The Canadian Medical Association appreciates this opportunity to respond to Health Canada's public consultation on the proposed regulatory approach for the proposed Cannabis Act, Bill C-45.
Our approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA endorsed the Lower-Risk Cannabis Use Guidelines1 and has expressed these views in our recommendations to the Task Force on Cannabis Legalization and Regulation,2 recommendations regarding Bill C-453 and submission on the cannabis excise duty framework.4
Therefore, we are limiting our response to those consultation questions that pertain to that approach and relate to our expertise and knowledge base. We are providing responses to questions 9, 10 and 11.
Packaging and labelling
9. What do you think about the proposed rules for the packaging and labelling of cannabis products? Do you think additional information should be provided on the label?
The CMA concurs with the proposed regulations. Packaging and labelling of cannabis products should include measures such as:
a requirement for plain and standard packaging,5 6
prohibition of the use of appealing flavours and shapes,
a requirement for adequate content and potency labelling,
a requirement for comprehensive health warnings,
a requirement for childproof packaging, and
a requirement that the content in a package should not be sufficient to cause an overdose.
Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people. In that regard, the regulations with respect to packaging and labelling should be viewed as an opportunity to maximize educational opportunities. Package inserts must outline and reinforce the health risks involved; they must also be designed by governments and health professionals, not cannabis producers or distributors.
Package inserts should include:
information on securing the product in the home to prevent access by youth and children,
recommendations not to drive or to work with hazardous chemicals or operate equipment while using the contents of the package,
information on the health and social consequences (including legal penalties) of providing cannabis to those under a designated minimum age for purchasing, and
contact information for hotlines for poison control and for crisis support.
In addition, the regulations for the marketing and advertising of cannabis should use an approach similar to those in place for tobacco and cigarettes.7 8 9
Cannabis for medicinal purposes
10. What do you think about the proposed approach to providing cannabis for medical purposes? Do you think there should be any specific additional changes?
CMA maintains its position that there should be one system with one set of regulations for medical and recreational cannabis.
The CMA believes that once the Act and regulations are in force, there will be no need for two systems. Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization, and for those who wish to use it for other purposes. The medical profession does not need to authorize use once cannabis is legalized, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process, and its anticipated removal as a controlled substance from the Controlled Drugs and Substances Act.
Those who have experienced a two-system approach in Washington and Colorado have remarked on the challenges of having dual standards and regulations (e.g., purchase and possession quantities, taxation levelsa 4) and the contribution to the grey market.b 11
Consistent with the advice it received from the Task Force on Legalization and Regulation of Cannabis,12 the government intends on pursuing both a medicinal and retail cannabis system at this time. In this instance the CMA supports regulations for each system being as similar as possible. Furthermore, the CMA strongly supports the need for appropriate and relevant data collection (e.g., interaction of individuals between the medicinal and retail systems) to provide the necessary evidence for the future legislative review, anticipated in three years' time. The CMA would expect to be involved and looks forward to participating in the criteria development, evaluation and performance review of the systems.
Sale of health products containing cannabis
11. What do you think about the proposed restrictions on the sale of health products containing cannabis authorized by Health Canada? Do they strike an appropriate balance between facilitating access to safe, effective and high quality health products, and deterring illegal activities and youth access?
Health products include prescription health products, non-prescription drugs, natural health products, cosmetics and medical devices. Although all these products are regulated by Health Canada, they undergo different levels of scrutiny for safety, efficacy and quality, and in some cases industry does not need to provide scientific evidence to support the claims made on the label. The level of proof required to obtain a Drug Identification Number (DIN) for prescription drugs is considerably higher than the level of proof required for a Natural Product Number (NPN); rigorous scientific evidence is needed for a DIN but not for a NPN. Consumers generally do not know about this distinction, believing that Health Canada has applied the same level of scrutiny to the health claims made for every product. As a result, consumers presently do not have sufficient information to choose appropriate products.
Health Canada launched a consultation in 201613 on the approval process of the categories of non-prescription drugs, natural health products and cosmetics ("self-care products") with the intent of modernizing the present regulations. The CMA fully supports this work and hopes it will be brought to a timely conclusion.14
With respect to all health products, the CMA supports a risk-based approach in which higher risk products, for example, those for which health claims are made, must meet a higher standard of review. Rigorous scientific evidence is needed to support claims of health benefits and to identify potential risks and adverse reactions.
All health products containing cannabis must meet a high standard of review for safety, efficacy and quality, equivalent to that of the approval of prescription drugs (e.g., Marinol(r) and Sativex(r)), to protect Canadians from further misleading claims. Prescription drugs are subject to Health Canada's pharmaceutical regulatory approval process, based on each drug's specific indication, dose, route of administration and target population. Health claims need to be substantiated via a strong evidentiary process.
With respect to the sale of cannabis products to youth, the CMA recommends the adoption of strict controls as outlined in the proposed regulations; as per the proposal, "All health products would be subject to provisions that control against practices that may appeal to youth, or the use of testimonials, real or fictional characters or animals, or lifestyle branding. Tamper-evident and child-resistant packaging requirements would also apply."15 We also support the additional precautions around medical devices, especially those sold to young persons.
The CMA urges caution around the exemption for paediatric formulations that would allow for traits that would "appeal to youth." The CMA understands that these products, used under strict health professional supervision, should be child friendly, for example, regarding palatability, but we do not support marketing strategies that would suggest their use is recreational (e.g., producing them in candy or animal formats).
There will be a need for careful monitoring of the health products released in the market and the health claims made. Experience has shown that regulations can and will be circumvented, and these activities will have to be addressed. Various examples have been reported in the media highlighting the need to be vigilant, as illustrated in Switzerland regarding health and other products with cannabis and high cannabidiol content.16 17
a The CMA supports similar taxation treatment of cannabis products for medical and non-medical purposes.
b Grey market refers to products produced or distributed in ways that are unauthorized or unregulated, but not strictly illegal.
1 Fischer B, Russell C, Sabioni P, et al. Lower-risk cannabis use guidelines: A comprehensive update of evidence and recommendations. AJPH 2017 Aug;107(8):e1-e12. Available: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.303818?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed& (accessed 2017 Jul 27).
2 Canadian Medical Association (CMA). Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on cannabis, legalization and regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27).
3 Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Submission to the House of Commons Health Committee. Ottawa: The Association; 2017 Aug 18. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2017-09.pdf (accessed 2018 Jan 17).
4 Canadian Medical Association (CMA). Excise duty framework for cannabis products. Submission to the Government of Canada consultation on the proposed excise duty framework for cannabis products. Ottawa: The Association; 2017 Dec 7. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2018-06.pdf (accessed 2018 Jan 17).
5 Vardavas C, Filippidis F, Ward B, et al. Plain packaging of tobacco products in the European Union: an EU success story? European Respiratory Journal 2017;50:1701232 Available: http://erj.ersjournals.com/content/erj/50/5/1701232.full.pdf (accessed 2018 Jan 17).
6 Torjesen I. Standardised packs cut adult smoking as well as discouraging young people, evidence indicates BMJ 2015;350:h935. Available: http://www.bmj.com/content/350/bmj.h935 (accessed 2018 Jan 17).
7 Hughes N, Arora M, Grills N. Perceptions and impact of plain packaging of tobacco products in low and middle income countries, middle to upper income countries and low-income settings in high-income countries: a systematic review of the literature. BMJ Open 2016;6:e010391. doi:10.1136/bmjopen-2015-010391. Available: http://bmjopen.bmj.com/content/bmjopen/6/3/e010391.full.pdf (accessed 2018 Jan 17).
8 White V, Williams T, Wakefield M. Has the introduction of plain packaging with larger graphic health warnings changed adolescents' perceptions of cigarette packs and brands? Tob Control 2015;24:ii42-ii49. Available: http://tobaccocontrol.bmj.com/content/tobaccocontrol/24/Suppl_2/ii42.full.pdf (accessed 2018 Jan 17).
9 Smith C, Kraemer J, Johnson A, Mays D. Plain packaging of cigarettes: do we have sufficient evidence? Risk Management and Healthcare Policy 2015;8:21-30. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396458/pdf/rmhp-8-021.pdf (accessed 2018 Jan 17).
10 Canadian Centre on Substance Use and Addiction (CCSA). Cannabis regulation: Lessons learned in Colorado and Washington State. Ottawa: CCSA; 2015 Nov. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Cannabis-Regulation-Lessons-Learned-Report-2015-en.pdf (accessed 2018 Jan 18).
11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016. Available: https://www.canada.ca/content/dam/hc-sc/healthy-canadians/migration/task-force-marijuana-groupe-etude/framework-cadre/alt/framework-cadre-eng.pdf (accessed 2018 Jan 18).
12 Government of Canada. Consultation on the regulation of self-care products. Ottawa: Government of Canada; n/d. Available: https://www.canada.ca/en/health-canada/programs/consultation-regulation-self-care-products.html (accessed 2018 Jan 17).
13 Canadian Medical Association (CMA). Regulation of self-care products in Canada. Ottawa: The Association; 2016. Available: http://www.cma.corp/dbtw-wpd/Briefpdf/BR2017-11.pdf (accessed 2018 Jan 17).
14 Health Canada. Proposed approach to the regulation of cannabis [consultation]). Ottawa: Health Canada; 2017 Nov. Available: https://www.canada.ca/content/dam/hc-sc/documents/programs/consultation-proposed-approach-regulation-cannabis/proposed-approach-regulation-cannabis.pdf (accessed 2018 Jan 17).
15 Knodt M. In Switzerland, high-CBD cannabis being sold legally as 'Tobacco Substitute'. Seattle: Leafly; 2018. Available: https://www.leafly.com/news/politics/switzerland-high-cbd-cannabis-sold-legally-tobacco-substitute (accessed 2018 Jan 17).
16 Wiley C. Could a legal quirk bring cannabis tourism to Switzerland? The Telegraph 2017 Jul 28;Travel Section. Available: http://www.telegraph.co.uk/travel/destinations/europe/switzerland/articles/cannabis-tourism-has-arrived-in-switzerland/ (accessed 2018 Jan 17).
The Canadian Medical Association (CMA) is pleased to provide input on the proposed regulations of the federal monitoring of Medical Assistance in Dying in Canada.
The CMA fully supports the proposed intent of the regulations, in particular, public accountability and transparency and safeguards for vulnerable patient populations. Tracking trends and carrying out research is very important to monitor the implementation and implications of medical assistance in dying.
The CMA further supports the intent to provide electronic reporting and guidance documents, and to leverage any synergies between the federal and provincial/territorial governments, especially to prevent duplication and to promote consistency in reporting across the country.
The CMA would like to raise the following critical areas for your consideration:
1. Definitions/parameters of terms
There continues to be a need to more clearly define several terms to ensure consistency of reporting. For example:
a. Who constitutes a “practitioner”? One can argue that there is a broad scope of who is “a medical practitioner or nurse practitioner”. Is it the practitioner who provides MAiD? Or he practitioner who first reads a patient’s request for MAiD? Or is the first practitioner? Or second practitioner who assesses the patient?
b. What constitutes a therapeutic relationship (as one of the eight proposed items to be collected about the practitioner)? A therapeutic relationship is not required to access MAiD. This criterion should be removed and if not, given the differences in opinion in the health professions as to what constitutes a therapeutic relationship includes, it should be clearly defined.
c. What constitutes a request, a written request, the receipt of a request? If reporting obligations are “triggered” by a patient’s “written request”, at what point is that request actually triggered? The very first practitioner who receives the patient’s written request? Or the practitioner who conducts the eligibility assessment upon receipt of the written request? Or the practitioner who provides the prescription or carries out the procedure?
d. On a related point, without clear definitions, any future comparative analysis of research or trends will be difficult as there will be no common starting point.
e. There continues to be confusion on how to count or when to start counting the required 10 clear days. There are many reasons why this requires more clarity.
2. Collection and protection of data
We applaud Health Canada for further reducing and revising data requirements. We submit, however, that further reductions are required for several reasons, including adherence to privacy best practices that require the collection of the least amount of data necessary to achieve reasonable purposes. In particular:
a. In view of the quantity and highly personal and sensitive data that will be collected about patients and practitioners, data sharing agreements should be required; for example, agreements between the federal government and provincial/territorial governments or between researchers and others requesting use of the data to facilitate the appropriate sharing of data.
b. Collection of personal information should be limited to what is relevant to the purpose of monitoring medical assistance in dying. Personal information, such as the patient’s full postal code, marital status, or principal occupation is beyond the scope of the eligibility criteria outlined in the legislation and thus beyond the scope of the purpose of monitoring the impact of the legislation.
c. Any “characteristics” of the patient should refer only to the eligibility criteria. If other data will be collected beyond that scope, the justification for doing so, and the characteristics themselves, should be clearly outlined.
d. The scope of the information collected about the practitioner could be narrowed. As is, it is very broad – a list of eight items – while the Quebec regulations, as a comparator, have only three-four items that must be collected in relation to the physician who administers MAiD.
3. Additional requirements
Schedule 4 [section 2(i)] of the proposed regulations requires that the practitioner opine as to whether the patient met, or did not meet, all of the eligibility criteria outlined in the legislation – with two significantly expanded requirements; the requirements that the practitioner: 1) provide an estimate as to the amount of time MAiD shortened the patient’s life; and 2) indicate the anticipated likely cause of natural death of the patient.
These additional requirements are beyond the letter and spirit of the legislation and, in many ways, are in direct contradiction to the legislation. The Legislature was not unaware when it drafted the Act that it did not follow other jurisdictions’ criteria requiring either a terminal illness or a prognosis of time within which the practitioner believed the patient would die, e.g., “within the next 6 months”.
It is specifically the lack of a timeframe that makes the legislation unique and provides flexibility for both patients and practitioners. By adding these two additional criteria for reporting, in effect, they become additional criteria for eligibility which is, as stated above, beyond the scope, and in contradiction to, the legislation.
4. Lack of clarity of reasons for ineligibility
There is a potential for misunderstanding as to whether reasons are required when the patient does not meet the criteria under Schedule 4, section 2(a) – (h). The introduction to section 2 speaks to the practitioner giving an indication as to (a) whether the patient met or (b) did not meet the criteria. However, in the itemized criteria [2(a)-(h)] it only speaks to the practitioner having to provide reasons when the patient meets the criteria (and not when the patient has not met the criteria). It would be helpful to specify that reasons should be required when the patient does and does not meet the criteria. This is also crucial for the publication of the Minister of Health’s annual report requiring that the reasons, and which eligibility criteria were not met, be addressed.
The CMA recognizes the importance of regulations to capture the provision, collection, use, and disposal of information for the purpose of monitoring MAiD. The CMA cautions against introducing reporting requirements that are beyond the scope of the legislation.
As noted in the legislation, practitioners who fail to provide information under the regulations may be found guilty under the Criminal Code and subject to possible imprisonment. It is thus imperative that the federal government drafts clear regulations that respect the legislation, privacy, research ethics, and a de minimus approach.
Clinical photography is a valuable tool for physicians. Smartphones, as well as other devices supporting network connectivity, offer a convenient, efficient method to take and share images. However, due to the private nature of the information contained in clinical photographs there are concerns as to the appropriate storage, dissemination, and documentation of clinical images. Confidentiality of image data must be considered and the dissemination of these images onto servers must respect the privacy and rights of the patient. Importantly, patient information should be considered as any information deriving from a patient, and the concepts outlined therefore apply to any media that can be collected on, or transmitted with, a smart-device.
Clinical photography can aid in documenting form and function, in tracking conditions and wound healing, in planning surgical operations, and in clinical decision-making. Additionally, clinical photographs can provide physicians with a valuable tool for patient communication and education. Due to the convenience of this type of technology it is not appropriate to expect physicians to forego their use in providing their patients with the best care available.
The technology and software required for secure transfer, communication, and storage of clinical media is presently available, but many devices have non-secure storage/dissemination options enabled and lack user-control for permanently deleting digital files. In addition, data uploaded onto server systems commonly cross legal jurisdictions. Many physicians are not comfortable with the practice, citing security, privacy, and confidentiality concerns as well as uncertainty in regards to regional regulations governing this practice.1 Due to concern for patient privacy and confidentiality it is therefore incredibly important to limit the unsecure or undocumented acquisition or dissemination of clinical photographs.
To assess the current state of this topic, Heyns et al. have reviewed the accessibility and completeness of provincial and territorial medical regulatory college guidelines.2 Categories identified as vital and explored in this review included: Consent; Storage; Retention; Audit; Transmission; and Breach. While each regulatory body has addressed limited aspects of the overall issue, the authors found a general lack of available information and call for a unified document outlining pertinent instructions for conducting clinical photography using a smartphone and the electronic transmission of patient information.2
The discussion of this topic will need to be ongoing and it is important that physicians are aware of applicable regulations, both at the federal and provincial levels, and how these regulations may impact the use of personal devices. The best practices supported here aim to provide physicians and healthcare providers with an understanding of the scope and gravity of the current environment, as well as the information needed to ensure patient privacy and confidentiality is assessed and protected while physicians utilize accessible clinical photography to advance patient care. Importantly, this document only focusses on medical use (clinical, academic, and educational) of clinical photography and, while discussing many core concepts of patient privacy and confidentiality of information, should not be perceived as a complete or binding framework. Additionally, it is recommended that physicians understand the core competencies of clinical photography, which are not described here.
The Canadian Medical Association (CMA) suggests that the following recommendations be implemented, as thoroughly as possible, to best align with the CMA policy on the Principles for the Protection of Patient Privacy (CMA Policy PD2018-02). These key recommendations represent a non-exhaustive set of best practices - physicians should seek additional information as needed to gain a thorough understanding and to stay current in this rapidly changing field.
* Informed consent must be obtained, preferably prior, to photography with a mobile device. This applies for each and any such encounter and the purpose made clear (i.e. clinical, research, education, publication, etc.). Patients should also be made aware that they may request a copy of a picture or for a picture to be deleted.
* A patient's consent to use electronic transmission does not relieve a physician of their duty to protect the confidentiality of patient information. Also, a patient's consent cannot override other jurisdictionally mandated security requirements.
* All patient consents (including verbal) should be documented. The acquisition and recording of patient consent for medical photography/dissemination may be held to a high standard of accountability due to the patient privacy and confidentiality issues inherent in the use of this technology. Written and signed consent is encouraged.
* Consent should be considered as necessary for any and all photography involving a patient, whether or not that patient can be directly recognized, due to the possibility of linked information and the potential for breach of privacy. The definition of non-identifiable photos must be carefully considered. Current technologies such as face recognition and pattern matching (e.g. skin markers, physical structure, etc.), especially in combination with identifying information, have the potential to create a privacy breach.
* Unsecure text and email messaging requires explicit patient consent and should not be used unless the current gold standards of security are not accessible. For a patient-initiated unsecure transmission, consent should be clarified and not assumed.
* Transmission of photos and patient information should be encrypted as per current-day gold standards (presently, end-to-end encryption (E2EE)) and use only secure servers that are subject to Canadian laws. Explicit, informed consent is required otherwise due to privacy concerns or standards for servers in other jurisdictions. Generally, free internet-based communication services and public internet access are unsecure technologies and often operate on servers outside of Canadian jurisdiction.
* Efforts should be made to use the most secure transmission method possible. For data security purposes, identifying information should never be included in the image, any frame of a video, the file name, or linked messages.
* The sender should always ensure that each recipient is intended and appropriate and, if possible, receipt of transmission should be confirmed by the recipient.
* Storing images and data on a smart-device should be limited as much as possible for data protection purposes.
* Clinical photos, as well as messages or other patient-related information, should be completely segregated from the device's personal storage. This can be accomplished by using an app that creates a secure, password-protected folder on the device.
* All information stored (on internal memory or cloud) must be strongly encrypted and password protected. The security measures must be more substantial than the general password unlock feature on mobile devices.
* Efforts should be made to dissociate identifying information from images when images are exported from a secure server. Media should not be uploaded to platforms without an option for securely deleting information without consent from the patient, and only if there are no better options. Automatic back-up of photos to unsecure cloud servers should be deactivated. Further, other back-up or syncing options that could lead to unsecure server involvement should be ascertained and the risks mitigated.
4. Cloud storage should be on a Canadian and SOCII certified server. Explicit, informed consent is required otherwise due to privacy concerns for servers in other jurisdictions.
5. AUDIT & RETENTION
* It is important to create an audit trail for the purposes of transparency and medical best practice. Key information includes patient and health information, consent type and details, pertinent information regarding the photography (date, circumstance, photographer), and any other important facts such as access granted/deletion requests.
* Access to the stored information must be by the authorized physician or health care provider and for the intended purpose, as per the consent given. Records should be stored such that it is possible to print/transfer as necessary.
* Original photos should be retained and not overwritten.
* All photos and associated messages may be considered part of the patient's clinical records and should be maintained for at least 10 years or 10 years after the age of majority, whichever is longer. When possible, patient information (including photos and message histories between health professionals) should be retained and amalgamated with a patient's medical record. Provincial regulations regarding retention of clinical records may vary and other regulations may apply to other entities - e.g. 90 years from date of birth applies to records at the federal level.
* It may not be allowable to erase a picture if it is integral to a clinical decision or provincial, federal, or other applicable regulations require their retention.
* Any breach should be taken seriously and should be reviewed. All reasonable efforts must be made to prevent a breach before one occurs. A breach occurs when personal information, communication, or photos of patients are stolen, lost, or mistakenly disclosed. This includes loss or theft of one's mobile device, texting to the wrong number or emailing/messaging to the wrong person(s), or accidentally showing a clinical photo that exists in the phone's personal photo album.
* It should be noted that non-identifying information, when combined with other available information (e.g. a text message with identifiers or another image with identifiers), can lead to highly accurate re-identification.
* At present, apps downloaded to a smart-device for personal use may be capable of collecting and sharing information - the rapidly changing nature of this technology and the inherent privacy concerns requires regular attention. Use of specialized apps designed for health-information sharing that help safeguard patient information in this context is worth careful consideration.
* Having remote wipe (i.e. device reformatting) capabilities is an asset and can help contain a breach. However, inappropriate access may take place before reformatting occurs.
* If a smartphone is strongly encrypted and has no clinical photos stored locally then its loss may not be considered a breach.
* In the event of a breach any patient potentially involved must be notified as soon as possible. The CMPA, the organization/hospital, and the Provincial licensing College should also be contacted immediately. Provincial regulations regarding notification of breach may vary.
Approved by the CMA Board of Directors March 2018
i Heyns M†, Steve A‡, Dumestre DO‡, Fraulin FO‡, Yeung JK‡
† University of Calgary, Canada
‡ Section of Plastic Surgery, Department of Surgery, University of Calgary, Canada
1 Chan N, Charette J, Dumestre DO, Fraulin FO. Should 'smart phones' be used for patient photography? Plast Surg (Oakv). 2016;24(1):32-4.
2 Unpublished - Heyns M, Steve A, Dumestre DO, Fraulin FO, Yeung J. Canadian Guidelines on Smartphone Clinical Photography.
The CMA is pleased to provide this submission to the Senate Standing Committee, Social Affairs, Science &Technology on Bill C-45, the Cannabis Act.
The CMA has long-standing concerns about the health risks associated with consuming cannabis,i particularly in its smoked form.1,2 Children and youth are especially at risk for cannabis-related harms, given their brains are undergoing rapid and extensive development.
The CMA's approach to cannabis is grounded in broad public health policy. It includes promotion of health and prevention of drug dependence and addiction; access to assessment, counselling and treatment services; and a harm reduction perspective. The CMA believes that harm reduction encompasses policies, goals, strategies and programs directed at decreasing adverse health, social and economic consequences of drug use for the individual, the community and the society while allowing the user to continue to use drugs, not precluding abstinence.3,4
Specifically, the CMA recommends a multi-faceted cannabis public health strategy that prioritizes impactful and realistic goals before, and certainly no later than, any legalization of cannabis.5 We propose that the first goal should be to develop educational interventions for children, teenagers and young adults. Other goals relate to data collection; monitoring and surveillance; ensuring a proportionate balance between enforcement harms and the direct and indirect harms caused by cannabis use; and research.
There is an ongoing need for research into the medicinal and harmful effects of cannabis use. As noted by the Lower-Risk Cannabis Use Guidelines, 6 there is limited evidence on such subjects as synthetic cannabinoids; practices like "deep inhalation" to increase the psychoactive effects of cannabis; and the combination of risky behaviours, like early-onset and frequent use, associated with experiencing acute or chronic health problems.6
Since 2002, the CMA has taken a public health perspective regarding cannabis and other illegal drugs. More recently, the CMA endorsed the Lower-Risk Cannabis Use Guidelines, and we submitted 22 recommendations to the Task Force on Cannabis Legalization and Regulation ("the Task Force").7
According to the recent Canadian Tobacco, Alcohol and Drugs Survey, cannabis is the most used illicit drug in Canada.8 In particular, 25%-30% of adolescents or youth report past-year cannabis use.9 This concerns the CMA. The increasing rate of high usage, despite the fact that non-medical use of cannabis is illegal, coupled with cannabis' increased potency (from 2% in 1980 to 20% in 2015 in the United States),10 the complexity and versatility of the cannabis plant,ii the variable quality of the end product, and variations in the frequency, age of initiation and method of use make it difficult to study the full health impacts and produce replicable, reliable scientific results.
The CMA submits, therefore, that any legalization of cannabis for non-medical use must be guided by a comprehensive cannabis public health strategy and include a strong legal-regulatory framework emphasizing harm reduction principles.
Given that the Task Force employed a minimizing of harms approach11 and given how the proposed legislation aligns with the Task Force's recommendations,12 the bill addresses several aspects of a legal-regulatory framework "to provide legal access to cannabis and to control and regulate its production, distribution and sale."13 This work provides the starting point for creating a national cannabis public health strategy. The CMA has long called for a comprehensive drug strategy that addresses addiction, prevention, treatment, enforcement and harm reduction.3
There are, however, key public health initiatives that the Canadian government has not adequately addressed and should be implemented before, or no later than, the implementation of legislation. One such initiative is education. Education is required to develop awareness among Canadians of the health, social and economic harms of cannabis use especially in young people.
Supporting a Legal-Regulatory Framework that Advances Public Health and Protection of Children and Youth
From a health perspective, allowing any use of cannabis by people under 25 years of age, and certainly those under 21 years of age, is challenging for physicians given the effects on the developing brain.1,3,14 The neurotoxic effect of cannabis, especially with persistent use, on the adolescent brain is more severe than on the adult brain.15,16
Further, neurological studies have shown that adolescent-onset cannabis use produces greater deficits in executive functioning and verbal IQ and greater impairment of learning and memory than adult-onset use.17,18
This underscores the importance of protecting the brain during development. Since current scientific evidence indicates that brain development is not completed until about 25 years of age,19 this would be the ideal minimum age for legal cannabis use.
Youth and young adults are among the highest users of cannabis in Canada. Despite non-medical use of cannabis being illegal in Canada since 1923, usage has increased over the past few decades.
The CMA recognizes that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach.3 Harm reduction is not one of polarities rather it is about ensuring the quality and integrity of human life and acknowledging where the individual is at within his/her community and society at large.5
The possibility that a young person might incur a lifelong criminal record for periodic use or possession of small amounts of cannabis for personal use means that the long-term social and economic harms of cannabis use can be disproportionate to the drug's physiological harm. The Canadian government has recognized this disproportionality for over 15 years. Since 2001, there have been two parliamentary committee reportsiii and two billsiv introduced to decriminalize possession of small amounts of cannabis (30 g). It was recommended that small amounts of cannabis possession be a "ticketable" offence rather than a criminal one.
Given all of the above, the CMA recommends that the age of legalization should be 21 years of age and that the quantities and the potency of cannabis be more restricted to those under age 25.
Supporting a Comprehensive Cannabis Public Health Strategy with a Strong, Effective Education Component
The CMA recognizes that Bill C-45 repeals the prohibition against simple possession while increasing penalties against the distribution and sale of cannabis to young people, but this is not enough to support a harm reduction approach.
We note that the Federal Tobacco Control Strategy, with its $38 million budget, is intended to help reduce smoking rates and change Canadians' perceptions toward tobacco.20 Similarly, there are extensive education programs concerning the dangers of alcohol, particularly for young people.v
The government of Canada has proposed a modest commitment of $9.6 million to a public awareness campaign to inform Canadians, especially youth, of the risks of cannabis consumption, and to surveillance activities.21
A harm reduction strategy should include a hierarchy of goals with an immediate focus on groups with pressing needs. The CMA submits that young people should be targeted first with education. The lifetime risk of dependence to cannabis is estimated at 9%, increasing to almost 17% in those who initiate use in adolescence.22 In 2012, about 1.3% of people aged 15 years and over met the criteria for cannabis abuse or dependence - double the rate for any other drug - because of the high prevalence of cannabis use.23
The strategy should include the development of educational interventions, including skills-based training programs, social marketing interventions and mass media campaigns. Education should focus not only on cannabis' general risks but also on its special risks for the young and its harmful effects on them.
This is critical given that for many, the perception is that (i) legalization of possession for both adults and young people translates into normalization of use and (ii) government control over the source of cannabis for sale translates into safety of use. Complicating this has been the fear-mongering messaging associated with illegal drugs.
The evidence shows that fewer adolescents today believe that cannabis use has any serious health risks24 and that enforcement policies have not been a deterrent.25 Having an appropriate education strategy rolled out before legalization of possession would reduce the numbers of uninformed young recreational users. It would also provide time to engage in meaningful research on the impact of the drug on youth. Such strategies have been successful in the past; for example, the long-termvi Federal Tobacco Control Strategy has been credited with helping reduce smoking rates to an all-time low in Canada.26
The Lower-Risk Cannabis Use Guidelines were developed as a "science-based information tool for cannabis users to modify their use toward reducing at least some of the health risks."6 The CMA urges the government to support the widespread dissemination of this tool and incorporation of its messages into educational efforts. Other strategies must include plain packaging and labelling with health information and health warnings.
Supporting a One-System Approach. Alternatively, a Review of Legislation in Five Years
The CMA believes that once the act is in force, there will be little need for two systems (i.e., one for medical and one for non-medical cannabis use). Cannabis will be available for those who wish to use it for medicinal purposes, either with or without medical authorization (some people may self-medicate with cannabis to alleviate symptoms but may be reluctant to raise the issue with their family physician for fear of being stigmatized), and for those who wish to use it for other purposes. The medical profession does not need to continue to be involved as a gatekeeper once cannabis is legal for all, especially given that cannabis has not undergone Health Canada's usual pharmaceutical regulatory approval process.
The Task Force's discussion reflects the tension it heard between those who advocated for one system and those who did not. One concern raised by patients was about the stigma attached to entering retail outlets selling non-medical cannabis. The CMA submits that this concern would be alleviated if the federal government continued the online purchase and mail order system that is currently in place.
Given that there is a lack of consensus and insufficient data to calculate how much of the demand for cannabis will be associated with medical authorization, the Task Force recommended that two systems be established, with an obligation to review - specifically, a program evaluation of the medical access framework in five years.11
If there are two systems, then in the alternative, the CMA recommends a review of the legislation within five years. This would allow time to ensure that the provisions of the act are meeting their intended purposes, as determined by research on the efficacy of educational efforts and other research. Five-year legislative reviews have been previously employed, especially where legislation must balance individual choice with protecting public health and public safety.vii For example, like Bill C-45, the purpose of the Controlled Drugs and Substances Act is to protect public health and public safety.27 Its review within five years is viewed as allowing for a thorough, evidence-based analysis to ensure that the provisions and operations of the act are meeting their intended purpose(s).viii Furthermore, a harm reduction approach lends itself to systematic evaluation of the approach's short- and long-term impact on the reduction of harms.5
The CMA, therefore, submits that if a two-system approach is implemented when the legislation is enacted, the legislation should be amended to include the requirement for evaluation within five years of enactment. Criteria for evaluation may include the number of users in the medical system and the number of physicians authorizing medical cannabis use. The CMA would expect to be involved in the determination of such criteria and evaluation process.
Support has risen steadily in Canada and internationally for the removal of criminal sanctions for simple cannabis possession, as well as for the legalization and regulation of cannabis' production, distribution and sale. The CMA has long-standing concerns about the health risks associated with consuming cannabis, especially by children and youth in its smoked form. Weighing societal trends against the health effects of cannabis, the CMA supports a broad legal-regulatory framework as part of a comprehensive and properly sequenced public health approach of harm reduction.
1. The CMA recommends that the legalization age be amended to 21 years of age, to better protect the most vulnerable population, youth, from the developmental neurological harms associated with cannabis use.
2. The CMA recommends that a comprehensive cannabis public health strategy with a strong, effective health education component be implemented before, and no later than, the enactment of any legislation legalizing cannabis.
3a. The CMA recommends that there be only one regime for medical and non-medical use of cannabis, with provisions for the medical needs of those who would not be able to acquire cannabis in a legal manner (e.g., those below the minimum age).
3b. Alternatively, the CMA recommends that the legislation be amended to include a clause to review the legislation, including a review of having two regimes, within five years.
i The term cannabis is used as in Bill C-45: that is, referring to the cannabis plant or any substance or mixture that contains any part of the plant.
ii The plant contains at least 750 chemicals, of which there are over 100 different cannabinoids. Madras BK. Update of cannabis and its medical use. Agenda item 6.2. 37th Meeting of the Expert Committee on Drug Dependence, Department of Essential Medicines and Health Products, World Health Organization; 2015. Available: www.who.int/medicines/access/controlled-substances/6_2_cannabis_update.pdf (accessed 2017 Jul 27).
iii House of Commons Special Committee on the Non-Medical Use of Drugs (2001) and the Senate Special Committee on Illegal Drugs (2002).
iv An Act to amend the Contraventions Act and the Controlled Drugs and Substances Act (Bill C-38), which later was reintroduced as Bill C-10 in 2003.
v For example, the Substance Use and Addictions Program (SUAP), a federal contributions program, is delivered by Health Canada to strengthen responses to drug and substance use issues in Canada. See Government of Canada. Substance Use and Addictions Program. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/services/health/campaigns/canadian-drugs-substances-strategy/funding/substance-abuse-addictions-program.html (accessed 2017 Jul 27).
vi The Federal Tobacco Control Strategy was initiated in 2001 for 10 years and renewed in 2012 for another five years.
vii Several federal acts contain review provisions. Some examples include the Controlled Drugs and Substances Act, SC b1996, c 19, s 9 (five-year review); the Preclearance Act, SC 1999, c 20, s 39 (five-year review); the National Defence Act, RSC 1985, c N-5, s 273.601(1) (seven-year review); the Public Servants Disclosure Protection Act, SC 2005, c 46, s 54 (five-year review); and the Red Tape Reduction Act, SC 2015, c 12 (five-year review).
viii The 2012 amendments to the Controlled Drugs and Substances Act were adopted from Bill S-10, which died on order papers in March 2011. The Senate Standing Committee on Legal and Constitutional Affairs reviewed Bill S-10 and recommended that the review period should be extended from two to five years as two years is not sufficient to allow for a comprehensive review. See Debates of the Senate, 40th Parliament, 3rd Session, No 147:66 (2010 Nov 17) at 1550; see also Senate Standing Committee on Legal and Constitutional Affairs, Eleventh Report: Bill S-10, An Act to Amend the Controlled Drugs and Substances Act and to Make Related and Consequential Amendments to Other Acts, with Amendments (2010 Nov 4).
1 Canadian Medical Association. Health risks and harms associated with the use of marijuana. CMA submission to the House of Commons Standing Committee on Health. Ottawa: The Association; 27 May 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/Brief-Marijuana-Health_Committee_May27-2014-FINAL.pdf (accessed 2017 Jul 27).
2 Canadian Medical Association. A public health perspective on cannabis and other illegal drugs. CMA submission to the Special Senate Committee on Illegal Drugs. Ottawa: The Association; 11 Mar 2002. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2002-08.pdf (accessed 2017 Jul 27).
3 Canadian Medical Association. Bill C-2 An Act to Amend the Controlled Drugs and Substances Act (Respect for Communities Act). CMA submission to the House of Commons Standing Committee on Public Safety and National Security. Ottawa: The Association; 28 Oct 2014. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/CMA_Brief_C-2_Respect%C3%A9-for_Communities_Act-English.pdf (accessed 2017 Jul 27).
4 Harm Reduction International. What is harm reduction? A position statement from Harm Reduction International. London, UK: Harm Reduction International; 2017. Available: www.hri.global/what-is-harm-reduction (accessed 2017 Jul 27).
5 Riley D, O'Hare P. Harm reduction: history, definition and practice. In: Inciardi JA, Harrison LD, editors. Harm reduction: national and international perspectives. Thousand Oaks, CA: Sage Publications; 2000.
6 Fischer B, Russel C, Sabioni P, et al. Lower-risk cannabis use guidelines: a comprehensive update of evidence and recommendations. Am J Public Health 2017;107(8):e1-e12.
7 Canadian Medical Association. Legalization, regulation and restriction of access to marijuana. CMA submission to the Government of Canada - Task Force on Cannabis Legalization and Regulation. Ottawa: The Association; 2016 Aug 29. Available: www.cma.ca/Assets/assets-library/document/en/advocacy/submissions/2016-aug-29-cma-submission-legalization-and-regulation-of-marijuana-e.pdf (accessed 2017 Jul 27).
8 Government of Canada. Canadian Tobacco, Alcohol and Drugs Survey (CTADS): 2015 summary. Ottawa: Government of Canada; 2017. Available: www.canada.ca/en/health-canada/services/canadian-tobacco-alcohol-drugs-survey/2015-summary.html (accessed 2017 Jul 27).
9 Health Canada. Canadian Alcohol and Drug Use Monitoring Survey (CADUMS): summary of results for 2012. Ottawa: Health Canada; 2014. Available: www.canada.ca/en/health-canada/services/health-concerns/drug-prevention-treatment/drug-alcohol-use-statistics/canadian-alcohol-drug-use-monitoring-survey-summary-results-2012.html (accessed 2017 Jul 27).
10 World Health Organization. The health and social effects of nonmedical cannabis use. Geneva: World Health Organization; 2016. Available: http://apps.who.int/iris/bitstream/10665/251056/1/9789241510240-eng.pdf?ua=1 (accessed 2017 Jul 27).
11 Task Force on Cannabis Legalization and Regulation. A framework for the legalization and regulation of cannabis in Canada: final report. Ottawa: Health Canada; 2016.
12 Government of Canada. Legislative background: an Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts (Bill C-45). Ottawa: Government of Canada; 2017.
13 An Act respecting cannabis and to amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts, Bill C-45, First Reading 2017 Apr 13.
14 Crean RD, Crane NA, Mason BJ. An evidence based review of acute and long-term effects of cannabis use on executive cognitive functions. J Addict Med 2011;5(1):1-8.
15 Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proc Natl Acad Sci USA 2012;109(40):E2657-64
16 Crépault JF, Rehm J, Fischer B. The cannabis policy framework by the Centre for Addiction and Mental Health: a proposal for a public health approach to cannabis policy in Canada. Int J Drug Policy 2016;34:1-4.
17 Pope HG Jr, Gruber AJ, Hudson JI, et al. Early-onset cannabis use and cognitive deficits: What is the nature of the association? Drug Alcohol Depend 2003;69(3):303-310.
18 Gruber SA, Sagar KA, Dahlgren MK, et al. Age of onset of marijuana use and executive function. Psychol Addict Behav 2011;26(3):496-506.
19 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): The National Academies Press; 2017.
20 Canadian Cancer Society. 2017 federal pre-budget submission. Canadian Cancer Society submission to the Standing Committee on Finance. 2014 Aug. Available: www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR8398102/br-external/CanadianCancerSociety-e.pdf (accessed 2017 Jul 27).
21 Health Canada. Backgrounder: legalizing and strictly regulating cannabis: the facts. Ottawa: Health Canada; 2017. Available: www.canada.ca/en/health-canada/news/2017/04/backgrounder_legalizingandstrictlyregulatingcannabisthefacts.html (accessed 2017 Jul 27)
22 Hall W, Degenhardt L. Adverse health effects of non-medical cannabis use. Lancet 2009;374(9698):1383-91.
23 Statistics Canada. Canadian Community Health Survey: Mental Health, 2012. The Daily. 2013 Sep 18. Statistics Canada cat. No. 11-001-X. Available: www.statcan.gc.ca/daily-quotidien/130918/dq130918a-eng.htm (accessed 2017 Jul 27).
24 Miech RA, Johnston LD, O'Malley PM, Bachman JG, Schulenberg, JE. Monitoring the future national survey results on drug use, 1975-2010. Vol 1: Secondary students. Ann Arbor: Institute for Social Research, University of Michigan; 2011.
25 Spithoff S, Kahan M. Cannabis and Canadian youth: evidence, not ideology. Can Fam Physician 2014;60(9):785-7.
26 Health Canada. Strong foundation, renewed focus: an overview of Canada's Federal Tobacco Control Strategy 2012-2017. Ottawa: Health Canada; 2012. Available: www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/publications/healthy-living-vie-saine/tobacco-strategy-2012-2017-strategie-tabagisme/alt/tobacco-strategy-2012-2017-strategie-tabagisme-eng.pdf (accessed 2017 Jul 27).
27 Controlled Drugs and Substances Act, SC 1996, c 19, s 9.
Dear Mr. Rodrigue:
The Canadian Medical Association is pleased to have this opportunity to participate in the consultation on the proposed front-of-packaging labelling (FOP) as posted in the Canada Gazette Part One on February 9, 2018.1 This new requirement will “provide clear and consistent front-of-package information and updated nutrient content claims to help protect Canadians from the risks of chronic diseases” related to the intake of foods high in sugar, sodium, saturated fats and trans fat.2
1 Canada Gazette Part One. Regulations Amending Certain Regulations Made Under the Food and Drugs Act (Nutrition Symbols, Other Labelling Provisions, Partially Hydrogenated Oils and Vitamin D) Department of Health Vol. 152, No. 6 — February 10, 2018
2 Ibid pg.1
3 Presentation to the House of Commons Standing Committee on Health, Nutrition Labelling, Canadian Medical Association, March 3, 2011 accessed at http://policybase.cma.ca
The CMA believes that governments have a responsibility to provide guidance on healthy eating that can be easily incorporated into daily lives, and that the federal government has a continuous obligation to promulgate policies, standards, regulations and legislations that support healthy food and beverage choices; provide user-friendly consumer information including complete nutritional content and accurate advertising claims; and increase the amount of information provided on product labels. We also commend Health Canada for its current work on revising the Canada Food Guide.
The CMA has supported a standard “at a glance” approach to FOP food labelling that can reduce confusion and help consumers make informed dietary choices since 2011.3 FOP labelling on packaged foods will help Canadians make healthier food and beverage choices. It will draw attention to those ingredients to be avoided in higher levels and can reinforce public health messaging on healthy eating. An added benefit may be an incentive to the food industry to reformulate processed foods with lower amounts of those nutrients highlighted in FOP labelling.
The CMA supports the placement of the proposed symbol on the upper and/or right hand side of the packaging, covering 25% of the principal display surface. The symbol
must be clearly delineated from the product packaging so that it stands out and can be located with relative ease. It is important for the symbol to convey to the consumer that there is a certain degree of risk involved in consuming these foods, hence the colours used and the shape will be important.
Of the four symbols proposed by Health Canada, our preference is for the one displayed here but with a more defined, thicker border, that includes a small outer buffer (in white). It will be essential for Health Canada to ensure that the symbol design has been tested thoroughly with consumers and is effective in conveying the intended “high in” message.
As such, manufacturers will need clear guidance about the constraints on the use and placement of these symbols to ensure they cannot be misconstrued and to prevent the use of configurations that will diminish their effectiveness. Manufacturers must not be permitted to place voluntary nutrient content or health claims below or near the main symbol that would distort the message and create confusion.
Foods to be exempted from front-of-package nutrition labelling
There will be foods that are exempt from the labelling requirements and consumers will need clear explanations with respect to those that are exempt and why; some will be obvious, some will not. The CMA supports the proposed exemptions for eggs, fruits, vegetables and unsweetened, unsalted plain milk, and whole milk. However, we do not believe flavoured and/or seasoning salts and “sea salts” should be exempted from the requirement to have an FOP symbol on the package. Health Canada will need to undertake an education program to explain to consumers that these products are actually high in sodium.
Nutrient thresholds for sodium, sugar & saturated fat
CMA policy has encouraged governments to continue to work to reduce the salt, sugar, saturated fat, trans-fat and calorie content of processed foods and prepared meals.4 The nutrient levels chosen will therefore be critical in that regard. The CMA supports the proposed levels to identify foods high in sugar, salt or saturated fats. The CMA believes that it is important that there is consistency across all nutritional and healthy eating information and advice for Canadians. Ensuring consistency between the “high in” threshold and the 15% “a lot” daily value (DV) message delivers a clear message of concern.
4 Healthy Behaviours: Promoting Physical Activity and Healthy Eating, Canadian Medical Association Policy, 2014, accessed at http://policybase.cma.ca.
While we understand the rationale behind increasing the nutrient threshold for prepackaged meals to 30% of the DV, we recommend that the threshold for “high in”
sugar of 30 grams or more total sugars per serving of stated size may be too high and should be reconsidered. It should also be noted that the different thresholds on prepackaged foods and prepackaged meals may cause confusion for consumers and should be introduced with some consumer education.
Nutrient content claims, in relation to Front-of-Packaging Labelling symbol
Allowing a food that qualifies for a “high in” sugar FOP symbol to also display a “no added sugars” claim would be very confusing to consumers. The product label information would appear as quite contradictory; therefore the CMA does support not allowing “no added sugar” claims on these foods. The CMA would suggest that a food that is high in two or more of sugar, sodium or saturated fats not be allowed to display any content claims to avoid any consumer confusion.
High-intensity sweetener labelling
Canadians have come to rely on easy-to-recognize information that alerts them that food may contain artificial sweeteners. Therefore, we do not support the elimination of the labelling requirement for artificial sweeteners on the principal display panel. For products that have high intensity sweeteners added and which bear claims such as “unsweetened” or “no sugar added,” a declaration of “artificially sweetened” should be clearly visible on the FOP. The specific sweetener does not need to be identified so long as it is declared in the list of ingredients. As long as quantity is displayed on the nutrition facts table it doesn’t need to be on the principal display.
Further, while we recognize that harmonizing with USA labelling regulations is desirable, we recommend strongly against the use of the term “phenylketonurics.” The proper approach would be to use the phrase “people with phenylketonuria” for any warnings on products containing aspartame, which contains phenylalanine.
For many Canadians, their diet can have a negative rather than positive impact on their overall health. There is a particular concern for children and youth who are growing up in increasingly obesogenic environments that reinforce practices that work against a healthy diet and healthy lifestyle. Determined action is required for children and youth to learn and acquire healthy behaviours that they will maintain throughout their life. The CMA supports the government’s Healthy Living Strategy and their efforts to create a healthier food environment. The addition of FOP nutrition labelling is an important tool to make the healthy choice the easy choice.
Jeff Blackmer, MD, MHSc, FRCPC
Vice-president, Medical Professionalism
Dear Minister Freeland:
We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons.
In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons.
A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals.
We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to
society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries.
Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women.
Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism.
Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind.
We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright.
Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely,
Margaret Gillis, President, International Longevity Centre Canada
Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada
Linda Garcia, Director, uOttawa LIFE Research Institute
cc: The Right Honourable Justin Trudeau Prime Minister of Canada
The Honourable Filomena Tassi Minister of Seniors
The Honourable Jean Yves Duclos
Minister for Families, Children and Social Development
Ambassador Marc-Andre Blanchard
Permanent Representative to Canada at the United Nations
The Honourable Ginette Petitpas Taylor
International Longevity Centre Canada
Dr. Kiran Rabheru
Chair of the Board, International Longevity Centre Canada
Linda Garcia, PhD
LIFE Research Institute
Dr. Laurent Marcoux
Canadian Medical Association
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
Dani Prud’Homme Directeur général FADOQ
Peter Lukasiewicz Chief Executive Officer Gowling WLG
Dr. Dallas Seitz, MD, FRCPC
Dr. Frank Molnar
President, Canadian Geriatrics Society
Dr. David Conn
Canadian Coalition for Senior’s Mental Health
Director - Canadian Coalition for Seniors’ Mental Health
Chief Executive Officer, Speech-Language & Audiology Canada
President Canadian Nurses Association
Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail-
Chief Executive Officer/Chef de la direction
Ondina Love, CAE
Chief Executive Officer Canadian Dental Hygienists Association
National Association of Federal Retirees /Association nationale
des retraités fédéraux
Laura Tamblyn Watts
National Initiative for the Care of the Elderly
Dr. Keri-Leigh Cassidy
Founder Fountain of Health
Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health
Dalhousie University Dept of Psychiatry
Jenny Neal and Janet Siddall
CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN)
President and CEO
Dr. Becky Temple, MD, CCFP, CCPE
Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI
J. Van Aerde, MD, MA, PhD, FRCPC
Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada
Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada
Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership
Dr. Rollie Nichol, MD, MBA, CCFP, CCPE
Associate Chief Medical Officer, Alberta Health Services
Dr. Shannon Fraser, MSc, FRCSC, FACS
Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital
Linda Gobessi MD FRCPC
Geriatric Psychiatry Community Services of Ottawa Ottawa
Executive Director / Directrice générale
Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa
Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN
Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research
Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders
Division of Neurology, Department of Medicine University of British Columbia
Senior Social Worker Baycrest Health Sciences
Harinder Sandhu, D.D.S., Ph.D
Professor and Past Director
Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry
Dr. Christopher Frank,
Chair of Geriatric Education and Recruitment Initiative
Jennie Wells, MD
Associate Professor, University of Western Ontario Department of Medicine
Chair/Chief Division of Geriatric Medicine Parkwood Institute
Laura Diachun, MD
Program Director, Undergrad Geriatric Education University of Western Ontario
Department of Medicine, Division of Geriatric Medicine Parkwood Institute
Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office
Niamh O’Regan, MB ChB,
Assistant Professor, University of Western Ontario Parkwood Institute
Michael Borrie, MB ChB, FRCPC
Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine
Jenny Thain, MRCP (Geriatrics)
Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital
Peter R. Butt MD CCFP FCFP
Assoc. Professor, Department of Family Medicine, College of Medicine,
University of Saskatchewan
Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital
President and CEO, PEAK MD Inc.
Dr. Shabbir Amanullah
Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych
Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry,
Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto
Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team
Addictions and Mental Health Program
Louise Plouffe, Ph.D.
Director of Research, ILC Canada (retired)
Kimberley Wilson, PhD, MSW
Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph
Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C)
Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care
Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP
Dr. Ken Le Clair
Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's notice as published in the Canada Gazette, Part 1 for interested stakeholders to provide comments on Health Canada's intent to amend Schedule 1 to the Controlled Drugs and Substances Act (CDSA) and the Schedule to the Narcotic Control Regulations (NCR) to include tramadol, its salts, isomers and derivatives and the salts and isomers of its derivatives.1
Tramadol has been marketed in Canada since 2005 and is available only by prescription.1 The CMA is concerned that, despite tramadol being judged low-risk in terms of addiction, it is nevertheless an opioid and should be placed in the Controlled Drugs and Substances Act, under Schedule 1.2
The Canadian Institute for Health Information reports that tramadol is one of six opioids accounting for 96% of all opioid prescriptions between 2012 and 2016.3 The report noted that there was a significant increase in tramadol prescriptions and Defined Daily Doses (DDDs) in that same 2012 to 2016 timeframe that may have been due in part to a decrease in prescriptions and DDDs for codeine.
Tramadol is considered a weak opioid and is used to treat "moderate pain that has not responded to first-line treatments."4 It is regarded as having a lower rate of overdose, misuse and addiction than more powerful opioids.4
However, it is not without risks. The addition of tramadol to the CDSA, Schedule 1, is important because, as with any opioid, dependence on tramadol can occur with use over prolonged periods. According to the World Health Organization "dependence to tramadol may occur when used within the recommended dose range of tramadol but especially when used at supra-therapeutic doses."5 Physical dependence is "distinct from addiction, which includes behavioural elements and harm despite continued drug use." Maintenance of patients on opioids sometimes is only to avoid withdrawal symptoms, caused by physical dependence, as opposed to being used to treat pain.6 Tramadol must be tapered under supervision from a health professional.
In addition, tramadol's analgesic effect can be unpredictable depending on a person's genetic capacity to metabolize the drug. Success or failure will be predicated "on it being converted by CYP2D6 to an active metabolite, O-desmethyltramadol."7 If there is a CYP2D6 inhibitor present or if the person's genetic make-up is such that they do not metabolize the enzyme very well, "conversion can be blocked so that little or none of the metabolite is produced and little analgesic effect is achieved."7 These tramadol pathways may also be blocked which could lead to the drug being "present at higher concentrations for longer periods."7 As one expert has noted "when a doctor prescribes tramadol, he or she rolls the dice, not knowing whether the patient will get a bit of opioid, a lot of opioid or none at all."6
The risks associated with tramadol with respect to children are such that the United States Food and Drug Administration (FDA) recently recommended that tramadol (and codeine) should not be given to children under 12.8 Their concern stems from the potential for tramadol (and codeine) to "cause life-threatening breathing problems in children."9 The FDA also recommended that breast-feeding women not be given tramadol because of the potential harm to the child. As well, teens 12 to 18 should not be given the drug "if there is a history of obesity, obstructive sleep apnea, or severe lung disease."9 Further, it warned that it should not "be given to children or adolescents as a pain medication after surgery to remove the tonsils or adenoids."9
It is very important for the health and safety of Canadians that tramadol be placed on CDSA's Schedule 1. As described in the Notice of Intent for this consultation, this change will "prevent diversion of tramadol and protect Canadians from the health risks associated with unauthorized use."1 Further, pharmacists will not be able to follow verbal prescriptions and or provide refills of tramadol, and other controls outlined in the Narcotic Control Regulations within the Controlled Drugs and Substances Act.10
In conclusion, the CMA is concerned that, despite tramadol being judged low-risk in terms of addiction, it is nevertheless an opioid and carries dangers similar to its stronger counterparts. Doctors support patients in the management of acute and chronic pain, as well as addictions, and as such we have long been concerned about the harms associated with opioid use. Therefore, as part of our advocacy, the CMA supports Health Canada's intent to amend Schedule 1 to the Controlled Drugs and Substances Act (CDSA) and the Schedule to the Narcotic Control Regulations (NCR) to include tramadol, its salts, isomers and derivatives and the salts and isomers of its derivatives. By doing so it will "help dispel the perception that it's somehow safer than other opioids."6
The CMA continues to urge governments to increase access to services and treatment options for addiction and pain management, as well as harm reduction.11
1 Controlled Drugs and Substances Act: Notice to interested parties - Proposal to add tramadol to Schedule I to the Controlled Drugs and Substances Act and the Schedule to the Narcotic Control Regulations Canada Gazette, Part I, 2018 Jun 16 152(24) Available: http://www.gazette.gc.ca/rp-pr/p1/2018/2018-06-16/html/notice-avis-eng.html#ne2 (accessed 2018 Jun 25)
2 Young JWS, Juurlink DN. Five things to know about Tramadol. CMAJ May 2013 185(5) Available: http://www.cmaj.ca/content/cmaj/185/8/E352.full.pdf (accessed 2018 Jul 31)
3 Canadian Institute for Health Information. Pan-Canadian Trends in the Prescribing of Opioids, 2012 to 2016. Ottawa, ON: CIHI; 2017.
4 Kahan M, Mailis-Gagnon A, Wilson L, et al. Canadian guideline for safe and effective use of opioids for chronic noncancer pain; clinical summary for family physician. Part 1: general population. Can Fam Physician November 2011 011;57:1257-66. Available: http://www.cfp.ca/content/cfp/57/11/1257.full.pdf (accessed 2018 Jul 30)
5 World Health Organization. Tramadol Update Review Report Expert Committee on Drug Dependence. Thirty-sixth Meeting Geneva, 16-20 June 2014 Available: http://www.who.int/medicines/areas/quality_safety/6_1_Update.pdf (accessed: 2018 Aug 1)
6 Juurlink DN. Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail November 27, 2017
7 Flint, A., Merali, Z., and Vaccarino, F. (Eds.). (2018). Substance use in Canada: improving quality of life: substance use and aging. Ottawa, Ont: Canadian Centre on Substance Use and Addiction. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Substance-Use-and-Aging-Report-2018-en.pdf#search=all%28aging%29 (accessed 2018 Aug 1)
8 Jin J. Risks of Codeine and Tramadol in Children. JAMA 2017;318(15):1514. doi:10.1001/jama.2017.13534 Available: https://jamanetwork.com/journals/jama/fullarticle/2657378 (accessed: 2018 Aug 2)
9 United States Food and Drug Administration. Codeine and Tramadol Can Cause Breathing Problems for Children. Consumer Update April 20, 2017 Available: https://www.fda.gov/ForConsumers/ConsumerUpdates/ucm315497.htm (accessed: 2018 Aug 14)
10 Minister of Justice. Narcotic Control Regulations C.R.C., c. 1041. Current to July 5, 2018. Last amended on May 20, 2018 Available: http://laws-lois.justice.gc.ca/PDF/C.R.C.,_c._1041.pdf (accessed: 2018 Aug 14)
11 Canadian Medical Association. Harms Associated with Opioids and Other Psychoactive Prescription Drugs. CMA Policy, 2015. Ottawa: The Association; 2015. Available: https://www.cma.ca/Assets/assets-library/document/en/policies/cma_policy_harms_associated_with_opioids_and_other_psychoactive_prescription_drugs_pd15-06-e.pdf (accessed: 2018 Aug 2).
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada’s proposed regulations entitled Tobacco Products Regulations (Plain and Standardized Appearance) and an Order to amend Schedule 1 to the Tobacco and Vaping Products Act with respect to colouring agents, in Canada Gazette, Part 1.
Canada's physicians have been working for decades toward the goal of a smoke-free Canada. The CMA issued its first public warning concerning the hazards of tobacco in 1954 and has continued to advocate for the strongest possible measures to control its use and for the past 30 years we have reiterated our long-standing support for the concept of tobacco products being sold in standardized packages in several briefs and policy statements.
The CMA has been a leader in advocating for plain and standardized packaging for tobacco products for many years. We established our position in 1986 in a resolution recommending to the federal government “that all tobacco products be sold in plain packages of standard size with the words "this product is injurious to your health" printed in the same size lettering as the brand name, and that no extraneous information be printed on the package.”
We are pleased to support the proposed regulations and that they will apply to the packaging of all tobacco products and that brand colours, graphics and logos will be prohibited on packages. No exceptions, including for cigars and pipe tobacco, should be considered. These measures will assist in promoting harm reduction efforts and further the goal of reducing and eliminating smoking.
In 2017, 16.2% of Canadians aged 12 and older smoked either daily or occasionally; this is down from 17.7% in 2015. These proposed regulations will be a significant step in the goal of further reducing the smoking rate. However, there are three areas that the CMA would like to see strengthened and are described below.
Slide and Shell Packaging – Minimum package dimensions and warning surface area
The CMA supports strongly the concept of tobacco products being sold in standardized packages. We recommended that only the “slide-and-shell” style of package be authorized and that the “flip-top” package be removed. This would reduce the permitted style to one type and allow for the largest possible surface area to be used to convey health warnings and other health-related information.
With respect to the draft regulation (s.39) concerning the dimensions of the new packages when closed, the CMA recommends that the measurements for the regular and king size cigarette packages be amended to allow for more surface area for warnings and to standardize packaging regulations across all Canadian jurisdictions.1 The Quebec requirement for a warning surface area of 46.5 sq. cm should be the minimum across Canada.
To achieve that, we suggest that the new slide and shell package for regular size cigarettes have the following dimensions when it is closed:
(a) its height must be no less than 74 mm and no more than 77 mm;
(b) its width must be no less than 84 mm and no more than 87 mm for a package of 20 cigarettes, and no less 103mm and no more than 106 mm for a package of 25 cigarettes.
A similar adjustment is recommended for the width of packages of king size cigarettes when closed:
(a) its width must be no less than 83 mm and no more than 87 mm for a package of 20 cigarettes, and no less 103mm and no more than 106 mm for a package of 25 cigarettes.
In both cases, this is over and above the dimensions in s.39 (1)(a) and (b) for regular size cigarettes and s.39(2)(b) for king size cigarettes. We also recommend that the number of cigarettes permitted in both package sizes be limited to 20 and 25 respectively, reflecting the quantities sold in the current market. This would also prohibit manufacturers from adding one or two additional cigarettes as a “bonus” or “premium.”
The appearance of brand names on the packages should be in a manner that is standard for all brands. Tobacco manufacturers should not be able to include terms such as “organic” or “natural” as part of a brand name. These descriptions would convey the perception that these products are somehow better or are healthier for the consumer. As well, they may be used to evoke a lifestyle or are fashionable. Such terms and phrases should be banned in the regulations; the European Union’s Directive 2014/40/EU of the European Parliament and of the Council could serve as the guide is this instance.
Tobacco manufacturers make frequent use of subtle marketing messages to render smoking attractive and glamorous to their customers. The CMA has always supported educational and public health initiatives aimed at countering these messages. Permitting a leaflet inside packages “that warns consumers of the health hazards arising from the use of the tobacco product or that provides instructions for its use” (draft regulation s. 36.3) is a positive step but should not provide manufacturers with a potential loophole to exploit. The draft regulation should be amended to indicate that the only instance where any instructions are permitted on the leaflet are when the product has an electronic component. This would prevent manufacturers from using the leaflet as any sort of a promotional platform to minimize, for example, the impact of health warnings on the package exterior.
Canada's physicians have been working for decades toward the goal of a smoke-free Canada and we are pleased to support the proposed regulations. We recommend that the draft regulations be strengthened in the following manner:
1) The measurements for the regular and king size cigarette packages be amended to allow for more surface area for warnings and to standardize packaging regulations across all Canadian jurisdictions.
2) The number of cigarettes permitted in both package sizes be limited to 20 and 25 respectively, reflecting the quantities sold in the current market.
3) Use of terms and phrases such as “organic” and “natural” in brand names should be banned in the regulations.
4) The only instance where any instructions are permitted on the proposed leaflets are when the product has an electronic component.
Tobacco and Vaping Products Act: Tobacco Products Regulations (Plain and Standardized Appearance) Canada Gazette, Part I, 2018 Jun 23 152(25). Available: http://gazette.gc.ca/rp-pr/p1/2018/2018-06-23/html/reg9-eng.html (accessed 2018 Aug 7).
Statistics Canada. Smoking, 2017 Health Fact Sheets Cat. No. 82-625-X June 26, Ottawa, Ont.: Statistics Canada, 2018. Available: https://www150.statcan.gc.ca/n1/en/pub/82-625-x/2018001/article/54974-eng.pdf?st=7HkJdkUB (accessed 2018 Sep 5).
Canadian Medical Association (CMA). Letter in response to Health Canada’s Consultation on “Plain and Standardized Packaging” for Tobacco Products. Potential Measures for Regulating the Appearance, Shape and Size of Tobacco Packages and of Tobacco Products. Document for Consultation. Ottawa: CMA; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2016-09.pdf (accessed 2018 Aug 29).
The European Parliament and The Council of the European Union. Directive 2014/40/EU of the European Parliament and of the Council of 3 April 2014 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco and related products and repealing Directive. 2001/37/EC. Brussels: Official Journal of the European Union, 2014. Available:
https://ec.europa.eu/health/sites/health/files/tobacco/docs/dir_201440_en.pdf (accessed 2018 Sep 4).
Dear Premier Ford and Minister Elliott:
We write to you as organizations concerned about the health and welfare of some of the most vulnerable Ontarians, following reports that your government plans to undertake an unnecessary review of the evidence on supervised consumption sites (SCS),1 and the even more troubling announcement that you are imposing a moratorium on the approval of new overdose prevention sites (OPS).2
All the available evidence, including substantial peer-reviewed scientific literature, demonstrates conclusively that these health services save lives and promote the health of people who use drugs. This includes opening doors to treatment. Rather than conduct an unnecessary review and delay expansion of these services, the Ontario government should work with community organizations and health providers to rapidly scale up these services. Delays mean more preventable overdose deaths and new infections of HIV, hepatitis C and other illnesses that could be averted.
Multiple reviews of the evidence have already been done, and have established that SCS and OPS:
provide a needed health service, reducing overdose deaths and the sharing of drug-injection equipment (and the associated risk of transmission of blood-borne infections);
increase access to addiction treatment and other necessary health services; and
benefit public order by reducing public injecting.3
As you know, Canada is experiencing a large-scale opioid overdose crisis. In Ontario alone, overdose deaths related to opioids increased by 45 per cent in 2017, with more than three people dying every day during that year.4 The opioid overdose epidemic has been called “the worst drug safety crisis in Canadian history.”5 HIV, hepatitis C and other infections, as well as overdose deaths, are preventable if the right measures are taken. These include increasing voluntary access to treatment for problematic drug use (where Ontario must do better), and also simultaneously scaling up evidence-based harm reduction services such as SCS and OPS.
We urge you to heed the recommendations of experts in public health, front-line clinicians, harm reduction staff, and people with lived experience of drug use. Rather than impeding access to life-saving health services, we urge you to work with community organizations and other health services providers to ensure greater, equitable access to SCS and OPS for the people of Ontario.
Aboriginal Legal Services
ACAS—Asian Community AIDS Services
Action Canada for Sexual Health and Rights
Addiction Services of Thames Valley
Addictions and Mental Health Ontario
Africans in Partnership Against AIDS
AIDS Coalition of Nova Scotia
AIDS Committee of North Bay and Area
AIDS Committee of Toronto
AIDS Committee of Windsor
AIDS Committee of York Region
AIDS Vancouver Island
Alliance for Healthier Communities
Atlantic Interdisciplinary Research Network on Hepatitis C and HIV
Black Coalition for AIDS Prevention
Breakaway Addiction Services
Butterfly (Asian and Migrant Sex Workers Support Network)
Canadian Aboriginal AIDS Network
Canadian AIDS Society
Canadian Association of Community Health Centres
Canadian HIV/AIDS Legal Network
Canadian Medical Association
Canadian Mental Health Association—Thunder Bay Branch
Canadian Nurses Association
Canadian Positive People Network
Canadian Public Health Association
Canadian Research Initiative on Substance Misuse—Prairie Node
Canadian Students for Sensible Drug Policy
Canadian Treatment Action Council
Centre for Addiction and Mental Health (CAMH)
Centre for Social Innovation
Centre on Drug Policy Evaluation
Chinese and Southeast Asian Legal Clinic
Community Legal Assistance Sarnia
Community Legal Services of Ottawa / Services juridiques communautaires d’Ottawa
Community YWCA Muskoka
Courage Co-Lab Inc.
Dr. Peter AIDS Foundation
Elgin-Oxford Legal Clinic
Four Counties Addiction Services Team
Gerstein Crisis Centre
Guelph Community Health Centre
Haliburton, Kawartha, Pine Ridge Drug Strategy
Halifax Area Network of Drug Using People (HANDUP)
Harm Reduction Nurses Association
Health Providers Against Poverty
HIV & AIDS Legal Clinic Ontario
HIV/AIDS Regional Services
HIV/AIDS Resources and Community Health
Houselink Community Homes
Housing Action Now!
Huron Perth Community Legal Clinic
Income Security Advocacy Centre (ISAC)
Injured Workers Community Legal Clinic
Inner City Health and Wellness Program
Interagency Coalition on AIDS and Development (ICAD)
Kensington-Bellwoods Community Legal Services
Lake Country Community Legal Clinic
Lakeside HOPE House
Lanark County Interval House
Legal Clinic of Guelph and Wellington County
Maggie’s Toronto Sexwork Action Project
Mission Services of Hamilton Inc.
Mississauga Community Legal Services
MODIFY: Drug Insight From Youth
Moms Stop the Harm
mumsDU - moms united and mandated to saving the lives of Drug Users
Native Youth Sexual Health Network
Neighbourhood Legal Services London & Middlesex
Nipissing Community Legal Clinic
OHIP for All
Ontario AIDS Network (OAN)
Ontario Nurses’ Association
Ontario Positive Asians (OPA+)
Overdose Prevention Ottawa
Parkdale Activity Recreation Centre
Parkdale Community Legal Services
Parkdale Queen West Community Health Centre
PHS Community Services Society
Planned Parenthood Toronto
Racial Health Equity Network
Reelout Arts Project
Regent Park Community Health Centre
Regional HIV/AIDS Connection
Registered Nurses’ Association of Ontario (RNAO)
Rideauwood Addiction and Family Services
Sandy Hill Community Health Centre
South Riverdale Community Health Centre
Stonegate Community Health Centre
Students for Sensible Drug Policy, Ryerson Chapter
Superior North Emergency Medical Service
Syme Woolner Neighbourhood and Family Centre
Tanner Steffler Foundation
The AIDS Committee of Cambridge, Kitchener, Waterloo and Area
The Children’s Aid Society of the District of Thunder Bay
The Interfaith Coalition to Fight Homelessness
The Mental Health Consumer Survivor Project for Simcoe County
Thunder Bay Catholic District School Board
Thunder Bay Drug Strategy
Timmins-Temiskaming Community Legal Clinic
Toronto Overdose Prevention Society
Toronto People With AIDS Foundation
Waterloo Region Community Legal Services
WellFort Community Health Services
West Neighbourhood House
West Toronto Community Legal Services
Women & HIV/AIDS Initiative, Ontario
YWCA Niagara Region
1 F. Merali, “PCs ‘playing politics with people’s lives’ on injection sites, drug policy expert warns,” CBC News, August 4, 2018. Available at: www.cbc.ca/news/canada/toronto/supervised-injection-sites-waiting-1.4771143.
2 K. Bueckert, “Ontario puts new overdose prevention sites approvals on hold,” CBC News, August 11, 2018. Available at: www.cbc.ca/news/canada/kitchener-waterloo/ontario-overdose-prevention-sites-approval-hold-1.4782132.
3 E.g., M. Kennedy, M. Karamouzian & T. Kerr. “Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: A Systematic Review,” Current HIV/AIDS Reports, 2017; 14(5): 161-183, doi: 10.1007/s11904-017-0363-y. Available at: www.salledeconsommation.fr/_media/public-health-and-public-order-outcomes-associated-with-supervised-drug-consumption-facilities-a-systematic-review.pdf.
4 Public Health Ontario, “Opioid-related morbidity and mortality in Ontario,” May 23, 2018. Available at: www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/trends.
5 Municipal Drug Strategy Coordinators’ Network of Ontario, “Opioid Epidemic: Call for Urgent Action That Can Save Lives Now,” December 9, 2015.
Dear Minister Elliott:
We write to you as organizations concerned about the health and welfare of some of the most vulnerable Ontarians, in response to the October 22 announcement that your government plans to replace supervised consumption sites (SCS) and low-barrier overdose prevention sites (OPS) with “Consumption and Treatment Services.”1
While we welcome the stated commitment to maintain existing SCS and OPS in Ontario, we are deeply concerned that your government’s new approach to supervised consumption services is creating more barriers instead of facilitating the rapid-scale up of a diversity of much-needed supervised consumption services across the province. This is especially troubling in the context of the public health crisis in which we now find ourselves.
In particular, we are concerned by the decision to impose one “Consumption and Treatment Services” model on service providers and essentially terminate low-threshold, flexible OPS. These life-saving services are part of a continuum of service models that should be made available to all people who use drugs who need them, including the most marginalized. Thousands of overdoses have been reversed using this model, and no deaths recorded at these sites.
As you know, OPS were created in response to the urgent need for rapid roll-out of these vital services. A specific legal regime under a federal class exemption issued to Ontario was put in place to allow for their rapid implementation in response to the current crisis. The requirement for both OPS and SCS, including already authorized ones, to undergo a new application process for funding is sapping concerted efforts from the federal and provincial governments to respond to the overdose crisis. Not only does the new application process replicate the onerous federal exemption process for SCS (such as requiring applicants to engage in ongoing community consultations), it will also impose additional requirements including requiring applicants to provide treatment and rehabilitation services and to conduct seemingly more extensive data reporting, monitoring and evaluations — all without dedicating additional funding to allow organizations to adequately comply. Moreover, the requirement for service providers to provide treatment and rehabilitation services is not in line with harm reduction values of meeting people where they are.
At the same time, the arbitrary decision to cap the number of sites at 21 without any justification means people who do not reside near existing or impending sites will be denied access to life-saving care, at a time when overdose deaths in Ontario are at an all-time high, with more than three people dying every day in 2017.2 Denying funding to new sites will undoubtedly mean more preventable overdose deaths and new HIV, hepatitis C and other infections.
We agree that there are inadequate drug treatment, mental health services and supportive housing options available for people who use drugs, and providing greater support for these services is laudable. But this should not come at the expense of life-saving supervised consumption services, including low-threshold services that are varied, responsive and meet the needs of their communities. We urge you to reconsider the decision to create new hurdles for service providers to receive funding to provide supervised consumption services and to limit the number of sites to 21. We call on you to work with people who use drugs, community organizations and other health service providers to ensure greater, equitable access to SCS and OPS for the people of Ontario. Lives are at stake.
Richard Elliott, Executive Director, Canadian HIV/AIDS Legal Network
Ryan Peck, Executive Director, HIV & AIDS Legal Clinic Ontario
Dr. F. Gigi Osler, President, Canadian Medical Association
Michael Villeneuve, Chief Executive Officer, Canadian Nurses Association
Ian Culbert, Executive Director, Canadian Public Health Association
Sarah Ovens, Coordinator, Toronto Overdose Prevention Society
Cc. The Honourable Doug Ford, Premier of Ontario
1 Ministry of Health and Long-Term Care News Release: Ontario Government Connecting People with Addictions to Treatment and Rehabilitation, October 22, 2018, online: https://news.ontario.ca/mohltc/en/2018/10/ontario-government-connecting-people-with-addictions-to-treatment-and-rehabilitation.html.
2 Public Health Ontario, “Opioid-related morbidity and mortality in Ontario” (May 23, 2018), online: https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/trends.