Health Committee on Dec. 2nd, 2013

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

We do have a lot of witnesses today, so thank you for coming.

As we get into this subject more and more, I find myself in a bit of a conundrum. I would certainly agree with Dr. Gerace when he says that it's a complicated issue. It's not necessarily that there's just a black and white answer; there are a number of things that need to be done.

Having now heard from so many witnesses or stakeholders who are involved, whether from a regulatory point of view, a professional point of view, or a practitioner point of view, I'm left wondering where the problem really is. Is it just a leaky vessel that's got so many holes in it that it's sinking? We are hearing from all of you that we have a very serious problem in Canada.

I want to relay an experience that I had a couple of weeks ago at a pharmacy in Vancouver. I went in to get a generic prescription renewed. It wasn't an antidepressant, it wasn't a stimulant, it wasn't an opiate, it was just your run-of-the-mill generic. I was kind of happy when the response was that I couldn't get it renewed, that I had too many days left. They actually counted it out, and I said that I travel a lot and I'm worried about it running out. They said that I had to wait a certain number of days.

The reason I was given did not have anything to do with safety or anything like that—I don't think there were any safety issues—but with insurance coverage. It was the insurance company through our federal plan that wouldn't have reimbursed me unless I met certain timelines. It left me wondering why I got that response when trying to renew a low-level prescription, yet on serious medications where there are serious issues of addiction, you're telling us that there are so many holes—I think that's what you're saying—and that we've got a huge problem.

I'm glad, Ms. Bouchard, that you talked about the monitoring surveillance system and what is going on in the United States. It seems to me that it's something that we have to do in Canada. There has to be some kind of pan-Canadian strategy for a monitoring surveillance system. I wonder if you can tell us a little bit more about how you think that would work.

My second question is for Mr. Barnes. Your front-line experience is very good for us to hear in the two cases that you provided. What struck me about what you said is that you talked about both of them with no judgment. That's good, because I think that for people facing addiction issues there's a stigma, whether they're a street user or whether they're the accountant that you talked about, the guy who was afraid to talk to his wife. From your point of view as a front-line health care professional, how do we deal with the stigma?

You obviously developed a really good relationship with that guy. I don't how rare that is; I would imagine it's somewhat rare. How do we reduce the stigma so that when people run into trouble they can get access to the proper interventions? The system has got to work, but when people do run into trouble, either intentionally or not intentionally, how do we remove the stigma so that we can actually then focus on getting them the proper appropriate interventions without criminalizing or stigmatizing people so they just end up going more and more underground?

Sorry, that's kind of long, but I would just like to get responses on those two things from Ms. Bouchard and Mr. Barnes.

[Carole Bouchard]

Thank you for your question.

With regard to a pan-Canadian monitoring system, I may answer that twofold. First, in most of the United States they already have a prescription drug monitoring program, and somehow they've realized, maybe a little bit too late, that they needed to have a mechanism to be able to connect those state prescription monitoring programs together in order to have a better picture for the country. Again, I don't think their system is a good proactive approach. I don't think it gives them everything they would have wished to have because of the differences between each of the states.

For Canada, though, if I look at the second part of the answer to your question, I think we need to have a pan-Canadian monitoring system where we have to really take advantage of what is being implemented in each of the provinces and territories in order to build a national program.

There used to be a time in Canada when a national system existed, but it was much more manual. It was really in the 1980s and 1990s, but with the years that has disappeared. Now electronic technologies are there so it certainly could work, and it would be an advantage because there is a really substantial category of drugs that could fall under that mechanism, but we need to be proactive.

[Mark Barnes]

I can definitely understand the drug plan issue. As you're aware, it happens on a daily basis with a day supply, so I can relate to what you're saying. Unfortunately, for addiction it doesn't work, because a patient who is diverting a medication will just pay cash. Unfortunately, the drug plan solution is not there.

You alluded to my approach earlier. It's unique in being a respect-based approach to addiction treatment. I had to evolve that respect myself because, unfortunately, I was a typical health care provider who was a non-believer. My evolution itself, through my patients, taught me that it can work. My respect comes from my experience.

So first, the answer is that respect is from experience, but we can also provide insight. I think there are three answers to your question. The first is about teaching respect at the university level through our students—med students, nursing students, pharmacy students, and dental students. I think that if we make them aware of the problems and teach them a respect-based approach to addiction treatment first...the education is very, very important, I think, as is having educators who have the same approach.

It starts there, but then it also has to continue among our own profession. I also sit on a committee for First Do No Harm, as well as a working committee for treatment teams, and there is no standardized treatment education level among pharmacists, as an example. Every province varies as to what education experience you require to be involved in addiction treatment and prevention, whether it be through the methadone program in Ontario.... I was just in Newfoundland giving a presentation at the university there. We need to have a standardized education system that looks at addiction treatment the same way, with this respect approach. I think that if we work in academia, as well as with our students, it can make a huge difference, and then having standardized or post-schooling training on addiction treatment....

The third thing is that you have to teach people. No matter if it's high blood pressure, when we're treating addiction, it's no different. We've done a phenomenal job with mental health over the last decade in bringing it in from the darkness, from being ashamed and seeing mental health as a character flaw, not really a true illness.

I think we have to use that same approach for addiction treatment. Unfortunately, addiction treatment doesn't go by itself; it's usually a triangle. There's pain, there's addiction, and there's mental health. There's a reason why. As my patients tell me, they didn't wake up in the morning and want to stick a needle in their arm. It's an escape from some reality.

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[Mark Barnes]

Yes, exactly. It's an escape from some unfortunate event, even in our own military, with post-traumatic stress, so it's very important that we approach those things with an open mind. As well, what we've done with mental health over the last 10 years has been phenomenal. We don't actually need to ask why there's addiction, but why there's pain.

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Barnes.

Those were good questions, Ms. Davies.

Ms. Adams, you have seven minutes.

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

Thank you.

Mr. Barnes, thank you very much. You've highlighted an excellent point, which is that unfortunately from province to province the clinical guidelines available to pharmacists vary.

Are you familiar with or is somebody at this table familiar with some of the best and leading clinical practice guidelines?

[Mark Barnes]

I would like to think of Ontario as one of the leaders. We have extensive training. If you want to be deemed methadone-certified in Ontario to be a dispenser, it requires a significant amount of training.

Being from Newfoundland, I can say that unfortunately in Newfoundland there is no such training; you have to read the guideline and have the guidelines on site. In Ontario, there's significant training. It's an online learning course for months, and then you go to CAMH and do a couple of days down there. It's actually extensive training, so I would say that Ontario is one of the leaders.

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

Thank you. That will help us as we're going forward.

If I could, I'll also put this question to you, Mr. Barnes, and perhaps to anyone around the table who would like to take it. Could you give us some concrete suggestions on how we might actually improve clinical practice guidelines when it comes to over-prescribing and overfilling?

Mr. Mock?

[Dr. David Mock]

If I may comment, only because of my involvement with CCSA and the RCDSO document on the education committee, and being an educator and member of the University of Toronto Centre for the Study of Pain, I think it was very well summed up by Mr. Barnes.

First of all, there are attempts right now at producing these guidelines. Regarding the documentation that will come forward in the CCSA, Mr. Barnes is working on the therapeutic end and I'm working on the education end. There are already excellent guidelines on opioid prescribing. The Canadian guidelines that were mentioned earlier came out of McMaster.

The committee that I'm on is hoping to produce a list of competencies that clinicians should have and that educational institutions, therefore, will be able to apply. The committee consists of representatives from all health care professions, plus lay people. These competencies are what clinicians, and thus students, should have. As well, other committees are producing guidelines for prescribing, dispensing, and in turn destroying opioids to get them out of the market. I think a lot of this is under way.

As I've already grabbed the microphone—and my colleagues know that I tend to talk too much—there is one further comment I would like to make. One of the areas I think this committee should consider and that has been mentioned is the area of pain. As soon as you consider opioids, you have to consider what they're used for, and that is pain management. One of the problems we have, which I see as a pain clinician, is the uneven availability of pain management across the country or across our own province, therefore leaving clinicians with only one option, the prescription of opioids. There are non-pharmacological or lesser pharmacological processes that should be made more available, which I think would help reduce the problem.

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

I very much look forward to receiving this documentation once it has been created, but are there any other concrete suggestions that anyone at the table would like to make?

[Dr. Rocco Gerace]

I would just highlight, as Dr. Mock did, the Canadian opioid use guidelines for chronic pain. They have been developed using current literature. They're being kept up-to-date by McMaster and more recently have been validated in an American journal as a comprehensive valid set of guidelines.

That work has been done, they're there—and we've alluded to them in our written submission—and I would urge the committee that they are well worth using going forward.

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

Thank you.

We've been hearing from a number of witnesses over the last couple of weeks and it's becoming abundantly clear that there isn't a great deal of knowledge about prescription drug abuse within the general public. How would you suggest that we approach that issue?

Yes, Dr. Mock.

[Dr. David Mock]

My working group coming out of the First Do No Harm exercise is actually looking at and will be making recommendations.

You're quite right: it's not just knowledge of the addiction issue and how easy it is to become addicted, but things that have been mentioned like storing of drugs when you get home. You get a prescription and where do you leave it? Do your children have access to it? If you don't finish a prescription, what do you do with the remainder? These are all educational issues for the public.

I know that all of the regulatory bodies and health associations are trying to address it within their jurisdictions. I think that coming out of this CCSA document, there'll be some broader recommendations nationally. You're quite right that it has to be addressed.

I do think it's under way. The process has started.

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

Thank you.

Mr. Emberley, through you, Mr. Chair.

[Phil Emberley]

Yes, I just have a comment.

One area that we should really focus on is that our young people are really not educated at a young age about the pitfalls of medication and the role of medication in treating disease. I think we need to catch them early. We need to go into schools and we need to talk to them about medication before they develop mistaken beliefs and ideas about drugs that they get on the street or from other people. We need to education them early.

We actually run some programs at CPhA, putting pharmacists into schools and educating young people on that. But I think it definitely begins with young people.

Then there's also an interprofessional approach to educating patients once they experience pain, about the potential for addiction, and how to perhaps avoid that. I think that's really important.

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

Just very quickly—

[The Chair, Conservative, Ben Lobb]

You have 40 seconds.

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

—we're challenged by the fact that it's difficult to find concrete metrics on how pervasive prescription drug abuse is. To whom would you direct us? Are there other nations that are at the forefront of this? [Technical difficulty--Editor]...what were genuine in looking to find the best possible advice?

[Dr. David Mock]

I think my colleagues would agree that's a very good and difficult question to answer, certainly nationally here, unless somebody knows something that I don't. I don't think we have such a database.

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

This is the challenge.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

You're right on time, Ms. Adams. Very good.

Next up is Ms. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair.

We talk a lot about misuse because that's what we're talking about in this committee, the misuse of prescription drugs, not just of opioids. A lot of prescription drugs have a tendency to be addictive.

The big question I wanted to ask is this, and I want to direct this specifically of Mark Barnes. There's the stigma you talked about earlier on, and we talk about people who take a prescription drug for pain. They injure their backs and they're taking it and then, of course, we talk about the people who are now on the street and are addicted to heroine or to everything. They're all the same drug.

I would like you as a pharmacist to explain the difference between Dilaudid and street heroine and any one of the drugs that we use when we are given them as a prescription for pain. Is there a difference in terms of opiates? Can you just explain this? I think I know the difference, but it might be interesting if I could hear it from you.

[Mark Barnes]

Regarding the potential to become addicted to an opiate itself, I would point out, first, that an opiate is a derivative of opium. It's the poppy seed originally and then it was obviously chemically produced, and they have different derivatives, the most famous probably being morphine. They're very efficacious and I hope that this committee doesn't look at opiates themselves as bad because, unfortunately, they're fantastic for pain management and in my own practice I'm an advocate of responsible opiate use, whether it be fentanyl or all of them.

The opiates themselves activate or attach to the opiate receptors, so really whether it be heroine, OxyContin, hydromorphone, or morphine, they all attach to the same receptor.

Certain chemicals have a higher affinity for the receptor than others, and certainly have a little more potential for some of the nasty effects of them, which is what we hear about, the overdoses, and the respiratory suppression, and the bradycardia, and the different things that make me nervous when dispensing them. But certainly from our standpoint, they are essentially opiates and so they all have the same class effects to different extents, and if diverted at the highest dose they certainly are dangerous, equally.

[Hedy Fry, Liberal, Vancouver Centre, BC]

We talked a lot about guidelines for prescription opioid use and on prescribing drugs. We talked about competencies within the profession for doing this. We talked about all of those things. We're talking then about the person who supplies the drug. If these drugs are prescribed, other than by a few bad apples, they're prescribed to help a patient. They're prescribed because they are needed and it's the only drug you can use.

But there are people who are more prone to addiction than others. Can you think of a way in which you can find out which patient is going to be more prone to addiction than others when you are prescribing?