Health Committee on Dec. 9th, 2013

[Lynn Cooper]

I believe one of the keys to appropriate management is improved communication between the health care provider and the person living with pain.

There are many tools that can be used to improve communication and have a better conversation. One of them would be a brief pain inventory that an individual can fill out and take to their visit with their doctor to explain where their pain is. It gives the physician an immediate snapshot of what's going on, what's being affected. For instance, is their sleep, their appetite, their functionality, or their mobility being affected?

When you have this type of communication, over time it builds trust, and eventually the two parties can determine together what type of medication might be needed, based on the physician's recommendation and what course of action comes next.

You happened to mention migraines. When I went in to see my doctor with an uncontrolled migraine, it was interesting because I had lost a little bit of weight. She looked at me and said she felt she couldn't give me what she prescribed the last time. She felt it would be far too much in my system. She asked would I be okay with a lesser amount. I said, “Absolutely, you are the expert on this.” So communication worked that day and my pain was reduced enough that I could go home and get better.

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

On the topic of monitoring prescription drug abuse, what tools can be used to gather relevant information? What are the challenges in gathering and sharing that information on prescription drug abuse?

[Dr. Norman Buckley]

If I may, I'll note that there are several layers of information. At the large population level, there's obviously epidemiologic data that's obtained from the surveys that have been referred to previously, some of them looking at health behaviours, and some of them looking at reports of drug use.

The RADARS program in the United States that Dr. Bromley referred to is one that captures a great deal of population data, which can describe specific drugs of abuse. We don't have a comparable system in Canada—certainly not realized at that level of complexity.

In terms of the individual physician's capacity to effectively monitor and treat their patients, a prescription monitoring program that captures not just specific drugs but all of the drugs that a patient may receive, from whatever source, allows physicians to actually be fully aware not only of drugs of abuse, but of a variety of relevant drugs that may have other impacts.

It is the case, for example, that certain drugs enhance liver enzyme activity, which means that other drugs will be less effective because they are more quickly metabolized, and you may have to adjust doses. There are other drugs that interfere with each other, so that a painkiller may be more or less effective.

If you're not aware of a patient's full receipt of medications, you're frequently hampered. In my pain practice, for example, I will ask a patient what drugs they take. They will limit themselves to telling me about the pain medications they take that I have prescribed them. I have to actively seek to find out the remainder of their drugs.

British Columbia has a program whereby the physician can run online a complete drug record during patient visits. It's captured at the pharmacy dispensing level, so it doesn't matter who pays for it. Alberta, I believe, has a similar system.

Many of the provinces have systems that report the drugs that are paid for by a provincial benefit program. In Ontario, for example, the Ontario drug benefit formulary can permit its pharmacists to track that medication list. It's hard for a physician to capture that.

Other provinces are bringing into play prescription monitoring systems, but that is one of the areas where a national program linking those...but first of all, allowing the dispersal of best practice.... Some provinces have already solved this problem, so you may not need a unique solution if you don't already have one. The other thing is to make them communicate.

[The Chair, Conservative, Ben Lobb]

Those are very good points, Mr. Buckley—

[Dr. Norman Buckley]

You're aware of my predilection for talking.

[Voices]

Oh, oh!

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

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Lizon.

Ms. DeGroote, I apologize. We're over time with Mr. Lizon's round. Perhaps one of his colleagues can direct their questions towards you in a subsequent round.

Next up for around five minutes in our second round here is Mr. Marston.

Please go ahead, sir.

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

I have to figure out a way to get into the first round, because I always have more questions than time.

Ms. DeGroote, I want to thank you for something you did today. I watched the body language of our friends across the way when you talked about a salad party, and I think you have reached some people with a very important message, because life on the ground is so different from the reality faced by many of us, our families, or extended friends and that.

We've been pounding away for a while in trying to get some attention for this particular issue. It's one I've raised here. One of our witnesses talked about the fact that 80% of new inmates get there with addictions already. This is far more extreme than anybody has really comprehended, I think.

You've also noted that there's a slight difference of view on injection sites between the two groups here, but clearly, for those people who are addicted to heroin, many of them got there by starting with prescription drug abuse or copping the pills out of their parents' cabinet and then later moving on up the chain. I'd like to hear your view on safe injection sites as a start to the process of bringing these people back into society.

Dr. Bromley, if you'd like to add anything to that, feel free.

[Peggi DeGroote]

As Dr. Bromley already mentioned, I am non-partisan in all of this. I look to the patient first and I look to our communities and ask what we can do to make a difference in our communities. We know we can't stop people from doing what their going to do in the addicted world, but we can ensure community safety with some of the things we do.

We have a safe injection site in Burlington and a needle exchange program, which I am quite certain serves a number of people in our community. I would rather have it monitored and cared for and have an opportunity to interact with somebody and to maybe get them to care, because you never know sometimes what a kind word will do.

When I was working at the methadone clinic, the thing that changed my life was when a six foot seven, 350-pound man with tattoos all over him, looking like a biker, broke down and cried when the doctor said to him she knew he could make a difference in his life and she believed he could get off those drugs. He started to cry and he said that no one had ever believed in him in his whole life. I know for the rest of the time I was there as a volunteer, that man came back every week and had negative urines, which meant he wasn't using any drugs, because for the first time someone said she believed in him.

You never know what interaction, what a smile can do one day. I was a teacher so you never know. I see some of my kids now, and they will remind me of things that happened in the classroom that I had no idea had any impact whatsoever on them, but they did. That's what we need to do and reach out to people in our communities. When we look after the people who are the most vulnerable in our communities and we give them a hand and we help them, then we will have better communities.

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

Thank you.

Dr. Bromley, would you like to add?

[Dr. Lisa Bromley]

Yes, I would.

I've been in the area of opiate addiction treatment for 12 years and I was initially opposed to supervised injection sites, but 12 years in the field has changed my mind. I think when someone starts treatment right away that is obviously the best outcome.

I'll reiterate what I said in my opening statement, that treatment for any illness doesn't always work right away in medicine. Supervised injection sites would be reserved for people with severe and advanced forms of the illness. Of course, after failing treatment it should not be the first line.

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

Ms. Cooper, listening to your presentation, the complexity of the information and knowledge required for a patient to manage pain is quite clear. It jumps out at me.

Forty years ago a telegraph pole I was working on broke off and put me through a fence and I had about 30 years of pain. We suddenly discovered physiotherapy that dealt with it. I felt like kissing that young lady every day I went for treatment because she found a way of correcting my neck. It sounds to me as if we've got a long way to go to inform patients, because in my case I had no concept whatsoever. I was in a travelling kind of job and not with a doctor who could spend the time.

What could the federal government do to assist in this kind of education? Do you see a role there at all?

[Lynn Cooper]

Yes, I do.

First and foremost, I firmly believe that if the federal government officially recognized chronic pain as a disease, and also stated that it is a health priority in Canada, Canadians would listen and take the situation seriously. I believe that if there were funding to develop a chronic pain self-management program so it could be delivered across Canada, a community-based six-week program run by two facilitators, one usually being a health care provider and the other a peer, that is, a person living with pain.... These are individuals trained in giving this program. The way that lives are changed for Canadians just by attending that program gets them started. Nothing about pain management is the fix, but this helps them to get involved in their pain care to be able to see solutions, to identify and problem solve and to gain back some control.

If this could be implemented across Canada, it would be perfect.

[The Chair, Conservative, Ben Lobb]

Very good. Thank you, Ms. Cooper.

I want to remind all my honourable colleagues today, for purposes of our study, to focus their questions on prescription drug abuse, because if we get off that, it's highly unlikely that the analyst will include the responses because they go away from the scope of our study. It's just a reminder to all honourable colleagues to try to keep this focused on prescription drug abuse. But again, it's your choice what you want to ask your questions on.

Mr. Wilks. Five minutes, sir.

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

I believe it's Mr. Young.

[The Chair, Conservative, Ben Lobb]

Okay.

Mr. Young, five minutes.

[Terence Young, Conservative, Oakville, ON]

Thank you, Mr. Chair.

Before I ask a question, Chair, I would like to get something on the record here. Mr. Marston's question was an apparent attempt to characterize the members on this side of the committee as somehow naive about teens and drugs. You heard Mrs. DeGroote say that Halton has some of the worst problems in this respect. Marijuana is the drug of choice for young people. In grades 7 to 12, 34% use marijuana. And it causes depression, it's linked with many cancers including brain cancer, it can cause psychosis, and it leads to diabetes. It's also linked to automobile accidents and industrial accidents, including death. So we're the party who wants to keep marijuana illegal for all of those reasons.

And it's your party and the Liberal Party who want to legalize marijuana, Mr. Marston. So I want to point out who was actually being naive about the risks of drugs.

Dr. Buckley, I think you remember that we met in Oakville at a seminar for young people with connective tissue disorders.

[Dr. Norman Buckley]

Yes.

[Terence Young, Conservative, Oakville, ON]

And I admire your work very much. I wanted to ask you a specific question about the dental use of prescription drugs. In 2007, Purdue Pharma paid a $600-million fine in the U.S. to settle charges that they had illegally marketed OxyContin. OxyContin is thought to be, if not our worst, one of our worst drug abuse problems in Canada and the United States. When they originally sold it in 1996, they told doctors that it was not addictive, or at least not as addictive as other painkillers, and that's how they marketed it. The exact opposite was true, so they paid a $600-million fine to settle this, and everybody walked away, nobody went to prison.

I have a problem now with some of my teens in Oakville who were given oxycodone or OxyContin when they went to get their wisdom teeth out by dentists and got addicted to those painkillers. Their parents have to drive them now to Peggi DeGroote's methadone clinic in Burlington to get help. It seems like everyone's just sitting on their hands. Is there any way to get a message to dentists that this is an overuse of medication? For getting wisdom teeth out, all you need is Tylenol, and it's foolish and irresponsible to give young people such powerful painkillers when they're getting their wisdom teeth out.

[Dr. Norman Buckley]

It turns out that's actually a question I know the answer to, which is comforting. The college of dentistry in Canada and in Ontario, the Royal College of Dentists, is actually addressing that issue specifically. I mentioned David Mock, the past dean of dentistry at the University of Toronto, who's the co-leader of the CCSA education strategy. He is working with his colleagues, taking the example from the College of Physicians and Surgeons of Ontario, to disseminate guidelines specifically to dentists about what constitutes an appropriate prescription after a minor dental surgical procedure.

So that problem is recognized. It turns out that although the total volume of prescribing is not huge, dentists do in fact write a very large number. Somewhere between 30% and 40% of the prescriptions for opioids written in Ontario are written after dental surgical procedures.

So that issue is being addressed.

[Terence Young, Conservative, Oakville, ON]

Thank you for that.

Mrs. DeGroote, addiction leads to abuse and abuse leads to addiction. You were talking about “salad” parties. What can we do to stop that kind of thing?

[Peggi DeGroote]

The first thing we have to do is ensure our children don't get the pills they need for entree into this. At a younger age, we first need to begin by educating our children that if your name isn't on the prescription, you shouldn't be taking it. I can tell you that I'm an avid golfer, and if I'm out and I say, “Oof” after a stroke, because I did something wrong and it hurt, three of the other four people in the team will say, “Well, here's something”, because in my age group we don't think that sharing prescriptions is wrong or that we shouldn't do it. That's also misuse, and we're doing it and not teaching our children that it's not right to do that. It's trouble.

[Terence Young, Conservative, Oakville, ON]

We discussed at some point earlier your idea regarding the use of fentanyl. Fentanyl is 10 times stronger than heroin. How might it be better controlled?

[Peggi DeGroote]

I think the fentanyl issue is a real issue. We first came upon it we knew even before it was announced that it was going to be an issue, because at my Wellbeing clinic, we actually tested for fentanyl as soon as it came out on the street, and we were finding that people who didn't have fentanyl prescriptions were testing positive for it. We were also finding that people who had prescriptions were testing negative for it. So that tells us that while a physician is writing the prescription, the person is likely diverting what he or she is getting, because it's not actually in his or her system.

I think what we could easily do, an easy fix, is to ensure, as with methadone or as with fentanyl patches, that before you get a reissue of your prescription you take your seven patches or your seven empty methadone bottles back to the pharmacy. Because if you're diverting, you're not going to have that to give back, and that should be a clear signal.