Health Committee on Dec. 4th, 2013

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Ms. Adams.

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

Thank you very much.

I will start my remarks, if I may, by perhaps stating the obvious. I'm sure many of us around this table feel the same way. I am profoundly sorry for your loss, Ada. I can't imagine the terrible pain it would be to lose your son. Thank you for coming here today to share with us your experience and to advocate in his name.

I'd like to turn to some of the experts that we've been hearing from around the table. We've had this recurring issue, and it's interesting that CAMH, that you as an individual on a police team, or the family physicians would all be saying the same thing, which is that we really lack concrete data as to the extent of this problem.

Ada, you also mentioned the same thing, that we don't have a proper surveillance system in place to truly understand and comprehend how widespread this problem is. You're absolutely bang on when you say that we're understating how widespread this issue is. This is why in the Speech from the Throne our government committed to expanding the national anti-drug policy to include prescription drug abuse, which is what brings all of you to the table today.

Over at CAMH, you indicated that in the United States there is a surveillance system where they're actively monitoring. Can you describe that system to us?

[Dr. Beth Sproule]

[Inaudible--Editor]...annual national household surveys that specifically address this issue, targeting prescription drug use and abuse, both on its own and as part of broader surveys.

They have a comprehensive system, one of which is called RADARS, a system that was set up specifically to do surveillance on the harms from prescription drugs. It was originally set up through Purdue, actually the pharmaceutical company that produced OxyContin, and then was branched out to other drug companies by being taken over by the Rocky Mountain Poison and Drug Center.

It looks at a number of different data sources through coroners' data and surveys, and admissions to treatment addiction centres. It is basically funded by contributions by different pharmaceutical industries. Then they have a hands-off approach, and this independent body now collects this information and disseminates it.

That's one model. They also have systematic data collection from emergency room visits, for example.

They have a number of systems that can all be taken together to provide quite comprehensive data on a regular basis.

Did you want to add something?

[Dr. Peter Selby]

Yes.

I'd like to add that there are some more technological advances that can be done in our data collection systems. They've actually automated the collection of data that can be done through the cloud, off people who are coming and seeking treatment. For example, when they deployed this in the state of California, they showed that you can get really rapid data access.

You can also see what trends are happening. More importantly, that data collection tool is also a treatment tool that helps treatment planning for the practitioners.

It meets the needs of surveillance. It meets the needs of the individual, because it helps give them an assessment. This is really using modern-day techniques of big data and data crunching that helps people end up getting real-time data on what's happening rather than waiting for a data collection tool that you get 10 years later to know what the trends are.

This is real-time stuff. We're trying to bring that into Canada if we can, but again, as you can imagine, it takes money, time, and effort, and convincing people so that we can actually have this here. These are validated instruments that are out there.

It costs $6.20 for each assessment. That's it: $6.20. You could deploy this in a police station. You could deploy it in a family doctor's office. It can be deployed anywhere, but we haven't yet operationalized on some of the big technological investments that have occurred in Canada. Things like high-speed Internet in the north, etc., could be used in a place like Canada.

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

Perhaps I could quickly squeeze in a question to Dr. Ulan before I run out of time.

You raised a very important point about prescription drug abuse pertaining to not simply opioids but also drugs like Ritalin. Could you expand on that?

[Dr. Susan Ulan]

It's difficult, because currently we don't have a lot of good data so we don't know the full scope of it. If we look at the International Narcotics Control Board data, Canada is one of the highest—I believe it was the highest in 2011—prescriber or consumer per capita of Ritalin.

I think the reason for that is poorly understood. It may be that in Canada we diagnose ADD more commonly. We know that recreational use of it has developed among college and university students who want to enhance their academic performance. We also know that it's misused commonly with other medications of abuse. It can be snorted and give an effect similar to that with cocaine. It can also be used to counteract the side effects of other medications or illicit drugs.

The reality is it hasn't received a lot of attention. We really don't have a lot of good data to know how much of an issue this is in Canada. Once again it speaks to the importance of having a surveillance system so that when we start to see that the use in Canada is rising, we can take proactive measures to evaluate that and develop strategies to improve the situation and reduce the harm.

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

Thank you.

Is the quantity that is dispensed provincially shared with you in any way?

[Dr. Susan Ulan]

It depends on the province. Many provinces do have prescription monitoring programs. In Alberta we have something called the triplicate program. I think we have a very good program in a lot of ways, because we have a provincial health record, which all physicians have the ability to log into. The majority of physicians do have access to that.

If you are directly involved in the circle of care for a patient, you can log in and look at the patient's prescribing data. You can log in and see what the patient has been prescribed and dispensed, from which doctors and which pharmacies. That allows physicians to make timely decisions. I think that is really important.

For the provinces that have prescription monitoring programs, we gather that data and we can use that information on stimulants or opioids and so on to identify potentially high-risk patients and high-risk physicians, and to look at how to interact with their physicians. That's really important. That's the other piece of monitoring, which I think Beth is alluding to. I think it's critical.

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

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you, Ms. Adams.

For our next round of seven minutes, go ahead, please, Ms. Fry.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thank you very much, Mr. Chair.

I want to say that we have that same system in B.C., and it really is a very important tool for the surveillance of patients as well as prescribing habits of physicians.

I want to thank everybody.

I want to say to Ms. Giudice-Tompson that I really am sad to hear about your son. I think you are a very important example of how, when someone is given a drug and dies of an overdose or dies from misuse of the drug, that can happen to anyone. It's not limited to those people, as you said, who we consider to be throwaway people, the people who are marginalized, the people no one seems to care about. It's really important that people understand the nature of how drugs work on the human brain and on the human body, and how they are not respecters of persons. It's important if we're going to deal with this, that we remember that. I want to thank you for pointing that out to us.

I want to thank Dr. Ulan for bringing up drugs other than just opiates and the opioids being prescribed. I want to thank you for bringing up benzodiazepines. I know Don MacPherson brought those up as well. We need to bring in the whole range of drugs: Ritalin, tranquilizers, sedatives, and narcotics of different kinds.

There are so many things we don't know, because we don't have a database. It's clear today—I heard from everybody—that we need a database. I know the provinces have databases and some provinces have good databases and some tracking. I think it's really important, as Dr. Selby said, that we have a federal leadership role in which the federal government coordinates all of this information into one place. This is something that is a federal role, to be a clearing house, to do data gathering, to have some national statistics, pan-Canadian statistics, that will help us to understand the nature of the problem and how it differs in each region, and what other regions are doing that might be helpful.

There's a question I want to ask. It's not a particularly scientific one—or it is a scientific one, actually. Don MacPherson talked about recreational use and prescription use. It is obvious that we have people who use a drug that is prescribed for them because it is necessary for their care, and it's obvious that there are some people who do not have a need for the drug in terms of a physical or mental problem, but they actually have a need for the drug in terms of an addictive problem, so they have a need for the drug per se.

What would you say is the difference between those people who use drugs recreationally and those who use them for prescription reasons and who may or may not become addicted to them, other than the criminal element of it? What are the differences you see in terms of how a federal government or governments should deal with this?

[Donald MacPherson]

That's a very tough question, and I wouldn't really use the word “recreational”. Much of the off-label use of opioids could be self-medication. There could be a whole range of reasons that people might be engaged in the non-official market for opioids.

Certainly, if you go from west to east in Canada, and I spend time in Prince Edward Island, almost 100% of prescription opioid use in the east, and in Vancouver, there is still a huge amount of heroin used. As we saw from the data from the U.S., people go back and forth depending on the circumstances. Markets for both illicit use of prescription drugs and illegal drugs use are very active, and there is very much a fluid interchange.

I guess I'm troubled by the term “recreational use”. I think even with the example of Ritalin there is a use; students are using it to sharpen their focus for exams, etc. It's part of the complexity of what we're looking at. It's difficult to come up with one solution. It has to be comprehensive. I do take a little bit of issue with what Dr. Selby said about harm reduction. Many harm reduction programs deal with people who are not in treatment. The Vancouver Police Department overdose response policy of not responding to routine overdose is to try to get people who use drugs to.... It's those sorts of things.

Very few people actually are in a form of addiction treatment. Most people who have addiction problems are not in treatment. There are lots of things we can do for those folks as well as people who are in a pain management who develop addictions as well.

I'm sure that didn't answer your question, but it's a very complicated issue.

[Hedy Fry, Liberal, Vancouver Centre, BC]

Thanks.

No, it's okay, Don. Somebody who was presenting to us had used the term “recreational use”. That's why I used it. I agree with you.

What I hear you saying is that there really is no difference. It is a continuum of use either going back and forth, or whatever, and whatever we do to help is going to have to accept that we can't categorize people into two groups of users. I think that was what I wanted to get out of you, and you did get there. Thank you so much.

On harm reduction, I think that Dr. Selby spoke about harm reduction. I was glad you brought it up. I was a little concerned that you linked it to treatment as Donald MacPherson said, but I wanted to talk a little bit about the whole issue of harm reduction. I noticed that in the “First Do No Harm” document, which uses the word “harm”, treatment is one of the modules, but there is no harm reduction pillar in there. There is just treatment, and harm reduction was missed out. How could you do no harm if you don't reduce harm? I think harm reduction is a key part. Everyone plays politics with this term, and I think it's an important term.

I just wondered what you thought of it being missing from the “First Do No Harm” document. Would you like to expand a little bit on harm reduction?

[Dr. Peter Selby]

Call it what you will, at the end of the day what we are here for is we want to make sure that Canadians live good, healthy lives, so you want to call it reducing harm while not using the term. The issue is, does the term become divisive, as opposed to integrative. If it is becoming divisive, you'll end up causing more harm by the term itself.

Personally, and I think what we work on is, what the person needs at this point. Whether it's a naloxone overdose or a kit, whether it's a needle exchange, or whether it is actually a reduced risk product or an easier access into treatment, or both, it's exactly, as you said, Ms. Fry, a continuum, and the dichotomy that we've created may inadvertently actually lead to net harm to all of society.

I think we have to use terms and labels appropriately to help further the issue of positive health for people, rather than getting caught up in whether it's harm reduction or not. As we know, these conditions, including addictions, are defined by criteria.

[Hedy Fry, Liberal, Vancouver Centre, BC]

I just think if you leave it out, then you leave it out, and it's going to be left out, period.

[The Chair, Conservative, Ben Lobb]

Okay, good.

Thank you very much.

Mr. Hawn, please, sir.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair.

Thank you to all our witnesses for being here.

Dr. Sproule, this one is going to come to you first.

I learned this the other day when I was talking to somebody about the production of tamper-resistant drugs. It's called OxyNEO. It's so hard, apparently, that you can't crush it and snort it. It's not soluble so you can't melt it down and pull it into a syringe and inject it. The pitch was that this would significantly reduce the amount of drugs that are misused, that are gained through legal means but then stolen or somehow mislaid.

Is that technology something we should be looking at, that the pharmaceutical industry should be looking at, and we should be promoting?

[Dr. Beth Sproule]

In short, yes. I do think that it's one strategy. Again, as we've talked about here, you need to come at this from all the different angles. This doesn't solve the problem because, as has also been said, once you make it either unavailable or less attractive, people may go to something else. But it's the right direction for sure.

There's good evidence from the U.S. For example, the product OxyNEO has been available in the U.S. for several years now; it's still called OxyContin there. There's good evidence through their different monitoring systems that when the formulations switched, there was an overall decline in the attractiveness of the drug and in the abuse rates of the drug. So there is some good evidence to show that it did happen.

I think some people were surprised, though, that the abuse of it didn't go away completely. I think, again, that's where we also need to be thinking that it does reduce one aspect of abuse, which is when people tamper with the drugs and crush them to inject to enhance the high, for example, but a significant proportion of prescription opioid abuse does happen just orally. People take the drug, swallow it, and still get the effects of it.

I think that these tamper-resistant formulations and formulations that put barriers up against the more risky use of crushing them and getting high doses all at once, which increases the risk of overdoses, is good and in the right direction. It's not a whole solution, though.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

I understand, and that wasn't the suggestion. I mean, there is no single measure here that's going to fix this. It's a whole host of things. This is one of them that I don't think we have in Canada at the moment, but it's something we should look at.

[Dr. Beth Sproule]

Exactly. I agree.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you.

Detective Harris, you talked about surveillance tools. What surveillance tools are police forces using now in Calgary?

[Det Collin Harris]

Currently, in regard to drug investigations regarding prescription drug abuse, generally the TPP program, the triplicate prescription program, will usually come on our radar once it's been identified by the College of Physicians and Surgeons.

It all depends on the type of offence that's being conducted. It could be doctor shopping, double doctoring, triplicate pads being stolen from prescribers, or break and enter into residences looking for different types of drugs. It all depends on the type of investigation.

Really, for law enforcement in particular, in regard to coordinating efforts with the College of Physicians and Surgeons and the pharmacists, we're looking at creating a new database in order to share this information. Right now everybody has their own little silos of information, and it's unfortunate that we can't share that information due to privacy laws. If that information were available, we could identify individuals a lot sooner, provide that intervention, and maybe have our law enforcement component act a little bit quicker than before the drugs hit the street. Right now, a lot of times the drugs are already on the street by the time we get to them.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thanks for that. I'm pleased to see that Alberta, like British Columbia, has had these programs for a very long time.

Dr. Selby, I think you talked about operationalizing surveillance systems, and that it would be very simple and very cost-effective. What would it take to operationalize those surveillance systems, or did I misunderstand your statement?

[Dr. Peter Selby]

No, you didn't, actually. We've got some models here on primary care whereby we've been able to deploy very rapidly—like a rapid prototype—the program. It would mean getting the program from the U.S. so that it's on a Canadian server. It would mean being able to have it available within the practices where people go. For anyone coming in for a pain prescription, they would have to go through this model that would assess their risk of abuse or misuse. It would detect any misuse, and then provide the practitioner and the patient with opportunities to make decisions jointly as to what treatment happens.

At the back end, this data, if it's done in enough clinics, as has been shown in the U.S.—in fact it was that model that actually showed when the OxyContin shifts were occurring—when you collate that data, you can very quickly get a sense. If you had this across the country in clinics, you would very quickly get a sense of what problems and trends were going on. You'd be actually integrating your clinical treatments with your data collection, with your analysis. There's benefit to the practice, the patient, the administrators, and the funding decision-makers.

It's a new way of thinking about health care delivery. It's difficult to make inroads like that in Canada, but I think we can with the appropriate supports.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

It challenges 13 different jurisdictions, or 14 if you count the feds.

Doctor Ulan, you talked about the ability of physicians in Alberta to log into a prescription monitoring system. Further to what we said before, any drug can be abused, legal, illegal, medically proper or not. It doesn't matter what it is, it can be abused, so we can't ban every drug that can be abused.

What about an obligation to log into that system for physicians in Alberta or anywhere else?