Minister of Health Jane Philpott's HR17 speech

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The Speech given by the Canadian Minister of Health Jane Philpott to the Harm Reduction International Conference on Sunday May 14:

Thank you for all of your efforts to come here.  It is wonderful to see everyone.  I want to acknowledge that we are on the traditional territory of the Mohawk and I want to thank the elder for welcoming us and starting today with prayer, starting the gathering here in a good way.  And I want to acknowledge that we still have Mohawk communities here, the Kanesatake, and the Kahnawake communities here near Montreal.  

Jane Philpott

Thank you so much for your banners that you’re presenting. I see them, I hear you.

I am grateful for the opportunity to be here today. I have the great honor of being the federal Minister of Health here in Canada, and I’m honored on behalf of the Prime Minister to welcome you here to this conference.

This conference is important; I don't need to tell you that.  It's important for so many reasons: because of the international reach, because you represent people from 70 countries that have come together, because the issues that you are discussing affect every nation on this planet.
 
In many ways, it’s been already acknowledged that Canada is playing catch-up. We are catching up with countries that have been innovating in the harm reduction space for decades. I am relieved to say, and as has been alluded to already this evening, that as of the fall of 2015, when you last gathered for the International Harm Reduction Conference, Canada has emerged from a decade of aggressive thinking and the propagation of failed approaches to drug policy.  

During that time, I will be the first to acknowledge that our country ignored innovators in our domestic context and shut out some of the most important voices in this discussion.

I want to acknowledge the inclusive nature of this gathering and your efforts to include a range of voices, including even politicians. Thank you for including health professionals and researchers. Thank you for including the voices of activists. Thank you for activists who stand up and share their messages. Thank you for including sex workers, people who use drugs, and many more.

You may not know that I was a family doctor for 30 years before I became a politician. It’s had a huge impact on how I view drug policy. Because when I think about drug policy, I think about patients. I was at a national drug policy forum a few weeks ago, and maybe some of you were there, I talked at that conference about a patient – I don’t use patients’ real names obviously in public—I called her Cynthia.

Cynthia was a patient of mine for many years. Cynthia became dependent on opioids due to range of factors that brought pain to her life - the tragic loss of her own children in a terrible accident when they were young, repetitive sexual abuse at the hands of multiple offenders, chronic unemployment and economic challenges, unstable access to housing…

I could have also talked about Kyle and Dean, they were a couple in my practice. They used illicit drugs on an intermittent basis. My conversations about reducing the potential harms of substance use for these men were intermingled with the simultaneous need to address the challenges they were facing with inadequate support from their family, mental illness, HIV, interactions with the criminal justice system and many other challenges…

I left my clinical practice 18 months ago. I miss my patients. When I think about Cynthia, Kyle and Dean, I wonder how they are. In 2017, in the context that we exist in here, Canada, with an epidemic of overdoses in Canadian cities, it is not sensational to wonder if they are alive. Have they avoided buying a bad batch of drugs? Have they been able to get the compassionate care they need and deserve?

Cynthia, Kyle and Dean were referred to me because of my interest in HIV primary care. Several of my patients who lived with HIV also used illicit drugs. I learned more from them than from almost any other subset of patients. In many cases, their lives were chaotic, their compliance to medication was erratic. Their behavior was often unpredictable, but I cared about every one of them very much.

Cynthia was smart, ambitious, creative, and kind. Kyle and Dean were charming, they were usually cheerful, and they were always grateful. But regardless of my sentiments toward them, they deserve excellent care. They need health and social services including reducing harms associated with substance use and other behaviours that expose them to health risks.

When it comes to drug policy, I’m proud to affirm here tonight that our government fully supports harm reduction as a key pillar. In the face of an unprecedented overdose epidemic, this approach is essential.

People like Cynthia, who use opioids every day – and people like Kyle and Dean whose drug use is intermittent, deserve to live and be well.

People who are dependent on opioids and other substances have a health problem – often described as addiction. Addiction is not a crime. It is not a moral failing. It is a health problem.
The drivers of problematic substance use are well known. They include:

  • Stigma and discrimination
  • Poverty and the absence of social supports
  • Isolation, rejection, abandonment
  • Abuse, conflict
  • Mental illness

Dr. Gabor Maté has eloquently documented the stories of patients he cared for, particularly in the Downtown Eastside of Vancouver.  He shares the message that hurt is at the centre of all addictive behaviour.

I want to note as we talk about hurt and unresolved trauma that lies at the core of addiction, that there is one subset of the Canadian population that is disproportionately impacted by psychological trauma. That is Indigenous peoples – in Canada First Nations are significantly more likely to die from alcohol and drug use disorders.

At the route of problematic substance abuse are those social issues that I talked about. But, in North America, the problem of opioid dependence was exacerbated in the past 20 years by the dramatic rise in opioid prescriptions – linked to deceptive marketing practices of a pharmaceutical company.

But the catalyst that has profoundly impacted the rate of overdoses is the emergence of fentanyl and other high potency opioids.  

What is the result? Well, in Canada there were approximately 500 overdose deaths last year in Alberta. More than 900 in British Columbia. Fentanyl has contributed to deaths in every region of the country.

But as you know it is getting worse. According to the BC Centre on Substance Use, the rate of overdose deaths in that province linked to illegal drugs rose 50% in the first three months of 2017 compared with same period last year.

If trends continue, B.C. is on track for 1,400 overdose deaths this year.
We still do not have data for 2016 for all of Canada. But we know at a minimum that 2,300 Canadians died last year from an opioid overdose.
The death toll is worse than any infectious epidemic in Canada (including the peak of AIDS deaths) since the Spanish flu took the lives of 50,000 people a century ago.

The heart of the response is the theme of your gathering today and I believe the heart of the response is equity, is fairness, is recognizing that the response ought to be as impactful, as powerful, as well supported as a response to any other epidemic and any other health cause.

One of the most deeply concerning aspects of this crisis – which frustrates us all, is the appalling dearth of data and the glacial pace at which we're getting information that is both timely and accurate.  

We know that data drives change. And the absence of data allows governments and others to look away.

The crisis of overdose deaths is one of the biggest public health challenges that our country is facing and we can’t fully quantify it.  

We don't know how many people in Canada are affected by opioid use disorder.  We don't know how many people died last year by overdose.

There are challenges associated with getting that meaningful data related to opioid use. Privacy rules. IT gaps. Feeble public health laws. These are not excuses.  We need all stakeholders to come together to provide a complete picture of the experience of opioid users.  

For the part of the federal government, we’ve been deploying epidemiologists. We've worked with coroners and medical examiners and public health leaders, we’ve put together a committee to improve information gathering and improve the evidence base.  

We still do not have an accurate profile of the people who die from overdose in Canada. We need a better understanding of the circumstances in which these deaths occur. Who are the victims? What are the drugs?

I’m pleased to announce that the Public Health Agency of Canada will work with provinces to launch an epidemiological study this summer. This investigation will inform where to intervene to have a real impact.
Data is a necessary foundation for our work. But Thomas Edison said, “The value of an idea lies in the using of it.” So we must take this data and compel action. I believe that our actions in response to this epidemic of overdose deaths must meet four principles. We must be comprehensive, collaborative, compassionate and evidence-based.  

Comprehensiveness means we don’t fool ourselves into thinking there are simple solutions or that any single law or policy decision will change the course of this crisis.  A comprehensive response requires the 4 pillars of prevention, treatment, law enforcement and harm reduction.

Canada’s previous federal government removed the pillar of harm reduction from the drug strategy. I am pleased to have put it back in.

A comprehensive response includes many steps. One of the first things I did as Health Minister was to change the status of naloxone to be available without prescription and in multiple formats.

We granted final approvals for 4 supervised consumption sites and tabled legislation to support the process for similar sites. Friday we completed the final steps so that 2 Montreal sites may offer services as early as next week. And I want to give my tremendous congratulations to Minister Charlebois and her team and also to the leadership of the municipality, health providers, and many others who made this happen.  

So the bill that you've heard us talk about tonight is called C-37.  It's a piece of legislation that we introduced in order to streamline the process for applying for and obtaining approvals for supervised consumption sites.  The Senate has adopted a number of amendments. Our government has supported some of them and some we have not.
I want to clarify to you our government does support an option for additional consultation at the discretion of the Health Minister, which would likely only be used in exceptional circumstances.  

So there is no requirement for an additional consultation period and I want to make sure that that's well understood.

We do not support citizen advisory committees due to the stigma they may cause. We firmly endorse expanding access to medication-assisted treatment, but cannot support a mandatory requirement at supervised consumption services due to obstacles this would present for sites and clients. The House of Commons will vote on these amendments tomorrow, and then we will urge the Senate to pass it quickly through the final stages. And I want to, at this time, give a shout out to my colleague, Minister Chagger, who is our House Leader, who worked extremely quickly to turn this around and got it back from the Senate in less than a week, to be able to get the next vote on this.  So kudos to the team and the government that are making this possible.  

We took other steps, we overturned the ban previously associated with evidence-based heroin assisted treatment so it is again available via the Special Access Program.

I listened to you, you said that was not enough, and so we have taken steps to fast track a proposal to allow the bulk importation and the use of medications that have been authorized in certain other countries but are not yet authorized in Canada to address urgent public health needs and this will include the ability to import diacetylmorphine, also known as heroine.

Nous avons tenu un sommet qui a réuni 42 organisations qui se sont engagées à prendre des actions concrètes pour répondre à cette crise. Cela s’est traduit par 129 engagements distincts d’un éventail d’intervenants qui offrent de l’aide sous tous les angles.
 
Nous avons engagé de nouveaux fonds pour la recherche sur l’utilisation problématique de substances et le traitement. Nous avons investi de nouvelles sommes dans  la Stratégie canadienne sur les drogues et autres substances; plus de 100 millions de dollars en nouvelles dépenses dans le Budget de 2017 pour la nouvelle Stratégie canadienne sur les drogues et autres substances – avec le pilier de la réduction des méfaits réintégré.

That’s a 20% increase to that strategy, so it now sits at close to $700 million over five years.

We provided $16 million in direct emergency funding to Alberta and British Columbia.

Recognizing the links between housing and health, our government is investing over $11 billion in housing over the next decade.
The National Housing Fund will prioritize support for vulnerable citizens, including seniors, survivors of domestic violence, veterans, persons with disabilities, those dealing with mental health and addiction.

Budget 2017 announced the expansion and reform of the Homelessness Partnering Strategy, funding for housing in the North and for Indigenous peoples, the creation of new affordable housing by making surplus federal lands and buildings available to housing providers at low or no cost.

We have committed to $5B to provinces and territories for increased access to mental health care, which has obvious links to problematic substance use.  

Recognizing the need to tackle the inappropriate prescribing of opioids, we funded McMaster University to update the Canadian Guidelines for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain.

These updates, released this month, were developed in collaboration with the provincial and territorial medical regulatory authorities and provide prescribers with recommendations for prescribing opioids.

We recognize, in the spirit of harm reduction, that those guidelines will need to be used cautiously and with great discretion on the part of health providers so as to reduce harms.  I also want to note that we passed just last week the Good Samaritan Act, so if it was not already clear to you, that our law now protects people who call 911 in the circumstance of an overdose, that they will not be charged with simple possession of drugs.

So none of those steps – and I think that's quite a lot in 18 months, but I recognize that for you, it's not enough – none of these steps will fix this problem overnight. But that does not mean we are not working every single day to solve this together.  

Which brings me to the second principle, and that is collaboration.  

It is critical that all parts of society work together, that we, even we in this room have a spirit of solidarity.  I can't do this alone, and neither can any of you.  We have to work together, folks.

We need to work respectfully with partners in provincial and municipal governments, with health professionals, with regulators, educators, first responders, civil society organizations and many, many more.  

A crisis of this magnitude requires a whole of society response.  That includes governments and law enforcement – some who may, until recently, have been seen as antagonists or adversaries.  And in case it's not abundantly clear, collaboration also includes people who use drugs.

I hope that it is evident to the people that are most affected by the Canadian overdose crisis that policymakers are listening.  We hear your views, we hear your perspectives.  I am listening even when your views are critical.  I will call you to account if you are inaccurate in your critique and encourage you to be sure that your criticism base, is based on the right information.  But we have to discover the levers that each of us has and we have to support one another.

So I say to you now, especially those of you who have your backs turned to me, I am not your enemy.  I am your ally.  We know that there are enough enemies, and I know that you don't feel that, that people are listening, and you're going to have to judge me on that basis, but I tell you that I think about this from the moment I wake up until the time I fall asleep, and I have poured everything I can into this, and I am determined to work with you as your ally to make sure that we bring an end to this overdose crisis.

This brings me to the third principle, that of compassion.  

Nous avons beaucoup de travail à faire en matière de compassion. Je n'ai pas besoin de dire à cet auditoire que les gens qui ont des dépendances aux substances font souvent l'objet de stigmatisation et de discrimination.  Je ne suis pas sûre qu'il y a un autre problème de santé dont les gens atteints sont plus susceptibles d'être blâmés, mal traités et se voir refuser des soins que le problème de la dépendance aux substances. Ceci est bien sûr non seulement d'aucune aide, mais cruel.
 
Beaucoup de Canadiens trouvent qu'il est facile de juger, et difficile de compatir avec ce qui amène les gens à la dépendance aux drogues, alors que tous les membres de la société ont l'obligation de traiter ceux qui ont des problèmes de dépendance aux substances avec compassion, dignité et respect.  Il faut dire que les professionnels de la santé ont une obligation claire à cet égard et qu'il y a certainement place à l'amélioration.

We do not accept discrimination on the basis of skin colour, sex or gender. We reject shaming people for obesity. Yet in some sectors it is still acceptable to blame addiction on poor decision-making.

We need to accept that the right to harm reduction is one that is shared by those in the Downtown Eastside of Vancouver, as much as it is by the teenagers buying counterfeit Percocet in the suburbs of Ottawa.

When we say drug policy is to be compassionate, it means recognizing that unresolved pain rests at the core of problematic substance use.  
This has many implications.

It means that appropriate treatment must include emotional care, counselling and social supports.  It means that there is a great deal of work to be done in the area of prevention.  To build a society where fewer people face abandonment and isolation, where emotional trauma is recognized and treated as a risk factor for further suffering.  

The final principle is that drug policy must be evidence-based.  

Quite simply, we need to take a look at what works and what doesn't work and then we need to do what works.  

The federal role in research is a critical component of our strategy to address the problematic substance use.

Through the CIHR (Canadian Institutes of Health Research), the federal government established the Canadian Research Initiative on Substance Misuse (CRISM). This network is a national research platform on addiction. Funding to CRISM contributed to evidence-based guidelines for management of opioid use disorder in British Columbia.

Our most recent federal budget added an additional $10 million to the work of Prism and researchers are now expanding the work that's been done in British Columbia to produce guidelines on how to best address the problematic use of opioids at a national level.

When I look through the abstracts for this conference, it fills me with hope.  So many of you are challenging orthodoxy and experimenting with new approaches. In fact, many significant advances in dealing with this problem have come from that type of work.

Many are familiar with SALOME and NAOMI Trials, the first trials of heroin-assisted therapy in North America, done in Canada.  We owe a debt of gratitude to researchers, health professionals who did this work in the context of a fair amount of suspicion from the government of the day.
Because of research that pushes the boundaries, we know that heroin-assisted therapy is a useful tool for some individuals with problematic substance use where other treatment options have failed.  

We know from other research in this area that for some individuals, physician supervised heroine injections are the only alternative to street heroine.  This can help not only in these individuals by reducing blood borne infections, reducing the possibility of a contaminated drug supply, but the general population is also helped by lowering rates of drug related crime, lowering health care costs and moreover, it keeps people alive.  

Not to mention that the cost of treating people in a clinic like Crosstown can be done for $25,000 a year providing social support and medication compared to an estimated cost of $47,000 per year factoring in the cost of emergency care, law enforcement and other services.

When we look at what works, we need to look not only at patient-level interactions, but health system strategies also.  We can learn from countries like Switzerland, whose approach over a decade led to a 50% decrease in drug-related deaths and a 90% reduction in property crime.

We can also look to Portugal, where they have had tremendous success in reducing the stigma and marginalization associated with drug use, by emphasizing the inalienable human dignity and value of all citizens.
Bringing together experts in medicine, law, social work, individuals with lived experience, they’ve found solutions that work for drug users.

They provide people who use drugs with accessible treatment options and lower barriers so individuals do not put themselves at further risk.
We owe it to citizens to see what we can learn from these examples and how principles could be adapted to our own society.

On June 22 I have asked CIHR to host a knowledge exchange event to learn how other jurisdictions address problematic substance use and look at the feasibility of implementing similar legal and policy frameworks here in Canada. This will support our commitment to evidence-informed policies and we will ensure that policy-makers are present to learn from the evidence.

Nous avons le devoir de prendre en considération ce que l'histoire et la science nous enseignent.  Les gens qui ont une utilisation problématique des substances comme ceux qui souffrent de tout problème de santé devraient avoir accès à d'excellents soins de santé.  Ceci devrait inclure l'accès aux soins de santé mentale et au soutien social.  L'éventail complet d'options de traitement devrait inclure toutes formes de traitements au moyen de médicaments.
 
Ceci veut dire que les traitements de substitution aux opioïdes et, le cas échéant, des injections supervisées d'héroïne de qualité pharmaceutique devraient être parmi les traitements offerts. 

A paradigm shift in drug policy takes time, but it will take a lot longer if we don't talk about it together, openly and discuss opportunities to improve our approach if it could save lives and have multiple social benefits.  

The topic of drug policy remains politically and emotionally charged and open to controversy.  But that must not deter us from an ambitious approach to finding and implementing solutions.  So let's go back to the beginning of the talk and think about Cynthia, Kyle and Dean.  

How could I have provided better care for them?  How could we avoid the cost to our health care system in caring for someone like Cynthia, including costly medications for blood borne infections, hospitalizations for conditions from overdose to endocarditis to osteomyelitis?  

How can we help Cynthia and others to adapt from perpetual chaos, violence and pain into a life that is predictable, peaceful and productive?
The response must be comprehensive.  It will require work to collaborate.  It demands a whole of society response and a lens of compassion. We must commit to an evidence-informed approach, even when evidence points to measures that appear daunting to implement.

I want to thank you for your commitment to this matter.  I want to assure you of my utmost dedication as long as I have the tremendous honor to serve in this capacity.  I look forward to working with you, to helping you to save lives, to meet the goal of justice, health and dignity for all.  You have said that this is about the heart of the response.  For me, the heart of the response is equity.  We need to recognize that all people are people, including people who use drugs.  

And in that spirit, I urge you to continue your work, to be creative, be bold and most of all, be kind.

Thank you.

HR17 Montréal
25th Harm Reduction International Conference
Montréal, Canada | 14 - 17 May 2017
www.hri.global/hr17 | #hr17 | @HRInews
At the heart of the response. Au coeur de la solution.
20 Years. Harm Reduction International

aidq. Association des intervenants en dépendance du Québec.