Health Committee on Dec. 2nd, 2013

[Mark Barnes]

I'm a pharmacist. I don't prescribe.

[Hedy Fry, Liberal, Vancouver Centre, BC]

It's to anyone who wants to answer. Maybe the college might want to answer, maybe the dental—

Go on, David.

[Dr. David Mock]

There are some tools to evaluate addiction potential. In fact, the CPSO—it's in your document, it's in the guidelines actually—have produced some. There are also some in the Canadian guidelines for opioids, and we're going to have them in our guidelines. They're not great. They're helpful, they're adjunctive. The basic decision still is made by the clinician, as you pointed out, knowing their patients and looking at the way the patient presents, but there are tools. There are a number of tools on the market that are certainly very helpful.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

How am I doing?

[The Chair, Conservative, Ben Lobb]

You have two minutes and 45 seconds left.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you.

I just wanted to ask another question, and this is about the generic drugs.

We know that one of the reasons OxyContin is such a drug of use on the streets is that it's easy to take and crush, and do all kinds of things with, inject, etc. It's a drug that can be used in multiple ways, so it gets onto the street very easily.

We are told the company that originally made the brand name has decided it can make a new product that is not as easy to use: OxyNEO. We're also told by all of the provincial health officers, the provincial health ministers, the United States, and the United States Attorney General that we should actually stop making generic OxyContin for that reason.

Do you agree with that, and if so, why are we still making it?

Who wants to take that on?

Mr. Keon.

[Jim Keon]

First of all, the product is approved by Health Canada. Health Canada has not determined that it's an unsafe product that should be banned. Our manufacturers produce the product according to all of the Health Canada guidelines.

The abuse of OxyContin did occur. The rapid rise in abuse occurred during what I would call the “exclusivity period”, when Purdue was the only company selling the product. Purdue is now not marketing that product.

As I mentioned earlier, the generics do not market or promote their product to doctors. If a doctor has a patient stabilized on OxyContin and wants to continue to use that, then the generic is there and available at the much lower price, typically, at which generics are sold. It is dispensed and supplied throughout the supply chain in a very safe, effective way.

That is the general answer.

Apotex is one of the companies. I'll let Dr. D'Cunha speak to that as well.

[Dr. Colin D'Cunha, Director Global Medical Affairs, Apotex Inc., Canadian Generic Pharmaceutical Association]

As Mr. Keon has already stated, the supply is controlled right to the point of pharmacy, at which point the dispensing decision is made.

I will point out that the generic market share of total sales of this compound is less than 5%, based on annual numbers that Mr. Keon showed me at lunchtime.

It seems to me that an element of better prevention, better treatment, and better control is needed.

[The Chair, Conservative, Ben Lobb]

Go ahead briefly, sir. We have a few seconds here.

[Dr. Peter Trainor]

Thank you.

I like to hear the word “prevention”. As dentists, we always work on a preventative model, and it's been very successful in dentistry.

Dr. Emberley said that we have to educate young people at an early age. Education, education, education—it's so important to inform families of the harm that can be created by leaving prescription drugs available to children. It needs to be taken into the school systems early, at an early age, so that they understand how the drugs they find in parents' medicine cabinets potentially have very harmful effects.

Coming back to how we can prevent and some of the strategies when dealing with the people who have prescribing rights, it all comes back to having a good, thorough medical history of the patient and an understanding of the patient's problems.

One of the problems we have in dentistry is that people don't think they need to disclose their full medical history to us as dentists. But it is so important, because if there is a history of addiction or something in that patient's history and I prescribe a medication for a painful experience or a surgical procedure I'm going to do, that could absolutely turn that patient right around and cause a catastrophic relapse of their addiction problem. As I say, we need to know so we can prevent these problems.

We all have to work together to develop this multifactorial education process, in all aspects.

[The Chair, Conservative, Ben Lobb]

That's a good point.

We're way over time.

Mr. Hawn.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair.

Thank you all for being here.

Dr. Gerace, you were anxious to chime in on that last point. Did you want to do that? Okay.

Dr. Mock, you talked about some of the non-pharmacological solutions to pain. I got the impression that we have an aversion to them or that we're just discovering them. Could you describe some of those?

[Dr. David Mock]

There are quite a number of things that have been shown to be very useful. Again, chronic pain is more of the concern that I have as opposed to acute pain, where you can get a drug for a short period. And there are things like cognitive behavioural therapy, for example. There's very good evidence that it's effective either on its own or in conjunction with lower dose medication or shorter duration medication, and physiotherapy, things like that, or occupational therapy.

In our clinic we get patients from parts of the province where the local physician has no choice because he doesn't have those modalities available and he has a patient in pain. He has no option but to prescribe a reasonably potent analgesic, very often an opioid. Other things are coming on the market and out into the public now that are just being tested, but the availability is often a problem, particularly in remote areas.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

I guess what I was getting at, and I appreciate—

[Dr. David Mock]

Biofeedback, acupuncture....

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Yes, there are some of the non-traditional remedies out there that come from the Chinese or whatever, from 5,000 years ago, and nobody knows why they work, but they just work.

[Dr. David Mock]

Yes, we have that too.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Is the mainstream medical profession—and I include dental in that—becoming more accepting of those?

[Dr. David Mock]

Certainly, in my experience, because I work primarily with physicians, yes.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Dr. Gerace, you talked about creating a better coordinated and accessible system for, I think it was, educating stakeholders, health care providers, and other stakeholders. What would that look like and what can we learn from somebody else who's done this successfully, because we're not the only country facing these kinds of situations?

[Dr. Rocco Gerace]

Well, I can't speak explicitly for other jurisdictions, but we do know there is a huge need for education. If we look at medical school and the residency curriculum around the management of chronic non-cancer pains, it's woefully lacking. I can't speak for other specialties, but we're simply not doing enough. We've heard about public education, which is critically important, and I would refer you to our report on that issue, which we will leave with you.

In terms of other modalities, I'll just go back for a second. The other problem is that many of these modalities are not insured, and we have a population that is in desperate need of treatment and can't afford it, and the public health system doesn't provide it.

So there is a real need for a comprehensive—and David alluded to that—approach to pain management, and not simply looking at opioids.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Is one of the challenges the fact we have 13 different jurisdictions—well, 14 if you count the federal government—in Canada? When you say “coordinated”, I assume a big part of that is just coordination between those 14 jurisdictions to come up with something common and common sense.

[Dr. Rocco Gerace]

It won't be a simple solution.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Simple, straightforward, and wrong.... Maybe it's a little bit complicated, but right. Where does the responsibility lie for that, between the various colleges, the provincial colleges and...? How do you get all those folks together?

[Dr. Rocco Gerace]

Well, I can tell you from the regulatory perspective that colleges have come together to produce recommendations, or in the case of the guidelines, to produce the guidelines along with the stakeholders. Everyone has a role, and I think one group can't do it alone.

So when we look at having a comprehensive database of narcotics, that's going to take the federal government's implementing changes to the CDSA, as was suggested. Education will involve the medical schools and the other health professions' educational programs. We don't have the resources to educate the public, so we're going to have to work together to produce public education campaigns so that people understand the dangers without scaring them away from the benefits of these important agents.