SNUD Committee Report
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CHAPTER 5: THE USE AND HARMFUL USE OF SUBSTANCES: PUBLIC HEALTH ISSUES Too often, drug users are portrayed as self-indulgent, morally corrupt, and generally responsible for the social and economic problems of our urban centers. Such scapegoating is entirely counterproductive and clouds the real issue. Specifically, drug use is primarily a public health issue and should be approached with prevention and treatment.135 HIV-AIDS and hepatitis are two diseases that are part of a declared public health emergency that has been called in the downtown east side, yet you have failed to act and, in doing so, have literally sentenced me and my brothers and sisters to death. HIV-AIDS prevalence rates rival those of sub-Saharan Africa, and we’re 100% saturated with hepatitis C — I repeat, 100%. There’s nobody down there who doesn’t have it. These diseases and others such as tuberculosis will eventually cost the health care system untold millions of dollars. What is particularly maddening is that it is all preventable. Overdose rates rival those anywhere in the free world. We lost 147 last year. In broad daylight last Saturday we lost a 16-year-old Aboriginal youth, a young male with a whole life ahead of him. It’s becoming unacceptable. What we need here is action. The mayor’s got it right; we have the framework for action. It’s been written, and it includes all four — enforcement, prevention, treatment, and harm reduction strategies — but it’s time to act.136 The Committee, in agreement with the vast majority of witnesses appearing before it, believes that the use and harmful use of substances are primarily public health issues. Some Canadian urban centres are the scenes of what some witnesses characterize as “public health disasters.” The most well-known and visible example is certainly the Vancouver Downtown Eastside where the Vancouver-Richmond Health Board declared a public health emergency in 1997 in response to the prevalence of HIV among injection drug users. Montreal and Toronto are also seeing soaring rates of disease and death among injection drug users in their communities. The public health crisis is on-going and cannot be ignored. Prevention, education, treatment and rehabilitation, and harm reduction are all elements of an integrated approach based on a public health model that must be implemented to address this crisis. To be successful, all partners involved in the field of addictions across Canada including provincial, territorial, and municipal authorities, as well as non-governmental agencies, must endorse and implement a public health approach. One of the things that is sorely lacking in this country is prevention and education. If you want to talk about dollars and cents and where your investments are best levered, that is certainly the area. The federal government does a great deal of work in tobacco reduction. We see Elvis Stojko skating around at the Olympics, and that is wonderful. We don’t hear anything about alcohol or drug abuse prevention.137 Research has demonstrated that a high number of young people will experiment with tobacco, alcohol, and/or illicit substances. However, “there are some who don’t use, some who use, and some who use to the extent of experiencing problems.”138 The social, health and economic costs of the harmful use of substances and dependence have clearly been established.139 Preventing the onset of substance use, reducing the risks of a progression from use to harmful use, educating young people who are engaging in substance use about safer use, and minimizing the harmful effects of excessive substance use and dependence are concerns shared by the vast majority of witnesses as well as by members of the Committee. All agree that prevention and education are key elements of Canada’s Drug Strategy. Prevention is a vital part of any drug strategy. We must embrace it not just with words, but also with concrete steps to ensure it is put in place adequately, consistently, and with the conviction needed to continue it over the long term. Prevention forms not only the most positive part of any drug strategy, any comprehensive approach to drugs, but it also is the most cost-effective component.140 How do we define prevention? Prevention is a broad concept that may best be defined in terms of a continuum of activities targeted at different populations, at different times of their lives. There are three basic categories of prevention activities: universal prevention, selective prevention, and indicated prevention.141
Dr. Christiane Poulin, associate professor at Dalhousie University and Canada Research Chair in Population Health and Addictions, told the Committee that we also need to look at harm minimization for mainstream teenagers in school to determine if such an approach should be an integral part of school-based drug prevention or drug education. At this point I’m going to bring to your attention the definition that is from Patricia Erickson, who is a criminologist. It was published in the Canadian Medical Association Journal. She breaks it down into a few components of what we think we might mean when we’re talking about harm minimization for teenagers in schools. It is education about rather than against drugs — the facts. It’s also the facts about the benefits, not just the risks. It is credible, accurate information — no propaganda. It acknowledges the appeal of drugs, why teenagers use them, but also acknowledges the flip side — the risks and the consequences. And finally, it takes into account where a teenager is in his or her development. There’s a world of difference between a 12- or 13-year-old and an 18- or 19-year-old in terms of the decisions they can make. An 18-year-old can vote for our prime minister. I’ve brought you back to the risk continuum at this point because it’s the most concrete way we’ve unearthed here in Nova Scotia by which to consider harm reduction at this point. What we’re talking about is that there’s a population of teenagers. There are some who don’t use, some who use, and some who use to the extent of experiencing problems. We need to take care of all teenagers from where they are. The idea is to bring teenagers back from the high end of the continuum, the red area, toward the green. Some teenagers will never be abstainers, but they do not need to face such dire consequences as some of them might be currently facing.142 The Committee applauds the innovative research currently being conducted by Dr. Poulin, and others, in the areas of prevention and education programming for young Canadians and believes that such research should continue and be supported under a renewed Canada’s Drug Strategy. Notwithstanding that innovative research, the Committee agrees with the majority of witnesses who appeared before it deploring the lack of funding and resources being spent on prevention in Canada. This is shocking to many witnesses as Canada’s Drug Strategy identifies prevention as one of the most cost-effective interventions. Dr. Jody Gomber, then-Director General of the Drug Strategy and Controlled Substances Programme within Health Canada, told the Committee that very limited resources are dedicated to prevention programming as prevention and education activities are, by and large, within provincial jurisdiction. We actually spend very little. Again, thinking about who all of the players are in Canada’s drug strategy, a large part of prevention activity is provincial. It becomes the province’s responsibility through the school system. It becomes the province’s responsibility through a number of other community kinds of organizations. So we spend very little ourselves on prevention.143 However, Health Canada supports some prevention activities through other initiatives within its portfolio. These prevention activities target high-risk populations such as Aboriginal people, women, children, and youth. They also address specific public health concerns such as preventing HIV/AIDS, Hepatitis C and Fetal Alcohol Syndrome/Fetal Alcohol Effect (FAS/FAE).144 Best practice documents have been published and distributed to these high-risk groups.145 Universal prevention, which addresses the determinants of health, is done mainly through “Early Child Development Initiatives” (e.g., Community Action Program for Children, Canada Prenatal Nutrition Program, and Aboriginal Head Start). In 1999, the federal government allocated $11 million over three years for the expansion of the “Canada Prenatal Nutrition Program” to allow for a sustained focus on FAS/FAE and improve the health of pregnant women. Some of these funds were used to launch a Canada-wide awareness campaign on FAS/FAE in collaboration with provincial and territorial governments. The FAS/FAE initiative includes a Canada-wide FAS/FAE Strategic Project Fund offering over $1.7 million for local projects such as FAS training for front-line workers in community-based projects. The federal government provides public health and health promotion services for First Nations people living on reserves and Inuit. The First Nations and Inuit Health Branch funds more than 500 alcohol and other substance abuse community-based prevention programs targeted at First Nations people living on reserves and Inuit, through the National Native Alcohol and Drug Abuse Program. As well, the 2001 federal budget allocated $185 million over two years to improve the well-being of Aboriginal children. Some of these funds will be used to implement the Aboriginal Head Start program and others to intensify the efforts to reduce the incidence of FAS/FAE on reserves.146 With respect to tobacco, Health Canada’s Tobacco Control Strategy has a 2001-2002 budget of $54.5 million. The Government of Canada has committed to investing over $480 million in the strategy over the next five years. The funds will reinforce existing programs, while $210 million will be directed to mass media campaigns targeted at Canadians of all age groups, with a special focus on youth and other high-risk populations. Other federal initiatives in the field of prevention include:
The DARE program is the most well-known school-based program in Canada.153 The Committee heard a significant diversity of opinion on whether and to what extent police have a role to play in delivering drug education and awareness programs in the community. Witnesses from several police forces spoke of their commitment to providing drug awareness programs within their local schools and clearly stated that they believe it to be an important service to the community, as well as a valuable opportunity to establish a relationship with youngsters at an early and impressionable age. By contrast, several witnesses challenged the effectiveness of the DARE program criticizing what they characterized as a “just say no” message that discourages honest discussion of the risks of illicit substance use, particularly among older students. The RCMP indicated that the DARE program is currently being redesigned to respond better to the needs of different age groups. Others argued that there was a need for prevention research and evaluation of prevention initiatives to ensure that drug education and awareness programs do not do more harm than good. An evaluation of the effectiveness of the DARE program in preventing the onset of substance use and in reducing the use and harmful use of substances among teenagers is on-going.154 A number of witnesses appearing before the Committee commented on the low level of public awareness related to the use and harmful use of substances. They suggested that there is not enough information or that the available information is not comprehensive or evidence-based. Concerns were also expressed over the effectiveness of a “just say no” message to drugs, since our society is rife with commercials advocating a “pill” for every problem. The Committee believes, in agreement with many witnesses appearing before it, that prevention and education activities must address the complexity of appropriate and inappropriate substance use. Finally, some witnesses expressed concerns over the lack of training on issues related to the harmful use of substances currently being offered to service providers, health professionals and others involved in this area. They suggested more accurate information and appropriate training would have a positive impact on prevention efforts as well as on the delivery of addictions services. The Committee, in agreement with the vast majority of witnesses appearing before it, believes that preventing the use and harmful use of substances can have a significant impact on the safety, security, health and overall quality of life of all Canadians. Consistent, long-term, comprehensive prevention efforts are effective. The tobacco control, and drinking and driving prevention initiatives are cases in point. Prevention does work. We know that prevention works because we have seen it in other areas. If you look at the drinking and driving campaigns, the campaigns to get people to wear seat belts and to stop smoking, these are examples of successful prevention campaigns. Every time I see commercials on TV and some of the other efforts in that area, I wonder why we don’t see the same kind of thing aimed at substance abuse prevention. We have never had that kind of a coordinated effort.155 The Committee believes that the implementation of Canada-wide mass media public awareness campaigns should be a priority of the Government of Canada. The campaigns should focus on promoting healthy lifestyles and educating the public about various licit and illicit substances and their health effects. There must also be a requirement to monitor the effectiveness of such campaigns, bearing in mind that preventing the use and harmful use of substances is a long-term process and that positive outcomes will not be evident for many years to come. The Committee also believes that prevention and education strategies should be coordinated with provincial, territorial, and municipal authorities, as well as community-based organizations, and involve various stakeholders from health, education and enforcement services as well as parents and young people. The aim of these initiatives should be to enhance community capacity, by strengthening local public health infrastructures, so as to ensure the sustained delivery of prevention programming. Prevention and education must:
1.1 COMMITTEE OBSERVATIONS - PREVENTION AND EDUCATION The Committee observed the following:
RECOMMENDATION 12 The Committee recommends that the Government of Canada, under a renewed Canada’s Drug Strategy, provide sustained funding and resources to develop and implement health-based public awareness, prevention and education programs related to the use and harmful use of substances and dependence, in collaboration with provincial, territorial, municipal authorities and community-based organizations. RECOMMENDATION 13 The Committee recommends that the Government of Canada, under a renewed Canada’s Drug Strategy, allocate funds to develop and implement effective Canada-wide mass media prevention and education campaigns related to the use and harmful use of substances and dependence. RECOMMENDATION 14 The Committee recommends that the Government of Canada, under a renewed Canada’s Drug Strategy, support the development of up-to-date information on the use and harmful use of substances and dependence, and of appropriate training for the benefit of healthcare professionals and all service providers involved in the field of addictions, in collaboration with provincial and territorial governments. 2. TREATMENT AND REHABILITATION The harmful use of substances and dependence are complex health problems that cannot be isolated from the social and economic environment in which they evolve. In many cases, individuals who develop a pattern of harmful use of substances also have a history of victimization, sexual and physical abuse, family violence, mental health issues, learning disabilities, school failure, and criminality. As a result, addiction treatment is never simple and must always be seen as part of a continuum of care that includes access to other social services such as affordable housing, education and vocational training.156 The Committee believes that a holistic, gender-relevant, comprehensive approach, which recognizes the importance of integrated services and partnerships, is an essential component of the delivery of treatment and rehabilitation programs and services. Treatment and rehabilitation services vary in their approach, philosophy, principles and goals. There are many kinds of treatment addressing the harmful use of substances and/or dependence including medical detoxification, outpatient or day programs, and short or long-term residential treatment. For most service providers, the goal of treatment is lifelong abstinence. However, many service providers specified that for some individuals, abstinence may not be realistic in the short-term and for them the best treatment may simply be crisis intervention and harm reduction, a first step toward establishing a healthier lifestyle. This is particularly true in the case of opiate dependent individuals and those addicted to cocaine, a substance that creates a severe psychological dependence, which is particularly difficult to treat. Substance dependency treatment includes many forms of therapies and/or medications, including methadone for some individuals addicted to opiates. Methadone is the only opioid currently permitted for long-term treatment of opiate-dependent persons in Canada. At this time, heroin maintenance is not an approved option. (a) Delivery of Services: The Federal Government’s Role Although the provinces and territories have primary responsibility for the development and implementation of drug and alcohol treatment services, the federal government has a role in funding them through contribution agreements. The provinces and territories provide the majority of funds for alcohol and drug treatment, through taxes, provincial health insurance funds, and federal transfer funds under the Canada Health Act. However, some federal programs also contribute dollars to treat substance-dependent individuals. The Office of Canada’s Drug Strategy provides $14 million on a cost-sharing basis, through the Alcohol and Drug Treatment and Rehabilitation Program (ADTRP), to the provinces and territories, to increase and expand innovative and effective treatment and rehabilitation programs related to alcohol and other psychoactive substances. This is an important component of Canada’s Drug Strategy, which brings all levels of government together to discuss alcohol and other substance issues and to develop best practice documents. As well, the federal government has a special role in providing health care to First Nations people living on reserves and Inuit. The harmful use of substances is one of the major health concerns among First Nations: 62% of First Nations people aged 15 and over perceive alcohol abuse as a problem in their community, while 48% state that drug abuse is an issue. Solvent abuse by youth is another concern: 22% of First Nations youth, who report solvent abuse, are chronic users.157 To address some of the issues raised by the harmful use of substances among this population, the National Native Alcohol and Drug Abuse Program (NNADAP) of the First Nations and Inuit Health Branch funds treatment services for First Nations people living on reserves and Inuit. Currently, $70 million are spent every year on this program. The goal of NNADAP is “to support First Nations and Inuit people and their communities in establishing and operating programs aimed at arresting and off-setting high levels of alcohol, drug, and solvent abuse among their target populations living on-reserve.”158 Now in its fifteenth year, the NNADAP includes a network of 54 treatment centres that represent approximately 700 in-patient treatment beds. The vast majority of the NNADAP resources (96%) are managed directly by First Nations through contribution and/or transfer agreements. The program was used by 4,616 clients in 1999-2000. The success rate was 66%. The recidivism rate was 30%. Forty-three percent of the clients are admitted for alcohol abuse, 20% for drug abuse and 24% for drug and alcohol abuse.159 There are nine treatment centres across Canada that address solvent abuse in Aboriginal communities, of which, six have been funded by Health Canada. Eight centres focus on young people between the ages of 12 and 19, and one centre addresses the needs of the 16 to 25 year old population. Together, these centres offer 114 beds across Canada at a cost of $13 million per year. Since their establishment, the centres have operated over the set capacity, treating a minimum of 228 clients each year.160 Many youths treated in these centres face numerous challenges including a history of not attending school, suicide ideation, family addiction, sexual victimization, family violence, involvement with the justice system, and prior participation in a treatment program. The treatment of solvent abuse is a relatively new area and “Canada is one of the world leaders in trying to find solutions for solvent abusers”.161 NNADAP treatment centres and the Youth Solvent Abuse Centres participate in an accreditation program developed by the Canadian Council on Health Services Accreditation. Together, they will form “the first network of treatment centres to have full accreditation in any jurisdiction on this continent.”162 The Committee recognizes the value of an accreditation process for addiction treatment facilities, as well as certification for addiction counsellors, and encourages all treatment centres and counsellors to consider the benefits of accreditation and certification. The Committee would like to express its concern for the welfare of off reserve and urban Aboriginal people and communities, many of whom live in inner city areas and are at high risk for developing a pattern of harmful use of substances and dependence. There is some confusion and controversy regarding which jurisdiction should provide services and programs to this population. The result is that urban and off reserve Aboriginal people have “fallen between the cracks.” This situation should be a priority for a renewed Canada’s Drug Strategy and may well be resolved by setting up a collaborative model among jurisdictions to specifically target urban Aboriginal people. The federal government is also responsible for the delivery of treatment programs to individuals incarcerated in federal institutions, members of the RCMP, members of the Canadian Armed Forces, and persons who have not lived in a province or territory long enough to receive insured health services.163 Delivery of treatment for federal inmates and other substance-dependent individuals involved in the criminal justice system is further discussed in Chapter 6. (b) Shortcomings in the Delivery of Treatment and Rehabilitation Services in Canada One of the main issues raised by witnesses appearing before the Committee is the delay facing individuals seeking treatment, particularly residential services, as a result of a shortage of funds and treatment beds.164 Many social, economic and political factors influence accessibility to treatment beds, and it therefore varies across Canada. The Committee was told that residential services for young people who have developed a pattern of harmful use of substances are virtually non-existent. According to a 1997 survey conducted by Health Canada, it is estimated that there were only 207 treatment programs across the country offering specialized services for adolescents.165 … in the fifth largest city in North America, Toronto, there is no residential treatment for youth. You have to go to Thunder Bay as your closest place. For a family to be involved in their teenager’s treatment is paramount, so sending your kid off to Thunder Bay is just not a good option.166 The Committee was also told that treatment is seriously underfunded and that some individuals in crisis may have to wait for two to four months to obtain access to treatment. For less urgent cases, the waiting list may be as long as six months.167 Service providers agree that it is crucial for individuals to obtain the services they need when they need them. As well, some witnesses suggested that there is a need for more culturally sensitive services for Aboriginal people as well as more gender-sensitive services. Furthermore, transportation to treatment facilities as well as a lack of daycare for children were also mentioned as barriers to obtaining treatment. The Committee believes that when an individual is ready to seek treatment, there should be a minimum of delay before an assessment is completed and an appropriate intervention made available. The Committee further agrees that treatment delivery should be sensitive to socio-economic and gender issues, as well as cultural diversity. Another issue raised by many witnesses appearing before the Committee relates to the lack of rehabilitation and social services to assist youth, adults and families to recover from the effects related to the harmful use of substances and dependence. Employability, housing and other social needs must be addressed in order to avoid relapses into a pattern of harmful use of substances and to increase the number of individuals who will achieve successful rehabilitation. The Committee believes that more attention needs to be paid to the social reintegration of individuals in recovery. There is a need for abstinence-focused subsidized housing that supports the recovery of both men and women. There are often clients on a waiting list for supportive housing. Right now we have ten waiting at Harbour Light who applied for supportive housing beds two months ago and who are still occupying treatment beds that could be filled by clients on the intake waiting list.168 (ii) Challenges in the Delivery of Treatment and Rehabilitation The Committee was told that the profile of people seeking treatment has changed as individuals are presenting more complex physical and mental health problems in combination with a substance use problem. Poly-drug use is also on the rise. Treating substance-dependent individuals who also suffer from Fetal Alcohol Syndrome and Fetal Alcohol Effects (FAS/FAE) is particularly problematic as service providers indicated they do not have the resources or the qualified personnel to respond to the special needs of this population. We are seeing more women in treatment as adults from an FAS/FAE background themselves, and so we are looking at ways we can present the material more effectively to them, so that they can understand it. They are certainly coming in with some disabilities, cognitively and behaviourally, participating in traditional psychotherapy and group therapy. They don’t do well in that sort of traditional model, and so we are continuing to assess it.169 According to a 1999 survey, cognitive, social, behavioural and neuro-psychological assessment services for FAS/FAE affected adolescents and adults were only available in British Columbia.170 Physician training in the diagnosis of FAS/FAE was available in just four provinces (British Columbia, Alberta, Manitoba, Ontario). Furthermore, at the time of the survey, only Manitoba reported having “recently opened a 20-bed residential youth addiction treatment unit that includes specific components for FAS/FAE-affected youth who reside in Winnipeg.”171 The Committee recognizes the challenges facing treatment providers and agrees that more research must be done to identify and/or develop standards of treatment that would better address the needs of multi-problem clients including FAS/FAE affected adolescents and adults. (iii) Treating Opiate Addiction A number of witnesses appearing before the Committee indicated that injection drug users, particularly those suffering from HIV/AIDS, are very marginalized and have more difficulty in obtaining access to treatment and rehabilitation programs. It is estimated that 125,000 people inject drugs such as heroin, cocaine, amphetamines, or steroids in Canada. Many injection drug users are HIV positive or have AIDS, and Hepatitis C affects an even greater number. Infectious diseases are particularly prevalent among people who inject cocaine as the “life of the substance” in the body is much shorter than heroin and people may inject up to 30 times a day, thereby increasing the risks of contracting blood-borne pathogens through unsafe injection practices. The overall prevalence of Hepatitis C Virus (HCV) infection is likely 70% to 80% among injection drug users in Canada. Overall approximately 11,000 persons in Canada would be infected with both HCV and HIV in Canada, and 70% of these co-infections would be related to injection drug use.172 Prior to 1993, less than 3% of new HIV infections in Canada were related to injection drug use. By 1996, 33.7% of all new reported positive HIV tests among adults were attributed to injection drug use. In 2001, Health Canada reported that this percentage had decreased to 24.6%. As well, 14.4% of all reported adult AIDS cases in 2001 were related to injection drug use, again a decrease from 21.1% in 1998.173 This downward trend is encouraging, but these percentages remain alarming. Furthermore, there are subsets of the population who are at higher risk of contracting infectious diseases and who are particularly affected by injection drug use. The problems of injection drug use and HIV and hepatitis C infection affect all Canadians in society. However, some populations have been particularly affected or even devastated by injection drug use and the associated harms. These are women drug users, street youth, prisoners, and Aboriginal people — basically people who are already in many terms marginalized and facing challenges in their lives above and beyond those related to injection drug use, and who are living with chronic illnesses such as HIV and hepatitis C.174 (a) Methadone Maintenance Treatment (MMT) Some witnesses argued that measures for treating opiate addiction are underdeveloped in Canada. The availability of methadone maintenance treatment (MMT) is said to be insufficient. For example, in Montreal: Fewer than 1,500 persons are currently under methadone treatment, whereas the number of spaces needed to reach 50% of those who could benefit from treatment is 2,500. Several hundreds of individuals are currently waiting.175 The shortage of physicians and other healthcare professionals who are willing to provide such treatment is one barrier to the availability of MMT. Some physicians providing MMT are apparently so overwhelmed with their patient load that they are unable to provide adequate counselling and support to these patients. It has been reported that some substance-dependent individuals have had to leave their province of residence to obtain access to MMT programs. We have problems in the Maritimes with having enough physicians who are licensed to prescribe methadone to addicts. I know, with the methadone programs in Halifax, there are patients moving there from New Brunswick and from Newfoundland just to get their methadone, which I think is horrendous. I wouldn’t want to leave my community because I required methadone. I think there needs to be a national strategy for delivery.176 Methadone maintenance programs are for many individuals a doorway into treatment and may significantly reduce the social and health costs associated with injection drug use. Methadone is a prescribed, legal heroin substitute that is apparently less habit-forming and is used to make contact with heroin users, stabilize them, and eventually reduce their dependence. The methadone maintenance program reduces the chance of overdose, given that the substance is controlled by a physician; reduces the transmission of diseases like HIV and hepatitis C; decreases crime associated with the need for drugs; and decreases the consumption of drugs in public.177 I should probably disclose to the Committee that I’m a methadone prescriber and I’m the chairman of the opiate agonist committee for the American Society of Addiction Medicine, and I’m involved in office-based treatment of opiate dependency with agonists — in other words, methadone and drugs like that — in both Canada and the U.S. I definitely believe the literature supports the use of that drug in the treatment of opiate dependency.178 The majority of Committee members believe that opiate-dependent persons in Canada should have access to methadone maintenance treatment and that such treatment should include primary health care, counselling, education and other social services. The Committee supports the use of methadone maintenance treatment where a specifically trained physician oversees the treatment and where this substitution treatment is part of a structured and carefully monitored recovery program.179 (b) Heroin Maintenance Treatment With respect to heroin maintenance, the Canadian Institutes of Health Research have agreed to fund a three-city heroin trial for drug-dependent individuals resistant to other forms of treatment, set to be undertaken in Vancouver, Toronto and Montreal.180 As a scientist, and that’s what I am, I always look at problems and say, if I apply ingenious or good methods, where does it end up? That’s where we’re at today on a heroin prescription trial. I have seen the disaster. Twenty percent of all the acute care patients who come into our hospital have addictions. What are we going to do, just let that number roll up? I can tell you now that the treatments are not that effective. We see the same people day in and day out. They come in; they go into, say, psychiatry; three months later they’re out; and four months later they’re back in. They come into the medical wards with endocarditis or HIV. They come in, are discharged, and come back in. So for me, as a practical person, it’s time to break the mould and look at some of these innovations. Try a heroin trial, because the status quo is not acceptable. We have one person a week die of HIV in our hospital. But with the natural history of the disease in the IDUs, we’re going to go back to where it was when I came ten years ago, where we’ll have a person a day die in my hospital from HIV, and they’ll almost all be addicts.181 The majority of Committee members recognize the importance and encourage the implementation of the proposed clinical trials pilot project, known as NAOMI (North American Opiate Medications Initiative), to test the effectiveness of heroin-assisted treatment in Canada. The target population are individuals who are dependent on opiates (in accordance with the criteria of the DSM-IV), who are at least 25 years old, and who have a history of opiate dependence of at least five years, a one-year injection history, and a treatment history of methadone maintenance at least twice in their past. Individuals who have a severe medical or psychiatric condition for whom the administration of opiates would be contraindicated, pregnant women, and people incapable of signing an informed consent to participate in the pilot project are ineligible.182 The Committee agrees that these trials must include protocols for rigorous scientific assessment and evaluation. 2.1 COMMITTEE OBSERVATIONS - TREATMENT AND REHABILITATION The Committee observed the following:
RECOMMENDATION 15 The Committee recommends that a renewed Canada’s Drug Strategy explicitly recognize the concept of and contribute toward a continuum of care, including low-threshold services, long-term treatment and recovery services, which would integrate the provision of social services as an essential element of treatment and rehabilitation. RECOMMENDATION 16 The Committee recommends that a renewed Canada’s Drug Strategy include abstinence as one of the wide range of successful treatment options that currently exist. RECOMMENDATION 17 The Committee recommends that a renewed Canada’s Drug Strategy explicitly recognize the need to provide treatment services in a timely manner and that these services be sensitive to socio-economic, gender and cultural diversity. RECOMMENDATION 18 The Committee recommends the development and delivery of treatment services adapted for individuals with Fetal Alcohol Syndrome/Fetal Alcohol Effect (FAS/FAE) or mental health disorders concurrent with the harmful use of substances and dependence. RECOMMENDATION 19 The Committee recommends that a renewed Canada’s Drug Strategy include “substitution treatment” such as methadone maintenance as part of a comprehensive approach to the treatment of opiate addiction that includes primary health care, counselling, education and other social services. RECOMMENDATION 20 The Committee recommends that the proposed clinical trials pilot project in Vancouver, Toronto and Montreal to test the effectiveness of heroin-assisted treatment for drug-dependent individuals resistant to other forms of treatment be implemented and that these trials incorporate protocols for rigorous scientific assessment and evaluation. RECOMMENDATION 21 The Committee recommends the removal of federal regulatory or legislative barriers to the implementation of scientific trials and pilot projects to determine the effectiveness of new and innovative methods in the treatment of individuals who have developed a pattern of harmful use of substances and dependence. From the merchant who wants to run a business, to the seniors’ group who want safe streets, to the provincial government trying to balance health budgets, to the political activists who demand social justice, to the police who want to reduce crime, to the street-involved person who has just witnessed a friend’s overdose, the status quo is not an option. It must be made clear to all groups who are impacted by drug use that a harm-reduction approach in no way promotes or legitimizes the use of drugs but rather is a rational approach that will benefit us all.183 Canada’s Drug Strategy’s stated goal is “to reduce the harm associated with alcohol and other drugs to individuals, families, and communities.”184 A harm reduction approach to the treatment and management of the harmful use of substances gained popularity during the 1980’s, when the spread of HIV/AIDS came to be viewed as a greater threat to individuals and public health than the use of substances. Although initially directed toward injection drug use, many jurisdictions have since adapted the harm reduction model to other illicit substances, as well as licit substances like alcohol and tobacco. According to Canada’s Drug Strategy, harm reduction is a “realistic, pragmatic, and humane approach” to substance abuse, “as opposed to attempting solely to reduce the use of drugs.”1 Harm reduction does not provide clear-cut answers and quick solutions, but it has the capacity, if properly applied, to address difficult problems while not compromising the quality and integrity of human life in all its rich and diverse complexity.186 (a) Issues Related to the Definition of Harm Reduction Evidence before the Committee clearly established that the definition of harm reduction is subject to debate and controversy. Some witnesses recognized that harm reduction is commonly misunderstood and often perceived as encouraging drug use, whereas most would agree that it is part of a continuum of care that can include the long-term goal of abstinence. The Committee believes it is unproductive to suggest a dichotomy between harm reduction and an abstinence-based treatment model, as both are essential to address the harmful use of substances and dependence. The notion of harm reduction is that if people are going to use drugs, we may not like it and we may not approve of it, but let’s try to keep them alive and as healthy as possible, and not see them get HIV and hepatitis C, so they can move into rehab programs and treatment programs and other sorts of programs.187 (b) Reducing the Harm Associated with Injection Drug Use The scope of the problem of injection drug use and its consequential health effects were the subject of a recent Federal/Provincial/Territorial (FPT) Advisory Committee report entitled Reducing the Harm Associated with Injection Drug Use in Canada.188 Information regarding rates and patterns of injection drug use is extremely limited. While there are no precise figures available, it is estimated there are approximately 12,000 injection drug users currently living in Montreal. As well, some studies suggest there are several thousand young people aged 13 to 25 living on the streets of Montreal and approximately half of them have previously injected drugs, while an estimated 8% of those young people begin using drugs intravenously every year.189 Other estimates suggest that approximately 10,000 to 15,000 injection drug users are living in Toronto. As for the number of injection drug users living in Vancouver’s Downtown Eastside, it was estimated at 4,700 in 2000, and the number in the Greater Vancouver region was estimated at 12,000.190 The Committee acknowledges that there is a significant degree of uncertainty surrounding the number of injection drug users in Canada as it is well known that surveys tend to under-represent marginalized populations such as those who are living on the streets, without telephones, hospitalized or in treatment facilities. However, the numbers above are the most recent estimates made available to the Committee. The FPT Advisory Committee report confirmed that injection drug use is a major risk factor for HIV/AIDS and hepatitis infections, carrying potentially disastrous consequences not only for infected individuals, but also their communities and Canadian society as a whole. Health Canada reported that 24.6% of all new reported positive HIV tests among adults and 14.4% of all reported adult AIDS cases were related to injection drug use in 2001.191 Aboriginal people are at higher risk than the average citizen of being infected with HIV, as they are over-represented in the sex trade, prison population and among inner-city injection drug use communities.192 Injection drug use is also a problem among inmates in correctional institutions.193 Other high-risk populations include women, street youth, sexually exploited children, men who have sex with men, and sex trade workers. Among other recommendations, the FPT Advisory Committee report called for harm reduction measures such as the expansion of needle exchange programs and increased access to treatment options including methadone maintenance. The report also advocated clinical trials of prescription heroin and urged consideration of a pilot or research project involving a “supervised injection site.” Harm reduction measures or strategies have become an integral part of the way many public health and addiction agencies deliver services across Canada. Many service providers see harm reduction as part of a continuum of addiction interventions that include education, prevention, treatment and rehabilitation programs. Examples of harm reduction measures and policies include:
Basically, there are three main ways in which these measures can have an impact on public health:
(i) Needle Exchange Programs (NEPs) The first needle exchange program in Canada was established in Vancouver in 1989. There are no definite data as to the number of NEPs currently in Canada. Estimates range from 100 to approximately 200 programs across the country. Some programs only offer an exchange service where used needles are exchanged for clean ones. Other programs offer a range of public health services including health and addiction assessments, counselling, primary health care, and testing for blood-borne diseases and other illnesses related to injection drug use, as well as referrals to treatment and rehabilitation programs. The Committee observed that there is no consistency in the procedure for the provision of needles and public health services. For example, some NEPs provide a “one-for-one” service where a clean needle is exchange for a used needle, while other NEPs do not require users to exchange any needles and will provide any amount of needles requested. Currently, the federal government is not involved directly in funding needle exchange programs. Some portion of federal transfer payments to the provinces and territories for health expenditures may ultimately support NEPs but it is impossible to determine in what proportion as transfer payments are not designated for specific use. These programs are the responsibility of provincial, territorial and municipal governments. For example, in Ontario, the Mandatory Health Programs and Services Guidelines mandate boards of health to “ensure that injection drug users can have access to sterile injection equipment by the provision of needle and syringe exchange programs as a harm reduction strategy to prevent transmission of HIV, hepatitis B, hepatitis C and other blood-borne infections and associated diseases in areas where drug use is recognized as a problem in the community.”195 A majority of Committee members encourage all provinces and territories to adopt similar guidelines to ensure that needle exchange programs are available throughout Canada. Research on needle exchange programs has demonstrated that some of these programs:
Many witnesses appearing before the Committee see community-based outreach programs such as needle exchange programs as an effective way of contacting substance users in their local communities to provide them not only with means to modify risky behaviours related to substance use, but also to modify other risky behaviours such as sex-related unsafe activities. Registered nurses and outreach workers distribute health information, sterile equipment, condoms, pregnancy test kits, vitamins and referrals for drug treatment, HIV, HBV (Hepatitis B) and HCV (Hepatitis C) testing and counselling. Low-threshold services offer substance users who have neglected their health for a long time, a renewed contact with healthcare services and professionals, which, for some injection drug users, may also be a first step to recovery. As I was saying before, I used the needle exchange, and thank God for the needle exchange, because now I’m a mother and I don’t have a death sentence over my head, but I think that anything that’s not geared toward abstinence is a waste of time. You have to get off the drugs. If you’re not geared towards that, then it’s useless.196 Many witnesses appearing before the Committee indicated that Canada is facing a severe public health crisis related to injection drug use. Some witnesses argued that the number of Needle Exchange Programs (NEPs) in Canada is insufficient and that their current location (centralized within large cities) is inadequate to respond to the needs of injection drug users. The existing services are clearly insufficient to address all these problems. For example, in the area of transmissible disease prevention, there are five community needle exchange programs in Montreal and approximately 25 other community and institutional partners offering the same service. There are also seven CLSCs and 150 pharmacies that sell syringes without prescription. Nevertheless, at the present time, approximately one million syringes are distributed or sold in Montreal every year. Although that figure has risen since 1995, it remains suboptimal and represents only 10% of estimated needs.197 Other witnesses appearing before the Committee expressed concerns with regard to NEPs as they perceive these programs as “giving up the fight” on substance use and believe they enable a drug-dependent person to continue using or that they may even encourage experimentation with injection drug use. The possibility that more dirty needles would be discarded on the streets and parks was another preoccupation for a number of witnesses. A majority of Committee members believe that Needle Exchange Programs, when integrated with the delivery of other health care services, contribute to the prevention of the spread of HIV/AIDS and other blood-borne pathogens among injection drug users. A majority of Committee members also believe that NEPs are effective in establishing a first contact with a very marginalized population that most likely would not obtain access to healthcare services otherwise. (ii) Safe Injection Facilities Safe injection facilities or consumption rooms, currently established in some European countries, are controlled healthcare settings where substance users can inject their own drugs using sterile equipment under the supervision of medically trained personnel. The personnel of such facilities can also refer substance users to counselling, healthcare agencies, treatment and rehabilitation programs, and can, in some cases, provide primary health care on the premises. Some European studies conducted in Switzerland and Germany indicate that safe injections facilities:
For example, in Germany, a government report indicates that it is noticeable that in those cities where drug consumption rooms are offered in addition to low-threshold contact services, the mortality rate among drug users has either fallen further, in contrast to the national trend, or else has stabilized at a low level.198 There have been few thorough impact evaluation studies of safe injection facilities conducted in Europe, and the majority of the published literature does not currently appear in English.199 However, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) has undertaken a review of available evidence from evaluation studies on consumption rooms in Europe and Australia and a summary of findings will be published by the end of the year 2002. The Canadian HIV/AIDS Legal Network studied the legal and ethical issues related to the establishment of safe injection facilities in Canada and concluded: Including safe injection facilities as one harm-reduction component of a broader policy response to injection drug use is likely to produce significant benefits for both drug users and the general community.200 The Committee was told that a proposal for the implementation of an 18-month pilot project of two safe injection facilities in Vancouver is currently under study. Some argue that a safe injection facility could reduce risks associated with drug-induced overdoses and resolve some of the public health issues that have plagued, particularly, the Downtown Eastside of Vancouver.201 The Office of the Chief Coroner of British Columbia determined that in 1998, there were 417 illicit drug deaths in that province. This number has decreased to 222 in 2001 (preliminary data), which is nonetheless an excessively high number of deaths considering that many overdose deaths could be prevented with better information on the purity of heroin on the market and with the implementation of harm reduction measures such as a safe injection site. An on-going study of the injection drug users in Vancouver (VIDUS)202 found “that 28% of users shared a needle; 75% of users reported injecting alone at least once; 10% experienced a non-fatal overdose; 14% of users reported injecting in a public place; 25% of addicts reported needing help injecting; and 18% found it hard to access sterile needles.”203 The establishment of supervised safe injection facilities may alleviate these risk-taking behaviours.204 Furthermore, safe injection facilities may also reduce the downstream health effects of such behaviours seen in high rates of emergency department visits and hospital admissions for soft-tissue infections, overdose, intoxication and withdrawal syndromes.205 While the scope of the open drug scene in the Downtown Eastside is unparalleled in Canada, no municipality is immune from such a public health and safety crisis. Montreal, Toronto and Ottawa also face significant public health problems related to injection drug use, while other urban and rural communities are seeing more and more problems. Some witnesses appearing before the Committee suggested that, in the absence of safe injection facilities and other low-threshold harm-reduction-based services, some injection drug users would continue to engage in dangerous, unhygienic methods of injection that increase the risk of fatal and non-fatal overdoses and of contracting blood-borne diseases such as HIV/AIDS and Hepatitis C. They pointed out that such negative consequences carry a very high cost to the individuals and society as a whole. The final thing I want to say is that within the context of HIV there’s something that people often forget. HIV causes AIDS. If you don’t get HIV, you do not get AIDS. Therefore, every time you prevent a case of HIV infection, you absolutely prevent a case of AIDS. Unlike other illnesses, we have a disease that is essentially 100% preventable, and that’s AIDS. Every time we prevent a case of HIV infection, we save $200,000 of downstream medical care costs. Each year in Canada about 4,000 people are becoming infected with HIV, half of whom are injection drug users. So the mortgage on our children at the present time for HIV is $800 million per year, $400 million of which is for injection drug users who have HIV infection. Therefore, if not for sound social policy but for economic policy, it’s absolutely critical that we try to prevent every single case of HIV infection, because the benefits economically and socially are enormous.206 Although most witnesses acknowledged the enormity of the problem, the Committee observed a general ambivalence with the idea of establishing safe injection facilities. Many witnesses were not completely opposed to the idea, but felt there is a need for more research before Canada endorses such an option. Others approved the establishment of safe injection facilities under very specific conditions (e.g., as a measure of last resort for severely addicted individuals; in specific locations; combined with health and treatment services; rigorous monitoring and evaluation; very tight and very controlled criteria of admission; etc.). However, a number of witnesses argued that establishing safe injection facilities endorses substance use and sends a message that can hinder prevention activities. Furthermore, some witnesses were concerned that these facilities could result in public nuisance and increased criminal activity in the communities where they would be established. Others disagreed, stating such fears are unfounded and contrary to existing evidence from European countries where safe injection facilities have been established.207 The Committee has seen directly the public health disaster unfolding in Vancouver. Recognizing that the effectiveness of safe injection sites remains to be demonstrated, a majority of Committee members support the development of more innovative measures to alleviate the very significant health and social problems related to injection drug use. A majority of Committee members also agree that experimental trials that include protocols for rigorous scientific assessment and evaluation are required to determine whether the establishment of safe injection facilities would significantly reduce the social and health problems currently evident in some drug-affected neighbourhoods. The trials should adopt an integrated public health model that would include the delivery of comprehensive health and social services. Finally, the Committee observed that very few agencies involved in the delivery of harm reduction programs and measures, as well as those involved in the delivery of prevention, education, treatment or rehabilitation services, could provide the Committee with information on the effectiveness and efficiency of their programs based on rigorous evaluations. The Committee believes that a public health approach to the delivery of services in the field of addictions must be evidence-based to achieve its goal of reducing harm related to the use of substances, and dependence. 3.1 COMMITTEE OBSERVATIONS - HARM REDUCTION The Committee observed the following:
RECOMMENDATION 22 The Committee recommends that the Government of Canada encourage and assist the provincial, regional and municipal authorities to integrate and deliver needle exchange programs through a public health care model including primary health care services as well as prevention and education, counselling, treatment and rehabilitation programs. RECOMMENDATION 23 With regard to safe injection facilities, the Committee recommends that the Government of Canada remove any federal regulatory or legislative barriers to the implementation of scientific trials and pilot projects, and assist and encourage the development of protocols to determine the effectiveness of safe injection facilities in reducing the social and health problems related to injection drug use. RECOMMENDATION 24 The Committee recommends that clear quantitative and qualitative goals be incorporated into all services related to the harmful use of substances, and dependence, together with a performance evaluation process to ensure that prevention, education, treatment, rehabilitation and harm reduction programs are evidence-based and reflect best practices. RECOMMENDATION 25 The Committee recommends that Canada’s Drug Strategy identify harm reduction as a core component of Canadian drug policy that supports interventions to maintain the health of individuals and minimize the public health risks associated with substance use. 4. MISUSE OF PRESCRIPTION DRUGS It is important at the outset to distinguish between individuals who misuse prescribed drugs to the detriment of their own health and those who abuse the health care system to obtain specific drugs that they sell for profit. The Committee was told that a lack of education and, hence, awareness among physicians, pharmacists and the general public about the risks of misusing certain drugs, or of developing a dependence on certain medications, may contribute to prescription drug misuse. Witnesses appearing before the Committee argued that physicians generally receive inadequate training on how to manage pain for patients, on how to detect problems associated with the harmful use of substances, and on how to treat those individuals who may be at risk of developing a dependence on substances. Similarly, the Committee was told that patients may misuse prescription drugs simply because they are not given sufficient information about the medications they are prescribed and the way they should be used. In Canada, we have had successful campaigns highlighting the dangers of smoking and alcohol consumption. We would recommend the development of a national campaign to explain the possible dangers of abuse and misuse of prescription drugs. Prescription drugs are now the medical intervention of choice, and usually for good reason, as they provide tremendous health benefits. People are under the impression that prescription drugs have no ill effects and can do no harm. A campaign should sensitize Canadians to the fact that while a drug is prescribed for a good reason, some drugs can lead to dependence and addiction and do not achieve their goals if taken improperly. The campaign should also provide people with information on what to look out for and whom they should be consulting when questions arise about their medications.208 The Committee agrees that there is a need to deliver better education and awareness programs to patients, physicians and other health care professionals about the risk of developing a dependence on certain prescription drugs. The Committee believes the risks of prescription drug misuse should be included in a national mass media public awareness campaign addressing the non-medical use of drugs and other substances as recommended earlier in this chapter. Another important issue related to the misuse of prescription drugs is that of the diversion of such drugs from legitimate markets. Codeine, Dilaudid, OxyContin, Talwin, Ritalin and Percocet are among the most common prescription drugs being misused and diverted in this way. Users ingest these drugs orally or crush the tablets and either snort the substance or dissolve it for injection. OxyContin has recently attracted much attention in the United States, but, thus far, has not been identified as a major problem in Canada. However, the profits to be made on the sale of OxyContin and other analgesics and stimulants on the illegal market are huge and attractive to those who misuse these prescription drugs, as well as to criminal organizations. For example, the Committee was told, “sixty 40 milligram OxyContin tablets retail for $300 US, but the same drugs would attract $2,400 on the street.”209 The manufacturer of OxyContin has recognized the problems associated with the diversion of this drug and “is currently developing a new product that will contain beads of the anti-opiate Naltrexol, which apparently will make the drug less rewarding for the addict”.210 According to a number of submissions to the Committee, prescription drug misuse is prevalent, to a greater or lesser extent, in most communities across Canada. Anecdotal evidence suggests that the illicit trade in certain prescription drugs is more prevalent in some smaller cities and rural areas where, coincidentally or not, heroin and cocaine are not widely available. Many factors contribute to or facilitate the diversion of prescription drugs. While they may be stolen from various points in the legitimate distribution system, some witnesses appearing before the Committee said that the vast majority of prescribed drugs come from legal prescriptions obtained through “double-doctoring” or “multi-doctoring”: In the past, when the RCMP have done investigations and apprehended certain information under search warrants, we have seen maps drawn by people who are going to go double-doctoring. They time their visits so they may visit 10 clinics in a day. Given the waiting time in some family physicians’ offices, you might wonder how that’s possible, but they know walk-in-clinics and other clinics are likely to give them quick access. They can literally hit 10 doctors in a day with a very sophisticated story of having lost their drugs, flushed them down the toilet, the dog eating them, or whatever, and they do get an enormous amount of a drug.211 Prescription monitoring programs have the potential to limit the growth of prescription drug misuse, reduce fraud and prevent the diversion of prescribed drugs. Although 10 of 12 provinces and territories apparently had triplicate prescription programs in place in 1997, the Committee was told that unless the information is readily obtainable from a central database, incidents of double-doctoring or inappropriate prescribing might not be discovered early enough to allow for a successful intervention. To prevent fraud and detect potential substance misuse problems, pharmacists and physicians need immediate access to a patient’s drug profile at the time a medication is being prescribed or dispensed. The Committee heard from representatives of various prescription monitoring programs from British Columbia, Nova Scotia and Saskatchewan. All agreed that the B.C. PharmaNet program, introduced by the province of British Columbia in 1995, is the most promising monitoring program currently available in Canada. The program relies on an electronic central database that gives physicians and pharmacists an easy access to up-to-date data on medications dispensed to a patient living in that province. The PharmaNet program, as you may well know already, is a joint venture of the Ministry of Health’s pharmacare, the College of Physicians and Surgeons, and the College of Pharmacists of our province. All prescriptions are electronically captured at the time they are dispensed so the data are very current: we can see what the patient received earlier today. […] The whole of the PharmaNet program has been reviewed by the Privacy Commissioner and has been approved. I think the PharmaNet program might be something to be considered across Canada as a means of addressing some of the problems with the diversion of prescribed drugs.212 The PharmaNet database is currently being used in all emergency departments in British Columbia on a pilot project basis. The BC College of Physicians and Surgeons is hoping that in the near future all physicians in private practice will have access to PharmaNet in their offices. This initiative is a first in Canada where a medical practitioner can request and access up-to-date records of medications dispensed to a patient by the secure transmission of information over the Internet. The program is not a “watchdog” but a proactive system, supported by the physicians of British Columbia, which provides them with valuable information on a patient’s drug profile and may help to avoid dangerous medication interactions and duplications. In addition, it has the benefit of limiting prescription fraud and serves as an early warning system of a potential substance misuse problem.213 The program also offers physicians the resources of an advisory committee of clinical pharmacologists, which can offer them advice when faced with problem patients.214 The Committee applauds the initiatives put in place to monitor prescribed drugs by colleges of physicians and surgeons across the country. The Committee also recognizes that prescription monitoring programs vary substantially from one province to another. The Committee, in agreement with a number of witnesses appearing before it, sees real benefits in the use of real-time electronic databases in monitoring prescribed drugs most commonly subject to misuse and diversion, and in providing health care professionals with access to reliable up-to-date data to make better informed decisions on a course of treatment. The Committee was also told that the fairly recent phenomenon of Internet prescribing is a source of concern. It is virtually impossible to monitor the drugs being prescribed and dispensed using the Internet, as a patient using such a service can acquire medications and easily bypass any prescription monitoring program currently in place. The Committee believes Internet prescribing raises many complex legal and ethical issues that should be investigated closely to determine what, if any, intervention is necessary. Finally, some concerns were raised over the misuse of over-the-counter drugs (e.g., drugs containing Dextromethorphan, antihistamine, codeine etc.). Unfortunately, there is virtually no Canadian data on this public health issue. The Committee believes that accurate information on the prevalence and incidence of use and harmful use of over-the-counter drugs is needed and should be integrated into a comprehensive drug policy addressing the harmful use of all substances. 4.1 COMMITTEE OBSERVATIONS - MISUSE OF PRESCRIPTION DRUGS The Committee observed the following:
RECOMMENDATION 26 The Committee recommends that a renewed Canada’s Drug Strategy include in its priorities the development of a strategy relating specifically to the misuse of over-the-counter and prescription drugs in Canada. RECOMMENDATION 27 The Committee recommends that the Government of Canada assist and encourage the provinces and territories in the development and maintenance of comparable real-time databases so as to track better the prescribing and dispensing of commonly misused prescription drugs.
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