Health Committee on April 10th, 2014

[Hedy Fry, Liberal, Vancouver Centre, BC]

Do you have a tracking system?

[Phil Emberley]

I believe provincial governments are able to track the prescribing habits of pharmacists, yes.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I have just one last question. With regard to prescribing opioids, I know in B.C. there's a triplicate prescription system. I know, as a physician, people would come in and they would say, “I'm from Alberta and, my gosh, I've been taking this medicine for 20 years. My doctor has been giving it. My back is so bad”, and blah, blah, blah. In the past, without the triplicate prescription, you didn't know what to do so you would try to call their doctor to say, “Is this true?”, because these are the patients who are shopping around for opioids. Do you have that problem? How do you assess that when it happens?

[Janet Cooper]

It is a problem. B.C. has had a province-wide drug network for more than 15 years. A pharmacist knows every prescription that is ever dispensed for that patient. We certainly don't have that here in Ontario. We need it. There are different things that have been put in place to try to prevent double doctoring and prescription drug abuse, but ultimately, province-wide drug systems, profile systems, electronic prescribing, electronic health records that everybody has access to are going to make a huge difference in addressing a lot of those challenges.

[Phil Emberley]

If I could just add to that, the Controlled Drugs and Substances Act regulates the controlled drugs in Canada, but it doesn't have a monitoring and surveillance side to it. I think maybe it's time to look at that. I think we need a national monitoring vehicle because people do move from province to province as well. So I think we need to look at this nationally.

[The Chair, Conservative, Ben Lobb]

Very good. Thanks a lot.

For the last round, Ms. Adams.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Thanks, Mr. Chair. If you would be kind enough, please alert me to the last two minutes so that I might split my time with Mr. Young, because I know he's keen to get some questions in to these witnesses.

If I might just pick up on what my colleague Mr. Lizon had said, I've had the very same experience when I've travelled through eastern Europe. If you're ill, you present yourself to the pharmacist and much like the traditional apothecaries, they would look and actually give you the medication you require and you're on your way. It seemed very efficient—just very, very efficient and very, very convenient.

While I understand what Ms. Fry has been indicating about the need to make sure that we're obviously not over-prescribing opioids and all sorts of other serious medications, I do think that there is an opportunity with expanded scope of practice to offer innovation and savings to the health care system and added convenience to Canadians across the country. I think especially, for instance, to experiences when my son would have an asthma attack at night and I would run out of refills for his puffers. It would have been so handy to just go straight to the pharmacy and have them refill the puffer. Instead I had to hike and try to find a 24-hour clinic that would give me a prescription that I could then take, and my son is in distress the entire time. I think that there are opportunities for savings here and convenience for consumers.

I also think what a terrible waste it is when people are about to travel, for instance, and they're taking up valuable physician time when they're simply seeking prophylactic antibiotics if they're about to go to some country. I think there is certainly an opportunity there where our pharmacies could play a role, where you do have laid out for you that these are the types of medications you ought to be taking with you. I'm thinking of some basic things like Cipro if you're going to go somewhere. Instead, what we find right now, though, is people are sitting in doctors' offices taking time and very limited, valuable resources. I think we've all had that experience, where you're sitting in the doctor's office and you're waiting, and these things I think could be more conveniently dealt with elsewhere.

I wonder, you know, just following up on Ms. Davies' question, how open is this renewing and extending prescriptions and so on? I wasn't familiar with it here in Ontario. I didn't think that you could just go to a pharmacy and have a prescription renewed.

[Phil Emberley]

This was actually put into place a couple of years ago. What we typically see is someone running out of their medication on a late evening or weekend, and it's a medication they've been taking routinely. It could be something for their blood pressure, or their cholesterol. Rather than get in touch with a doctor and perhaps have to wait a little bit, we're able to continue that therapy. Doctors are always made aware of this. There is a requirement that they be informed.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

So the following day you then call in and ensure that the prescription refill was appropriate?

[Phil Emberley]

Yes, exactly.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Does the patient have to come back for the full refill, or you give them enough to go home with?

[Phil Emberley]

Usually it would be, for example, for a month on a maintenance medication or three months. Again, it's at the judgment of the pharmacist. There's real judgment involved here. It's not simply a case of saying “oh, this is fine”. There is some degree of assessment that is required as well.

[Janet Cooper]

If I could add to that, in Alberta it's best in class in the world what they do in scope of practice. I think in a few years time we won't have a chart, it will be green checks everywhere. But also the government pays for pharmacists to provide these types of services, and they have a very good payment model.

But I spoke to somebody recently. They were travelling to somewhere in Africa. They went into a Rexall pharmacy and they got all their injections for their vaccines, they got the prophylactic prescriptions that they needed, they got other advice, all that type of stuff, in and out. They paid for it because those aren't usually covered by government services, but it was so convenient, and that level of convenience is a huge part of what's driving this, that access to care. There are over 9,000 pharmacies out there and they're open evenings and weekends, and you don't need appointments.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Yes.

Can I pop it back to part of our federal role in providing, obviously, services in the far north and to our first nations communities—

[The Chair, Conservative, Ben Lobb]

Just in fairness to Mr. Young there.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

We're at time?

[The Chair, Conservative, Ben Lobb]

You probably should pass it over.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Just very quickly, do you have a position on drug sampling for nurses in remote communities?

[Janet Cooper]

No, we don't.

[Eve Adams, Conservative, Mississauga—Brampton South, ON]

Okay.

Mr. Young.

[Terence Young, Conservative, Oakville, ON]

Thank you.

I'm very concerned about the number of patients who have adverse drug reactions, which are the fourth leading cause of death in North America, 70% of which are preventable. I have tremendous respect for pharmacists. I wish you had more power in your scope of practice to challenge doctors' prescriptions. But I am concerned that some drugs like Remicade, for example, which, if memory serves me well, is approved for up to three months for rheumatoid arthritis, which is prescribed off-label by doctors for longer periods of time for Crohn's disease, and 11% of patients who take Remicade long term will get cancer, or may get cancer. Are pharmacists allowed to prescribe off-label? And are they allowed to continue prescriptions or renew prescriptions that are off-label?

If you can give me a short answer, I have one more quick question.

[Phil Emberley]

Again, there is a high degree of judgment involved in this. It has to be within the pharmacist's level of expertise. I would say most pharmacists are not going to be in a position to prescribe Remicade. This is something that a specialist is going to be prescribing.

A pharmacist may be able to detect if a patient is perhaps failing on the Remicade and that maybe it is not the best medication for them. There would be a lot of collaboration with a patient like this. Obviously this is a serious drug that we are talking about, and the potential for cancer cannot be overlooked.

[Terence Young, Conservative, Oakville, ON]

Here is something else that concerns me a great deal. I support a broader scope if, and only if, it's safer for patients.

How can pharmacists prescribe if they are not allowed to diagnose? Diagnosis is critical to a prescription. How can you have the power to prescribe if you don't know how to diagnose?

[Janet Cooper]

A good example is a physician could write “diagnosis: hypertension” on a script. It goes to the pharmacist, and then the pharmacist, based on the evidence and the clinical practice guidelines, could then manage the drug therapy. They can start insulin, adjust insulin doses, those types of things.

They may be the first person to detect that the patient has high blood pressure, send them to the physician for that workup—

[Terence Young, Conservative, Oakville, ON]

It still requires a prescription from a doctor.