Health Committee on Dec. 2nd, 2013

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

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Wilks.

Next up is Mr. Marston.

You have five minutes, sir.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Thank you, Mr. Chair.

I certainly appreciate this opportunity.

I'm having some problems with my iPad here. I haven't got an eight-year-old grandson here to help me with it.

[Voices]

Oh, oh.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

I'll start with Mr. Keon.

Perhaps I could take you to the recent court decision on generics, relative to Shoppers Drug Mart. What kind of implications does that have for Canadians?

[Jim Keon]

Well, as I understand it, the concern was that the generic medicine was interchanged with the brand-name medicine without the patient’s being notified.

We talked earlier about the multiple jurisdictions in Canada. The issue of whether a patient should be notified when products are switched is a matter for the provincial college of pharmacy. Certainly, as generic drug manufacturers, we are quite confident and supportive of full information going to the patient. We would be very supportive of a national policy requiring that the patient be notified of any switch from a brand to a generic. That's certainly the situation in a number of provinces, including in Ontario. That's the first point.

The second point is, in terms of adverse drug reactions, they happen. There are no more reactions from either brand-name or generic medicines. In this case, if there has been, we feel bad about that. There is an opportunity for doctors to put on medication “No Substitution”. Most drug plans will accept those if it's a medically necessary reason, a valid reason.

Those are my comments on that.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Thank you.

[Dr. Rocco Gerace]

I would suggest that the changes in Ontario actually save the taxpayer over a billion dollars a year. That's the net effect.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Okay.

Mr. Barnes, you seem to be one of the more popular witnesses today. I have a suspicion it's because your work is more on-the-ground, dealing with those aspects of abuse.

We had a Mr. Head from the prison system here last week. He said that 80% of new inmates come to prison with some kind of addiction problem. We've had this First Do No Harm strategy. Well, someplace along the line, there's been an awful lot of harm done, if we consider the magnitude of that statement. That's haunted me ever since. How many of these people became criminals as a result of their addiction, the natural follow through from that?

Is it realistic for Canadians to expect that pharmacists and owners take a significant role in the tracing of prescriptions and the dispensing of the medication because of the risk of abuse? You have spoken of that to a certain extent already. Is that fair?

[Mark Barnes]

It is fair.

The problem with pharmacies over the last decade is that we haven't really sold ourselves well as a profession. But we're certainly more educated—no disrespect to dentists or doctors—in the actual therapeutics and some of the side effects, and seeing diversion at the ground level. We know the problems, we see the acting, the potential for abuse, and we can actually have a big effect and we probably are, already.

I think that education, as I alluded to earlier, has to happen at the pharmacy schools, to make sure that we're ready in how to treat the problem, because if we're going to identify the addiction problem, then we had better be ready to treat it as well, appropriately and respectfully.

I'm so glad you brought up the prison system because a lot of my patients became addicted in prison, which is the first time I'm hearing that. Whether they're incarcerated because of break and enters as children or whatever led them to the criminal system, they actually became addicted in prison, which is traumatic.

I have information, if anyone is interested, on Recovery Kentucky. Rather than putting patients back in jail, they put them in treatment. This is funded through the judicial system, not through the health care system, which is an interesting thing you need to look into.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

How much time do I have, Mr. Chair?

[The Chair, Conservative, Ben Lobb]

You have 20 seconds.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Well, that's over.

Thank you, Chair.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up is Mr. Lizon.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

Thank you very much, Mr. Chair.

Thank you, everybody, for coming to the committee this afternoon.

I would like to start with a comment. Since we started this study, we've heard from several witnesses, every single one of whom has mentioned opioids. I assume that this is not the only thing abused by people, but I guess it's maybe the most common.

We talk about unintended consequences, we talk about misuse, abuse, and improper use of a prescription. If we talk about opioids, I'm surprised, because I think we're missing something—at least, I'm missing something. It may be that I don't understand the whole issue—it's hard to understand because it's so complex. Opioids have been around for almost 200 years as a medicine. I think the first time morphine was extracted was probably 200 years ago, more or less. Therefore, this is not a new issue nor should it be surprising. People have been getting addicted to opioids over all these years.

All these frameworks and guidelines we're talking about; those are fine, they deal with consequences. But what is the proactive action that we can take? You, as a doctor, or anybody who has to prescribe medicine to a patient, know this may cause an addiction, a situation that Mr. Barnes described—the fellow who had an injury and that's how he got hooked. People get hooked in different ways. We can do all the education campaigns we want; we do it for drinking and smoking, and to some degree I guess it works. I don't know if the problem exists in Canada, but in some countries, medical professionals get addicted to the very medicine they prescribe because they have access to it.

Can you comment on this? This is something that I think is the base of the problem we should be discussing. What do we do to stop addiction, not treat addiction, but to stop addiction?

I will hear from anybody, Mr. Chair.

[Dr. Peter Trainor]

I can tell you that within the dental profession in Ontario we are placing renewed and greater amounts of education on the aspects of responsible prescribing. You don't overprescribe in terms of quantities so that diversion becomes a problem or they're available for children to misuse or seek adventure with. As I said, that educative model has to be looked at very seriously. I know we place a great deal of emphasis on that.

Also, as Dr. Mock was saying, we are looking at possible alternatives for analgesics and analgesia, as opposed to some of the things that we used to rely on. It was easy just to rely on the opioids, but you have to look at the alternatives that are available today.

[Wladyslaw Lizon, Conservative, Mississauga East—Cooksville, ON]

I was looking more at the situation that, if you have to prescribe opioids to a patient, is there a moment when you, as a doctor, say, “Listen, this may be addictive. You may get addicted and you won't be able to help yourself. If you feel a craving and you think you need more and you don't have more pain, come and see me. You need help right away.” I think this kind of preventive action should be in place.

[Phil Emberley]

I think one advantage of the recent national opioid guidelines was that they were truly an interprofessional approach to the treatment of pain. For that reason I'm quite optimistic, because, really, it suggests that there's not simply a prescriber and a patient working together, but an entire team that helps to prevent situations in which the patient gets into trouble. It's truly an interprofessional approach in which there's support for the patient, to steer them away, and to do, say, medication reviews at the pharmacy level. But at every touch-point that patient has with the health care system, there's this common knowledge and a common support system so we can prevent patients from falling through the cracks and getting into addictive situations.

[Dr. Rocco Gerace]

I think you're absolutely right. Opioid addiction has been around for a long, long time. I think in the last decade we have seen prescription opioids overtaking heroin on the street as the opioids of choice for addiction because they are so readily available. Recently we've seen a recurrence of heroin addiction, because we actually are being somewhat successful—although I don't think successful enough—at controlling the prescription drugs. But it's not just about prescription drugs—opioid addiction has been around for a long time.

[The Chair, Conservative, Ben Lobb]

Thank you, Dr. Rocco and Mr. Lizon.

Ms. Morin, go ahead.

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

Thank you very much, Mr. Chair.

Ms. Bouchard, I would like to go back to the question my colleague raised about the national oversight program. Do you remember why it was abolished?

[Carole Bouchard]

That is a good question, Ms. Morin. I have no answer for you. Thinking back, I believe that there may have been a change in practices and policies; perhaps it ended because of budget cuts.

In the program I was talking about a few minutes ago, everything was done on paper. Unfortunately, there was no electronic database. But the transactions were reviewed by the staff, one by one, with a view to detecting problems. But it was abolished.

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

Okay, but you do not remember why it was abolished.

My next questions are for Mr. Barnes.

A little earlier, you said something that startled me. You told us, I think, that there is no registry of medications that you have destroyed. I thought pharmacists were required to destroy medications, by which I mean medications that have expired on the shelves of their pharmacies or medications that have been returned to them. If I understood you correctly, there are no checks on that.

[Mark Barnes]

There is monitoring of stock we have purchased for sale but no longer use. That's monitored by the federal government, and we write to Health Canada. There's a log of the destruction of the narcotics that we have purchased for sale, but nobody will govern or control what's brought back to a pharmacy. It is a problem. It's been a problem forever, actually. Most pharmacists, because they are diligent in the responsible provision of medications and the destruction of medications, will destroy them on site. I employ a student to do that, to destroy the medications appropriately every night, and the destruction is witnessed. I can't speak for other pharmacies, nor is there a policy in Ontario to monitor that.

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

Say someone brings back an unidentified medication to you. For example, when my grandmother passed away a few years ago, we were cleaning out her house. We found a lot of medications that were poorly stored. We had no idea what kinds of medications they were. What happens in a case like that? Do they go back to you? Those little white pills could be anything. You can't always identify them. What do pharmacists do then?