Health Committee on Feb. 13th, 2014

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Lunney. That's not really a point of order.

Mr. Morin, carry on.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

I will continue on that topic, then. If Ms. Adams wants to talk about the approach of the Conservative government to the abuse of prescription drugs, I think I can do so as well in my questions.

You have heard my questions. What do you think of the Conservative government's approach to its fight against drugs, including prescription drugs? In your opinion, is that the best approach, or should the government change its perspective?

[Dr. Maire Durnin]

That's a very difficult question for me to answer, because I'm not sure what the whole approach entails. I'll give you a generic version of what I think we should be doing.

Number one, I think there needs to be a firewall between pharma and doctors. In other words, pharma contributes to funding for research and education of doctors, but that should be a common fund that helps to educate. They do not direct the education. It comes from individuals such as Dr. Kahan and Dr. Persaud, who can provide evidence-based information to train our doctors.

Secondly, the prescription issue itself needs to be controlled.

Thirdly, you mentioned stigma. I think that is a huge factor that is lacking.... As we've talked about before, stigma is massive, and it needs to be addressed. The level of ignorance.... I have doctors not doing surgery on my patients because they're on methadone, doctors making excuses not to do it. I have nurses telling my pregnant patients that they shouldn't be on methadone, when in fact we know that this is a safe, effective, and recommended treatment. I have other addicts who tell my patients that because they're on methadone, they're not really clean and sober.

That's just within the people who should know better. When it comes to the public...and I've heard some questions in this forum that indicate clearly there's a great deal of misinformation out there. I think that's what this government needs to direct its attention to in order to educate people on what is going on and to educate them correctly, through people like me, like Dr. Kahan, etc., and like Lorinda, people who have been there and done that, who are in the trenches, and who can really explain to people what's going on. We would invite you to come to our places of work to see that.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Do you have any concrete ways for the government to spread that information? You mentioned health professionals who might not have accurate information and also the general public. Based on the fact that we have a pan-Canadian government that has a lot of ways to reach Canadians, do you know concretely how the Government of Canada could do this?

[Dr. Maire Durnin]

I think that's a matter for further discussion around here, but you need a panel of people who can speak to, for example, the language used in addiction, which is massively important. On the terminology you use, the best analogy I can give you in terms of the stigma and the way we approach it is where we are with homophobia these days, compared to where we were 30 years ago. The analogy is very strong, although homophobia is not an illness, and this is.

I think you need to have a committee of educated individuals who can direct a campaign, such as the take back prescription drugs day that's already occurred. That's the direction that I think this kind of education should take: national campaigns, teaching in schools, and education by people who are qualified to give that education, not by lay individuals.

[The Chair, Conservative, Ben Lobb]

Mr. Lunney, you have five minutes.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you, Mr. Chair.

Thank you to all the witnesses for being here as we wrap up a really important study. You can see there's a lot of interest in the subject matter.

Dr. Landau, I just wanted to express, you made some admissions in the beginning of your presentation that you agree that opioids are sometimes over-prescribed, perhaps inappropriately prescribed. Your conclusion was that we all have a lot of work to do.

It was other witnesses who brought forth the fact that your company actually did pay a pretty substantial fine for a misleading advertising campaign. I just find it rather astonishing and perhaps disappointing that in your defence you mentioned the 400 employees in Pickering and that ultimately, as the president, it's your responsibility to ensure that the ink is black and not red.

I just thought it might have been helpful to acknowledge that your company was in fact responsible and convicted of a very serious problem in the United States and there's action pending in Canada as well. Having said that, I'll just leave that for you to think about.

I want to move on to Dr. Persaud. You brought up some very interesting points about where physicians get their information on prescribing. I'm very interested in the remedies that you both, our Toronto witnesses, brought forward. I'm aware that you mentioned the advertising campaign, the clearly inappropriate advertising and misleading campaign, that Purdue conducted.

But when physicians are asked, according to polling, where they get their prescribing information, what's their most reliable source? Is it the drug reps? Is it the product monographs? I think the most common answer, according to one poll that I saw, was actually the ads that are in the peer-reviewed journals and in the CPS, the Compendium of Pharmaceuticals and Specialties.

Some of the slickest ads in the world.... I think the perception is that they're peer-reviewed. Of course the articles in the journals may be peer-reviewed, but the advertisements have never been peer-reviewed.

Would you agree with that assessment, that it's a particular problem? I think it goes along with some of the other comments you were making.

[Dr. Navindra Persaud]

I completely agree and thank you for the question. We recently completed a study that demonstrated that Canadian medical journals, such as the Canadian Medical Association Journal, when compared with journals in the United Kingdom and the United States, such as the British Medical Journal and the Journal of the American Medical Association, had five times the number of ads. Some issues of Canadian journals actually had more pages of ads than they did journal content.

There are many studies that have demonstrated that the content of pharmaceutical ads is misleading, and in some cases, even contains inaccuracies. The medications that are advertised in journals are different from the medications that are discussed in the peer-reviewed content of journals.

I completely agree with your point that this is an important area that could easily be redressed. Obviously the reason journals carry ads is to generate revenue, so we did a calculation of how much it would cost each recipient of the Canadian Medical Association Journal to have an ad-free journal instead.

Currently, Canadian physicians, who have an average salary of about $300,000 per year, pay just $12 a year for 18 issues of the Canadian Medical Association Journal delivered right to their door. In order to have that journal ad-free, it would cost only about $48 per year to have the journal delivered 18 times a year to the door of each physician in Canada.

So it would be very easy to make that change to ad-free journals and I think it would be an important step forward.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you for that. That's a very interesting analysis that you've brought forward.

So who, primarily, would be responsible? The solution you put forward would be an ad-free journal in that particular example, which a lot of people would think would probably be very helpful.

But if there's going to be advertising in journals and in the CPS, who should primarily be responsible for reviewing those ads for accuracy to make sure there isn't misleading advertising going forward, very slick advertising, that is actually designed to misdirect people?

[Dr. Navindra Persaud]

It's currently the Pharmaceutical Advertising Advisory Board that has to approve every ad that appears in a print medical journal. I have had discussions with them about ads that I had concerns about, ads that I thought were misleading and could potentially harm patients and in cases where there's a concern about inaccuracies that could cause harm, the PAAB usually refers those cases to Health Canada. Health Canada's general position when I have communicated with them has been that they don't proactively monitor every statement that is made and they don't have the resources to do that.

So I would say the short answer is that the pharmaceutical ads are not effectively being regulated right now. There really isn't a body that's looking carefully at the content of pharmaceutical ads to make sure that they are accurate and that patients are being protected.

Medical journals are also receiving revenue from the ads and they have an interest in displaying ads regardless of how accurate they are.

[The Chair, Conservative, Ben Lobb]

Ms. Morin is going to ask you a few questions in French.

So go ahead, Ms. Morin.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Thank you very much.

I am going to continue in the same vein as my colleague.

Dr. Persaud, you said that in some countries the industry does not have direct contact with physicians. Could you tell us in which countries that is the case, and explain the regulation that governs this?

[Dr. Navindra Persaud]

Thank you for the question.

My comments may not have been clear. I'm not aware of any countries where there are no interactions between the pharmaceutical industry and physicians. I made some statements about.... I was contrasting the pharmaceutical industry here in Canada with other health care industries such as the medical testing industry.

Physicians routinely receive visits from sales reps of pharmaceutical companies and we are—to the last question—constantly being exposed to advertisements by the pharmaceutical industry. But if you contrast that with the medical testing industry, i.e. the companies that do blood tests and lab tests, they don't advertise in medical journals in general. They don't send sales reps to visit individual physicians. I was drawing that distinction in order to illustrate that industries can be profitable and they can contribute to the health care of Canadians without relying on marketing at all.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Is that governed by regulations, or is it only a tendency? If it is governed by regulation, how could we implement that for pharmaceutical companies?

[Dr. Navindra Persaud]

I think certain practices should be banned or severely restricted, and that could happen at the level of medical schools. For example, that's the way to help control what happens when medical students and residents are taught. You could also work with national bodies like the Canadian College of Family Physicians. They routinely accredit continuing medical education programs that are sponsored by the pharmaceutical industry. I don't think that should be happening. I think all continuing medical education should be completely independent of the pharmaceutical industry, and those national bodies should never accredit such educational sessions.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Thank you very much.

Dr. Kahan, in your statement, you mentioned that Health Canada's expertise in assessing the monographs published by the industry may not be adequate. You said that it might be good to entrust that task to independent experts.

Would it not be a better idea to strengthen the expertise within Health Canada, to make some adjustments, rather than calling on independent experts? Does that make sense to you? What would be the best thing to do?

[Dr. Meldon Kahan]

I personally think it would be better to have independent reviewers because there are so many hundreds of medications that it's impossible to believe that Health Canada could in itself have the internal staff to cover all these medications.

In 2010 we actually complained to Health Canada about the OxyContin monograph, and they simply wrote back and said it was not their jurisdiction to comment on the clinical accuracy of the monograph. I found that astonishing, actually, and it suggests to me that not only did they not have the expertise, but they don't think it's their job. I think it is their job or someone's job to say that what is in the product monograph has to be safe, true, and accurate.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Thank you very much.

I have one last question for Mr. Landau.

There was a crisis in the United States that involved your product. Could you describe in a detailed way what the American regulatory bodies asked you to do? What obligations did they place on you?

[Dr. Craig Landau]

When the company in the United States first became aware of the problem—what became an emerging crisis of abuse—we met with the FDA frequently to share knowledge and to discuss plans to address the condition. We did put out at the time, although it was prior to my involvement, a multi-point plan that involved both the drug development activities that would ultimately produce the OxyNEO product nine years later, but also other risk mitigation activities that focused on education, proper prescribing, safe use, storage, and disposal initiatives, tamper-resistant prescription pads—we've heard other witnesses describe the benefit from these—law enforcement, and education. It was a multi-part plan.

I think most important to this discussion here in Canada is that we worked very closely hand in hand with the regulators and external experts in the United States to get to where we are today.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Were you asked to do the same thing in Canada?

[The Chair, Conservative, Ben Lobb]

Sorry, you're over your time.

Mr. Wilks, you have five minutes.

[David Wilks, Conservative, Kootenay—Columbia, BC]

Thank you, Mr. Chair.

My questions will be directed toward Lorinda Strang.

Thank you for being here today. Just on a personal note, you and I probably have two mutual friends in Bill Wilson and Dr. Bob Smith that you can probably relate to.

I want to go back to a very interesting point you brought up, and that was with regard to data from recovery centres that could be useful for our study. I'd like you to expound on that a bit, because I think we're really missing an opportunity here. You work at the grassroots level, right at the front lines. If we're going to get information, the best people to get it from is those who've been directly affected by it. I wonder if you could talk about that for a few minutes.

If I have any time left, Mr. Chair, I will divert it to Mr. Young.

[The Chair, Conservative, Ben Lobb]

Thank you.

[Lorinda Strang]

Yes, I think we have a valuable resource in our early recovering clients who are going through medically assisted detox. We do also use medically assisted treatment protocols at the Orchard. Our goal is always abstinence for our clients. They cannot always get off of the medications in a short period of time, so we teach them tools in every area.

But with regard to statistics, I can tell you the peaks and the valleys, and what happens. OxyContin concern increased almost 167% in 2011. We saw a decline in 2012 and 2013, dropping almost 41% in those two years. Then we see an increase in fentanyl patches. We see all the different drugs of abuse, and we see the patterns and the trends, which can probably be directly related to the marketing of these medications as well.

We have that information. We have information on even zopiclone being a drug of abuse. Pharmacies and doctors may not even be aware of this. I think it's becoming more readily accessible knowledge now, but several years ago they believed that zopiclone was non-addictive and non-habit-forming.

We can tell you straight from—

[David Wilks, Conservative, Kootenay—Columbia, BC]

Perhaps I can interject for a second, Lorinda.

Mr. Chair, if any of this information is available and can be provided to the committee for further evaluation, I think it would be greatly appreciated.