HESA Committee Report
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Report and Recommendations on the Opioid Crisis in Canada Canada’s opioid crisis is complex and multifaceted. The current overdose emergency, driven primarily by a rapid increase in the use of fentanyl and other powerful illegal opioid drugs, has led to an unprecedented number of overdose deaths; but, this crisis reaches far beyond the illegal drug market. For many Canadians, this crisis has its roots in high levels of addiction to legal opioids, caused in part by inappropriate prescribing practices and poor education about the risks associated with opioids. For others, substance use disorders have much deeper roots in trauma, social and economic inequities and mental health issues. The Government of Canada has already taken numerous steps to address the current crisis, including making naloxone more readily available, regulatory amendments which overturned the ban on the sale of diacetylmorphine (heroin) for emergency treatment and now allow for the consideration of applications made to the Special Access Program, and introducing Bill C-37 to simplify and streamline the application process for supervised consumption sites. Bill C-37 will also provide law enforcement with tools to prevent illegal drugs from being imported and manufactured in Canada. More broadly, the government is supporting research and surveillance to support the development of robust, evidence-based strategies for preventing, treating, and reducing the harms of addictions and drug dependencies. However, these enabling actions alone are not enough. Provincial Governments, municipal governments, regulatory colleges, healthcare providers, front line workers and users of drugs all have a critical role in responding to the overdose emergency and turning the tide on the crisis. To that end, the Government of Canada remains committed to a comprehensive, collaborative, compassionate and evidence-based approach to addressing this crisis and the underlying causes of problematic substance use over the long term. The Overdose Emergency in Canada Opioids are a powerful class of painkilling drugs derived either directly from the opium poppy (e.g., morphine, codeine), produced semi-synthetically (e.g., heroin, oxycodone) or produced synthetically (e.g. fentanyl). The strength of opioids can vary by orders of magnitude. Codeine is 0.15 the strength of morphine while fentanyl is 50-100 times stronger than morphine. Carfentanil is 10, 000 times stronger than morphine. Many of these medications have legitimate medical uses to manage pain, in particular for end of life care. However, they can also pose serious risks. Over the past year, the number of overdose deaths associated with opioids in Canada has increased at an alarming rate. In 2016, British Columbia experienced a total of 914 overdose deaths from illegal drug use, an 80% increase from 2015. Alberta also saw an increase in overdose deaths in 2016 with 343 deaths related to fentanyl, an almost 25% increase from 2015. Although the overdose emergency is particularly acute in western Canada, front-line responders are warning that the crisis is moving eastward. Similarly, while the focal point of the overdose emergency has been illegal drug use in the lower-east side of Vancouver, the crisis affects individuals and families from all demographics. Emergence of Powerful Opioids in Illegal Drugs Illegally produced versions of powerful opioids with legitimate medical use (e.g. fentanyl) are showing up in Canada’s illegal drug market alongside traditional street drugs like heroin as a drug of choice. In fact, fentanyl is increasingly being found mixed with non-opioid drugs like cocaine, making it more dangerous because of the lower tolerance of users. While the response to the evolving illegal drug market must include interdiction by law-enforcement and border services, a public health approach is central to protecting the lives of Canadians and addressing the drivers of opioid addiction in Canada. Opioid Overconsumption in Canada The current overdose emergency is only the most recent manifestation of the longer term problem of opioid addiction and overconsumption in Canada which has been growing for decades. Opioid use disorder is a chronic relapsing illness seen in people from all educational and socioeconomic backgrounds, and it often co-occurs with other mental health disorders. Opioid use disorder is associated with serious harms such as infectious disease, overdose and death, as well as social issues such as poverty, homelessness, and incarceration. It may involve the use of illegal opioids, such as heroin or street fentanyl, or the misuse of prescription opioid medications. Over the last twenty years, Canada has become the second highest consumer of opioid medications in the world, after the United States. One of the main drivers of this crisis has been physician prescribing practices. Some research suggests the overprescribing of opioids can be traced back to several misleading studies from the 1980s that suggested opioids were less addictive than they actually are and could therefore be used liberally to treat a variety of types of pain. Research has also shown a very strong correlation between dispensing of opioid medications and mortality and morbidity in Canada and the United States. As prescribers authorised more opioids to be dispensed over the past decades, the number of opioid related deaths and people in treatment for opioid addiction has risen significantly. As a primary measure, this research suggests that decreasing overall dispensing levels would likely reduce prescription opioid related harms on a population level. Other researchers have explored how marketing and promotional efforts by the pharmaceutical industry in the United States contributed to the problem. The parent company of Purdue Pharma in the United States pled guilty to misbranding their product OxyContin when they suggested it was less addictive and more suitable for general use than it was and paid a fine of over $600M. Public Health Emergency (Recommendation 1) The Government of Canada has been taking action on this crisis for more than year. While speaking before the United Nations in June 2016, the Minister of Health outlined measures already underway from late 2015 to help save lives and described the increasing number of opioid related deaths in Canada as a public health crisis and has committed to using all of the tools available to her to address it. On April 14, 2016, British Columbia’s Provincial Health Officer declared a public health emergency under provincial legislation, which allowed medical officers’ immediate access to real-time information on drug overdoses which supported effective prevention planning. For example, the data allowed officials to issue targeted warnings about the presence of powerful opioids in other street drugs and to increase distribution of take home naloxone (an antidote for opioid overdose) kits. In February 2017, the Government of Canada announced it will provide $10 million in urgent support to the Province of British Columbia to assist with its response to the overwhelming effects of the emergency in that province. Some have called on the federal government to declare a national emergency under the Emergencies Act (formerly the War Measures Act). The Emergencies Act, which has never been used (including for major public safety and public welfare events like the Manitoba and Saguenay floods, the Ice Storm, 9/11, Bovine spongiform encephalopathy (BSE), SARS, H1N1, Y2K, Hurricane Juan, Lac Megantic and the Fort McMurray fires), is a tool of last resort to ensure safety and security in the event of a national emergency that cannot be addressed by other levels of government or laws. The Act is intended to provide a short term response and the declaration of an emergency must be reviewed every 30 days. In order to make declaration of a public welfare emergency, the Lieutenant Governor in Council of the province where the emergency is located must indicate to the Governor in Council that the situation exceeds the capacity or authority of the province to manage before a state of emergency can be declared under the Act. Taking into consideration the needs identified by provincial and local governments and organizations on the front lines of the overdose emergency, there have been no requests made of the federal government that could not be addressed under existing authorities. In addition, the Government believes that the crisis requires a longer term, sustained, and co-ordinated effort, which the Emergencies Act is not designed to provide. To create additional tools for dealing with the crisis, the federal government introduced Bill C-37 which would better control pill presses and encapsulators, improve enforcement at the border, and streamline the application processes for supervised consumption sites among other improvements to the Controlled Drugs and Substances Act. Though the Government does not believe that declaring a National Emergency under the Emergencies Act would be an effective tool at this point in time, it does not mean that the Government is not treating the current situation as an emergency. Canada’s Interim Chief Public Health Officer, Dr. Theresa Tam, is leading the federal public health emergency response to the opioid crisis and is working closely with P/T counterparts to support a cohesive and collaborative approach to addressing this public health crisis. The Public Health Agency of Canada and provincial and territorial governments have jointly activated a Special Advisory Committee on the Epidemic of Opioid Overdoses (SAC) co-chaired by Canada’s Interim Chief Public Health Officer, Dr. Theresa Tam, and the Chief Public Health Officer for Nova Scotia, Dr. Robert Strang. The SAC consists of members of the Pan-Canadian Public Health Network Council (which is composed of senior public health officials from the federal, provincial and territorial governments) and the Council of Chief Medical Officers of Health and has been the key mechanism for Federal, Provincial and Territorial coordination during public health events of national significance including for Ebola. The SAC is focusing on urgent issues related to overdose and deaths linked to opioids, including illegal opioids. More specifically, the SAC’s initial focus has been on supporting harm reduction, improving data and surveillance, and addressing treatment options. The Public Health Agency of Canada has also offered its mobile mini-clinics to provinces and territories as well as epidemiological supports. The short-term emergency response by the Public Health Agency of Canada is complemented by urgent regulatory action taken by the Federal Minister of Health over the past year including the March 2016 decision to make naloxone available without a prescription and the July 2016 Interim Order to allow the emergency import and sale of naloxone nasal spray – a more user-friendly product from the United States. Interim orders permit the federal Minister of Health to take immediate action under the Food and Drugs Act to deal with a significant risk to the health and safety of Canadians. Health Canada subsequently conducted an expedited review of the naloxone nasal spray and authorised it for sale in Canada in October 2016. To encourage individuals to call for help in the event that they experience or witness an overdose, the Government is also supporting the Good Samaritan Drug Overdose Act (Bill C-224), currently before Parliament, which would provide immunity from simple drug possession offences for anyone having sought assistance and having remained at the scene until the arrival of emergency services. An awareness campaign will be launched when the legislation is passed. Collaboration
and Federal Leadership The Government recognizes that a collaborative approach involving all jurisdictions and many partners is necessary to save lives, reduce the harms associated with problematic opioid use, and turn the tide on the crisis. In addition to activating the Special Advisory Committee, the Federal Minister of Health co-hosted an Opioid Conference and Summit with the Ontario Minister of Health and Long-Term Care on November 18-19, 2016. The event brought together 240 participants, including experts and partners from across the country, for a national discussion on actions to address and reduce the harms related to opioids in Canada. The webcast of the conference will remain available online. Following a series of productive discussions and panels, a Joint Statement of Action to Address the Opioid Crisis was released. It contains 129 commitments from 45 individual organizations, including, for example, dental, nursing, physician and allied health professional associations and regulatory bodies. Nine provincial and territorial health ministries also shared the actions they are taking to address this crisis. The complete joint statement and a list of participants are included in this response as Annexes. In addition to the SAC, a Health Portfolio Taskforce, composed of Assistant Deputy Ministers, is operational as is a Deputy Minister Committee that includes Health Canada, Public Safety Canada, Global Affairs Canada and the Privy Council Office (National Security Advisor). These committees will provide strategic direction and integrate domestic and international initiatives to address the opioid crisis. The federal government also supports provinces and territories in delivering health care services to Canadians, including services related to reducing harms associated with problematic opioid use, through the Canada Health Transfer. The federal Government will transfer $36.1B in 2016/2017 to the provinces and territories through the transfer. In December 2016, the Government offered to provide an additional $11B to provinces and territories over the next 10 years primarily for home care and mental health. Mental health supports and treatment fall within provincial and territorial jurisdiction, but these additional supports will be helpful in addressing upstream and downstream challenges related to problematic substance use. An additional $544 million will be provided over 5 years for federal and pan-Canadian health organizations to support work on health innovation and prescription drugs. Canadian Drugs and Substances Strategy The Government’s approach will protect lives and protect the health of communities. Health Canada developed an Opioid Action Plan which was announced in June 2016 and expanded under the Joint Statement of Action to Address the Opioid Crisis. The Opioid Action Plan outlines the importance of providing leadership to address the opioid crisis as well as six specific areas of actions including better informing Canadians about opioid risks; supporting better prescribing practices; reducing easy access to unnecessary opioids; supporting better treatment options; reducing the availability and harms of street drugs; and gathering data to inform evidence-based activities. The Government of Canada is committed to a drug policy that is comprehensive, collaborative, compassionate, and evidence-based. These values are reflected in the Government’s new Canadian Drugs and Substances Strategy that will replace the National Anti-Drug Strategy. Announced on December 12, 2016, and led by the Minister of Health, the Canadian Drugs and Substances Strategy reflects a balanced and health-focused approach to drug policy through a strong foundation in evidence and the restoration of harm reduction as a key pillar, alongside prevention, treatment and enforcement. Initiatives under Health Canada’s Opioid Action Plan and work outlined in the Joint Statement of Action to address the Opioid Crisis fall within the four pillars of the Canadian Drugs and Substances Strategy and are presented below. In February 2017, the Government of Canada announced $65 million over five years for federal activities to support the implementation of the new Canadian Drugs and Substances Strategy. This funding could be used towards: increasing national lab testing capacity; developing and implementing a national public awareness campaign; increasing research on problematic substance use; expanding supports for First Nations and Inuit communities, such as access to naloxone kits; strengthening national data surveillance and monitoring; funding grants and contributions to address various issues that are unique to the opioid crisis; and supporting new regulatory activities related to, for example, supervised consumption sites and oversight of prescription opioids.. Four Pillars of the Strategy Prevention The Prevention pillar of the Canadian Drugs and Substances Strategy aims to prevent problematic drug and substance use before it starts. At the federal level, communicating accurate and up to date information is one key prevention activity. Given that overprescribing of opioids has been identified as a significant contributor to opioid related harms, efforts are also being made to better inform prescribers about the risks associated with opioid based medications and support them in recognizing early signs of potential addiction or dependency. The Government recognizes that trauma and mental health are often closely related to substance use disorders, and prevention and treatment interventions should consider these as potential root causes that can co-occur with substance use. The Substance Use and Addictions Program funds projects to guide the integration of trauma-informed practices into health promotion, prevention and treatment services, develop evidence-based screening tools for mental health and substance use concerns, and better equip health professionals to work safely and effectively with survivors of violence through trauma-informed care. Alternatives to Prescribing Opioids When properly prescribed and used, prescription medication (including opioids) can be beneficial for treating health conditions and improving the quality of patients’ lives. Given that opioids are often prescribed for chronic pain management, alternative treatment options are one way to reduce opioid prescribing. The Canadian Institutes for Health Research and its partners are investing $25 million over 5 years to support the Canadian Chronic Pain Network through Canada’s Strategy for Patient-Oriented Research. The Network connects patients with researchers, health care professionals and government decision makers to increase access to care for people suffering from chronic pain and to speed up the introduction of the most current research findings into clinical practice. Further, through the Joint Statement, the Canadian Agency for Drugs and Technologies in Health has committed to analyzing the international literature to identify best practices and provide evidence-based recommendations, advice and decision support tools that will inform and guide patients, clinicians and policy-makers regarding pain management interventions (drug and non-drug), as well as the treatment of opioid addiction. Appropriate Prescribing of Opioids: Physician Education, Guidelines, and Best Practices As set out in the Joint Statement, Health Canada will continue to work with partners to develop and implement appropriate training and other educational tools to support health professionals in preventing and responding to problematic prescription drug use. The Government will work with provinces and territories, including through the Special Advisory Committee on the Epidemic of Opioid Overdoses, to support the dissemination, promotion, and adoption of updated opioid prescribing tools. Given provincial responsibilities related to the practice of medicine, the commitments made in the Joint Statement by the provincial colleges of physicians and surgeons, provincial and territorial ministries of health, the Association of Faculties of Medicine of Canada, the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and the Canadian Medical Association are expected to have a significant impact on prescribers. The federal government is providing support to the health sector through targeted investments to improve prescribing practices while encouraging dissemination and uptake of best practices. For example, Health Canada, through its Substance Use and Addictions Program, makes $26.3 million available annually to support evidence-informed and innovative initiatives across the health promotion continuum for problematic substance use from health promotion and prevention to harm reduction and treatment. The Canadian Centre on Substance Abuse, a key federal partner in responding to the substance misuse and the opioid crisis, will receive $7.8 million this year to work with associations such as the Assembly of First Nations Mental Wellness Committee, the College of Family Physicians of Canada and the Royal Canadian Mounted Police to expand access to community-based opioid dependence treatment programs, improve opioid prescribing activities and support the development of evidence-informed information on fentanyl among other projects to address opioids, other licit and illegal drug problems and emerging issues. The next call for proposals is planned for 2017-18 and will aim to fund projects that will address problematic opioid use and related harms, among other key priorities. Approximately $4 million of the Substance Use and Addictions Program’s funds between 2015 and 2017 were allocated to develop evidence-based practices for appropriate prescribing. The projects include: 1. McMaster University is updating the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain and is expected to be completed by the end of March 2017. On January 30, 2017, McMaster released the draft recommendations to inform the guidelines, for public consultation. McMaster is also developing a dissemination and knowledge transfer plan. Health Canada is working with McMaster to ensure a comprehensive and coordinated approach to dissemination and uptake. 2. The University of Waterloo’s School of Pharmacy is developing and implementing a collaborative, web-based education program focused on adherence to opioid guidelines. 3. The Canadian Association of Schools of Nursing is developing prescriber practice competencies for controlled drugs and substances for nurse practitioner and registered nurse education programs, as well as an e-resource for nursing faculty to facilitate the integration of the competencies into curricula. 4. L’institut national de santé publique is developing tools for prescribing physicians in Quebec to better understand the prescribing habits and needs required to improve opioid drug prescription practices and training. 5. The Toronto Rehabilitation Institute’s University Health Network is developing opioid self-assessment and web-based tools for family physicians using the revised Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. 6. The Institute for Safe Medication Practices Canada is improving Clinical Decision Support Systems for Electronic Medical Records and Non-Electronic Medical Records, to assist physicians and other health professionals with decision-making regarding the introduction and management of opioid therapy. Prescription Monitoring and Electronic Prescribing Prescription monitoring programs can help medical regulatory bodies to quantify the scope of over-prescribing, to influence prescriber behaviours, and to support best practices. In addition to helping identify risky prescribing practices, prescription monitoring programs can also contribute to identifying high-risk patients who may benefit from early interventions by their healthcare practitioner. Prescription monitoring programs currently exist in 6 provinces including British Columbia, Alberta, Saskatchewan, Manitoba, Ontario and Nova Scotia. Newfoundland and Labrador, New Brunswick and Prince Edward Island have programs in development and Yukon is linked in with the Alberta program. However, a pan-Canadian system is not yet in place. Recognizing that a pan-Canadian prescription monitoring tool may be beneficial in preventing or identifying opioid or other problematic substance use, work is being conducted to evaluate the interoperability and effectiveness of current systems. The Canadian Institute for Health Information (CIHI) is currently developing a pan-Canadian opioid surveillance system to contribute to the national evidence base on opioid use and related harms. By November 2017, CIHI will develop key metrics on the prevalence, consumption and harms of opioid misuse. As a part of this work, CIHI is developing a pan-Canadian drug information system that intends to address common data standards and interoperability of Canada’s current drug data held by partners, such as hospitals, emergency responders and coroners/medical examiners. To complement CIHI’s work and improve the effectiveness of prescription monitoring programs, Budget 2016 also provided Canada Health Infoway with $40 million to work with provinces and territories to develop an electronic prescribing system. PrescribeIT is a multi-jurisdiction e-prescribing solution currently under development that will enable prescribers to electronically transmit a prescription to a patient’s pharmacy of choice. Alberta and Ontario will be among the first provinces to work with Infoway to launch PrescribeIT. The tool’s secure electronic transmission will protect prescriptions from being altered or forged and will provide valuable data to physician regulators, policy makers, and others. Regulatory Initiatives to Support Appropriate Prescribing Health Canada uses its regulatory levers to support prevention efforts. For example, pursuant to the Controlled Drugs and Substances Act and its regulations (e.g., the Narcotic Control Regulations), Health Canada is able to share some prescribing practice information obtained from pharmacy inspections with provincial and territorial licensing authorities, as appropriate. The regulations compel the Minister to provide factual information, obtained under the Act or associated regulations, about a practitioner to the provincial professional licensing authority if the Minister has reasonable grounds to believe the practitioner has contravened a provision of this regulation or a rule of conduct established by the authority, including rules of conduct relating to prescribing. Provincial authorities may also request this information by writing to the Minister. This is an important regulatory opportunity to support prevention efforts. Health Canada is also supporting prevention measures to reduce easy access to unnecessary opioids. For example, Health Canada is working on regulatory proposals to: mandate new warning stickers and patient information sheets for prescription opioids; require drug companies to put in place concrete plans to characterise, minimize, and prevent risks related to prescription opioid drugs and determine the success of current measures. Additional risk minimisation measures may be considered (e.g. contraindications to be included in the Canadian Product Monographs). A Scientific Advisory Panel was held in November 2016 to provide recommendations on the warning stickers, information sheets and risk management plans. Another Scientific Advisory Panel will be convened in March 2017 to provide advice and recommendations on contraindications. Health Canada will also provide updated guidance to pharmacies on the handling and destruction of consumer-returned prescription drugs in the upcoming months. Prevention - Public Awareness Recognizing that the prevention of drug use is critical, Health Canada and the Public Health Agency of Canada will work with stakeholders to inform Canadians about the risks associated with opioids. For example, Health Canada will continue its five year national marketing campaign which began in 2014 to raise awareness of the harms and importance of proper monitoring, storing, and disposing of prescription drugs. Moving forward, this campaign will be adjusted to focus on the current opioid crisis, including overdose prevention and response. According to the 2015 Ontario Student Drug Use and Health Survey, 10% of students in grades 7–12 (an estimated 95,000 in Ontario) reported using a prescription opioid non-medically in the past year. The majority (59%) of past year users reported obtaining the drug from someone at home. Prescription drug take-back initiatives aim to reduce the harms associated with prescription drugs such as opioids by promoting safe storage and disposal and reducing the amount of these drugs available in people’s homes for possible diversion, misuse and accidental poisonings. From 2013-2016, the Canadian Association of Chiefs of Police led, in collaboration with the Government of Canada, the Canadian Centre on Substance Abuse and other partners, national Prescription Drug Drop-Off Days. In 2014, 42% of Canadian police agencies participated actively in Prescription Drug Drop-Off Day. Participating agencies reported recovering over 1.5 tons of drugs. Of the 19 agencies that reported details on number and types of pills recovered, opioids were found to be the predominant drug-type (32%) in the 22,000 pills that were identified. Health Canada is also developing evidence-based fact sheets on a number of opioid-related topics, such as the effects of opioids, risk factors for misuse, how to reduce harms, and tips for having effective conversations about problematic opioid use. Health Canada will also be working with provinces and territories, including through the Special Advisory Committee on the Epidemic of Opioid Overdoses and the Pan-Canadian Public Health Network Council, to share information on respective public education and awareness strategies and identify possible joint opportunities to raise public awareness across jurisdictions. The Treatment pillar of the Canadian Drugs and Substances Strategy supports innovative approaches to treatment and rehabilitation. In response to the current crisis, it has become increasingly important to better understand how to treat opioid addiction, improve access to treatment as well as address underlying determinants such as mental health. In addition, Health Canada also provides targeted funding through grants and contributions to pan-Canadian health organizations, institutions, business associations, other levels of government, off-reserve First Nations, Metis and Inuit not-for-profit organizations to support research and the development of clinical guidelines and other solutions to address problematic substance use, facilitate improvements to the treatment continuum of care, and improve awareness, knowledge and skills of key stakeholders. The federal government also supports better treatment for Canadians by investing in research. Through the Canadian Institutes of Health Research (CIHR), the federal government established the Canadian Research Initiative in Substance Misuse (CRISM) to conduct research on best practices in preventing and treating problematic substance use, including opioid addictions. Through this pan-Canadian research network, the CIHR invested more than $12 million to establish four research nodes across Canada (British Columbia, the Prairies, Ontario, and Quebec/Maritimes) to create a strong platform for research on problematic substance use. The Minister of Health has recently requested that the CRISM build on their work in British Columbia and lead the development of a National Guideline for opioid use disorder treatment and that the work be expedited given the time sensitivity of the current crisis. The Canadian Agency for Drugs and Technologies in Health recently conducted a literature review and published a report, comparing the clinical effectiveness of buprenorphine/naloxone and methadone for the treatment of opioid dependence in an effort to help inform physician and broader healthcare decisions on treatment options. The Agency will also be conducting an analysis of best practices to provide evidence-based recommendations, advice, and decision support tools for the treatment of opioid addictions. Regulatory Initiatives to Support Access to Treatment Mental Health Supports The Government also provided $111.8 million over two years through Budget 2016 to the Homelessness Partnering Strategy. Through this Strategy, the Government provides direct support and funding to communities across Canada for projects to prevent and reduce homelessness, including Housing First initiatives that help homeless Canadians secure stable housing while providing them with support for underlying issues, such as mental health or addiction. Within the Health Portfolio, the Public Health Agency of Canada is responsible for mental health promotion. The focus is on primary prevention (preventing mental health problems before they develop) that helps Canadians build resilience and coping skills. Intervention research and support to community-based programs for vulnerable populations, such as children and survivors of violence, contribute to the evidence on effective programs in mental health promotion. Surveillance of mental health and mental illness includes problematic substance use as an indicator that is monitored over time. The Public Health Agency of Canada also funds the Health Behaviour in School-aged Children study, a national school-based health promotion survey for children aged 11-15. This study provides data related to mental health during early adolescence, including on problematic substance use. Health Canada, through the Substance Use and Addictions Program, provides funding to support problematic substance use and co-occurring mental health issues. For example, the Centre for Addiction and Mental Health receives funding to enhance youth-focused evidence-informed treatment in the area of problematic substance use and concurrent mental health issues. The Centre is implementing a validated tool that screens for both problematic substance use and mental health concerns at 14 sites in Saskatchewan, British Columbia, Nova Scotia, Ontario, Prince Edward Island and Newfoundland. The common screening tool is used by youth service providers in different sectors, where youth are not necessarily screened for problematic substance use and/or co-occurring mental health concerns, including the specialized addictions sector, youth justice, mental health, outreach services, housing and support, health and primary care, and child welfare. The project includes a referral system that will improve referrals among providers and pathways into needed treatment for those with problematic substance use and mental health concerns. (Recommendations 5, 6, 8, 9) The harm reduction pillar of the Canadian Drugs and Substances Strategy takes a public health approach to reducing the negative consequences of problematic drug and substance use. Harm reduction initiatives can focus on reducing rates of overdose death as well as transmission rates of diseases like HIV/AIDS and Hepatitis C, without requiring or precluding abstinence from drug use. The Government recognizes that these initiatives protect public health and improve public safety and are a necessary component of Canadian drug policy. The Government has already demonstrated its commitment to moving forward with concrete, evidence-based measures which are aimed at reducing the harms of problematic substance use in Canada, including overdose and death, and efforts to prevent the risk of exposure to blood-borne disease such as HIV and Hepatitis C Virus. Prevention of HIV and Hepatitis C Virus depends upon reducing exposure risks, including preventing the initiation of drug use and risky practices, and transmission of infectious diseases among users of injection drugs. Supervised Consumption Sites Evidence has shown that, when properly established and maintained, supervised consumption sites can save lives and improve health without increasing drug use and crime in the surrounding area. Supervised consumption sites provide a clean and controlled space so that: life-threatening infections and disease are not spread; overdose-related deaths are reduced; the amount of public drug use and discarded paraphernalia that puts public safety at risk is reduced; and vulnerable individuals are connected with other health and social services including detox and treatment. As of March 2016, Health Canada has approved five supervised consumption sites. Health Canada granted Insite, Canada’s first supervised consumption site located in the Downtown Eastside of Vancouver, an unprecedented 4-year exemption to continue its important work. The second exemption was granted to the Dr. Peter Centre, a world-renowned HIV/AIDS treatment and support facility, to operate a supervised consumption site. In addition, Health Canada approved three exemption applications from the Centre intégré universitaire de santé et de services sociaux to operate three supervised consumption sites in Montreal. Bill C-37 was introduced by the government in December 2016 and, if passed, the bill would repeal the previous, burdensome legislative regime for applications for supervised consumption sites and would align the application requirements with the five factors set out by the Supreme Court of Canada in Canada v. PHS Community Services Society. By streamlining the application and renewal process and adding in a new transparency provision, communities that want and need supervised consumption sites can be assured that the process will not cause unreasonable burden or delay. Health Canada seeks to ensure that supervised consumption sites are established based on evidence and with sufficient support so that the sites will be properly maintained. Through the Joint Statement, the Minister of Health committed to supporting efforts to establish supervised consumption sites which include: continually supporting potential applicants to complete the application process through proactive engagement; and keeping the public up to date on the status of applications that have been submitted to Health Canada, including their stage in the review process. Health Canada will be working with provinces and territories, including through the Special Advisory Committee on the Epidemic of Opioid Overdoses to share best practices and lessons learned regarding the establishment and operation of supervised consumptions sites and members will discuss ways to reduce barriers within the proposed federal application process. Additional Harm Reduction Measures to Reduce Overdoses As outlined above Health Canada has taken measures to facilitate access to naloxone, an overdose-reversing drug, by changing the status from prescription to non-prescription. Other federal partners have taken action to make use of this life saving drug. Royal Canadian Mounted Police has acquired 17,082 kits of naloxone, and as of February 14, 2017, 15,252 Royal Canadian Mounted Police members have been trained to use naloxone which has been deployed 83 times, resulting in victim survival in 77 cases. It is very important to note that the Royal Canadian Mounted Police are not the police of jurisdiction in every community across Canada (e.g., the City of Vancouver is serviced by the Vancouver Police Department). The Royal Canadian Mounted Police developed a training course in fall 2016 for first responders to describe the signs and symptoms of opioid exposure, how to respond, the steps to take before administering naloxone, how to administer it and the side effects and mitigation strategies. The RCMP has also developed guidelines for first responders in fall 2016 to outline how to handle suspected drugs safely. As the illegal use of fentanyl and other synthetic opioids continues to grow in Canada, there is increased risk of inadvertent exposure with potentially life-threatening consequences. In addition, to encourage individuals to call for help in the event that they experience or witness an overdose, the Government is supporting Private Member’s Bill C-224, the Good Samaritan Drug Overdose Act. This bill would provide immunity from simple drug possession offences under section 4 of the Controlled Drugs and Substances Act for individuals who experience or witness an overdose and call for emergency assistance. The Canadian Institutes of Health Research is also supporting a research project at St. Michael’s Hospital in Toronto aiming to develop an overdose response toolkit and test its effectiveness through use with vulnerable populations in emergency departments. More specifically, this project will generate tools and evidence to extend the overdose education and naloxone distribution into clinical practice in emergency departments, family practice, opioid substitution clinics and inpatient settings. Information sharing and testing on emerging illegal drugs The Health Canada Drug Analysis Service role is to provide drug testing services to law enforcement. However, in the context of the current crisis, Health Canada’s Drug Analysis Service has launched a new initiative for issuing drug alerts to law enforcement agencies and provincial and territorial health authorities on emerging potent illegal drugs identified from substances submitted by law enforcement for analysis. Health Canada will continue to consider applications for exemptions for drug testing under the Controlled Drugs and Substances Act on a case-by-case basis. (Recommendations 33-38) The fourth pillar in the Canadian Drugs and Substances Strategy is enforcement. The Canada Border Services Agency and the Royal Canadian Mounted Police administer or enforce federal laws related to drug importation, production, supply, and distribution. Health Canada also has responsibilities under the Controlled Drugs and Substances Act and the Food and Drugs Act that support enforcement. In collaboration with provinces, territories and international partners, the Government of Canada is currently examining the most effective and efficient mechanisms to control the importation of illegal opioids. Criminal investigations and intelligence identify China as the main source country of fentanyl and its analogues entering Canada. The Royal Canadian Mounted Police publicly report on the fentanyl seizures. Furthermore, the Government of Canada is currently advancing bilateral and trilateral efforts to interdict the importation of illegal opioids. Bilateral work is underway with the United States Drug Enforcement Administration from an intelligence and strategic perspective to understand how best to engage in a trilateral cooperative manner with China. The Government of Canada will work collaboratively with internal and external partners to ensure consistent and effective responses to stem the flow of illegal opioids at the Canadian border. It will look at ways to enhance the Canada Border Services Agency’s ability to detect and interdict opioids in an environment of increasing volume in shipments. This includes supporting enforcement and interdiction through the use of risk targeting, intelligence, detection technology, and laboratory sampling and analysis. Bill C-37, An Act to amend the Controlled Drugs and Substances Act and to make related amendments to other Acts was introduced into the House of Commons by the Minister of Health on December 12, 2016 and proposes amendments that would address critical gaps to keeping illegal opioids from making their way onto Canadian streets. Currently, officers at the border have the authority to open imported mail or mail to be exported if they suspect on reasonable grounds that it contains goods referred to in the Customs Tariff, or goods the importation of which is prohibited, controlled or regulated under an Act of Parliament. However, there is an exception for mail weighing 30 grams or less, which officers may only open upon consent of the addressee, or when the sender has completed and attached a label to the mail. The Bill would remove this exception allowing officers at the border to open all imported or exported mail, regardless of weight, if they suspect on reasonable grounds that it contains goods referred to in the Customs Tariff, or goods the importation of which is prohibited, controlled or regulated under an Act of Parliament. Regulatory Measures Providing Scientific and Technical Services to Support Enforcement Health Canada’s Drugs Analysis Service is working closely with law enforcement officials to support enforcement measures by providing scientific and technical services, including: conducting analysis of seized materials suspected to contain controlled substances; providing support for investigations and safe dismantling of clandestine laboratories; providing training and scientific knowledge on illegal drugs, manufacturing processes and precursor chemicals; and providing expert testimony in court. Further Study by Parliament
Data and Evidence
All pillars of the Canadian Drugs and Substances Strategy are supported by a strong evidence base. The Government of Canada aims to better identify trends, target interventions, monitor impacts, and support decisions with evidence-based information. The Government acknowledges that data and evidence play a key role in providing a robust and effective response to the opioid crisis and to delivering an effective and sustainable national drug strategy. Important data and evidence related initiatives have already been discussed under the other pillars of the drug Strategy, including Infoway’s PrescribeIT and the Canadian Institute for Health Information’s (CIHI) work on developing pan-Canadian opioid surveillance system and generating data to build the national evidence base on opioid use and related harms. Health Canada has committed to improving the evidence base upon which policy decisions are made by: improving data collection and the Canadian evidence base to support drug policy decision making; considering the recommendations from the recent Best Brains Exchange on a Canadian Drug Observatory; hosting Scientific Advisory Panels to advise on scientific elements of the Canadian Drugs and Substances Strategy; supporting research to enhance knowledge about opioid misuse, as well as to evaluate and develop treatments for opioid addiction, and publicly reporting on the results of the Health Portfolio's initiatives to address the diversion and misuse of prescription drugs (2014 commitments) and projects funded through Health Canada's Substance Use and Addictions Program. The Canadian Network for Observational Drug Effect Studies (CNODES) is conducting an analysis of opioid prescribing patterns across Canada from 2007-2016 which includes trends by province and type of drug. The analysis will provide information regarding health outcomes and an algorithm to better attribute deaths to opioid use, based on coroner’s records across the country. Further, CNODES is developing a system to mine hospital admission records and coroner databases which could enable the timely reporting of fatal and non-fatal overdoses. Finally, at the Opioid Summit, the Canadian Institutes of Health Research committed to launch new research funding opportunities by June 2017 to support research projects on gender implications of opioids and to support a synthesis grant aiming to review the current literature and increase our knowledge related to the harms associated with opioids in Canada. First Nations and Inuit Key principles of a trauma-informed approach include giving the client back choice and control, which includes choices in when and how care is received and from which provider. Considering that residential schools targeted culture, using culturally-responsive approaches helps respond to Truth and Reconciliation Commission calls to action, including recognizing the value of Indigenous healing practices and using them in the treatment of Indigenous patients, in collaboration with Indigenous healers and Elders, where requested by the individual.
Culturally
Appropriate Care Health Canada is committed to working collaboratively with First Nations and Inuit to provide culturally safe programs and services, guided by the First Nations and Inuit Health Strategic Plan (2012). Developed in collaboration with First Nations and Inuit, the Plan commits to providing culturally safe mental health and addictions services and supports to First Nations and Inuit communities that includes community, cultural, and clinical approaches to mental wellness services, spanning the continuum of care. At the regional level, regional partnership tables with First Nations and/or Inuit partners direct decision making related to mental wellness programs and services. First Nations and Inuit have also taken on various levels of responsibility to direct, manage and deliver a range of federally-funded health services. For example, Health Canada is working with and supporting the Canadian Indigenous Nurses Association to complete a report identifying best practices in enhancing access to culturally appropriate clinical care. Health Canada is also supporting First Nations partners to implement service delivery models that are grounded in the holistic First Nations vision of health and provide a comprehensive range of high quality, effective and culturally safe health services, including land-based activities. In some communities this approach is reflected in the provision of problematic prescription drug use programs that have the flexibility of including on the land-based activities alongside methadone or buprenorphine/naloxone opioid replacement therapy/treatment. Health Canada will continue to work with partners to ensure treatment and mental health support programs are culturally safe, trauma-informed, and grounded in culture. Treatment and Prevention Services Health Canada funded community-based programming provides prevention, intervention, aftercare and follow-up services in the majority of First Nations and Inuit communities across Canada, while residential treatment occurs through the national network of National Native Alcohol and Drug Abuse Program/National Youth Solvent Abuse Program (NNADAP/NYSAP) treatment centres that are operated by First Nations organizations and communities to provide both in- and out-patient services. Central to success are the collaborative approach to programming that blends cultural practice and safety with mainstream treatment approaches, and cultural awareness of the treatment providers. Health Canada is committed to working with partners to improve access to buprenorphine/naloxone in communities as part of an approved Community-based Opioid dependence program. Health Canada’s Non-Insured Health Benefits (NIHB) Program has been providing coverage for buprenorphine/naloxone as a Limited Use benefit since December 2011. In fact, the Program was the first plan in Canada to ensure that prescribers can choose the most appropriate treatment option. The Program implemented changes in September 2014 to increase access to buprenorphine/naloxone by expanding criteria under its Limited Use status. There are approximately 3,000 NIHB clients currently approved for buprenorphine/naloxone coverage. Buprenorphine/naloxone is a controlled substance and poses risks to clients and communities if it is diverted to the illegal market. In remote or isolated locations, NIHB confirms that supports are in place to safely store, handle and undertake the daily witnessing of buprenorphine/naloxone before coverage is approved. The NIHB Program also includes any clients receiving coverage for opioid addiction therapy medications in the Prescription Monitoring Program which places additional safety measures on their coverage. Within the NNADAP/NYSAP network of treatment centres, 21 of the 43 treatment centres (49%) accept clients on buprenorphine/naloxone and 14 (33%) accept clients on methadone. To accommodate the unforeseen realities (e.g. weather delays) of delivering client specific medications to remote First Nation communities, Health Canada added naloxone to the Nursing Station Formulary in 2013 for communities using this drug as part of approved Community-based Opioid Addiction Treatment Programs to make sure there is continuity of treatment. Harm
Reduction Many centres within the network of Health Canada funded treatment centres have existing, or are taking on, harm reduction initiatives. First Nations community-based programs have the flexibility to adapt to the needs of community members accessing a program. Training on how to administer naloxone (by injection or nasal spray) is taking place in multiple regions with community-based workers, treatment centre staff, and individuals connected with friends and family members using opioids. For remote and isolated communities, injectable naloxone is listed in the Health Canada Nursing Station Formulary as a “must stock” antidote, to reverse the effect of opioid overdose. The injectable naloxone currently available in nursing stations is only administered by trained health professionals such as nurses and physicians to reverse the effect of acute opioid overdose as required. Naloxone in these health facilities is replenished as needed. As an initial effort to provide timely access to at-risk clients and their families, Health Canada is stocking a nasal spray version of naloxone for remote and isolated community through Nursing Stations. Health Canada is working with existing provincial public health programs under the framework for take-home naloxone injection kits distribution to high risk clients for opioid overdose, as part of their opioid harm reduction strategy. Nursing stations are involved as an extension of that work (e.g. Alberta take-home naloxone injection kits). Health Canada’s NIHB provides First Nations and Inuit with coverage for injectable naloxone as an open benefit, which means that clients can obtain naloxone at retail pharmacies at no cost. Coverage for nasal naloxone will also be provided when available for purchase in retail pharmacies. Health Canada supports First Nations communities in the implementation of a variety of harm reduction initiatives identified as community priorities, such as provision of biohazardous waste containers and needle exchange where appropriate. Health
Human Resources Health Canada provides approximately $300M annually on an ongoing basis for community based mental health and addictions programming. In April 2015, Health Canada announced it would provide more than $13M over five years and $3M annually on an ongoing basis to enhance prevention and treatment capacity for problematic prescription drug use within First Nations across Canada. Most funding is provided directly to First Nations communities or partner organizations to deliver health programs and services. The type of contract arrangements a community can enter into with service providers is largely determined by the type of funding arrangement it has with Health Canada. As of March 31, 2016, 74% of communities have a high degree of autonomy due to their block or flexible funding arrangements. This means that funding is contributed over multiple years and recipients have the ability to re-profile funding as needed. Health Canada employs primary care nurses in 52 of 79 remote and isolated communities. For the remainder of the communities (27), health services have been transferred to the communities, where the Band is responsible for employing primary care nurses. Although dedicated to primary care services, these nurses play a role in addictions treatment and to support them, guidelines that define the Health Canada nurse’s role in the therapeutic management of opioid dependence have been developed. Other remote and non-remote communities may choose to employ health care providers directly for addictions treatment. As primary care providers, Health Canada’s nurses can initiate pharmaceuticals that are prescribed by a Nurse Practitioner or Physician and provided by a retail pharmacy in support of addictions treatment as long as it is within provincial regulatory requirements. However, given the ongoing nature of buprenorphine/naloxone and methadone-reliant treatment, client treatment is initiated by nurses and then typically referred to community-based addictions programming for ongoing observed treatment and support. National Native Alcohol and Drug Abuse Program and National Youth Solvent Abuse Program treatment centres offer an array of special programming, with 49% accepting clients on buprenorphine/naloxone. Depending on the treatment centre, treatment cycle length can range from 7 to 180 days. Problematic prescription drug use projects located in communities and treatment centres are demonstrating promising practices with culture as the foundation, community ownership, and collaboration at their core. Many have the flexibility to include the land-based activities in conjunction with methadone or buprenorphine/naloxone treatment. Health Canada is also working with the First Nations Mental Wellness Continuum Implementation Team to support First Nations partners to develop First Nations service delivery models, including crisis response and prevention as well as land-based healing and wellness programs, which strengthen relationships with the land and traditional culture. These service delivery models will draw upon promising community practices to facilitate their integration into existing mental wellness programming in other communities. Conclusion The Government is seized with the urgency of the situation, has taken action, and is committed to continuing to act to address the opioid crisis. The Federal approach is comprehensive, compassionate, collaborative, and evidence-based. The Canadian Drugs and Substances Strategy, including making naloxone available by non-prescription status, an emergency order to allow easy to use naloxone nasal spray into Canada, approval of five supervised consumption sites, and the introduction of Bill C-37, are concrete steps to protect lives and protect the health of communities. The Government will continue to use all the tools at its disposal to respond to the crisis while being a strong partner and encouraging parallel action from provinces, territories, municipalities, health care practitioners, law enforcement, and civil society. Annex I to the Government Response Joint Statement of Action to Address
the Opioid Crisis Canada faces a serious and growing opioid crisis. We see its consequences in the rates of addiction, overdoses, and deaths across the country. This is a complex health and social issue with devastating consequences for individuals, families, and communities. The response to this crisis needs to be comprehensive, collaborative, compassionate and evidence-based. On November 18, 2016, we heard a number of perspectives on this crisis: from people who use drugs, from families, healthcare providers, first responders, educators and researchers. Today, we have come together to identify specific actions to address this crisis and publicly commit to taking these actions. This Joint Statement of Action to Address the Opioid Crisis reflects our combined commitment to act on this crisis. We have agreed to work within our respective areas of responsibility to improve prevention, treatment and harm reduction associated with problematic opioid use through timely, concrete actions that deliver clear results and we commit to reporting on our progress in delivering those results. As Health Ministers, our focus today is on the important actions being taken by players in the health community. We recognize that this is just the beginning. Much work is already underway separately in the areas of law enforcement, corrections, education and elsewhere. We will invite leaders in these communities to join us as we build on the commitments made today. The Honourable Jane Philpott The Honourable Eric Hoskins Our Actions To achieve this vision, we commit to taking the following specific actions to address the opioid crisis in Canada Health Canada commits to:
The Province of British Columbia commits to:
BC is in a unique position relative to the rest of Canada. The opioid overdose crisis is a public health emergency in our province - and to address this crisis, we have taken a multi-sectoral and integrated approach, engaging both health and public safety. Recognizing that some of BC's priority actions are not within the purview of the federal Minister of Health, BC respectfully and in a spirit of cooperation and collaboration commits to:
Manitoba Health, Seniors and Active Living, Province of Manitoba commits to:
The Ministry of Health, Province of New Brunswick commits to:
The Department of Health and Wellness, Province of Prince Edward Island, commits to:
The Ministry of Health and Community Services, Province of Newfoundland and Labrador commits to:
The Ministry of Health and Social Services, Government of the Northwest Territories commits to:
The Ministry of Health and Wellness, Province of Nova Scotia commits to:
The Ministry of Health and Long-Term Care, Province of Ontario commits to: Implementing Ontario's first comprehensive Opioid strategy to prevent opioid addiction and overdose by enhancing data collection, modernizing prescribing and dispensing practices, and connecting patients with high quality addiction treatment services.
The Ministry of Health, Province of Saskatchewan commits to:
Accreditation Canada commits to:
Sébastien Audette, President, Global Standards and Programs The Association of Canadian Faculties of Dentistry commits to:
Paul Allison, President The Association of Faculties of Medicine of Canada commits to:
Geneviève Moineau, President and Chief Executive Officer The Association of Faculties of Pharmacy of Canada commits to:
Beth Sproule, Clinician Scientist / Associate Professor, Leslie Dan Faculty of Pharmacy,
University of Toronto Canada Health Infoway commits to:
Michael Green, President The Canadian Agency for Drugs and Technologies in Health commits to:
Brian O'Rourke, President and Chief Executive Officer The Canadian Association of Poison Control Centres commits to:
Margaret Thompson, President The Canadian Association of Schools of Nursing commits to:
Cynthia Baker, Executive Director The Canadian Centre on Substance Abuse commits to:
The First Do No Harm Executive Council commits to:
Rita Notarandrea, Chief Executive Officer The Canadian Chiropractic Association commits to:
Allison Dantas, Chief Executive Officer The Canadian Council of Registered Nurse Regulators commits to:
Cynthia Johansen, Registrar and Chief Executive Officer The Canadian Institute for Health Information commits to:
David O'Toole, President and Chief Executive Officer The Canadian Institutes of Health Research commits to:
Jane Aubin, Chief Scientific Officer and Vice-President, Research, Knowledge Translation and Ethics Portfolio The Canadian Medical Association commits to:
Cindy Forbes, Past President The Canadian Medical Protective Association commits to:
Gordon Wallace, Managing Director, Safe Medical Care The Canadian Nurses Association commits to:
Barb Shellian, President The Canadian Pharmacists Association commits to:
Alistair Bursey, Chair of Board of Directors The Canadian Pain Society commits to:
Fiona Campbell, President Elect Le Collège des médecins du Québec and l'Ordre des pharmaciens du Québec commit to:
Pauline Gref, Medical Advisor of Executive Officer The College of Family Physicians of Canada commits to:
Jennifer Hall, President The College of Physicians and Surgeons of Alberta commits to:
Karen Mazurek, Deputy Registrar The College of Physicians and Surgeons of British Columbia commits to:
Heidi Oetter, Registrar The College of Physicians and Surgeons of Ontario commits to:
Rocco Gerace, Registrar The College of Physicians and Surgeons of Newfoundland and Labrador commits to:
Linda Inkpen, Registrar The First Nations Health Authority, Province of British Columbia commits to:
Evan Adams, Chief Medical Officer Health Quality Ontario commits to:
Anna Greenberg, Vice President,
Health System Performance The Institute for Safe Medication Practices Canada together with the Canadian Patient Safety Institute and Patients for Patient Safety Canada commit to:
Sylvia Hyland, Vice President and
Chief Operating Officer Chris Power, Chief Executive Officer Canadian Patient Safety Institute and Patients for Patient Safety Canada The National Association of Pharmacy Regulatory Authorities commits to:
Anjli Acharya, President The Royal College of Dental Surgeons of Ontario commits to:
David Mock, Professor The Royal College of Physicians and Surgeons of Canada commits to:
Kevin Imrie, President The Council of Chief Medical Officers of Health commits to:
Robert Strang, Chief Medical Officer
of Health for the Province of Nova Scotia Annex to the Government Response: Participant List at the November Opioid Conference and Summit
RECOMMENDATIONS from the Report of the Standing Committee on Health entitled, “Report and Recommendations on the Opioid Crisis in Canada” General Recommendation 1 That the Government of Canada declare the opioid overdose crisis a national public health emergency. Recommendation 2 That the Government of Canada create a national multi-sectoral taskforce on the opioid crisis. Recommendation 3 That the Government of Canada work with provincial and territorial counterparts to immediately develop an ongoing and fully coordinated pan-Canadian surveillance system for drug overdoses. Harm Reduction Recommendation 4 That the Government of Canada reinstate “harm reduction” as a core pillar of the National Anti-Drug Strategy, and also define “harm reduction.” Recommendation 5 That the Government of Canada work with the provinces and territories to establish a network of harm reduction facilities. Recommendation 6 That the Government of Canada work with the provinces and territories, and first responders’ regulatory authorities, to ensure that first responders, individuals who use drugs and others have access to naloxone and appropriate training on how to use it. Recommendation 7 That the First Nations and Inuit Health Branch of Health Canada ensure that adequate supplies of naloxone and appropriate training on its use are available in reserve communities. Naloxone should be included in the safer injection kits provided on reserve by Health Canada nurses in First Nations, Inuit and Métis communities. Recommendation 8 That the Government of Canada repeal or significantly amend the Controlled Drugs and Substances Act where it creates barriers to communities in establishing supervised consumption sites, and in the interim, work with communities and organizations to overcome administrative hurdles in relation to seeking exemptions under the Controlled Drugs and Substances Act in relation to supervised consumption sites. Recommendation 9 That the Government of Canada grant exemptions under the Controlled Drugs and Substances Act for the purposes of drug testing at supervised consumption sites. Prevention – Prescribing Recommendation 10 That all medical regulatory agencies in Canada work with their respective memberships to develop information and training tools relating to recognizing addiction (including evaluating a patient’s history of prescription drug use), making appropriate referrals to evidence-based treatment programs, and treating individuals who have substance abuse issues in a respectful and compassionate manner. Recommendation 11 That appropriate regulatory agencies develop a review system in relation to prescribing practices of physicians and pharmacists. Recommendation 12 That the new opioid prescribing guidelines be expedited, and that the Government of Canada work with the provinces and territories to encourage provincial licensing bodies to mandate their adoption. Recommendation 13 That the Government of Canada work with the provinces and territories to facilitate a broader approach to reducing opiate prescribing and integrate alternatives for pain management. Recommendation 14 That Health Canada review and revise if necessary its approved indications for opioids to reflect peer-reviewed data. Recommendation 15 That the Government of Canada work with the provinces and territories to establish a comprehensive, real-time, national electronic prescription monitoring system. Prevention – Education Recommendation 16 That the Government of Canada, through either Health Canada or the Public Health Agency of Canada, work with the provinces and territories to develop public awareness tools in relation to the risks associated with opioid use, and how to respond to overdoses. Public awareness tools should include materials targeted at youth. Treatment Recommendation 17 That the Government of Canada invest significant new funding to expand treatment for addictions. Recommendation 18 That the Government of Canada work with the provinces and territories to significantly increase the availability of community-based, publicly funded substance abuse treatment programs. Recommendation 19 That the Government of Canada work with the provinces and territories to strengthen existing detoxification treatment programs and create new ones. Recommendation 20 That the Government of Canada work with the provinces and territories and their medical regulatory authorities to develop effective clinical practice guidelines relating to addiction treatment. Recommendation 21 That the Government of Canada improve access to medications for opioid addiction treatment such as Suboxone® and other effective medications not currently available in Canada, especially for people at high risk of complication and death. First Nations communities Recommendation 22 That the First Nations and Inuit Health Branch of Health Canada consult with First Nations and Inuit communities to ensure that culturally appropriate care and assistance for addictions are available on reserve, and Recommendation 23 That the Government of Canada work with the provinces and territories to ensure that culturally appropriate care and assistance for addictions is available to Indigenous individuals off reserve. Recommendation 24 That the Government of Canada ensure that working with Indigenous communities to address the opioid crisis is carried out in the context of addressing the recommendations made by the Truth and Reconciliation Commission of Canada and the social determinants of health such as adequate housing, education, and access to health services including mental health services. Recommendation 25 That the Government of Canada increase funding to First Nations communities to allow for multi-year health and social service provider contracts and appropriate accountability and transparency measures. Recommendation 26 That the Government of Canada commit to providing stable needs-based funding for First Nations in order for them to implement the First Nations Mental Wellness Continuum Framework. Recommendation 27 That Health Canada eliminate its current time restrictions on the scopes of practice of nurses relating to treating addiction on reserve. Recommendation 28 That the Government of Canada provide a full and adequately funded continuum of services for Indigenous Canadians that includes long-term funding for community-based prescription drug abuse programs, such as opioid substitution therapy with Suboxone®, along with land-based treatment and other cultural therapies. Mental Health Supports Recommendation 29 That the Government of Canada work with the provinces and territories to ensure treatment for active drug users is available to address the underlying mental health issues that may contribute to or exacerbate drug addiction. Recommendation 30 That the Government of Canada work with the provinces and territories to develop a national strategy to provide better training and mental health services for front-line workers and first responders. Data, National Leadership Recommendation 31 That the Government of Canada work with the provinces and territories to compile information relating to fatal and non-fatal overdoses due to opioid use and that this information be reported by the Public Health Agency of Canada in a timely manner. Recommendation 32 That the Government of Canada work with the provinces, territories to establish provincial/territorial and municipal support services that will allow for the monitoring and surveillance of drug use patterns to better facilitate treatment strategies on a national scale. Law Enforcement and Border Security Recommendation 33 That the Government of Canada take measures to grant authority and lawful privilege to Canada Border Services Agency officials to search and/or test suspect packages that weigh under 30 grams. Recommendation 34 That the Government of Canada develop a federal enforcement and interdiction strategy around the importation of illegal opioids. Recommendation 35 That the Government of Canada adopt measures to regulate commercial pill presses to limit their possession to pharmacists and others who hold an appropriate licence. Recommendation 36 That stronger criminal penalties for having a production machine be established. Recommendation 37 That the Government of Canada provide more resources for drug testing packages and other shipments. Recommendation 38 That the Standing Committee on Public Safety and National Security undertake a study into the primary source for illegal opioids in Canada to determine the risk to public safety and evaluate the current methods and relationships to determine if Canada can be more successful at stemming the flow of illegal opioids into Canada. |