Government Response - 8512-421-134 - House of Commons of Canada (2023)

GOVERNMENT RESPONSE TO THE REPORT OF THE STANDING COMMITTEE ON HEALTH ENTITLED
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

(Recommendation1)

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
(Recommendations2, 4)

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
(Recommendations 10-16)

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-occurwith 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 healthprofessionals 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, Budget2016 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.

Treatment
(Recommendations 17-21, 29, 30)

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.

With the exception of health services for First Nations and Inuit, treatment falls within provincial and territorial jurisdiction. However, as noted earlier, the Government of Canada makes significant investments in health care services through the Canada Health Transfer.

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.

On February 7, 2017, CRISM researchers published ‘A Guideline for the Clinical Management of Opioid Use Disorder’, for the Government of British Columbia. It aims to provide comprehensive education and clinical care guidance to health care providers spanning the addiction care continuum to improve access to evidence-based treatment for patients and families and reduce the significant harms associated with opioid disorder in British Columbia.

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.

CIHR, in collaboration with Health Canada and the Public Health Agency of Canada, will host a knowledge exchange event in spring 2017 to outline and share best practices for the treatment of opioid addiction for national uptake. This event also aims to examine gaps and existing barriers to implementing these best practices in healthcare systems across Canada.

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

Health Canada officials are looking at regulatory initiatives that may help support access to treatment. For example, officials are exploring whether the current regulatory requirement for a prescriber to have a special exemption under the Controlled Drugs and Substances Act to prescribe methadone poses an unnecessary barrier to this important treatment option. Health Canada is also promoting increased access to buprenorphine/naloxone as a first line treatment choice and expediting the review of non-opioid pain relievers. In October 2016, Health Canada amended its regulations to allow doctors to seek access to pharmaceutical diacetylmorphine, also known as pharmaceutical-grade heroin, through the Special Access Programme. This treatment has a history of successful use in various European countries for the treatment of chronic relapsing opioid dependence. The federal Minister of Health has written to provinces and territories indicating that Health Canada officials are available to rapidly process requests for access to medications through the Special Access Programme and asked them to provide information on the types and volumes of medications that they may require. Consideration is also being given to other regulatory mechanisms to facilitate the ability of provinces and territories to import medication not currently approved for sale in Canada.

Mental Health Supports

The Government acknowledges that untreated mental illness is a common cause of addiction which requires early intervention. As part of its funding plan under a new Health Accord of $11.5 billion over ten years, in December the Federal Government proposed its plan to provide $5-billion of new targeted funding over the next 10 years to provinces and territories to improve access to mental health services The Government of Canada remains open to working with participating jurisdictions to deliver on these important investments.

The Government also provided $111.8 million over two years through Budget2016 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.

The Government also renewed funding for the Mental Health Commission of Canada for the next two fiscal years (2017-18 and 2018-19). The Commission’s activities will support suicide prevention, addressing problematic substance use, and increasing Canadians’ understanding of mental health issues. Health Canada, the Public Health Agency of Canada, Statistics Canada, the Canadian Institutes of Health Research, the Canadian Institute for Health Information, and the Canadian Centre for Substance Abuse collaborate with the Mental Health Commission of Canada on the Mental Health and Addictions Information Collaborative, which is a consortium of national organizations that aim to align the collaborative practices among individuals and organizations that work with mental health and addictions.

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.

Further, the Canadian Institutes of Health Research invests more than $50 million each year in mental health research in academic institutions across the country. This investment contributes to informing best practices and in developing new tools and treatments for patients.

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.

Harm Reduction
(Recommendations5, 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 ofVancouver is servicedby 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.

Enforcement
(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.

Importation of illegal Opioids

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.

The Royal Canadian Mounted Police and the Canada Border Services Agency are focusing collective operational efforts with law enforcement counterparts in China. A Memorandum of Understanding between the two police agencies was renewed in September 2016 to enhance cooperation on combatting crime. Both parties have committed to work together to combat the flow of illegal fentanyl and other opioids into Canada. The Royal Canadian Mounted Police and the Chinese Ministry of Public Security continue to discuss how to advance investigations against such shared threats. Since then, China has recently controlled four dangerous fentanyl analogues under their domestic framework.

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.

From a North American perspective, Canada has engaged in trilateral discussions with the United States and Mexico on the opioid crisis through the new North American Drug Policy Dialogue. In October 2016, the three countries met to discuss the current opioid crisis, and agreed, among other measures, to explore an aligned approach by the three countries to countries outside of the continent that are influencing the illegal opioid threat in North America regarding shipment of precursor chemicals and trafficking of synthetic drugs to North America.

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.

Legislative Measures

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.

Bill C-37 also proposes to control the importation of designated devices (e.g. pill presses and encapsulators). These devices can be used for the manufacturing of illegal pills containing opioids and other controlled substances. Bill C-37 would require every pill press or encapsulator imported into Canada to be registered with Health Canada. Border officials would have the authority to detain designated devices such as pill presses and encapsulators to verify compliance and registration requirements. Bill C-37 would also allow registration information to be shared with Canadian police forces in the course of an investigation. In addition, Bill C-37 would broaden prohibitions and penalties that apply to the possession, production, sale, importation or transport of anything where a person intends on using it in the traffic or unlawful production of any controlled substance. This would increase the police’s ability to take enforcement action against suspected drug production operations. Further federal government initiatives are currently examining measures and resources to interdict illegal drugs and other illegal goods such as guns at the border.

Regulatory Measures

The Government has also made changes to Schedule VI, under the authority of the Controlled Drugs and Substances Act, and to the Precursor Control Regulations on November 30, 2016 to control certain chemicals used to produce fentanyl which will help to interrupt the illegal supply of fentanyl. Health Canada will also support law enforcement by disseminating educational materials related to the Food and Drugs Act offences for sale of unauthorized drugs that are not controlled under the Controlled Drugs and Substances Act to better outline investigation abilities under the Controlled Drugs and Substances Act.

Providing Scientific and Technical Services to Support Enforcement

The Government of Canada will work collaboratively with partners to ensure consistent and effective response to stem the flow of illegal opioids. This includes supporting enforcement, interdiction through the use of risk targeting, intelligence, laboratories and detection technology.

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.

Similarly, the Canada Border Services Agency’s laboratory analyzes suspected contraband drugs seized by Border Services Officers at Canada’s Ports of Entry, including International Mail Centres. The Canada Border Services Agency is also analyzing and testing field detection systems and instruments that can be used for the detection and identification of fentanyl and fentanyl like substances at Ports of Entry.

Further Study by Parliament

The Government of Canada supports the recommendation for the Standing Committee on Public Safety and National Security to 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. To help inform the approach and efforts of the Standing Committee on Public Safety and National Security, the Government of Canada strongly encourages the Standing Committee to undertake an initial consultation with groups like the North American Drug Policy Dialogue in order to provide a baseline of information and avoid duplication.

Data and Evidence
(Recommendations3, 31, 32)

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.

Improved Evidence Base

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.

Given the urgent need for comprehensive and comparable data on drug overdose deaths to address the opioid crisis, Health Canada has provided funding to CIHI to improve the comparability of this data. In collaboration with all provincial and territorial coroners/medical examiners, CIHI has developed pan-Canadian recommendations for the investigation of drug-related deaths. A critical meeting was held on March 1, 2017 with chief coroners/medical examiners to discuss the recommendations and reach consensus on a consistent approach to reporting drug-related deaths to improve comparability and enable pan-Canadian reporting. The Minister of Health has asked Provincial and Territorial Health Ministers to support her in highlighting the need to reach an agreement from the provincial coroner/medical examiner to move forward.

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.

Concurrently, the Special Advisory Committee on the Epidemic of Opioid Overdoses is also collaborating to share existing data on opioid overdoses (both deaths and other harms) in jurisdictions as part of the response to monitor the extent of the crisis and to help inform collaborative efforts.

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

Health Canada funds mental health and addiction services in First Nations and Inuit communities, including mental health promotion, addiction and suicide prevention, counselling, crisis response services, treatment and aftercare, and supports for former students of Indian Residential Schools and their families. Health Canada currently spends over $300 million annually for community-based mental health and addictions programs. In June 2016, the Government of Canada announced an additional $69 million over three years for measures to address mental health crises in First Nations. The measures Health Canada is undertaking are consistent with the Truth and Reconciliation Commission Calls to Action.

Given the number of adverse experiences and the history of trauma in First Nations communities, a trauma-informed approach to care equips the service provider with a better understanding of the needs and vulnerabilities of First Nations. Through this innovative approach, care providers are better able to support clients in a compassionate manner.

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.


Further, the Federal Government, through Budget2016, invested $4.6 billion over five years to support infrastructure in First Nations and Inuit communities, $270 million of which was to support the construction, renovation and repair of nursing stations, residences for health care workers, and health offices that provide health information on reserve.

Culturally Appropriate Care
(Recommendations22, 23, 24, 26, 28)

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.

Health Canada works closely with First Nations and Inuit partners at all levels to ensure their principles and values are reflected in decision making. For example, both the Assembly of First Nations (AFN) and Inuit Tapiriit Kanatami sit on the First Nations and Inuit Health Branch’s (FNIHB) Senior Management Committee. FNIHB and the Assembly of First Nations have created and implemented a joint Engagement Protocol. Inuit Tapiriit Kanatami’s Inuit Health Approach is also being used as a guiding document for engagement on all health issues, including those associated with addictions.

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.

Collaboratively with First Nations and Inuit, through these and other engagement mechanisms, frameworks and guidance documents have been developed, including the First Nations Mental Wellness Continuum Framework and Honouring Our Strengths: A Renewed Framework to Address Substance Use among First Nations People in Canada. These frameworks support and promote culturally appropriate care including trauma-informed approaches and will continue to guide Health Canada’s actions in the delivery of mental health and addiction 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
(Recommendation7)

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
(Recommendations 25, 27)

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
November 19, 2016

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
Federal Minister of Health

The Honourable Eric Hoskins
Ontario Minister of Health and Long-Term Care

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:

  • Providing leadership to address the opioid crisis by working with health professionals, addiction experts, provinces and territories, and other stakeholders, to implement Health Canada's Opioid Action Plan.
  • Improving access to buprenorphine/naloxone treatment in rural and remote First Nations communities by taking steps to ensure that the supports are in place to safely store, handle and undertake the daily witnessing of buprenorphine/naloxone.
  • Engaging with prescriber colleges and regulatory bodies, as part of the First Nations and Inuit Health Branch's Non-Insured Health Benefits Program, to improve awareness of its Prescription Drug Abuse Strategy and Prescription Monitoring Program.
  • Collaborating with the Non-Insured Health Benefits Program and other public drug plans on plan-based prescription drug abuse initiatives to increase innovation and prevent the shifting of costs and problems from one payer to another.
  • Supporting a range of tools and harm reduction measures for communities, including supervised consumption sites. This will include: proposing any necessary amendments to the Controlled Drugs and Substances Act to remove any undue barriers introduced through the Respect for Communities Act; 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.
  • By February 2017:
    • Publishing a report on Health Canada's Opioid Action Plan and keeping it evergreen by posting regular updates and progress reports; and
    • Publishing a report on the Health Portfolio's Prescription Drug Abuse initiatives.
  • Implementing Health Canada's Opioid Action Plan, which comprises the following elements:
    • Better informing Canadians about the risks of opioids:this includes mandating new warning stickers and patient information sheets for all dispensed opioids; conducting targeted public awareness activities; and disseminating youth prevention tools that reflect best practices.
    • Supporting better prescribing practices: this includes continuing to promote best practices and national approaches through the Federal/Provincial/Territorial Prescription Monitoring Program Network; and sharing prescribing practice information obtained from pharmacy inspections with selected Provincial/Territorial regulatory authorities, as appropriate.
    • Reducing easy access to unnecessary opioids:this includes adding new contraindications for approved opioids; requiring a prescription for low-dose codeine products; requiring manufacturers to develop and implement risk management plans for high-risk opioids; and providing updated guidance to pharmacies on the handling and destruction of consumer-returned prescription drugs.
    • Supporting better treatment options for patients:this includes expediting the review of non-opioid pain relievers; consulting stakeholders on whether the special exemption requirement for methadone prescribers poses undue barriers to access to treatment; implementing the recent regulatory change to enable access to diacetylmorphine (heroin) via Health Canada's Special Access Programme (SAP); accepting applications to SAP for other drug treatments not yet available in Canada and encouraging manufacturers to take the necessary steps to bring those drugs to the Canadian market; and promoting increased access to buprenorphine/naloxone as a first line treatment choice by disseminating the results of the recent Canadian Agency for Drugs and Technologies in Health (CADTH) report, Buprenorphine/Naloxone Versus Methadone for the Treatment of Opioid Dependence: A Review of Comparative Clinical and Cost-Effectiveness and Guidelines.
    • Improving the evidence base upon which policy decisions are made:this includes 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 National Drug Observatory for Canada; hosting Expert Advisory Panels to advise on scientific elements of the Opioid Action Plan; and publicly reporting on the results of the Health Portfolio's Prescription Drug Abuse initiatives and projects funded through Health Canada's Substance Use and Addiction Program (SUAP).
    • Reducing the availability and harms of street drugs:this includes continuing to facilitate increased access to naloxone in line with Health Canada's actions to date (i.e., making it available without a prescription, issuing an emergency Order to allow bulk import of naloxone nasal spray from the United States, and conducting an expedited review to authorize the nasal spray in Canada); publishing regulations to control fentanyl precursors; sharing Health Canada's Drug Analysis Service lab analysis with Provincial/Territorial authorities in a timely manner so they may respond effectively to local drug trends; considering options for controlling pill presses; and educating law enforcement agencies on their ability to investigate and press charges for offenses under the Food and Drugs Act, particularly for the sale of unauthorized drugs that have not yet been controlled under the Controlled Drugs and Substances Act.
  • Continuing to implement theHealth Portfolio's Prescription Drug Abuse Strategy, which received $44M over five years (2014-2019) to support: increased pharmacy inspections to help reduce the diversion of prescription drugs; enhanced access to prevention and treatment capacity for prescription drug abuse within First Nations communities across Canada; a national marketing campaign aimed at parents and youth; research on new clinical and community-based interventions for preventing and treating prescription drug abuse; a coordinated pan-Canadian approach for the monitoring and surveillance of prescription drugs, including the data reporting standards necessary to establish a national network of coroner's reports to better understand the impact of opioids on death rates in Canada; and the development of evidence-based practices for appropriate prescribing. A key deliverable for March 2017 is an updated Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain and associated training tools for prescribers, for which Health Canada provided funding to McMaster University. Health Canada, through its Substance Use and Addictions Program, is also funding a variety of additional prevention and treatment initiatives across Canada.

The Province of British Columbia commits to:

  • Establishing supervised consumption services in locations of high need; BC presented two applications for exemptions in October 2016 and will present four more exemption requests to Health Canadaby the end of 2016. BC looks forward to working collaboratively with Health Canada to facilitate timely review of applications to open a minimum of eight new supervised consumption servicesin 2017.
  • Supporting federal efforts to improve the application process for Section 56 exemptions under the Controlled Drugs and Substances Act required to operate supervised consumption services; BC will continue to provide Health Canada with recommendations for areas of the Controlled Drugs and Substances Act, as amended through Bill C-2, that can be substantially modified or eliminated without compromising public health or public safety to facilitate the timely establishment of supervised consumption services in BC and nationally.
  • Sharing knowledge about treatments for opioid use disorder that are new and emerging in Canada and supporting the development of a national framework for the provision of injectable opioid agonist therapies.
  • Sharing new provincial guidelines for treating opioid use disorder scheduled for releasein January 2017, as well as further updates incorporating new treatments later in 2017.
  • Encouraging Health Canada to continue its efforts to remove any unnecessary regulatory barriers that prevent or inhibit access to evidence-based pharmacotherapies for the treatment of opioid use disorder. Given BC's current public health emergency and the unprecedented number of preventable overdose deaths, BC appreciates Health Canada's support to date and looks forward to further cooperation to ensure the full spectrum of evidence-based pharmacological treatment options for opioid use disorder (including methadone, buprenorphine/naloxone. long acting injectable naltrexone formulations, long acting buprenorphine implants, injectable hydromorphone, diacetylmorphine, and, in the future, additional safe and effective pharmacological treatments currently in development) are maximally available to health care providers and their patients.
  • Supporting the creation of a nationally coordinated surveillance hub providing ongoing active surveillance of illegal and prescribed fatal and non-fatal overdose and other drug-related harms in Canada. During the public health emergency, BC will continue the release of weekly and monthly data tracking illegal drug overdose deaths, the proportion of deaths where fentanyl is detected, non-fatal overdoses requiring emergency service response and/or emergency department care, data disaggregated by age, sex, and region, as well as regular exploration of the contextual factors associated with the current emergency situation. Once the public health emergency is over, BC will continue its work with other provinces/territories and the federal government to generate and share data that helps build a national picture of the harms related to substance use.
  • Encouraging Health Canada to create a nationally coordinated process to develop common case definitions for surveillance (for health, coroners, and other drug data),beginning in early 2017.
  • Continuing to support the federal government in its exploration of improved scheduling of substances and equipment under the Controlled Drugs and Substances Act and Precursor Control Regulations-including pill presses, sorters, tableting machines and pill dies-to permit monitoring and control of access to non-legitimate users.

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:

  • Continuing to advocate that the federal government support an enhanced RCMP/Canadian Border Services Agency (CBSA) federal partnership and increased federal funding to re-instate federal RCMP resources to interdict the importation and trafficking of illegal opioids such as Fentanyl.
  • Encouraging federal counterparts to pursue diplomatic efforts to reduce fentanyl sale and importation to Canada, and supporting Canada to engage in discussions with China with the aim of entering into a bilateral agreement to stem the export of Fentanyl and its analogues. Such an agreement could emulate the USA - China agreement established on Sept 3rd, 2016:
    • China committed to targeting USA-bound exports of substances controlled in the United States, but not in China;
    • The USA agreed to increase their exchange of law enforcement and scientific information with a view towards coordinated actions to control substances and chemicals of concern;
    • The USA will continue to work with China bilaterally and multilaterally to tighten international scheduling and improve the capacity of states to monitor and analyze illegal synthetic drugs.
  • Contributing provincial surveillance data that outlines the magnitude of the fentanyl problem in BC, including the proportion of illegal drug overdose deaths where fentanyl is detected, to inform the national picture, and sharing appropriate information with federal health and enforcement sectors to support an intersectoral and multi-level approach to reducing overdoses and overdose deaths.
  • Continuing to report on progress publically every eight weeks during the public health emergency.

Manitoba Health, Seniors and Active Living, Province of Manitoba commits to:

  • Improving data collection to better target interventions.
  • Expanding access to Manitoba's Provincial Naloxone Distribution Program.
  • Improving prescription drug monitoring to prevent prescription drug misuse.
  • Providing specialized education for service providers and parents.

The Ministry of Health, Province of New Brunswick commits to:

  • By December 2016,completing the roll-out of New Brunswick's Drug Information System (DIS), currently on track.
  • Implementing a Prescription Monitoring Program Application that will provide alerts and tools to prescribers and pharmacists in real-time that will support the appropriate prescribing and use of monitored drugs, help prevent harms, and help identify patients who may be at risk of addiction.
  • Continuing to collaborate with stakeholders with respect to the distribution of Naloxone kits and the associated necessary training.

The Department of Health and Wellness, Province of Prince Edward Island, commits to:

  • Convening focused planning tables of key stakeholders in the coming months to develop targeted initiatives to combat opioid abuse. Areas of focus will include:
    • initiating prescription drug monitoring and accountability framework under theNarcotics Safety and Awareness Act
    • enhancing opioid surveillance to establish a strong evidentiary base to support decision-making
    • collaborating with Justice staff and other officials to develop strategies that target illegal sources of opioids and diversion of prescribed opioids

The Ministry of Health and Community Services, Province of Newfoundland and Labrador commits to:

  • By December 31, 2017:Implementing aProvincial Prescription Monitoring Programfocused on prescription drugs with high potential for abuse. Specific actions include:
    • By December 2016: Establishing the governance structure for the program;
    • By January 2017: Implementing of Safe Prescribing Course for Physicians;
    • By May 2017: Establishing wide-scale access to patient drug profiles for physicians;
    • By May 2017: Implementing a Provincial Pharmacy Network;
    • By December 2017: Operationalizing Prescription Monitoring Program database and analytics capacity; and
    • Exploring the legislation required to enable the Prescription Monitoring Program.
  • Implementing aprovincial Take Home Naloxone Kit programto increase capacity for Opioid Overdose response. Specific actions include:
    • By December 2016: Collaborating with community partners, regional health authorities, and other government departments in the development of a provincial Take Home Naloxone Kit program;
    • By December 2016: Establishing target populations and provincial distribution sites;
    • By January 2017: Developing and implementing related training, education and program awareness materials;
    • By October 2017: Developing and implementing a program evaluation framework to strengthen the effectiveness of the provincial Take Home Naloxone program; and
    • By January 2017: Developing and implementing a multi-faceted opioid overdose awareness and education campaign.
  • By March 2017: Initiatingcoverage of suboxone under special authorization, until an Atlantic Common Drug Review can be completed. Specific actions include:
    • By December 2016: Determining updated physician licensure requirements to prescribe suboxone;
    • By December 2016:Identifying training/operational requirements for physicians/pharmacists/others working with clients on suboxone;
    • By January 2017: Communicating and consulting on the plan with Newfoundland and Labrador Medical Association, Association of Registered Nurses of Newfoundland and Labrador, Prescribers, Pharmacy Association of Newfoundland and Labrador and others as required;
    • By February 2017: Finalizing and implementing training and any operational requirements, e.g. revised billing codes; and
    • By March 2017: Communicating publicly.

The Ministry of Health and Social Services, Government of the Northwest Territories commits to:

  • Establishing a Northwest Territories Opioid Drug Misuse and Overdose Task Force, led by the Northwest Territories Chief Public Health Officer. This task force will develop a comprehensive action plan to respond to the ongoing issues related to opioid drug misuse and overdose and to provide strategic oversight, leadership and coordination on the implementation ofinitiatives related to opioid drug misuse and overdose.
  • As a key action item, developing and implementing of a new public education initiative focusing on enhancing awareness of the dangers of street fentanyl.

The Ministry of Health and Wellness, Province of Nova Scotia commits to:

  • By March 2017:Developing detailed actions in the following seven areas:
    • Data Collection and Monitoring
    • Health Promotion
    • Harm Reduction
    • Access to Naloxone
    • Opioid Addiction treatment
    • Enhancing opioid prescribing and pain management
    • Justice/Law Enforcement
  • Opioid Misuse and Overdose Response Plan Work Groups have been established and will report to the Opioid Misuse and Overdose Response Plan Leadership Team.

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.

  • Modernizing opioid prescribing and monitoring
    • Ontario's First-Ever Provincial Overdose Coordinator: Designate Ontario's Chief Medical Officer of Health as Ontario's first-ever Provincial Overdose Coordinator.
    • Quality Standards: Develop evidence-based quality standards for health care providers on appropriate opioid prescribing.
    • Appropriate Prescribing: Develop new, evidence-based training modules and academic programs that will provide modernized training to all health care providers who prescribe or dispense opioids.
    • Patient Education: Improve access to important medication information, including a patient guide, for all patients prescribed opioids to help them better understand the associated risks.
    • Practice Reports: Provide reports to physicians that show how their opioid prescribing compares to that of their peers and to best practices.
    • Narcotics Monitoring System (NMS): Make NMS data readily available to health care providers, including physicians and pharmacists so they have access to up-to-date dispensed medication information for their patients when making decisions concerning opioid prescribing.
    • Overdose Monitoring: Launch a new overdose surveillance and reporting system to support Ontario's Provincial Overdose Coordinator.
    • High-Strength Opioids: Beginning January 1, 2017, high- strength formulations of long-acting opioids will be delisted from the Ontario Drug Benefit Formulary.
    • Province-wide expansion of the Fentanyl Patch for Patch Program: Beginning October 1, 2016, stricter controls on the prescribing and dispensing of fentanyl patches took effect. Patients are now required to return used fentanyl patches to their pharmacy before more patches can be dispensed.
  • Improving the Treatment of Pain
    • Investing in the Chronic Pain Network: Invest $17 million annually in multi-disciplinary care teams, including 17 Chronic Pain Clinics across Ontario, to ensure that patients receive timely and appropriate care to help them manage chronic pain.
    • Expansion of the Low Back Pain Strategy:Expand access and availability of health care services for more Ontarians who suffer from low back pain. This comprehensive model of care includes a rapid low back pain assessment within an average of two weeks, as well as evidence-based management plans and educational tools to help patients manage pain.
    • Chronic Pain Training for Health Care Providers: Expand training and support to primary care providers, including in rural and remote communities, to enable them to safely and effectively treat chronic pain.
  • Enhancing addiction supports and harm reduction
    • Expanded Access to Naloxone: Expand participation in the Ontario Naloxone Program. Naloxone, an antidote for opioid overdose is now available free of charge for patients and families through pharmacies and eligible organizations.
    • Naloxone Kits for At-Risk Inmates: Begin providing naloxone kits free of charge to at-risk inmates at the time of their release from provincial correctional institutions.
    • Intranasal Naloxone: Explore providing naloxone in nasal spray form to first responders.
    • Expand Access to Suboxone: Effective October 11, 2016, Suboxone is available as a General Benefit on the Ontario Drug Benefit Formulary. Ontario will ensure that access to Suboxone treatment is better integrated into a holistic, primary care approach to opioid addiction treatment.
    • Harm Reduction: Develop an evidence-based harm reduction framework, which could include expanding needle exchange programs and supervised injection services which have been demonstrated to save lives and reduce costs within the health care system.
    • Health Care Delivery and Primary Care Integration: Enhance integration of comprehensive primary care, mental health and Suboxone/methadone treatment to better support patients with opioid addiction.

The Ministry of Health, Province of Saskatchewan commits to:

  • Continuing to provide data and financial support to the College of Physicians and Surgeons of Saskatchewan to operate the Prescription Review Program to reduce the abuse and diversion of opioids.
  • Continuing with the provincial Pharmaceutical Information Program to allow authorized health care professionals to electronically view current and past prescriptions of Saskatchewan residents.
  • Continuing to support the RxFiles, a Saskatchewan-based academic detailing program that provides ongoing education to health professionals on various aspects of drug therapy, including pain management and prescription misuse.
  • Continuing the work initiated in 2015 to provide training and Take Home Naloxone kits at no cost to eligible Saskatchewan residents in collaboration with regional health authorities.
  • Working with the provincial coroner's office to ensure the Saskatchewan Ministry of Health has up to date information on the number of opioid overdose deaths, and monitor for regions and populations where risk is increasing.
  • Increasing the number of locations across the province that provide the training and distribute Take Home Naloxone kits to individuals at risk of an opioid overdose.
  • Working with the Pharmacy Association of Saskatchewan to have Take Home Naloxone kits in retail pharmacies and to ensure that complementary training occurs in these situations.

Accreditation Canada commits to:

  • By December 2017:
    • Reviewing existing Qmentum medication management standards, including those with respect to identifying, monitoring and addressing opioid misuse, abuse and diversion in light of the Joint Statement of Action to Address the Opioid Crisis.
    • Developing a specific standard(s) to incorporate and reflect the language of the Joint Statement of Action to Address the Opioid Crisis.
    • Contributing to any potential updates to Abuse and Diversion of Controlled Substances: A Guide for Health Professionals or any other guidelines that may emerge as a result of the Joint Statement of Action to Address the Opioid Crisis and related processes.

Sébastien Audette, President, Global Standards and Programs

The Association of Canadian Faculties of Dentistry commits to:

  • By September 2017:
    • Teaching every student registered in dentistry programs across all 10 dental schools in Canada to develop the knowledge and skills required to reduce the harms associated with opioids.
    • Course outlines for all dentistry students will include the topic of opioid use, prescribing and related harms, and include relevant knowledge and skills evaluations.

Paul Allison, President

The Association of Faculties of Medicine of Canada commits to:

  • Continuing to ensure that the accreditation standards for Canada's medical schools include instruction in the diagnosis, prevention, appropriate reporting and treatment of the medical consequences of common societal problems, including the opioid crisis.
  • By November 2017: Having faculty experts:
    • review opioid educational activities currently in use in its 17 faculties of medicine; and
    • create and share a repository of educational products that reflect best
    • practice and provide them to all faculties.

Geneviève Moineau, President and Chief Executive Officer

The Association of Faculties of Pharmacy of Canada commits to:

  • Conducting an environmental scan to identify faculty experts, best teaching practices and the extent to which current curricula addresses pain management, opioid use and misuse.
  • By September 2017:Adapting and disseminating the recommendations of the First Do No Harm: Responding to Canada's Prescription Drug Crisis Strategy "Competencies for health professionals in pain management, drug prescribing, dependence, addiction and abuse" within the curricula for undergraduate levels and continuing professional development of the 10 faculties of pharmacy.

Beth Sproule, Clinician Scientist / Associate Professor,

Leslie Dan Faculty of Pharmacy, University of Toronto
for
Ann Thompson, President

Canada Health Infoway commits to:

  • Reducing the harm and costs of opioid-related fraud and misuse with the launch of PrescribeIT(tm) Canada's national e-prescribing service. PrescribeIT's secure electronic transmission will ensure that prescriptions cannot be altered or forged and will provide value-added data to physician regulators, policy makers, and others. This effort will include the following elements:
    • By December 2016:Establishing a national medication management stakeholder community where clinical leaders can share information and tools with others across the country to discuss, learn and apply knowledge to promote medication safety practices, leveraging collaborative platform tools.
    • By January 2017:Conducting an environmental scan of countries that have adopted electronic prescribing for narcotics and apply the lessons learned to the Canadian context.
    • By January 2017:Undertaking research with the Canadian Pharmacists Association and MDBriefcase to better understand the prescribing and dispensing process in Canada.
    • By March 2017:Providing education and awareness of legislation and regulations associated with e-prescribing.
    • By March 2017:Providing updated national Electronic Medication Reconciliation Toolkit developed in partnership with the Institute for Safe Medication Practices Canada.
    • By June 2017:Launching a publicly-available clinical drug list for use by prescribers in collaboration with Health Canada's Health Products and Food Branch.
    • By June 2017: Updating e-prescribing standards - both terminology and messages to enable interoperability for the PrescribeIT (e-prescribing service).
    • By March 2018: Launching improved analytics feeds in Ontario and Alberta, as the beginning of a staged rollout across the country to provide for narcotics surveillance.

Michael Green, President

The Canadian Agency for Drugs and Technologies in Health commits to:

  • By November 2017: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), and the treatment of opioid addiction.

Brian O'Rourke, President and Chief Executive Officer

The Canadian Association of Poison Control Centres commits to:

  • Working to establish a Canadian national database of poisonings to improve information about the extent of exposures across Canada. This database offers a unique picture of the number and outcomes of exposures across Canada.
    • By March 2017:initiation of upload of anonymized call exposure information to a national hub which can be mined for opioid exposures, as an example. Patterns of use, location mapping, symptoms and outcomes of exposures are possible data elements that could provide an early warning signal of localized increases in poisonings from opioids or other drugs.

Margaret Thompson, President

The Canadian Association of Schools of Nursing commits to:

  • By November 2017:Disseminating evidence-based educational resources on opioid use through a communication strategy for nurse educators, registered nurses and nurse practitioners, and students in collaboration with the Canadian Nurses Association.
  • Educating nursing faculties on the growing opioid crisis in Canada through a series of blogs, lunch-and-learn webinars, and a dedicated editorial section in our newsletter reaching over 2,000 members. As a result, nursing faculty will have the increased knowledge and support to educate the future generation of nurses about opioid prescribing and the harms associated with opioids.

Cynthia Baker, Executive Director

The Canadian Centre on Substance Abuse commits to:

  • On a quarterly basis starting March 2017:reporting on the Joint Statement of Action to Address the Opioid Crisis by communicating regularly with, connecting, monitoring the progress of, and facilitating reporting by all members.
  • Starting immediately, working with Health Canada to engage stakeholders and identify new partners with clear accountability for action for reducing the harms associated with opioids and other problematic substance use.
  • Providing leadership and guidance to individual and collective efforts, as part of ongoing work related to the First Do No Harm Strategy to address the harms associated with opioids and other psychoactive prescription drugs.
  • Promoting the inclusion of the newly developed Competencies for Healthcare Professionals related to Addiction and Pain, in licensing exams and educational programs and curricula.
  • By March 2018, assessing the effectiveness of different clinical pathways to improve treatment for youth and older adults in Canada experiencing issues related to opioids and other psychoactive prescription drugs.

The First Do No Harm Executive Council commits to:

  • As stewards of the First Do No Harm Strategy, proving ongoing guidance in the coordination, implementation and evaluation of the Strategy's recommendations through quarterly teleconferences.
  • Continuing this role of expertise and coordination in the complex areas of problematic substance use.
  • For example, in collaboration with McMaster University, contributing to updating the existing Canadian Guidelines for Safe and Effective Use of Opioids for Non-Cancer Pain and contributing to the development of e-tools for prescribers (train-the-trainer modules, face-to-face delivery, tool kits).
  • By March 2017:Producing a manuscript examining prescribing patterns for short- and long-acting opioids in Ontario using Institute for Clinical Evaluative Sciences data.
  • By November 2017:Promoting the more effective identification and treatment of those addicted to opioids and promoting the resources to address opioid overdose.

Rita Notarandrea, Chief Executive Officer

The Canadian Chiropractic Association commits to:

  • By June 2017:Developing evidence‐based professional practice recommendations and guidelines to facilitate the appropriate triage and referral of Canadians suffering from chronic and acute musculoskeletal conditions and reduce reliance on opioids. The recommendations will aim to:
    • better understand the burden of pain related to musculoskeletal conditions;
    • develop key recommendations for the appropriate role of chiropractic care (in anticipation of similar efforts for other key alternatives to opioids); and
    • facilitate dissemination of key recommendations.

Allison Dantas, Chief Executive Officer

The Canadian Council of Registered Nurse Regulators commits to:

  • ByJune 2017:Developing a guidance document for all registered nurse and nurse practitioner regulators that will support the implementation of a consistent, standardized approach to:
    • Opioid and controlled substance prescribing for nurse practitioners;
    • Education and practice for nurse practitioners with respect to harm reduction, including prescribing suboxone and methadone to reduce the harmful effects of illegal drug use;
    • Utilization of electronic pharmacy management e-systems that support medication reconciliation;
    • Monitoring of prescribing and quality assurance;
    • Entry-level and remedial education on prescribing competencies for nurse practitioners; and
    • Entry-level competencies for registered nurses that include ways to support effective pain management and limit potential for abuse amongst patients/clients.

Cynthia Johansen, Registrar and Chief Executive Officer

The Canadian Institute for Health Information commits to:

  • As a matter of priority, continuing to contribute to the development of a pan-Canadian prescription opioid surveillance system and to the national evidence base on opioid use and related harms. To that end:
  • By November 2017:Developing key metrics on the prevalence, consumption and harms of opioid misuse and to publicly report on an ongoing basis:
    • the number of people receiving opioids per 1000 population;
    • the number of defined daily doses (DDDs) of opioids per 1000 population;
    • the number of hospital admissions due to opioid poisonings; and
    • the number of emergency department visits due to opioid poisonings.
  • By August 2017: Collaborating with provincial/territorial chief coroners and medical examiners to release recommendations for the investigation and reporting of drug-related deaths. These recommendations will improve the quality of data collection and will increase the Canadian evidence base on the use and harms of opioids.
  • By November 2018:Begin to publicly report on an ongoing basis the number of opioid-related deaths.

David O'Toole, President and Chief Executive Officer

The Canadian Institutes of Health Research commits to:

  • By November 2017:Working with policy makers on an ongoing basis to ensure they have the research evidence needed to address the issue of opioid addictions and misuse in Canada, including the dissemination of research supported through Canadian Institutes of Health Research funded programs, such as results from the Canadian Research Initiative in Substance Misuse.
  • By June 2017:Launching two funding opportunities:
    • to support a synthesis grant aiming to review the current literature and increase our knowledge related to the harms associated with opioids in Canada; and
    • to support new research projects on gender implications related to opioids.

Jane Aubin, Chief Scientific Officer and Vice-President, Research, Knowledge Translation and Ethics Portfolio

The Canadian Medical Association commits to:

  • By December 2017:Disseminating new tools and resources to promote the uptake, use and impact of the updated Canadian Guideline for Opioids in Chronic Non-Cancer Pain, among over 83,000 physicians. This will also include creating a new webpage to host relevant educational resources and updated guidance documents.
  • By December 2017:Surveying a sample of its members on the facilitators and barriers to implementation of the new Canadian Guidelines for Opioids in Chronic Non-Cancer Pain, to determine the level of awareness and educational needs of Canadian physicians, as well as identify system issues such as access to pain and addiction treatment options.

Cindy Forbes, Past President
for
Granger Avery, President

The Canadian Medical Protective Association commits to:

  • Monitoring and reporting on medical-legal issues and lessons learned related to opioid prescribing by physicians.
  • Sharing this analysis with Joint Statement of Action partners and other groups to promote system level changes to improve opioid prescribing and to inform the development of educational offerings across Canada.
  • Further enhancing the Canadian Medical Protective Association's educational outreach to increase awareness of appropriate prescribing practices, and reporting on the number of presentations delivered to physicians and stakeholders in 2017.
  • In 2017, publishing a short series of evidence-based articles on better prescribing that will be distributed to all 95 thousand Canadian physicians; these will also be made publically available on our web site with other existing publications on this topic.
  • Developing and implementing a social media campaign on tips to improve opioid prescribing with a potential reach of many thousand physicians and trainees.

Gordon Wallace, Managing Director, Safe Medical Care

The Canadian Nurses Association commits to:

  • By November 2017:Developing and disseminating educational resources related to opioid use for provincial and territorial nursing associations and colleges in collaboration with the Canadian Association of Schools of Nursing. These resources will provide current, evidence-based information to support registered nurses, nurse practitioners, clinical nurse specialists and licenced practical nurses in their practice.

Barb Shellian, President

The Canadian Pharmacists Association commits to:

  • By October 2017:Developing a sector-wide strategy in Pharmacy on opioid misuse focused on prevention, control and monitoring and addiction management. This will include maximum dispensed quantities of narcotics, effective pain management, Drug InformationSystem/ ElectronicHealth Recordmonitoring systems to help reduce diversion, and addiction treatment programs, among others. The strategy will advance education programs, as well as regulatory and practice guidelines.
  • Undertaking and promoting pharmacy practice based research in the area of opioid abuse (e.g., addiction management, optimal strategies for managing co-morbidities, innovative and best practice pharmacy approaches, and de-prescribing strategies).
  • Producing an environmental scan of Continuing Professional Development programs across the country as they relate to pharmacists to better understand what already exists and to ensure that there is no duplication.
  • Continuing to work with Health Canada, Regulatory Authorities and stakeholders towards extending prescribing authority for pharmacists to include medication management of controlled substances.

Alistair Bursey, Chair of Board of Directors

The Canadian Pain Society commits to:

  • Supporting the activities of the Joint Statement of Action by acting as a content resource (about pain and its management) to government and partners who are working to reduce harms caused by opioids.
  • Working with the joint action members to assure that any strategy that aims to prevent diversion or misuse of opioid analgesics will contain measures to assure that they remain available to those patients who require them for appropriate medical use, and that these individuals are treated compassionately.
  • Continuing to emphasize the need for better education for health professionals and patients about appropriate pain care and safe use of opioid analgesics for the treatment of pain.
  • Continuing to emphasize the need for better interprofessional multimodal treatment for patients with pain (e.g. physiotherapy, psychotherapy), which may not only reduce opioid requirements, but also potentially mitigate pain and suffering.

Fiona Campbell, President Elect
for Brian Cairns, President

Le Collège des médecins du Québecandl'Ordre des pharmaciens du Québeccommit to:

  • Mobilising partners to establish an action plan for the safe use of opioids in Quebec.
  • Establishing a Prescription Monitoring Program and identifying high-risk prescribers and at-risk patients. Interventions after identifying practices will include targeted professional development and training programs and, if necessary, additional actions under the jurisdiction of professional regulatory associations (inspection visits, formal investigations, or disciplinary processes).
  • Promoting the optimal use of opioids and modifying key prescribing practices in hospitals, especially in surgical specialties, to reduce or eliminate the practice of systematically prescribing long-term opioids for post-operative pain management.
  • Promoting common curriculum in all four universities for the management of chronic pain and best practices in opioid prescription and pain and addiction management.
  • Collaborating with partners to update guidelines and training programs with respect to best practices in the use of opioids and the treatment of pain.

Pauline Gref, Medical Advisor of Executive Officer

The College of Family Physicians of Canada commits to:

  • By December 2017:Implementing the Pan-Canadian Collaborative on Education for Improved Opioid Prescribing. Activities include:
    • Curating an online repository of Continuing Professional Development courses in opioid prescribing;
    • Determining educational needs and knowledge gaps for a variety of audiences, and designing program elements to address them;
    • Using Prescription Monitoring Program and other data to assess the impact of specific educational interventions; and
    • Evaluating educational approaches for subgroups of prescribers, patient education initiatives, and programs for pain management to refine future approaches based on efficacy.

Jennifer Hall, President

The College of Physicians and Surgeons of Alberta commits to:

  • By December 2016: Providing every physician in Alberta who prescribes opioids and/or benzodiazepines in a community setting a comparative prescribing pattern report which includes data plus a list of patients whose doses exceed guidelines.
  • By March 2017:Adopting a standard of practice on safe prescribing that will require physicians to prescribe opioids consistent with the latest opioid guidelines.
  • By December 2017:Subject to receiving Ethics approval, conducting a randomized control trial to assess the effectiveness of sending physicians their prescribing data along with different educational supports. Physicians will receive their data referenced to the guideline and also to their peers.
  • By December 2017:Requiring every physician who prescribes very high-dose opioids (3000 oral morphine equivalents or higher) for chronic non-malignant pain to at least one patient to work closely with a mentor to reduce the dose to the lowest possible dose for the patient.
  • By December 2017:Conduct large scale targeted educational interventions using data (audit and feedback) each quarter.

Karen Mazurek, Deputy Registrar

The College of Physicians and Surgeons of British Columbia commits to:

  • By March 2017:Forming a Prescription Monitoring Oversight Committee that will receive PharmaNet data and do detailed analysis of that data to deliver customized reports to regulatory Colleges to identify prescribing that may be unsafe.
  • By March 2017:Publishing a new Professional Standard and Guideline on PharmaNet Access.

Heidi Oetter, Registrar

The College of Physicians and Surgeons of Ontario commits to:

  • By June 2017: Collaborating with the Ontario Ministry of Health and Long-Term Care on the recently released strategy and development of a plan to use Narcotics Monitoring System data held by the Ministry to promote patient safety. This includes:
    • identifying possible high risk prescribing and referring to regulatory bodies for follow up; and
    • developing a plan to identify low risk prescribing and providing a variety of educational interventions, including tools, that are tailored to individual needs of prescribers.
  • By December 2017: Publicly reporting, as permitted by legislation, on the outcomes of the current approach.
  • By December 2017:Updating existing policy to reflect revised Canadian Guidelines and Health Quality Ontario Quality Standards (if available).
  • Once all physicians have access to narcotics profiles, inclusion of expectation in policy for physicians to check the medication profile prior to prescribing narcotics.
  • Using prescribing information (comparative prescribing reports or prescribing data), when available, to inform educational approaches in conjunction with assessment of physician practice.
  • Supporting and contributing to a broader strategy to ensure necessary supports are available to patients and other health professionals.

Rocco Gerace, Registrar

The College of Physicians and Surgeons of Newfoundland and Labrador commits to:

  • By June 2017:Developing and implementing a new education tool, a Safe-Prescribing Program, which will be mandatory for all new physicians seeking a license to practise medicine in this province for the first time; current practising physicians will be directed to complete the program on the College's instructions.
  • This will provide focused instruction on safe and appropriate prescribing practices for opioids, stimulants and benzodiazepines.
  • This program will also be extended to other health care provider groups, such as nurse practitioners, dentists and pharmacists.

Linda Inkpen, Registrar

The First Nations Health Authority, Province of British Columbia commits to:

  • Preventing overdose-related deaths through promoting awareness and appropriate use of naloxone and awareness of the harms associated with fentanyl and other opioids through Indigenous learning circles.
  • Working with partners, design and establish safe consumption sites for First Nations communities in collaboration with Regional Health Authorities.
  • Working with partners on the ongoing process of implementing the Declaration on Cultural Safety & Humility throughout the health system.
  • Working with the Ministry of Health and the Regional Health Authorities to ensure that the evidence-base on opioid use and related harms, in particular overdose rates, is collected. Once data is received, the First Nations Health Authority can match against the First Nations Client File.

Evan Adams, Chief Medical Officer

Health Quality Ontario commits to:

  • Developing quality standards for opioid use disorder and opioid prescribing for pain.
  • By September 2017: Distributing drafts of these standards for public feedback.
  • Supporting prescribing practices consistent with the quality standards by providing every family physician in the province with a report showing how their opioid prescribing compares to their peers and to best practice.
  • Developing a specialized public report on opioid prescribing and opioid-related harm in Ontario.
  • Involving people with lived experience in all of these activities.

Anna Greenberg, Vice President, Health System Performance
for
Joshua Tepper, President and Chief Executive Officer

The Institute for Safe Medication Practices Canada together with the Canadian Patient Safety Institute and Patients for Patient Safety Canada commit to:

  • By August 2017:Empowering patients to improve knowledge about the use of opioids, the options for non-medication treatment of pain, and the prevention of harm from medications by developing tools for patients and their healthcare providers.
  • Tools will include: the questions to ask; the information that helps answer the questions; and a template for non-pharmacological options that can be used during hospital discharge or in primary care.
  • Selected hospitals and community pharmacies will provide this information to every patient with an opioid prescription.
  • By November 2017:Providing resources for dealing with left-over end-of-life opioid supplies in the home. These resources will include information and procedures addressing improved in-house storage to reduce the risk of accidental harm, information about the safe storage and disposal of medicines, and procedures for the safe disposal of medicines and equipment.

Sylvia Hyland, Vice President and Chief Operating Officer
for
David U, President and Chief Executive Officer Institute for Safety Medications Practices Canada

Chris Power, Chief Executive Officer Canadian Patient Safety Institute and Patients for Patient Safety Canada

The National Association of Pharmacy Regulatory Authorities commits to:

  • By November 2017:Developing and implementing a pharmacist-patient communication tool that will provide guidance to pharmacists on how to have difficult conversation with patients regarding opioid use.
  • By November 2018:Contributing to national monitoring and surveillance through compiling the extent by which provinces are able to gather data from multiple sources on the doses of opioids, for example, in "morphine equivalents" or another common measure, to possibly correlate national Prescription Monitoring Program data with new national guidelines on watchful doses that are prescribed to patients across all provinces and territories and Canadian Forces Pharmacy Services.

Anjli Acharya, President

The Royal College of Dental Surgeons of Ontario commits to:

  • By December 2017:Requesting and reviewing Narcotics Monitoring System data for opioid prescriptions by dentists and dental specialists for the calendar year 2016 and comparing this data to that received for the calendar year 2014 to assess the impact of the Guidelines on the Role of Opioids in the Management of Acute and Chronic Pain in Dental Practice (published in 2015).

David Mock, Professor
for
Irwin Fefergrad, Registrar

The Royal College of Physicians and Surgeons of Canada commits to:

  • By March 2017:Engaging experts to develop a Royal College statement of principles on safe opioid prescribing.
  • By June 2017:Creating a central e-portal to host educational and practice related reference resources that will be accessible to all Fellows and residents in order to bring a greater focus to the medical and surgical dimensions of safe opioid prescribing.
  • Carrying out a communication plan to engage with and disseminate knowledge to Fellows of the Royal College.

Kevin Imrie, President

The Council of Chief Medical Officers of Health commits to:

  • Exchanging and disseminating best practices and lessons learned from jurisdictions addressing the opioid crisis.
  • Providing evidence-based public health advice to the Public Health Network Council and Conference of Deputy Ministers of Health.
  • Providing support and input in the establishment of key metrics for comparable data collection and reporting across Canada.

Robert Strang, Chief Medical Officer of Health for the Province of Nova Scotia
on behalf of
Heather Morrison, Chair, Council of Chief Medical Officers of Health and Chief Public Health Officer for the Province of Prince Edward Island


Annex to the Government Response: Participant List at the November Opioid Conference and Summit


Sheriff Abdou
Public Health Agency of Canada

Horacio Arruda
Québec Ministry of Health and Social Services

Jeff Blackmer
Canadian Medical Association

Hon. Glen Abernethy
Northwest Territories Health and Social Services

Lisa Ashley
Canadian Nurses Association

Linda Blake-Evans
Hamilton Public Health Services

Anjli Acharya
National Association of Pharmacy Regulatory Authorities

Savanah Ashton
Canadian Centre on Substance Abuse

Jean-François Boivin
Canadian Centre on Substance Abuse

Evan Adams
First Nations Health Authority

Jane E. Aubin
Canadian Institutes of Health Research

Rob Boyd
Sandy Hill Community Health Centre

Keith Ahamad
BC Centre on Substance Use

Guy Aucoin
Santé Canada

Terry Bremner
Chronic Pain Association of Canada

Maureen Allen
Dalhousie University

Cynthia Baker
Canadian Association of Schools of Nursing

Nora Bressette
Thunderbird Partnership Foundation

Paul Allison
Association of Canadian Faculties of Dentistry

Kim Barker
Nunavut Health

Stephen Brown
Ministry of Health (BC)

Carl Amrhein
Alberta Health

Glenn Barnes
Barnes & Associates

Martin Bruce
Vancouver Police Department

Havelin Anand Canadian Association of Occupational Therapists

Sharon Baxter
Canadian Hospice Palliative Care Association

Julie Bruneau
CRCHUM, Université de Montréal

Bob Bell
Ministry of Health and Long-Term Care


Alistair Bursey
Canadian Pharmacists Association

Uppala Chandrasekera
Canadian Mental Health Association Ontario

Ian Culbert
Canadian Public Health Association

Jason Busse
McMaster University

Feng Chang
School of Pharmacy, University of Waterloo

Chris Cull
Inspire by Example

Jane Buxton
BC Centre for Disease Control

Ward Chickoski
Health Canada
Deborah Cumming
Royal College of Physicians and Surgeons of Canada

Thomas Cameron
Global Affairs Canada

Lynn Cooper
Canadian Pain Coalition

Gail Czukar
Addictions and Mental Health Ontario

Fiona Campbell
Canadian Pain Society

Kim Corace
The Royal Ottawa Mental Health Centre

Heather D'Alessio
Canadian Students for Sensible Drug Policy

Hon. Larry Campbell
Senator

André Corriveau
Northwest Territories Health and Social Services

Lisha Di Gioacchino
Canadian Centre on Substance Abuse

Shelagh Campbell-Palmer
Nova Scotia College of Pharmacists

Richard J. Côté
INSPQ

Patrick Dicerni
Ministry of Health and Long-Term Care (ON)

Jean-Claude Camus
Ministry of Health and Long-Term Care (ON)

Joe Cressy
Toronto City Council/Toronto Drug Strategy

Karine Diedrich
Canadian Centre on Substance Abuse

Colin Carrie, MP
House of Commons

Kim Critchley
Department of Health and Wellness (PEI)

James Dixon
University of Saskatchewan, Department of Community Health and Epidemiology

Walter Cavalieri
Canadian Harm Reduction Network

Kelly Crowe
Canadian Centre on Substance Abuse

Stephanie Chandler
Health Canada


Scott Doige
Non-Insured Health Benefits Program, FNIHB, Health Canada
Anita Fineberg
Anita Fineberg, Barriister & Solicitor
Rebecca Gilman
Health Canada
Joyce Douglas
Canadian Medical Association
Benedikt Fischer
CAMH & University of Toronto
Ada GiudiceTompson
Advocates for the Reform of Prescription Drugs (ARPO)
Richard Elliott
Canadian HIV/AIDS Legal Network
Michel Fontaine
Québec Ministry of Health and Social Services
Hon. Leo Glavine
Nova Scotia Health and Wellness
Tonia Enger
Police Services Division - Ministry of Public Safety and Solicitor General
Cindy Forbes
Canadian Medical Association
Hon. Kelvin Goertzen
Health Seniors and Active Living (MB)
Todd Evans
Health Canada
Hon. Hedy Fry, MP
House of Commons
Tara Gomes
St. Michael's Hospital
Rob Eves
Canadian Centre on Substance Abuse
Andrea Furlan
Toronto Rehab - UHN
Marie-Eve Goyer
Centre de recherche et d'aide pour les narcomanes
Doug Eyolfson, MP
House of Commons
Marion Gallagher Bremner
Action Atlantic Pain Society/ Chronic Pain Association of Canada
Michael Green
Canada Health Infoway
Melody Favretto
Health Canada
Michael Gardner
Royal College of Dental Surgeons of Ontario
Anna Greenberg
Health Quality Ontario
Gillian Fernie
Shepherds of Good Hope
Hilary Geller
Health Canada
Pauline Gref
Collège des médecins du Québec
Adele Fifield
National Association of Pharmacy Regulatory Authorities
Rocco Gerace
College of Physicians and Surgeons of Ontario
Karen Grimsrud
Alberta Health

Hon. John Haggie
Newfoundland and Labrador Department of Health and Community Services

Hon. Eric Hoskins
Ministry of Health and Long-Term Care (ON)
Mel Kahan
Substance Use Service, Additions Medicine Women's College Hospital
Angie Hamilton
Families for Addiction Recovery
Peter Anthony Howlett
Portage
Mae Katt
Dennis Franklin Cromarty High School
Brendan Hanley
Government of Yukon
Dirk Huyer
Office of the Chief Coroner for Ontario
Perry Kendall
Ministry of Health (BC)
Michael Hanson
Government of Yukon
Sylvia Hyland
Institute for Safe Medication Practices Canada
Pam Kent
Canadian Centre on Substance Abuse
David Henderson
Canadian Society of Palliative Care Physicians
Terri Irwin
Health Quality Ontario
Jim Keon
Canadian Generic Pharmaceutical Association
Bonnie Henry
Ministry of Health ( BC)
Sonia Isaac-Mann
First Nations Health Authority
Nandni Khera
Public Health Agency of Canada
Karen Herd
Province of Manitoba
Ahmed Jakda
Cancer Care Ontario
Betty-Lou Kristy
Lived experience and family advocate
Ramm Hering
Vancouver Island Health Authority
Rebecca Jesseman
Canadian Centre on Substance Abuse
Gary Lacasse
Canadian AIDS Society
Lindsay Hitchcock
Privy Council Office
Cynthia Johansen
College of Registered Nurses of BC
Hon. Terry Lake
British Columbia Provincial Government/ Minister of Health
Jennifer Hollington
Health Canada
David Juurlink
University of Toronto

Christopher Lalande
Office of Ron McKinnon, MP
Meredith MacKenzie
Street Health Centre (part of Kingston Community Health Centres)
Karen Mazurek
College of Physicians & Surgeons of Alberta
Anne Lamar
Health Canada
Shane Mackenzie
Office of Sonia Sidhu, M.P.
Leslie McBain
Moms Stop the Harm
Hugh Lampkin
Vancouver Area Network of Drug Users
Kent MacLeod
Nutrichem Pharmacy
Suzanne McGurn
Ministry of Health and Long-Term Care (ON)
Lisa Lapointe
BC Coroners Service
Donald MacPherson
Canadian Drug Policy Coalition
Opal McInnis
Government of Nunavut
Sylvie-Anne Lavigne
Correctional Service Canada
Gisele Maillet
New Brunswick Department of Health
Ron McKinnon, MP
House of Commons
Pascale Leclerc
Direction régionale de santé publique - CIUSSS du Centre-Sud-de- l'île-de-Montréal
Ian Manion
Institute of Mental Health Research
Joshua McLarnon
Ministry of Health and Long Term Care (ON)
Pamela Leece
Public Health Ontario
Edward Mantler
Mental Health Commission of Canada
Cathy McLeod, MP
House of Commons
Fleur-Ange Lefebvre
Federation of Medical Regulatory Authorities of Canada
Rho Martin
Canadian Centre on Substance Abuse
Neelam Merchant
Health Canada
Diane Legault
CDRAF/FCORD
Kirsten Mattison
Health Canada
Jamie Meuser
College of Family Physicians of Canada
Larry Levin
Canadian Dental Association
Donna May
mumsDU - moms united and mandated to saving the lives of Drug Users
David Mock
Royal College of Dental Surgeons of Ontario
Geneviève Moineau
Association of Faculties of Medicine of Canada

Cindy Moriarty
Health Canada
John Oliver, MP
House of Commons
Zachary Patterson
Canadian Centre on Substance Abuse
Carole Morissette
Direction régionale de santé publique de Montréal- Centre intégré universitaire de santé et des services sociaux du Centre-Sud-de- l'Ile -de-Montréal
Aaron Orkin
University of Toronto
Bernadette Pauly
Canadian Nurses Association
Heather Morrison
Prince Edward Island Department of Health and Wellness
Brian O'Rourke
Canadian Agency for Drugs and Technologies in Health
Hon. Brandy Payne
Alberta Associate Minister of Health
Christopher Mushquash
Lakehead University
David O'Toole
Canadian Institute for Health Information
Clayton Pecknold
Ministry of Public safety and Solicitor General
Rita Notarandrea
Canadian Centre on Substance Abuse
Harlie Outhwaite
Health Canada
Sony Perron
Health Canada
Matilda Nowakowski
St. Joseph's Healthcare Hamilton
Sheena Pahwa
Justice Canada
Hon. Jane Philpott, MP
Minister of Health
Warren O'Briain
Ministry of Health (BC)
Marc Paris
Drug Free Kids Canada/Jeunesse sans drogue Canada
Susan Pierce
Non-Insured Health Benefits Program, Health Canada
Heidi Oetter
College of Physicians and Surgeons of British Columbia
Michael Parkinson
Waterloo Region Crime Prevention Council Municipal Drug Strategy Coordinators Network of Ontario
Darlene Pinto
Canadian Centre on Substance Abuse
Gerald Olin
Canadian Chiropractic Association
Arlene Paton
Ministry of Health (BC)
Pierre Poirier
Paramedic Association of Canada
Maggie Patterson
Canadian Centre on Substance Abuse
Roberta (Bobbi) Reinholdt
Canada Health Infoway

Ana Renart
Health Canada
Peter Selby
Centre for Addiction and Mental Health
Bill Spearn
Vancouver Police Department
Kimberly Riles
Government of the Northwest Territories
Mike Serr
Abbotsford Police Department
Sheryl Spithoff
Women's College Hospital
Adair Roberts
Adair Roberts & Associates
Saqib Shahab
Ministry of Health (Saskatchewan)
Beth Sproule
Centre for Addiction and Mental Health
Paula Robeson
Canadian Centre on Substance Abuse
Rita Shahin
Toronto Public Health
Ivanka Stewart-Patterson
Centre de recherche et d'aide pour narcomanes
Miguel Rodrigues
U.S. Embassy
Supriya Sharma
Health Canada
Robert Strang
Department of Health and Wellness (NS)
Alyson Rowe
Office of the Ontario Minister of Health
Lauren Shute
Canadian Association of Schools of Nursing
Abhimanyu Sud
Continuing Professional Development, Faculty of Medicine, University of Toronto
Élise Roy
Université de Sherbrooke et INSPQ
Anthony Silva
Neighbourhood Pharmacy Association of Canada
Theresa Tam
Public Health Agency of Canada
Myrella Roy
Canadian Society of Hospital Pharmacists
Patrick Smith
Canadian Mental Health Association
Cara Tannenbaum
CIHR-Institute of Gender and Health
Jennifer Russell
Government of New Brunswick
Sharon Lee Smith
Ministry of Health and Long-Term Care (ON)
Gregory Taylor
Public Health Agency of Canada
Chander Sehgal
Innovative Medicines Canada
Paul Sobey
Canadian Society of Addiction Medicine

James Taylor
Public Health Agency of Canada
Elise Weiss
Health Seniors and Active Living (MB)
Beverley Zwicker
Nova Scotia College of Pharmacist
Kathy Thompson
Public Safety Canada
Dan Werb
International Centre for Science in Drug Policy
Margaret Thompson
Canadian Association of Poison Centres
Jordan Westfall
Canadian Association of People Who Use Drugs
Philip Tibbo
Dalhousie University / Nova Scotia Health Authority
Alison Whelan
Royal Canadian Mounted Police
Michael Trew
Alberta Health Services
David Williams
Ministry of Health and Long-Term Care (ON)
Mark Tyndall
BC Centre for Disease Control
Tom Wong
First Nations & Inuit Health Branch, Health Canada
Peter Vamos
Portage
Linda Woodhouse
Canadian Physiotherapy Association
Joelle Walker
Canadian Pharmacists Association
Theresa Woolridge
Canadian Centre on Substance Abuse
Margo Warren
Ministry of Health and Long-Term Care (ON)
Matthew Young
Canadian Centre on Substance Abuse
Joan Weir
Canadian Life and Health Insurance Association

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.

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