Health Committee on Dec. 2nd, 2013

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Okay, thank you.

Mr. Fefergrad.

[Irwin Fefergrad]

I wanted to reiterate what has been said, in that I think the regulators have it right. The regulators are working together collaboratively and cooperatively on this very important subject. I don't know that governments are as good as getting together on it as the regulators are. Perhaps because we focus on our mandate of public interest protection, we're able to come up with some really good solutions that will help public health. We desperately need help legally. We need help through regulation and through legislation.

As Dr. Gerace pointed out, we need help financially—not for us, but for people who can't avail themselves of treatment that is very efficacious but isn't drug-related.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

That's fair comment.

Mr. Barnes, pharmacists are responsible for disposing of unused prescriptions and so on.

How do you actually go about that, and how do you track getting something back from this guy and something else from another guy? Do you do that? Do you track it that way?

[Mark Barnes]

As Carole Bouchard alluded to earlier, those are some of the problems in the Food and Drugs Act and the Controlled Drugs and Substances Act as they stand. We take everything back. It's not just controlled substances; it's all prescription drugs, whether they be over the counter or not, depending on what schedule it is. And there's no accountability.

The problem is that if I take back medication from my community, I'm not just taking medications from my patients. I'm taking back medications from others, so there's no access to information with regard to where those prescriptions came from.

Sometimes the simplest solutions are actually in the policy itself, or sometimes controlling the access. At my pharmacy, I started a fentanyl return program about a year ago. Fentanyl is a patch used for chronic pain. I simply use it as an awareness campaign, not necessarily to complicate the treatment of chronic pain or to reduce access to fentanyl.

Fentanyl is a problem in Ottawa in a certain area, and more than heroin to a certain extent. All I said to my patients was, “Well, before you get your next part fill of your fentanyl, can I see those patches back?”

It has worked extremely well. I'm actually educating the patients that this is a dangerous drug and what's left in this patch is still usable and abusable. I'm a target for having it, so I want it out of my possession. I destroy them. In my pharmacy, I put them in a bucket and pour alcohol on them and cut them and get rid of them. But there's no real accountability among pharmacies as to what they're doing with those things.

As cbc.ca said to me online through the blog, I could be using them myself, which is not the case, but certainly it points to the lack of policy on that.

[The Chair, Conservative, Ben Lobb]

Were you done, Mr. Hawn?

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Yes, sir.

[The Chair, Conservative, Ben Lobb]

Now we're into our second round of questions.

Mr. Morin.

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

Thank you very much, Mr. Chair.

We have been talking a lot about the First Do No Harm report over the last hour and a half. The report goes into the government's anti-drug strategy. The abuse of medication works on a continuum. The people who abuse medications, drugs, even if they do it innocently at the outset, get caught on a slippery slope. They always want more of the same drug, or they want a drug that gives them a greater effect. I see a systematic, societal problem there. Since 2010, Canada ranks first or second in the world in per capita opioid consumption. The situation is very critical and I think we have to look at the big picture.

Mr. Barnes, what I liked about your answers was that you really put the emphasis on why the people are abusing those types of drugs. They are essentially in pain, and they just need some relief, physical or mental, from what they're experiencing. We know that in 2007 the Conservative government removed from the anti-drug strategy of Canada the fourth pillar, which was to reduce harm. Nowadays, we do speak a lot about whether this pillar is really important in the overall strategy in Canada to make sure Canadians are living drug-free.

For the past couple of years, this pillar has been removed and the funding across Canada that is tied to reducing harm has been cut.

Do you think that in 2013 we are ready to put it back into the overall anti-drug strategy, or do you feel that we should just leave it aside?

[David Mock]

I'm not sure I completely understand because I may not know the history.

[The Chair, Conservative, Ben Lobb]

Mr. Barnes, please, first.

[Mark Barnes]

I think it's absolutely necessary.

As practitioners, no matter what profession, it's our responsibility to do no harm and put the patients best interests first. Certainly in Ontario, choosing not to prescribe a medication because you are afraid of misuse or diversion actually is something that we can bill, as pharmacists, as practitioners, now. In Ontario, it's something we actually need to do.

On a national level, it's absolutely necessary. We need to be able to have that time and also the funding and education to be able to do no harm at times. Whether it be to restrict quantity, which I think is probably more reasonable....

Again, as Dr. Emberley alluded to earlier, we cannot just cut someone off from narcotics. That leads to problems. That's not smart. But at that point we can offer two days' supply, have the discussion—multi-disciplinarian—with their physician or dentist at that point, on Monday or Tuesday, or whatever day we can get together and have a conversation. Lots of times in my practice, because I am sensitive to addiction treatment, I'll say, I think we have identified a problem and there are solutions, so let's talk about the solution.

I think that's probably putting the respect first, but “do no harm” is absolutely necessary.

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

Thank you.

I am reassured to hear that health professionals like yourself are taking this matter to heart. As I do not have a lot of time available, I will move to another topic.

Ms. Bouchard, you told us earlier that, in the 1980s, Canada had a national drug oversight program with the objective of identifying potential cases of excessive prescriptions and overuse all across the country.

Can you give us more information about that? Can you tell us whether, in your opinion, it would be worthwhile to start another initiative like that in 2013? Could we look at selecting its best features and adapting them to today's reality?

[Carole Bouchard]

Yes, indeed, in the 1980s, there was a national oversight program that monitored prescriptions for controlled substances. All the pharmacists in Canada were required to report their sales of certain products that were controlled under federal legislation. The reports of those sales were all sent to Ottawa where the data was put into a system and reviewed.

Specific programs assessed trends by product or by specific region, by appointment or by multiple appointments. Of course, hundreds and thousands of prescriptions were written each year. A program of that kind serves to identify behaviours that might suggest inappropriate prescriptions, multiple appointments or abuses that, in some cases, could implicate health professionals in terms of purchases for use in the office. Under federal legislation, investigations were launched when suspicious behaviours were discovered that required specific action. The program was in existence for several years. It was not abolished until the 1990s. I do not know the exact date.

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

Do you remember—

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Mr. Wilks, five minutes or thereabouts.

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

Thank you, Mr. Chair.

To Mr. Barnes and Mr. Emberley, and I guess to the dental society as well, it seems to me that every time the dentist's office calls me—they call me quite frequently to remind me that I have a dental appointment coming—I go, because eventually, I know, if I don't go, they'll continue phoning me. I might as well just go and get it over with.

[Voices]

Oh, oh!

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

It seems to me, from the perspective of returning drugs that have a due date or those that have a “use before” date, that we could go along the same lines and create some form of dialogue with patients to remind them that the drugs will have reached their overdue date by a certain time, if they haven't used them, and that they can return them. There was something along those lines discussed this morning at the CCSA meeting.

I wonder if you could talk about different types of ideas for returning drugs to pharmacies and/or to doctors, or whomever.

[Mark Barnes]

I think it's a great idea. It poses some challenges, especially for the “as required” medication. As an example, my father has a chronic back condition that flares up every now and then. He's given a narcotic at times that he can use for travel or what not.

So I think from a return standpoint for medication that's prescribed, it can certainly be problematic in that light; for expiry dates, absolutely, or even after one year.

As I think Dr. Emberley alluded to earlier, on the medication review we could say, “Hey, listen, you're not using this medication anymore. Do you have any left? Can you return it to the pharmacy?” We could have that dialogue and documentation. I think the medication review is probably your best avenue for that.

With regard to how much goes out the door, I think there's a lot we can do with regard to restricting quantity. I understand that every pharmacy is open late, so unfortunately a lot are open on weekends. With this accessibility comes responsibility. That responsibility means we have to be able to restrict access to the medication in larger quantities.

Unfortunately, diversion happens when there's a large quantity. From my experience, patients do have legitimate pain, but they also see it as a revenue stream. They actually take some of the medication and then divert some of it. The larger-quantity reduction could reduce that tremendously.

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

Thanks.

My next question is to Mr. Keon, and it's on one of my favourite subjects, which is medical marijuana.

As you know, the Supreme Court of Canada has mandated the federal government to provide medical marijuana to those who can obtain it through their doctor, although I find it somewhat interesting that pharmacies have been bypassed in the whole process.

But there is generic THC, which has been around for quite a while. Can you provide me with some information on generic THC and how popular it has been with regard to chronic pain and other issues?

[Jim Keon]

I'd have to get back to you on that. I'm not aware that any of our members are producing that product.

[Dr. Rocco Gerace]

I was told I wasn't allowed to talk about medical marijuana, but now that you've brought it up, I would like to say something.

I think it's absolutely abominable the way the federal government has dealt with medical marijuana. In fact, it was a divisional court decision that suggested that there was an obligation to provide it, a decision that was overturned by the Court of Appeal. So there is no court decision, and yet this substance is being made available without any of the safeguards that exist for opioids—and we are facing a crisis with opioids.

We are either all going to be getting marijuana legally five years from now or everyone's going to be sitting around the table talking about the public health crisis with marijuana. There is absolutely no control over who should get it or for what indications it should be given, and yet doctors are being asked—and I'll use the term loosely—to prescribe this substance that has no safety profile. I think it's awful.

We've reflected our concerns to Health Canada, and yet we've not seen nearly a response that we think would be in the public interest.

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

Mr. Fefergrad, go ahead.

[Irwin Fefergrad]

Thank you.

I can't let your comment about the dentists in Kootenay, British Columbia, go without a comment from the registrar in Ontario.

Dentistry is based on a model of prevention. It's based on a model of dentists caring for their patients. It's based on a model of calling you and saying that it's time for a checkup. With the prevention model, dentists are able to deal with prevention so that your oral health condition doesn't become more serious, where you're involved in some substantial treatment requirements.

I know you know that, and I know you love your dentist.

Is that a no or a yes?

[Voices]

Oh, oh!