Strengthening Canada’s Approach to Substance Use Issues

1. Purpose

There is a growing agreement in Canada that problematic substance use is a health issue that can be prevented, managed, and treated, and that requires a health focussed response. The Government of Canada recognizes that there is an opportunity to do a better job of protecting and supporting Canadians who are affected by substance use.

On December 12, 2016, the Minister of Health announced an updated drug strategy for Canada: the Canadian Drugs and Substances Strategy (CDSS). The CDSS guides the federal government’s response to all substance use issues, including the opioid overdose crisis, and the move towards the legalization and strict regulation of cannabis.

The Government of Canada is launching a public consultation to ask Canadians for new and innovative ideas on how to further strengthen the federal government’s health-focussed approach to substance use issues through the CDSS. This document provides background information, grouped according to the following themes:

• Addressing root causes of problematic substance use
• Better addressing the needs of Canadians living with pain
• Reducing stigma around substance use
• Improving access to comprehensive, evidence-based treatment services
• Exploring innovative approaches to harm reduction
• Applying a health lens to regulation and enforcement activities
• Supporting Indigenous peoples
• Addressing the needs of at-risk populations
• Grounding substance use policy in evidence

This document has been designed to complement an online questionnaire that asks for specific feedback on substance use issues, including:

• What sorts of circumstances do you see within your networks, communities or in society that you think contribute to problematic substance use?
• How can governments best act to reduce stigma across the country?
• What obstacles or barriers do people face when they want to access treatment in Canada?
• How can we better bring public health and law enforcement together to explore ways to reduce the cycle of involvement for people who use substances with the criminal justice system?
• What are effective policies and programs to help improve access to prevention, treatment, and harm reduction services for at-risk populations?

2. Substance use in Canada

Why do people use psychoactive substances?

Psychoactive substances (commonly known as “drugs”) are substances that affect mental processes, including mood, thinking or behaviour.

Most Canadians will use some kind of psychoactive substance in their lifetime. Some of the most common in Canada include alcohol, tobacco, prescription medications (such as opioid painkillers or anti-depressant drugs) and cannabis. A smaller number of Canadians use other drugs such as cocaine, heroin, ecstasy, and methamphetamine.

We know that people use substances for a lot of different reasons, including for personal enjoyment, to relax, socialize, or to cope with pain, stress or other problems. Most will do so without causing harm to their health or well-being.

The term substance(s) will be used through the remainder of this paper to refer to all psychoactive substances.

When does substance use become a problem?

Problems occur when substance use causes harm to an individual, their family and friends, or their communities.

Problematic substance use is an ongoing public health and safety concern in Canada. It is estimated that approximately one in five Canadians aged 15 years and older experiences a substance use disorder^{Footnote *} in their lifetime.^{Footnote 1}

Examples of problematic substance use include:

• Driving while impaired puts people at a higher risk of having an accident and hurting themselves or someone else.
• Drinking to excess (binge drinking) can have short- and long-term negative effects, such as alcohol poisoning, impaired judgement, unintentional injuries, violent behaviour, and can lead to depression, liver damage, and increased risk of heart disease and stroke, among other health problems.
• Sharing supplies when injecting substances can increase the risk of transmission of infectious diseases such as HIV/AIDS and Hepatitis C.

Canadians use many different substances:

• Canadians use alcohol most commonly. In 2015, 3.3 million Canadians consumed enough alcohol to be at risk for immediate injury, while at least 4.3 million consumed enough to be at risk for long-term health effects such as liver damage.^{Footnote 2}
• Almost 4 million Canadians aged 15 years and older reported that they used at least one illegal substance in the past year. Illegal substances included cannabis, cocaine/crack, ecstasy, hallucinogens, heroin or speed/methamphetamines.^{Footnote 3}

  Note:
  On October 17, 2018, the personal possession of small quantities of cannabis (up to 30 grams of dried legal cannabis or equivalent in public) will become legal in Canada. Until then, it remains illegal to buy, possess or use cannabis for anything other than authorized medical or research purposes.

• Of these substances, Canadians use cannabis the most. A higher proportion of youth aged 15-19 (21%) and young adults aged 20-24 (30%) use cannabis, compared to adults aged 25 or older (10%).^{Footnote 4}
• The estimated total cost to society of alcohol and illegal drug use in 2014 was $38.4 billion, with tobacco and alcohol accounting for almost 70% of the total.^{Footnote 5}

In recent years, the potential harms from illegal drug use have been made worse by a supply that is often contaminated with synthetic opioids like fentanyl.

3. The Canadian Drugs and Substances Strategy

Addressing substance use issues in Canada is a shared responsibility between all levels of government, in collaboration with a wide range of civil society partners and stakeholders.

Everyone has their role. For its part, the federal government provides leadership, funding and supports collaboration. It is responsible for laws and regulations controlling substances in Canada. It conducts research, increases public awareness around substance use issues, and directly funds or provides prevention, treatment and harm reduction services to specific populations such as First Nations and Inuit, veterans, members of the military, and people in federal prisons. Provincial and territorial governments (including municipal governments) are primarily responsible for the delivery of prevention, treatment and harm reduction programs and health and social services to Canadians, and also are involved in local law enforcement and community safety efforts.

A wide range of civil society groups also play a role, including professional medical associations, universities and research-based organizations, local public health units, harm reduction organizations, and stakeholder groups. These organizations have many roles, which can include developing regulations and standards, conducting research, providing harm reduction and prevention services, and providing educational programming and outreach.

In December 2016, the Government of Canada announced that it was replacing the former National Anti-Drug Strategy with the CDSS. The strategy, now led by the Minister of Health, is delivered in collaboration with fourteen other federal departments and agencies, and includes four pillars - prevention, treatment, harm reduction and enforcement - which are supported by a strong evidence base.

Goal and objectives of the CDSS

The goal of the CDSS is to protect the health and safety of all Canadians by minimizing harms from substance use for individuals, families and communities. To achieve this goal, the Government of Canada is proposing the following objectives:

• Encouraging governments, civil society, and the Canadian justice, health care and other social systems to address problematic substance use as a health and social issue;
• Supporting the use of modern, effective and compassionate approaches to prevention, treatment, harm reduction, and enforcement, including addressing the root causes of problematic substance use;
• Reducing stigma associated with substance use, and encouraging the development of policies and programs designed to defend and promote the health, dignity and human rights of people who use drugs;
• Collecting data and coordinating national efforts on surveillance and research to provide the best possible evidence to program and policy makers across the country; and,
• Designing and supporting the development of evidence-based policies and programs in collaboration with provinces and territories, Indigenous communities and leadership, and civil society, including people with lived and living experience with substance use.

Guiding principles of the CDSS:

• Comprehensive
  Integrates prevention, treatment, harm reduction and enforcement approaches, while also including cross-cutting considerations such as stigma and at risk populations.
• Collaborative
  Recognizes that addressing substance use issues requires working together and that all levels of government and all stakeholders, including people with lived and living experience with substance use, have an important role to play.
• Compassionate
  Treats problematic substance use as a health issue and not a moral one, and recognizes that stigma associated with substance use can be harmful to people who use drugs and lead to violations of their dignity and human rights.
• Evidence-based
  Seeks out the best available data, surveillance and research to support substance use policy and program design, and supports continuous improvements in these areas.

Did you know?

• The Substance Use and Addictions Program (SUAP) is a federal program under the CDSS that is delivered by Health Canada and provides $28.3M annually to provinces, territories, non-governmental organizations and key stakeholders to strengthen responses to drug and substance use issues in Canada.
• The CDSS encompasses all substances. Given the long-standing public health response to tobacco, Canada's approach to tobacco is addressed through Canada's Tobacco Strategy. The CDSS and Canada's Tobacco Strategy will continue to work together to ensure a common approach, recognizing that people often use multiple substances.

4. How to get there - Issues for discussion

4a. Addressing root causes of problematic substance use

Traditional approaches to substance use prevention seek to reduce health and social harms related to substance use. The focus is largely on encouraging individuals to avoid, delay, or reduce substance use.

While broad-based awareness campaigns have shown limited effectiveness, targeted communication of accurate and trusted information on the impacts of problematic substance use can reduce its associated harms. To date, educating Canadians about the potential risks of substance use through information and awareness campaigns such as those targeting opioids, cannabis use, and impaired driving has been the focus of many prevention initiatives, for example the Don't Drive High campaign. Going further, a comprehensive public health approach to substance use will also look to address the root causes of problematic substance use.

It is widely recognized that determinants of health are often at the root of problematic substance use. Determinants of health are the broad range of personal, social, economic and environmental factors that influence individual and population health, and that can affect all Canadians.

Some of the main determinants of health include:

• Income and social status
• Employment and working conditions
• Housing stability
• Education and literacy
• Childhood experiences
• Physical environments
• Social supports and coping skills
• Lifestyle behaviours
• Access to health services
• Biology and genetics
• Gender
• Culture

Included in the determinants of health are a specific group of social and economic factors, often referred to as social determinants of health. These relate to an individual's place in society, such as income, education or employment. Experiences of racism, discrimination or historical trauma can also be important social determinants of health for certain groups, including Indigenous peoples and racialized communities in Canada.

Addressing social determinants of health means sparking changes in systems which in turn, can support healthy behaviours and help to reduce the likelihood of problematic substance use among Canadians.

Strengthening protective factors using culture

The Government of Canada has committed to implementing the Truth and Reconciliation Commission's 94 Calls to Action. Support for land-based programs is an example that aligns with the call to recognize the value of Aboriginal healing practices and using them in treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients (Call to Action #22).

Land-based programs common to Indigenous peoples can include a wide variety of formally organized activities that take place on the land. They help to revitalize Indigenous cultures, languages, and traditions, and can also support healing, promote wellness, and help address the root causes of problematic substance use and other social issues. They may be taught and practiced within the context of trapping, fishing, and hunting, or they can be selectively organized such as a medicine walks or crafts workshops. They may include ceremonial activities or use of cultural medicines.

We know that there are multiple personal and environmental risk factors^{Footnote 6Footnote 7} in life that may lead someone to engage in problematic substance use. Some examples include:

• exposure to problematic substance use in the home or in peer networks
• exposure to abuse or trauma
• adverse childhood experiences
• a lack of parental support or supervision
• poor academic performance
• uncertain employment or loss of employment
• certain behavioural traits, such as ability to manage stress, or risk taking
• early initiation of substance use
• ready availability of substances

Did you know?

The Government of Canada is investing in key areas that will have positive impacts on social determinants of health, including:

• The announcement of Opportunity for All - Canada's First Poverty Reduction Strategy with new investments of $22 billion that the Government has made since 2015 to reduce poverty and improve the economic well-being of all Canadian families, so that they can have a real and fair chance to succeed.
• $7 billion over ten years, starting in 2018, to support all Canadian families and help Canadian children get the best start in life, by creating more high-quality, affordable child care spaces across the country.
• $11 billion over ten years, announced in Budget 2017, to provinces and territories, specifically targeted to improve home and community care, as well as mental health and addiction services.

One approach to substance use prevention is to strengthen protective factors,^{Footnote 8Footnote 9} which help to reduce the risk of problematic substance use. Some examples include:

• building healthy family and peer relationships
• providing supportive school and work environments
• improving community connectedness and cultural supports
• improving individual coping skills (to address stress, emotional trauma, etc.)

Addressing risk and protective factors for problematic substance use requires that all sectors of society work together. Successful efforts to address these root causes of problematic substance use have been shown to be effective in reducing future health-care and crime-related costs.^{Footnote 10Footnote 11}

Examples of addressing root causes

Strengthening Families

The Strengthening Families for Parents and Youth program is an internationally recognized, evidence based skill-building program for families with teens 12 to 16 years old. The program helps parents and teens to develop protective factors such as trust, mutual respect, communication and resiliency.

Housing First Approach

The Housing First Approach involves quickly moving people experiencing homelessness into independent and permanent housing, without first requiring them to stop using substances. Once housed, people are linked to the services they need to keep their housing and reintegrate into the community.

4b. Better addressing the needs of Canadians living with pain

Pain affects many Canadians

Chronic pain is widely recognized as a serious health problem that affects approximately 1 in 5 Canadians.^{Footnote 12} Pain can have profound negative effects on an individual's quality of life, and may also have broader societal and economic impacts - such as loss of productivity and increased use of health services.

Health care professionals can look to a variety of interventions to treat pain, including opioid medications. Opioids can be effective in managing pain for some Canadians, allowing them to lead full and productive lives; however, as with all medications, opioids have risks and potentially dangerous side effects. For example, opioids can produce euphoria (feeling "high"), which puts some individuals at risk of using more opioids than prescribed. Opioids can also suppress breathing, leading to overdose and death, especially when taken at high doses or when combined with other substances, such as alcohol or anti-anxiety medication (benzodiazepines). Other treatments may also help individuals manage their pain, such as physical therapy, cognitive-behavioural therapy, meditation, and relaxation techniques; however, these therapies may not be offered everywhere, or they may be cost-prohibitive for some patients.

Prescription opioids and Canada's opioid crisis

Canada is the second highest per capita consumer of prescription opioids in the world,^{Footnote 13} and there has been a lot of public and media attention around the role of prescription opioids in Canada's opioid crisis. At the same time, many chronic pain patients have described facing stigma from the medical community, and some patients have indicated that they are now having difficulty obtaining the medication that they need to manage their pain.

Maintaining a balanced approach

Ultimately, treatment decisions should be made between a health care practitioner and their patient. The Government of Canada will continue to work with both prescribers and the chronic pain community to find a balanced approach that promotes appropriate opioid prescribing practices, informs Canadians about the benefits and risks associated with opioid use, and ensures that those who need opioid medications to manage their pain continue to have access to them.

4c. Reducing stigma around substance use

Stigma can be defined as the negative attitudes and actions directed toward a group of people due to their circumstances in life, including judging, labeling, stereotyping and exclusion.

We know that problematic substance use is a challenging, but treatable health condition. However, for people who use substances, stigma can add a barrier to accessing health care, or other social services.

For example, stigma in the health care system may lead to the denial of health services, if a health care provider does not offer treatment options based on an assumption that the patient is "drug seeking" or is assumed to be under the influence of alcohol.^{Footnote 14} This can cause people who use substances to be reluctant to use the health care system. Stigma can also lead women who have children or who are pregnant to avoid interacting with health care or social programs, out of fear of losing custody.^{Footnote 15}

From an employment perspective, stigma may prevent someone from telling their employer about past or current substance use, for fear of career repercussions. This could negatively impact someone's ability to seek treatment if they are uncomfortable asking for time off.

People who use substances can also internalize stigma from society, leading to isolation, a decreased sense of self-worth, and potentially risky substance use patterns, such as hiding one's use from family and friends, or using alone. Further, some people may face stigma for multiple reasons (e.g., substance use, poverty, gender, racism, etc.), which can compound the impact on their lives.

Reducing stigma is key to effectively addressing problematic substance use, and is a critical step in recognizing the fundamental rights and dignity of all Canadians, including those who use substances. People who use substances, the families of people struggling with substance use, and people in recovery provide a unique and valuable perspective that can help ensure a more compassionate and effective approach to substance use issues.

Changing how we talk about substance use

The language we use to talk about substance use has a direct and profound impact on people who use substances, the way others treat people who use substances, and the policy and program approaches taken to address problematic substance use. The negative impacts of stigma can be reduced by changing the language we use when talking about substance use.

The Government of Canada has published information on stigma, and using non-stigmatizing language, including how to use "people first" terminology.

Toward the Heart, a project of the BC Centre for Disease Control, has published resources to help change the conversation on drug use and encourage the use of respectful, non-stigmatizing language when describing substance use disorders and people who use drugs.

4d. Improving access to comprehensive, evidence-based treatment services

The evidence is clear that problematic substance use is a health condition that can be managed and treated.^{Footnote 17} Treatment ranges from services that address immediate distress to services that provide ongoing care for long-term conditions.

The goal of treatment is different for everyone. It is important to recognize that there are many treatment paths, and recovery does not always mean abstinence. Sometimes, it may mean replacing toxic street drugs with medications prescribed by a health care practitioner. Recovery can also include improvements to other areas of life, such as stable housing, employment, mental health supports or improved relationships.

The health system needs to offer many treatment options to address the individual needs of people who use substances. This continuum includes: early identification of patient needs (e.g., screening and early intervention); management of withdrawal symptoms (i.e., "detoxification"); inpatient and outpatient services; and, long-term care and follow up (e.g., cognitive-behavioural therapy). Evidence shows that the chances for successful recovery are enhanced when treatment is tailored to an individual's unique circumstance (including medical, social, cultural, and experience with trauma).^{Footnote 18}

As part of a range of treatment services, medication (such as methadone, buprenorphine-naloxone, or naltrexone) can help stabilize and improve health, including helping to manage symptoms, reduce cravings, and prevent overdoses. There are a number of medications available to treat opioid and alcohol use disorders;^{Footnote 19} however, effective medications are not available for all kinds of problematic substance use. Non-medical supports are also critical and are recommended by best practice in conjunction with other treatments - these can be known as "wraparound" services (e.g., stable housing, education, training, employment, and child care). Where appropriate, family members and caregivers may be well placed to contribute to more positive outcomes.

Examples of best practices in treatment

ARCH - Edmonton, AB

The Addiction Recovery and Community Health Clinic (ARCH) at Edmonton's Royal Alexandra Hospital works with a patient's care team in the emergency department or inpatient setting to provide comprehensive, wraparound care to support treatment, including income supports, housing, and linkages to other health care services.

Portage - Montreal, QC

Portage provides specialized drug rehabilitation through its Mother and Child Program, offered in its Montreal centre, which enables women to be with their children while pursuing treatment, and helps build and strengthen parenting skills.

Managed Alcohol Program - Thunder Bay, ON

The Canadian Institute for Substance Use Research is studying 13 managed alcohol programs across Canada, including the Kwae Kii Win Centre in Thunder Bay. These programs work to stabilize patients and prevent binge drinking, provide ongoing health assessments, shelter, counselling, and other supports. Results from a pilot study of Kwae Kii Win include a decrease in: consumption of non-beverage alcohol, detoxification episodes, hospital admissions and police contacts leading to custody.

When someone is ready, treatment needs to be available quickly. Unfortunately, only a small fraction of people in Canada who seek treatment for problematic substance use are able to access it when they need it. For example, population survey data indicate that only 15% of Canadian respondents, aged 15 years or older, with a substance use disorder (but without a concurrent mood/anxiety disorder) reported that all of their perceived health care needs were met.^{Footnote 20} Part of the challenge is that treatment options are not always available when and where Canadians need them, partly driven by insufficient numbers of health professionals with the appropriate training in substance use issues. Another factor is a deficit of coordination between health, social, and law enforcement services. These intersecting social systems can be difficult to navigate.

There are a number of private treatment providers in Canada; however, they are not regulated and the quality of services that they provide often varies - putting people seeking care for problematic substance use at risk of poor outcomes due to the lack of minimum standards and consumer protections. Cost considerations often also mean that private services are out of reach for many Canadians, particularly those most marginalized and at risk.

Provincial and territorial governments maintain primary responsibility for providing treatment services to their residents, while the federal government primarily provides leadership, funding, and information to improve the health and safety of Canadians, as well as providing or funding direct health care services to specific populations. For example, the federal government works with First Nations and Inuit peoples to support access to culturally-appropriate mental wellness and substance use treatment services. In Canada, all levels of government play a role in substance use treatment, and must coordinate and collaborate if care in Canada is going to improve.

New approaches are required to improve access to evidence-based treatment services and to enhance health care providers' understanding of problematic substance use, through better tools to support training and education.

Did you know?

The Government of Canada's Drug Treatment Court Funding Program funds drug treatment courts (DTCs) in order to reduce recidivism and offer non-violent offenders the opportunity to complete a court monitored drug treatment program as an alternative to incarceration. DTCs provide integration of enforcement and treatment services to better meet the needs of clients.

4e. Exploring innovative approaches to harm reduction

Harm reduction aims to reduce the negative health, social and economic impacts of substance use on individuals, their families and communities, without requiring abstinence. It acknowledges the central role of people who use drugs in program development and aims to improve people's health and help them to make connections with important health and social services, including treatment for those who are ready for it. Harm reduction programs in Canada are largely delivered by provinces, territories, municipalities, First Nations governments, and non-governmental harm reduction organizations.

Evidence shows that harm reduction is a critical part of a comprehensive public health approach to substance use. Some examples of harm reduction services include the following:

• Needle exchange programs help reduce the transmission of blood-borne diseases such as HIV and Hepatitis C.^{Footnote 21Footnote 22}
• Improving the availability of naloxone, a drug that may temporarily reverse the effects of an opioid overdose, helping to reduce overdose fatalities.^{Footnote 23} This includes making naloxone available without a prescription and also providing naloxone in all First Nations primary health care centres.
• Supervised consumption sites, where people who use drugs can receive medical support in the case of an overdose, and be connected with other important health and social services, to improve health outcomes.^{Footnote 24}
• Managed alcohol programs, where participants are provided with monitored and controlled doses of alcohol to reduce withdrawal symptoms and harmful alcohol-seeking behaviour.

Examples of harm reduction

Insite - Supervised Consumption Site, Vancouver, BC

Insite was first opened in Vancouver's Downtown Eastside in 2003. Insite's work has been shown to have reduced HIV transmission, prevented overdose death, improved public safety, and increased referrals to treatment and other health and social services. As of August 2018, Canada has approved 26 supervised consumption sites across the country that are currently operating and providing services. To date there have been no overdose deaths that have occurred within an SCS in Canada.

AIDS Outreach Community Harm Reduction Education and Support Society (ARCHES) - Lethbridge, AB

In February 2018, ARCHES, an outreach and support facility, opened the first supervised inhalation site in North America that allows people to smoke drugs, such as methamphetamine, in specially ventilated rooms that are supervised by trained medical staff. This approach recognizes that people are dying from all modes of substance use.

Take-home naloxone

Inmates may be at particular risk of an overdose if their tolerance to opioids has diminished while incarcerated.^{Footnote 25Footnote 26} The Correctional Service of Canada (CSC) developed educational materials for offenders and now provides take-home naloxone kits to inmates upon release across the country. CSC has also implemented a prison needle-exchange program.

While many Canadian harm reduction initiatives have been designed to reduce the harms of opioid use, evidence-based harm reduction approaches are also important for other substances. Guidance documents such as Canada's Low-Risk Alcohol Drinking Guidelines and the Lower-Risk Cannabis Use Guidelines identify harm reduction measures to help people reduce health risks when using these substances.

Moving forward, the Government of Canada is committed to supporting innovative measures to address harms from substance use, including other classes of drugs such as stimulants (e.g., amphetamines).

4f. Applying a health lens to regulation and enforcement activities

Drug regulation and enforcement in Canada encompasses a wide range of activities, including enforcement, regulation of activities with controlled substances, border control, and financial surveillance and tax audit measures to reduce the profitability of drug trafficking. A number of these activities touch directly upon the health of individuals and communities.

A comprehensive approach to substance use includes regulation and enforcement, and considers the safety needs of the whole community, while acknowledging that the use and sale of drugs may sometimes be associated with crime and violence.^{Note de bas de page 27Note de bas de page 28} The federal government's regulatory and enforcement activities aim to take a balanced approach, working to reduce the supply of illegal drugs by working to prevent illegal manufacturing, trafficking, and the diversion of substances from medical use and scientific research into the illegal market. Through the CDSS, the Controlled Drugs and Substances Act (CDSA) and its regulations, the Government of Canada works to:

• regulate how controlled substances are used in Canada (e.g., to ensure they are used for authorized medical, industrial and research purposes);
• prevent controlled substances from being illegally smuggled into Canada through border control and surveillance activities; and,
• pursue drug law enforcement activities to counter drug trafficking in a manner that balances public health and safety concerns, and that focuses on organized crime (including seizing assets resulting from the illegal drug trade).

Two key priorities for the Government of Canada are addressing organized drug crime, and working to reduce the flow of illegal drugs across our borders, in partnership with provinces, territories, and municipalities, as well as the United States.

Did you know?

The Government of Canada is undertaking a wide range of activities to address drug regulation and enforcement in Canada. Through Budget 2018, the Government of Canada has provided funding to:

• support training of police officers with respect to harm reduction and the de-stigmatization of people who use substances
• enhance international cooperation, particularly with the United States and Mexico, to increase knowledge of issues, gaps, and best practices related to illegal opioids
• explore other potential domestic supply reduction actions, including addressing imported pill presses and encapsulators used to manufacture drugs, and the trafficking of fentanyl and other dangerous substances through the domestic postal system

The Government of Canada continues working with China and other countries to stop the flow of highly toxic substances like fentanyl into Canada. The federal government is also providing grants and contributions to projects that encourage a more effective youth justice system, respond to emerging youth justice issues and enable greater citizen and community participation in the youth justice system.

While a number of drug regulation and enforcement activities critical to helping to reduce supply often happen "behind the scenes", there are some that can have direct impact on the health of individuals and communities. Evidence shows that approaches to enforcement that do not take into account the health issues related to substance use have not been as effective in reducing use or in protecting public health and safety, and may deter people who use substances from accessing health services.^{Note de bas de page 32Note de bas de page 33}

Examples of health informed enforcement activities

Overdose and Treatment Policies

The Vancouver Police Department (VPD) has developed a specific overdose-response protocol where officers attend an overdose only if required (e.g., in case of death, or a public safety risk), with the goal of encouraging people to call for emergency help. In recognition of the opioid crisis, the VPD has also called for treatment-on-demand to better support the needs of people who use drugs.

Integrated Teams

The Surrey Outreach Team (Surrey, British Columbia) is a three-year pilot project that includes RCMP officers, bylaw officers, and several community providers from the health, housing and social services sectors. Members focus on building relationships with vulnerable groups, including people who use drugs, and directing them to community resources. Similarly, the Law Enforcement Assisted Diversion (LEAD) program in Seattle, Washington, allows law enforcement to redirect low-level offenders engaged in drug related activities or the sex trade to community-based services, instead of jail.

We know that certain historically marginalized groups, including Indigenous peoples, Black Canadians and other racialized communities, those living in poverty, and persons with mental illness, are disproportionately represented in the criminal justice system. For example, despite making up approximately 3% of the overall Canadian population, Indigenous peoples account for a quarter of all admissions to correctional services.^{Note de bas de page 34} In 2014, the Office of the Correctional Investigator reported that 80% of federally-sentenced offenders had problems with substance use, and over half reported that their crime(s) were linked to their substance use.^{Note de bas de page 35} This suggests that there are opportunities to intervene and design specialized services to help steer at-risk individuals away from the criminal justice system.

Canada's law enforcement officers are often the first point of contact for individuals dealing with problematic substance use and underlying issues such as poverty, homelessness and mental health issues. There is growing recognition from law enforcement, other first responders, and those working with at-risk populations that problematic substance use needs to be treated as a health issue first and foremost.

As such, officials have begun to pilot and implement more collaborative approaches, where law enforcement, health officials, community members and leadership come together to provide interventions, programs and strategies that aim to steer at-risk individuals away from the criminal justice system and towards health and social supports. Through the CDSS consultation, the Government of Canada wants to hear Canadians' innovative ideas to help ensure drug regulation and enforcement measures support both public health and community safety.

Did you know?

• The Good Samaritan Drug Overdose Act became law in Canada in 2017. It provides some legal protection from certain minor drug-related charges and/or conditions for individuals who seek emergency help during an overdose.
• The Government of Canada is transforming Canada's criminal justice system to make it more just, compassionate and fair.
• The Government has committed to creating new and stronger laws to punish more severely those who drive while under the influence of drugs, including cannabis. To support these measures, the Government has committed up to $161 million for training frontline officers in how to recognize the signs and symptoms of drug-impaired driving, building law enforcement capacity across the country, providing access to drug screening devices, developing policy, bolstering research, and raising public awareness about the dangers of drug-impaired driving.

4g. Supporting Indigenous peoples

The Government of Canada is committed to working to advance reconciliation and renew the relationship with Indigenous peoples, based on the recognition of rights, respect, cooperation and partnership. This includes working with Indigenous governments, leadership and communities to support culturally safe prevention, treatment, harm reduction, and enforcement approaches to address substance use issues.

The Government of Canada recognizes that experiences with historical and intergenerational trauma, including the impact of colonization, loss of traditional culture and language, and experiences with Indian Residential Schools, have all contributed significantly to the elevated risk of mental health issues and substance use amongst Indigenous peoples.^{Note de bas de page 36} Indigenous peoples often face major social and economic challenges such as high unemployment, poverty, substandard housing, and inequitable access to education, health and other critical social services compared to non-Indigenous Canadians.

These disparities in social determinants of health between Indigenous peoples and other Canadians contribute to challenges with problematic substance use in some Indigenous communities. For example, in the context of the current opioid crisis, we are seeing overdose death rates for First Nations peoples in Alberta and British Columbia that are three and five times higher than non-First Nations people, respectively.^{Note de bas de page 37Note de bas de page 38} Population survey data show that more Inuit (26%), aged 15 years or older, report heavy drinking compared to the overall Canadian population (18%).^{Note de bas de page 39} Similarly, recent data developed from the Métis Nation of Alberta, showed that Métis Albertans experienced higher rates of opioid prescribing, and hospitalizations or emergency department visits related to opioid use, compared to non-Métis Albertans.^{Note de bas de page 40}

It is critical that we continue to take a distinctions-based, collaborative approach that recognizes the unique needs of First Nations, Inuit, and Métis communities, in terms of effectively responding to substance use issues. It is also important that we examine the unique needs of individuals within these populations. For example, Indigenous peoples living in remote areas with limited road service may not be able to access appropriate treatment services, which can negatively impact their health and wellbeing. In addition, we know that Indigenous women and girls can face challenges in accessing appropriate health and social services that respect and respond to their specific needs. This shows how important it is to tailor responses to people's specific needs and circumstances.

Under the CDSS, the Government of Canada will continue to work with Indigenous governments, leaders and communities to better address substance use and related issues from a culturally competent, holistic, distinctions-based approach, that addresses the social determinants of health and ensures that the unique rights, interests and circumstances of the First Nations, Inuit and Métis peoples are acknowledged, affirmed and implemented in partnership.

Examples of Indigenous-led approaches

The First Nations Mental Wellness Continuum Framework and Honouring our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada, seek to address substance use challenges and are rooted in cultural knowledge and emphasize holistic approaches.

The Thunderbird Partnership Foundation promotes a holistic approach to healing and wellness for First Nations and Inuit that values culture, respect, community and compassion. One example includes the Buffalo Riders Program. It strengthens community capacity to support Indigenous youth with problematic substance use issues, including through culturally specific teachings about youth resiliency, risk and protective factors, and developmental assets/factors critical for successful growth and development.

4h. Addressing the needs of at-risk populations

While we know that most people who use substances will not experience significant harms, a large number of Canadians are at risk, often due to underlying social and economic factors. Developing effective responses to substance use issues requires us to consider a broad range of factors, including the impacts of sex, gender, race, age, and culturally-specific understandings of healing and wellness.

Did you know?

As a matter of good public policy, the Government of Canada conducts Gender-Based Analysis Plus (GBA+) in the development of its policies, programs and legislation. GBA+ goes beyond a sole focus on sex and gender to explore how these factors intersect with other identities such as: sexual orientation, race, ethnicity, religion, age and mental or physical disability. It provides federal officials with the means to continually improve their work and attain better results for Canadians by being more responsive to specific needs and circumstances, including substance use issues.

For example:

• Research suggests that men are more likely to use illegal drugs than women, and are less likely to seek help.^{Note de bas de page 41Note de bas de page 42} While women generally have lower levels of use than men, they are at greater risk of developing related health problems.^{Note de bas de page 43}
• In 2017, the majority of accidental apparent opioid-related deaths occurred among males (78%).^{Note de bas de page 44}
• Youth aged 15 to 24 have the highest rate of problematic substance use nationally and the highest rate of past year use of illegal drugs.^{Note de bas de page 45Note de bas de page 46} They are also more likely to experience harms related to substance use than older adults.^{Note de bas de page 47} Further, the 18-25 year-old age group has the highest rates of binge drinking.^{Note de bas de page 48}
• Youth with a history of child welfare involvement are particularly at risk, as the initial transition out of foster care is associated with increased rates of problematic substance use.^{Note de bas de page 49}
• Older Canadians are vulnerable to problematic substance use due to unique risk factors such as chronic physical conditions, unexpected or forced retirements, social isolation, and bereavement.^{Note de bas de page 50}
• People with a mental illness are twice as likely to experience problematic substance use compared to the general population.^{Note de bas de page 51}
• Those experiencing homelessness have a much higher rate of problematic substance use compared to the general Canadian population.^{Note de bas de page 52}
• Indigenous peoples are at greater risk of experiencing mental health and substance use issues due to multiple factors, including the intergenerational effects of residential schools, and other devastating consequences of colonization.^{Note de bas de page 53Note de bas de page 54}
• Evidence shows that gay, lesbian and bisexual individuals are at higher risk of problematic substance use compared to heterosexual individuals.^{Note de bas de page 55} For example, gay, lesbian and bisexual adolescents have been found to be 2 to 4 times more likely to use substances^{Note de bas de page 56} and lesbian and gay adults have been shown to experience higher rates of heavy drinking, compared to their heterosexual counterparts.^{Note de bas de page 57}

This provides some examples of the complexity associated with harms from substance use in Canada, the need for ongoing data collection and research, and the importance of using this information to develop tailored programs and interventions to effectively reach and support those most at-risk.

Projects that address trauma, sex and gender

Trauma/Gender/Substance Use Project (TGS)

The Centre of Excellence for Women's Health engaged with leaders from across Canada to further integrate trauma-informed, sex and gender informed, and gender transformative approaches into substance use and addiction practice and policy. Knowledge exchange materials and resources were developed in collaboration with regional stakeholders across Canada.

The Mothering Project (Manito Ikwe Kagiikwe) is a low-threshold harm reduction program located at Mount Carmel Clinic in Winnipeg's North End, which provides trauma-informed, community-based and de-stigmatizing services for pregnant women and mothers in need. Services include addiction support, culturally-informed trauma counselling, prenatal care, parenting and child development support, group programming, and advocacy.

4i. Grounding substance use policy in evidence

Through the CDSS, the Government of Canada is committed to pursuing an evidence-based approach to addressing substance use in Canada. This relies on timely and accurate data, as well as up to date and comprehensive research and surveillance activities.

We know that there are gaps in our approach to evidence generation. Several government agencies collect and analyze information on substance use (e.g., the Public Health Agency of Canada, the Canadian Institute for Health Information, and the Canadian Centre on Substance Use and Addiction); however, Canada does not currently have a central organization for data collection and analysis on substance use issues as exists elsewhere such as in the European Union, Australia, the United Kingdom, and the United States.

In addition, the quality of data about substance use in Canada varies significantly across provinces and territories. Further, existing survey data may not capture all people who use substances - particularly those who are marginalized. This has significant impacts on the ability of governments, the health system, law enforcement, and the research community to respond to substance related issues and crises, and design and implement measures to help prevent crises in the first place.

Building the evidence base through coordinated surveillance

There is a need to systematically and comprehensively collect a wide range of data, including emergency room visits, poisonings, coroner reports, overdoses, prescribing rates, crime rates, incarceration rates, impaired driving rates, and use of treatment and harm reduction facilities, and to disaggregate these across social and economic characteristics, and sex, gender, and diversity factors. In addition, data collection on Indigenous populations should be done in partnership with Indigenous leadership, communities and Indigenous organizations.

Through collaborative efforts between the provinces, territories and the Public Health Agency of Canada, we have been working to collect data, surveillance and research on the opioid crisis, including reporting data on opioid-related deaths to Canadians on a quarterly basis. Health Canada's Drug Analysis Service labs also share information about emerging illegal drugs with law enforcement and provincial and territorial health authorities.

To help address this gap, the Government of Canada is working towards developing and implementing a Canadian Drugs Observatory that would provide systematic and sustained data collection in Canada, act as a central hub to provide authoritative information about drug and substance use among Canadians, and inform Canadian drug policies, programs and decision making.

Did you know?

Current data on substance use in Canada is available through the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) and the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS). These biennial surveys collect information on substance use among Canadians aged 15+ in the provinces (CTADS) and Canadian students in grades 7 to 12 (CSTADS), and inform approaches to address the problematic use of tobacco, alcohol and other drugs, including opioids and cannabis.

Data on hospital visits due to opioid poisonings in Canada are collected through the Canadian Institute for Health Information's (CIHI) Hospital Morbidity Database. Two key metrics used to collect this data include the number of hospital admissions and the number of emergency department visits.

Innovative research initiatives

Complementing the need for robust and systematic data collection is the need to ensure that the interventions, models of care, and policies being developed and implemented on an ongoing basis are examined for their effectiveness and scalability, across jurisdictions, and for key populations. This is particularly true as Canada is acting rapidly to address the multi-faceted issues contributing to the opioid crisis.

A made-in-Canada approach towards evidence-building is essential to provide the information that jurisdictions and other stakeholders need to assess the impact of policies and programs for Canadians, and to identify ongoing need and update priorities.

To this end, the Canadian Institutes of Health Research (CIHR) is supporting the Canadian Research Initiative on Substance Misuse (CRISM), a national research network that connects researchers, service providers, decision makers, and people with lived experience from across Canada to address problematic substance use through creation of innovative programs and services. CRISM's mandate is to ensure that evidence-based interventions for reducing problematic substance use are developed, tested, and brought to scale for population impact. In parallel, CIHR is supporting rapid response mechanisms to address emerging issues in a timely fashion. CIHR is connecting those on the front lines of the opioid crisis with researchers to fill their most pressing information gaps, and is also supporting activities to provide information on the impacts of legalization and regulation of cannabis.

To facilitate the evolving evidence needs on substance use and related issues, the Government of Canada is further developing large-scale, innovative research initiatives that will supply the evidence-base for policy makers, key stakeholders, Canadians at risk, and those living with and impacted by problematic substance use, across jurisdictions and sectors. In addition, the Government of Canada will continue to support innovative research initiatives that will inform the work of policy makers, service providers, and those living with and impacted by problematic substance use.

The Government of Canada wants to hear from Canadians about how we can move forward with evidence-based policies and programs, and whether there are gaps in our approach to evidence.

5. Next Steps

Thank you for reading this background document. Please proceed to the online survey to provide your input on future approaches for substance use issues in Canada.

The Government of Canada is committed to considering all of the comments received through this process in developing next steps for the Canadian Drugs and Substances Strategy. A “What We Heard” report will be developed and made available after the close of this consultation.

Take the online survey to share your ideas

Glossary

Discrimination

An action or a decision that treats a person or group badly for reasons such as their race, age, or other characteristic.^{Note de bas de page 58}

Distinctions-based approach

Recognizing the unique interests, needs and issues of constitutionally-recognized Indigenous peoples - First Nations, Inuit and Métis.

Diversion

The unlawful movement of regulated drugs from legal sources and uses to illegal ones (e.g., selling one’s pharmaceutical drugs to someone else).

Harm reduction

Policies, programs, and practices that aim to reduce the adverse health, social and economic consequences of the use of drugs, without first requiring abstinence.

Intergenerational trauma

The historical and ongoing effects of colonization and the residential school system in Canada which continue to impact First Nations, Inuit and Métis communities across several generations.^{Note de bas de page 59Note de bas de page 60}

Prevention

A policy or program aimed at delaying, reducing or preventing substance use.

Problematic substance use

The use of any psychoactive substance in a manner, situation, amount, or frequency that is harmful to the individual or to society.

Psychoactive substance

Substances which affect the central nervous system and alter a person's mood, thinking and/or behaviour.

Recovery

A process whereby individuals work to improve their own health and wellness and to live a meaningful life in a community of their choice while striving to achieve their full potential.

Social determinants of health

The broad range of personal, social, economic and environmental factors that determine individual and population health.

Stigma

Negative attitudes and beliefs about a group of people due to their circumstances.

Substance(s)

Refers to all psychoactive drugs both legal and illegal, including but not limited to alcohol, tobacco, cannabis, opioids and other forms of drugs such as cocaine.

Trafficking

The illegal cultivation, manufacturing, distribution and/or sale of illegal drugs.

Trauma

A person’s response (physical and/or emotional) to an overwhelmingly distressing or disturbing event or experience.

Wraparound services

Additional individualized services that help successfully support someone in treatment (can include child care, education and employment training, housing, transportation, and help with finances and/or legal issues).

Notes

References