text:
Ethics and medical professionalism 1
Health care and patient safety 11
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs 25
Population health/ health equity/ public health
Parliamentary submission 3
Response to consultation 1
topic:"Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs"
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Health Canada consultation on Canadian drugs and substances strategy
Pharmaceuticals/ prescribing/ cannabis/ marijuana/ drugs
The Canadian Medical Association (CMA) is pleased to provide this submission in response to Health Canada's consultation on new and innovative ideas on how to further strengthen the federal government's health-focussed approach to substance use issues through the Canadian Drugs and Substances Strategy (CDSS) Question 1 What sorts of circumstances do you see within your networks, communities or in society that you think contribute to problematic substance use? There are multiple factors that contribute to problematic substance use. It is a serious, chronic and relapsing medical condition for which there are effective treatments. However, using the social determinants as a framework, most health promotion and prevention efforts will take place outside of the traditional health and medical care services. . Many Canadians face barriers in their physical, social and economic environments which can contribute to problematic substance use, and certain populations are at higher risk given these circumstances. For example, early childhood is a critical time in the social, emotional, cognitive and physical development of a person. Experiences in early life can 'get under the skin', changing the ways that genes are expressed. Negative experiences such as poverty or family or parental violence can have significant impacts on this important period of development. What is necessary is a coordinated effort across government sectors to ensure that all policy decisions serve to increase opportunities for health. Improving population health and reducing inequities should be an overall objective for all governments in Canada. Question 2 Have you seen or experienced programs, practices or models at the local or regional level that could be expanded, or implemented more broadly, to improve circumstances or social determinants of health that influence substance use? Income is critical to individual health and is closely linked to many of the other social determinants of health. These include but are not limited to: education, employment, early childhood development, housing, social exclusion, and physical environment. Adequate consideration must be given to the social and economic determinants of health, factors such as income and housing that have a major impact on health outcomes. Minimizing poverty should be a top priority. In 2015, the CMA passed a resolution endorsing the concept of a basic income guarantee, which is a cash transfer from government to citizens not tied to labour market participation. It ensures sufficient income to meet basic needs and live with dignity, regardless of employment status. A basic income guarantee has the potential to alleviate or even eliminate poverty. It has the potential to reduce the substantial, long-term social consequences of poverty, including higher crime rates and fewer students achieving success in the educational system. Drug use must not be treated with a criminal justice approach, which does not address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. More investments need to be made in prevention, harm reduction and treatment, keeping individuals out of the criminal justice system. Drug use is a complex issue, and collaboration among health and public safety professionals, and society at large, is essential. Question 3 What needs to change to make sure that opioid medications are being provided and used appropriately, based on the needs of each patient? Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care. Doctors support patients in the management of acute and chronic pain, as well as problematic substance use, and as such have long been concerned about the harms associated with opioid use. Treatment options and services for both problematic substance use as well as pain management are woefully under-resourced in Canada. Experts believe that improved access to specialized pain treatment could reduce inappropriate use of pain medications. Current best practices in pain management include care by an interprofessional team that could include physiotherapists, occupational therapists, psychologists and other health professionals; non-pharmaceutical interventions such as therapy for trauma and social pain, social supports and coping strategies; appropriate pharmaceutical prescription options, covered by provincial formularies; and a focus on patient participation and empowerment.12 Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services. It is also important to support clinicians in their practice. The 2017 Opioid Prescribing Guidelines need to be kept current through ongoing funding. Physicians require tools, including those that facilitate monitoring of effectiveness and tolerance by tracking pain and physical function; screening for past and current substance use; screening for depression; and, tapering of problematic or ineffective doses. Question 4 How can we make sure that those who require prescription opioids to manage their pain have access to them, without judgement or discrimination? Governments need to incorporate the identification and elimination of stigma as a quality of care indicator in the ongoing monitoring of health system performance at all levels. They also need to implement and evaluate national public awareness and education strategies to counteract the stigma associated with substance use issues as well as enforcing legislation and regulations to guard against discrimination against people with mental and substance use issues. Health professionals need to have access to education on pain management and treatment of problematic substance use, recognizing both issues as serious medical conditions for which there are effective treatments. Question 5 Which kinds of messages would work best to help Canadians understand the serious harms that can result from stigma around substance use? A recent report from the Canadian Centre on Substance Use and Addiction (CCSA) and Public Safety Canada cited stigma as "an enormous barrier to individuals seeking and maintaining treatment." Even though there is broad recognition that we are in a public health crisis, until very recently the focus of the federal National Anti-Drug Strategy was heavily skewed towards a criminal justice approach rather than a public health approach with an emphasis on enforcement, as opposed to prevention, treatment and harm reduction.8 This has serious implications in how society views people who use drugs. As noted in the CCSA-Public Safety report, "Language matters. Speak about people first, with compassion and respect."13 A stigma reduction strategy must be core to the activities of the federal government. Stigma involves thoughts, emotions and behaviours; thus, a comprehensive approach includes interventions to target each of these dimensions at both the individual and population level. The strategy should include aspects of: * Public awareness and education to facilitate understanding about the importance of early diagnosis, treatment, recovery and prevention; * Enhanced provider/student education and support; * Policy analysis and modification of discriminatory legislation; * Support for a strong voluntary sector to voice the concerns of patients and their families; * Exposure to positive spokespeople (e.g. prominent Canadians) who have mental illness and/or addiction in order to highlight success stories; * Researching stigma. Question 6 How can we best act to reduce stigma across the country? Engagement with people who use drugs to help them share their stories and experiences with stigma with the public Question 7 What would you recommend to improve substance use treatment services in Canada? This challenge requires a complex and multifaceted solution; and to further this aim, Canada needs a comprehensive national strategy to address the harms associated with psychoactive drugs in Canada, whether illegal or prescription-based, complementing existing strategies to address the harms associated with the other two legal drugs - alcohol and tobacco. This comprehensive approach is necessary, as isolated measures can have unintended consequences, such as under-medicating people that require a medical treatment or constraining people to seek illegal drugs as an option when medications are made tamper-resistant. One of the fundamental principles of health care is that it be patient centred.11 CMA defines patient-centred care as "seamless access to the continuum of care in a timely manner … that takes into consideration the individual needs and preferences of the patient and his/her family and treats the patient with respect and dignity." It is essential that patients be core members of the health care team, working with health care providers to address their individual needs, preferences and aspirations and to seek their personal paths to well-being. Physicians and other health professionals can help patients make choices about their treatment and can provide information and support to patients and their families as they seek to cope with the effects of problematic use and live functional lives. The health care provider community needs tools to assist in the reduction of stigma, access to resources and supportive environments. Question 8 What obstacles or barriers do people face when they want to access treatment in Canada? Obstacles to treatment include the lack of publicly-funded treatment centres, access to locations for remote areas, limited number of beds available, the cost of private treatment (lack of insurance), and stigma. The CMA supports the enhancement of access to options for treatment that address different needs.12 Treatment programs must be coordinated and patient-centred, and address physical, psychological, social and spiritual circumstances. For example, it is important that treatment programs be culturally relevant for Indigenous communities. Question 10 In addition to current harm reduction initiatives – such as supervised consumption sites, needle exchange programs – what other harm reduction services should governments consider implementing in Canada? There is a dire need to address harm reduction in prisons. Even back in 2005, the CMA recommended to the Correctional Service of Canada that it develop, implement and evaluate a pilot needle exchange program in prison(s) under its jurisdiction. These services are not widespread and accessible to prison populations. In Canada, people in prison face far greater risk of HIV and hepatitis C infection because they are denied access to sterile injection equipment as a harm reduction strategy. Hospitals need to incorporate harm reduction strategies as well, allowing people who use drugs to access much needed health services. Question 12 How can we better bring public health and law enforcement together to explore ways to reduce the cycle of involvement for people who use substances with the criminal justice system? Training for police and other frontline criminal justice and corrections workers in how to interact with people with substance use issues is essential. The CMA believes that the government must take a broad public health policy approach. Changes to the criminal law affecting cannabis must not promote normalization of its use and must be tied to a national drug strategy that promotes awareness and prevention and provides for comprehensive treatment.13 The CMA recognized that a blanket prohibition of possession for teenagers and young adults would not reflect current reality or a harm reduction approach. 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. Question 13 What further steps can the federal government take to better address current regulation and enforcement priorities, such as addressing organized drug crime and the dangerous illegal drugs like fentanyl being brought into Canada? The federal government must continue to work closely with the RCMP, local and provincial law enforcement agencies, Canada Post, the Canadian Border Services Agency, Crown attorneys, the Canadian military, and international health officials and law enforcement agencies to address this issue. This topic was covered in the recent CCSA/Public Safety Canada report.10 Question 14 Recognizing Indigenous rights and self-determination, how can all governments work together to address the high rates of problematic substance use faced by some Indigenous communities? Difficulties in access are particularly acute for Canada's Indigenous peoples. Many live in communities with limited access to health care services, sometimes having to travel hundreds of miles to access care. Additionally, there are jurisdictional challenges; many fall through the cracks between the provincial and federal health systems. While geography is a significant barrier for Indigenous peoples, it is not the only one. Indigenous peoples living in Canada's urban centres also face difficulties. Poverty, social exclusion and discrimination can be barriers to needed health care. Of all federal spending on indigenous programs and services only 10% is allocated to urban Aboriginals. This means that Aboriginals living in urban areas are unable to access programs such as Aboriginal head start, or alcohol and drug services, which would be available if they were living on reserve. Further, even when care is available it may not be culturally appropriate. Canada's indigenous peoples tend to be over-represented in populations most at risk and with the greatest need for care, making the lack of access a much greater issue for their health status. It is important that problematic substance use programs be culturally relevant for Indigenous communities. It is clear that the First Nations and Inuit peoples of Canada experience mental illness, problematic substance use and poor mental health at rates exceeding that of other Canadians.11 Individual, community and population level factors contribute to this including socioeconomic status, social environment, child development, nutrition, maternal health, culture and access to health services. The urgent need to work with these communities and identify the structures and interventions to reduce the burden of mental illness and substance use is critical to the health and wellness and future of First Nations and Inuit peoples. Enhanced federal capacity should be created through First Nations and Inuit Health that will provide increased funding and support for First Nations and Inuit community health strategies. The establishment of a working groups comprised of First Nations and Inuit health experts and accountable to First Nations and Inuit leadership is essential for the success of this initiative. Both expert and resource supports are integral elements to facilitate and encourage culturally appropriate strategies and programming in these communities. Question 15 What can we learn from Indigenous approaches to problematic substance use, such as using holistic approaches, that may help inform activities under the CDSS? The federal government must consult First Nations, Inuit, and Métis representatives to develop programs that are culturally relevant and appropriate for Indigenous communities. Question 16 How can governments, and the health, social, and law enforcement sectors design more effective substance use policies and programs for at-risk populations? The government must identify and consult those communities and populations most at risk. This includes First Nations, Inuit, and Métis representatives, community advocates, municipalities, and provincial and local public health officers. Data that describes rates of use and issues specific to each at risk group is important to be able to better understand and address needs. Question 17 What are effective policies and programs to help improve access to prevention, treatment, and harm reduction services for at-risk populations? There are innovative approaches to address the needs of high-volume users as well as at-risk populations. As many of these involve greater integration between health and the community sector and attention to issues not traditionally funded through health care payment systems, there is a need to provide access to funds to enable these innovations to continue and be spread across the country. A targeted, integrated approach to identify communities in need is required and this must be based on reliable community data (i.e., meaningful use of patient data) which can be used to integrate resources to improve health status. For example, the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first multi-disease electronic medical records (EMR) surveillance and research system that allows family physicians, epidemiologists and researchers from across the country to better understand and manage chronic care conditions for their patients. Health information is collected from EMRs in the offices of participating primary care providers (e.g. family physicians) for the purposes of improving the quality of care for Canadians suffering from chronic and mental health conditions and three neurologic conditions including Alzheimer's and related dementias. CPCSSN makes it possible to securely collect and report on vital information from Canadians' health records to improve the way these chronic diseases and neurologic conditions are managed (http://cpcssn.ca/). Question 18 What urgent gaps related to substance use (in terms of data, surveillance, and/or research) need to be addressed in Canada? Improvements are being made in the collection of data in Canada. This is crucial to be able to assess the harms and track the trends and impact of the introduction of policy changes.12 As well, the government must continue to improve the ability of the Public Health Agency of Canada, the Canadian Institute of Health Information, the chief coroners of Canada and related agencies to collect, analyze and report data. One such program is the surveillance system in the United States called RADARS (Researched Abuse, Diversion and Addiction-Related Surveillance system) that is "a surveillance system that collects product-and geographically-specific data on abuse, misuse, and diversion of prescription drugs." It surveys data involving opioids including poison control centres, treatment programs, on the "illicit acquisition or distribution of prescription opioids, stimulants, and other prescription drugs of interest from entities investigating drug diversion cases," among other opioid-related issues. The CMA has recommended that all levels of government work with one another and with health professional regulatory agencies to develop a pan-Canadian system of real-time prescription monitoring. As a first step, the CMA recommends the establishment of consistent national standards for prescription monitoring. Prescription Monitoring Programs (PMP) should be compatible with existing electronic medical and pharmacy record systems and with provincial pharmaceutical databases. Participation in prescription monitoring programs should not impose an onerous administrative burden on health care providers. PMPs should not deter physicians from using controlled medications when necessary. Further, PMPs are a valuable component in addressing the gaps related to substance use. Question 19 How can we use research tools to better identify emerging substance use issues as early as possible? See above response to question 18 - "RADARS" Government of Canada. Consultation on strengthening Canada's approach to substance use issues. Ottawa: Health Canada; 2018. Available: https://www.canada.ca/en/health-canada/programs/consultation-strengthening-canada-approach-substance-use-issues.html (accessed 2018 Sep 5). Canadian Medical Association (CMA). Health in all policies. Ottawa: The Association; 2015 Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-10.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Early childhood development. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-03.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Canadian Medical Association Submission on Motion 315 (Income Inequality). Ottawa: The Association; 2013. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2013-07.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). CMA's recommendations for effective poverty reduction strategies. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-04.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Bill C-2 An Act to amend the Controlled Drugs and Substances Act. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-11.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada. Ottawa: The Association; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-15.pdf (accessed: 2018 Nov 26). Canadian Medical Association (CMA). Non-prescription availability of low-dose codeine products. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2018-04.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Health Canada consultation on restriction of marketing and advertising of opioids. Ottawa: The Association; 2018. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2018-13.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Joint Canadian Medical Association & Canadian Psychiatric Association Policy - Access to mental health care. Ottawa: The Association; 2016. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf (accessed 2018 Nov 26). Canadian Medical Association (CMA). Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-15.pdf (accessed 2018 Nov 26). Public Safety Canada, Canadian Centre on Substance Use and Addiction. 2018 Law Enforcement Roundtable on the Opioid Crisis. Meeting Summary. Ottawa; 2018. Available: https://www.publicsafety.gc.ca/cnt/rsrcs/pblctns/lw-nfrcmnt-rndtbl-pd-crss-2018/index-en.aspx?utm_source=stakeholders&utm_medium=email&utm_campaign=opioidcrisis (accessed 2018 Nov 29). Canadian Medical Association (CMA). Study on Mental Health, Mental Illness and Addiction in Canada: Supplementary Submission to the Senate Standing Committee on Social Affairs, Science and Technology. Ottawa: The Association; 2006. Available: http://policybase.cma.ca/dbtw-wpd/BriefPDF/BR2006-01.pdf (accessed 2018 Nov 29). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Nov 2018). Canadian Medical Association (CMA). Bill C-45: The Cannabis Act. Ottawa: The Association; 2017. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2017-09.pdf (accessed 2018 Nov 28). Canadian Medical Association (CMA). Ensuring equitable access to health care: Strategies for governments, health system planners, and the medical profession. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD14-04.pdf (accessed 2018 23 Nov). Canadian Medical Association (CMA). Submission to Advisory Panel on Healthcare Innovation. Ottawa: The Association; 2014. Available: http://policybase.cma.ca/dbtw-wpd/Briefpdf/BR2015-06.pdf (accessed 2018 Nov 29). Radars System. 2018. Available: https://www.radars.org/. (accessed: 2018 Nov 29). Canadian Medical Association (CMA). Harms associated with opioids and other psychoactive prescription drugs. Ottawa: The Association; 2015 Available: http://policybase.cma.ca/dbtw-wpd/Policypdf/PD15-06.pdf (accessed 2018 Dec 4). Sproule B. Prescription Monitoring Programs in Canada: Best Practice and Program Review. Ottawa, ON, 2015 Canadian Centre on Substance Abuse. Available: http://www.ccsa.ca/Resource%20Library/CCSA-Prescription-Monitoring-Programs-in-Canada-Report-2015-en.pdf (accessed 2018 Dec 4).
Statement to the House of Commons Committee on Health addressing the opioid crisis in Canada
Health care and patient safety
Thank you Mr. Chair. I am Dr. Jeff Blackmer, the Vice-President of Medical Professionalism for the Canadian Medical Association. On behalf of the CMA, let me first commend the committee for initiating an emergency study on this public health crisis in Canada. As the national organization representing over 83,000 Canadian physicians, the CMA has an instrumental role in collaborating with other health stakeholders, governments and patient organizations in addressing the opioid crisis in Canada. On behalf of Canada's doctors, the CMA is deeply concerned with the escalating public health crisis related to problematic opioid and fentanyl use. Physicians are on the front lines in many respects. Doctors are responsible for supporting patients with the management of acute and chronic pain. Policy makers must recognize that prescription opioids are an essential tool in the alleviation of pain and suffering, particularly in palliative and cancer care. The CMA has long been concerned with the harms associated with opioid use. In fact, we appeared before this committee as part of its 2013 study on the government's role in addressing prescription drug abuse. At that time, we made a number of recommendations on the government's role – some of which I will reiterate today. Since then, the CMA has taken numerous actions to contribute to Canada's response to the opioid crisis. These actions have included advancing the physician perspective in all active government consultations. In addition to the 2013 study by the health committee, we have also participated in the 2014 ministerial roundtable and recent regulatory consultations led by Health Canada — specifically, on tamper resistant technology for drugs and delisting of naloxone for the prevention of overdose deaths in the community. 3 Our other actions have included: · Undertaking physician polling to better understand physician experiences with prescribing opioids; · Developing and disseminating new policy on addressing the harms associated with opioids; · Supporting the development of continuing medical education resources and tools for physicians; · Supporting the national prescription drug drop off days; and, · Hosting a physician education session as part of our annual meeting in 2015. Further, I'm pleased to report that the CMA has recently joined the Executive Council of the First Do No Harm strategy, coordinated by the Canadian Centre on Substance Abuse. In addition, we have joined 7 leading stakeholders as part of a consortium formed this year to collaborate on addressing the issue from a medical standpoint. I will now turn to the CMA's recommendations for the committee's consideration. These are grouped in four major theme areas. 1) Harm Reduction The first of them is harm reduction. Addiction should be recognized and treated as a serious, chronic and relapsing medical condition for which there are effective treatments. Despite the fact that there is broad recognition that we are in a public health crisis, the focus of the federal National Anti-Drug Strategy is heavily skewed towards a criminal justice approach rather than a public health approach. In its current form, this strategy does not significantly address the determinants of drug use, treat addictions, or reduce the harms associated with drug use. The CMA strongly recommends that the federal government review the National Anti-Drug Strategy to reinstate harm reduction as a core pillar. Supervised consumption sites are an important part of a harm reduction program that must be considered in an overall strategy to address harms from opioids. The availability of supervised consumption sites is still highly limited in Canada. The CMA maintains its concerns that the new criteria established by the Respect for Communities Act are overly burdensome and deter the establishment of new sites. 4 As such, the CMA continues to recommend that the act be repealed or at the least, significantly amended. 2) Expanding Pain Management and Addiction Treatment The second theme area I will raise is the need to expand treatment options and services. Treatment options and services for both addiction as well as pain management are woefully under-resourced in Canada. This includes substitution treatments such as buprenorphine-naloxone as well as services that help patients taper off opioids or counsel them with cognitive behavioural therapy. Availability and access of these critical resources varies by jurisdiction and region. The federal government should prioritize the expansion of these services. The CMA recommends that the federal government deliver additional funding on an emergency basis to significantly expand the availability and access to addiction treatment and pain management services. 3) Investing in Prescriber and Patient Education The third theme I will raise for the committee's consideration is the need for greater investment in both prescriber as well as patient education resources. For prescribers, this includes continuing education modules as well as training curricula. We need to ensure the availability of unbiased and evidenced-based educational programs in opioid prescribing, pain management and in the management of addictions. Further, support for the development of educational tools and resources based on the new clinical guidelines to be released in early 2017 will have an important role. Finally, patient and public education on the harms associated with opioid usage is critical. As such, the CMA recommends that the federal government deliver new funding to support the availability and provision of education and training resources for prescribers, patients and the public. 4) Establishing a Real-time Prescription Monitoring Program Finally, to support optimal prescribing, it is critical that prescribers be provided with access to a real-time prescription monitoring program. 5 Such a program would allow physicians to review a patient's prescription history from multiple health services prior to prescribing. Real-time prescription monitoring is currently only available in two jurisdictions in Canada. Before closing, I must emphasize that the negative impacts associated with prescription opioids represent a complex issue that will require a multi-faceted, multi-stakeholder response. A key challenge for public policy makers and prescribers is to mitigate the harms associated with prescription opioid use, without negatively affecting patient access to the appropriate treatment for their clinical conditions. To quote a past CMA president: "the unfortunate reality is that there is no silver bullet solution and no one group or government can address this issue alone". The CMA is committed to being part of the solution. Thank you.
Study on Mental Health, Mental Illness and Addiction in Canada : Supplementary Submission to the Senate Standing Committee on Social Affairs, Science and Technology
The Canadian Medical Association, Canadian Paediatric Society, Canadian Psychiatric Association, Canadian Society of Addiction Medicine and College of Family Physicians of Canada are pleased to provide a joint supplementary submission to the Senate Standing Committee on Social Affairs, Science and Technology study on mental health, mental illness and addiction in Canada. This submission provides advice on the areas that we believe require the most immediate attention from the federal government over the short term, and that will have the most direct benefit for those affected by mental illness, poor mental health and addiction. The four areas are: 1. Federal Leadership &Capacity 2. Access Benchmarks and Surveillance Information 3. Best practices in mental illness, mental health and addiction 4. Human resource planning This submission also provides recommendations for specific "priority tasks" under each of these four general areas. 1. Federal Leadership & Capacity Federal leadership and capacity must be rapidly and significantly enhanced in order to address the existing deficiencies in the mental health system. This will signal and institutionalize a renewed commitment by the federal government and will ultimately provide support for Canadians impacted by mental illness, poor mental health and addictions. Federal capacity can be enhanced through one of 3 models: a unit in an existing federal department, a federal arm's length agency, or a pan-Canadian arm's length agency. Model 1: Unit within an existing federal department Under this option, a new Branch led by an assistant deputy minister (ADM) would be created within Health Canada to provide policy leadership and deliver federal programs and services in the area of mental health, mental illness and addiction. The ADM would have general authority for its management and direction, be answerable to the deputy minister, and work with all other federal departments and agencies to develop and coordinate policies, programs and services in this area. Model 2: Creation of a federal arm's length Centre for Mental Illness, Mental Health and Addiction This option would entail the creation of a more independent organization within the purview of the federal government. The 'Centre for Mental Illness, Mental Health and Addiction' would be structured as a federal agency in which decision-making powers are vested in a Board of Directors with a CEO responsible for the daily operations. This Board would be representative of all relevant stakeholders including health providers, health researchers, governments and affected populations. The Centre would remain under the health portfolio, with accountability through the Minister of Health. The Centre's main function would be to deliver federal programs and services, working closely with Health Canada, the Public Health Agency of Canada, Department of Justice and other organizations such as the Canadian Centre for Substance Abuse. While the Centre would provide advice, the responsibility for federal policy development with respect to mental illness and mental health would continue to reside within Health Canada. Model 3: Pan-Canadian arm's length institute This option consists of incorporating an Institute as a not-for-profit entity with the federal and provincial governments as shareholders. This model has been used in other areas where federal-provincial collaboration is essential, such as the Canadian Institute for Health Information. As in the previous model, the Institute for Mental Illness, Mental Health and Addiction would have a board, and a CEO. However, instead of direct accountability to the Minister of Health, the institute would be accountable to the Conference of F-P-T Ministers of Health. It would be responsible for delivering pan-Canadian programs and services that are complementary to provincial and territorial mental health/illness programs and services. Policy development responsibilities for mental health, mental illness and addiction would continue to reside with federal and provincial/territorial governments. Each of the models outlined above has strengths and weakness. It is also possible that we could move from one model to another over time once the system is stabilized. However, for the short term, we contend that Model 1, a dedicated unit within Health Canada, would be the best fit with our objective of enhancing federal leadership and capacity to address mental illness, mental health and addiction issues. The strength of Model 1 is that by elevating responsibility for mental health /illness issues to the branch level it raises the profile and importance of these issues. This would reinstate and indeed increase the capacity that had existed within Health Canada but was lost through numerous reorganizations and resource reallocations. In addition intra-departmental and inter-departmental synergies can be maximized with this model. Should this model be chosen, it is important that the federal government demonstrate the kind of collaborative leadership that it has shown in the area of primary care through initiatives funded via the Primary Health Care Transition Fund. 1 The same leadership principles apply to reform of the mental health system in that while there are common problems and solutions across Canada there are also the needs of specific communities which must be addressed individually. Of immediate priority for this unit are initiatives to reduce stigma and to address the mental health needs of First Nations and Inuit Peoples. Stigma Reduction A stigma reduction strategy is an on-going function that must be core to the activities of the federal government. Stigma involves thoughts, emotions and behaviours, thus a comprehensive approach includes interventions to target each of these dimensions at both the individual and population level. The strategy should include aspects of: * Public awareness and education to facilitate understanding about the importance of early diagnosis, treatment, recovery and prevention; * Enhanced provider/student education and support; * Policy analysis and modification of discriminatory legislation; * Support for a strong voluntary sector to voice the concerns of patients and their families; * Exposure to positive spokespeople (e.g. prominent Canadians) who have mental illness and/or addiction in order to highlight success stories; * Researching stigma. The stigma associated with mental illness in children can hinder early identification and intervention and places them on a damaging path of suffering and pain. The effective treatment and community reintegration of people with mental illness and/or addiction will not only improve the lives of those directly affected but will also work to reduce stigma in the long term. First Nations and Inuit Peoples All people with mental illness and/or addiction have a right to programs and services that facilitate recovery and/or improve their quality of life. It is clear that the First Nations and Inuit peoples of Canada experience mental illness, addiction and poor mental health at rates exceeding that of other Canadians. Individual, community and population level factors contribute to this including socioeconomic status, social environment, child development, nutrition, maternal health, culture and access to health services. The urgent need to work with these communities, and identify the structures and interventions to reduce the burden of mental illness and addiction is critical to the health and wellness and future of First Nations and Inuit peoples. Enhanced federal capacity should be created through First Nations and Inuit Health that will provide increased funding and support for First Nations and Inuit community mental health strategies. The establishment of a First Nations and Inuit Mental Health Working Group that is comprised of First Nations and Inuit mental health experts and accountable to First Nations and Inuit leadership is essential for the success of this initiative. Both expert and resource supports are integral elements to facilitate and encourage culturally appropriate mental health strategies and programming in these communities. We believe that as a population, the First Nations and Inuit peoples should be the priority for the federal government in the provision of much need treatment and support. Priority tasks: A. Establish a Mental Health, Mental Illness and Addiction Branch at Health Canada. B. Implement a Stigma Reduction Strategy C. Improve the capacity of First Nations and Inuit peoples to address the mental health needs of their communities in a culturally appropriate manner. 2. Access Benchmarks and Surveillance Information Access to services, both public and private, currently acts as a barrier to treatment and recovery from mental illness, poor mental health and addiction. Promotion of collaborative care models along with better coordination of services would greatly improve the quality of care received. Governments must facilitate integration and access to these services. Recently, the Supreme Court decision in the case of Chaoulli and Zeliotis vs Quebec struck down two provisions in Quebec's health insurance legislation that prohibit Quebec residents from purchasing private insurance for insured health services. This decision suggests that if Canadians wish to keep their "single-tier" system of universal, first dollar public coverage for health care, then governments must ensure that needed services are available to all Canadians at the time and to the extent of need, including mental health services. Governments must provide timely access to essential services within the public system in order to maximize potential for recovery and quality of life. With the support of the federal government, and on behalf of the medical community, we (CMA, CPA, CPS, CSAM, CFPC) can coordinate and implement a process to develop medically acceptable wait time benchmarks for access to mental illness and addiction care for children and adults. The outcome of this process would be to provide all governments with performance goals to strive for in providing timely access to mental illness and addiction services. With the establishment of benchmarks we will be able to measure how the system is performing. A basic mental illness surveillance system exists and the primary dissemination product is "A Report on Mental Illness in Canada". However, there is agreement that the current information is limited for several reasons: * There is limited data in the system regarding mental health, addiction and many mental illnesses; * The quality of the data in the system has not been validated for many mental illnesses and addictions; * Not all data sources have been accessed for the surveillance system; * Since many supports and services for mental illness and addictions lie outside the formal health system, the collection of these data has not been possible with current constraints; * There is a need for a broader dissemination system. An expanded mental illness surveillance system should work closely with other chronic disease surveillance initiatives to ensure that indicators of common interest are obtained collaboratively and in an efficient manner. Priority Tasks: A. Federal government financially support the coordination and implementation of a process to develop wait time benchmarks for accessing mental illness and addiction services developed by the CMA, CPA, CPS, CSAM, CFPC. B. Creation of an enhanced mental illness surveillance system to produce: * Information about the prevalence and incidence of mental illnesses, addiction and risk factors at the national, provincial/territorial and regional level. * Progress on improving the availability and accessibility to services. * The availability and accessibility of community resources to support people with mental illness and addiction. * Progress on improving the availability and accessibility to community resources. * Information about the cost of mental illness, poor mental health and addiction to people with the conditions, their families and the health system. * Wait list information for mental health services. 3. Best practices in mental illness, mental health and addiction There are numerous interventions that are effective for various mental illnesses and addiction but ensuring optimal use of effective interventions in the real world has been a challenge. Several factors including lack of use by physicians, failure to prescribe or implement in the recommended manner, costs associated with treatment, and undesirable side effects limit the effectiveness of proven therapies for individual patients. A key element in our capacity to prevent and offer treatment for mental illness and addiction rests with the application of evidence or the promotion of best practices. Therefore we are proposing a pan-Canadian program that can facilitate knowledge exchange across disciplines to optimize outcomes for this population. We are aware that there is currently an initiative led by the Public Health Agency of Canada to establish a Consortium of Best Practices for Chronic Disease prevention. The goal of the Consortium is to create a Pan-Canadian forum for knowledge exchange between governments, researchers, non-governmental organizations and consumers. This initiative is a positive step and should be closely aligned with our proposed program for mental illness, mental health and addiction. The program we are proposing would go further than just prevention, to include treatment and policy alternatives, both within and outside the health domain. The program would serve to enhance best practice approaches through activities such as: * Development of a clearing house to hold evidence-based information for mental illness, mental health and addiction by searching, reviewing and summarizing the current literature and web resources; * Identification of gaps in knowledge, and gaps between evidence and practice; * Development of tools to promote best practices relating to mental illness, mental health and addiction, such as the Canadian Collaborative Mental Health Initiative Tool Kit. Priority Task: A. Establish a program to specifically promote inter-disciplinary best practices in prevention, treatment, community interventions and social supports across the continuum of research, policy, to support practice for evidence-based decision making in the area of mental health, mental illness and addiction. 4. Human resource planning Improving access to specialized and primary mental health diagnostic and treatment services with psychosocial community services that support early intervention, prevention of further disability, rehabilitation, improvement of quality of life and recovery should be considered a fundamental underlying goal of a pan-Canadian action plan. Several initiatives are currently under way in various parts of the country to enhance collaborative approaches to care among health care providers and to better integrate primary and secondary health care services. However, these efforts are taking place in a context of relative shortage of addiction specialists, psychiatrists, paediatricians, family physicians and other mental health care professionals. Family doctor and specialist shortages and changing practice patterns have created serious gaps in the availability of mental health services for many Canadians. Health human resource planning needs to consider and address functionally sub-specialized areas of practice as growing numbers of family doctors are moving into these areas, for example general practice psychotherapy and addiction medicine. Health human resource planning must also continue to ensure sustainability of current initiatives and continued access to care. Early interventions in general and with children specifically are critical to preventing long term disability and minimizing the devastating impact of mental illness. There are far too few mental health professionals to help children, insufficient resources allocated to support their mental health needs, and inadequate research being conducted to fill the gaps in knowledge which exist in this area. We believe that improving the mental health of Canada's children, including strategies that increase the amount of health providers with expertise in this area must be a priority for the federal government. Priority Tasks: * Establish a pan-Canadian mental health human resource infrastructure responsible for collecting data, monitoring, conducting research, reporting, and making recommendations related to Canada's ongoing mental health human resources needs, with a priority focus on children's services, in order to ensure a sustainable supply of health human resources; * Introduce toolkits to assist health practitioners and consumers to implement best practices in collaborative care and develop new models of care in the area of mental health; * Support the evaluation of new models of care in achieving patient centred objectives and improving outcomes; * Increasing research capacity and resources in the area of children's mental health. Conclusion: Again, our organizations, representing the medical community, appreciate the opportunity to submit to the Committee further elaboration on key initiatives to ensure federal leadership is taken. We want to thank the committee not only for seeking our advice but also for bringing national attention to issues related to mental illness, mental health and addiction. End Notes 1 The Primary Health Care Transition fund supported provinces and territories in their efforts to reform the primary health care system in addition to supporting various pan-Canadian initiatives to address common barriers. Although the Primary Health Care Transition Fund itself was time-limited, the changes which it supported were intended to have a lasting and sustainable impact on the health care system.
Mental Health, Mental Illness & Addiction : CMA Submission to the Standing Committee on Social affairs, Science and Technology
The Canadian Medical Association (CMA) welcomes the opportunity to provide input to the Standing Senate Committee on Social Affairs, Science and Technology's study of mental health, mental illness and addiction in Canada. The Committee is to be commended for their commitment to the examination of the state of mental health services and addiction treatment in Canada. The Interim Report Mental Health, Mental Illness and Addiction: Overview of Policies and Programs in Canada is a most comprehensive and thorough study. It highlights and reinforces the myriad of players, programs and services as well as the scope and breadth of concerns related to mental health/mental illness care. The Issues and Options paper cogently outlines all the major issues facing mental health, mental illness and addiction care today and provides a platform to stimulate an important public debate on the direction that should be taken to address mental health reform in Canada. The CMA was pleased to appear before the Committee during its deliberations in March of 2004 to speak to the issues facing mental health and mental illness care and put forward recommendations for action by the federal government. The CMA recommended: * developing legislative or regulatory amendments to ensure that psychiatric hospitals are subject to the five program criteria and the conditions of the Canada Health Act, * adjusting the Canada Health Transfer to provide net new federal cash for these additional insured services, * re-establishing an adequately resourced federal unit focussed on mental health, mental illness and addiction, * reviewing federal policies and programs to ensure that mental illness is on par, in terms of benefits, with other chronic diseases and disabilities, * mounting a national public awareness strategy to address the stigma associated with mental illness and addiction. The physicians of Canada continue to support these recommendations. While the Committee has asked for input on a number of important issues in its Issues and Options paper, CMA will focus on the role of the federal government in three areas: * national leadership and intergovernmental collaboration, * accessibility, * accountability. We understand that the Canadian Psychiatric Association, the College of Family Physicians of Canada and the Canadian Paediatric Society will, in their submissions to the Standing Committee, address specific issues of concern to the medical profession in the areas of primary care, child and adolescent mental health and mental illness services, and psychiatric care. The CMA supports the positions of these national specialty organizations. THE ROLE OF THE FEDERAL GOVERNMENT The economic burden of mental health problems is estimated, at a minimum, at $14.4 billion annually. 1 Mental illness and addiction affects one in five Canadians during their lifetime. According to a 2003 Canadian Community Health Survey, 2.6 million Canadians over the age of 15 reported symptoms consistent with mental illness during the past year. Mental illness impacts people in the prime of their life. Estimates from 1998 indicates that 24% of all deaths among those aged 15-24 and 16% of all deaths among those aged 25- 44 are from suicide 2. In contrast, the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) that tragically, resulted in 483 cases and 44 deaths with an estimated economic impact in the Greater Toronto Area of 2 billion dollars served as the 'wake-up call' that galvanized the federal government into paying attention to public health in Canada. In the aftermath of SARS, the federal government appointed a Minister of State for Public Health, established the Public Health Agency of Canada and selected a Chief Public Health Officer for Canada. Nine hundred and sixty five million dollars has been invested by the federal government in public health in the two federal budgets following SARS and a new spirit of federal-provincial-territorial cooperation on public health issues has been spawned. The evidence of the enormous burden that mental illness and addiction places on Canadian society has been a clarion call to many concerned stakeholder organizations across the country to mobilize and search for solutions. It is astounding that the federal government has not heard the call. And it is hard to imagine just what more could constitute a 'wake-up call' for mental health care. In fact the federal government falls woefully short of fulfilling its responsibilities to the people of Canada. The Interim report of the Committee correctly outlines the state of fragmentation and gaps in services to those specific populations under direct federal jurisdiction. It also notes the 'apparent ambivalence' over the years by the federal government about the place of mental health services within publicly funded health care. This ambivalent approach also spills over to the broad national policies and programs of the federal government that can impact those suffering from mental illness, addiction or poor mental health. The federal government has systematically excluded mental health services since the earliest days of Medicare. Mental illness has been treated like a second class disease with little dedicated federal funding, and with programs and services not subject to national criteria or conditions as are set out in the Canada Health Act. In fact, the federal government could be seen as moving in reverse with the downgrading of mental health resources within Health Canada through the 1980s and 1990s. Leadership The CMA firmly believes that strong federal leadership is required to address the sometimes invisible epidemic of mental health problems and addiction in Canada.The government must lead by example and begin by 'cleaning up its own backyard' in terms of its direct role as service provider to those Canadians under its jurisdiction. It should take a 'whole of government' approach that recognizes the interplay of health services, education, housing, income, community and the justice system on mental health and mental illness care. Further, the federal government has a responsibility to ensure that there is equitable access to necessary services and supports across the county. This will require a strong degree of cooperation and collaboration among provinces and territories and the federal government. The federal, provincial and territorial governments must come together to develop a national action plan on mental health, mental illness and addiction modeled on the framework developed by the Canadian Alliance on Mental Illness and Mental Health in 2000. The CMA has noted the options put forward to elevate mental health, mental illness and addiction in government priorities: A Canada Mental Health Act or a Minister of State for mental health, mental illness and addiction. We continue to believe that an adequately resourced, dedicated federal centre focussed on mental health, mental illness and addiction must be established within Health Canada. This will ensure that mental health, mental illness and addiction are not seen as separate from the health care system but an integral component of acute care, chronic care and public health services. A centre with dedicated funding and leadership at the Associate Deputy Minister level is required to signal the intent of the government to seriously address mental health, mental illness and addiction in terms of both its direct and indirect roles. This centre must also have the authority to coordinate across all federal departments and lead F/P/T collaborations on mental health, mental illness and addiction. The responsibility of the provinces and territories for the delivery of services for mental illness and addiction within their jurisdictions is unquestioned. But, as CMA has noted in relation to the acute care and public health systems, we have a concern with the disparity of these services across the country. We believe that the federal government must take a lead role, working with the provinces and territories, in establishing mental health goals, standards for service delivery, disseminating best practices, coordinating surveillance and research, undertaking human resource planning and reducing stigma. It is unfortunate that the Council of Deputy Ministers of Health withdrew its support of the F/P/T Advisory Network on Mental Health in 1990. The lack of a credible and resourced F/P/T forum for information sharing, planning and policy formation has impeded inter-provincial cooperation and collaboration for over a decade. F/P/T collaboration is essential to ensure adequacy of services in all parts of the country and end the piecemeal approach to mental illness and addiction. It would also encourage pan Canadian research and knowledge transfer. The CMA therefore recommends: 1. That the federal government create and adequately resource a Centre for Mental Health within Health Canada led by an Associate Deputy Minister with a mandate to initiate and coordinate activity across all federal departments to address the federal government's responsibilities to specific populations under its direct jurisdiction, to oversee national policies and programs that impact on mental health, mental illness and addiction and to support intergovernmental collaboration. 2. That the federal government re-establish and adequately resource the F/P/T Advisory Network on Mental Health with a broader mandate to encompass mental health, mental illness and addiction. 3. That the federal government work with the provinces, territories and the Canadian Alliance on Mental Illness and Mental Health to establish a Pan Canadian Mental Health, Mental Illness and Addiction Network to develop a national mental health strategy, mental health goals and action plan; and serve as a forum for inter-provincial cooperation and collaboration on mental health, mental illness and addiction. Accessibility Accessibility leads the way as the number one concern regarding the health care system for patients and their families. This concern is in no way lessened when we look at access to mental health and addiction services and programs. The CMA has long identified accessibility as an essential issue that must be addressed to improve the health care system. In recent years, public concern over timely access has been growing. Recent polling for the CMA has shown that a significant majority of Canadians have suffered increased pain and anxiety while waiting for health care services. 3 The same polling clearly demonstrated that the vast majority of Canadians attributed long waits for health care services to a lack of available health providers and infrastructure. More recently, another opinion poll found that Canadians gave the health care system an overall grade of "C" in terms of their confidence that the system will provide the same level and quality of service to future generations. 4 The 2003 Hospital Waiting Lists in Canada report released by the Fraser Institute included a psychiatry waiting list survey which revealed that wait times from referral by a GP ranges from a Canadian average of 8.5 weeks to 20 weeks in New Brunswick. Patients then face a further delay as they wait for appropriate treatment after they have been seen by the specialist. This wait can be anywhere from 4 weeks to 19 weeks depending on the treatment or program. 5 The 2004 National Physician Survey, a collaboration between the CMA, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada, found that 65.6% of physicians rated accessibility to psychiatrists as fair or poor. 6 These statistics do not reflect those patients that do not make it on to lengthy waiting lists where access is effectively denied. In September 2004 the CMA released a national plan of action to address issues of accessibility, availability and sustainability across the health system 7 . Better Access Better Health lays out a number of recommendations designed to ensure that access exists at times of need, and to improve system capacity and the sustainability of the system. While Better Access Better Health speaks to the health care system writ large, the provision of mental health services and addiction treatment clearly falls under this umbrella. Specific recommendations detailed in the plan of action for pan-Canadian wait-time benchmarks, a health human resource reinvestment fund, expanding the continuum of care and an increase in federal "core' funding commitments would all have a positive impact on the accessibility of mental health and addiction services. The review of mental health policies and programs in select countries (Report 2 of the Interim Report) is striking for the similarity of problems facing mental health care. In each of the four countries studied there is concern for the adequacy of resources as well as recognition of the need to coordinate and integrate service delivery. The CMA agrees with the Committee's commentary that: "The means for achieving these objectives that stands out from our survey of four countries is to set actionable targets that engage the entire mental health community, and to establish measurable criteria for the ongoing monitoring of reform efforts. Comprehensive human resource planning in the mental health field, as well as adequate funding for research and its dissemination are also suggested as key elements of a national strategy to foster mental health and treat mental illness." CMA strongly supports setting national standards and targets with regard to mental health services and addiction treatment, but it must be understood that standards and targets can not be established until we have a clear and accurate picture of the current situation in Canada. Pan-Canadian research is needed to determine the availability of services across the country. Surveillance of mental illness risk factors, outcomes and services is essential to guide appropriate development and delivery of programs. Research is also needed to determine ways of integrating the delivery of mental health services between institutional and community settings. The Health Transition Fund supported 24 projects between 1997 and 2001 that made a substantial contribution toward a practical knowledge base in mental health policy and practice. The 2000 Primary Health Care Transition Fund is also supporting projects in the mental health field. For those projects that are due to be completed in 2006, they should be encouraged to put in place a prospective evaluation framework to determine the feasibility and scalability of collaborative care initiatives. As noted in Better Access Better Health availability is first and foremost about the people who provide quality care and about the tools and infrastructure they need to provide it. The shortage of family practitioners, specialists, nurses, psychologists and other health care providers within the publicly funded health care system is certainly an impediment to timely access to care. A health human resources strategy for mental health, mental illness and addiction is a first step in finding a solution to the chronic shortage of health professionals. The CMA therefore recommends: 4. That the federal government, through the Institute of Neurosciences, Mental Health and Addiction, undertake a program of surveillance and research to determine actual availability of services for mental health, mental illness and addiction across the country. 5. That the federal government in consultation with provincial and territorial governments, health care providers and patients/clients establish national standards and targets for access to services. 6. That the Institute of Neurosciences, Mental Health and Addiction and the Institute of Health Services and Policy Research within Canadian Institutes of Health Research establish a joint competition for research on ways of integrating the delivery of mental health services between institutions and community settings. 7. That the federal government undertake an evaluation of those Health Transition Fund and Primary Health Care Transition Fund projects in the mental health, mental illness and addiction field to determine the feasibility and scalability of collaborative care initiatives. 8. That the federal government work with the provinces and territories to develop a health human resource strategy for the field of mental health, mental illness and addiction. Accountability In its presentation to the Committee in March of 2004, CMA recommended that the federal government make the legislative and/or regulatory amendments necessary to ensure that psychiatric hospital services are subject to the criteria and conditions of the Canada Health Act. This would accomplish two objectives. It would signal the federal government's serious intent to address the historical imbalance in the treatment of mental health and illness care while at the same time increase the accountability of these institutions and services to the values espoused in the Canada Health Act. This would be a very positive step, but we must also develop accountability mechanisms that can measure the quality and effectiveness of the mental health services provided. Since 2000, First Ministers and their governments have committed to reporting on numerous comparable indicators on health status, health outcomes and quality of services. In September 2002, all 14 jurisdictions including the federal government, released reports covering some 67 comparable indicators. In November 2004, these governments released their second report covering 18 indicators with a focus on health system performance including primary health care and homecare. Unfortunately, mental illness--despite its magnitude--has received little attention in these reports. Of the now 70 indicators that have been developed, only 2 directly address mental illness (potential years of life lost due to suicide and prevalence of depression). Furthermore, no performance indicators related to mental health outcomes or wait times for mental health services have been included in these reports. This is one more example of the oversight of mental illness related issues and the vicious circle that exists since few indicators makes it difficult to present the case for greater attention. The lack of information on availability of services, wait times and health outcomes for mental health services compromises governments' ability to establish a funding framework to allocate funding equitably. Research that will reveal gaps in service delivery, and the establishment of targets should allow governments to better calculate sustainable funding levels needed to build capacity in the mental health, mental illness and addiction fields. As important as it is to ensure that mental health and addiction services within the health system are available, accessible and adequately resourced we must not lose sight of the fact that to effectively address mental health, mental illness and addiction issues services from a broad range of government sectors are required. Therefore the proposed Associate Deputy Minister for Mental Health must be accountable to ensure collaboration across sectors within the federal government. As in public health in general, a clarification of the roles and responsibilities of the various levels and sectors of government and health providers involved in the provision of mental health, mental illness and addiction services would allow for greater accountability. The CMA therefore recommends: 9. That performance indicators for mental health services and support, based on the work of the F/P/T Advisory Network on Mental Health, are incorporated in the federal, provincial and territorial reporting of comparable indicators on health status, health outcomes and quality of services called for in the 2003 First Ministers' Accord on Health Care Renewal. 10. The federal, provincial and territorial governments establish resource targets based on national standards for access to services and minimum wait times to determine and commit to sustainable funding levels. 11. That the Health Council of Canada report on the performance of the mental health, mental illness and addiction system. CONCLUSION The CMA welcomes the spotlight that the Committee has shone on the mental health, mental illness and addiction system in Canada and has been pleased to provide input on behalf of the physicians of Canada. The neglect of those impacted by mental illness and addiction must not be allowed to continue. It is unconscionable that millions of Canadians do not have access to the programs, treatments or supports that would ease their suffering. The federal government must recognize its responsibility towards these Canadians, embrace its leadership role and ensure that the mental health, mental illness and addiction system is placed on an equal footing within the health care system in Canada. Physicians are an integral part of the mental health, mental illness and addiction field. We are eager to work with governments and other concerned stakeholders to bring to fruition a national mental health strategy with mental health goals and an associated action plan that can effectively address the concerns of today and prepare the mental health, mental illness and addiction system for the future. CMA recommendations on Mental Health, Mental Illness and Addiction 1. That the federal government create and adequately resource a Centre for Mental Health within Health Canada led by an Associate Deputy Minister with a mandate to initiate and coordinate activity across all federal departments to address the federal government's responsibilities to specific populations under its direct jurisdiction, to oversee national policies and programs that impact on mental health, mental illness and addiction, and to support intergovernmental collaboration. 2. That the federal government re-establish and adequately resource the F/P/T Advisory Network on Mental Health with a broader mandate to encompass mental health, mental illness and addiction. 3. That the federal government work with the provinces, territories and the Canadian Alliance on Mental Illness and Mental Health to establish a Pan Canadian Mental Health, Mental Illness and Addiction Network to develop a national mental health strategy, mental health goals and action plan; and serve as a forum for inter-provincial cooperation and collaboration on mental health, mental illness and addiction. 4. That the federal government, through the Institute of Neurosciences, Mental Health and Addiction, undertake a program of surveillance and research to determine actual availability of services for mental health, mental illness and addiction across the country. 5. That the federal government in consultation with provincial and territorial governments, health care providers and patients/clients establish national standards and targets for access to services. 6. That the Institute of Neurosciences, Mental Health and Addiction and the Institute of Health Services and Policy Research within Canadian Institutes of Health Research establish a joint competition for research on ways of integrating the delivery of mental health services between institutions and community settings. 7. That the federal government undertakes an evaluation of those Health Transition Fund and Primary Health Care Transition Fund projects in the mental health, mental illness and addiction field to determine the feasibility and scalability of collaborative care initiatives. 8. That the federal government works with the provinces and territories to develop a health human resource strategy for the field of mental health, mental illness and addiction. 9. That performance indicators for mental health services and support, based on the work of the F/P/T Advisory Network on Mental Health, are incorporated in the federal, provincial and territorial reporting of comparable indicators on health status, health outcomes and quality of services called for in the 2003 First Ministers' Accord on Health Care Renewal. 10. The federal, provincial and territorial governments establish resource targets based on national standards for access to services and minimum wait times to determine and commit to sustainable funding levels. 11. That the Health Council of Canada report on the performance of the mental health, mental illness and addiction system. 1 Stephens T and Joubert N, The Economic Burden of Mental Health Problems in Canada, Chronic Disease in Canada, 2001:22 (1) 18-23. 2 Health Canada. A Report on Mental Illnesses in Canada. Ottawa, Canada 2002. 3 Health Care Access and Canadians, Ipsos-Reid for the CMA, 2004. 4 2004 National Report Card on the Sustainability of Health Care, Ipsos-Reid for the CMA, 2004. 5 Hospital Waiting Lists in Canada (13th edition), Critical Issues Bulletin, The Fraser Institute, October 2003. 6 National Physician Survey, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, 2004, (http://www.cfpc.ca/nps/English/home.asp), accessed April 6, 2005. 7 Better Access Better Health: Accessible, Available and Sustainable Health Care For Patients, CMA September 2004 , attached as Appendix I.


"It is impossible to think of an environmentally-conscious generation without thinking about the children. So I visit primary schools every so often to have environmental awareness talks with the pupils. Some days, we plant flowers around the school and have pupils adopt them.
Yes, the government has its role, but putting up litter bins is not enough. Citizens have to understand the role they play in keeping the environment clean. Getting people to fund the project is also a problem because the results are not tangible, yet most people prefer to contribute to causes where the results are physically tangible.
"I have an undergraduate degree in microbiology and biotechnology. I was set for a career in the health care or pharmaceutical industry. Then just before graduation, I took up a part-time job as a waitress at a restaurant. While here, I got to meet an interesting breed of people. People who seemed utterly content with their lives and happy with their jobs. I knew that the path my degree was taking me towards would not make me happy, so I quit the waitressing job and took some time to do some soul-searching. It opened my eyes to just how dirty Nairobi was, so I immediately registered my foundation and went back to school for a master's in environmental planning and management to get the skills I needed.
"It has been three years now and my team of four and I have done 25 environmental clean-ups in Nairobi. Every day is another chance to reduce littering and promote better waste management. My programme is community-based.
"I am up at 6am every morning to do the house chores before setting out for work. I spend most of my days in meetings trying to talk people round to partnering with me in my initiative. In three years, I have recruited 2, 000 volunteers. The youngest volunteer is 16 and the oldest, 40. The most fulfilling part is knowing that in addition to cleaning the environment, I am helping clean up their minds. I source most of the volunteers on social media.
"The greatest challenge has been changing the "tunaomba serikali" mentality, where Kenyans absolve themselves from taking responsibility for anything, and instead expect the government to do everything. Yes, the government has its role, but putting up litter bins is not enough. Citizens have to understand the role they play in keeping the environment clean. Getting people to fund the project is also a problem because the results are not tangible, yet most people prefer to contribute to causes where the results are physically tangible.
"There are days that what I am doing feels insignificant. Reminding myself that it is actually important even when I can't see the results, is what keeps me going. Eventually I want to go beyond litter. I want to go into people's homes and talk to them about proper waste management. Other than having a clean environment, my ultimate goal is to give people jobs.


text:
The number of guns found at the Whatcom County Airport has been released
January 21, 2023 user
Transportation Security Administration officials in Washington set a record for the number of firearms found at checkpoints in 2022, according to an emailed statement Friday, Jan. 20.
But TSA officers found only one firearm in carry-on luggage at Bellingham International Airport last year, the TSA said in a statement.
Security officials in Washington found 164 firearms among travelers' personal belongings in 2022.
Most of the firearms, 113, were discovered at security checkpoints at Seattle-Tacoma International Airport during routine X-ray screening of carry-on bags.
Nationwide, TSA officers found 6,542 firearms at 262 airports last year, according to the TSA.
Bellingham International Airport, codenamed BLI, saw 338,000 travelers in 2022, far fewer than Sea-Tac's 17.3 million passengers.
Two firearms were found at Bellingham Airport in 2021, none in 2020, and four in 2019.
Robert Mittendorf covers civic issues, weather, traffic and how people are coping with high housing costs for The Bellingham Herald. A journalist since 1984, he is also a volunteer firefighter with the South Whatcom Fire Department.
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June 11, 2022 15:02 Published by: June 11, 2022 15:02 Updated: June 11, 2022 15:18…
27 Jan 23 user
JBLM not in favor of Pierce Airport sites, Thurston
A new commercial airport built near Joint Base Lewis-McChord would be inconsistent with military aviation…
5 Jan 23 user
Society reacted to Brian Koberger's visit to Moscow
1 hour ago Posted by: January 4, 2023 10:30 p.m Updated: January 4, 2023 11:12…

redpajama_set_name: RedPajamaCommonCrawl


We sourced Pinot Noir fruit from McLaren Vales planted 40 years ago. The fruit was picked early to acidity, ideal for Sparkling wine. Delicate skin contact ensured translucent pink colour, vibrancy and elegancy.
The bouquet exhibits fresh strawberry, red guava and apple. This refined Sparkling displays, strawberry, lemon and white cherry flavours, which are enhanced by subtle brioche autolysis characters from the secondary fermentation. The wine shows a fine bead, lively mousse and tight crisp finish.


A study carried out by researchers at New Mexico State University (NMSU), has shown that Bombshell, by Victoria' Secret, is an effective mosquito repellent.
In the study, published in the Journal of Insect Science, NMSU researchers tested eight commercial insect repellents and two perfumes, including Bombshell.
"We tested VS Bombshell because one of our test subjects had gotten it as a birthday present, so it was a completely random pick,".
"Since it smells flowery and sweet, we thought that it would attract mosquitoes, but the reverse was true."
"In our experiments, best protection was achieved with 30 percent or 95 percent DEET-containing repellents, or oil of lemon eucalyptus," Hansen told TODAY. "I personally use a 30 percent DEET repellent when I go into the field — or my backyard."


"You will be the greatest tattoo fairy that ever lived." The words echoed in Grindlespit's mind as she twinkled into the mortal world, teeth bared, hovering on hair-thin wings over the writer's bed. Those words had grated at her since the prophecy was first made, filling her belly with a feeling like barbed wire.
She loved her art, adored every second of biting patterns into the skin of sleeping humans. But being destined to be great felt like cheating. Worse, it felt like she had been cheated, robbed of the opportunity to become something on her own terms.
Pulling a pot of graveyard grey ink from her belt, she sank her needle thin teeth through its seal. As colour filled the tubes in her teeth she contemplated how best to execute this job. The writer had wished for some obscure superhero, and then left her shoulder exposed as she slept. A heroic stance near the top of the arm was the obvious use of the space, but Grindlespit wasn't great because she did obvious. Something more dynamic was called for.
She floated down onto the duvet, light as a feather. A sprinkle of pixy dust anaesthetised the sleeper – there was nothing worse for art than a wriggling canvas – and then Grindlespit set to work.
The vision in her head was flowing, vibrant, full of life and energy. It should have been a delight to create, each bite a tiny addition to her body of work. But instead she felt more miserable each time her teeth sank into flesh. She wanted to create art, not to be trapped and defined by the visions of others.
Missing the seal, her teeth ground against a pot of scab brown ink. She sank into the duvet, head in hands, wings fluttering, and sobbed. Was she only doing this because it had been destined? Or was she doing what she loved? Was it both, and she could never have satisfaction without giving in to the will of the universe?
The agitated twitching of her wings turned into a frantic buzz. She hurtled into the air, unable to think straight, flapping from place to place. She landed on a desk in the corner of the room, kicked an eraser into the waste bin, flung a pencil on the floor. Picking up a pile of the writer's chaotic notes, she gnashed at it with her teeth, staining the paper with hundreds of tiny bitemarks.
At last her rage subsided and she sank back down, the paper trembling in her hands. The mess she had made was almost beautiful, a jumble of shapes and colour. Not a tattoo, but still art, a work for which she had never been destined.
The smallest of smiles fluttered in Grindlespit's heart. This was the way. She could still create without bowing to prophecy. She could be her own artist.
The air twinkled as she faded from the room.
The writer woke groggily and looked down at her arm. Half a face had appeared on the skin. It looked vaguely familiar.
"What the hell?" she gasped.
This story was inspired by regular reader Glenatron, who suggested I should write something about destiny, and by a brief conversation on Twitter with Jennifer Williams. Its weirdness is all my own.
Next Next post: Free Fantasy Book!


There are no better experts in DJI products than those at DJI. Every refurbished product has undergone a professional refurbishing process that brings it up to the same high standards as brand new products, and all refurbished products come with new parts, new packaging and DJI's standard Manufacturer Warranty.
Q4. HOW DO I IDENTIFY REFURBISHED PRODUCTS?
Q5. WHAT IS INCLUDED IN THE PACKAGE?
The Phantom 4 Pro boasts a 3-axis-stabilized gimbal camera with a 20MP, 1" CMOS sensor capable of shooting up to 4K/60fps video and well as photo bursts at up to 14 fps. The hull has been updated from the previous Phantom 4, now featuring magnesium alloy construction for increased rigidity and reduced weight.
>> The FlightAutonomy system adds dual rear-vision sensors plus infrared sensing for a total of five directions of obstacle sensing and four directions of obstacle avoidance.
A 5.5in 1080p screen integrated with the Phantom 4 Pro Plus + offers 1000 cd/m2 of brightness, more than twice as bright as conventional smart devices. It makes bright, vivid colors easily visible in direct sunlight. With this screen, a mobile device is not required, simplifying pre-flight preparations. As the DJI GO app is built into the screen, hardware and software can be fully optimized, further reducing video lag. Integration of an HDMI port, Micro-SD card slot, microphone, embedded loudspeaker, and Wi-Fi connection allow images to be edited inside DJI GO to share almost instantly. Lastly, a five-hour battery life makes the Phantom 4 Pro + a complete aerial imaging solution.
An UpRated Camera is equipped with a 1-inch 20-megapixel sensor capable of shooting 4K/60fps video and Burst Mode stills at 14 fps. The adoption of titanium alloy and magnesium alloy construction increases the rigidity of the airframe and reduces weight, making the Phantom 4 Pro similar in weight to the Phantom 4. The FlightAutonomy system adds dual rear vision sensors and infrared sensing systems for a total of five-directions of obstacle sensing and four-directions of obstacle avoidance.
The onboard camera has been redesigned to use a 1-inch 20-megapixel CMOS sensor. A custom engineered lens made up of eight elements is arranged in seven groups, it is the first DJI camera to use a mechanical aperture that eliminates rolling shutter distortion that can occur when taking images of fast moving subjects or when flying at high speed and a mechanical focus. In effect, it is as powerful as many traditional ground cameras. More powerful video processing supports H.264 4K videos at 60fps or H.265 4K at 30fps, both with a 100Mbps bitrate. Advanced sensors and processors ensure everything is captured with more image detail and the image data needed for advanced post-production.


text:
Kägelvaxskinn (Phlebia georgica) är en svampart som tillhör divisionen basidiesvampar, och som beskrevs av Erast Parmasto. Kägelvaxskinn ingår i släktet Phlebia, och familjen Meruliaceae. Enligt den svenska rödlistan är arten otillräckligt studerad i Sverige. Arten förekommer i Götaland. Artens livsmiljö är skogslandskap.

Källor

Externa länkar
 Artfaktablad för Phlebia georgica

Basidiesvampar

redpajama_set_name: RedPajamaWikipedia


A new version of MJaoune's DS adaptation of Pocket God is now out folks, bringing a slew of new features and improvements.
Added Time, Date, and version info on the top screen.
Added a tree (Still doesn't have fruits(Yet)).
Added a bar on the bottom screen with all the functions to use.
Fixed the glitch that used to keep changing weather when the sun is on the corner of the bottom screen.
Some GFX Fixes and changes.


text:
Q: Resources for understanding SQL Server locking and concurrency? As demonstrated by a recent question of mine locking and concurrency are HARD.
Can you suggest any good resources for intermediate-to-advanced SQL professionals to do a thorough study on these that would, properly learned, enable better navigation of all the inherent pitfalls in this area?
I'm thinking of all kinds of resources--tutorials, blogs, manual pages, PASS sessions, or anything.

A: Best book on the subject, and the most complete resource, is Kalen Delaney's SQL Server 2008 Internals. You really can't do any better. Another good book on the subject is Chris Bolton's SQL Server 2008 Internals and Troubleshooting. I don't think it's as complete as Kalen's book, but it does cover things pretty well, especially around locking and concurrency.

A: *

*Transaction Processing: Concepts and Techniques.

*Readings in Database Systems

*Principles of Transaction Processing
While product specific books do a great job at explaining how to use the products (and Kalen Delaney's series is awesome!), they don't really stand a chance against the 'black book' and the 'red book' of the database systems. Specially the black book (the first link) is pretty much a mandatory reading if you want to understand these concepts. The red book is a collection of research papers, many available online. I keep a page with links to some of them. The third book linked is basically a more up-to-date rewrite of the 'black book' (also cheaper and available on Kindle...)
There are also several good blogs, I would first and foremost recommend the SQL Server CSS blog.

A: Locking and concurrency is a topic I learnt most about through testing and observation.
Start by reading Isolation Levels in the Database Engine and Concurrency Effects, so you have an understanding of the relationship between the two. Now you can experiment:

*

*Construct the SQL for a test transaction. Something simple and self-contained with a context/domain you understand e.g. shopping cart checkout or bank transfer. Ensure you have a method of verifying that the data is in the expected state after testing.

*Run your scenario, observing the type, duration and sequence of locks applied by the database engine.

*Alter the isolation level or apply hints and observe the change to the locks taken.

*When you think you have a transaction that will survive concurrency, load test it.

I tend to check lock sequences with trace flag 1200 or a Profiler trace. I believe extended events could also be used but I've not tried myself as yet.

A: One other resource is Kendra Little's clever poster on isolation levels. There are also links to her presentation, resources and some discussion.

redpajama_set_name: RedPajamaStackExchange


text:
package org.seltest.test;

import org.openqa.selenium.By;
import org.openqa.selenium.NoSuchElementException;
import org.openqa.selenium.StaleElementReferenceException;
import org.openqa.selenium.WebDriver;
import org.openqa.selenium.WebElement;
import org.openqa.selenium.support.events.AbstractWebDriverEventListener;
import org.seltest.core.Browser;
import org.slf4j.Logger;
import org.slf4j.LoggerFactory;

public class WebEventListener extends AbstractWebDriverEventListener {

	private static final Logger log = LoggerFactory
			.getLogger(WebEventListener.class);
	private static final LoggerUtil logger = LoggerUtil.getLogger();
	private final Browser browser = new Browser();
	private ReportUtil report = ReportUtil.report;

	public void afterClickOn(WebElement element, WebDriver driver) {
		log.trace("After Click On : {} ", element);
		/*
		 * NOTE : Dont Add any check here as Alert will fail if some action is
		 * done after click
		 */
	}

	public void beforeFindBy(By by, WebElement element, WebDriver driver) {
		log.trace("Before Find By :{} ", by);
	}

	public void afterFindBy(By by, WebElement element, WebDriver driver) {
		log.trace("After Find By : {} ", by);
	}

	public void afterNavigateTo(String url, WebDriver driver) {
		log.info(LoggerUtil.webFormat() + "(NAVIGATE)	-> To Url : {} ", url);
		browser.waitForPageLoaded();
		report.reportWebStep(null, "GO TO ", url, "");
	}

	public void beforeClickOn(WebElement element, WebDriver driver) {
		String elemIdentity = LoggerUtil.getElementIdentity(element);
		log.info(LoggerUtil.webFormat() + "(CLICK ON)	-> Element = '{}'",
				elemIdentity);
		report.reportWebStep(element, "CLICK", elemIdentity, "");

	}

	public void afterChangeValueOf(WebElement element, WebDriver driver) {
		String elemValue = element.getAttribute("value");
		String elemIdentity = LoggerUtil.getElementIdentity(element);
		log.info(LoggerUtil.webFormat() + "(CHANGED)	-> Element = '"
				+ elemIdentity + "' New Value = '{}'", elemValue);
		report.reportWebStep(element, "CHANGED", elemIdentity, elemValue);

	}

	public void beforeChangeValueOf(WebElement element, WebDriver driver) {
		String elemValue = element.getAttribute("value");
		String elemIdentity = LoggerUtil.getElementIdentity(element);
		log.info(LoggerUtil.webFormat() + "(CHANGING)	-> Element = '"
				+ elemIdentity + "' Old Value = '{}' ", elemValue);

	}

	public void onException(Throwable throwable, WebDriver driver) {
		if ((throwable instanceof NoSuchElementException)
				|| (throwable instanceof StaleElementReferenceException)
				|| (throwable instanceof AssertionError)) {

			log.debug("( HANDLED EXCEPTION) 	-> Message = "
					+ throwable.getClass());
			log.trace(throwable.getMessage());
		} else {
			log.info(LoggerUtil.webFormat() + "(EXCEPTION) 	-> Message = "
					+ throwable.getLocalizedMessage() + " ");
			logger.exception(throwable); // stack trace as a string
//			report.reportException("EXCEPTION", throwable
//					.getLocalizedMessage().substring(0, 50), "");// TODO Make it
//																	// Small
//																	// message
			log.trace(throwable.getMessage());
		}
	}

}

redpajama_set_name: RedPajamaGithub


text:
// Copyright 2022 The Chromium Authors
// Use of this source code is governed by a BSD-style license that can be
// found in the LICENSE file.

package org.chromium.support_lib_boundary;

import android.content.ContentProvider;
import android.database.Cursor;
import android.net.Uri;
import android.os.Bundle;
import android.os.ParcelFileDescriptor;

import androidx.annotation.NonNull;
import androidx.annotation.Nullable;

import java.io.FileNotFoundException;

/**
 * Boundary interface for DropDataProvider.
 */
public interface DropDataContentProviderBoundaryInterface {
    boolean onCreate();
    String[] getStreamTypes(@NonNull Uri uri, @NonNull String mimeTypeFilter);
    ParcelFileDescriptor openFile(@NonNull ContentProvider providerWrapper, @NonNull Uri uri)
            throws FileNotFoundException;
    Cursor query(@NonNull Uri uri, @Nullable String[] projection, @Nullable String selection,
            @Nullable String[] selectionArgs, @Nullable String sortOrder);
    String getType(@NonNull Uri uri);
    Uri cache(byte[] imageBytes, String encodingFormat, String filename);
    void setClearCachedDataIntervalMs(int milliseconds);
    void onDragEnd(boolean imageInUse);
    Bundle call(@NonNull String method, @Nullable String arg, @Nullable Bundle extras);
}


Sliced tomatoes, fresh garlic, sweet basil, ricotta cheese, black pepper.
Herb infused potatoes, garlic, bacon, truffle oil, fresh herbs.
Roasted red peppers, spinach, ricotta cheese, garlic, sausage.
San Marzano tomato sauce, fresh mozzarella cheese, sweet basil, extra virgin olive oil.
Sausage, pulled mozzarella cheese, cherry peppers, extra virgin olive oil.
Pepperoni, onions, peppers, sausage, bacon mushrooms.
Grilled chicken, spicy blue sauce, chives.
Grilled chicken, bourbon BBQ sauce, chives.
Grilled pesto chicken, spinach, onions.
Chicken tikka sauce, tandoori chicken, onions, fresh herbs.
Served with homemade blue cheese dressing & celery.
Bacon wrapped & cherry peppers stuffed chicken, orange chili sauce.
Cherry bomb chicken, Buffalo chicken dip, fried mozzarella.
Herb & panko crusted mozzarella served with marinara.
Golden fried russet potato fries.
Five blend cheese, roasted garlic butter, fresh herbs.
Belgian beer battered, honey mustard.
Homemade herb crusted meatballs, mozzarella cheese blend, herbs.
Sweet & spicy Italian sausage, roasted peppers, mozzarella cheese, herbs.
Hand pulled chicken, Buffalo blue cheese fondue, sea salt tortilla chips.
Potato boat, smoked bacon, five cheese blend, chives, creme fresco.
Homemade chile con queso, sea salt, tortilla chips.
Served with homemade garlic crostini.
Mesclun mix, cucumbers, tomatoes, shredded carrots, balsamic vinaigrette dressing.
Romaine lettuce, grilled chicken, candied bacon, gorgonzola cheese, tomatoes, egg, avocado, balsamic vinaigrette dressing.
Romaine lettuce, fried chicken, avocado, pepper jack cheese, black bean salsa, lime, chipotle ranch dressing.
Mesclun mix, hand pulled mozzarella cheese, sliced tomatoes, balsamic drizzle.
Mesclun mix, tandoori chicken, red onions, tomatoes, lime, chipotle ranch dressing.
Romaine lettuce, aged parmesan cheese, croutons, Caesar dressing.
Half pound Angus beef patty, served with house fries.
American cheese, lettuce, tomatoes, onions, pickle, mayo.
Lettuce, tomatoes, bacon, onion straws, chipotle mayo.
Roasted onions, roasted marsala mushrooms, Swiss cheese & mayo.
Grilled chicken, tomato, basil, pulled mozzarella, salt, cracked pepper, balsamic drizzle.
Fried chicken, romaine, tomatoes, red onion, mayo, American cheese.
Bacon, romaine, tomato, mayo, salt, cracked pepper, a splash of red vinegar.
Romaine, tomato, basil, pulled mozzarella, salt, cracked pepper, balsamic drizzle.
Grilled chicken, romaine lettuce, tomatoes, blue cheese.
Fried chicken, romaine lettuce, tomatoes, black bean salsa, pepper jack cheese, chipotle mayo.
Romaine, tomatoes, basil, pulled mozzarella, salt, cracked pepper, balsamic drizzle.
Homemade meatballs, marinara sauce, parmesan, herbs.
Spaghetti pasta with homemade marinara sauce, aged parmesan cheese, herbs.
Chicken breast, marinara, mozzarella, parmesan, herbs, served with spaghetti.
Hand rolled semolina pasta, bolognese sauce, mozzarella, ricotta, parmesan, herbs.
Ziti, bolognese, mozzarella, ricotta, parmesan, herbs.
Ricotta cheese, stuffed shells, marinara, mozzarella, parmesan, herbs.
Crispy panko crusted eggplant, mozzarella, parmesan, herbs served with spaghetti.
Sauteed chicken, creamy Alfredo parmesan sauce, roasted garlic, broccoli and herbs, served with pasta.