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Insite: CMA submission regarding Insite supervised injection site and program.

https://policybase.cma.ca/en/permalink/policy14129
Date
2011-02-17
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Court submission
Date
2011-02-17
Topics
Health care and patient safety
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
S.C.C. File No.: 33556 IN THE SUPREME COURT OF CANADA (APPEAL FROM THE BRITISH COLUMBIA COURT OF APPEAL) BETWEEN: ATTORNEY GENERAL OF CANADA AND MINISTER OF HEALTH FOR CANADA Appellants (Appellants/Cross-Respondents) —and — PHS COMMUNITY SERVICES SOCIETY, DEAN EDWARD WILSON and SHELLY TOMIC, VANCOUVER AREA NETWORK OF DRUG USERS (VANDU) Respondents (Respondents/Cross-Appellants) —and — ATTORNEY GENERAL OF BRITISH COLUMBIA Respondent (Respondent) —and — ATTORNEY GENERAL OF QUEBEC, DR. PETER AIDS FOUNDATION, VANCOUVER COASTAL HEALTH AUTHORITY, CANADIAN CIVIL LIBERTIES ASSOCIATION, CANADIAN HIV/AIDS LEGAL NETWORK, INTERNATIONAL HARM REDUCTION ASSOCIATION AND CACTUS MONTREAL, CANADIAN NURSES ASSOCIATION, REGISTERED NURSES' ASSOCIATION OF ONTARIO AND ASSOCIATION OF REGISTERED NURSES OF BRITISH COLUMBIA, CANADIAN PUBLIC HEALTH ASSOCIATION, CANADIAN MEDICAL ASSOCIATION, BRITISH COLUMBIA CIVIL LIBERTIES ASSOCIATION, BRITISH COLUMBIA NURSES'S UNION Interveners FACTUM OF THE INTERVENER, CANADIAN MEDICAL ASSOCIATION BORDEN LADNER GERVAIS LLP 100 Queen Street — Suite 1100 Ottawa, ON KIP 1J9 Guy J. Pratte/Nadia Effendi Tel: (613) 237-5160 Fax: (613) 230-8842 Counsel for the Intervener, Canadian Medical Association 2 TO: Roger Bilodeau, Q.C. REGISTRAR SUPREME COURT OF CANADA AND TO: Robert J. Frater Attorney General of Canada Bank of Canada Building 234 Wellington Street, Room 1161 Ottawa, Ontario KlA OH8 Telephone: (613) 957-4763 FAX: (613) 954-1920 E-mail: robert.fratergustice.gc.ca Counsel for Appellant/Respondent on Cross- Appeal, the Attorney General of Canada Robert J. Frater Attorney General of Canada Bank of Canada Building 234 Wellington Street, Room 1161 Ottawa, Ontario KlA OH8 Telephone: (613) 957-4763 FAX: (613) 954-1920 E-mail: robert.frater@justice.gc.ca Counsel for Appellant/Respondent on Cross- Appeal, the Minister of Health for Canada Joseph H. Arvay, Q.C. Arvay Finlay 1350 - 355 Burrard Street Vancouver, British Columbia V6C 2G8 Telephone: (604) 689-4421 FAX: (604) 687-1941 E-mail: jarvay@arvayfinlay.com Counsel for Respondent, PHS Community Services Society Jeffrey W. Beedell McMillan LLP 300 - 50 O'Connor Street Ottawa, Ontario K113 6L2 Telephone: (613) 232-7171 FAX: (613) 231-3191 E-mail: jeffbeedell@mcmillan.ca Agent for Respondent, PHS Community Services Society 3 Joseph H. Arvay, Q.C. Arvay Finlay 1350 - 355 Burrard Street Vancouver, British Columbia V6C 2G8 Telephone: (604) 689-4421 FAX: (604) 687-1941 E-mail: jarvay@arvayfinlay.com Counsel for Respondent, Dean Edward Wilson and Shelly Tomic John W. Conroy, Q.C. Conroy & Company 2459 Pauline St Abbotsford, British Columbia V2S 3S1 Telephone: (604) 852-5110 FAX: (604) 859-3361 E-mail: jconroy@johnconroy.com Counsel for Respondent/Appellant on Cross- Appeal, Vancouver Area Network of Drug Users (VANDU) Craig E. Jones Attorney General of British Columbia 1001 Douglas Street, 6th floor Victoria, British Columbia V8V 1X4 Telephone: (250) 387-3129 FAX: (250) 356-9154 E-mail: craigjones@gov.bc.ca Counsel for Respondent, the Attorney General of British Columbia Hugo Jean Procureur general du Quebec 1200 Route de l'Èglise, 2e etage Ste-Foy, Quebec G1V 4M1 Telephone: (418) 643-1477 FAX: (418) 644-7030 E-mail: hjean@justice.gouv.qc.ca Counsel for Intervener, Attorney General of Quebec Jeffrey W. Beedell McMillan LLP 300 - 50 O'Connor Street Ottawa, Ontario K113 6L2 Telephone: (613) 232-7171 FAX: (613) 231-3191 E-mail: jeffbeedell@mcmillan.ca Agent for Respondent, Dean Edward Wilson and Shelly Tomic Henry S. Brown, Q.C. Gowling Lafleur Henderson LLP 2600 - 160 Elgin St P.O. Box 466, Stn "D" Ottawa, Ontario KIP 1C3 Telephone: (613) 233-1781 FAX: (613) 788-3433 E-mail: henry.brown@gowlings.com Agent for Respondent/Appellant on Cross- Appeal, Vancouver Area Network of Drug Users (VANDU) Robert E. Houston, Q.C. Burke-Robertson 70 Gloucester Street Ottawa, Ontario K2P 0A2 Telephone: (613) 566-2058 FAX: (613) 235-4430 E-mail: rhouston@burkerobertson.com Agent for Respondent, the Attorney General of British Columbia Pierre Landry Noel & Associes 111, rue Champlain Gatineau, Quebec J8X 3R1 Telephone: (819) 771-7393 FAX: (819) 771-5397 E-mail: p.landry@noelassocies.com Agent for Intervener, Attorney General of Quebec 4 Andrew I. Nathanson Fasken Martineau DuMoulin LLP 2900 - 550 Burrard Street Vancouver, British Columbia V6C 0A3 Telephone: (604) 631-4908 FAX: (604) 631-3232 Counsel for Intervener, Dr. Peter AIDS Foundation Ryan D. W. Dalziel Bull, Housser & Tupper LLP 3000 - 1055 West Georgia Street Vancouver, British Columbia V6E 3R3 Telephone: (604) 641-4881 FAX: (604) 646-2671 E-mail: rdd@bht.com Counsel for Intervener, British Columbia Civil Liberties Association Sheila Tucker Davis LLP 2800 Park Place 666 Burrard Street Vancouver, British Columbia V6C 2Z7 Telephone: (604) 643-2980 FAX: (604) 605-3781 E-mail: stuckergdavis.ca Counsel for Intervener, Vancouver Coastal Health Authority Paul F. Monahan Fasken Martineau DuMoulin LLP 333 Bay Street, Suite 2400 Bay Adelaide Centre, Box 20 Toronto, Ontario M5H 2T6 Telephone: (416) 366-8381 FAX: (416) 364-7813 E-mail: pmonahan@fasken.com Counsel for Intervener, Canadian Civil Liberties Association Scott M. Prescott Fasken Martineau DuMoulin LLP 1300 - 55 Metcalfe Street Ottawa, Ontario K1P 6L5 Telephone: (613) 236-3882 FAX: (613) 230-6423 E-mail: sprescott@fasken.com Agent for Intervener, Dr. Peter AIDS Foundation Brian A. Crane, Q.C. Gowling Lafleur Henderson LLP 2600 - 160 Elgin St Ottawa, Ontario K1P 1C3 Telephone: (613) 233-1781 FAX: (613) 563-9869 E-mail: brian.crane@gowlings.com Agent for Intervener, British Columbia Civil Liberties Association Marie-France Major McMillan LLP 300 - 50 O'Connor Street Ottawa, Ontario K113 6L2 Telephone: (613) 232-7171 FAX: (613) 231-3191 E-mail: mane-france.maior@mcmillan.ca Agent for Intervener, Vancouver Coastal Health Authority Julia Kennedy Fasken Martineau DuMoulin LLP 55 Metcalfe Street Suite 1300 Ottawa, Ontario K1P 6L5 Telephone: (613) 236-3882 FAX: (613) 230-6423 E-mail: ikennedy(&fasken.com Agent for Intervener, Canadian Civil Liberties Association Michael A. Feder McCarthy Tétrault LLP Suite 1300, 777 Dunsmuir Street Vancouver, British Columbia V7Y 1 K2 Telephone: (604) 643-5983 FAX: (604) 622-5614 E-mail: mfeder(qmccarthv.ca Counsel for Intervener, the Canadian HIV/AIDS Legal Network, International Harm Reduction Association and CACTUS Montréal Rahool P. Agarwal Ogilvy Renault LLP 3800 - 200 Bay Street Toronto, Ontario M5J 2Z4 Telephone: (416) 216-3943 FAX: (416) 216-3930 E-mail: ragarwal(iogilvyrenaul1.com Counsel for Intervener, Canadian Nurses Association, Registered Nurses' Association of Ontario and Association of Registered Nurses of British Columbia Owen M. Rees Stockwoods LLP 77 King Street West Suite 4130, P.O. Box 140 Toronto, Ontario M5K IHI Telephone: (416) 593-7200 FAX: (416) 593-9345 E-mail: owenr~stockwoods.ca Counsel for Intervener, Canadian Public Health Association 5 Brenda C. Swick McCarthy Tétrault LLP 200 - 440 Laurier Avenue West Ottawa, Ontario KIR 7X6 Telephone: (613) 238-2000 FAX: (613) 563-9386 Agent for Intervener, the Canadian HIV/AIDS Legal Network, International Harm Reduction Association and CACTUS Montréal Sally A. Gomery Ogilvy Renault LLP 1500 - 45, O'Connor Street Ottawa, Ontario KIP lA4 Telephone: (613) 780-8661 FAX: (613) 230-5459 E-mail: sgomery(qogilvyrenaul1.com Agent for Intervener, Canadian Nurses Association, Registered Nurses' Association of Ontaro and Association of Registered Nurses of British Columbia Dougald E. Brown Nelligan O'Brien Payne LLP 1500 - 50 O'Connor S1. Ottawa, Ontario KIP 6L2 Telephone: (613) 231-8210 FAX: (613) 788-3661 E-mail: dougald.brown(inelligan.ca Agent for Intervener, Canadian Public Health Association Marjorie Brown Victory Square Law Office 100 West Pender Street Suite 500 Vancouver, British Columbia V6B 1R8 Telephone: (604) 684-8421 FAX: (604) 684-8427 E-mail: mbrown(avslo.ca Counsel for Intervener, British Columbia Nurses' Union Michael A. Chambers Maclaren Corlett 50 O'Connor Street, Suite 1625 Ottawa, Ontario KIP 6L2 Telephone: (613) 233-1146 FAX: (613) 233-7190 E-mail: mchambers(amacorlaw.com Counsel for Intervener, Real Women Canada 6 Colleen Bauman Sack Goldblatt Mitchell LLP 500 - 30 Metcalfe St. Ottawa, Ontario KIP 5L4 Telephone: (613) 235-5327 FAX: (613) 235-3041 E-mail: cbauman~sgmlaw.com Agent for Intervener, British Columbia Nurses' Union TABLE OF CONTENTS Part I — Statement of Facts ........................................................................................................... .1 A. Overview ......................................................................................................................... 1 B. CMA's Interest in the Appeal ............................................................................................ 1 C. CMA's Position on the Facts ............................................................................................ 1 Part II — Statement of the Questions in Issue ................................................................................3 Part III — Statement of Argument .................................................................................................3 A. Charter Interpretation Must be Guided by Reality, Not Ideology ......................................... 3 B. The Impugned Provisions Infringe Section 7 of the Charter ................................................. 5 (1)Denying Access to Necessary Health care Infringes Section 7 of the Charter.................. 5 (2)The Rights to Life and Security of Patients Have Been Infringed ................................... 5 (3)Drug Addicts Have Not Waived Their Statutory and Constitutional Right to Treatment .................................................................................................................. 6 (4)The Rights to Liberty of the Individual Respondents Have Been Infringed ..................... 8 (5)The Principles of Fundamental Justice Have Not Been Respected ................................. 8 a) The Impugned Provisions Are Arbitrary ..................................................................... 8 b) The Impugned Provisions Are Overbroad ................................................................... 9 C. If There is an Infringement of Section 7, the Law is Not Saved by Section 1 of the Charter ................................................................................................................................ 9 D. Remedy ......................................................................................................................... 10 Part IV — Submissions as to Costs .............................................................................................. 10 Part V — Order Sought ................................................................................................................10 Part VI — Table of Authorities .................................................................................................... 11 Part VII — Statutes, Regulations, Rules ...................................................................................... 13 PART I — STATEMENT OF FACTS A. Overview 1. Fair and equitable access to medically necessary, evidenced-based health care is of fundamental importance to Canadian patients and physicians, as this Court recognized in Chaoulli. 2. Where life and security of a person is at risk because of a medical condition, like drug addiction, the Court's delineation of a government or legislature's constitutional obligations should be guided by facts. Unfounded ideological assumptions about the character of patients must not trump clinical judgment based on the best medical evidence available; otherwise, the life, liberty and security of patients is put at risk arbitrarily, contrary to section 7 of the Charter. 3. The Appellants' position that those addicted to drugs have foregone any right to access medical treatment is antithetical to the raison d'être of the Canadian health care system and inconsistent with the federal government's obligations under section 7 of the Charter. 4. Neither the statutory law nor the Constitution allows the state to deny access to health care because of "lifestyle" choices or presumed waiver of legal or constitutional rights. B. CMA's Interest in the Appeal 5. The Canadian Medical Association ("CMA") is the national voice of Canadian physicians with over 74,000 members across the country. Its mission is to serve and to unite the physicians of Canada and to be the national advocate, in partnership with the people of Canada, for the highest standards of health and heath care. 6. Critical to CMA's role is the upholding of harm reduction as one pillar in a comprehensive public health approach to disease prevention and health promotion. Further, the CMA possesses a distinct expertise and broad-based knowledge of many aspects of policy and law concerning harm reduction as a clinically mandated and ethical method of care and treatment. C. CMA's Position on the Facts 7. By Order dated February 17, 2011, the CMA was granted leave to intervene in this Appeal. 2 8. The CMA accepts the facts as stated by the Respondents. 9. This appeal flows from separate actions commenced by some of the Respondents seeking relief that would obviate the need for exemptions granted by the Federal Minister of Health under section 56 of the Controlled Drugs and Substances Act (the "Act"), S.C. 1996 c. 19. Thus, when within the confines of the Vancouver Safe Injection Site ("Insite"), patient drug users were not liable to prosecution for possession of a controlled substance contrary to section 4(1) of the Act, or staff for trafficking contrary to section 5(1). The initial exemptions, based on "necessity for a scientific purpose", were granted for a term of three years commencing September 12, 2003. They were thereafter extended to December 31, 2007, and then to June 30, 2008. Insite's ability to operate was dependent upon the exemptions. However, no further extensions were forthcoming. 10. In their actions, the Respondents, in addition to the division of powers argument, contended that sections 4(1) and 5(1) of the Act violated section 7 of the Charter, were unconstitutional, and should be struck down. The Respondents were successful before the Applications Judge and the Court of Appeal. 11. The Applications Judge found that sections 4(1) and 5(1) of the Act infringed section 7 of the Charter and declared them to be of no force and effect. 12. On appeal by the Attorney General of Canada and cross-appeal by the Respondents, PHS, Wilson and Tomic, the majority of the Court of Appeal found that sections 4(1) and 5(1) of the Act were inapplicable to Insite by reason of the application of the doctrine of interjurisdictional immunity. 13. In concurring reasons, Rowles J.A. also found that sections 4(1) and 5(1) engaged section 7 of the Charter and that such application did not accord with the principles of fundamental justice because of overbreadth. 14. The findings of the Applications Judge and Rowles J.A. under the Charter are, the CMA submits, premised on the correct and supported fact that harm reduction is an evidenced-based form of medical treatment for patient drug addicts suffering from the illness of addiction. It is unconstitutional for governments to prevent access to treatment on pain of criminal penalty and deprivations of life, liberty and security of the person on grounds informed by ideological 3 assumptions and not the evidence. PART II - STATEMENT OF THE QUESTIONS IN ISSUE 15. The following constitutional questions, as stated by the Chief Justice on September 2, 2010, are to be determined in this appeal: 1. Are ss. 4(1) and 5(1) of the Controlled Drugs and Substances Act, S.c. 1996, c. 19, constitutionally inapplicable to the activities of staff and users at Insite, a health care undertaking in the Province of British Columbia? 2. Does s. 4(1) of the Controlled Drugs and Substances Act, S.c. 1996, c. 19, infringe the rights guaranteed by s. 7 of the Canadian Charter of Rights and Freedoms? 3. If so, is the infringement a reasonable limit prescribed by law as can be demonstrably justified in a free and democratic society under s. 1 of the Canadian Charter of Rights and Freedoms? 4. Does s. 5(1) of the Controlled Drugs and Substances Act, S.C. 1996, c. 19, infringe the rights guaranteed by s. 7 of the Canadian Charter of Rights and Freedoms? 5. If so, is the infringement a reasonable limit prescribed by law as can be demonstrably justified in a free and democratic society under s. 1 of the Canadian Charter of Rights and Freedoms? 16. Questions two to five, which relate to the Charter, are of particular importance for the CMA, and are addressed in more detail below. The CMA submits that sections 4(1) and 5(1) of the Act infrnge the rights guaranteed by section 7 of the Charter and are not justified under section 1. PART III - STATEMENT OF ARGUMENT A. Charter Interpretation Must be Guided by Reality, Not Ideology 17. When determining whether or not impugned legislation infringes the Charter, courts must not play host to political debates, but instead must rise above them by ensuring that public policy passes constitutional muster. Chaoull v. Québec (Attorney General), (2005) 1 S.c.R. 791, at para. 89 (CMA Authorities, Tab 2). R. v. Morgentaler, (1988)1 S.C.R. 30 at 45-46 (CMA Authorities, Tab 13). 18. The Appellants' position is clearly premised on ideological preconceptions with regard to individuals suffering from addictions. Yet, as the history of birth control legislation in Canada shows, a legal framework informed by ideological assumptions about the morality of patients seeking to control their reproduction can violate a person's most fundamental rights. See R. v. Morgentaler, supra at 62 where the Court rejected arguments that it should assess administrative structures in the abstract: "when denial of a right as basic as security of the person is infringed by the procedure and administrative structures created by the law itself, the courts are empowered to act" (CMA Authorities, Tab 13). 4 19. In order for the courts to meet their role in determining whether a particular piece of legislation is constitutional, it must consider Parliament's enactments by relying on the available evidence. In fact, it is well established that a deprivation of the rights to life, liberty or security of the person must be proven by solid evidence. Taylor, M. and Jamal, M., The Charter of Rights in Litigation, loose-leaf (Canada Law Book: Aurora, 2010) at para. 17:15 [CMA Authorities, Tab 20]. 20. The presentation of facts is not a mere technicality, but rather it is essential to a proper consideration of Charter issues: Charter cases will frequently be concerned with concepts and principles that are of fundamental importance to Canadian society. For example, issues pertaining to freedom of religion, freedom of expression and the right to life, liberty and the security of the individual will have to be considered by the courts. Decisions on these issues must be carefully considered as they will profoundly affect the lives of Canadians and all residents of Canada. In light of the importance and the impact that these decisions may have in the future, the courts have every right to expect and indeed to insist upon the careful preparation and presentation of a factual basis in most Charter cases. The relevant facts put forward may cover a wide spectrum dealing with scientific, social, economic and political aspects. Often expert opinion as to the future impact of the impugned legislation and the results of the possible decisions pertaining to it may be of great assistance to the courts. MacKay v. Manitoba, [1989] 2 S.C.R. 357 at 361 [CMA Authorities, Tab 5]. 21. Specifically, with respect to section 7 of the Charter, this Court has confirmed that the task of the courts is to evaluate the issue in "the light, not just of common sense or theory, but of the evidence". The Court dispenses with unsubstantiated theoretical arguments, relying instead on empirical and scientific evidence presented by the parties: In support of this contention, the government called experts in health administration and policy. Their conclusions were based on the "common sense" proposition that the improvement of health services depends on exclusivity (R.R., at p. 591). They did not profess expertise in waiting times for treatment. Nor did they present economic studies or rely on the experience of other countries. They simply assumed, as a matter of apparent logic, that insurance would make private health services more accessible and that this in turn would undermine the quality of services provided by the public health care system. The appellants, relying on other health experts, disagreed and offered their own conflicting "common sense" argument for the proposition that prohibiting private health insurance is neither necessary nor related to maintaining high quality in the public health care system. Quality public care, they argue, depends not on a monopoly, but on money and management. They testified that permitting people to buy private insurance would make alternative medical care more accessible and reduce the burden on the public system. The result, they assert, would be better care for all [...] To this point, we are confronted with competing but unproven "common sense" arguments, amounting to little more than assertions of belief. We are in the realm of theory. But as discussed above, a theoretically defensible limitation may be arbitrary if in fact the limit lacks a connection to the goal. This brings us to the evidence called by the appellants at trial on the experience of other developed countries with public health care systems which permit access to private health care. The experience of these countries suggests that there is no real connection in fact between prohibition of health insurance and the goal of a quality public health system. 5 Chaoulli, supra at paras. 136-149 (see also paras. 115, 117, 136-149, 150, 152 where the Court refers to Statistics Canada studies and evidence from other western democracies) [CMA Authorities, Tab 2]. See also Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519 at 601-602 [CMA Authorities, Tab 16]. 22. Drug addicts suffer from a medical condition that can be treated. Hence, Insite is designed as a health treatment aimed at reducing the harmful consequences of drug use as well as exposing its vulnerable patients to other health care options. In this context, the federal legislation and government actions at issue amount to a denial of evidence-based medical treatment whose effect is to put the life and security of patients at great risk. 23. Charter interpretation should generally be grounded on fact rather than speculation or ideological assumptions, especially where life and security of the person (i.e., the patient) is at risk because of a medical condition (such as addiction). In such cases, the Court's delineation of the state's constitutional obligations should be guided by evidence-based medicine and independent clinical judgment. Chaoulli, supra at paras. 85, 107 [CMA Authorities, Tab 2]. See also Operation Dismantle Inc. v. The Queen, [1985] 1 S.C.R. 441 at 452-454 [CMA Authorities, Tab 7]; Auton (Guardian ad litem of) v. British Columbia (Attorney General), [2004] 3 S.C.R. 657, at para. 66 [CMA Authorities, Tab 1]. 24. Accordingly, CMA submits that, at the very least, in the health care field where lives are at risk, there must be sound evidentiary basis for legislative and government action that deny medical care. B. The Impugned Provisions Infringe Section 7 of the Charter (1) Denying Access to Necessary Health care Infringes Section 7 of the Charter 25. While the legislature is generally entitled to enact legislation prohibiting drug use or trafficking, this legislation (however well-intended) cannot have the effect of putting the lives of affected persons at risk. This Court has already found in Chaoulli that section 7 of the Charter was infringed when governments impeded timely patient access to care. (2) The Rights to Life and Security of Patients Have Been Infringed 26. Both the Applications Judge and the Court of Appeal found that the right to life and security was engaged in the present case. The evidence on these issues was plentiful: 1. Addiction is an illness. One aspect of the illness is the continuing need or craving to consume the substance to which the addiction relates; 6 2. Injection drug use leads to an increased incidence and prevalence of infectious diseases including HIV/AIDS, Hepatitis A, B and C, and skin- and blood-borne infections; frequent drug overdoses resulting in significant morbidity and mortality; increased hospital and emergency service utilization; 3. The risk of morbidity and mortality associated with addiction and injection is ameliorated by injection in the presence of qualified health professionals at Insite; 4. User of Insite who are addicted to heroin, cocaine and other controlled substances are not engaged in recreation. Their addiction is an illness frequently, if not invariably, accompanied by serious infections and the real risk of overdose. Reasons for Judgment of the Applications Judge, paras. 87, 89, 135-136, Appellants' Record, Vol. I, pp. 24-25, 34. See also Reasons for Judgment of the B.C. Court of Appeal, para. 30, Appellants' Record, Vol. I, p. 65. (3) Drug Addicts Have Not Waived Their Statutory and Constitutional Right to Treatment 27. The Appellants did not really dispute the medical evidence to the effect that addiction to drugs was a disease. They sought instead to justify their position by claiming that drug addicts had "chosen" their lifestyle and were solely responsible for their medical condition. For the following reasons, this "rationale" does not pass constitutional muster. 28. The Appellants assert that the section 7 rights are not engaged as they stem from an alleged "choice made by the consumer", relying on the fact that 95% of the injections in the downtown east side of Vancouver do not take place at Insite. The Appellants do not explain how this assertion demonstrates why addicts are able to make a choice not to inject themselves, given that it only addresses where they inject themselves. In any event, contrary to the Appellants' choice theory, the evidence before the Applications Judge and his findings were to the contrary: the reasons for the addiction and resulting need are based on a complicated combination of personal, governmental and legal factors, some of which lend themselves to choice and others that do not.' Further, the Applications Judge found that it is the illness of addiction, and the failure to manage it, that has led to further illness and death. Reasons for Judgment of the Applications Judge, paras. 65, 89, 142, Appellants' Record, Vol. I, pp. 21, 24-25, 35. See also Reasons for Judgment of the B.C. Court of Appeal, para. 39, Appellants' Record, Vol. I, p. 67. Contra the facts in R. v. Malmo-Levine; R. v. Caine, [2003] 3 S.C.R. 571 [Malmo-Levine] [CMA Authorities, Tab 12]. 29. The Appellants' position amounts to a claim that the users of Insite have effectively waived their constitutional rights under section 7. Notwithstanding that the jurisprudence is In fact, the evidence is clear that in the case of the Respondent Tomic, her first experience with illegal drugs was not a personal choice [Reasons for Judgment of the Applications Judge, para. 65, Appellants' Record, Vol. I, p. 21]. 7 unclear as to whether a right under section 7 can actually be waived, it is well established that a waiver or a renunciation of any right under the Charter must be voluntary, freely expressed and accompanied with a clear understanding of the purpose the right was meant to serve and the consequences of declining its protection. There is no evidence whatsoever that the patients of Insite who suffer from addiction, knowingly and unequivocally waived their rights under the Charter, and more specifically their right to access medical treatment. See e.g. Godbout v. Longueuil (City), [1997] 3 S.C.R. 844, at paras. 71-72; Syndicat Northcrest v. Amselem, [2004] 2 S.C.R. 551, at paras. 96-102; R. v. Richard, [1996] 3 S.C.R. 525, at paras. 22-26; R. v. L.T.H., [2008] 2 S.C.R. 739, at paras. 41-42; R. v. Clarkson, [1986] 1 S.C.R. 383 at 394-396; Korponay v. Canada (Attorney General), [1982] 1 S.C.R. 41 at 49; Yorkton Union Hospital v. S.U.N. (1993), 16 Admin. L.R. (2d) 272, at para. 44 (C.A.) [CMA Authorities, Tabs 3, 17, 15, 11, 8, 4, 18 respectively]. 30. Indeed, Canadians do not forego their right to health care or to protection from section 7 violations because of their "choice" of lifestyles. The Appellants' position that addicts must take responsibility for the choice they make undermines the raison d'être of the Canadian health care system, namely (as found by the Applications Judge and the Court of Appeal) the fundamental right of Canadians to access medical treatment and the ethical and clinical responsibilities of their health care providers. 31. The Appellants' position skirts the clinical question at issue for physicians and their patients: physicians must treat patients as a matter of good medical practice and ethical obligation, whether the patient is believed to contribute to his or her injury or not. In Canada, neither the ethical obligations of physicians to treat patients, nor the patients' legal right to treatment, are subject to a moral assessment of a patient's lifestyle. Behaviours that might be deemed "risky" do not deprive patients of their rights of access to clinically required medical care. 32. Section 31 of CMA's Code of Ethics (relied on by the Court in the past e) provides that all physicians must "[r]ecognize the responsibility of physicians to promote fair access to health care resources". The patients at Insite would be deprived of positive health outcomes if Insite were to close or even continue to operate under the ongoing threat of closure. 33. Adopting the Appellants' approach to Charter interpretation would set an extremely dangerous precedent. Thus, if one were to apply the rationale of "choice" to other medical 2 See e.g. R. v. Dersch, [1993] 3 S.C.R. 768 at 784-785, where the Court refers to CMA's Code of Ethics [CMA Authorities, Tab 9]. 8 contexts, such as chronic disease, patients suffering from diabetes because of contributing factors such as poor nutrition and lack of exercise would, under the same logic, be denied medical care. Indeed, many of the complex elements beyond individual choice such as socio-economic and genetic factors found by the Applications Judge in the case at bar to shape addiction as an ilness are prevalent in other diseases. This approach would be not only unethical and clinically unsound, but unconstitutionaL. (4) The Rights to Liberty of the Individual Respondents Have Been Infringed 34. The courts have recognized that the threat of criminal prosecution and possibility of imprisonment for an offence is suffcient to trigger the liberty interest and scrutiny under section 7. Malmo-Levine, supra at para. 84 ICMA Authorities, Tab 12). R. v. Parker (2000),188 D.L.R. 4th 385, at para. 101 (Ont. C.A.) ICMA Authorities, Tab 14). 35. Vulnerable patients suffering from addiction and the health care providers who provide treatment at Insite suffer violations of their constitutionally guaranteed rights (section 7 of the Charter) because of the threat of prosecution under the Act. The uncertainty associated with a ministerial exemption mechanism for Insite from certain provisions of the Act imposes a great burden on those already labouring under the weight of addiction. Moreover, health care providers are also put at risk in their ability to provide medically necessary and evidence-based health care services in a timely manner to all citizens by the capricious exemption mechanism contained in the Act. (5) The Principles of Fundamental Justice Have Not Been Respected 36. It is well established that a law that is arbitrary or overbroad will constitute a breach of the principles of fundamental justice. The CMA submits that the Applications Judge was correct when he found that the impugned provisions were arbitrary, or if not arbitrary, grossly disproportionate and overbroad. The Court of Appeal agreed that the provisions were overbroad. P. Hogg, Constitutional Law of Canada, 5th ed., loose-leaf (Carswell: Toronto, 2007) at 47-52 to 47-60.1 ICMA Authorities, Tab 19). R. v. Heywood, (1994) 3 S.c.R. 761 at 792-794 ICMA Authorities, Tab 10). Chaoull, supra at para. 127 ICMA Authorities, Tab 2). Rodriguez, supra at 590-591 ICMA Authorities, Tab 16). a) The Impugned Provisions Are Arbitrary 37. A law is arbitrary when it bears no relation to, or is inconsistent with, the objective that 9 lies behind it. In order not to be arbitrary, a limit on the section 7 right requires not only a theoretical connection between the limit and the legislative goal, but a real connection on the facts. Chaoulli, supra at paras. 130-131 [CMA Authorities, Tab 2]. 38. In the present case, by prohibiting access to evidence-based, medically necessary care, the government has contributed to the very harm it claims it seeks to prevent, i.e. drug possession and addiction. The best available medical evidence suggests that clinics such as Insite not only protect life, but offer positive health outcomes and care alternatives to vulnerable patients. 39. Moreover, the justification of any denial of access to necessary medical care based on ideology rather than facts is arbitrary since, by definition, it bears no real connection to the facts. b) The Impugned Provisions Are Overbroad 40. It is a well-established principle of fundamental justice that criminal legislation must not be overbroad. If the government, in pursuing a legitimate objective, uses means which are broader than is necessary to accomplish that objective, the principles of fundamental justice will be violated. Heywood, supra at 792-793 [CMA Authorities, Tab 10]. See also Malmo-Levine, supra at paras. 130-131 [CMA Authorities, Tab 12]. 41. A fortiori, that will be true when the state itself has a particular interest in acting to protect vulnerable persons. In the present case, the evidence before the Applications Judge demonstrated that harm reduction has been a component of Canada's drug strategy for many years. In 2002, the House of Commons Special Committee on the Non-Medical Use of Drugs rejected the dichotomy between harm reduction and an abstinence-based treatment model. It also specifically considered the creation of a safe injection facility in the downtown east side of Vancouver because it recognized that that community presented a "public health disaster". 42. Hence, while the government may be justified in preventing drug possession and trafficking, it cannot cast a legislative prohibition so widely that it captures persons in need of medical care. C. If There is an Infringement of Section 7, the Law is Not Saved by Section 1 of the Charter 43. Should the Court find that sections 4(1) and 5(1) of the Act infringe the rights guaranteed Guy Pratt /Nadia ffend Borden L dner Gervais L 1 0 by section 7 of the Charter, the CMA submits that the provisions cannot be justified under section 1 of the Charter as any law that offends the principles of fundamental justice cannot be justified, and more specifically, meet the minimal impairment branch of the section 1 analysis. See e.g. New Brunswick (Minister of Health and Community Services) v. G. (J.), [1999] 3 S.C.R. 46, at para. 99 [CMA Authorities, Tab 6]; Heywood, supra at 802-803 [CMA Authorities, Tab 10]. D. Remedy 44. Fundamental justice requires either permanent exemptions or a declaration that the impugned law, as it applies to users of supervised injection sites, is invalid. The CMA submits that this position is consistent with sound constitutional interpretation of section 7 of the Charter, while protecting the most vulnerable patient populations in accordance with evidence-based medicine and physicians' ethical obligations. PART IV — SUBMISSIONS AS TO COSTS 45. The CMA seeks no costs and asks that none be awarded against it. PART V — ORDER SOUGHT 46. The CMA submits that constitutional questions two and four should be answered affirmatively. Should the Court answer these questions in the affirmative, however, constitutional questions three and five should be answered negatively. 47. The CMA seeks leave of this Court, pursuant to rule 59(2) of the Rules of the Supreme Court of Canada, to present oral argument at the hearing of this appeal. Rules of the Supreme Court of Canada, SOR/83-74, as amended, Rule 59(2) [Part VII of Factum]. ALL OF WHICH IS RESPECTFULLY SUBMITTED THIS 13th DAY OF APRIL, 2011. OTTO1 \ 4423086 \ 7 11 PART VI — TABLE OF AUTHORITIES TAB SOURCES Paras. in factum where cited Cases 1. Auton (Guardian a litem of) v. British Columbia (Attorney General), [2004] 3 S.C.R. 657 23 2. Chaoulli v. Quebec (Attorney General), [2005] 1 S.C.R. 791 17, 21, 23, 36, 37 3. Godbout v. Longueuil (City), [1997] 3 S.C.R. 844 29 4. Korponay v. Canada (Attorney General), [1982] 1 S.C.R. 41 29 5. MacKay v. Manitoba, [1989] 2 S.C.R. 357 20 6. New Brunswick (Minister of Health and Community Services) v. G. (J.), [1999] 3 S.C.R. 46 43 7. Operation Dismantle Inc. v. The Queen, [1985] 1 S.C.R. 441 23 8. R. v. Clarkson, [1986] 1 S.C.R. 383 29 9. R. v. Dersch, [1993] 3 S.C.R. 768 32 10. R. v. Heywood, [1994] 3 S.C.R. 761 36, 40, 43 11. R. v. L.T.H., [2008] 2 S.C.R. 739 29 12. R. v. Malmo-Levine; R. v. Caine, [2003] 3 S.C.R. 571 28, 34, 40 13. R. v. Morgentaler, [1988] 1 S.C.R. 30 17, 18 14. R. v. Parker (2000), 188 D.L.R. 4th 385 (Ont. C.A.) 34 15. R. v. Richard, [1996] 3 S.C.R. 525 29 16. Rodriguez v. British Columbia (Attorney General), [1993] 3 S.C.R. 519 21, 36 17. Syndicat Northcrest v. Amselem, [2004] 2 S.C.R. 551 29 18. Yorkton Union Hospital v. S. UN. (1993), 16 Admin. L.R. (2d) 272 (Sask. C.A.) 29 12 TAB SOURCES Paras. where in factum cited Secondary Sources 19. Hogg, P., Constitutional Law of Canada, 5th ed., loose-leaf (Carswell: Toronto, 2007) at 47-52 to 47-60.1. 36 20. Taylor, M. and Jamal, M., The Charter of Rights in Litigation, loose-leaf (Canada Law Book: Aurora, 2010) at para. 17:15 19 13 PART VII — STATUTES, REGULATIONS, RULES
Canadian Charter of Rights and Freedom, sections 1 and 7
Controlled Drugs and Substances Act, S.C. 1996, c. 19, sections 4(1), 5(1), 56
Rules of Supreme Court of Canada, SOR/83-74, as amended, Rule 59 14 Canadian Charter of Rights and Freedoms PART I OF THE CONSTITUTION ACT, 1982 Charte canadienne des droits et libertes PARTIE I DE LA LOI CONSTITUTIONNELLE DE 1982 Rights and freedoms in Canada 1. The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society. Life, liberty and security of person 7. Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice. Droits et libertes au Canada 1. La Charte canadienne des droits et libertes garantit les droits et libertós qui y sont enonces. Its ne peuvent etre restreints que par une regle de droit, dans des limites qui soient raisonnables et dont la justification puisse se demontrer dans le cadre d'une society libre et democratique. Vie, liberte et securite 7. Chacun a droit a la vie, a la liberte et a la securite de sa personne; it ne peut etre porte atteinte a ce droit qu'en conformite avec les principes de justice fondamentale. 15 Controlled Drugs and Substances Act S.C. 1996, c. 19 Possession of substance 4. (1) Except as authorized under the regulations, no person shall possess a substance included in Schedule I, II or III. Trafficking in substance 5. (1) No person shall traffic in a substance included in Schedule I, II, III or IV or in any substance represented or held out by that person to be such a substance. Exemption by Minister 56. The Minister may, on such terms and conditions as the Minister deems necessary, exempt any person or class of persons or any controlled substance or precursor or any class thereof from the application of all or any of the provisions of this Act or the regulations if, in the opinion of the Minister, the exemption is necessary for a medical or scientific purpose or is otherwise in the public interest. Loi reglementant certaines drogues et autres substances L.C. 1996, ch. 19 Possession de substances 4. (1) Sauf dans les cas autorises aux termes des reglements, la possession de toute substance inscrite aux annexes I, II ou III est interdite. Trafic de substances 5. (1) Il est interdit de faire le trafic de toute substance inscrite aux annexes I, II, III ou IV ou de toute substance presentee ou tenue pour telle par le trafiquant. Exemption par le ministre 56. S'il estime que des raisons medicales, scientifiques ou d'interet public le justifient, le ministre peut, aux conditions qu'il fixe, soustraire a l'application de tout ou partie de la presente loi ou de ses reglements toute personne ou categorie de personnes, ou toute substance designee ou tout precurseur ou toute categorie de ceux-ci. 16 Rules of the Supreme Court of Canada (in force on October 13, 2006) Regles de la Cour supreme du Canada. (en vigueur le 13 octobre 2006) 59. (1) In an order granting an intervention, the judge may (a) make provisions as to additional disbursements incurred by the appellant or respondent as a result of the intervention; and (b)impose any terms and conditions and grant any rights and privileges that the judge may determine, including whether the intervener is entitled to adduce further evidence or otherwise to supplement the record. (2)In an order granting an intervention or after the time for filing and serving all of the memoranda of argument on an application for leave to appeal or the facta on an appeal or reference has expired, a judge may, in their discretion, authorize the intervener to present oral argument at the hearing of the application for leave to appeal, if any, the appeal or the reference, and determine the time to be allotted for oral argument. (3)An intervener is not permitted to raise new issues unless otherwise ordered by a judge. 59. (1) Dans l'ordonnance octroyant l'autorisation d'intervenir, le juge petit : a) prevoir comment seront supportes les &pens supplementaires de l'appelant ou de l'intime resultant de l'intervention; b) imposer des conditions et octroyer les droits et privileges qu'il determine, notamment le droit d'apporter d'autres elements de preuve ou de completer autrement le dossier. (2)Dans l'ordonnance octroyant l'autorisation d'intervenir ou aprês l'expiration du Mai de depOt et de signification des memoires de demande d'autorisation d'appel, d'appel ou de renvoi, le juge peut, a sa discretion, autoriser l'intervenant a presenter une plaidoirie orale a l'audition de la demande d'autorisation d'appel, de l'appel ou du renvoi, selon le cas, et determiner le temps alloue pour la plaidoirie orale. (3) Sauf ordonnance contraire d'un juge, l'intervenant n'est pas autorise a soulever de nouvelles questions.
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Healthy Living: CMA's Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy10058
Date
2011-02-08
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2011-02-08
Topics
Population health/ health equity/ public health
Text
I would like to thank the Committee for inviting the Canadian Medical Association to appear on this very important topic. As a family physician in Saskatoon and the past president of the CMA, I can assure you that Canada's physicians have an acute interest in drawing attention to the health consequences of poor nutrition and lack of physical activity, and the challenge of obesity. We know that obesity is a contributor to a number of chronic diseases, such as diabetes, cardiovascular disease, hypertension and liver disease, as well as breast, colon and prostate cancer. We know that over-consumption of salt, sugars, and saturated and trans fats can be a factor in hypertension, cardiovascular disease and stroke, and kidney disease. And we know that Canadians have become dramatically less physically fit in recent decades. As a country, we need to espouse a culture of health and wellness, based on good nutrition and physical activity. Finding solutions will require a collaborative, system-wide approach involving all levels of government, the health, education, industry, finance and transportation ministries, and the private sector. We know that if provided with support when young, children can adopt healthy life styles. That is why the CMA continues to call on governments across the country to work with school boards to: * provide at least 30 minutes of active daily physical education for all primary and secondary grades, given by trained educators in the field; * provide access to attractive, affordable, healthy food choices and clearly post the nutrition content of the foods they sell; and * ban junk food sales in all primary, intermediate and secondary schools in Canada. The CMA has advocated policies and regulations for food safety, and promoted healthy eating and physical activity as key components of healthy living and the prevention of disease. The CMA policy statement Promoting Physical Activity and Healthy Weights calls for a Canada-wide strategy for healthy living that includes: * information and support for Canadians to help them make healthy choices; * support for health professionals in counselling patients on healthy weight and in treating existing obesity; * community infrastructure that makes healthy living choices easier; and * public policies that encourage healthy eating and physical activity. All Canadians need access to nutritious food at affordable prices. The price of milk, produce and other healthy foods varies greatly in different parts of Canada. In remote areas, they are even more expensive because of high transportation costs. In urban areas, nutritious food may be unaffordable for people on low incomes and unavailable as grocery stores move to the suburbs thus creating "food deserts". Among other strategies, governments should consider: implementing school meal programs; and taking into account the cost of nutritious food when setting social assistance rates. The proliferation of packaged, prepared foods and fast foods has contributed to excess amounts of salt, sugar, saturated and trans fat and calories in our diet. While we welcome the federal government's support for the reduction of trans fats and sodium levels in processed foods, reliance on the food industry to voluntarily reduce these ingredients has not been successful. We believe that regulation is needed to safeguard the health of Canadians. Healthy living begins with an awareness of the impact of food and exercise on health. While individuals must take responsibility for making healthy choices, the CMA believes that governments have an obligation to provide guidance on healthy eating and physical activity that can be easily incorporated into daily lives. We commend the federal and provincial/ territorial governments for their recent Framework for Action to Promote Healthy Weights. Physicians were also pleased to see the revised Canada's Food Guide in 2007, and the recent update to Canada's Physical Activity Guide. The CMA supports nutrition and caloric labeling on packaged foods to help Canadians make informed food choices. The federal nutrition labeling awareness initiative is useful to consumers but we think information can be simplified. For example, the UK is testing front of pack 'traffic light' coding for fats, salt, sugar and calories. The CMA has also called for a clear display of caloric counts, and sodium, trans-fats and protein levels on restaurant and cafeteria menus. The CMA believes encouragement of active transportation, that is walking and cycling, is a way to increase physical activity. Communities need to make it easier for Canadians to be physically active in their day-to-day life by providing sidewalks and pedestrian-friendly intersections; bike lanes, paths and parking spaces; and trails, parks and green spaces. One area that we believe warrants further study is the use of incentives to promote healthy behaviours. By transferring funds or other benefits to an individual, incentives provide immediate rewards for behaviours that can lead to long-term health gains. An example in Canada is the Children's Fitness Tax Credit, which is intended to help children be more active by off-setting some of the costs incurred by families for sports and leisure programs. Government disincentives largely involve the use of regulation and taxation in order to change individual behaviour. This helps to create an environment in which healthy choices are easier to make. It is impossible to overstate the importance of nutrition and physical activity to our health. Encouraging Canadians to make healthy choices requires a wide ranging, long-term and collaborative approach. The CMA believes this challenge should be met urgently. Canada's physicians are more than ready to work with governments to ensure that Canadians can improve and maintain their health.
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Nutrition Labelling: CMA's Presentation to the House of Commons Standing Committee on Health

https://policybase.cma.ca/en/permalink/policy10085
Date
2011-03-03
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Parliamentary submission
Date
2011-03-03
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Thank you very much for inviting the Canadian Medical Association back to this committee as you continue your study on healthy living. A few weeks ago my colleague Dr. Doig was here to talk about the health consequences of poor nutrition and lack of physical activity and the policies CMA has advocated to promote healthy living. Today I would like to expand upon nutrition labelling and health claims on foods, and on the labelling of foods regulated as natural health products. Nutrition facts tables can be an important source of information, but many Canadians have difficulty interpreting them. A 2009 Health Canada review of research on nutrition labelling indicated that: * those with little nutrition knowledge have difficulty using the tables and are unable to relate the information they contain to their own dietary needs; and that * the concept of percentage of daily value is often misunderstood. There has been an increase in the use of health claims on the front of packaging expressed as slogans or logos such as "healthy choice," as well as in disease reduction and nutrient content claims. Studies have shown that foods carrying health-related claims are seen by consumers as healthier choices. But the myriad of different claims can be confusing and may, in fact, draw attention away from the less healthy characteristics of a food, or oversimplify complex nutritional messages. We believe a standard consistent "at a glance" approach to front-of-package food labelling could reduce confusion and help consumers make informed dietary choices. The "traffic light" front-of-pack labelling currently in voluntary use in the UK is an example. The front-of-pack labels on composite processed foods use green, amber and red to indicate low, medium or high levels of the nutrients most strongly associated with diet-related health risks: fat, saturated fat, sugars and salt. Also included is calorie count per serving and percentage daily amount information. Research in the UK has shown that consumers generally understand these labels. Shoppers are most likely to use them when buying a product for the first time; to compare different products; when shopping for children; when trying to control intake of certain ingredients such as fat or salt, for health reasons; or when trying to lose weight. Not surprisingly, research in the UK and Canada also shows that those most likely to read nutrition labels are those who are already interested in healthy eating. For this reason, labelling policy must be embedded in a broader nutrition policy that uses multiple instruments to foster education and interest in healthy eating, and helps ensure that Canadians have healthy food choices by, for example, regulating amounts of salt in processed food. In addition, physicians have become quite concerned about a recent tendency toward regulating 'fortified foods 'as Natural Health Products. The Food and Drugs Act effectively prevents products classified as foods from being marketed as having medicinal benefits unless there is compelling scientific evidence that the claims are true and the products are safe. The same strong legislation does not apply to Natural Health Products (NHPs), which are regulated under a different act. This is a concern because a trend is emerging whereby manufacturers of products normally sold as foods fortify their products with approved natural health products such as vitamins or minerals. Examples of these are energy drinks and vitamin-enhanced juice, power bars, gums and candy. The manufacturer can then request federal approval to market the product as a 'health product in food format.' If approved, food labelling requirements no longer apply and health claims that would not be allowed under the Food and Drugs Act can be made. Without proper nutrition labelling, it is difficult, if not impossible, for consumers to make informed food choices. This can be particularly troubling for those with special diets or health concerns. Further, those misled by dubious health claims might be consuming empty calories or high amounts of fat or sodium, with no corresponding benefit. The result is that the health of Canadians may be compromised. The CMA has called on Health Canada to require compelling evidence of health benefits before changing a product's regulatory status from food to natural health product, and nutrition labelling for all foods regulated as a natural health product. Faced with an array of products and health claims, and a barrage of advertising extolling their benefits, Canadians can find it challenging to make healthier food choices. To find our way through to the right choice, we need good nutritional information, and the ability to access and understand this information. Governments and health care providers share a responsibility to help Canadians make choices that will help them achieve and maintain good health. Canada's doctors are partners in healthy living and are ready to work with governments and others toward a healthy population. I welcome your questions.
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Joint position statement: The role of health professionals in tobacco cessation

https://policybase.cma.ca/en/permalink/policy10090
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-03-05
Replaces
Tobacco : the role of the health professional in smoking cessation : joint statement (2001)
Topics
Population health/ health equity/ public health
Text
The Role of Health Professionals in Tobacco Cessation - Joint position statement This statement was developed cooperatively by the Canadian Association of Occupational Therapists, Canadian Counselling and Psychotherapy Association, Canadain Dental Hygienists Association, Canadian Medical Association, Canadian Nurses Association, and Canadian Physiotherapy Association. POSITION There is a role for every Canadian health professional in tobacco-use cessation.1 Tobacco use2 inflicts a heavy burden on Canadians' health and on the Canadian health-care system, and health professionals can advocate effectively for tobacco-use cessation at the clinical and public health levels. As providers of client and patient-centered services, health professionals are involved in tobacco cessation by: * assessing and documenting all forms of tobacco use, willingness to quit and risk of exposure to second-hand smoke; * discussing with clients and patients the negative health effects of tobacco use and exposure to second-hand smoke, and the health and other benefits (e.g., financial) of becoming tobacco free; * offering to help, and helping, tobacco users to quit; * offering a variety of tobacco-cessation strategies (e.g., counselling, behavioural therapy, self-help materials, pharmacotherapy) as appropriate to their knowledge, skills and tools; * providing strategies for non-smokers to help them reduce their exposure to second-hand smoke; * being knowledgeable about and providing referrals to community-based initiatives and resources; * recognizing that relapse occurs frequently, and conducting follow-up assessment and intervention; * tailoring interventions to the needs of specific populations (e.g., age, gender, ethnicity, diagnosis, socio-economic status); and * using a collaborative, multidisciplinary approach. As educators and researchers, health professionals are involved in tobacco cessation by: * including education on tobacco-cessation strategies and strategies for resisting tobacco use in basic education programs for health professionals; * providing professional development programs for health professionals on tobacco cessation; * conducting research to encourage and improve health professionals' knowledge and provision of tobacco cessation; and * communicating research evidence about tobacco-cessation strategies. As administrators of health-care organizations, health professionals are involved in tobacco cessation by: * offering training on tobacco cessation as part of employee orientation; * providing access to professional education on tobacco cessation for employees; * enforcing applicable bans on tobacco wherever health professionals are employed (e.g., health-care facilities, private homes); and * ensuring that tobacco-cessation programs and tobacco-free workplaces are included in accreditation standards. As public health advocates, health professionals are involved in tobacco cessation by: * increasing public awareness that health professionals can help people remain tobacco free or stop using tobacco; and * advocating for federal, provincial and territorial governments' investment in comprehensive tobacco control that includes programs, legislation and policies to prevent the uptake of tobacco and reduce tobacco use (e.g., bans on tobacco advertising). Programs must focus on health promotion and include community-based initiatives. BACKGROUND Tobacco is an addictive and harmful product, and its use is the leading cause of preventable death in Canada.3 Each year in Canada, more than 37,000 people die prematurely due to tobacco use.4 Approximately 17 per cent of the population 15 years of age and older (about 4.8 million Canadians) smoke.5 Strong evidence has revealed that smoking is associated with more than two dozen diseases and conditions.6 The economic costs of tobacco use are estimated at $17 billion annually ($4.4 billion in direct health-care costs and $12.5 billion in indirect costs such as lost productivity).7 Second-hand smoke is also harmful. Each year, more than 1,000 non-smoking Canadians die due to second-hand smoke.8 Exposure to second-hand smoke is the number two cause of lung cancer (smoking is the number one cause).9 Second-hand smoke can also aggravate allergies, bring about asthma attacks and increase the risk of bronchitis and pneumonia.10 Research also suggests that there may be a link between second-hand smoke and the risk of breast cancer.11 Tobacco use is the result of the complex interaction of individual and social factors, such as socio-economic status, having family members who smoke and exposure to marketing tactics of the tobacco industry. Reduction and elimination of tobacco use requires comprehensive, multi-faceted strategies addressing both physical dependence and social context. Such strategies will include: * prevention - helping to keep non-users from starting to use tobacco; * cessation - helping current smokers to quit, and helping prevent relapse; and * protection - protecting all Canadians from the harmful effects of tobacco use and from the influences of tobacco industry marketing. Prevention is the most important strategy of the three; being tobacco-free is a vital element of a healthy active life. Thus, for current tobacco users, quitting is the single most effective action they can take to enhance the quality and length of their lives. Most tobacco users would like to improve their health, and in a Canadian survey 30 per cent of all smokers stated that they intended to quit as means of doing so.12 Indeed, in studies in Canada, the U.K. and Germany, smokers rated health concerns and current health problems as the primary reason for wanting to quit;13 other reasons why smokers quit include the cost of cigarettes14 and persistent advice to quit from family15 and health professionals.16 However, the relapse rate is very high because of the addictive nature of tobacco.17 Most smokers attempt to quit several times before they finally succeed. Smoking cessation counselling is widely recognized as an effective clinical strategy. Even a brief intervention by a health professional significantly increases the cessation rate.18 Furthermore, counselling programs that initiate follow-up calls to smokers as a "proactive" measure have been found to increase smoking-cessation rates by 50 per cent.19 The majority of Canadians consult a health professional at least once a year,20 creating several "teachable moments" when they may be more motivated than usual to change unhealthy behaviours.21 A smoker's likelihood of quitting increases when he or she hears the message from a number of health-care providers from a variety of disciplines.22 However, health professionals encounter barriers that require solutions, notably: - the need for better education for health professionals (e.g., how to identify smokers quickly and easily, which treatments are most effective, how such treatments can be delivered); - the need to allow for sufficient time to provide counselling; - the need to focus on preventive care by * increasing funding for preventive care (e.g., providing reimbursement for smoking cessation interventions, follow-up or support); and * encouraging health-care settings to facilitate preventive care (e.g., access to quick reference guides or tools to identify people with specific risk factors); - the need to increase public awareness of the smoking cessation services a health professional can provide; and - the need to recognize the frustration associated with the high rate of relapse. Because of the powerful nature of tobacco dependence, smokers often go through a long period of reaching readiness before they finally quit. References Bao Y., Duan N., & Fox S. A. (2006). Is some provider advice on smoking cessation better than no advice? An instrument variable analysis of the 2001 National Health Interview Survey. Health Services Research, 41(6), 2114-2135 Breitling, L. P., Rothenbacher, D., Stegmaier, C., Raum, E., & Brenner, H. (2009). Older smokers' motivation and attempts to quit smoking. Deutsches Arzteblatt International, 106(27), 451-455. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment. (2008). Dynamic guidelines for tobacco control in Canada Version 1.0 [Wiki clinical practice guidelines]. Toronto: Author. Canadian Cancer Society. (2010). Second-hand smoke is dangerous. Toronto: Author. Retrieved May 19, 2010, from http://www.cancer.ca/canada-wide/prevention/quit%20smoking/second-hand%20smoke.aspx Canadian Centre on Substance Abuse, (2006). The costs of substance abuse in Canada in 2002. Ottawa: Author. Canadian Lung Association. (2006). Smoking and tobacco: Second-hand smoke. Retrieved June 14, 2010, from http://www.lung.ca/protect-protegez/tobacco-tabagisme/second-secondaire/hurts-nuit_e.php Canadian Dental Hygienists Association. (2004). Tobacco use cessation services and the role of the dental hygienist - a CDHA position paper. Canadian Journal of Dental Hygiene, 38(6), 260-279. Canadian Medical Association. (2008). Tobacco control [Policy statement]. Ottawa: Author. Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., & Curry, S. J. (2008). Treating tobacco use and dependence: 2008 update [Clinical practice guideline]. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service. Health Canada. (2009). Smoking and your body: Health effects of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/body-corps/index-eng.php Health Canada. (2007). Overview of health risks of smoking. Ottawa: Author. Retrieved June 17, 2010, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/res/news-nouvelles/risks-risques-eng.php Nabalamba, A, & Millar, W. J. (2007). Going to the doctor [Statistics Canada, catalogue 82-003]. Health Reports, 18(1), 23-35. Retrieved January 26, 2011, from http://www.statcan.gc.ca/pub/82-003-x/2006002/article/doctor-medecin/9569-eng.pdf Physicians for a Smoke-Free Canada. (2005). Smoking in Canada: A statistical snapshot of Canadian smokers. Ottawa: Author. Retrieved May 14, 2010, from http://www.smoke-free.ca/pdf_1/SmokinginCanada-2005.pdf Registered Nurses' Association of Ontario. (2007). Integrating smoking cessation into daily nursing practice [Nursing best practice guideline]. Toronto: Author. Ross, H., Blecher, E., Yan, L., & Hyland, A. (2010) Do cigarette prices motivate smokers to quit? New evidence from the ITC survey. Addiction, November 2010. Shields, M. (2004). A step forward, a step back: Smoking cessation and relapse. National Population Health Survey, Vol. 1, No. 1. Ottawa: Statistics Canada. Statistics Canada. (2009). Canadian tobacco use monitoring survey (CTUMS): CTUMS 2009 wave 1 survey results. Ottawa: Author. Retrieved January 25, 2011, from http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/research-recherche/stat/_ctums-esutc_2009/w-p-1_sum-som-eng.php Stead, L. F., Lancaster, T., & Perera, R. (2006). Telephone counselling for smoking cessation (review). Cochrane Database of Systematic Reviews, Issue 3. Vangeli, E., & West, R. (2008). Sociodemographic differences in triggers to quit smoking: findings from a national survey. Tobacco Control, 17(6), 410-415. Young, R.P., Hopkins, R.J., Smith, M., & Hogarth, D.K. (2010). Smoking cessation: The potential role of risk assessment tools as motivational triggers. Post Graduate Medical Journal, 86(1011), 26-33. Replaces: Tobacco: The role of health professionals in smoking cessation [Joint position statement]. (2001) 1 For detailed recommendations and guidelines for tobacco treatment related to health professionals, see Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, (2008); Registered Nurses' Association of Ontario, (2007); and Canadian Dental Hygienists Association, (2004). 2 For the purpose of this position statement, tobacco includes products that can be inhaled, sniffed, sucked or chewed (e.g., flavoured cigarillos, kreteks, chewing tobacco, moist snuff, betel or qat, hookah or shisha, bidis, cigars and pipes). 3 (Health Canada, 2009) 4 (Health Canada, 2007) 5 (Statistics Canada, 2009) 6 (Health Canada, 2007) 7 (Canadian Centre on Substance Abuse, 2006) 8 (Canadian Cancer Society, 2010) 9 (Canadian Lung Association, 2006) 10 (Canadian Cancer Society, 2010) 11 (Canadian Cancer Society, 2010) 12 (Physicians for a Smoke-Free Canada, 2005) 13 (Vangeli & West, 2008; Ontario Tobacco Research Unit - Tobacco Informatics Monitoring System (TIMS), 2008; Breitling, Rothenbacher, Stegmaier, Raum & Brenner, 2009) 14 (Ross, Blecher, Yan & Hyland, 2010) 15 (Young, Hopkins, Smith & Hogarth, 2010) 16 (Bao, Duan & Fox, 2006) 17 (Fiore et al., 2008; Shields, 2004) 18 (Fiore et al., 2008) 19 (Stead, Lancaster & Perera, 2006) 20 (Nabalamba & Millar, 2007) 21 (Canadian Medical Association, 2008) 22 (Fiore et al., 2008)
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Recommended guidelines for low-risk drinking

https://policybase.cma.ca/en/permalink/policy10143
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2019-03-03
Date
2011-03-05
Topics
Population health/ health equity/ public health
Text
Note: These Guidelines are not intended to encourage people who choose to abstain for cultural, spiritual or other reasons to drink, nor are they intended to encourage people to commence drinking to achieve health benefits. People of low bodyweight or who are not accustomed to alcohol are advised to consume below these maximum limits. Guideline 1 Do not drink in these situations: When operating any kind of vehicle, tools or machinery; using medications or other drugs that interact with alcohol; engaging in sports or other potentially dangerous physical activities; working; making important decisions; if pregnant or planning to be pregnant; before breastfeeding; while responsible for the care or supervision of others; if suffering from serious physical illness, mental illness or alcohol dependence. Guideline 2 If you drink, reduce long- term health risks by staying within these average levels: Women Men 0–2 standard drinks* per day 0–3 standard drinks* per day No more than 10 standard drinks per week No more than 15 standard drinks per week Always have some non-drinking days per week to minimize tolerance and habit formation. Do not increase drinking to the upper limits as health benefits are greatest at up to one drink per day. Do not exceed the daily limits specified in Guideline 3. Guideline 3 If you drink, reduce short- term risks by choosing safe situations and restricting your alcohol intake: Risk of injury increases with each additional drink in many situations. For both health and safety reasons, it is important not to drink more than: Three standard drinks* in one day for a woman Four standard drinks* in one day for a man Drinking at these upper levels should only happen occasionally and always be consistent with the weekly limits specified in Guideline 2. It is especially important on these occasions to drink with meals and not on an empty stomach; to have no more than two standard drinks in any three-hour period; to alternate with caffeine-free, non-alcoholic drinks; and to avoid risky situations and activities. Individuals with reduced tolerance, whether due to low bodyweight, being under the age of 25 or over 65 years old, are advised to never exceed Guideline 2 upper levels. Guideline 4 When pregnant or planning to be pregnant: The safest option during pregnancy or when planning to become pregnant is to not drink alcohol at all. Alcohol in the mother's bloodstream can harm the developing fetus. While the risk from light consumption during pregnancy appears very low, there is no threshold of alcohol use in pregnancy that has been definitively proven to be safe. Guideline 5 Alcohol and young people: Alcohol can harm healthy physical and mental development of children and adolescents. Uptake of drinking by youth should be delayed at least until the late teens and be consistent with local legal drinking age laws. Once a decision to start drinking is made, drinking should occur in a safe environment, under parental guidance and at low levels (i.e., one or two standard drinks* once or twice per week). From legal drinking age to 24 years, it is recommended women never exceed two drinks per day and men never exceed three drinks in one day. 2 Approved by the CMA Board in March 2011 Last reviewed and approved by the CMA Board in March 2019. The above is excerpted from the report, Alcohol and Health in Canada: A Summary of Evidence and Guidelines for Low-Risk Drinking Available: https://www.ccsa.ca/sites/default/files/2019-04/2011-Summary-of-Evidence-and-Guidelines-for-Low-Risk%20Drinking-en.pdf (accessed 2019 March 01).
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Determining the impact of chemical contamination on human health

https://policybase.cma.ca/en/permalink/policy10149
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Population health/ health equity/ public health
Text
Industrialization and manufacturing have had enormous positive benefits for humankind, but the consequences of hazardous by-products (chemical contamination) to human health and the environment are less well recognized. A major incident such as Bhopal is an unequivocal example of catastrophic poisoning caused by industry. However, more subtle human health impacts can result from low levels of exposure to chemical and industrial by-products from agriculture, consumer products, manufacturing, and even medical sources. Chemicals from industrial sources have been found in the soil, water, air, food and human tissue. Due to improving technology, even minuscule amounts of potentially noxious substances can be detected. Some exposures warrant remedial action, but in others the health impact may be negligible: the toxin, dose, route and duration of exposure must be considered. Of course, there are potentially toxic substances that have been found to pose little or no harm to human health, but there are many more for which the health effects are unknown. A substantial knowledge gap exists in that the effects of many chemical agents have not been fully studied. As a result, rigorous surveillance and assessment to ensure potential health impacts are reduced or avoided is necessary. Chemicals like dichlorodiphenyltrichloroethane (DDT) can persist in the environment or in living beings long after the product was pulled from the market, making it essential that full and rigorous testing of new and existing chemicals is undertaken. Finally, research is needed to determine whether emerging issues, such as the presence of pharmaceuticals in drinking water, pose a legitimate threat to human health. Chemicals, properly managed, can and will continue to provide enormous benefits to society, but caution is warranted because of the potential health consequences. Provided below is a discussion of certain classes of chemicals that need to be regulated, monitored and properly researched. Agriculture Agriculture represents the largest component of the global economy. Rising pressures to meet the needs of a growing population have resulted in the mechanization of farming, and the widespread use of fertilizers and pesticides.1 Fertilizer and pesticide run-off has been found in soil, water and the human food supply.2 Approximately 40 chemicals classified by the International Agency for Research on Cancer (IARC) as known, probable, or possible human carcinogens, are EPA registered pesticides available on the open market.3 Long-term low dose pesticide exposure has been linked to various cancers, immune suppression, hormonal disruption, reproductive abnormalities, birth defects, and developmental and behavioural problems.4 Certain pesticides are also known to be persistent in the human body.5 While many individual pesticides can be safely used, there is a lack of research on the effect of certain pesticides when used in combination. Consumer Products Modern technologies have led to advances with a positive impact on the quality of human life. While newer consumer products have benefits over earlier materials, their use is not without side effects. Both the chemicals used to make these products and those that form key components of the products themselves may be harmful. Bisphenol A (BPA) is an industrial chemical added to many hard plastic bottles and to metal based food and beverage cans since the 1960s.6 In August 2010, Statistics Canada reported that measurable levels of BPA were found in the urine of 91 per cent of Canadians aged six to 79.7 Concerns have been raised about effects on the brain, behaviour, and prostate gland from exposure to this chemical, particularly in fetuses, infants, and children.8 In 2008, Canada banned BPA in infant bottles.9 In October 2010, Canada went a step further by becoming the first jurisdiction in the world to declare BPA toxic.10 Manufacturing With the growing demand for consumer products, there has been a corresponding growth in manufacturing. Manufacturing is one of the biggest contributors to outdoor air pollution, and contributes to soil and water pollution.11 In 2004, US industry released 1.8 billion pounds of potentially toxic chemicals. Exposure to some of these chemicals has been linked to severe health effects, including cancer. 12 One of the released chemicals, dioxin, can be harmful at very low levels. Dioxins accumulate in fats and break down slowly. This leads to contamination of the food supply, and human exposure through the consumption of meat, dairy, fish and shellfish.13 Even in the far north, animals have been found to contain dioxins.14 The EPA estimates that the cancer risk from dioxins already present in the general public is 1-per-1,000.15 In most cases the emissions pose minimal risk to human health. However, chemicals, and chemical combinations which remain unstudied should be properly assessed.16 Medical Practices Advancements in medical science and the use of pharmaceuticals, diagnostic equipment and other medical treatments have prolonged life expectancy. However, these interventions can also contribute to environmental contamination. In 2008, the Associated Press reported pharmaceuticals in the water of 24 major metropolitan areas in the United States, serving 41 million people.17 There is a concern that these pharmaceuticals could negatively impact male fertility, lead to birth defects, cause breast and testicular cancer in humans, and lead to antibiotic resistance.18 For many pharmaceuticals found in water sources, no concerted environmental impact surveys have been carried out.19 Mercury is used in fever thermometers, sphygmomanometers, gastrointestinal tubes, and oesophageal dilators20. Reports indicate that medical waste incinerators are among the largest sources of anthropogenic mercury emissions in both the United States and Canada.21 Medical waste, while not the principle source of mercury poisoning, contributes to the mercury levels present in the environment. In fetuses, infants and children, low-dose exposure to mercury can cause severe and lifelong behavioural and cognitive problems.22 At higher exposure levels, mercury may adversely affect the kidneys, the immune, neurological, respiratory, cardiovascular, gastrointestinal, and haematological systems of adults.23 It has also been linked to cancer.24 These examples highlight the major categories of human exposure to chemicals. As the review suggests, some of these chemicals have been linked to harmful human health impacts. What is important to keep in mind, however, is that the harm is conditional on the level and lengths of exposure. For most people, these chemicals pose no harm because the exposure is so low. In some cases, such as BPA, it has been determined that the potential harm is not worth the risk: the Canadian government has decided to declare BPA toxic and regulate it accordingly. In other cases, such as pharmaceuticals, the evidence simply warrants further study and surveillance. Given the potential harm to human health, surveillance and research are vitally important in all categories. The more information that is available to policy makers and health care professionals, the better the chance of limiting human health impacts. What has been done? International Action Concerns regarding chemical contamination and human health have led to numerous interventions from the international community. These include the International Programme on Chemical Safety (1980), the Inter-Organization Programme for the Sound Management of Chemicals (1995), the Globally Harmonized System of Classification and Labelling (2002), and the Strategic Approach to International Chemicals Management, which was adopted by governments and stakeholders at the first International Conference on Chemicals held in Dubai in 2006. 25 Various conventions have also been passed, including the Stockholm Convention (2004) on persistent organic pollutants such as DDT, and the Rotterdam Convention (2004) which applies to pesticides and industrial chemicals.26 There is some concern about the continued effectiveness of the Rotterdam convention. In 2006, the Canadian government was instrumental in preventing the listing of asbestos as a toxic chemical. Given the persuasive evidence of the harm caused by asbestos, this action undermines the legitimacy of voluntary international conventions.27 Canadian Action In addition to being a signatory to all international agreements listed above, the Canadian government has programs for chemical management domestically. The main tool is the Canadian Environmental Protection Act (CEPA) 1999. Jointly administered by Environment Canada and Health Canada, it is intended to prevent pollution and address the potentially dangerous chemical substances to which Canadians are exposed.28 The plan calls for increased surveillance of certain chemicals to monitor exposure and health effects, and will increase focus on the management of the health and environmental risks of pharmaceuticals, personal care products, and chemical contamination in food.29 There were 23,000 chemical substances on the Domestic Substances List (DSL) in Canada in 1999. To date, only about 1,000 of these chemicals have been fully assessed. Of the remaining 22,000, 85% have been categorized as not requiring any additional action.30The most recent Canadian Chemicals Management Plan states that full assessments will be done on 550 substances identified as potentially harmful. Even with these additional assessments, more than 3,000 chemicals will not have been assessed. Canadian Medical Association In 2009, the Canadian Medical Association and the Canadian Nurses Association released a joint position statement on environmentally responsible activity for the health-care sector. Recommendations included the proper handling and disposal of toxic chemicals and the reduction of products using these substances. An adapted version of this position statement was then endorsed by a coalition of 12 national healthcare organizations and the David Suzuki Foundation. In October 2010, the World Medical Association, of which CMA is a member, adopted a policy statement on environmental degradation and the management of chemicals. The statement calls for mercury-free health care, support for international efforts to restrict chemical pollution and to monitor harmful chemicals in humans and the environment, and mitigation of the health effects of toxic exposure to chemicals. What needs to be done? Research and Surveillance Research on chemicals produced through man-made activities remains insufficient. While some of the more toxic chemicals have been reviewed and are now more closely regulated, thousands remain that have had neither health nor environmental assessments. The Domestic Substances List in Canada has 3,300 chemicals of concern that have not been assessed. There is limited research on the effect of these chemicals in combination or in different mediums. Finally, work must be done to ensure environmental and human surveillance of potential chemical exposure threats. The CMA: 1. Urges the government to complete the health and environmental assessment of the chemicals on the Domestic Substances List. 2. Encourages research on the health impacts of chemical substances, as well as the combinations of these substances in different products (e.g. pesticides), and in different mediums (e.g. pharmaceuticals in drinking water). Long-term research programs are required to determine health impacts from prolonged low-dose exposures. 3. Encourages ongoing surveillance of chemicals in the environment. 4. Encourages ongoing research on the impact of regulations and monitoring of chemicals on human health and the environment. Advocacy Regulations have been developed both internationally and domestically to undertake chemical management. However, gaps remain, largely due to the voluntary nature of the frameworks. Canada can play a lead role by respecting its commitments, seeking continued adherence to these agreements and providing leadership in developing effective domestic programs and legislation. The CMA: 5. Urges the government to continue to support international efforts to manage chemical pollution. In particular CMA urges the government to fully support the principles of the Rotterdam Convention and support the listing of Asbestos as an Annex III toxic chemical. 6. Supports government legislation and regulation which reduces dangerous chemical pollution, detects and monitors harmful chemicals in both humans and the environment, mitigates the health effects of toxic exposures, and requires an environmental and health impact assessment prior to the introduction of a new chemical. Regulatory frameworks should be favoured over voluntary frameworks in order to ensure a level playing field for all manufacturers and to secure rapid and equitable health protection for all Canadians. CMA encourages the government to advocate for similar legislation internationally. Leadership Physicians can participate in the monitoring of patients for potential health effects from chemical exposure. Additionally, physicians can be leaders in encouraging greener health care practices. Finally, physicians can support national medical organizations in developing clinical tools to assess patient risk to chemical exposure. The CMA: 7. Supports the phase out of mercury and other persistent, bio-accumulating and toxic chemicals in health care devices and products. 8. Supports the development of effective and safe systems to collect and dispose of pharmaceuticals that are not consumed. 9. Supports the development of clinical tools for physicians to help assess their patients' risk from chemical exposures. Education and Professional Development Physicians have a role to play in educating their patients, the public, and current and future colleagues about the potential human health consequences of chemical contamination. Medical education and continuing professional development in this area could have a significant impact on human health. The CMA: 10. Should assist in building professional and public awareness of the impact of the environment and global chemical pollutants on personal health. 11. Supports the development of locally appropriate continuing medical education on the clinical signs, diagnosis and treatment of diseases that are introduced into communities as a result of chemical pollution. 12. Encourages physicians to inform patients about the importance of safe disposal of pharmaceuticals that are not consumed. Conclusion National and International initiatives have substantially reduced the incidence of harmful chemical contamination, but more work is needed. Evidence of health effects (or lack thereof) may be strong for certain chemicals, but for others it remains incomplete. Given the dangers of chemicals such as dioxin, which can cause severe effects with small doses, more comprehensive research is warranted. To ensure human health consequences are identified and risks are minimized, improved surveillance is essential. Further policies and regulations are needed to ensure that chemicals utilized are as safe as possible. The Canadian BPA ban demonstrates the use of the precautionary principle in the presence of convincing if not complete evidence. While there are clear benefits associated with the use of chemicals, it is necessary to ensure that potential harmful effects are considered.' Finally, public and health care provider information is sorely lacking. Physicians can play a role in correcting some of these deficiencies through their actions to support research and surveillance, advocacy, leadership, education, and professional development. References 1 Ongley, Edwin D. (1996) Control of water pollution from agriculture- FAO irrigation and drainage paper 55.Chapter 1: Introduction to agricultural water pollution Food and Agriculture Organization of the United Nations. Available at: http://www.fao.org/docrep/w2598e/w2598e00.HTM 2 Peters, Ruud J.B. (2006) Man-Made Chemicals in Food Products. TNO Built Environment and Geosciences. Available at: http://assets.panda.org/downloads/tno_report.pdf 3 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk: What We Can Do Now: 2008-2009 Annual Report. President's Cancer Panel. Available at: http://deainfo.nci.nih.gov/advisory/pcp/annualReports/pcp08-09rpt/PCP_Report_08-09_508.pdf 4 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk...; Shah, Binod P. & Bhupendra Devkota (2009) "Obsolete Pesticides: Their Environmental and Human Health Hazards." The Journal of Agriculture and Environment. Vol:10 June 2009. Available at: http://www.nepjol.info/index.php/AEJ/article/view/2130/1961 ; Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution: Burden and Strategies for Control in Disease Control Priorities in Developing Countries. Disease Control Priorities Project. Available at: http://files.dcp2.org/pdf/DCP/DCP43.pdf 5 California Environmental Protection Agency (2002) Environmental Protection Indicators for California: Chapter 3: Environmental Exposure Impacts Upon Human Health. Available at: http://oehha.ca.gov/multimedia/epic/2002reptpdf/Chapter3-7of8-HumanHealth.pdf 6 United States Food and Drug Administration (2010) Update on Bisphenol A for Use in Food Contact Applications. Available at: http://www.fda.gov/newsevents/publichealthfocus/ucm064437.htm 7 CBC News (October 13, 2010) BPA declared toxic by Canada. Available at: http://www.cbc.ca/health/story/2010/10/13/bpa-toxic.html 8 States Food and Drug Administration (2010) Update on Bisphenol A... 9 Health Canada (2008) Government of Canada Protects Families with Bisphenol A Regulations Available at: http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2008/2008_167-eng.php 10 CBC News (October 13, 2010) BPA declared toxic by Canada... 11 Kjellstrom, Tord et.al. (2006) Chapter 43: Air and Water Pollution... 12 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health: An Analysis of Toxic Chemicals Released in Communities across the United States. U.S. PIRG Education Fund. Available at: http://cdn.publicinterestnetwork.org/assets/KTfes5EXnCLOgG9eWTKU6g/ToxicPollutionandHealth2007.pdf 13 World Health Organization (2010) Dioxins and their effects on human health. Available at: http://www.who.int/mediacentre/factsheets/fs225/en/index.html 14 Woolford, Julian & Noemi Cano Ed. (2006) Killing them softly... 15 Cassady, Alison & Alex Fidis (2007) Toxic Pollution and Health... 16 Ibid 17 Natural Resources Defense Council (2010) Dosed Without Prescription: Preventing Pharmaceutical Contamination of Our Nation's Drinking Water. Available at: http://www.nrdc.org/health/files/dosed4pgr.pdf 18 Wright-Walters, Maxine & Conrad Volz (2009) Municipal Wastewater Concentrations of Pharmaceutical and Xeno-Estrogens: Wildlife and Human Health Implications. Available at: http://www.chec.pitt.edu/Exposure_concentration_of_Xenoestrogen_in_pharmaceutical_and_Municipal_Wastewater__Final8-28-07%5B1%5D.pdf; Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment. Available at: www.epa.gov/osp/regions/emerpoll/daughton.ppt; Nikolaou, Anastasia; Meric, Sureyya & Despo Fatta (2007) "Occurrence patterns of pharmaceuticals in water and wastewater environments." Analytical and Bioanalytical Chemistry. 387: 1225-1234; Natural Resources Defense Council (2010) Dosed Without Prescription... 19 Daughton, Christian G. (N.D.) Pharmaceuticals and the Environment... 20 Environment Canada. (N.D.)Mercury and the Environment. Available at: http://www.ec.gc.ca/MERCURY/SM/EN/sm-mcp.cfm#MD 21 Health Care Without Harm (2007) The Global Movement for Mercury Free Health Care. Available at: http://www.noharm.org/lib/downloads/mercury/Global_Mvmt_Mercury-Free.pdf; World Health Organization (2005) Mercury in Health Care: Policy Paper. Available at: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf 22 Environmental Working Group (N.D.) Chemical Pollution: The Toll on America's Health. Available at: http://www.ewg.org/files/EWG-kid-safe-toll-on-health.pdf 23 California Environmental Protection Agency (2002) Environmental Protection Indicators... 24 Reuben, Suzanne H. (2010) Reducing Environmental Cancer Risk... 25 World Health Organization (N.D.) International Programme on Chemical Safety: About us. Available at: http://www.who.int/ipcs/en/; World Health Organization (N.D.) Inter-Organization Programme for the Sound Management of Chemicals. Available at: http://www.who.int/iomc/brochure/brochure_english.pdf; United Nations Economic Commission for Europe (N.D.) Globally Harmonized System of Classification and Labelling of Chemicals (GHS). Available at: http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html; Weinberg, Jack (2008) An NGO Guide to SAICM: The Strategic Approach to International Chemicals Management. Available at: http://www.ipen.org/ipenweb/documents/book/saicm%20introduction%20english.pdf 26 Eskenazi, Brenda et.al. (2009) "The Pine River Statement: Human Health Consequences of DDT Use." Environmental Health Perspectives. 117:1359-1367 Available at: http://www.eoearth.org/article/Human_Health_Consequences_of_DDT_Use#gen4; World Health Organization (N.D.) Rotterdam Convention: Share Responsibility. Available at: http://www.pic.int/home.php?type=t&id=5&sid=16 27 Kazan-Allen, Laurie (2007) Rotterdam Treaty Killed by Chrysotile Asbestos! International Ban Asbestos Secretariat. Available at: http://www.ibasecretariat.org/lka_rott_meet_geneva_oct_06.php 28 Government of Canada (2007) The Canadian Environmental Protection Act, 1999 (CEPA 1999). Available at: http://www.chemicalsubstanceschimiques.gc.ca/about-apropos/cepa-lcpe-eng.php 29 Government of Canada (2010) Chemicals Management Plan. Available at: http://www.chemicalsubstanceschimiques.gc.ca/plan/index-eng.php 30 Ibid.
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Medication use and seniors (Update 2017)

https://policybase.cma.ca/en/permalink/policy10151
Last Reviewed
2019-03-03
Date
2011-05-28
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
  1 document  
Policy Type
Policy document
Last Reviewed
2019-03-03
Date
2011-05-28
Replaces
Medication use and seniors
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Text
Older Canadians represent the fastest-growing segment of our population and are the largest users of prescription drugs. Seniors take more drugs than younger Canadians because, on average, they have a higher number of chronic conditions. According to the Canadian Institute for Health Information, in 2012, nearly two-thirds of seniors had claims for 5 or more drug classes, and more than one-quarter of seniors had claims for 10 or more drug classes. The number of drugs used by seniors increased with age. The use of multiple medications, or polypharmacy, is of concern in the senior population. The risk of drug interactions and adverse drug reactions is several-fold higher for seniors than for younger people. This phenomenon is associated with pharmacokinetic and pharmacodynamics factors in seniors, including changes in renal and hepatic function, increased sensitivity to drugs and, potentially, multiple medical problems. In older persons, adverse drug reactions are often complex and may be the direct cause of hospital admissions for acute care. Cognitive and affective disorders, for example, may be due to adverse reactions to sedatives or hypnotic drugs. Chronic pain is a common issue, and it is important to carry out research into and education for health care providers concerning the unique challenges of managing pain in older adults. The CMA supports the development of a coordinated national approach to reduce polypharmacy and prevent adverse drug reactions. Prescribers must be vigilant to optimize pharmacotherapy and in reconciling medications, taking into consideration physiological changes as a person ages. Deprescribing should be considered, reducing or stopping medications that may be harmful or no longer be of benefit, seeking to improve quality of life. There has been considerable interest in determining which factors affect prescribing behavior and how best to influence these factors. Strategies that improve prescribing practices include evidence-based drug information provided through academic detailing; objective continuing medical education; accessible, user-friendly decision support tools available at point of care; and electronic prescribing systems that allow physicians access to their patient's treatment and medication profiles. The following principles define the basic steps to appropriate prescribing for seniors.
Know the patient.
Know the diagnosis.
Know the drug history. Keep a medication list for each patient and review, update, reconcile and evaluate adherence at each visit. Instruct the patient to bring all prescription and over-the-counter medications, including medications prescribed by other physicians, and natural health products, to each appointment. In some provinces, pharmacists conduct medication use reviews for patients on public drug benefit programs.
Know the history of use of other substances such as alcohol, tobacco, cannabis, opioids and caffeine.
Consider non-pharmacologic therapy, including diet, exercise, psychotherapy or community resources. Continuing medical education in specific non-pharmacologic therapies is valuable. For example, evaluation and management of behavioural and psychological symptoms of dementia should be considered before anti-psychotic therapy. As well, Canadian standardized non-pharmacologic order sets should be developed for the treatment of delirium.
Know the drugs. Critically evaluate all sources of drug information and use multiple sources such as clinical practice guidelines, medical journals and databases, continuing medical education and regional drug information centres. Monitor patients continually for adverse drug reactions. Appropriate drug dosage depends on factors such as age, sex, body size, general health, concurrent illnesses and medications, and hepatic, renal and cognitive function (for example, older people are particularly sensitive to drugs that affect the central nervous system).
Keep drug regimens simple. Avoid mixed-frequency schedules when possible. Try to keep the number of drugs used for long-term therapy under five to minimize the chance of drug interactions and improve adherence.
Establish treatment goals. Determine how the achievement of goals will be assessed. Regularly re-evaluate goals, adequacy of response and justification for continuing therapy. Time to benefit of prescribed medications should be a key consideration when providing care to seniors at end of life.
Encourage patients to be responsible medication users. Verify that the patient and, if necessary, the caregiver, understands the methods and need for medication. Recommend the use of daily or weekly medication containers, calendars, diaries or other reminders, as appropriate, and monitor regularly for compliance. Encourage the use of one dispensary. The Institute for Safe Medication Practices Canada has developed a program, Knowledge is the best medicine (https://www.knowledgeisthebestmedicine.org), that can be helpful to seniors and their healthcare team manage medicines safely and appropriately. Approved by the Board on May 28, 2011 Update approved by the Board on March 02, 2019
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Testing of antibiotics

https://policybase.cma.ca/en/permalink/policy10157
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC11-69
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
Health care and patient safety
Resolution
GC11-69
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
Text
The Canadian Medical Association supports the routine testing of antibiotics manufactured in or imported into Canada to ensure that they all comply with the labelling on the containers.
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Mentoring of early career physicians

https://policybase.cma.ca/en/permalink/policy10161
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-22
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Health human resources
Physician practice/ compensation/ forms
Resolution
GC11-22
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
Text
The Canadian Medical Association supports the development of programs that will facilitate the mentoring of early career physicians in their transition to clinical practice by experienced physicians.
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Scopes of practice

https://policybase.cma.ca/en/permalink/policy10162
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-23
The Canadian Medical Association supports physicians engaging in their full scope of practice.
Policy Type
Policy resolution
Last Reviewed
2018-03-03
Date
2011-08-24
Topics
Physician practice/ compensation/ forms
Health human resources
Resolution
GC11-23
The Canadian Medical Association supports physicians engaging in their full scope of practice.
Text
The Canadian Medical Association supports physicians engaging in their full scope of practice.
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