Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 11 - Evidence - April 9, 2014
OTTAWA, Wednesday, April 9, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:13 p.m. to study prescription pharmaceuticals in Canada (topic: the nature of unintended consequences in the use of prescription pharmaceuticals).
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[English]
The Chair: Honourable colleagues, I call the meeting to order. Just before I do the normal introductions, I will remind us that we are operating under an unusual circumstance where senators need to be back for a vote at 5:30. As a consequence of this, the meeting will end no later than 5:15. Any senator is at liberty to leave a bit early if they need more time to get back to the chamber. In any event, that is the situation.
I apologize to our distinguished witnesses we have today. We have two distinguished visitors whom I will introduce when I ask them to make their presentations.
[Translation]
Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie, a senator from Nova Scotia, chair of the committee. I'm going to invite my colleagues to introduce themselves, starting on my left.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
Senator Cordy: Jane Cordy, senator from Nova Scotia.
Senator Chaput: Maria Chaput from Manitoba.
Senator Nancy Ruth: Senator Nancy Ruth from Toronto.
Senator Seth: Asha Seth from Toronto.
Senator Enverga: Tobias Enverga from Ontario.
Senator Eaton: Nicole Eaton, also from Ontario.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: Thank you very much, colleagues. I want to remind you that we are on the fourth section of our four-part series on prescription pharmaceuticals in Canada. In this section, we are dealing with unintended consequence.
I will invite Stan Beardy, Regional Chief in Ontario for the Assembly of First Nations, to make his presentation. We discussed who will speak first. We will go in the order you appear on the agenda. Mr. Beardy, the floor is yours.
Stan Beardy, Regional Chief, Ontario, Assembly of First Nations: Thank you very much. Meegwetch. To begin, I would like to thank the Algonquin people on whose territory we are meeting today.
It is my pleasure to appear before you to speak to the Standing Senate Committee on Social Affairs, Science and Technology to further inform the committee's study and final report on prescription pharmaceuticals in Canada.
The Assembly of First Nations considers engagement with government on the subject of prescription pharmaceuticals to be a top priority.
First, I would like to speak to the United Nations Declaration on the Rights of Indigenous Peoples, Article 23, which states:
Indigenous peoples have the right to determine and develop priorities and strategies for exercising their right to development. In particular, indigenous peoples have the right to be actively involved in developing and determining health, housing and other economic and social programmes affecting them and, as far as possible, to administer such programmes through their own institutions.
Second, it has long been the goal of the Assembly of First Nations to close the gap in health outcomes between First Nations and the general Canadian population. This objective is to be shared by Health Canada as demonstrated by the express mandate to "address health barriers, disease threats, and attain health levels comparable to other Canadians."
While we clearly share similar objectives, the fact remains that First Nations people continue to suffer disproportionately with poor health. Subsequently, there is a need to acknowledge the connection between the historical, cultural, economic, political and legal factors affecting the well-being of First Nations peoples, namely the social determinants of health.
Third, equitable access to pharmaceuticals through the Non-Insured Health Benefits Program, NIHB, is a serious concern for First Nations people. As with many of your previous presenters, First Nations share similar interests and concerns with the consequences of the non-intended use of pharmaceuticals, as well as surveillance and, more importantly, the approval of modern and effective pharmaceuticals within the Non-Insured Health Benefits drug formulary.
Examples of these concerns include delisting of benefits; changes to eligibility of benefits; prior approval requirements and pre-determination; reductions in pharmacists' service costs, like markup and dispensing fees; and enforcement of low-cost pharmaceutical alternatives, such as generic drugs.
Increasingly, providers — including pharmacists, dentists and orthodontists — have moved First Nations individuals to a cash basis due to ongoing frustrations with the program's administration, issues like delays in receiving payment and excessive paperwork. As a result, many First Nation individuals requiring necessary services do not have the resources to pay up front and are being denied more and more essential treatment.
For many years now, the AFN has seen numerous resolutions calling for the need to attend to the increasing opioid addiction problem in some First Nations communities, as well as the need to address the flawed Non-Insured Health Benefits Program. Specifically, we would like to voice our concerns regarding the strikingly limited amount of quality data on prescription opioid misuse available to First Nation communities and how this acts as an impediment to effective planning of appropriate supports and services for First Nation communities.
More specifically, the Non-Insured Health Benefits Program does not facilitate access to Suboxone for First Nations clients, irrespective of where they live, nor do Non-Insured Health Benefits coordinate standards and procedures with the use of Suboxone in the continuum of mental wellness and addictions.
Currently, the Non-Insured Health Benefits Program and the First Nations and Inuit Health Branch do not fund long-term recovery programs as best practices in the treatment of mental health and addictions. Most notably, First Nations require sustainably funded and culturally appropriate treatment and long-term recovery models for optimal health outcomes.
Overall, we urge the government to provide sustainable funding for community-based addictions services as well as important training for health care professionals and front-line workers to effectively administer Suboxone in First Nations communities.
Recently, the National Chief and I met with Health Minister Rona Ambrose, and we agreed to conduct a comprehensive joint review of the Non-Insured Health Benefits Program to better identify program gaps and efficiencies. While we look forward to the next steps in this joint review process, we want to flag the urgent need to modernize and improve transparency of the Non-Insured Health Benefits Program to better serve the needs of First Nations people.
Currently, the Non-Insured Health Benefits Program does not take into consideration industry standards and best practices for medical services covered within the program. For example, specific to mental wellness is the lack of coverage in the Non-Insured Health Benefits Program for modern medications that are considered mainstream treatment options in other populations.
Moreover, the Non-Insured Health Benefits Program covers older medications that are less expensive than newer, modern medications used to treat mental health disorders, regardless of the fact that the older medications result in long-lasting side effects, some of which are permanent.
Recently, the Canadian Dental Association made a presentation to this very committee, citing the issue of access to pain medication for First Nations clients. Most importantly, they had raised the concern that the Non-Insured Health Benefits Program does not cover Toradol, a non-steroidal, anti-inflammatory drug and a non-narcotic, non-addictive medication to treat pain. As a result, we are concerned that the non-addictive, non-narcotic options that are available to the general population are not available to First Nations clients. Clearly, options to treat pain are limited within this program for First Nations patients and their health care team professionals.
To conclude, the AFN works with the First Nations and Inuit Health Branch program areas that include prescription drug abuse strategies specific to First Nations communities in the areas of prevention, treatment and enforcement. These include a First Nations and Inuit Mental Wellness Strategic Action Plan; a mental wellness continuum; the National Anti-Drug Strategy; the National Native Alcohol and Drug Abuse Program; and the National Youth Solvent Abuse Program.
In addition to our partnership with the First Nations and Inuit Health Branch, the AFN has participated on the prescription drug abuse coordinating committee and the Canadian Centre on Substance Abuse.
The AFN is also partnering on mutual areas of interest with the Canadian Medical Association, the Canadian Dental Association, as well as the Canadian Pharmacists Association and other professional agencies to move this important work forward.
We welcome continued engagement and encourage continued, collaborative efforts to address prescription pharmaceuticals and prescription drug abuse. We also continue to call for flexible and sustainable, long-term funding to ensure that the solutions to prescription drug abuse are community-driven so that our families can continue to heal from the impacts of colonization and move forward on the path to wellness.
First Nations are the youngest, fastest growing population in Canada. This work is in all our interests. Strong and healthy First Nations make for a strong and healthy Canada.
In conclusion, the AFN makes the following recommendations:
First, the Standing Senate Committee on Social Affairs, Science and Technology undertake a comprehensive review of the Non-Insured Health Benefits Program.
Second, the Non-Insured Health Benefits Program and all systems of health care ensure sustainability of resources that are matched to population growth and health needs.
Third, support appropriate funding, implementation and evaluation of the National Prescription Drug Abuse Strategy, "First Do No Harm," which the Canadian Centre on Substance Abuse released in 2013.
Fourth, support a First Nations mental wellness continuum to include long-term sustainable funding.
Fifth, support and fund the creation of a long-term recovery network for First Nations in the model of the National Native Alcohol and Drug Abuse Program.
The Chair: Thank you very much. I will now turn to Carol Hopkins, who is Executive Director of the National Native Addictions Partnership Foundation.
Carol Hopkins, Executive Director, National Native Addictions Partnership Foundation:
[Editor's Note: Ms. Hopkins spoke in her native language.]
Thank you for the invitation to present to you this afternoon. I also acknowledge the Algonquin people, whose territory we are gathering on today.
I've prepared for you a lengthy presentation, but there are five key points that I want to focus your attention on to describe the unintended consequence of prescription drugs on the First Nations population in Canada. Those five points are related to community capacity, withdrawal management and pharmaceutical interventions, neonatal abstinence syndrome, hepatitis C, HIV/AIDS, and violence and crime. I also leave with you some information related to the increased pressure on the health care system, stigma and discrimination, and then child welfare and family functioning.
Numerous reports have identified the issues related to the exacerbation and the precipitation of substance abuse issues amongst First Nations people. Some of those include childhood abuse, cultural loss that has been significantly documented, the rates of domestic violence, education levels, employment, gang-related activities, grief and loss, historical trauma and on and on.
A comprehensive review of a number of these areas reveals that there's no national data for Canada and certainly none specific to First Nations populations. Where data was available, that has been extrapolated to provide some context to a First Nations population.
We know that prescription drugs to address both physical and psychological pain, such as benzodiazepines and opiates, have significant unintended consequences among First Nations people in Canada. We also know that there are many existing strengths among First Nations people in Canada, specifically related to our culture, and that where culture has been applied to address substance abuse issues, there have been significant benefits.
In relation to community capacity, we know also that there are not enough resources in communities to specifically address mental health and addictions issues. Community-based NNADAP — National Native Alcohol and Drug Abuse Program — services often mean that there's one community worker left to deal with screening, early intervention and withdrawal management, care and coordination, and then coordination from a community development and health promotion approach.
First Nations communities that report crisis levels of opiates are also now talking about the high number of children with behaviour issues related to opiate addiction within the family and the residual effects of methadone. What I mean by that is research demonstrates that bonding and attachment disorders increase for mothers with opiate addictions and then due to the issues related to that — problems in feeding, irritability, problems sleeping — even when parents do well and regain a sense of well-being and address psychiatric issues and distress, those improvements don't often translate into the parent-child relationship, and adjustments in those relationships are rare.
First Nations communities that have been addressing the unintended harms associated with prescription drugs are starting to see the effects in the classrooms now. Those behavioural issues are not met with appropriate resources. As we know, tuition formulas for First Nations schools lack relevant attention to these special needs.
For example, also talking about the education system, I received a report from an education director in a First Nations community who was talking about three schools in the community and had reports of significant concern where the education staff, not just First Nations staff, across the education system in that community were engaged in illicit use of prescription drugs.
Residential treatment programs such as the National Native Alcohol and Drug Abuse Program and the National Youth Solvent Addiction Program are faced with a lack of resources as well to adequately address the complex and poly-substance use issues, including clients who are engaged in pharmacological interventions. There's a recognition that more resources are needed for treatment centres to be able to maintain a qualified workforce to meet the high standards of quality through accreditation and to ensure that they have the capacity to meet the complex needs and appropriately address the prescription drug use issues.
Where there was capacity amongst the NNADAP programs, it was seen that opiates had been used amongst the clients for at least 15 years. At least 30 per cent of clients in treatment also had an opiate addiction. One third of those clients had also reported a diagnosed or a suspected mental health disorder.
With limited resources to address the prescription drug abuse issues available in NNADAP programs, First Nations clients seek treatment elsewhere. Oftentimes in desperation there is confusion over who's paying for treatment in private and public treatment services. Recently, a community reported that they now have an invoice of $14,000 received from a private treatment facility to treat such clients.
Treatment centres have also reported that clients on methadone come to their care without appropriate information about care pathways that can lead to getting off of methadone completely. Where communities have taken a culturally relevant community development approach to addressing prescription drug use issues, there has been community-wide success, which has been seen through improved family relationships and family resources being redirected from drug abuse. These resources amount to about 80 per cent of their income going back towards family functioning, such as providing food, home furnishings and children's toys restored in the home and in the community and there is a reconnection to culture and First Nations identity. It has been through pooled resources across the community that has allowed communities to provide more coordinated and collaborated efforts in programs that have a community-wide effect. However, even in those situations there was a need for pre-existing or additional resources to help collaborate and to manage the collaboration.
Community-based opiate replacement programs only scratch the surface of needs. Where communities talk about the benefits of opiate replacement therapy, they also identify that once clients start to get better there's a whole host of other needs that are identified. Community resources are not able to meet those needs. For example, with the increased burden on mental health and addictions staff, communities are overwhelmed by the sudden increase for attention to education, financial organization and counselling. Once the success is heightened in the communities, other members of the communities who are not opiate users are also looking for additional support.
The issue of poor relationship with health care providers also leaves First Nations people in a vulnerable position with physicians, where First Nations people don't feel as though they can clarify or have discussion, or enter into a quality relationship where there's discussion about the course of treatment being prescribed, including the medications and their addictive qualities.
Post-traumatic stress is a common disorder diagnosed amongst residential school survivors and frequently treated with benzodiazepine. That does help people to increase functioning in their life, but it certainly doesn't address the unresolved trauma related to the residential school issues and the need for increased resources for counselling and therapy. A fear was also reported that where doctors are not able to manage addictions, they are more reluctant to appropriately prescribe opiates to First Nations people.
In terms of withdrawal management and pharmacological approaches, I provide you with a number of stats about the rates of use. We have seen that the increase has been consistent and growing exponentially of First Nations Aboriginal people in Canada being prescribed methadone compared to the Canadian population, which seemed to come to a plateau in 2012 when Suboxone was available by exception. The policies around the availability of Suboxone and the policy around availability by exception is creating significant issues for First Nations communities related to managing client daily transportation to obtain methadone; managing continuing care; and the impact on the overall community where communities are particularly close to adjacent towns or cities with methadone programs.
Rurally, this seems to be a very big issue. For-profit methadone dispensers have to keep a client load and profit to justify location, and on the surface, this seems a conflict of interest. Where clients may desire to taper from methadone, some dispensers are reluctant or hold on to the view that opiate addiction is a lifelong illness, so the client will be on methadone for life.
Anecdotally, Suboxone is better tolerated with clients, and clients feel as though they can get back to things in their life and pursue their health and wellness.
Unlike methadone, which is a restricted medication, Suboxone can be dispensed in communities by physicians, nurses and trained laypeople, which means it provides more immediate care for First Nations people who are looking to withdraw from or to address the opiate addiction.
It also addresses the travel and disruption to family and community left behind when First Nations members have to travel from remote and isolated communities to obtain methadone, and the cost reported by Non-Insured Health Benefits in 2012 suggest that Suboxone is cheaper per client annually than the cost of methadone.
However, anecdotally, I've been told that one of the barriers to making Suboxone more readily available in First Nation communities is the burden on nursing, which is, primarily, the only primary health care services available in First Nations communities. It's a workload issue, but it's also the safety and safe storage of medication that's often not available on First Nations communities that are part of those issues.
We need to make it clear that the addiction to prescription medication is at epidemic levels in communities and cannot be addressed with short-sighted initiatives, workload issues and current levels of resourcing. Withdrawal poses increased risk of suicide and overdose. Where First Nations are at NNADAP treatment centres, such as a program in Saskatchewan and other programs in the Atlantic regions, where methadone programs have been offered and governed in First Nations health care, in First Nations communities, they have reported greater success in helping First Nations people to address the opiate issues, including complete withdrawal from methadone.
In relation to neonatal abstinence syndrome, there is no consistency among best practice guidelines in relation to treatment of pregnant women with opiate dependence. A number of guidelines do concur that detoxification should be avoided during pregnancy, especially in the first trimester, and there are guidelines indicating maintenance therapy should be offered to pregnant, opiate-dependent women. Two guidelines find that methadone and buprenorphine maintenance treatment improve maternal and fetal outcomes.
While buprenorphine monotherapy, Subutex, was preferred in one guideline, methadone was recommended for use in pregnant women in the WHO guidelines. Another guideline recommended against buprenorphine naloxone use in pregnant women.
The prevalence of infants with neonatal abstinence syndrome is increasing significantly, and this information comes from Ontario specifically. It indicates that neonatal abstinence syndrome is five times higher among infants born to mothers who deliver their first child prior to age 19. We know that at least 20 per cent of First Nations births are to teenage mothers. It's not surprising that NAS rates are estimated to be higher in northern Ontario, and doctors don't always consistently identify NAS cases, so actual NAS incidents in Ontario can be significantly higher.
The issue related to managing opiate withdrawal in pregnancy is that the approval often takes several weeks for access to buprenorphine. We know that it's vital to manage narcotic withdrawal in pregnant women, and sudden withdrawal can put the health of both the mother and fetus at risk. Pregnant women addicted to opiates tend to deliver earlier and faster, and they also need postnatal care that's close to home. That's an issue for isolated rural communities. There are a number of issues with babies on methadone that need to be kept in hospital longer, and there is also research that indicates 74 per cent higher rates of sudden infant death syndrome to babies whose mothers are on methadone during pregnancy. We know that there is also a progression from oral to nasal to intravenous use of oxys, and there is information in your packages related to the high rates of hepatitis C and HIV/AIDS amongst the Aboriginal population, and increasing significantly are the issues related to opiate withdrawal.
In relation to crime and violence, a growing number of First Nations have associated elevated rates of prescription drug abuse and misuse with increased levels of violence, criminality, illicit drug trafficking and other forms of abuse and suicide in First Nations communities.
There have been reports about severe abuse and crime, and, specifically, vulnerable populations — women, young people and children — being used as mules for drug trafficking.
I'll end with the recommendations that I wanted to leave you with. Similar to the Assembly of First Nations recommendations, it is about sustained and flexible funding to support First Nations communities, and currently, the proposal-driven resources available to First Nations communities certainly can't sustain any wellness that is achieved in those initiatives. First Nations communities need more support in planning service delivery; evaluation; human resource development; establishing continuity of care in culturally relevant ways; culturally relevant and supported withdrawal management; community-based opiate replacement therapy, including making Suboxone and Subutex more available and by eliminating the "by exception" policies under the Non-Insured Health Benefits Program; increased support to First Nation education to address the unique needs of children impacted by prescription drug abuse issues, including early learning programs to support culturally relevant parent-child attachment parenting programs; increased support for youth crime prevention programs in First Nations communities; and finally increased support for culturally relevant interventions using indigenous knowledge by indigenous practitioners.
Thank you.
The Chair: Thank you very much. I will now open up the floor to questions.
Senator Eggleton: Thank you for your presentations. I want to ask you about OxyContin. I noticed, Chief Beardy, you mentioned another prescription, non-steroid anti-inflammatory Toradol and said you couldn't get it under the NIHB program.
What about OxyNeo? The manufacturer took OxyContin off the market and replaced it with OxyNeo, but then OxyContin came back in a generic form, which is rather unfortunate, considering the misuse of OxyContin that has occurred. Are you able to get OxyNeo under the NIHB Program?
Ms. Hopkins: Yes.
Mr. Beardy: One of the things that are happening to us as First Nations people is that the policy interpretations change on a regular basis, so there is a lot of grey area in terms of what we can and cannot access. The Non-Insured Health Benefit Program is a policy, therefore, not on a legislative base, so it's never really clear what we can and cannot access. In some cases, we probably can, but in most cases the interpretation is left to pharmacists or whoever is dispensing those drugs. That's part of the difficulty we have because it's never clear what it is we can access.
Senator Eggleton: There are so many different programs and so many different reports. What would you say is probably the best program to deal with some of these issues? I note, for example, in a December 2012 document signed by the National Chief, the conference talked about Suboxone detoxification and after-care program models. We have not heard too much about that today, but is that the prime program that you operate that you see is helping to deal with these questions of pharmaceutical abuse and unintended consequences?
Mr. Beardy: I think one of the things we're pushing for is a joint review of the NIHB Program itself. But to look at the big picture, we need to make sure that the services that First Nations people are getting have some legislative base. Without a legislative base, we're operating on a policy, and if you operate on a policy, there is no standard or minimum. So it is just what is available that we end up getting.
I think as part of addressing access to quality health for First Nations people, we have to look at what kind of legislative basis is required to make sure that there are standards and minimums and how we can access quality health care.
Senator Eggleton: Ms. Hopkins?
Ms. Hopkins: As we said, Suboxone is available by exception, so the report that you're referring to where there was community-based access to Suboxone was also supplemented or in collaboration with culturally specific approaches and interventions. There were high rates of success in those communities, but those examples are few and far between.
That is not a consistent story across Canada. It's not a consistent story across First Nations populations that are trying to address the unintended consequences of prescription drugs.
Senator Eggleton: Why is that?
Ms. Hopkins: Because Suboxone is not readily available.
Senator Eggleton: Is it not available under the NIHB Program?
Ms. Hopkins: By exception it's available, and there are long waiting periods to get the approvals, and it's not always consistently understood. As Chief Beardy said, the policy is not applied consistently across the country, and it's not consistently understood. It's not more readily made available because of concerns over who administers the medication and the safe storage of the medication. It's not because there is no evidence that supports its benefits.
Senator Eggleton: Thank you.
Mr. Beardy: In terms of Suboxone, in the far northern Ontario that I am most familiar with, they do have community-based detox programs, but because there is no explicit policy on it, it does not address treatment or after-care or transition. All we're trying to do is deal with the addiction rate in the far North where it's up to 80 per cent, so it's a real challenge because there are no policy, financial resources or professionals made available to support the efforts of First Nations at the community level.
Senator Seidman: I would like to refer to a special bulletin that you issued at the end of 2013 regarding regional round tables and a national policy forum that was scheduled for early 2014, specifically to address the crisis. You called it a crisis in the Non-Insured Health Benefits Program, and I would like to know what the status of that is. I presume you had those regional round tables in February, and you were supposed to have a national policy forum in March. You say here that you would like to decide on the best options and actions to facilitate and create change in NIHB Program.
Did you have provincial government representation at those regional round tables, and did you come up with a series of recommendations that we might benefit from while looking at our recommendations in our study?
Mr. Beardy: Thank you very much for your question. We started a process of round tables across Canada regions, right after New Year's, and we had 10 round tables across the region. We had our national wrap-up session in Toronto on March 19 and 20, and we started to bring all the commonalities across Canada.
We're just in a process at AFN to pull all the findings together and identify common trends across the country, so it will be a national framework but also specific regional challenges and opportunities.
The focus here was to try to be creative and offer solutions so that we develop multiple partners to begin to address the challenges. We understand that we cannot solely depend on governments, so we bring in NGOs. We developed AFN multi-partnerships because we need to incorporate industry standards and best practices, and definitely Ontario is part of those discussions. They're at the table talking to us.
I have a commitment to meet with the federal health minister again in May to begin to look at the immediate priorities across Canada and begin to develop some dialogue, conversations and strategies around that so we can move forward, while in the meantime we will continue to flesh out and help develop policies around those other challenges across the country.
Senator Seidman: Thank you very much, Chief Beardy. I appreciate that.
Ms. Hopkins, in your presentation you identified certain population sub-groups that were more at risk for prescription drug abuse.
What I would like to know is have any programs been developed and aimed specifically at these at-risk sub-groups, and is Health Canada supportive of such a targeted approach to these programs?
Ms. Hopkins: I'll give an example of the crime prevention program funded by Public Safety Canada.
In terms of youth-specific programs and First Nations schools, there are no Health Canada funded programs.
In terms of Health Canada funding to First Nations communities, there is funding under the National Native Alcohol and Drug Abuse Program and the youth solvent addiction program. That funding often results in one worker in a community, and, depending on the population size of the community, it might not even fund one whole full-time position. That worker is left to address the needs of the population.
There has been some funding in Ontario: $2 million was invested in community-based programs. That program funding was geared towards community development, and it was in collaboration with the provincial government, but I don't think that funding was sustained, or, last I checked, it wasn't sustained funding between the federal government and the provincial government in Ontario.
While community development is a long-term initiative, and it's a good initiative to address the prescription drug use issues, again, the funding programs are short-lived and often with the expectation of achieving significant outcomes that can't be achieved in such a short amount of time, for example, in a year.
Senator Seidman: Okay, I'll leave it at that for now.
The Chair: I have three people on the list. It's important that we get the questions on the record. I'd like to ask each of the senators on the list to present their questions. They will be recorded. Once we get through them asking their questions, if there's still time left after they've asked their questions, we'll come back and try to get them answered in a series.
For those that don't get answered, the clerk will follow up with you in writing with the questions, and we would invite you to respond following the meeting. Would you be prepared to do that?
Ms. Hopkins: Yes, I would.
The Chair: Thank you very much. The three senators I have are Senator Eaton, Senator Enverga and Senator Cordy.
Senator Eaton: I have two small questions. Ms. Hopkins, you identified five key points. You talked about community capacity, HIV, withdrawal management, neonatal programs, care management and, I think, crime and violence. Could you prioritize? If you could wave your magic wand and set one program up across Canada, could you prioritize the programs for us?
Lastly, to follow up on what Senator Seidman started to ask, do you feel, chief, that you fall between the federal governments and the provincial governments in terms of best practices? Yes, the federal government is responsible for First Nations' health care, but sometimes, because it's a provincial jurisdiction, perhaps provincial governments know more about best practices or have greater experience. When you do that, can you talk about regional differences in opiate addiction?
Senator Enverga: It looks like opioid and other prescribed drugs are basically the problem. Should we give different training to our doctors or health care providers who go to First Nations?
There was this transparency issue that was mentioned by you and by Mr. Atleo. Could you tell us what that is, maybe explain the transparency issue that's happening right now?
Senator Cordy: Thank you very much. First, I'd like to talk about the neonatal abstinence syndrome program. Certainly, as you indicated, Ms. Hopkins, there are conflicting best practice guidelines. It seems like it would be a good place to start with healthy mothers, healthy babies. Yet, when we read the information that you gave us, one set of guidelines says one treatment and another says another treatment. What are you going to do, and who are you going to listen to so that we can have healthy mothers and babies?
The next one is related to OxyContin. Health Canada refused to prohibit the generic formulation of OxyContin despite the health ministers from the provinces and territories saying that they wanted it at least delayed if not outright banned. They wanted it delayed until the department could assess the safety of the drug. Is this assessment taking place? You have asked that the generic forms of OxyContin not be listed on the NIHB. Has that happened?
My last question is, where do we start? You talked about starting in the community, but, when you start in the community and reach beyond that, the services aren't there. Where do we start from a federal perspective, as Senator Eaton was mentioning earlier?
The Chair: Thank you. Just before I come back to Senator Eaton's first question, I'd like to follow up on the point you made, the testimony we heard earlier, and where Senator Cordy wound up with regard to the painkiller issues. First, I'd like you to, if you would, indicate the degree to which you feel it is important that the non-narcotic painkillers be readily available when they will serve the purpose for dealing with legitimate pain.
Second, to really follow up on Senator Cordy's question about your views with regard to the difference — Senator Eggleton started off with this issue as well — between OxyNeo versus OxyContin, the protected form of the opioid that is not so easily transferred into the general population, I'm asking you to take those questions and your own comment and to give us a very thoughtful position that you would have with regard to those issues. We have heard the importance of this before, and we think it's extremely important to hear your full views on those particular matters.
I think we can probably get Senator Eaton's first question in, and that was where she asked you, Ms. Hopkins, if you took your five priority issues, are they in priority order as you've listed them? If not, what would you rank as top priority of those five?
Ms. Hopkins: That's a difficult question.
Senator Eaton: I know they're all priorities.
Ms. Hopkins: They're all priorities, but I would have to say community capacity. If you're addressing community capacity, then you're looking at the broader population needs. Also, in addressing community capacity, you're including addressing the resources that are already there by supplementing them with specifics to address prescription drugs.
For example, it has been proven that methadone that's governed by First Nations communities and linked to other resources in First Nations communities can have success. The problem we have right now is that that's not widely the case. Where Suboxone is available in First Nations communities, we have even greater success. We've seen that Suboxone in First Nations communities has also motivated widespread intentions towards wellness.
Senator Eaton: Are those drugs as addictive as, say, opiates? Are Suboxone and methadone as addictive as opiates?
Ms. Hopkins: For Suboxone and methadone, you do have dependencies, but the course of treatment in time for Suboxone is less than for methadone.
Senator Eaton: Thank you.
The Chair: Senator, your second question was on the record, and, if you don't mind —
Senator Eaton: That's fine; I understand.
The Chair: As to Senator Enverga's question, I think we have time for you to respond with your views on the need for special training for health care providers on reserves that is sensitive to the community in addition to their normal medical training. Would either of you like to respond to that? Chief?
Mr. Beardy: The question of prescription drug abuse is new even to research. It is more pronounced in isolated communities. In the far North, we have nursing stations. The first contact of health care is with a nurse. In many cases, we have two levels of nurses. One is Health Canada. The other one is what they call agency nurses. Those are ward nurses from downtown Toronto or some urban centre that go out there to fill the spots. They don't have the necessary training to understand the question of prescription drug abuse and addictions. Specialized training is required for all of the health caregivers, including the physicians themselves. For physicians to administer Suboxone, for example, which is a narcotic, they need specialized training and certification to be able to deal with that. The problem we have is that they don't necessarily have the understanding relationship with communities to understand the support mechanisms that are required to make it more effective other than to prescribe the narcotic. So there is an urgent need to train professional health care providers, the doctors, the nurses and the front-line workers. There's definitely a requirement to have specialized training that has to be there.
The Chair: Thank you very much. I know from past experience that senators will be starting to leave to go to the vote, and I don't want people to be leaving during your answers. That's why we have the questions on the record. The clerk will follow up with each of you in writing with the questions that were placed on the record, and we look forward to your responses.
Senator Cordy: Just before you sign off, the responses that we receive are considered to be official documentation for the committee. Is that correct?
The Chair: That's correct. That's why I got the questions on the record so that they turn out to be that way.
Senator Cordy: Thanks.
The Chair: Otherwise, I wouldn't have done it. It would have been a waste of everybody's time.
We do want to thank you very much for your being here with us today. This is a very important part of our study. You know the issues you are dealing with are special to you in special ways, but they're also issues for the country as a whole. You've brought very important insights to these, and we value your recommendations. The thoroughness of your reports to us is going to be very helpful to us. We thank you for that.
Once again, I want to thank my colleagues just before they jump out of their seats. I hereby declare the meeting adjourned.
(The committee adjourned.)