an abundance of information that they can all put together in possibly the right way. But think about this: ecstasy on the weekend, and Prozac on Monday to help the detrimental effects.

¿ (0950)

The Chair: Thank you, Mr. Black. You've left us with a lot of things to think about.

[Translation]

Mr. Réal Ménard (Hochelaga--Maisonneuve, BQ): Can we have copies of these slides?

The Chair: We need a translation before circulating them.

À (1000)

[English]

Mr. John Graham: My name is John Graham, and I'm the executive director at the Charles J. Andrew Youth Restoration Centre in Sheshatshiu, Labrador.

I'll be making a PowerPoint presentation as well. Over the course of the next five minutes, I'd like to look at some of the things we've learned since 1994, when solvent abuse was in the media and was brought to the attention of the Canadian public. I would like to look at some of the things we're doing to address the problem of solvent abuse, and look at some recommendations for prevention and intervention.

In our mission statement, we say that the Charles J. Andrew Youth Restoration Centre “is committed to empowering aboriginal youth through the provision of a holistic healing program.” I'd like to point out that we're just one of nine centres that have been set up across Canada since 1994 to address the issue of solvent abuse in aboriginal communities. Ours was the last centre to be set up, and we have been in operation since April 2000.

As I've said, the solvent abuse centres were started in 1994. That year, widespread media attention was paid to the issue, and that attention spurred on a national survey to determine the extent of inhalant use on first nations reserves across Canada. The survey showed widespread use. As a result of that, six centres were funded by Health Canada. Later, in 1998, Saskatchewan opened up a second centre, and in 2000, Alberta and Labrador also opened up treatment facilities.

Now, you'll have to excuse my French, but I'm going to make an effort here.

[Translation]

There are nine treatment centres in every region of Canada. Eight of them focus on young people 12 to 19 and the ninth deals with 16 to 25-year olds. These nine centres can treat 114 patients.

[English]

In other words, there are 114 beds across Canada.

[Translation]

The treatment cycle is 180 days long. Centres work in cooperation with communities in order to optimize support for the young.

[English]

There are nine centres. One is located in Sheshatshiu, Labrador, another one is in Quebec, and there are two in Ontario, one of which is down in the London—and I'm sorry, but I forget the area the other Ontario one is in. And we also have another one in Manitoba, two in Saskatchewan, one in Alberta, and one in British Columbia.

[Translation]

The youth solvent abuse treatment program improves the quality of life and the functional abilities of people addicted to solvents. It includes an outreach program, education for community workers and families as well as follow-up services for clients when they return to the community. The cost for the nine centres is $13 million a year.

[English]

As a result, the executive directors of the nine centres meet quarterly in an effort to establish a quality program across Canada and to share information with one another. This committee meets on a regular basis, and our vision is to develop a partnership to provide quality solvent abuse treatment services for first nations and Inuit youth, people, and their families.

Our mission as a youth solvent addiction committee is to create a first nations and Inuit health recovery network of solvent treatment centres for native young people, their families, and their communities. This national continuum of quality support services will be based on first nations and Inuit principles and values committed to developing partnerships.

In other words, we'll see that there's a cultural component at most of the centres. For example, at our centre, one of the things we'll do is use the sweat lodge, a process that also helps in detoxification. It helps to get the youths to sweat and to get rid of some of the solvents located in their fat tissue.

Just recently, two of our youths participated in a walk into the country. They spent four weeks walking a traditional aboriginal route. They prepared and made their own snowshoes before they left, they made their own moccasins and toboggans before they left, and they took those in for four weeks. We saw the two youths come back from the country with huge smiles and beautiful tans. They worked very hard but felt it was a really successful journey for them.

Another part of our goal is to recognize and respect the natural value of the first nations and Inuit youth, and to assist them in recapturing their self-worth and their sense of belonging and balance with their families and their communities. In part, our centres located across Canada are trying to bring ourselves as close as we can to the communities where those youths come from. Our particular centre has primarily serviced youths from Labrador. Like the other centres, we have taken youths from across Canada, but we do try to have those centres located close to the aboriginal communities.

The YSAC network of centres will be a first. Some of our achievements as a YSAC committee...I talk about the YSAC because we're trying to bring and ensure quality services across the country, and also share our experiences. It's a relatively new area, and Canada is one of the world leaders in trying to find solutions for solvent abusers.

One of the things we have worked towards is getting all nine of the centres accredited. Four of the nine are now accredited, and I believe all nine centres will have been accredited by February of next year. The agency that will be providing that accreditation is the same agency that would accredit any of the hospitals in Canada, so we're asking to have very high standards applied to our treatment centres. This will also make us the first network in the world to have all its treatment centres accredited.

On the development of a best practices manual, we're looking around the world, but we're discovering that we have most of the information here. In fact, the United States is coming to our committee meetings from their solvent abuse treatment centre in Alaska. They're looking at our best practices and are asking us to help them with the development of their program.

We've also initiated the development of a first nations and Inuit addictions information system. We're trying to make sure the treatment models that we're developing and using are based in research. We're finding out what is happening out there, and we're trying to then continue to develop our program in an effective manner.

What are some of the things we've learned? We know 25 percent of the youths who have been in treatment have come from the Atlantic region, and most of them have been from Labrador. We know 7 percent are from Quebec, 17 percent are from Ontario, 24 percent are from Manitoba, 18 percent are from Saskatchewan, 4 percent are from Alberta, and 5 percent are from British Columbia, with only 1 percent from the Northwest Territories.

Over the last two years, some of the statistics that we've kept indicate that our bed occupancy has been very high. We've been able to fill most of our beds, making them cost-effective. We're operating at almost full capacity.

We know 75 percent of the youths who come to our centre have not been attending school prior to coming to the centre. Most of our youths are from the ages of 12 to 18, so what we're seeing is that most of those youths have not been attending school before they come to us.

We know more than half of them have had a history of suicide ideation before coming to treatment.

We know there's a history of family addiction, and we can see that it's very high. These youths who are coming to our centres are coming from families in which there are other addictions.

We see that there's a history of sexual victimization. Again, that applies to more than half of the youths.

We see a history of family violence. Again, the incidence is fairly high.

We see involvement with the justice system. Almost half of the youths have had previous involvement.

And finally, we see that 34 percent have attended a previous treatment program.

In Labrador, some research has been done in that area. A very large study was done on local public health infrastructure development. It surveyed over 2,000 youths and their families, from many of the communities. Most of the communities in Labrador were surveyed when this was conducted in October 1999, and the organizers were the Health Labrador Corporation, the Sheshatshiu Innu Band Council, and CIET Canada.

I thought I'd just highlight some of the information from that survey for you. It has helped us in our programming in terms of trying to determine how to be most effective. About 52 percent of the youths reported having ever sniffed gas. Even if they sniffed once, they're included here. Of all Sheshatshiu youths, 24 percent are sniffing gas regularly. This is just from the one community—as I said, the survey took in all of Labrador, but I'm highlighting a couple of points here—and regular was defined as being more than twice a month.

What are some of the risks we're seeing with youths sniffing gas? Youths are five times more likely to damage property if they're sniffing gas, and they're three times more likely to use other drugs. If their friends sniff gas, Sheshatshiu Inuit youths are seven times more likely to sniff gas.

School attendance appears to be a protective factor. What we found was that, of those in school, 16 percent were regular gas sniffers—again, those sniffing twice a month. Of those not in school, 36 percent were regular gas sniffers. We can see from this that one of the intervention strategies would be to try to have these youths in school.

If parents have low mastery scores, we see that their children are five times more likely to sniff gas. Again, a prevention strategy here might be to work with parents on their parenting skills.

À (1025)

Ms. Cindy MacIsaac (Program Director, Direction 180): I can understand that, but I guess it's that we're more open to the process, although the process doesn't always happen right away for everyone. If we say to these clients that we'll kick them out if they use other drugs five times, chances are that they will get kicked out, that they will continue to use intravenous drugs, that they will continue high-risk behaviour like engaging in the sex trade, and that they will go through criminal system and all the long-term effects. So our philosophy is that it's a process.

They are still testing positive for other drugs; however, opiate use has decreased. Mainline Needle Exchange has distributed 54 percent less needles in the past year since our program opened. That alone gives some indication that, in terms of intravenous drug use, we have seen a harm reduction, a decrease.

Mr. Randy White: Not necessarily. I've talked to people who have said they've given individuals a hundred needles. That doesn't mean needle use has expanded, it just means they've given a hundred needles. I don't see that as a—

À (1030)

The Chair: We're talking about pure needles though.

Ms. Cindy MacIsaac: Pure needles, yes.

Mr. Randy White: That's all right, but I'm talking about the other end. I'm not sure whether the number of those issued, high or low, is a valuation of success.

How much time do I have?

The Chair: Twenty seconds.

Mr. Randy White: Twenty seconds?

Well, I always ask this, so I'm going to ask it today. Maybe you can fill us in at the end, because I think we need your answers.

This committee is charged with a wide gambit of issues, ranging from rehabilitation to intervention, from treatment to enforcement, from Canada's Drug Strategy to funding, from coordination to definitions, and from legislative changes to when our surveys are taking place. I'd like to ask each one of you to give us your top two priorities that you feel this committee should deal with. I want to see where you're coming from and where you think this committee should make recommendations to effect changes in Canada.

I've run out of time, but perhaps you could leave us with that. Or maybe the chair will give us some time at the end of our session so that you can tell us the two most important things to you that we could go away with from here.

The Chair: Do you want them to tell us now or at the end?

Mr. Randy White: Let them give it some thought.

The Chair: Why don't I return to that question? If you could think about it during the rest of the questions, that would be great.

Monsieur Ménard.

[Translation]

Mr. Réal Ménard: First, I want to deal with the whole question of methadone. I represent the riding of Hochelaga--Maisonneuve in East Montreal. We have a needle exchange site in our area which has a relatively serious drug use problem. We visited that site some time ago. When I started getting involved with this committee, methadone in my area was considered as a substitution drug. I was under the impression that methadone treatment was a fairly effective and credible way to reduce harm and stop progression in drug use.

Mr. Black, when you answered Randy's question, I felt as if you were equating methadone with other drugs and other opiates.

Why do some people feel that methadone treatment leads to a reduction in drug use? Why is it considered as a substitution treatment?

[English]

Mr. Shaun Black: There are two parts to your question.

Firstly, it's a pharmacological substitute for the opiate that they're using. The body recognizes it in the exact same way it recognizes the opiate they were using. In terms of decreasing the use of other drugs, that has been shown in the literature, so you achieve those two particular goals. In our particular program, we can clearly show a decrease in the drug-use trends when we compare the times before and after these individuals have gone on methadone. The principle is that, if I'm an IV drug user, you've now substituted that drug with one I'm taking orally once a day. That's the rationale.

Why is methadone preferred? Why not make it morphine or something else? If I were to substitute morphine for what you're on, I'd have to put you on it four times a day. If you were injecting on a base, I'd have to put you on it four times a day. With morphine, if anyone has been on morphine before, you get itchy and you're scratching. So methadone is chosen primarily based simply on its pharmacology. That's all that is there. You're substituting one for the other.

In both of our programs here, we've seen huge quality-of-life changes. With methadone, I sometimes think the only outcome people are interested in or may be looking at is abstinence. The outcomes we want to look at when it comes to methadone would have to be a lot different from just the abstinence part.

Does methadone work for everyone, sir? I think that may be what you're getting at here. No, in my opinion, it does not. No pharmaceutical out there works for everyone. Methadone can be no different.

Part of the problem with opiate addiction and methadone is that the word “methadone” implies that it works for everyone. In my opinion, in my experience, and based upon what I've seen, it doesn't. So I think the problem may be that the assumption is that it works for everyone, but that certainly is not true.

Does that answer at least part of what you asked?

À (1035)

[Translation]

Mr. Réal Ménard: Yes, this is all right. Our colleague Hedy Fry gave us a presentation on the reason why some people end up resisting to methadone. This is very clear in my mind.

I would like to talk a little bit about ecstasy. My riding is Hochelaga--Maisonneuve but I have many friends who are professionals, engineers, lawyers, architects and who make a good living. They are somewhat younger than me. I will be 40 on May 13. I don't know if you feel different when that happens. I'll just wait and see. So I have many professional friends who use ecstasy. These are young affluent people who make a lot of money and who lobby me saying that Parliament should legalize ecstasy.

I will keep in mind the image of a brain with white membranes that you showed us. I've been told that ecstasy is a mood drug, that users became depressed for days after taking it and that, in the long term, high use of could lead to a generation of depressed people.

Are there actually any scientific longitudinal studies that may lead us to conclude, as a committee, that large scale and recurrent use of ecstasy is a definite cause of depression and breakdown?

[English]

Mr. Shaun Black: Is that directed to the three of us?

[Translation]

Mr. Réal Ménard: The question is for whoever can answer it.

[English]

Mr. Shaun Black: Given the way we and legislative people look at drugs of abuse, part of the problem with them in terms of dealing with a policy would be to make the mistake of listening when someone says they've used the drug and have had no problem with it. Am I making sense? That would be like saying I'm 40-years old, and success....

If we take alcohol as example, when you think about how alcohol has been used in our community and in our culture historically, we've seen it used when someone is born, when someone dies, and when someone graduates. A lot of us have gone through university and have used extensive amounts of it, and have then gone on to different and healthier lifestyles afterwards. So arguments around using it and having no problems with it...I think that's a very good point to bring out. I don't think it's a fair way to examine the consequences, either legislatively or policy-wise.

In terms of long-term ecstasy use and the damage that can occur there, I would again refer to Jim Anderson's Health Canada paper on the toxicology of it. He would probably have taken a much larger and broader look at it. When I present, I usually do it on a very narrow point, on the neurotransmitters.

But as parents in the room—and again, we've talked about this—for young people being out between the hours of midnight and eight o'clock in the morning while on a stimulant, you need to know they're going to sleep for the next 24 hours. Young people have healthier bodies, but just in terms of the short-term effects of that—

[Translation]

Mr. Réal Ménard: This is not what my question is about. I don't think [Editor's Note: Inaudible]. This is not what I said. What I'm trying to understand is that ecstasy, as far as I can see it empirically, can... In my riding, there are people who use cocaine and heroin and who are stoned and have functional problems. People I know who use ecstasy do it in raves but they are professionals, architects, engineers, lawyers who apparently don't have any functional problems.

If marijuana is legalized, should we also legalize ecstasy? The argument we're hearing is that ecstasy creates a problem by reducing the level of serotonin, which means that high use causes mood swings which lead to depression. Is serotonin renewable? What information do we have on the damage to mental balance and on mood-altering effects? This is what I want to understand.

Perhaps you can't answer this question. We may then try to find the article you quoted. I made a note about it. Maybe your colleague... I'm trying to understand the actual effects of ecstasy and what it would mean if the committee chose to legalize it.

[English]

The Chair: For instance, are there long-term depression studies in regard to ecstasy?

À (1040)

Mr. Shaun Black: The problem is that ecstasy use in Canada has not been occurring for a long enough period of time. It has only been around for probably ten years, so the fundamental problem is what you mean by “long-term”.

Secondly, when you're asking about serotonergic damage, I put up those two slides on some animal models. They've shown the same thing as the functional damages that have occurred in rats' brains as well.

From the point of view of legalization, ecstasy was a drug actually introduced in 1914 by the pharmaceutical company Merck. It was introduced as an appetite suppressant. It was actually part of the First World War. The soldiers were using it then. Clinically, what they found was that the soldiers were exhibiting bizarre behavioural responses while on it. Stimulants are used to keep people up. In terms of that, it was pulled off the market in 1915 or 1916, very shortly after it was introduced. So I would base that upon whether...

To me, legalization isn't the issue; it's whether or not a drug has any therapeutic value. In 1985, when psychologists and psychiatrists were using it to supposedly improve therapeutic intimacy with their clients, the Food and Drug Administration removed it from that marketplace as well. So I think there's a wealth of information about it.

So on that question about legalization, does it have a therapeutic value? Figure that one out first, and then your next step might be one in regard to legalization.

[Translation]

Mr. Réal Ménard: Do I have time for a last question?

The Chair: A very brief one.

Mr. Réal Ménard: We've heard a few times in this committee that the difference between marijuana users in the 1960s and now is that there's a higher level of THC that can therefore be more harmful. One of our first witnesses tabled a report quoting from a UK study which said that legalizing marijuana would have few negative consequences.

To the best of your knowledge, did Health Canada laboratories or other Canadian laboratories conduct really serious studies on marijuana, THC and short-term memory?

[English]

Mr. Shaun Black: There's a paper either in The Lancet or in The New England Journal of Medicine on the adverse consequences of cannabis. It goes through dependency, immunological response, pregnancy, and short-term memory, although I can't quote the paper exactly.

With respect to Health Canada, I think that's the issue right now in regard to being licensed to possess marijuana for medicinal purposes. I think Health Canada is showing leadership, in that it has issued a five-year contract to a company in Saskatchewan to produce 5%-THC marijuana in both bulk and cigarette form, in order to look at its medicinal value. Under tighter scientific scrutiny, we'll be able to look at the health consequences of that drug.

To answer your question about the long-term and short-term stuff, though, sir, I can't quote a journal article. I can only tell you that either The Lancet or The New England Journal of Medicine actually did that.

The Chair: Thank you. We'll get that article.

Did anybody else want to comment? No?

[Translation]

Thank you very much.

[English]

Dr. Fry.

Ms. Hedy Fry (Vancouver Centre, Lib.): Thanks very much. My question is for Mr. Black.

I think you make a very important point that is at the heart of what this committee is looking at. It really doesn't have to do with whether a substance is addictive or not addictive. The misuse and abuse of any substance has to do with its harm to the individual in some form, or with its harm to society. That indeed is how we should be looking at this, because no drug that I know of is totally without harm. In other words, when you use it and how you use it is what we're talking about. We have a tendency to think that if it's not addictive, then as you say, some people will say it's a fine drug because they can handle it, and that it therefore should be taken willy-nilly and whatever.

I wanted to ask you about something with regard to methadone. Some people see methadone as a type of bridging, as hopefully being a bridge to help people to move off the potentially dangerous component of the injectable drug, etc., and to move them to a space in which they can start talking about living a different life and getting off the drug. We know there are people who are resistant to methadone. Well, it's not that they're resistant; it just doesn't work for them.

You talked about LAAM as well, but there is also a consideration from some people that for some of these methadone-resistant people, heroin per se may be something worth trying. No trials have been done on this yet, but what do you think of the concept of some sort of heroin trial that is completely and properly done? It would be a full-blind study done over a period of time, with very good evaluations for those people who cannot use the methadone. I'd like your answer to that question.

Finally, Mr. Graham, why is it that we see a solvent use and abuse rate that is so high in aboriginal communities? Is it just because of ease of access? Is that the only reason? We don't see the same percentage of solvent abuse in non-aboriginal communities. Given that it's so easy to access, I just want to know why more young people aren't using solvents.

Those are my two questions.

À (1045)

The Chair: I think Ms. MacIsaac also wants to comment on the methadone one as well.

Do you want to start, Ms. MacIsaac?

Ms. Cindy MacIsaac: I'm thinking about the methadone and the heroin. Shaun may know more about this than I do, but methadone does not have a euphoric effect, so they're not experiencing a high as such. I don't know if that would be possible with a heroin treatment. I think heroin may be more of a substitute.

The Chair: But what about a trial—

Ms. Hedy Fry: —a trial with people who are completely unable to use methadone? That's what I'm asking about.

Ms. Cindy MacIsaac: I don't know if somebody is completely unable to use methadone. I'm just not sure everybody is willing to work with methadone.

Ms. Hedy Fry: Shaun, would you like to answer that one?

Mr. Shaun Black: Yes.

As a scientist or a researcher, if you used the words “placebo-controlled, double-blinded study”, with all the ethics and so forth in place for it, I would have to be for that. My professors from university would not be happy campers right now if I were to say it would not be a good idea. For our particular country now and for where we are with methadone in its utility and its delivery, though, I would be opposed to such a study. I just don't think we've really exhausted all the models that could be applicable to the delivery of methadone.

Secondly, heroin's pharmacology is far different from that of methadone. As Cindy has said, from a euphoric point of view, there is no comparison between taking methadone and taking heroin.

Now, is that the best way for scientists to look at it? I'm worried about any potential diversion from that, because even when people are on methadone right now, there may be some diversion to the street as well. So although across the world they've done heroin substitution trials for “methadone-resisting clients”, I'm not in favour of them in our particular country, but that's more of a subjective feeling that I have. I'm worried about the consequences of that, and, secondly, I'm worried that, from a scientific point of view, we—meaning Health Canada and our country—haven't fully examined all the potential values and usefulness of methadone right now. I think there could be tremendous health care consequences to that.

The Chair: Thank you.

Mr. Graham.

Mr. John Graham: In terms of why aboriginal youths are using solvents, it's a good question and a difficult one to answer. Some of the information that I showed earlier...

One reason is definitely easy access. It's easy to find gas in the community. It's all around us.

These are also isolated communities, so access to many of the other drugs that are being talked about by my colleagues are not problems in Labrador. Alcohol, marijuana, and LSD are the ones we're seeing. We're seeing other drugs, but those are the ones we're seeing problems with. Again, though, drugs and alcohol are not easily available in many of the isolated communities. In terms of getting alcohol into the communities, there is no place to sell it there. It's flown in or whatever, so ease of access is one of the issues for sure.

We're seeing the youths starting on solvents at a very young age. They're experimenting with solvents as earlier as 6 years old. We see a lot of youths aged between 12 and 16. We also see that, at around 16 or 17, they begin to switch to using alcohol and to using other drugs like marijuana and LSD.

I'd also like to point to one of my slides, which showed that of the youths coming into treatment centres because of solvent abuse, approximately 90% have family members who also have addiction problems. So one of the issues is parenting. There's a need for parents to know where their children are, and there's a need to know the parents are going to discipline their children. Those are some of the issues that need to be addressed in the communities we're working with.

Does that answer some of your questions?

À (1050)

Ms. Hedy Fry: Some, but not all.

Ease of access would be the same for any youth living in any rural community. My question is why aboriginal kids are so susceptible to or so prone to using solvents when non-aboriginal kids in other isolated areas—kids who have the same problems with access to other drugs and the same ease of access to solvents—aren't using solvents to the same extent? Is there some sort of physiological, pharmacological, cultural...? Is there something else here that we don't understand?

Mr. John Graham: I haven't seen any studies or had any information that would suggest that there's a physiological component to that.

Ms. Hedy Fry: Is it cultural?

Mr. John Graham: It seems to be cultural, yes.

We look at many of the communities. Even if I look at Labrador, not all of the aboriginal communities have youths who are using. Again, some of those factors behind that may be parenting or may be boredom. We're finding that most of the kids who are using are saying they're bored. If we look at some of the communities that have good recreational programs, ones in which children are attending school on a regular basis, we're finding that those are some of the factors that reduce their usage of solvents.

The Chair: Thank you, Dr. Fry.

Mr. Sorenson, followed by Mr. Lee.

Mr. Kevin Sorenson: Just as a follow-up to what Ms. Fry asked, Mr. Graham, you listed some things that would, according to your research, help aboriginal communities and help the communities you serve. Some of those were promoting strong families, building academic and employment skills, providing mentors and mentoring, and building social skills.

I've been involved in aboriginal communities. Wouldn't it be fair to say one of the reasons we see such things in aboriginal communities is that we perhaps have a breakdown, basically, of the family unit, perhaps at a higher degree than what we see in other communities? We do have a lack of academic and employment skills in many of our aboriginal communities, and there is a strong need there. Couldn't we just do a reverse on that answer to Ms. Fry by saying that's part of the problem that we see in a lot of aboriginal communities?

I want to go back to the methadone issue again. I'm having a hard time understanding it. I always thought methadone was used to bring someone down from drugs. Today, I'm basically getting the feeling that it's just another drug that can be given once a day rather than four times a day, and that it doesn't have to be administered by a needle but can be given via a drink, a pill, or whatever. Basically, methadone is more specific to harm reduction that it is to removing someone from a dependency on drugs. Is that assessment correct?

The Chair: First of all, Mr. Graham, could you comment on the other issue that was raised?

Mr. John Graham: I would say there is. When we're looking at prevention, one of the things we do need to be looking at does in fact include helping some of the families having difficulty with their own addiction, in order to deal with that addiction. Having youths coming for treatment at our centres and then going back to home environments that haven't changed is a recipe for failure. In other words, we need to be dealing with some of the addictions in the homes of those youths who are coming out for treatment.

Children are coming to our centre, are getting academic skills, and are improving their own skills and their own sense of their own destination. We're finding that they are able to control these things, and we are seeing some successes. They're going back to their home communities, participating in the school programs, and using those programs as an anchor, as a place where they can maintain their sobriety.

Even in Labrador, we see a difference between aboriginal communities. I don't want to give the impression that there's a breakdown in the family unit in all aboriginal communities, but we're seeing that breakdown in some of our communities. In some communities, we're seeing strong families. Where there are good recreation programs and things like that in a community, those youths aren't getting into trouble in the same in which youths do in other communities.

Some of your comments very accurately reflect the things I've said as well in terms of needing to respond in the area of prevention; needing to target the families; needing to look at strengthening the families; and helping the families work with their youths, their own sense of their self-mastery skills, and their ability as parents to control their own destination, influence their children's future, discipline their children if those children need discipline, and be aware of where their children are at night.

Thank you for your question.

À (1055)

The Chair: Mr. Black or Ms. MacIsaac.

Mr. Shaun Black: Could I just ask you to reiterate the last part of what you were saying about methadone? Maybe Cindy and I can then address it.

Mr. Kevin Sorenson: Basically, it was about drug substitution. My concern today is that we're using methadone as a treatment or substitute because these people can't afford the drugs on the street. If we were going to set up a methadone treatment program, how would we ensure that it was not simply a drug replacement program?

Mr. Shaun Black: First of all, it's usually called methadone maintenance treatment, and one aspect of it would be pharmacological substitution.

I've borrowed from what the chair has asked me to do. I've breathed, stopped, and reiterated over and over again the point about substituting for the intravenous route by using something with a long half-life and giving it via an oral route. But that's only one aspect of pharmacological substitution. Within any methadone program, there will be a litany of clinical expectations and deliveries in terms of a comprehensive program.

Health Canada will be releasing a best practices manual on methadone maintenance treatment. I was on the working group that oversaw that, and I can suggest quite strongly that a lot of the issues, from a clinical delivery point of view, will be addressed in that particular document.

After the pharmacological substitution is achieved, methadone is the drug of choice to do that, in my opinion. In terms of the outcomes of the value of methadone maintenance, the other parts of it are well listed in the literature. There have been improvements in employment and there have been improvements in parenting skills. I realize those are softer outcomes, but they are critically important.

I'll give you an example. A number of years ago, 35 individuals wanted methadone maintenance here, and 38 children were involved. As part of being an opiate user, your parenting skills are diminished significantly, but by taking a drug once a day instead of multiple times a day, the parenting skills improve. There are economic benefits to society, the criminal activity associated with getting the drug is then waylaid a bit, and there are huge pregnancy outcome benefits to methadone as well. So I'm hoping that neither Cindy nor I have ever left a message here in any way that methadone maintenance treatment is simply a pharmacological substitution.

Our particular program at Drug Dependency Services is a twelve-week program that you come to every day for the first six weeks, and then every day except on the weekends for the next six before you even get to the community. We have a methadone recovery group, we have immunization, and we have partners in the community to do that as well, and all the addiction counselling programs are there. That is my vision of what a methadone program should be. The very first part is the methadone, and the rest of it would then have to go along with it.

And I think you've raised a good point, because I've reiterated this thing about talking slowly and using periods and commas in my sentences. I have reiterated over and over the idea of once-a-day dosing, but that's barely the surface of what methadone maintenance should be.

Mr. Kevin Sorenson: Let's say we've had a discussion on marijuana as the gateway to other drugs. Let's say we're in a prison where someone has not—

The Chair: But we didn't actually discuss that with this panel.

Mr. Kevin Sorenson: No, but we have heard other people over the past week say that marijuana is a gateway to other drugs.

If we were in a prison where someone had not had heroin and had not had cocaine, but had used marijuana fairly constantly over a period of time, what would happen if he started taking methadone?

Mr. Shaun Black: Let's assume you and I are non-tolerant, opiate-dependent people, and that our response would be the same as that of a person entering into corrections. Methadone is an opiate. If you've ever had surgery and then had Demoral or morphine after you woke up, you know how good it feels when the pain is relieved and you go off into a dream-like state. That's the effect of a narcotic. Depending upon how much you take, you get immediate relief for your pain. You get sleepy. Your respiratory system might start to decrease and you could die, depending on the particular dose that you take.

Fundamentally, within the addiction world, when you line up a set of drugs in front of people and don't tell them what those drugs are...if I did that at this table and you all took the drugs, I would guarantee you that you would not all respond the same way.

The Chair: Can I clarify something? People don't get methadone to replace marijuana.

Mr. Kevin Sorenson: No, I'm not saying that. What I'm saying is that if we were in a correctional facility where some people were drug-dependent, and of we incorporated a methadone treatment centre there—

The Chair: [Editor's Note: Inaudible]

Mr. Kevin Sorenson: Okay, but for the heroin, what I'm asking is whether or not there's an advantage for a guy in prison who's looking for something and can get methadone all of a sudden.

The Chair: Someone who was never using drugs?

Mr. Kevin Sorenson: Someone who was using marijuana perhaps, but was not on heroin.

Mr. Shaun Black: Within a correctional setting, no prescription medication would ever be used without a full assessment.

The Chair: You wouldn't get heart drugs or insulin without—

Mr. Shaun Black: That would never happen. The medical side would not allow that to happen.

Secondly—

Mr. Kevin Sorenson: The black market has any kind of pill at any time.

Mr. Shaun Black: That's fully understood, but the way you made it sound, you were saying that would be something that would be accessible in there. Any black-market diversion within a correctional setting would make us all vulnerable while we're in there. There is a lethal dose to methadone. It's 70 milligrams in a non-tolerant individual. If you were part of a methadone program, you would have to be fully assessed, and as Cindy and I have said, you wouldn't get it unless you showed me some opiate withdrawal symptoms. Therefore, I don't think that particular analogy would actually happen.

Ms. Cindy MacIsaac: There would be urine and blood testing as well.

Mr. Shaun Black: Yes, there would be urine testing to find out if you're actually opiate-dependent.

Mr. Kevin Sorenson: I have one other quick question here, on the last slide that you showed us, Mr. Black, regarding ecstasy and serotonin. It showed how parts of the brain had been destroyed and how the membranes had deteriorated. How constantly had the drug been administered?

Mr. Shaun Black: I'm not sure. That was in an animal—

Mr. Kevin Sorenson: It was in a monkey, but you said they had a seven-year...was that a seven-year...?

Mr. Shaun Black: In that actual model, it was the normal period without any drug. They exposed the monkeys for two weeks, and they autopsied one of them. They then didn't administer any more for the next seven years. That was to show—

Mr. Kevin Sorenson: So it was used for two weeks, period.

Mr. Shaun Black: Yes, two weeks.

Mr. Kevin Sorenson: And after seven years, we still saw a very dramatic change and a very dramatic picture of how the brain was different.

Mr. Shaun Black: Yes.

Now, the science behind that—the clinical significance, the research, and the set-up—was more or less demonstrated here in order for us to talk about that particular issue as a country. The clinical significance of it has yet to be determined, but having seen it, it frightens me from an addiction point of view. And within Cindy's population, I'm not sure what she has seen in regard to ecstasy use over the long term either.

Ms. Cindy MacIsaac: It's not as predominant. We don't see a lot of the ecstasy usage.

Mr. Kevin Sorenson: Mr. Graham mentioned using the sweat lodge. From a pharmaceutical point of view, does a sweat lodge work? We know alcohol and things like that can be sweated out of the system, but from a pharmaceutical point of view on other drugs, is there any advantage to sweat lodges?

Mr. Shaun Black: I don't have that research, so I would base it upon John's understanding of that. I honestly do not know.

The Chair: John, are you aware of any studies that show benefits from sweating out the drugs that are in your system?

Mr. John Graham: I haven't seen any studies. For youths who have been in the sweat lodge at the centre and haven't been sniffing gas for a while, though, we notice that when they go into the gym to play a game of basketball, we can start to smell the gas again. In other words, it is coming out of their bodies. It's lodged in their fat and we smell it when they sweat it out. What we think is happening is that it is coming out of the fat at that point, and this is helping them to detoxify themselves.

Mr. Kevin Sorenson: That's why people smell hamburgers when I go to a gym.

Voices: Oh, oh!

The Chair: We won't get into the pharmacological effects of that.

Mr. Kevin Sorenson: Thank you, Madam Chair.

The Chair: Thank you.

Mr. Lee.

Mr. Derek Lee: Thank you, Madam Chair.

That sounded like a commercial for fast foods.

I had several questions, but the major one was touched upon by Mr. Sorenson. I wanted to find something out—and I asked this question yesterday. Does anyone on this panel have any idea of the approximate size of the opiate-dependent population around greater Halifax? Has anyone ever tried to put a number on it? Is it 200? Is it 2,000?

Á (1105)

Ms. Cindy MacIsaac: We have 500 coded drug users using Mainline Needle Exchange, primarily in the Halifax–Dartmouth area. We also have individuals coming in from the rural areas to access that service for needles.

Mr. Derek Lee: In addition to those who are taking their drugs by IV, would others be dependent on opiates that they don't take intravenously?

Mr. Shaun Black: Oh, yes. At the moment, there's a prescription monitoring program in Nova Scotia. Through that program—and these are guesses, but my numbers are fairly close—we know about 250,000 opiate prescriptions are written on a yearly basis, 175,000 of which are codeine-based.

Our detox doesn't just have people who use opiates intravenously. They could be using something as simple as Tylenol No. 1, which is available over the counter. It has eight milligrams of codeine in it. The biggest problem with that medication is its acetaminophen, which can destroy the liver. Lots of individuals get into problems with Tylenol No. 3, Percodan, Percocet, Darvon, and others that are taken orally. In other words, again, the committee should not underestimate the oral opiate problem that can also occur.

In terms of estimates, there are estimates in the literature. It's estimated that there are anywhere from 60,000 to 90,000 illicit opiate users in Canada. World prevalence rates are usually 1,000 to 4,000 per million in population, so those would be rough estimates for that. In combination with Cindy, we've had about 225 separate individuals coming through our methadone program since 1996.

Last but not least, to identify the IV opiate user is a little bit problematic, in that they're probably IV-ing other drugs in combination with it. Fundamentally, the biggest change we're seeing now really is poly-drug abuse. Trying to glean out how many people use alcohol, how many use benzoates, and how many use opiates, becomes a very difficult question.

Mr. Derek Lee: Are we talking almost definitely about a number in excess of 1,000 people in the Halifax area?

Mr. Shaun Black: No, there are about 400,000 here, and about a million in the province.

Mr. Derek Lee: I'm sorry. I'm talking about drug-dependent people, not about the population.

Mr. Shaun Black: What was your number again?

Mr. Derek Lee: In excess of 1,000 persons in and around Halifax would be opiate-dependent. If we just used the statistics, it might even be a couple of thousand.

Mr. Shaun Black: That's a world prevalence rate. The cultural and societal demographics in Canada are different from elsewhere, but, yes, that may be a possibility.

Mr. Derek Lee: So if I just threw out the figure of 1,000 to 2,000, you wouldn't throw me off the ship.

Mr. Shaun Black: It would depend on how big the ship is—

Mr. Derek Lee: But you wouldn't throw me off.

Mr. Shaun Black: —and how much food is on it.

Mr. Derek Lee: But I could be right? I wouldn't be...?

Mr. Shaun Black: No, you would not be totally.... That's part of what Cindy and others and I have talked about. It may be that the actual numbers are larger than we're able to actually treat.

Mr. Derek Lee: Of the big social harm groups here, one of them is the IV users because of the higher risk of spread of the deadly viruses HIV and hepatitis-C. Those are killers and those are being spread by IV drug use, right?

Mr. Shaun Black: Yes.

Mr. Derek Lee: These are big harms, so this would be a target group. From a public health point of view, we have to deal with this.

Mr. Shaun Black: It may be that the services that have been available to IV drug users are also an issue that has been driving this. As you start to offer and develop services and as you change the culture of organizations, I think you are able to attract people who may not have had access to the services before. As this issue is talked about, language that was used in mid-1990s about the marginalization and stigmatization of IV drug users is being addressed within a lot of our community groups, and that makes our services a little bit friendlier for them.

Mr. Derek Lee: You have 500 people in the Halifax area who are registered in some provincial system. That's what I took your number of 500 to mean.

Ms. Cindy MacIsaac: There are 500 coded—

Mr. Derek Lee: What is “coded”?

Ms. Cindy MacIsaac: “Coded” means they either have a first name or they come on a regular basis. There could be more as well on a regular basis.

Á (1110)

Mr. Derek Lee: They come where?

Ms. Cindy MacIsaac: To the needle exchange.

Mr. Derek Lee: Oh, you're talking about your own needle exchange, in that 500 persons have contacted it.

Ms. Cindy MacIsaac: They have contacted us or have returned and exchanged needles.

Mr. Derek Lee: All right. And you have a program now that will handle sixty people for methadone maintenance.

Ms. Cindy MacIsaac: Yes.

Mr. Derek Lee: Okay, that's what I was looking for.

Ms. Cindy MacIsaac: In terms of the risk of the target population that uses opiates, I would say 85 percent to 90 percent of the opiate addicts start taking opiates in pill form. Quite often, it's due to an injury. Because of that injury, they're taking opiates for pain. They find that they develop a tolerance and—

Mr. Derek Lee: I understand that. We've come across that a lot, and it takes me to the next issue.

You probably don't have the technical answers to this, but how is it that there appears to be so much abuse of prescription drugs, drugs that are supposed to be controlled by doctors and pharmacists? We keep running into people who are addicted through that linkage and who serve their addiction through that mechanism.

As a legislator, I'm saying the control system we have for prescription drugs, at least in this region, is in a disastrous state of organization. Somebody has to be dropping the ball, because we're seeing too many people in too many places whose addictions are related to drugs they acquire through prescriptions directly or indirectly.

I can go through the list, but it has already been mentioned here today. It's not the black-market-supplied heroin or cocaine, although those drugs are certainly out there. It's all the drugs you see in the pharmacy, where you have a dispensary and you need a piece of paper to get them.

Somebody somewhere is letting us down. Do you know why that is? Is there more than one link? Are our doctors and pharmacists conspiring to undermine our social order by shovelling these drugs out the back door? What's happening?

The Chair: They don't seem to care.

Mr. Derek Lee: I don't know what's going on. I'll admit that, in different regions of the country, there are different drugs of choice and different sources. You have gasoline in one spot, hairspray in another, and codeine in a third. But in this particular region, it's in our face with prescription drugs.

Do any of you have a comment on that?

The Chair: Mr. Black?

Mr. Shaun Black: Yes, I do.

The problem with prescription medications is not a totally flawed breakdown in the system. One level of problem would be the education that our pharmacists and physicians are receiving in the area of addictions. In their private practices, they receive far more education in areas they're probably never going to be faced with. In my opinion, the concept of someone with a drug and alcohol problem being in a general practitioner's office is not being addressed uniformly in the medical schools across the country.

Let's be honest. To address issues of addiction with a patient.... Imagine those of you in this esteemed room trying to address the issue of an addiction with a loved one. I think it brings up an awful lot of issues. To get to the appropriate training level for our health care professionals, it would have to be something we have to examine right across the board.

There are examples across this country of where they're looking at this, but I can say here that, at least in our city, those concepts of addiction and treatment do not exist in the training of our health care professionals.

Another problem with opiates is that when people become tolerant for analgesic or pain purposes, the dosage can often get very high. That's a question of good health care management. The issue around opiates is managing pain. In some cases, we ran into the problem of everyone being worried about addiction if they're on an opiate. However, when you really look at the numbers of opiate prescriptions that are out there, relative to the number of people who get into opiate abuse or addiction, those numbers are relatively small.

I would disagree that we have a breakdown right across the system relative to the amount that's out there. The vast majority of people do not like the effects of an opiate. They don't like them, so not everyone is going to gravitate in that direction. When they do, though, the consequences are going to be very severe.

Fundamentally, when we're asking questions about prescribing and about addiction when the dosages get to be very high, training would improve that. But I disagree that there's a fundamental breakdown around that.

Secondly, prescription medications are perceived to be safe. If I walk into a doctor's office and I'm given a prescription, I'm being told this drug is safe for me. That's the message. I'm given something by someone with a lot of education. I get it at a pharmacy, and linkages for safety and protection are related to it, so there's an intrinsic sense of safety. But as your dosages get higher, you may start to like the effects. With pain management, though, if you're not getting enough, then you're using more and more.

I don't want to go on ad nauseam, but you're asking about where the breakdowns may be. I think there's an educational breakdown in addiction training for healthcare professionals, and there's a bit of a breakdown in terms of funding the agencies that can provide the treatment for that. Secondly, but not least, when you look at the numbers in terms of percentages of individuals who get into problems with addictions, and when they're matched to the funding in our country right now to deal with them, there's a total mismatch. I'm not a politician, but that's the bottom line. The money is not there to do it in the organizations that we come from.

I'll stop there.

Mr. Derek Lee: Thank you.

Mr. Shaun Black: Can I add one last thing? The Nova Scotia Prescription Monitoring Program—I'm a non-voting member on that particular board—does an absolutely fabulous job at working with community partners such as us. They've been at our meetings, and they know there are flaws in the system.

I don't know if you've heard about this across the country, but there are some problems with prescription monitoring in terms of the release of the information that is collected. Monitoring programs here in the Maritimes can monitor opiates, amphetamines, and barbiturates, but if you're a family practitioner, there are all sorts of legal implications around some of the information you may get back. Oftentimes, a family GP has problems even getting the information back.

Á (1115)

Mr. Derek Lee: I have two more quick questions.

Your statistic on cannabis use among youths— or it may have been the general population—was around 40 percent, plus or minus. That's fairly high, and it exceeds the usage of tobacco in one instance or one age group. It's not legal to possess that particular drug, so we have a very high percentage here of what I would call law-breaking and...what's the other part of it? I don't know. But those statistics have been ratcheting up over the years. We didn't get there overnight.

Do you have any comment on the social impacts, if any, in regard to that apparently relatively high level of use of cannabis?

The Chair: Just to clarify something, those were Christiane Poulin's stats.

Mr. Derek Lee: The same stats?

The Chair: Yes, and they were only for 1998. Cannabis exceeded nicotine in that particular year.

Mr. Derek Lee: Yes, I just saw it on the graph here this morning. More people are smoking marijuana than are smoking tobacco, but that wouldn't be immediately apparent from the retail shelf of the local variety store.

The Chair: No.

Mr. Black, do you have any comment?

And it may be something we need to send a question on to Madam Poulin about, not these guys.

Mr. Derek Lee: I'm going to ask him for it, though.

Mr. Shaun Black: There are a couple of issues here. That work studied students from grades 7, 9, 10, and 12. That's the first issue. There's quite a change from grade 7 to grade 12 in terms of the people there. In our organization, cannabis use—this is from CHOICES, our adolescent program—outweighs nicotine.

I heard the concept of a gateway drug. There's a lot of debate around gateway drugs if you're smoking cigarettes. As young adolescents, if you're smoking cigarettes, you have the technique to bring the cannabis into your lungs. If I'm faced with smoking cannabis or nicotine, and if I get high from the cannabis, I'd probably use the nicotine. We've all been youths before.

The Chair: Do you mean that you'd use the cannabis?

Mr. Shaun Black: From a treatment point of view, as a young adolescent, if I'm faced with the option of having cannabis or nicotine, and if I'm a cigarette smoker, I think it explains why cannabis use outweighs the others.

I think that rise is varied with tobacco and other products. As you know, if your parents smoked, then you're more likely to smoke. From a societal point of view over the last ten years, the talk about legalization and parents' views on things has translated down to our children, and that may explain it.

The impact of this is way beyond my understanding of all the things that could have contributed to the ten-year change in reported use.

Á (1120)

Mr. Derek Lee: Join the club.

Mr. Shaun Black: Yes.

The Chair: Can I ask a question while you're thinking about your last one, Mr. Lee?

Mr. Derek Lee: Yes, Madam Chair, please go ahead.

The Chair: Mr. Black, what committee on pharmaceutical drugs do you sit on?

Mr. Shaun Black: I'm a non-voting member on the Nova Scotia Prescription Monitoring Program, which is comprised of six voting members from the pharmacy, dental, and physician communities.

The Chair: Well, it's fair to say we've been quite stunned by the high prescription rate for Dilaudid in this province, and the ease with which people seem to be getting it. And it's not just the ease with which they've been getting it, but the ability to double-, triple-...I don't even know what “eight-times”-doctoring is.

The fact is that we met people who were given 270 pills at a walk-in clinic, with a double repeat. I can see how there may be some value in needing a walk-in clinic on a Saturday night in order to get a couple of pills to hold you over until Monday, when you can go back to your normal doctor. But to get 270 or however many pills that you can order the repeats on immediately, because they're really not holding you until the end of those pills? It's an industry. You get pills, you sell the drugs. You feed your other habits or you put dinner on the table. I'm not sure what people are doing.

I think all of us have been quite stunned by the information we've been given here. Some have suggested in some of their comments that it's just Dilaudid. If it wasn't Dilaudid, though, it might be heroin or it might be other things that would be the bigger choices here. But it would seem there isn't a very good monitoring system.

Yesterday, we heard from someone who said that doctors don't have real-time information, which doesn't help them. The pharmacists also don't have real-time information about what's being linked, although perhaps that was mentioned in New Brunswick, actually.

It's too bad we didn't get the name of the doctor. I think he should be reported, given the information we got yesterday. It's outrageous.

We also heard at the clinic, Cindy, that people were dropped out of a hospital on a Saturday, having had Dilaudid—I'm not positive—maybe for the first time, but with no concept that, you know what, they might have developed a little problem and that someone had better manage this. No one told them an exit strategy for leaving the hospital following their surgery because it was thought there could be some other problems there. It should not have been a case of, “By the way, you've been out for two days and you're going through withdrawal, so we'll put you back on drugs.”

Mr. Black, you said there doesn't seem to be a lot of education and awareness. I don't understand why there isn't a huge push to get Dalhousie Medical School—I think that's the medical school here—to do something serious, knowing that a lot of the doctors are going to be practising in this area. Yes, nationally, we have to do something, but to most of us on this committee, what is currently going on in this area is outrageous.

That was a bit of a statement more than it was a question, but could additional initiatives be undertaken? Are we missing things? Are we not understanding something that's missing in this process?

You're a non-voting member, but you're the closest we've gotten to anybody on the committee.

Mr. Shaun Black: Please, do not walk away from the Atlantic provinces with the assumptions that our medical professionals and others who are involved aren't on top of this and that this is a huge problem. I would absolutely challenge every member of this particular group that, outside of Montreal, Toronto, and Vancouver, your primary opiate problem is not prescription. And I can challenge you because I've sat on the board—

The Chair: Is prescription.

Mr. Shaun Black: Right, is prescription.

So please do not walk away from the Maritimes seeing just bucketfuls of prescriptions out on the street, and that we're different from anywhere else, other than the three cities I've mentioned. That would be a horrible—

The Chair: You're absolutely right. We spend more time in the bigger cities.

Mr. Réal Ménard: There is a difference between Montreal, Toronto, and Vancouver, absolutely.

The Chair: But I think Mr. Black's point is right, Mr. Ménard. We have been in the bigger cities; we haven't been in as many rural environments. While Halifax is the biggest city here, it may be more of a rural or a not-Toronto-Vancouver-Montreal problem.

Á (1125)

Mr. Shaun Black: Given the dynamic of heroin, you'd want a big population to sell it to. That's what you would need. To bring heroin here, you'd probably be bringing it across from the west. There would be all sorts of problems to circumvent legally, like the police, the RCMP. We don't have the population base to probably support heroin.

The Chair: Hopefully, you never will.

Mr. Shaun Black: Yes, God bless. Let's hope that's the case.

So, again, to think these things are not being...you asked what our impressions would be on some of those things—

The Chair: Okay, but let's say there's a problem in rural Manitoba, in rural Ontario, in all these other places. Let's say it's going on. There is a captive audience here, you do have a medical school here, and you do have a pharmacists' association here in this province. What are the initiatives that we're not hearing about that will improve the situation, that will manage the situation, that will prevent the intensity of the problems?

You're right. It's probably not the majority of the population. Even for the majority of the population using opiates to manage pain on a regular basis, it's only a subgroup as well. But we seem to have met a number of them, and the ease with which they were facilitated in their habit is extremely disturbing. These were not Ms. MacIsaac's clients, people whose doctors are helping them to manage until they can get into the methadone program. These were people who were given 270 pills with a double repeat at a walk-in clinic in Halifax, and they have a serious opiate problem. And I can't believe any doctor would have prescribed that in the first place.

Mr. Shaun Black: That is inappropriate prescribing. In the way the Prescription Monitoring Program is set up, there are thresholds. If they are exceeded, you receive either an explain or alert letter. In an explain letter, you have to write back and say why you prescribed that much.

Secondly, for the person walking in there, there are lots of ways to get health card numbers around here. On the issues associated with that particular example, I'm in total agreement with the people at the table. That's inappropriate prescribing and dispensing.

When that information was given, did it come from a reputable source? Where did it come from?

The Chair: It came from an addict who had received the pills. Interestingly, that person then met the doctor in the rehab centre because the doctor had a problem.

Mr. Derek Lee: It was non-corroborated.

The Chair: Not that doctor, another doctor.

Mr. Shaun Black: When that type of information is delivered, be careful about whether or not 270 was the exact number.

The Chair: Okay, but the double repeat on it is disturbing enough.

Mr. Shaun Black: Oh, yes, assuming it was real. All I'm suggesting is that, in terms of what that person pointed out to you, the issue here is the way in which an opiate-dependant person might be able to access—

The Chair: I'm sorry. I'm being told it was three separate prescriptions. That 270 was the total. One was for 90 Percocet, another was for 90 Dilaudid, and there were a couple of other things.

Mr. Shaun Black: And you got the paperwork?

The Chair: No, you're right, we should always be careful about the information.

Mr. Shaun Black: Oh, yes, please.

The Chair: However, it didn't seem to be stunning information. It doesn't seem to be an exception. It seems to be fairly exceptional in its intensity, but there seems to be a bit more...but even you agree that there is a need to educate more people. What 's being done for the doctors who are being trained at Dalhousie? You may not know, but is there an initiative to try to make sure they at least get an addiction course?

Mr. Shaun Black: A number of years ago, John Ruedy brought people together when the students left Dalhousie University, although I don't even know what they call the test they have to go through. The physicians graduating were not doing that well on their addiction component to those particular tests. They called a number of people together to look at that.

The Nova Scotia Prescription Monitoring Program has a program operation committee that looks at issues around dispensing. The Capital Health District called a meeting in May of last year and brought a lot of the partners across the province together to talk about it. The Mainline Needle Exchange and Direction 180 were there, along with representatives from our Capital Health District and the Nova Scotia Department of Health. It was Capital Health in nature but had provincial implications behind it, and I'm co-chairing a group right now to look at furthering that particular initiative in order to look at the prescribing of opiates and their impacts around methadone itself.

You have to realize that when it comes to opiate dependency and prescriptions in the Maritimes, there are a small number of us. In that regard, in terms of reiterating the people involved and getting people together, it's a little bit easier to do and to initiate things. So, yes, we are on top of that.

And getting back to that example of those three separate prescriptions, as a doctor, you cannot write a prescription for three different opiates in a thirty-day period of time. It can't be done.

Á (1130)

The Chair: Maybe I'll get the doctor's name and the name of the pharmacy.

Mr. Shaun Black: I'm just challenging the story, that's all.

Mr. Kevin Sorenson: Who would flag those letters? Would it be the pharmacy, would it be the people at Health Canada, or would it be whoever's paying the bill to the pharmacy?

Mr. Shaun Black: No, the letters are called “explain” or “alert.“ An explain letter would tell you that when you had prescribed this to a certain person, four other doctors had also written an opiate prescription. The flaw is that when you receive the alert letter, you're not told who the other four doctors were.

The Chair: Who writes the letter?

Mr. Shaun Black: The Prescription Monitoring Program delivers the letter after it is cued by the data-entry system itself.

The Chair: All opiates are data-entered?

Mr. Shaun Black: Yes, and then there are cues and so forth set around amounts and dispensing intervals that cannot be exceeded.

The Chair: So if I hit 99, it's okay, but if I hit 100, I'm going to generate a letter, for example.

Mr. Shaun Black: The number of prescriptions versus the length of time is always a problem, and we're addressing that right now. We're putting a narcotic prescribing guideline group together right now to look at that.

Mr. Kevin Sorenson: Obviously there would be some collaboration between the doctor and the pharmacist. If it gets by the pharmacist, who flags it after that? Is there anyone who does that?

The Chair: It's not the pharmacist who writes the letter, it's the monitoring board that writes the letter. The board monitors the pharmacist who dosed it out and the doctor who prescribed it.

Derek has a quick question, I'm going to ask all of you for your priorities, and then we have to wrap up.

Mr. Derek Lee: Just in following up, I am fairly supportive of methadone maintenance, at least as it has been developed and is being studied now. I just want to get something on the record.

We heard from Mr. Black about some of the positive effects on clients of methadone maintenance—he went through a short list earlier—but I wanted to ask Ms. MacIsaac the reverse question. Given your experience, what would you think if we were to pull the funding for the methadone maintenance program that's there now for the sixty people? What would be the negative impacts? Where do you think they would be sociologically, financially, etc.?

I am shocked, of course, that the funding for this program doesn't come from the health care system and doesn't come from the justice system, but comes from a federal housing program. I'm going to fall off my chair here—and Mr. White's making noises. I don't understand how a housing program that I thought I understood fairly well from the Toronto perspective is now being used. I'm not unhappy that it is being used for this, for the reason I stated, but I want to get this on the record too.

So could you answer the basic question about what you think would happen to your clients as a result of the withdrawal of this program?

Ms. Cindy MacIsaac: First of all, I would leave town very quickly.

I think it would be devastating for our client population. Some of the clients might be able to go over to Drug Dependency Services and might make it. There's a good possibility that they could comply and could make it. But others would probably return to their old ways and means of getting more. I think the supply and demand in this area would definitely go up, and I can't imagine what the cost would be.

In terms of socio-economics, I think the baby steps they have taken forward in this past year would become giant steps backward very quickly. That's what I think would happen.

Mr. Derek Lee: Crime rates, courtroom appearances, enforcement, and those things—

Ms. Cindy MacIsaac: That's right, definitely.

Mr. Derek Lee: I'm leading you an awful lot here, but you think they would go up.

The Chair: Please outline exactly what else it would mean.

Ms. Cindy MacIsaac: They would engage in crime, the sex trade, stealing, theft, and selling drugs, including other drugs, and cocaine use would probably increase. I think their sense of well-being, their esteem, would definitely decrease even more, and they would lose their family connections that they have established. A lot would be incarcerated.

I think the Nova Scotia Hospital would see a considerable number of them. We have several clients who have other mental health issues, but the methadone has enabled them to become stable and take their other medications on a regular basis, so I think that would be an issue. Their health would deteriorate.

Mr. Derek Lee: Thank you.

Á (1135)

The Chair: Thank you.

There are some who would suggest that the methadone maintenance program prolongs harm. In other words, it isn't reducing harm, it's prolonging harm. You've outlined how harm should include the impacts on our community and on our health care system. I would imagine that, in the needle exchange particularly, reducing the transmission of hepatitis-C isn't just about the population using intravenous drugs and engaging in some high-risk behaviours. It could affect me if I don't know. It could affect all of us. You mentioned prostitution, which touches all aspects of our society, of course, and particularly young males who often have good jobs, families, and what have you. So it spreads right across the population.

What do you say to those people who say it's harm maintenance?

Ms. Cindy MacIsaac: It's controversial. I hear it a lot. People say we're just giving an addict a drug for drugs, and they ask what harms we're decreasing. We're decreasing the spread of blood-borne diseases, we're decreasing the associated risks, and we're decreasing criminal behaviour. We're providing different levels of stability. I'm not going to say all of the addicts being maintained at Direction 180 have stable lives and have addressed the myriad of issues in their lives, but little by little—

The Chair: They don't have two kids and a car and a house in the suburbs.

Ms. Cindy MacIsaac: No, but they're beginning to address some of those things and they're beginning to experience a healthier life. They're making healthier choices. So when you look at it through that lens, you see a decrease in the harms associated with intravenous drug use.

The Chair: Okay, thank you.

We are way over our time, and I apologize to all of you for that. I do have one question for you, though, Mr. Graham. I had forgotten it.

How many kids are you actually treating at your centre? What are the outcomes that you're actually seeing? Is there any information on that? You only started in April 2000, so you've been in the field for about two years. Is there a marked difference? Can I feel like things are happening in Sheshatshiu, that those kids are getting some better chances?

Mr. John Graham: I don't have a lot of statistical information with me, but I do have some. We have 12 beds at the centre, so we have the capacity for 12 youths at a time. Our program runs for approximately 6 months, so we're able to accommodate about 24 youths a year. We have a continuous intake program, so it may be that if somebody leaves early, somebody else comes in. At the end of the year, then, it may be that we've had more than that in the program.

Just before coming down, we were talking to the RCMP in Davis Inlet. They were saying they're seeing a marked difference in Davis Inlet at the moment. They're not seeing as many youths out in the streets sniffing gas, and they're not seeing as much vandalism taking place. They indicated that they're really having problems with only three youths at the moment. That's a significant difference from what we saw a couple of years ago in terms of the number of youths sniffing gas.

So I think we are having an impact, but there is still a problem and we may see that cycle again. We might see it go up, but I'm not sure where it will go in the future. It may be that we're starting to have an impact that will sustain itself.

The Chair: Thank you.

This committee is going to hear testimony until probably about the end of June. If you have any more information, or if there's something that comes up—for example, Ms. MacIsaac, one of your clients may want to participate more actively in the process—Carol Chafe will...oh, sorry, before I do that, I have to ask you what your two priorities are for the committee. What do you want us to tell the government to do differently? Ms. MacIsaac, you can go first.

Ms. Cindy MacIsaac: In terms of intravenous drug use, I think it has to start with individuals working with this population. In communities and across the government, we have to look at this as a disability, as a disease. Drug addiction is not a moral deficiency, so we can't look at it through a criminal lens. We have to look at addiction through the lens of individuals with disabilities, because it is a disease.

The second thing would be that our approaches have to be best practices models in order to address and to capture those individuals, so that the effects are not affecting non-infected individuals, society, and the health care system. Otherwise, the costs are going to be that much greater.

Á (1140)

The Chair: Thank you.

Mr. Black.

Mr. Shaun Black: When we talk about addictions, we usually talk about a rate of 10 percent of our population having an addiction to something. For those individuals, ten others are affected. If you use those numbers across our country, nothing else is as intertwined amongst all of our families, community, and society, as addiction is. In terms of health care funding, it is one of the most poorly funded parts of all health care service delivery part in our country.

I've never been able to figure this question out. Across the board now, most organizations talk about being underfunded, about things getting more complex, about how more and more people are coming to their doors. I don't want to echo that, but I don't have a better idea. There has to be some other way in which we can talk about the need for this, but in terms of funding for addictions, it affects so many people. It's something most of us don't like to talk about, but I think Health Canada needs to take a leadership role in this and make this a priority for our country.

The second one would be the population health philosophy at Health Canada, with determinants of health being the framework or the footing for that philosophy. We talk about income and education being determinants of health, but I would also suggest that drugs and alcohol are also determinants of health. That's what I believe. Do I have the scientific background to back up what I'm saying? No. But when you think of a determinant of health, it's something that affects both your health and the entire population. Nothing else out there that I can think of affects health more than drugs and alcohol. They affect everything.

So those would be my two wishes: funding, and integrating addiction into population health and calling it a determinant of health.

The Chair: Thank you.

Mr. Graham.

Mr. John Graham: The saying is that it takes a whole community to raise a child. When I look at the communities I'm working with, it is into prevention that we need to be putting our resources. Some of those resources need to be put into building the capacity of the community, but they also need to be put into helping parents parent their children.

Secondly, I would say we need to base our treatment models on good information. We need to support addiction information systems. We need to collect data for our communities specifically, but also on a national basis. We need to be able to set up best practices, know what's working in other areas of the country, and then bring those two areas together and adjust them culturally to meet our needs. But we need to gather good information.

The Chair: Thank you.

It's always a great question that we like to ask people, because we get such great ideas from them. You have fulfilled that expectation.

We really appreciate the time you have taken to come before us. As I was saying, there is a process here. We're continuing to hear from people. If you have other information that you want to send us, if there's somebody else you think we should be talking to, or if you want to get the kids in your program to tell us what they think, Mr. Graham, we really do encourage lots of input.

Not only do we appreciate the time you have taken to prepare your presentations and to come here to talk to us, each of us at this table really appreciates the energy you have and the commitment you make to the work you're doing. We really wish you lots of success, and we hope you continue to have that great passion for your work.

As committee members, it has sometimes been fairly frustrating for us to have such a big mandate. We sometimes wish we could wave a magic wand and have the problem go away, with everyone leading healthier and happier lives. That doesn't work, though, so sometimes you hear our frustration.

In Halifax and in P.E.I., we've had some terrific panels. We've had panels on harm reduction, enforcement, and research, and now this panel on prevention and treatment, and we've also done some site visits. It has been a really awesome opportunity for us to get a better understanding. As you point out, Mr. Black, it's not just what's going on in this region, but what's going on in some of the smaller communities across the country.

So we really appreciate that you have shared your experiences and information with us. Thank you, everybody. It really has been great.

I'll now adjourn this meeting.