[Recorded by Electronic Apparatus]
Tuesday, March 11, 1997
.0909 
[English]
The Acting Chairman (Mr. John Murphy (Annapolis Valley - Hants, Lib.)): Order. We welcome the people from the Portage Program for Drug Dependencies, Mr. Peter Howlett andMr. Peter Vamos.
Welcome. We're glad you're here with our committee to give us evidence.
Mr. Howlett.
Mr. Peter Howlett (President, Portage Program for Drug Dependencies Inc.):Mr. Chairman and members of the committee, I will recount some information you probably are entirely familiar with, and at the risk of being laborious.
In our society drug addiction remains a corrosive and unchecked malaise. The media relish the stories of drug smuggling, drug proliferation, gangland killings, and other drug-related crime. Government initiatives, such as they are, receive scant attention. Matters of treatment and rehabilitation receive next to none.
.0910
In 1970 a royal commission, headed by Judge LeDain, was established to find answers to this problem. Twenty-six years later the problem has escalated exponentially, with social and economic costs in Canada exceeding $25 billion a year. That's a number I spoke to late last year for the Montreal Chamber of Commerce, and I propose to you that this number is conservative.
Violence in our schools, widespread drug use in the workplace, escalating crimes against persons and property in our cities are the concomitants of this runaway epidemic.
Another concomitant is the exorbitant demand on the health care system. The incidence of highly contagious and virulent illnesses, such as hepatitis, tuberculosis, AIDS, and a plethora of STDs is far greater among the addicts. When one contemplates the impact of this population on the social welfare system, on the criminal justice system, and when we consider the extended impact of each addict on their often neglected children, spouses, and families, the magnitude of the problem becomes truly staggering.
I might add that the annual report of the UN international drug control program published last week states that drug abuse is once again on the rise in Canada.
Substance abusers are socially maladapted or socially traumatized individuals who have difficulty integrating into society. They are individuals with psycho-social problems that can and should be treated. Drug addiction is therefore emphatically a health issue as well as a legal one.
The Portage program was created in 1970 by a group of concerned Montreal citizens preoccupied by the growth of drug addiction in the city. The group was impressed by the results achieved through the therapeutic community approach in New York and resolved to set up a similar program in Montreal.
Today, Portage operates non-profit treatment centres in the provinces of Quebec, Ontario, and New Brunswick. Over the last 25 years, Portage has contributed to the establishment and operation of treatment programs in 25 prisons in the United States, Canada, and elsewhere and has conducted training and educational exchanges in forums in Canada and many other countries.
This is a very brief portrayal of Portage, and we would welcome questions on some of the other experiences we've been engaged in.
Portage's approach is drug free, emphasizing self-help and the creation of a positive environment with family-like support systems. It is a comprehensive residential program designed to rehabilitate, educate, and reorient individuals to a healthy new way of life. Over the years, thousands have completed the program and have become productive members of society.
We believe very strongly that alternatives to prison must be found for substance abusers. By way of illustration, Canada has a prison system that acknowledges the use of drugs in its facilities to such an extent that it provides needles, syringes, and bleach to inmates. On several occasions, solicitors general have indicated that inmate drug use may exceed 80%. It has even been said that our correction system exists to warehouse substance abusers. Yet research studies in the United States clearly demonstrate that in terms of drug use and rearrest, community-based treatment has been shown to be much superior to incarceration as a method of dealing with drug-dependent offenders.
Canadian statistics show that it costs more than $50,000 per annum to incarcerate an offender in a federal institution, while the total annual cost for adult residential treatment at Portgage is about $25,000. This includes residential services, therapy, educational services, family care, after care, and the list goes on. Clearly, in the current climate of deficit reduction and severe cuts in many services, governments should be looking at cost-effective options to incarceration that produce results.
Recent changes to the Criminal Code provide such an opportunity. The amendments to the Criminal Code contained in Bill C-41 provided inter alia for the use of sanctions and diversion and alternative punishment in dealing with the suspects and offenders detained under the criminal justice system. With respect to offenders with drug abuse problems, the new legislation provides for the optional use of treatment programs as part of sentencing orders.
Encouraged by the provisions outlined in Bill C-41, Portage decided, in collaboration with the Canadian Bar Association, to convene a nation-wide symposium on drug rehabilitation and criminal justice in May last year. The symposium brought together 60 people from across Canada who are highly regarded in the criminal justice system. They represented the judiciary, crown and defence lawyers, police and probation officials, treatment providers, and government officials from the Departments of Health, Justice, and the Solicitor General.
One of the main concerns expressed at the symposium was the sorrowful lack of effective coordination and cooperation among the various departments of government, be it Justice, Corrections or Health. A prime example of this was the fact that the Criminal Code had been amended to permit the diversion of an offender to a drug treatment program, and few, if any, in the addictions field knew anything about the legislative change. In addition, no effort had or has been made to date by the provincial health departments to provide additional treatment facilities to cope with the referrals from the criminal justice system.
.0915
Here is an opportunity to bring Canada in line with the policies of other industrialized nations to deal with drug offenders, and our governments have made no commitment of resources to implement it.
There are those in our society who would have us believe that drug addiction constitutes freedom of choice, who accept the destruction as inevitable, who would surrender to the moral decay in the name of liberalism. This form of moral abdication is ignorant, cowardly, and dishonest. Let us categorically state that we don't have to give in. There are strategies to deal with substance abuse, and chief among them is the fact that addiction treatment works. Addiction can be beaten. In human terms, in economic terms, in public health terms, the most effective approach to addiction is treatment.
In 1993, the Office of National Drug Control Policy in the United States reviewed the published research on treatment outcomes and concluded that for every $1 spent on treatment, between $2 and $7 are either averted in public health and criminal justice costs or gained in productivity related to resumed employment.
In a study following 10,000 addicts from treatment to five years later, it was found that serious predatory crimes dropped by 50% or more over the five years among patients who stayed in treatment for more than three months, saving society an estimated $1 to $4 for each $1 spent on treatment. Additional gains were in higher employment and lower health care costs.
In 1994, a California study of 1,900 addicts found that even for drop-outs from treatment, each day of treatment yielded a financial return to society. By treating 150,000 Californians at a cost of $200 million, the state saved an estimated $1.5 billion, largely due to reduction in crime during treatment and in the first year afterwards.
While the various forms of out-patient treatment approaches can save society between $1,500 to $2,500 per year, the therapeutic community can save an impressive $6,000 per year.
Helping an asocial individual convert from an adversarial relationship with society to a productive and collaborative one requires a treatment experience that fosters the development of an adaptive value system and social competencies. The therapeutic community treatment approach has demonstrated that you can take damaged individuals and return them as functioning participants and productive members of society.
The Portage program is successful because it is of the community, for the community, and by the community. It embodies community values. It is administered and operated by members of the community. It works because it responds to community needs in an efficient and effective manner. It has successfully combined private sector energy and resources with public sector programs.
In summary, we would like to make the following observations.
Previously there was little and now there is no coordination at the federal or provincial level among Departments of Justice, Health, and Corrections to deal with substance abusers.
Such drug treatment approaches as exist function without controls or standards.
For treatment of addiction to be effective, it must be comprehensive, with a residential component and after-care resources.
To reduce drug addiction in the long term, there must be a credible partnership between criminal justice and treatment. Parenthetically, an initiative followed in France provides that addicted offenders must receive treatment before release.
Our recommendations are that the government undertake to increase the number of drug treatment facilities across Canada through collaboration with provincial health departments and the purchase of services from appropriate treatment programs; that these facilities be based on a Portage-like model to ensure that the services maintain a standard of excellence, respond to the needs of the delinquent substance abuser, reflect the values of a community, be accountable to the community, remain cost effective and non-profit, and provide for transition of the client back to society; and that the government establish a mechanism to permit greater consultation with the private sector and community-based organizations to formulate substance abuse policy.
.0920
Over 25 years such initiatives as have been instituted have been essentially a union of bureaucracies with almost no connection to community-based treatment organizations that are carrying the load.
Ladies and gentlemen, that concludes our formal presentation.
The Vice-Chair (Mr. Harbance Singh Dhaliwal (Vancouver South, Lib.)): Thank you very much, Mr. Howlett. Does that conclude both of your presentations?
Mr. Howlett: It does.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Those were very interesting conclusions you brought forward, Mr. Howlett, and I'm very interested in some of the recommendations you've made.
One is in terms of making sure that anybody who has a drug problem is put into treatment. Could you give us the timeframe? You looked at three to six months. Would you recommend a three- to six-month program, and would you recommend that this be mandatory for every person who is brought before our justice system for drug abuse?
Mr. Howlett: Peter Vamos is the executive director of Portage.
Mr. Peter Vamos (Executive Director, Portage Program for Drug Dependencies Inc.): I think our concern is that a number of people who end up in front of the criminal justice system get processed one of two ways: either they are discharged without treatment or they are incarcerated without treatment.
Bill C-41 provides a window of opportunity to divert into treatment programs those who do not necessarily need to be incarcerated, and those who need to be incarcerated could be treated while incarcerated, perhaps following the model that's been in effect in France for some years now. But taking someone with an addiction problem who has committed a crime motivated by their addiction, incarcerating them for a number of years without treating them, and allowing them to have continued access to drugs inside the correctional system is just a waste of time and a tremendous waste of human resources and money.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): One other question, Mr. Vamos, is in terms of your success rate. For patients who come into Portage, people who I guess you can say at the end of the treatment basically have been drug free, or have kicked the habit if they were drug addicts, what sort of success rate would you have?
Mr. Vamos: First, I would like to redefine our notion of success. Having someone exclusively drug free does not constitute success in our books. You have to be more than drug free. You also have to be crime free and you have to be gainfully employed to be considered successful in our scheme of things.
At that level, between 80% to 90% of those who complete our type of program remain what we call successful three years after treatment.
A number of people drop out prior to completing a program such as ours, and among those there is still a very high rate of drug-free lifestyle and gainful employment lifestyle. The research indicates that any time after three months there are cumulative benefits from having engaged in treatment such as ours.
So I think it would be safe to say that anyone who participates in an ongoing treatment program of three months or more is going to have a far greater opportunity to live a drug-free, crime-free lifestyle than someone who had less. Three months would be the critical period, in my estimation.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much.
We'll go to Mr. de Savoye for any questions for our panel.
We have some technical problems with our listening device, so have patience. We're getting some interference on the translation. We'll try to deal with it, and if it appears we're having a problem, we'll stop.
[Translation]
Mr. de Savoye.
Mr. Pierre de Savoye (Portneuf, BQ): Mr. Chairman, I noticed that our witnesses are using a report. Would it be possible for committee members to obtain a copy?
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): I'm sure it would be possible. If we don't have it, we'll make sure each member of the committee gets that report.
.0925
[Translation]
Mr. Howlett: Certainly.
Mr. Pierre de Savoye: You say that a person who abuses drugs is someone who is poorly adapted to society and that criminalization or incarceration provides no solution to this person's problems. What he needs is appropriate treatment.
You say that in your view success does not consist solely in stopping this habit of drug consumption but also in eliminating certain forms of criminal behaviour that a person may have so that he can become a full member of society.
I'd be interested in knowing whether all consumers of drugs engage necessarily in criminal behaviour and whether those who do not still require treatment.
[English]
Mr. Vamos: Clearly not everyone who uses drugs has a criminal history. Many people need varying degrees of intervention in their lives. However, someone who becomes a serious drug abuser necessarily develops along with it a lifestyle, and that lifestyle is very destructive of that individual, of the family, and of society in general. When we talk about drug addicts, that's whom we are referring to. We are referring to those people for whom drugs have taken over their lives. Criminality and asocial behaviour accompany that.
[Translation]
Mr. Pierre de Savoye: What you are telling me, Mr. Vamos, is that drug abusers adopt a criminal lifestyle. Why is this so?
[English]
Mr. Vamos: There are a number of reasons for it. It becomes a chicken-and-egg question. People often debate whether these people were attracted to a delinquent lifestyle first and drugs were a concomitant of that delinquent lifestyle or vice versa. It's safe to say that when we look at the profile of those individuals who become seriously addicted, we are looking at individuals who lack certain capacities to function well in society. They lack self-respect. They lack social stability. They lack family stability. They lack certain skills. As a result, alternate behaviours develop, behaviours that are combined with drug addiction.
There is often a notion that the reason drug addicts turn to criminality to support their habit is that drugs are illegal. I would like to say that from our perspective, and having dealt with thousands of seriously addicted people, we found nothing to support that notion. People turn to criminality, people turn to alternate lifestyles, because they are socially incompetent to live in this society, to cope with society's pressure. The fact that drugs are illegal and they need x dollars rather than fewer dollars to support their habit is a nuisance but not the motivating factor.
[Translation]
Mr. Pierre de Savoye: That's a very interesting remark. If I understand you correctly, you are pointing to the root cause of asocial behaviour. In your view, it is not a matter of criminalizing or decriminalizing drugs. Above all this is not something that can be dealt with through punishment or jail sentences. It is first and foremost a failure to adjust to society and this is the aspect we must deal with, either through prevention or corrective measures. In your particular case, I gather that your organization is involved in the corrective side.
[English]
Mr. Vamos: Yes, and that's precisely the way we see it. There are a number of experiences in other jurisdictions where law enforcement on drug addiction is more lax, if you like, such as Holland, such as certain parts of Switzerland, and I can categorically state the number of addicts engaging in asocial types of criminal behaviours have not diminished in these jurisdictions, because the basic problem, the inadaptés sociaux, remains. The inability to cope with life and social structures remains. So until that is corrected, for this population, addiction remains a constant.
.0930
[Translation]
Mr. Pierre de Savoye: Can you make a parallel with alcoholism in this respect?
[English]
Mr. Vamos: Yes. I think there are a number of issues with alcoholism that make it similar to and at the same time somewhat different from addiction.
Alcoholism is a major and destructive disease. Unfortunately, it's widespread, but alcoholism, over the years, has developed more of an aura of respect, if you like. There are hundreds of excellent alcoholism treatment centres that are able to address the problems of these individuals and to support the return of these individuals to society. There are also a number of excellent self-help groups that maintain the individual in their society in that community.
Drug addiction is still seen as a quasi-criminal, bad type of behaviour. The individuals who tend to be attracted to narcotic drugs, if you like, or the intravenous use of cocaine, tend to be individuals with very little self-pride and very little to lose, ergo, their behaviour is fairly marginal.
Even though it is not uncommon to see a middle-aged alcoholic executive who may also sniff cocaine, that individual has hundreds of options for treatment, typically non-legal; whereas a 24-year-old heroin addict who hates himself and has been alienated from his society and family for a number of years has almost no treatment options. Sometimes the best friend this individual can have is the policeman on the beat who often takes him by the scruff of the neck and steers him towards treatment rather than criminal justice.
This is why our organization applauds Bill C-41. We think it's enabling the good cops and the court system to come to the aid of these individuals who, up to now, have been marginalized by the regulations that prevented them from being steered to treatment.
I don't know if I have responded to your question.
[Translation]
Mr. Pierre de Savoye: That's quite interesting. It shows that there might be light at the end of the tunnel.
How much time do I have left?
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): This is your final question.
[Translation]
Mr. Pierre de Savoye: Thank you.
You do provide treatment for people and you mention that the cost was approximately $25,000. A year in prison costs $50,000. If a person is in prison for two, three or four years and in addition to this receives treatment, it will cost taxpayers a fortune. On the other hand, if he is sent for treatment to you or to a similar institution for $25,000, we will end up with an individual who is able to take his place in society.
Are you telling us that money would be better spent on a cure rather than criminal procedure?
[English]
Mr. Vamos: I think a number of things need to be somewhat rethought. That's why we are very happy that this committee exists and that it's going to make recommendations on policy.
There will always be some individuals who will constitute a danger to society and who, for various reasons, will need to be incarcerated. What happens to them during the course of their incarceration becomes very important.
Portage's chairman, Mr. Howlett, has referred to the experience in France where the incarcerated drug addict gets treatment while being incarcerated. Their discharge is delayed until that treatment is complete. So this individual has an opportunity to go out there and go straight.
If you put someone in jail for three years or more, maintain their drug habit, and then discharge them after, what chance does that individual have to survive? Very little.
We are recommending that the committee perhaps take a look at the treatment options both inside and outside the criminal justice system and at the various partnerships that are available between community-based organizations and the criminal justice system.
[Translation]
Mr. Pierre de Savoye: Thank you, Mr. Chairman.
.0935
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): John Murphy, please.
Mr. John Murphy (Annapolis Valley - Hants, Lib.): Thank you, Mr. Chairman.
In your presentation, Mr. Howlett, you mentioned the terminology of ``therapeutic community''. I'm wondering if that's the Maxwell Jones model of therapeutic community, whereby you pull together and the team becomes much wider in terms of the police and justice, etc. You may wish to explain a bit about that, because it is a very valid model.
The other question I have is contrary to the treatment aspect. I had some people come to me recently wanting to try to put together a better system of policing offshore drugs coming in by pulling together the RCMP, etc. What part does that play, in your experience, in doing something about this major problem?
Mr. Vamos: Maxwell Jones has been a pioneer and a great friend of Portage. Portage has developed a therapeutic community model that first and foremost started out in Quebec. It was readapted in various other parts of the country. It was to combine two modalities to come up with something that would harness the energies of the community and teach responsibility to the participants.
I wish to tell you that we think the core contribution, the most important contribution, that the therapeutic community makes to the individual's recovery from addiction is teaching the individual responsibility for their behaviour and recovery.
As to your question about the interdiction part of the exercise, we believe this is very important. Unchecked supplies flowing into the country would clearly exaggerate the problem rather than reduce it.
At the same time, we recognize that as long as the demand stays high, the supply is going to keep flowing in. We think police work is very important. We think the punishment of mercenary drug dealers is very important. We think there has to be a very tight partnership between supply reduction and demand reduction if this issue is going to be dealt with.
We also feel this is a community issue. One of the frustrations we felt as an organization is that it had become a bureaucratic ivory tower issue. There were people in places like Ottawa who were philosophising about what's right and wrong for our society without consulting the communities in which the problem existed. We think this problem has to be addressed in the communities and that communities have to take responsibility for it.
Mr. John Murphy: The reason I wanted to raise the latter issue is that it's something we should be looking at in terms of part of our strategy. It hasn't, to this date, come up. I think we should pursue the supply aspect of that.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you, Mr. Murphy.
Mr. Szabo.
Mr. Paul Szabo (Mississauga South, Lib.): Thank you, Mr. Chairman.
Thank you, gentlemen, for the presentation. There's no question that one day of treatment is better than none.
Can I ask you two or three questions, very focused, very quickly? Can you give us an idea of the impact on the probability of rehabilitation where the drug user wants to have treatment, as opposed to those who are forced to have treatment?
Mr. Vamos: It's very difficult to treat anyone who doesn't want to be treated. It's nearly impossible. The only thing you can hope to do is try to motivate them to look at their own behaviour.
At the same time - I hope I'm not divulging information that you imparted to us over coffee earlier, Mr. Szabo, but you did mention something that we believe in very much - these are individuals. Their family relationships have broken down. The mentoring system that helped most of us along our way broke down fairly early on in life.
There's the fact that you put individuals into a value-laden environment in which certain types of behaviours and values are espoused and a certain type of social learning can occur, which many of these individuals never had a chance to learn. This cannot harm them. It certainly may budge them even if they're unwilling to have treatment at that point.
.0940
People need to be exposed to knowledge and certain types of social skills. Unfortunately, if you look at the addict population of our country that organizations such as ours deals with, you'll find that you're looking at very seriously damaged individuals who were denied the parenting, community involvement, and educational support that most of us had that got us through our adolescence and into a good way of life.
Mr. Paul Szabo: That takes care of question two, because it really is the root cause of some of the problems in some cases.
I guess this is my last question. It's important to me, and I hope to other members, to try to wrestle with this whole issue. You've touched on it. Let's not put people in jail for crimes they committed because of their drug problems. This is admittedly a toughie for me.
When someone commits a crime, other than by being a drug user, you have to explain to society why they shouldn't be punished for that crime the way someone else is when they committed exactly the same crime. Do we get into a catch-22 situation where, all of a sudden, a declaration of substance abuse is a way out of being punished for your crime?
Mr. Vamos: No more than alcoholism would be. Alcoholism is not considered to be a real mitigation in the case of a serious crime.
I think there are crimes and there are crimes. I hate to sit in front of a Canadian government committee and talk about the United States, but maybe it puts us in a no-so-bad light, so maybe it's okay.
In the United States, in states like New York, the jails are filled with young, drug-addicted people who are there because they were dealing in drugs to support their addiction. That becomes sort of a self-perpetuating, vicious cycle. I have yet to meet anyone who could honestly look me in the face and tell me that he pistol-whipped someone because he took drugs. It's something that I wouldn't accept.
There are people who are criminals first and abuse drugs along with it. These people are complicated and will probably have to be incarcerated for a time, because they are criminals first and their treatment will probably have to occur in the criminal justice system.
There are others who are individuals who do not commit crimes against persons and whose crimes are typically crimes either against property or victimless crimes. They could probably be better served by being steered toward treatment.
Mr. Paul Szabo: I have one last question about Portage. Can you tell me how much time a typical client, as it were, really spends in the program, as opposed to going out on an outpatient basis?
Mr. Vamos: Let me tell you that our typical client is about 25 years old, has nine years of severe drug history, and has both a psychiatric and criminal justice history. They will spend, on the average, six months in residential treatment, up to two years in addition in a post-treatment follow-up, and then there's outpatient support and so on.
When you look at the degree of degeneration and the recovery time, it's really not that long.
Mr. Paul Szabo: Good for you. Thank you very much.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much, Mr. Szabo.
I just have one or two final questions.
First of all, let me say that it's very important to have you here because you people are on the front lines and you really see the problem on a day-to-day basis.
I just want to ask you this. If people are asked to participate in your program on a volunteer basis, is that good enough? You said in your earlier remarks that it's hard to help people who don't want it. What if there was some sort of motivation for these people to take that? Say we recognized that is the root of the problem. Wouldn't it be better to have some sort of partial method for pushing people into these treatment programs? ``Mandatory'' may be a different subject, so I'd like to hear whether or not you think they should be mandatory. In what sorts of ways can we put them through the treatment programs, through programs like your own? What incentives could we give those people?
.0945
Mr. Vamos: We don't want to pretend that it's going to be a panacea, but Bill C-41 gives us an opportunity. We're proud to say this was first tried in Quebec, and we understand it has subsequently spread to the rest of the country.
Since 1977, we have been able to divert individuals from criminal justice treatment by instead assessing them into treatment with the collaboration and support of the judge. What ended up happening was that an accused would end up in front of a judge when charged with a crime. The judge, along with the crown attorney and the defence attorney, allowed the individual to go to treatment prior to sentencing. If the individual managed to rehabilitate himself in the course of time between his appearance in front of the judge and the time of sentencing, the individual was given a suspended sentence.
A number of things happened. First, the offender typically was off the street longer than he would have been if he had been incarcerated. Second, at the end of treatment, he was typically given a three-year suspended sentence, so society had another three-year warranty on the behaviour of that individual. If there was a relapse, the individual could be steered back into the system and, if necessary, could be incarcerated because of that suspended sentence hanging over his head.
Again, Bill C-41 allows the police officer, the crown attorney, and finally the judge to legally make these types of dispositions. Until now, though, this was an informal type of arrangement that could have been challenged. Mercifully, it never was.
We are very hopeful that if the treatment resources exist the courts will use the sanction and pressure of the criminal justice system to steer people - people who are not initially fully motivated - towards treatment.
There is volunteerism and volunteerism. If you're standing in front of a judge and the judge is saying you have an option to go either to treatment or to a penitentiary for a number of years, you are making a voluntary choice. Just how voluntary that choice is, I suppose, is for a philosophy class to debate, but there is that choice. Let me tell you that it has worked effectively. On file, we have hundreds and hundreds of cases who came to us that way, who turned their lives around, and who managed to stay out of jail. So we are very encouraged by this act.
Our fear is that the government has passed an act that now makes it possible to divert individuals from the criminal justice system by using the criminal justice system as a motivation for going into treatment, but the treatment resources do not exist across the country. Is the community ready to accept these individuals? Has the community been mobilized enough to provide the resources in order that those resources can provide the alternative to incarceration? I guess you will probably look at some of those issues in your deliberations.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much for your excellent presentation. We now have two more witnesses coming forward, but we'll try to get your written report in order that we can pass it on.
Mr. Vamos: Thank you.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Our next witness is Catherine Hankins, a public health epidemiologist. Ms Hankins is also the chair of the National Task Force for Action on HIV and Injection Drug Use.
Welcome, Catherine. We look forward to your presentation.
Ms Catherine A. Hankins (Public Health Epidemiologist, Régie régionale de la santé et des services sociaux): Thank you.
[Translation]
I you don't mind, I'll be making my presentation in English but I'll be able to answer questions in French.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much.
By the way, there is a presentation that everybody should have for this. If you don't have it, please tell us and we'll make sure you get one.
Sorry about that. Go ahead.
.0950
Ms Hankins: I'm here to speak to you today in my present capacity as chair of the National Task Force for Action on HIV and Injection Drug Use. This task force is supported by Health Canada through a contribution agreement with the Canadian Centre for Substance Abuse, working in partnership with the Canadian Public Health Association. Task force members include representatives of the Canadian AIDS Society, the Canadian Bar Association, the Canadian Association of Chiefs of Police, and researchers, public health professionals, former injection drug users, a provincial government representative, and an aboriginal representative.
You received a copy of our draft document entitled ``HIV/AIDS and injection drug use: A national action plan''. This draft document was circulated to over 80 correspondents. After discussing the many responses at a task force meeting here in Ottawa last week, we are currently incorporating these changes and reflecting this input.
In the few minutes available to me I would like to focus above all on the urgency of the situation and on some of the specific recommendations the task force will be making. First the urgency.
Although only 8.2% of cumulative AIDS cases reported to date are among injection drug users, the proportion of AIDS cases attributed to injection drug use has increased over time. For women in particular this increase has been dramatic, from 6% of cases before 1989 to 15% during the period 1989 to 1992, and now to 24% of AIDS cases for the period of 1993 to 1996.
More recent data from HIV-testing programs are cause for concern. In British Columbia, for example, injection drug use accounted for 38% of new HIV-positive tests in 1995, compared with only 9% prior to 1995.
If we look at HIV prevalence, which gives us a snapshot of the proportion of injection drug users who are currently infected, in Montreal this has reached 20% and in Vancouver it is now over 25%. New infections are occurring at a rapid rate. Already in Montreal it is five per 100 person-years. In Vancouver a study that has recruited more than 500 people has documented a rate of 19 per 100 person-years. This means among 100 uninfected individuals on January 1, 1997, who continue injecting in Vancouver, 19 will have become infected with HIV by the end of this year. This is the highest rate in North America today.
Why is this happening? Why in Canada is the IDU epidemic continuing to evolve, and why in particular in Vancouver is it evolving so rapidly? One major hypothesis relates to the changing profile of drug consumption, with cocaine having entered the market in Vancouver approximately two years ago. Although HIV was present among injection drug users in Vancouver prior to this, with approximately one in 25 people infected, the HIV epidemic in Vancouver has really taken off, coinciding with the arrival of cocaine, with now one in four people who inject drugs infected.
This is of concern, but not only for Vancouver. Communities across the country, from the Northwest Territories to Edmonton to Winnipeg, for example, are reporting that cocaine use is increasing. As pointed out in our report, the higher injection rate with cocaine, as many as 20 times per day when users are binging, leads to an increased risk of acquiring HIV. Cocaine users may start out knowing which needle is theirs, but it very rapidly becomes difficult to keep track.
Why should we care? Of the estimated 50,000 injection drug users in Canada, it is thought that as many as 2,000 are being infected each year, adding to the 6,000 or so who are already infected. The direct and indirect costs associated with these HIV infections are being calculated now, but they will no doubt justify a dramatic increase in investment to keep this epidemic under control.
Secondly, people who inject drugs do not continue to do so all their lives. When they successfully leave off injecting, as a society we want them to have years of productive life ahead of them.
Thirdly, injection drug users do not live in a vacuum. How many of us can honestly say we have never heard of a relative, a friend, a neighbour, an acquaintance, a co-worker who has injected drugs? Perhaps it is a son or daughter, niece or nephew of one of them. They are members of our community. Both during and after their injecting career they form intimate partnerships and have children.
.0955
The following analogy made by Dr. Martin Schechter is apt. The glowing embers of the Vancouver epidemic have now burst into flames and this fire is beginning to heat up the area beyond the core. Although epidemiologists agree that it will not create a wildfire heterosexual epidemic of the same intensity, this fire will touch many lives, infecting and affecting many people who have never used drugs.
This urgent situation is an absolutely critical one for aboriginal people. As many as one-third of injection drug users in Vancouver are aboriginal, and in a recent study they were shown to be more likely to have HIV infection than were non-aboriginal people.
Many aboriginal people migrate back and forth between our urban cities and reserves. Many factors are likely to lead to an important heterosexual epidemic in this population. Among the most important are the high rates of sexually transmitted diseases found in some aboriginal populations. As you may already know, HIV in the presence of sexually transmitted disease is far more easily acquired and transmitted.
Aboriginal people comprise 14% of federal inmates and up to 40% of inmate populations in some provinces, and as we now know, prison clearly constitutes a risk factor for HIV acquisition.
Finally, the Vancouver Native Health Clinic, which used to have fewer than 10 patients who were HIV positive, is now following over 400 HIV positive aboriginal patients. The situation is critical and it is already late in the day.
What needs to be done?
The national action plan has been anchored in a philosophical background of harm reduction and population health. Guiding principles have included enhancement of community capacity to respond, collaboration with a wide base of partners, and involvement of affected persons in the development of policy and programs. The overall recommendations are aimed at decreasing the marginalization and stigmatization of injection drug users and particularly those living with HIV-AIDS. The HIV epidemic will not be beatable unless we take these issues on.
Among the recommendations, I would like to highlight just a few examples of the kinds of specific recommendations you can expect to see in the final document.
Currently, with respect to methadone access, there are 3,600 treatment places, a number that is woefully inadequate compared to other industrialized countries, including the U.S. We recommend that these be doubled within the next 18 months.
Another example is the recommendation that in order to fund the diversion programs recommended in Bill C-41 to keep injection drug users out of prison - where HIV transmission is occurring - and encourage them to get involved with treatment, there should be a 25% surtax on fines dealt to drug dealers. As well, we are recommending that 50% of all assets seized under drug-related charges go to drug treatment and prevention, including funding for the national AIDS strategy and the national drug strategy, both of which are sunsetting, as you know.
With respect to drug law reform in Canada, the task force recognizes that current drug laws are contributing to HIV spread, because both the cost of currently illegal drugs and the fear of detection are leading people to take drugs by injection rather than smoking, snorting, or ingesting, all of which are safer methods with respect to HIV, hepatitis B, and hepatitis C than is injecting.
The task force is recommending that possession of currently illegal drugs for personal use should not be subject to prosecution. We are recommending that possession for personal use be decriminalized.
We are recommending that the amounts of drug that would be considered evidence of trafficking be defined nationally by drug and that resulting regulations and guidelines have national application. The task force recommends that specific exemptions be provided under the legislation to ensure that physicians who are specifically trained and licensed may prescribe narcotics and provide medicalized case management.
Finally, to conclude, the national action plan in its final form will focus on building allies from the community-based level to the national level in order to address what is now a very real public health crisis concerning HIV and injection drug use that is facing our country.
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Thank you.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much, Ms Hankins. Can you just clarify for me what you mean when you say 19 per 100 person-years?
Ms Hankins: The best way to think of it is that if you started off at the beginning of the year with 100 people who were not HIV infected and you followed them over that year, at the end of the year 19 would have become infected.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): This would be drug users.
Ms Hankins: Yes. It's a way of looking at exposure over time as opposed to prevalence, which I described as a snapshot. It's like taking a photo and saying how many are infected right now, whereas what we call an incidence figure, person-years, looks over the period of observation at how many people get infected, how many new cases are occurring.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): In terms of British Columbia you've said there was a 38% increase of new HIV infected cases. Over what period of time is that?
Ms Hankins: No. What I'm saying is that of all the HIV tests that were done in British Columbia in 1995 - these are voluntary HIV tests done through the provincial laboratory in B.C. - 38% of those that were found to be positive came from injection drug users, whereas before 1995 only 9% of the positive tests came from injection drug users.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): All right.
Mr. de Savoye, do you have questions for the panel?
[Translation]
Mr. Pierre de Savoye: Ms Hankins, you tell us we are facing a serious epidemic problem caused mainly by the use of needles. Having identified the problem and the vector, you recommend a number of solutions. One of your recommendations is that the simple possession of drugs no longer be considered an offence.
Can you tell us whether similar experiments are being carried out in other countries and, if so, what were their results?
M. Hankins: Let me tell you right away that an experiment is being conducted in this country. For at least a year in Vancouver, there has been no prosecution in cases of possession. From what I understand from the Vancouver police the reason for this is that there is no follow-up in the court system. There are two many cases before the courts and they consider that it is impossible to proceed. So for at least a year the police have simply confiscated the drug and allowed the person to go free.
M. Pierre de Savoye: Without any legal prosecution or criminal record or anything?
Ms Hankins: Yes. So we are recommending that the same thing be done throughout the country to avoid attracting too many drug addicts to Vancouver where the epidemic has actually broken out. We must first of all define what our practice will be at the national level. Will we provide a grant? Will we do what is done in Vancouver and let the culprit get off? What will our procedure be?
Secondly, what do we mean by possession? What quantity of each particular drug constitutes the offence of possession? That is why we need a good definition for each drug.
I gather that in Vancouver it is 90 decks. Personally I don't know what a deck is but I imagine that it's enough for a person to have a hit. It's done arbitrarily in Vancouver. We are recommending that it be standardized by regulation at the national level.
Mr. Pierre de Savoye: Ms Hankins, I understand what you are saying but there is a contradiction I'd like you to clarify. You say that there is a serious epidemic in Vancouver and at the same time people in this city are no longer prosecuted for the possession of drugs. You claim that this lack of prosecution should result in a decrease. Has any decrease been observed in Vancouver?
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Ms Hankins: The reason for this practice in Vancouver, it's something I forgot to mention, is that the police want to focus their efforts on the big drug dealers. I don't think a relationship has been established between the fact that they are no longer prosecuting and HIV transmission, because the police are no longer attempting to arrest the little guys and send them to prison for two months.
The other aspect of your question dealt with the effects of decriminalization in other countries. There aren't many examples. We do have the example of Holland where decriminalization has taken place. It isn't so much decriminalization but the fact that proceedings are not taken against people possessing marijuana. In the United States, eleven states decided to enact similar provisions.
I am not aware of any country where heroin is actually decriminalized. There are countries providing access to medical programs like Britain and Switzerland. In Berne, Switzerland, the population voted in a referendum to support a pilot project for the medical administration of heroin to drug addicts. So there have been experiments but not really decriminalization. It's more of a change in the application of the law.
The reason for this is that many countries feel constrained by the international treaties they signed under pressure from the United States and the United nations. So for the time being ways have to be found to get around that with a change in the application of law and eventually through decriminalization at the national level.
Mr. Pierre de Savoye: What this amounts to then is a kind of harm reduction, isn't it?
Ms Hankins: Exactly.
Mr. Pierre de Savoye: I gather that Australia has a harm reduction program that has brought about a significant reduction in its HIV infection rate. Are you aware of what is being done in Australia?
Ms Hankins: Yes. They started early, they took strong measures and they flooded the market with needles and syringes. I can't tell you what their treatment capacity is compared to ours but they offer a lot more. They are now considering setting up a pilot project for heroin but it hasn't begun yet.
Mr. Pierre de Savoye: So you're telling us that if we really want to stamp out the epidemic, it's not merely a matter of decriminalizing possession of drugs, we also have to think of providing needles, setting up harm reduction programs and providing treatment for those in need.
Ms Hankins: Yes. It's a multipronged strategy, including prevention of initiation to drugs.
Mr. Pierre de Savoye: Thank you.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much.
On the question of decriminalization, we've had people make presentations before this committee saying they felt this would be the wrong way to go because this will encourage more people to use drugs because there won't be the same penalties. Maybe you can comment on what would be the long-term result if we decriminalize simple possession of certain drugs or all drugs. What do you think the long-term effect of that would be?
Ms Hankins: I think what most people are arguing is that we look at the full gamut of drugs, those that are currently illegal, those that are currently legal, and assess what the societal damage is, assess what is likely to happen if some are made illegal, if some are made legal, and make more cogent decisions about what should be done.
We're in a situation now where I think Eugene Oscapella has calculated that one in 50 adult Canadians has a criminal record for drugs. I don't think there's any other country in the world with that kind of rate. Now, a lot of that is marijuana possession, but anybody.... I'm a physician. Any physician looking at the damage done by alcohol and comparing it to the damage done by marijuana would say immediately this drug should be illegal and this drug should be legal.
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I think we should look at having regulations and laws that control the socially undesirable behaviour associated with drugs. All the issues about driving cars, operating heavy machinery under the influence, initiating drug, alcohol, or cigarette use with adolescents, giving people free product to get them started, whether cigarettes, alcohol, or drugs, are all things that I think we should regulate, but I think we sit here sort of saying if we open up the floodgates everybody is going to start taking heroin three times a day. It's just not the case; it just won't happen.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): So your view and the task force's view is that in the long term you're not going to get any real increase in the use of, say, marijuana if we decriminalize it.
Ms Hankins: I don't know if you would have an increase in the use of marijuana. You might have an increase in the quality of product, depending on how far you want to regulate that.
The thing about decriminalization, as I understand it, is that you remove it from the Criminal Code and then make it open to regulation. So you might have regulations about who can grow it, who can sell it. You might want to make it a more public system of distribution as opposed to the current one, where people have concerns that if the guy who's selling you marijuana has other things available, he might suggest you try a little cocaine or a little something else. Marijuana is a drug we might want to treat quite separately from the rest of the other drugs.
As to heroin and cocaine, I would think we would want to set up a treatment system for people who have drug problems with those drugs, where they can register with physicians and be followed very closely.
I guess the advantage of your group right now is that you have the option of looking globally at all of them.
We've just passed a very strong piece of legislation on cigarette advertising that probably should have happened a very long time ago. Most of the people I've talked to are very much in favour of it, even though I live in Montreal and there's concern about support for activities in Montreal.
I think the next step is to look a lot more closely at alcohol. We're throwing a lot of money into alcohol treatment but alcohol continues to be socially sanctioned, as was said by the previous speaker. I think there are people who would prefer to use marijuana rather than alcohol and do not do so simply because it's illegal.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much.
Mr. Joseph Volpe (Eglinton - Lawrence, Lib.): I wonder if we could just follow that up for a second. As you probably know, this committee, as others, has wrestled with the idea of what are the consequences of decriminalization. You've just expressed, I suppose, faith in the fact that you will not get a greater incidence of consumption if you decriminalize and regulate any of these drugs.
One of the arguments we heard in the last debate on tobacco seemed to go completely against your article of faith, and I don't mean that disparagingly. If I heard it once in committee, I must have heard it at least a dozen times: this is a legal product, so why are you trying to regulate it?
Do you not see that same sort of counter-view and perhaps a developing sense that if it is a legal product, yes, I'm going to use it, I'm going to put pressure on the government to diminish the regulations, I'm going to ask for greater opportunities to advertise its availability, and I'm going to legitimize its acceptance in the community by associating it with, for example, cultural events, as in the case of tobacco?
Ms Hankins: I think we should turn that argument on its head. The people who are arguing those points are obviously trying to use the fact that it's a legal drug to say, therefore, you shouldn't touch it. I think when we're talking about decriminalizing we're not making it legal. We wouldn't be making marijuana or heroin legal. That's legislating to say that these are legal products. We would be decriminalizing them and then we could regulate. I don't see the problem with proceeding that way.
Mr. Joseph Volpe: Do you not see that every time you regulate you infringe upon the freedom associated with the movement of that products and its purveyors in the community?
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Ms Hankins: Yes, but we do that with a lot of things. I'm a public health professional and we have tonnes of regulations on all kinds of things: food, water...lots of things. I suppose the food industry could argue -
Mr. Joseph Volpe: And medicine.
Ms Hankins: - medicine - that they're being regulated too far. It's a constant pull.
Mr. Joseph Volpe: Just to get away from the philosophy of it, I wanted to draw attention to a very real situation that took place in the last several weeks and culminated in legislation going through the House last week, where those arguments were precisely at the forefront of any discussions on the merits of legislation or the desirability of legislation or regulations. I'm just wondering whether those of us on committees who have heard the argument that says if you do anything to loosen the reins, you are opening the floodgates...which I think was the word you used. The kind of debate we had over the course of this last couple of weeks would suggest perhaps we should put a little more weight on that kind of a concern than we might otherwise.
Ms Hankins: This is my own personal opinion. I think the problem is that we do not have enough alternative nicotine delivery systems available from research yet. The problem people have is a nicotine addiction. The way they are taking that drug - and it is distinctly a drug - is harmful to their health and to the health of those around them. In the case of nicotine I think we should be putting a lot more money into developing these alternate delivery systems. There are some - there's the patch and there's gum and so on - but a lot more work needs to be done on that, simply because most smokers I think want the nicotine and don't want the smoke.
I don't know if I'm responding to your question, but more thinking needs to be done about how, not only in the case of tobacco but in the case of all drugs, we can reduce the harm associated with them for those people who are opting to choose to use them. Whether they are legal or illegal, some people are going to try to use them anyway, and we're not providing them with enough options to make it safer for them to do so if they are going to do so.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Mr. de Savoye.
[Translation]
Mr. Pierre de Savoye: Ms Hankins, what do you think of conditions in prison? According to the information I've obtained and you can confirm if this is so, in the case of women in Canadian prisons, the hepatitis C infection rate is close to 40%. Can you confirm whether this figure is correct? If is isn't, what exactly is the rate? What do you think of the situation? What could we do to improve things?
Ms Hankins: For as long as it is our policy to incarcerate people who inject drugs, the hepatitis C and hepatitis B infection rates will reflect this policy.
I did a four-year study in Montreal in the women's prison and I observed that 8% of the women were infected with HIV and that the infection rate of drug addicts was 15%. The risk factors were the sharing of dirty needles and unprotected sexual relations.
So the 40% figure that you quote for hepatitis C does strike me as plausible. In Vancouver, in the co-op I mentioned, there's an alarming HIV infection rate and 85% of the people are already infected with hepatitis C. In Quebec, in Montreal, between 60 and 80% are already infected with hepatitis C.
Mr. Pierre de Savoye: If I understand you correctly, you are making two fundamentally different points. First of all, we have a high infection rate because we incarcerate drug addicts. So these people are already infected when they arrive.
Ms Hankins: Yes. That reflects what is taking place in the community.
Mr. Pierre de Savoye: Secondly, you tell us that this is spreading in the prison environment, that dirty needles are being used and there are unprotected sexual relations.
So in fact the problem at the two levels is being reinforced. Would you go so far as to say that we should stop incarcerating drug addicts? The previous witness suggested that treatment would be preferable. Secondly, if they are to be incarcerated, should we not at least take certain minimum health measures such as providing clean needles and what is required for safe sex? Is that what you would suggest?
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Ms Hankins: We are creating shooting galleries within are correctional institutions. When the drug gets in the institution, someone finds a needle somewhere and the same needle is used by as many as 20 people. So in view of the existing infection rate, when people start sharing these needles, then transmission takes place within the prison.
Personally I think we should first of all take a look at what is done when people are incarcerated. What is the purpose of this measure? Is it possible for Bill C-41 to strengthen diversions, respite orders etc.? Can this be addressed as a public health problem rather than a criminal matter?
Would it not be possible to reduce the crime rate by registering people with a serious drug abuse problem as patients of a doctor who would follow them closely and provide them with drugs?
A pilot project of this type should be set up somewhere in Canada. An attempt should at least be made because I think that the jail approach we are taking is unethical. As already emphasized, a large proportion of these people are aboriginal.
The vice-chairman (Mr. Harbance Singh Dhaliwal): Thank you, Mr. de Savoye.
[English]
I just want to ask one question before giving Mr. Szabo an opportunity.
One of your recommendations is that we register some of the drug addicts so that doctors can administer properly if those addicts are heroin or cocaine users. Do any pilot projects currently exist within Canada to try to do that? Are there projects in which they're trying to get drug addicts registered so that they can be followed by doctors?
Ms Hankins: At the present time, no. A proposal is now being developed in three cities for a clinical trial that would recruit people to receive methadone, LAAM - that's a long-acting substitute for heroin - potentially heroin in that arm, or other possible treatments, but it really still is at that proposal stage right now.
As you may know, in the Liverpool, England, area they have had physicians prescribe smokable heroin. People who were shooting up before are now smoking heroin under a physician's supervision. From what I've read about this, I gather that families who were quite dysfunctional have been able to start to work again. They are functioning together as families again with that kind of scheme.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): I would presume that the end result is to try to reduce the use of that drug by reducing the amount on a gradual program, so that these individuals are totally free of the heroin.
Ms Hankins: As with any methadone program in Canada, it's clear that there are people for whom long-term maintenance is going to be required. There are some who want to be detoxed with methadone and come right off the drug. There are others who will take a short term of therapy, maybe six or nine months. There are others for whom it's going to go on for a long time.
If you have to go to the pharmacy every day to pick up your methadone, at some point you may decide that you'd like to see if you could come off it. If it means you can't travel to the U.S. for a weekend because they'll stop you at the border by asking you what it is you have there, those kinds of impediments are important. The majority of people eventually do come off methadone treatment, but there are some who are on it for 15, 16, 17 years. I sit on the board of the CRAN, which is the methadone treatment agency in Montreal, and we have people who have been on the program for 15 years.
One of the things we're pleased about is that, with the devolution of responsibility for methadone from the federal government to the provinces, the provinces are now actively looking at how they can use their current methadone programs to evaluate and assess people, stabilize them, and then get them out into the community, where they can then be followed by family physicians who have been trained to follow people on methadone. We're therefore hoping that our recommendation for increasing the number of treatment places is a realistic one.
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The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you.
Mr. Szabo.
Mr. Paul Szabo: Very briefly, in the first page of your presentation, under ``The Urgency,'' there's a lot of very large numbers, but if you look at them carefully, I have to tell you that it tends to paint a picture that is trying to be.... I'm sure you're trying to be dramatic here.
Ms Hankins: It is dramatic, I have to say.
Mr. Paul Szabo: It is dramatic, but it's misleading, and I want to tell you why.
Health Canada has appeared before our Subcommittee on HIV/AIDS, and according to Health Canada, the latest information available, which is only up to the end of 1994 in terms of their reports, is that 82% of all known cases of AIDS in Canada from the very beginning are caused by homosexual activity. That's the starting point from Health Canada: 82%.
I raise that for you because I think it's important if we want to make a point, not to fog it up by messing with numbers. But it says here that for women in particular the increase has been dramatic - 6% of all cases before 1989, up to 15% from 1989-1992, and 24% of AIDS cases for the period 1993-1996 - and all of a sudden you get a little excited about this.
We're talking about injection drug use. Those statistics you've used and only provided are for women, and homosexual activity tends to exclude women here.
I raise it because I think if the credibility of the data is going to be there, you can't play with percentages; you have to start giving the absolute number of cases and show on a relative basis what's happening here. I really think it's important, but you have to keep it in the context of the overall incidence and also, from the evidence that was given by Health Canada and others, the carving out, the problem in the prisons as a controlled situation, which isn't in control.
So there are some very important elements that skew it here, because I think you've tried to overdramatize by using figures related to women instead of the whole population of injection drug users.
Ms Hankins: I could give you the figures for men. These are from Health Canada as well. One percent -
Mr. Paul Szabo: But the point is, you didn't give them in here.
Ms Hankins: But I can give them to you for your information: 1% during the period before 1989; 2.6% for 1989-1992; and 5% for 1993-1996. So we're seeing a doubling in the last two periods, in men.
Mr. Paul Szabo: How many cases?
Ms Hankins: The total number of cases...I could probably figure it out in a moment. I don't have it on here.
I don't think it's useful to be facetious about these figures. These are real figures, and I had five minutes to present to you and I brought out to you what I think are the important points.
Women have a double jeopardy in the sense that they're more likely to acquire HIV sexually when they're exposed than are men. So I think you'll always see an increase like this in women because of the heterosexual aspect.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you.
We're running out of time, so one very quick question.
Mr. Pierre de Savoye: This is not a question, but an observation for you and for my friend Paul.
Witnesses are coming here willingly to help us reflect. You may feel misled by some information, and any one of us feeling that way should ask for clarification, not pass judgment on what is being presented to us.
Mr. Paul Szabo: I agree with you.
Mr. Pierre de Savoye: Thank you, Paul.
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much for your presentation. Your advice and recommendations are very valuable to the committee.
Our next witness...is it Mario Bilodeau?
[Translation]
Mr. Mario Bilodeau (Coordinator, CACTUS Montreal (Centre d'action communautaire auprès des toxicomanes utilisateurs de seringues)): My name is Mario Bilodeau.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Welcome, Mario.
Mario is from the group, CACTUS Montréal. Welcome to the committee. You have the floor.
I see another name was on there. Is anybody else joining you?
[Translation]
Mr. Bilodeau: No. There was a last minute cancellation.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Okay, go ahead.
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[Translation]
Mr. Bilodeau: I've come to present to your committee the work of CACTUS Montreal. My name is Mario Bilodeau and I have been director of CACTUS Montreal since 1996 and I've worked for this organization since 1991. During this time I've been directly involved with injection drug users and as I said, I am now director of the service.
CACTUS Montreal is a community based centre providing service to addicts who inject drugs. This community organization has been in existence since 1989 and its aim is to prevent the transmission of the AIDS virus among injection drug users.
How is this achieved? It is not easy to work with injection drug uses (IDU). We have set ourselves four objectives. The first is to increase the number of available syringes through the exchange of dirty needles for new ones. This is a practical aim. We also distribute condoms.
Our second aim is educational. We attempt to improve injection drug users skill in using syringes. The idea is to teach people to do a better job of injecting drugs in order to do less harm to themselves.
Our third objective is to support, encourage and accompany injection drug users as they go about the process of change, including among other things, the use of our detoxification services. Because of its scope a project like CACTUS does have an impact on the environment. We try to influence the social and physical environment by bringing IDU's and the population at large closer together so that we can do more effective work.
People are afraid of injection drug users. They don't know what to do. These drug users are stigmatized and marginalized. It is difficult for us to get in touch with these people, that is our main problem.
As for our services, CACTUS exchanges used needles for new ones and distribute condoms. We promote low risk behaviour. We listen to people, we give them support and direct them to other services and we also promote a healthy environment.
What concrete form do these principles take? CACTUS does have an office location with the collaboration of the CLSC des Faubourgs, which has given us permission to operate on its premises. We have a regular location open seven evenings a week from 8 p.m. to 3 a.m. We have a street worker who looks after marginal youth in the city centre since we've noted that there is an increase in injection drug consumption among young people. There are also people we were unsuccessful in reaching and we decided to go to the mountain since they didn't come to us. We have a street worker who establishes contacts with these young people directly in their environment so that we can provide needle exchange and encourage long-term changes that people are willing to undertake.
We also have a street worker who looks after women and other sexual categories because we know there is a significant effect on women as a group. We have a female worker who does similar street work aimed at women. We also carry out more specific interventions for other sexual categories since this is the clientele that is even more invisible than most others.
The problem in working with this kind of marginal group is that the people are quite invisible. When people disappear, this hinders our ability to act and provide prevention or information services or support to these people. In this respect, we are a high tolerance project.
We also do promotion, the kind done by our female street worker who looks after women and other sexual categories. This promotion focuses on AIDS prevention and access to services. We work directly in prisons, in Bordeaux, in Tanguay and rehabilitation centres so that we can deal with these people during their period of arrest. When these people are under arrest, they are more receptive to information about how to prevent AIDS, and the availability of services and other resources.
So we work with them directly when they are under arrest, whether by choice or otherwise. When people are in prison, they are not necessarily off drugs by choice. We meet with them, we talk to them about their concerns while they are under arrest, which are not necessarily the same concerns they have when they are actually using drugs. When they stop for a while, they are more receptive to our message.
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We also do some satellite volunteer work. These are people who are involved with us, but who are not officially part of CACTUS. They work on health promotion, syringes and needle exchange, condom distribution, and provision of information on community resources. These people get in touch with our workers, particularly in the case of people who make heavy use of the exchange program. When these officers go back to their communities, they pass on our message to more people.
Clearly, the purpose of our work is to make more people aware of the situation of injection drug users, in order to bring together the various parties involved and promote more effective work in this area.
We often compare our work to what goes on in a football field. If everyone beats up on anyone else, we will never achieve a good quality of life, because we will always be looking for a guilty party. Thus, we are trying to create better links so that we do not lose contact with the injection drug users who live in downtown Montreal so that we can continue with our work.
Those are the main points we, the representatives of CACTUS, wanted to make to you. You may have some questions for us.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Yes, we'll go to questions now.
Mr. de Savoye.
[Translation]
Mr. Pierre de Savoye: Mr. Bilodeau, you have told us about daily lives that are very far removed from our own. You are on the front line. Here we are quite far away from the situation, and we count on people like you to tell us what is going on and what the needs are.
In this regard, I would like to ask you some very specific questions about the work done by CACTUS. If we do not count Bordeaux and Tanguay, how many clients do you have at the moment?
Mr. Bilodeau: At the moment, it is difficult to say how many clients we have. Since our guiding principle is anonymity, it is hard for us to tell how exactly many clients we have. However, I can tell you that we get over 30,000 visits every year.
Mr. Pierre de Savoye: These are people who come back?
Mr. Bilodeau: Yes, I'm talking about 30,000 individual visits to our fixed location. Not counting our street and community work, at the fixed location alone, at least 30,000 people come in each year to exchange needles and syringes, to get condoms, to pick up information, and so on. Our priority is needle and syringe exchange. Every year, we distribute approximately 200,000 syringes.
Mr. Pierre de Savoye: Thirty thousand visits and 200,000 syringes.
Mr. Bilodeau: That is correct. We get 30,000 visits each year and we distribute 200,000 needles and syringes each year. If you're interested in age groups, I can tell you that at the moment - because there are changes over time - 24% of our visitors are under 24, 20% are between 30 and 34 and 19% are 40 or over. Those are the three main age groups.
Mr. Pierre de Savoye: What about the male/female breakdown?
Mr. Bilodeau: We see more men than women. At the moment, the ratio of men to women at our fixed location is 3 to 1.
Mr. Pierre de Savoye: These people are drug users.
Mr. Bilodeau: Yes.
Mr. Pierre de Savoye: Consequently, strictly speaking, these are people who commit crimes.
Mr. Bilodeau: I couldn't say. I don't know. CACTUS has a number of ethical rules: no drugs are to be used inside our office, there is no solicitation and no sale or purchase of equipment. When people come in, they do so strictly because of their need.
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I could say that they may be involved in criminal activity. I am sure some authors have studied this. I can also say that the drug users we see at CACTUS have never been involved in violence, security problems, theft or anything else. They come to us quite freely; our centre is open. However, there are problems of violence, theft, and so on involving people who drink alcohol, which is a legal substance.
We have never had any trouble establishing links with the people who come to us or in working with them. I cannot answer that question at this time.
Mr. Pierre de Savoye: My question was about the behaviour of these people, and you answered it.
Mr. Bilodeau: People who use drugs are always capable of carrying on a conversation, of being involved in a follow-up. Our problem is rather to establish contacts with people, to develop ties with as many people as possible so that we can meet their needs. Our greatest problem is marginalisation - sometimes people disappear. From our point of view, prevention and zero tolerance are completely contradictory concepts, because one tends to chase people away, while the other helps establish ties with them.
How do we go about finding a happy medium between the two? I think it is important to establish a connection with people so that we can intervene later on as required.
Mr. Pierre de Savoye: The people who come to see you who have quite a serious problem. They come to see you because they need physical support, such as the syringe, for example, but they also need psychological support. They may also need to talk to someone. I understand that the main purpose of your work is to reduce the harmful effects of drug use. Do you manage to establish relationships that enable you to help people solve their problem?
Mr. Bilodeau: Yes, definitely. We are very positive about this. Thirty thousand people come to us every year. That makes between 50 and 60 people during a seven-hour shift. Obviously we cannot spend an hour talking to each one or providing follow-up. That is physically impossible.
It is the funnel principle. Many people use drugs and syringes. They do not see it as a problem. Not all of the 30,000 who come to see us have a serious problem. We must bear in mind the enjoyment and satisfaction factors. Not everyone has a problem. I would even go so far as to say that most of the people who use drugs, even the injection drug users, do not necessarily have more problems than people generally.
Some of these drug users have problems, and we use our funnel approach to establish a connection and provide follow-up. Our objective, of course, is to direct people towards existing resources. Since we are open at night, our services are limited. So we work with the people and try to get them to make certain choices and take action based on their needs.
Mr. Pierre de Savoye: I was struck by something you just said. You said that not all drug users have a problem.
Mr. Bilodeau: That is correct.
Mr. Pierre de Savoye: The witnesses we heard previously, particularly those from Portage, told us about people with serious social problems, because criminal behaviour is often associated with drug use. They have to treat a host of problems. You are saying that there are people like that, but that there are also people who do not have a drug problem. Could you help us distinguish between these groups and perhaps give us percentages or other information that might help us understand this better?
Mr. Bilodeau: Detoxification centres such as Portage see people who want to stop using drugs, people who have a drug problem. Those involved in drug treatment and rehabilitation see mainly people with drug problems. Our objective is to prevent the transmission of the AIDS virus. So we see people who are still finding enjoyment, and perhaps satisfaction in using drugs. We see a whole range of people.
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The people who come to CACTUS represent all social classes: workers, unemployed people, people with mental health problems and representatives of various ethnic groups. All the various types of people found in downtown Montreal are represented among our clients. Not everyone in this broad group has a drug problem. To the extent that people find enjoyment or some satisfaction in drug use, there is no problem with the substance.
Mr. Pierre de Savoye: Are you telling me that there are people who used heroine, cocaine or other substances and who lead normal lives, who do not need to fall into crime and who, in the end, are like all of us here?
Mr. Bilodeau: Absolutely. Some people are able to manage their doses of heroine or cocaine, whether they take them by injection or otherwise, who do not lose their jobs or their homes, and who have not turned to prostitution, theft of any other type of such activity. Some people are able to manage their doses very well and continue to lead normal lives for many years. I've seen people of this type since 1991. So, for me, that means they exist, even though we do not hear about them.
[English]
The Vice-Chair (Mr. Harbance Singh Dhaliwal): Thank you very much for your presentation.
That wraps up this morning, ladies and gentlemen. The meeting is adjourned.