Health Committee on Feb. 6th, 2014

[Libby Davies, NDP, Vancouver East, BC]

Do I have more time?

[The Chair, Conservative, Ben Lobb]

Yes, you do, two minutes.

[Libby Davies, NDP, Vancouver East, BC]

Okay. Thank you very much for that.

To follow up, I know you just represent the Ontario coroner's service and you can't necessarily speak for across the country, but in terms of the accidental deaths that you look at in Ontario, how many would relate to...? Can you give us an age breakdown? I'm curious to know whether or not we're looking at an older population in terms of the death rate.

[Dr. Roger Skinner]

I don't have the numbers in front of me. The majority of deaths from drug toxicity would take place in individuals between the ages of 20 and 50, but the relative rate in the elderly is probably higher. In other words, the incidence per individual in the population is higher and has increased as of late. I think that's because we're seeing people carry their problems through. As they get older, the addiction problem, the pain problem, or the poor prescribing problem travels with them throughout their life. They're living longer, and we're seeing it more and more at that end of the scale.

I apologize, I don't have those numbers in front of me today. I'd be happy to get those for you if you're interested.

[Libby Davies, NDP, Vancouver East, BC]

They would be helpful. If you'd like to submit them, I'd certainly appreciate that.

Do I have a little more time?

[The Chair, Conservative, Ben Lobb]

Twenty seconds.

[Libby Davies, NDP, Vancouver East, BC]

I don't know, Dr. Skinner, if you have any comments about research and the fact that we do need to focus more on research of non-addictive pain management. I think you did mention that. I wonder if you have anything else you want to offer.

[Dr. Roger Skinner]

I think one of the frustrations of prescribers, of physicians, is that they have a limited tool box when someone comes to them with pain. Because of the issues of access to non-medical treatment or to non-pharmacological treatment, often the easiest or the most expeditious route is to write a prescription.

In fact, if we had better access to other modalities of pain relief and pain management, we might be able to avoid some of this issue.

[The Chair, Conservative, Ben Lobb]

Thank you very much. I think that's touching on an important point.

Mr. Lizon, you have five minutes.

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

Thank you, witnesses, for coming to the committee this morning.

Mr. Chair, I would like to direct the first question through you to Dr. Skinner.

Doctor, I've been on the committee for some time and on this study since we began it. A lot of the information we've heard today and most of the witnesses who appeared spoke about opioids. There must be some misuse or abuse of other prescription drugs, but on opioids I'm a bit confused. It seems to me there's some kind of a vicious circle, a catch-22 situation that includes patients, doctors, drug manufacturers, and the regulators at different levels of government. At one point, for the patient to get a drug, it is a doctor who prescribes it.

Doctor, how can we break that vicious circle? The statistics you provided about the number of deaths exceeding the number of people killed in car accidents, it is tragic. At one point there is a doctor prescribing a drug that's addictive and some people get addicted. Opioids have been known for more than a hundred years. Where is the problem?

[Dr. Roger Skinner]

In regard to why there's been a change in recent years, again, I think it goes back to availability and to a changing culture in medicine. It used to be that opiates were reserved for end of life care, acute management of injury or post-operative care. However, in that timeframe, from the late 1970s through the 1990s, there was a shift towards the use of opiates for non-cancer related pain, for chronic non-cancer pain. It was not just a shift to the use of them, but a shift in the thinking that we should give maximal doses to relieve people's pain completely, without the research basis for the effectiveness of that model. That's the spiral you're talking about.

We're now in the phase where we've seen that the pendulum has swung too far and we're trying to bring it back. It's going to be a process. It's not just the physicians who have their hands in this pot now. As you said, there are the manufacturers, the dispensers, those who would profit from it illegally, and there are the patients themselves and their expectations. All of this needs to be brought back to a more moderate approach and to one that's based upon evidence showing that, in fact, giving people these drugs does make their life and their situation better. We don't have that evidence right now.

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

Thank you very much.

Doctor, could you briefly talk about abuse of prescription drugs that are not opiates?

[Dr. Roger Skinner]

Yes, I've come and talked about opiates, but they're not the only drugs that kill people. You're absolutely right. As I said, the other drugs are more likely to be seen in isolation in incidents of intentional ingestion, but not absolutely. One of the difficulties is that people with chronic pain and people who access opiates often have other comorbidities. They may have mental health issues. They may have medical issues for which they are also prescribed other medications that are equally dangerous and in combination with opiates, even when individual levels are not fatal, the combined toxicity can be fatal. Most often these people are dying of what we call mixed drug toxicity, either opiate and alcohol, or opiate and psychoactive drugs plus or minus alcohol.

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

Thank you very much.

Mr. Chair, do I have any time left?

[The Chair, Conservative, Ben Lobb]

You have 15 seconds for a final thought.

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

I think I'll give it up. Thank you very much.

[The Chair, Conservative, Ben Lobb]

We have another five-minute slot here and Mr. Lunney is going to use that slot. If you allow me, I have one quick question I'd ask Dr. Skinner and then I'll turn it over to you.

Dr. Skinner, I just wondered if you could give some thought to this committee about whether or not anti-psychotics should be prescribed to patients in nursing homes who have Alzheimer's and dementia. Could you give the committee a thought on that?

[Dr. Roger Skinner]

Oh boy. You have only five minutes, right?

[The Chair, Conservative, Ben Lobb]

I have 50 seconds.

[Dr. Roger Skinner]

I also chair our geriatric and long-term care committee that reviews specific deaths in long-term care facilities. This is certainly a hot topic within the industry.

The answer is, in selected circumstances, under conditions such that there is a trial of a dose and a withdrawal if there's no improvement, it might be appropriate. But there's no question that the widespread use of anti-psychotics in long-term care facilities is a factor in the deaths of individuals in those facilities.

[The Chair, Conservative, Ben Lobb]

Mr. Lunney.

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

Thank you very much for that. It was an excellent question.

Dr. Skinner, you mentioned a couple of reports earlier. This is sort of a housekeeping thing. The committee, in the earlier part of this study before some of us were part of the committee, may have had access to those reports. You mentioned a report by the college of physicians and surgeons. Was that the Ontario college? What was the name of that report?

[Dr. Roger Skinner]

That's correct. It was the Ontario college, and the title of the report, and it's on their website, is “Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis.”

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

You also mentioned another report, “First Do No Harm”. Who was responsible for that? Can I ask the analyst whether the committee already has access to these reports?

[Karin Phillips, Analyst, Library of Parliament]

Yes I do, and I can send them to you.