Health Committee on Feb. 6th, 2014

[James Lunney, Conservative, Nanaimo—Alberni, BC]

Thank you for that.

I'll go back to Dr. Skinner and the coroner's office in just a moment, but first I want to pick up on something that Cameron Bishop said.

You made a very extensive list of recommendations. You talked about amending the generalized labelling on the products. You also talked about painkillers and addiction, and that they should clearly mention the possibility of addiction or death. For over 200 milligrams, you said that doctors probably should have special qualifications. Doctors are regulated provincially. Would you recommend a pan-Canadian strategy of some kind to address this, that all of the provinces might work on together to make sure that anybody prescribing these higher doses has special qualifications?

Perhaps you could comment on that.

[Cameron Bishop]

When you look at section 56 and the requirement to have an exemption to prescribe methadone—that has to come through Health Canada, but the colleges handle it—this is something where I think the federal government could look at it and say, “What's going on with the addiction treatment side? Do we need to add some sort of wording, some sort of amendment, that would require some form of an exemption for anybody wanting to go over and above that?”

I can tell you that on our committee, that's been a debate in terms of how that looks. We're not 100% sure what that should look like. I would say that because of section 56 and the language in there, I would think the discussion could start at the federal level, and see if there is a way to kind of work language in that would allow for some form of qualification over and above what they already have.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

I appreciate that.

You made a reference to increased transparency in all the clinical data. I think you went on to talk about making it an offence if a company is convicted of misleading the regulator.

I think we had a pretty egregious example of that back in 2007, of a company, part of Purdue, that I think was charged in the United States with misleading the regulator. There was a fairly hefty fine involved. That would be on the U.S. side, wasn't it? It had to do with OxyContin.

Is that what you're driving at with this?

[Cameron Bishop]

One of the things we do lack is an accountability mechanism for some of the regulators for the companies. I have to say I'm pleased with, for example, Bill C-17, but in that context there's a lot of stuff that could be done to tighten it up, based on the recommendations here, that could make Bill C-17 stronger and could go a little bit of the way to addressing some of the things we've talked about here today.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

I'll turn to the Chiefs of Police now. Thank you for being here today.

Mr. Mander, I want to ask you about some of your comments regarding the tools police have available in terms of surveillance tools, or tracking tools, for pharmaceuticals.

[Chief Mark Mander]

First, when we thought about this as an issue....

We're very adept at tracking all the illicit drugs. We're very good at tracking the criminal element that's involved in that, but quite often we're cut short when all of a sudden the drug of choice in the community becomes a prescribed drug. It becomes very difficult for us to manage that from the investigative and enforcement perspective.

If you have a number of people in the community who have drugs, and they're trading among each other, you can't distinguish between one person's scrip for 20 Dilaudid pills and another's. You can't tell whether or not those have been exchanged, but quite often that is what happens. In the culture that these folks are in, someone can score some drugs from a physician and trade them to someone else.

When we talk about deaths in Nova Scotia—we've had roughly 400 in the past five years—that's what we're seeing, this cocktail of alcohol and drugs, some illicit and some licit, methadone, etc. That is what, unfortunately, people are succumbing to. From an investigative perspective, when we go to these scenes, it's very difficult to manage from a policing perspective, especially when you have the families asking what we can do from a policing perspective, as someone sold this person those drugs.

Certainly we're getting there. There have been some charges laid in relation to folks trafficking those drugs to people who have subsequently succumbed.

[James Lunney, Conservative, Nanaimo—Alberni, BC]

I can see that Mr. Bishop wants to jump in. I'm heading your way anyway, so—

[The Chair, Conservative, Ben Lobb]

If you have a brief comment, that's fine, or we'll just go on.

[Cameron Bishop]

I was just going to say, Dr. Lunney, that in terms of a monitoring system, I would encourage committee members to look at the RADARS system in the United States. It's quite fantastic.

Is it the best there is? That I can't say, but I do know it's certainly one model we could look at.

[The Chair, Conservative, Ben Lobb]

That's good. Is that in California?

[Cameron Bishop]

It's based in Colorado.

[The Chair, Conservative, Ben Lobb]

I was thinking about maybe a committee trip to go and have a look at that, but I—

[Voices]

Oh, oh!

[Cameron Bishop]

You can go skiing in Colorado, Mr. Chair.

[The Chair, Conservative, Ben Lobb]

Okay, very good.

Our next questions are going to be from Mr. Morin en français.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much Mr. Chairman.

Dr. Skinner, my first question is for you. You stated in your opening remarks that one of the problems is lack of knowledge about the toxicity of medication. What do you feel is lacking? Is it knowledge on the part of the medical profession or continuous training on addictive prescription drugs?

I would like you to give us some more information so that we can better understand Canada's situation.

[Dr. Roger Skinner]

Yes, I think the shortcomings are twofold.

First of all, there's inadequate research evidence about the effectiveness of treatment of non-cancer pain, especially with opiates. That's an area that needs to be looked at in a more in-depth and scientific way.

Second, you are absolutely correct when you say that physicians receive very little formal training when it comes to pharmaceuticals and when it comes to prescribing, and when it comes to prescribing opiates in particular. During their medical school training and residency, there are very few hours spent on that subject.

It's often learned as we go. After we are licensed, there's no requirement to learn anything more. This might be the benefit of looking at some sort of an exemption system, such as we have for methadone, in that in order to get that exemption and be allowed to prescribe high doses of opiates, you would have to show some evidence of training and knowledge in order to be able to practise in that way.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you.

My second question is also for you.

In your opening remarks you also stated that one of the problems is aggressive marketing on the part of companies. In Quebec, where I come from, the rules on drug-related advertising are not the same as those in the rest of Canada. I think that drug-related advertising in Quebec is more subtle—

[The Chair, Conservative, Ben Lobb]

Pardon me for a second. I think we just got the last two seconds. We'll tack the time back on and start over again, okay? I'm sorry about that.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

It's not a problem.

As I was saying, my second question is for you, Dr. Skinner.

In your opening remarks you referred to aggressive marketing on the part of companies. I come from Quebec. Drug-related advertising, especially on television, is quite different there compared to the rest of Canada. I would even say it's more subtle.

Could you speak to us about the situation throughout Canada and give us some concrete examples of just how aggressive marketing is? « Aggressive marketing » are the words you used.

[Dr. Roger Skinner]

I'll speak from my experience when I was practising, especially during the 1980s and 1990s when drugs like OxyContin were on the rise.

We, being physicians, obviously don't get our information from TV commercials. We get it from advertisements in medical journals and also from representatives of pharmaceutical companies who come to the office for the purpose of educating us about their new products. It was in that forum where the message of the safety of the product and the message of changing our practice to prescribing whatever dose it took to completely eliminate pain was made.

As was referenced, I think this was some of the issue that came out with Purdue south of the border as well. The marketing was targeted at prescribers at the office level.

[Dany Morin, NDP, Chicoutimi—Le Fjord, QC]

Thank you very much.

My last question is for you, Mr. Bishop. In your opening remarks you said that it is important to expand treatment of all kinds. Do you believe that harm reduction should be one of those kinds of treatments?

In Canada, there are various kinds of harm reduction, especially when it comes to drug abuse, whether those drugs have been prescribed or not. Prior to 2007, harm reduction was the fourth pillar of Canada's National Anti-Drug Strategy. That was eliminated under pressure from the Conservative government.

Do you feel that harm reduction is still indicated in Canada in 2014?

[Cameron Bishop]

I would submit that “harm reduction” is a very charged term; however, I would submit that any form of treatment is necessarily harm reduction. Whether you're taking methadone or Suboxone, or psychosocial support, or whatever it might be, I would suggest that yes, it does need to be a pillar. Does it need to be specified? Yes. However, I would suggest that for a variety of reasons the term “harm reduction” rubs some people the wrong way, and they don't understand it.

I think when you look at anything, you are lessening the harm to somebody when you're getting them into some form of treatment. Whether or not you want to officially call it harm reduction, or you want to put it into a pillar, or this, that, or the other thing, the reality is that if you're in any form of treatment, you're necessarily in harm reduction.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up, for five minutes, is Mr. Terence Young.

[Terence Young, Conservative, Oakville, ON]

Mr. Bishop, could you please tell the committee, is your background in practising medicine, or clinical research, or...?