Question Period Note: INTERSECTION OF COVID-19 AND SUBTANCES USE

• What is the Government of Canada doing to respond to the ongoing overdose crisis which has worsened during the COVID-19 pandemic?

• Tragically, over the past few months, the COVID-19 pandemic has exacerbated long-standing challenges regarding substance use and the opioid overdose crisis, with devastating impacts across the country. Many jurisdictions are reporting increases in overdose deaths and harms, including record breaking levels in several provinces.
• Throughout the COVID-19 pandemic, the Government has taken action to enable the health system to better meet the needs of people struggling with problematic substance use and avert the harms associated with the increasingly toxic supply of street drugs and challenges associated with accessing treatment and harm reduction services
• To date, we have made it easier for people with substance use disorder to access the medications they need and have also made it easier for overdose prevention sites to be established rapidly in temporary community shelters and other locations.
• To build on significant funding provided in Budget 2018 and Budget 2019, the government will provide an additional $66 million over two years, starting in 2020-21, to support community-based organizations responding to substance use issues, including to help them provide frontline services in a COVID-19 context.
• By providing for these new measures, vulnerable people will be better able to get the supports they need, while respecting public health directives for physical distancing and self-isolation. We remain committed to working closely with our provincial, territorial, and municipal partners, along with other key stakeholders, to advance innovative solutions to address this devastating dual crisis.

In September 2020, jointly with the provinces and territories, the Government of Canada released updated data indicating that at least 16,364 Canadians lost their lives between January 2016 and March 2020 to apparent opioid-related overdoses. This most recent national data indicated that, from January to March 2020, 77% of accidental apparent opioid-related deaths involved fentanyl or fentanyl analogues, compared to 54% in 2016. The presence of fentanyl and its analogues in the illegal drug supply is therefore the main driver of recent overdose deaths.
In many regions of the country, the COVID-19 pandemic is compounding the ongoing public health crisis related to high rates of overdoses and deaths as well as acute substance use harms. In British Columbia in September 2020, there were 127 suspected illicit drug toxicity deaths. This is more than double the number of deaths seen in September 2019 (60). The June 2020 total represented the highest number of illicit drug toxicity deaths ever recorded in a month in B.C (183). Postmortem toxicology results suggest that there has been a greater number of cases with extreme fentanyl concentrations in April-September 2020, compared with previous months. During that time period, approximately 15% of cases had extreme fentanyl concentrations as compared to 8% from Jan 2019 to March 2020. Ontario, Alberta, Saskatchewan, Manitoba, Quebec, Prince Edward Island, Yukon, and Northwest Territories are also reporting increases in toxicity of the illicit drug supply, overdose deaths and/or emergency medical service (EMS) calls.

These crises are exacerbated in communities where there is chronic overcrowding, including a shortage of housing or other shelters. At the intersection of these public health crises, people who use drugs (PWUD) are experiencing a number of increased risks:

• Mortality due to COVID-19 given higher prevalence of underlying health conditions (respiratory illnesses, immune comprised, etc.)
• Spread of COVID-19 due to multiple close contacts, including in the community to support drug-seeking behaviours and/or within primary care system for harm reduction/treatment
• Other severe health risks such as drug withdrawal for those who must self-isolate or quarantine
• Overdose and other harms related to an increasingly toxic illicit supply

Substance use, mental health, and pain are inter-connected and it is often challenging to manage one without attending to the others. Many people who live with pain are coping with underlying health conditions or receiving pain treatments (ongoing use of opioids and other medications, steroid injections used in pain interventions), which are immune suppressing, placing people living with pain at higher risk of contracting and experiencing severe illness due to COVID-19. Public health measures required to respond to the pandemic have also increased the risk of social isolation, mental illness, and suicidality, which are already prevalent among people with chronic pain. Health and social services that help maintain function and keep disability at bay, such as psychological supports, physical therapies, and self-management options are more difficult to access. Canadians living with pain are therefore reporting decreased functional capacity and quality of life, fear and anxiety, cancellations of needed in-person care, surgeries and diagnostics, and drug shortages of certain pain medications (i.e., opioids).

On May 13, 2020, the Ministers of Health, Public Safety and Emergency Preparedness, and Justice, received an open letter from Richard Elliott, Executive Director of the Canadian HIV/AIDS Legal Network, on behalf of more than 50 civil society organizations from across Canada. The letter highlights a series of factors that increase people’s vulnerabilities during the pandemic and calls on the Government to decriminalize personal use drug possession as a public health measure to mitigate harms from the parallel public health emergencies caused by COVID-19 and the ongoing crisis of overdoses and deaths.

On July 9, 2020, the Canadian Association of Chiefs of Police (CACP) released their Findings and Recommendation Report entitled “Decriminalization for Simple Possession of Illicit Drugs: Exploring Impacts on Public Safety and Policing.” The report positions problematic substance use as a public health issue, and examines and endorses current best practices in harm reduction, including supervised consumption sites and safer supply projects. In the report, the CACP endorses alternatives to criminal sanctions for simple possession of illegal drugs, and recommends a national task force to recommend alternatives to criminal sanctions for the simple possession of controlled substances.

Federal actions to date on this issues have been:

Increasing the reach of health system, including enabling Opioid Agonist Treatment (OAT)
Issued on March 19, 2020 exemptions that, if permitted within the applicable provincial/territorial scopes of practice, permit pharmacists to extend and/or transfer prescriptions; permit prescribers to issue verbal orders to extend or refill a prescription; and permit pharmacy employees to deliver prescriptions of controlled substances to patient’s location. These measures facilitate self-isolation or quarantine to prevent the spread of COVID-19.
• Fully implemented in BC, AB, SK, ON, QC, NB, NS; partially implemented (no verbal prescriptions) in PEI, NL; being considered in MB, YU, NU; No information NWT

Flexible access to harm reduction services
Issued on April 6, 2020 class exemptions for all provinces and territories, for a duration of 6 months, allowing them to modify the operations of existing supervised consumption sites and establish new temporary spaces for the safe consumption of drugs, without having to apply to Health Canada. This saves valuable time for local officials who want to establish temporary overdose prevention services within shelters or other temporary sites to house homeless or housing unstable people.
• Health Canada has received formal notice from British Columbia and Quebec that they have adopted the class exemption and Saskatchewan has indicated its intention to do so. No other formal notices of implementation by provinces or territories have been received to date. Health Canada has requested to be informed if there is a decision to implement.

Disseminating information and guidance
Developed and disseminated new “tool kit”, on May 5, 2020, to support service providers and PWUD to socially distance and self-isolate, and the web link was made available as of June 11, 2020:
• Providing an easy-to-understand summary of the various exemptions now in place for health care practitioners (HCP) and allied HCP, which facilitate flexible models of care during the pandemic;
• Consolidating prescribing and practice guidelines for HCP to foster an increase in prescribing of medications to address symptoms of withdrawal experienced by PWUD, including Suboxone, methadone and medications considered “safer supply” (hydromorphone, prescription grade heroin); and
• Assisting PWUD, harm reduction advocacy groups and families who support PWUD to understand how to effectively navigate the changing healthcare environment to secure medications and treatment supports as well as educate on harm reduction measures.

Increasing access to mental health supports, including those for problematic substance use, and provide advice for overall well-being during the pandemic to reduce the risk of overdose death and prevent the spread of COVID-19

Leveraging the existing mental health as well as crisis lines and services, including the Federal COVID-19 – Mental Health and Substance Use Portal, to provide support for substance use and people experiencing chronic pain, including referrals to community services.

Since April, CIHR has launched three funding opportunities under the COVID-19 and Mental Health Initiative to support rapid research on mental health and substance use in the COVID-19 context:
• CRISM Operating grant: CIHR is currently providing support to CRISM to undertake urgent activities related to challenges faced by people who use drugs (PWUD), service providers and decision makers in relation to COVID-19. This includes the development of six national guidance documents and a rapid assessment of the issues PWUD are experiencing during the COVID-19 crisis, and the health service interventions to support them. All six CRISM national guidance documents are now available (telemedicine for addiction services; supervised consumption and safer supply in emergency shelters; acute care services for PWUD; harm-reduction worker safety; supporting recovery services; supporting patients to self-isolate).
• Knowledge synthesis grants: CIHR is supporting 45 research projects to support rapid knowledge synthesis and mobilization of current evidence on mental health and substance use services, delivery, and related guidelines, in the COVID-19 context. These include projects with a focus on priority populations, including people who use drugs. Preliminary results from the knowledge syntheses are now available online.
• Operating grants: On June 4, 2020, CIHR launched a new funding opportunity to support implementation science and population-level intervention research to address the impacts of the COVID-19 pandemic and its containment measures on mental health and substance use. Four provincial health research funding agencies are partnering with CIHR on this funding opportunity: the Michael Smith Foundation for Health Research (BC), the New Brunswick Health Research Foundation, the Ontario Ministry of Health and Long Term Care, and the Saskatchewan Health Research Foundation.

Isotonitazene
Isotonitazene is classified as a novel opioid but is dissimilar from fentanyl and U-series analogues. It is currently a controlled substance under Canada’s Controlled Drugs and Substances Act (CDSA). This substance has been reported to cause psychoactive effects similar to heroin, fentanyl, and other opioids. Novel opioids have also caused adverse events, including deaths, as described in the literature.

Although the toxicity of isotonitazene has not been extensively studied, this substance has been associated with a number of overdose deaths. The Center for Forensic Science Research & Education (CFSRE) recently released a report on isotonitazene outlining a recent increase in case reports of overdose attributed to this substance. As well, isotonitazene has been linked to 18 deaths in the United States between August 2019 and January 2020, and was first encountered by Health Canada’s Drug Analysis Service in November of 2019. Moreover, the Office of the Chief Medical Examiner of Alberta has identified isotonitazene (designer drugs) in three separate deaths.

Given the potential for harm posed by this substance, Health Canada will continue to work with stakeholders to monitor the presence of isotonitazene within Canada. Data sources that will be able to provide information on Canadian cases include poisoning data from the Canadian Surveillance System for Poison Information (CSSPI), law enforcement seizure data, DAS laboratory results, as well as web monitoring. In addition, more sources of data that aim to provide more timely evidence about the illicit market are in development, including data from web scraping and surveys targeted at people who use new psychoactive substances.

SYNOPSIS
• Tragically, the COVID-19 pandemic is exacerbating long-standing challenges regarding substance use and the overdose crisis, with many communities now reporting increases in overdose deaths and harms, to record breaking levels in some cases. In addition to the dangers of COVID-19, people who use drugs are also facing additional barriers and risks related to the toxicity of the illegal drug supply and reduced access to health and social services, including life-saving harm reduction and treatment.
IF PRESSED ON FURTHER ACTIONS
• Building on these early efforts, the Government is also supporting community-based projects funded under the Substance Use and Addictions Program that address the dual crises of COVID-19 and substance use, including those that provide safer, pharmaceutical grade alternatives to the toxic illegal drug supply.
• The Government announced new funding in the Fall Economic Statement released on November 30, 2020 in response to the worsening of the opioid crisis and a surge in opioid deaths. This includes an additional $66 million over two years, starting in 2020-21, to support community-based organizations responding to substance use issues, including to help them provide frontline services in a COVID-19 context.
• Given the deeply worrying data about the surge in overdose deaths and growing concerns about the impact of the pandemic, the Government is identifying additional areas where federal actions, including exemptions, guidelines or funding, could help mitigate and reverse the current trend, including ways to address urgent needs and strengthen the continuum of care.
IF PRESSED ON IMPACT OF COVID-19 ON OVERDOSE DEATHS
• The Government of Canada remains deeply concerned about the devastating impact that the opioid overdose crisis continues to have on people, families and communities across the country. There is further concern that the response to the COVID-19 pandemic may have unintended negative consequences, including as it relates to opioid-related overdose deaths and problematic substance use in Canada more broadly.

• The British Columbia Coroners Service has reported alarming data showing record numbers of illicit drug toxicity deaths in the province. There were over 170 illicit drug toxicity deaths per month from May to July, with a record of 183 in June. Deaths have remained high into the fall, with 162 deaths recorded in October 2020, compared to 75 deaths in October 2019. In total, from March to October 2020, there were 1,232 suspected illicit drug toxicity deaths in B.C. To put this in perspective, this is approximately four times the total number of persons who have tragically died in B.C. from COVID-19. B.C. paramedics responded to almost 1,600 overdose events in September alone. Tragically, overdose deaths among First Nations people in B.C. have also surged, almost doubling between January and May 2020 compared to 2019.

• Other jurisdictions across the country are reporting similar trends. For example, Alberta reported a record high 301 opioid poisoning deaths from April-June 2020, more than double the number that occurred from January-March. Saskatchewan is reporting 296 suspected/confirmed drug toxicity deaths so far in 2020, breaking the record total in 2018, and, in Quebec, July saw the highest number of overdoses in Montreal in over five years. Recently released data from Ontario suggests that there was a 38.2% increase in opioid-related deaths in the first 15 weeks of the COVID-19 pandemic.

• The Government of Canada remains committed to addressing the crisis of opioid-related overdoses and continues to work to identify ways to maintain lifesaving supports, including treatment and harm reduction services for people who use drugs.
IF PRESSED ON RESEARCH FUNDING
• On April 23, our Government announced new funding for COVID-19 research, including $10 million for the COVID-19 and Mental Health Initiative, led by the CIHR. Under this research initiative, CIHR is supporting rapid research on mental health and substance use to ensure that COVID-19 responses are based on the latest evidence. Last May, CIHR granted funding to 45 research teams across the country to conduct rapid knowledge synthesis of current evidence on mental health and substance use, with a focus on priority and vulnerable populations. Preliminary results from this research are now available and provide timely, high quality, and relevant evidence to decision makers at municipal, provincial, territorial, and federal levels.

• Under the COVID-19 and Mental Health Initiative, CIHR also launched – in partnership with four provincial research agencies – a funding opportunity to better understand mental health and/or substance use needs of individuals and communities due to the pandemic, and support the development of innovative adaptations of mental health and substance use services.

• Through the Canadian Institutes of Health Research (CIHR) and the Canadian Research Initiative in Substance Misuse (CRISM), national guidance documents have been produced and disseminated that address the needs of people who use drugs, services providers, and decision makers in relation to COVID-19.
IF PRESSED ON HEALTH CANADA’S ACTIONS TO ADDRESS COVID-19 IN COMMUNITIES WHERE THERE IS CHRONIC OVERCROWDING, INCLUDING A SHORTAGE OF HOUSING
• We understand the unique challenges associated with containing the spread and protecting homeless Canadians from COVID-19.
• On September 2, 2020, we proactively took steps and extended Provincial and Territorial exemptions to make it easier for overdose prevention sites to be rapidly established in temporary community shelters for vulnerable individuals (e.g., homeless/housing unstable) exposed to COVID-19, and to allow existing supervised consumption site operators to adjust their services to support physical distancing and respect public health directives. These exemptions have been extended to September 2021.
• We have also developed a set of resources to help frontline service providers understand and comply with existing regulations associated with medications for substance use disorder or as a safer, pharmaceutical grade alternative to the
• street supply.
• These measures will not only make it easier for people who are staying at shelters to respect public health directives to distance and isolate, they will also protect them from the risks and harms of overdose.
• These efforts will help ensure vulnerable Canadians have access to the health services they need during the serious health threat posed by COVID-19.
IF PRESSED ON FEDERAL INVESTMENT TO ADDRESS ISSUES AT THE INTERSECTION OF SUBSTANCE USE AND COVID-19
• On July 16, 2020, the Government of Canada committed to providing $500 million to address immediate needs and gaps in the support and protection of people experiencing challenges related to mental health, substance use, or homelessness. This investment is part of the more than $19 billion invested through the Safe Restart Agreement to help provinces and territories safely restart their economies and ensure Canadians have the support they need in these challenging times.

• Budget 2019 committed $30.5 million over 5 years, starting in 2019–20, with $1 million in ongoing funding, to address persistent gaps in harm reduction and treatment in their response to problematic substance use. In July 2019, we announced an additional investment of $76.2 million to scale up key life-saving measures, help circumvent the toxic illegal drug supply, and identify and address
• emerging drug threats.

• Recent investments made through Health Canada’s Substance Use and Addictions Program (SUAP) are helping to relieve some of the extraordinary stresses placed on people, communities and health organizations struggling to deal with the dual demands of overdose crisis harm reduction and pandemic response.

• For example, in February of this year, our Government announced funding of over $32 million over five years to support 26 projects across the country that will address a range of harm reduction and treatment needs, including:

o $10 million to support 13 projects relating to Harm Reduction, Community-led and Front Line Initiatives;
o $16 million in support of 5 projects aimed at Increasing Access to Pharmaceutical-Grade Medications (also referred to as “safe supply”); and,
o $6 million to support 8 projects aimed at finding Approaches to Problematic Methamphetamine Use.
IF PRESSED ON SAFER SUPPLY
• We know that the pandemic has led to a more uncertain and dangerous illegal drug supply, even while services to people who use drugs are being limited, and we have seen the tragic increases in overdose deaths in British Columbia and elsewhere.
• The Government of Canada has taken actions to reduce barriers to providing people who use drugs with a safer, pharmaceutical-grade alternative to the toxic illegal drug supply.
• For example, we have issued exemptions to pharmacists, and eased restrictions on the transportation of controlled substances, to make it easier for people to access the medications they need during the pandemic while following public health advice, such as physical distancing.
• In addition to the five safer supply pilot projects that we were funding through Health Canada’s Substance Use and Addictions Program, we have now committed to providing short-term funding to an additional six sites to address immediate needs.
• These innovative projects will be independently evaluated and this assessment will contribute to building the evidence base to support the scaling up of effective models.
IF PRESSED ON A POSSIBLE SECTION 56 EXEMPTION REQUEST FROM THE CITY OF VANCOUVER THAT WOULD DECRIMINALIZE THE PERSONAL POSSESSION OF DRUGS OR THE HIV LEGAL NETWORK PRIMER FOR MUNICIPAL AND PROVINCIAL GOVERNMENTS
• The Government of Canada is committed to a comprehensive public health approach to the overdose crisis that is focused on reducing harms, saving lives, and getting people the supports they need.

• As with any requests for an exemption under the Controlled Drugs and Substance Act, Health Canada is committed to carefully and thoroughly reviewing these requests on a case-by-case basis. This includes any request for an exemption that might be received from the city of Vancouver or other jurisdictions. When reviewing exemption requests, Health Canada takes into account all relevant considerations, including evidence of potential benefits and risks or harms to the health and safety of Canadians.

• The Government will continue to work with civil society organizations, first line responders, academics, people with lived and living experience and other key stakeholders to assess options that could better support the needs of people who use drugs, during this difficult time.

• We encourage cross-disciplinary collaboration, including the formation of partnerships between law enforcement and health and social services to help divert people who use drugs away from criminal sanctions and towards health and social services.

• For example, on August 18, 2020, the Public Prosecution Service of Canada released new guidance to prosecutors regarding the prosecution of simple possession offences under the Controlled Drugs and Substances Act. The new guidance aligns with a health-focused approach to substance use by directing prosecutors to consider alternatives to prosecution and pursue diversion from the criminal justice system for simple possession cases.
THE RELEASE OF THE CANADIAN ASSOCIATION OF CHIEFS OF POLICE REPORT ON DECRIMINALIZATION
• As we fight the COVID-19 pandemic, we cannot forget the opioid overdose crisis has exacted a heavy toll on thousands of families in communities throughout the country. This crisis, now intensified by the pandemic, continues to be one of the most serious public health threats in Canada’s recent history, and our Government remains committed to a comprehensive and compassionate approach to address it.

• Problematic substance use is first and foremost a health issue. That is why the actions we have taken have focused on advancing a public health approach to addressing substance use and expanding the accessibility of vital health and social services for people who use drugs.

• These actions include passing the Good Samaritan Drug Overdose Act, funding programs like drug treatment courts for those whose substance use contributes to their offending, supporting enhanced access to harm reduction services such as supervised consumption sites, access to pharmaceutical-grade medications, also known as safer supply, and an expanded range of treatment options.

• In July, the Canadian Association of Chiefs of Police released a report that recognizes substance use as a public health issue and examines a range of
• alternatives to criminal sanctions in response to the offence of simple possession. We welcome their endorsement of a holistic approach including harm reduction and diversion, and thank them for their recommendations.
IF PRESSED ON THE INTRODUCTION OF ISOTONITAZENE IN QUEBEC
• Tragically, the COVID-19 pandemic is exacerbating long-standing challenges regarding substance use and has contributed to the worsening overdose crisis. In addition to the dangers of COVID-19, there is an increasingly toxic illegal drug supply, including drugs like isotonitazene.

o This is why it is important to have access to harm reduction services such as supervised consumption, overdose prevention sites and naloxone.
o There are no legitimate uses of isotonitazene in Canada. Any isotonitazene being sold in Canada has been illegally produced or imported.
o The diversion of controlled substances and precursor chemicals frequently used in the production of illegal drugs is a worldwide problem that requires a global solution.
o The Government of Canada works with a wide range of partners both domestically and internationally to address organized drug crime and drug trafficking, and monitor shifts in the illegal drug market.
o Health Canada works closely with Provinces and Territories, law enforcement and border services to closely monitor changes to the drug
o supply. Health Canada’s Drug Analysis Service analyzes suspected illegal drugs that are seized by Canadian police forces (RCMP, provincial, regional and municipal) and Canada Customs.