Health Committee on Feb. 13th, 2014

[Dr. Navindra Persaud]

I agree with all those suggestions and I'll just list a few more, if it pleases the committee.

First, at the stage of approval of medications, there should be higher standards for new products being approved. I think that currently there are too many different drugs that could potentially be abused, and in particular, too many opioids that are currently marketed in Canada.

The promotion and marketing of pharmaceuticals in Canada should be monitored proactively by Health Canada. They should not await complaints. That will of course require additional resources for Health Canada. They currently, I understand, do not have the resources to proactively monitor the marketing and promotion of medications.

Certain marketing practices should be banned.

You were quite right, Ms. Davies, when you said that there's a large challenge. Several billion dollars are spent by pharmaceutical companies in Canada every year. Estimates range from between $2 billion and $5 billion a year. It's difficult to counter that with medical education, so I think certain practices should be banned.

That would include visits from sales representatives to physicians. There is no good reason for those to take place. Samples should be banned. Sales representatives drop off samples of pharmaceuticals to physicians. Again, there is no reason for them, and in the end, patients end up paying for them.

There should never be any influence from pharmaceutical companies in the curricula of medical schools or in continuing medical education sessions. That should be completely banned and is something that the government could have a role in banning. Certainly, colleges such as the College of Family Physicians of Canada should not accredit educational sessions that are funded, sponsored, or influenced by the pharmaceutical industry.

Finally, Health Canada should also monitor for the harms, as I mentioned in my remarks. They currently don't have the resources to do that, as I understand it, but for particular medications where there is a risk of abuse, such as opioids, Health Canada should be able to say how many deaths there have been in Canada and at least provide estimates of the number of people dependent on the medications.

Finally, in order to set an example and to generate revenue for these investigations, past wrongdoings should be investigated. As I mentioned in my remarks, Purdue Pharma was investigated in the United States and ended up paying $634 million—I believe that was the amount—but nothing so far has happened in Canada. It actually sends exactly the wrong message to pharmaceutical companies in Canada. It says that it is easier here to market medications and that the regulations here are less strict.

[The Chair, Conservative, Ben Lobb]

Thank you very much. We're way over time, but I wanted to let you get your points in before we conclude.

Ms. Adams, you have seven minutes.

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

Thanks very much, Chair Lobb.

I'd like to thank everyone, all of the witnesses and all of our members

Today constitutes the last day of our study on this subject, and I think all members of this committee were heartened to see that the economic action plan proposes to invest almost $45 million for this very subject. We'll be expanding the national anti-drug strategy to include prescription drug abuse. It's pretty clear that the government has been paying attention to the hard work of all our committee members, so that was very welcome news.

According to the National Advisory Council on Prescription Drug Misuse, women may be considered an at-risk group for prescription drug abuse because they're more likely than men to be prescribed to for non-medical reasons, such as coping with stress or grief, or apparently, for adjusting to childbirth or menopause.

Perhaps I can turn this question to Dr. Durnin-Goodman. I was particularly impressed by your very practical advice in treating those with substance abuse. Based upon your research, do you find that women are over-prescribed to? Is this an issue?

I read this and found it incredibly patronizing, to be frank with you, but by the same token, if there is a real phenomenon, I think we need to be turning our attention to it.

[Dr. Maire Durnin]

I'm going to say that I live on the north shore of Vancouver, which is a middle- to upper-class area, and my impression from speaking to family doctors in that area is that there is a problem. I've had family doctors tell me that women, especially, will order their medication online. It will come over from the States, and that's not picked up on. They will pop it at parties, whether it's oxycodone or a benzodiazepine such as Valium, and they'll have it along with their glass of wine and “off we go”. However, what I am more concerned about, to be honest, is the pervasive use of sedative-hypnotic medications, which I find more damaging or more difficult to deal with in women, for whatever reason. That's not a statistical thing. That's my personal observation.

Women, as you know, cope with stress at both ends—at home and at work, with the kids, etc. They do the double shift and they have to find ever-increasing ways of coping. We don't support, as a system, the other means of coping that we know are healthier, such as cognitive behavioural therapy, etc. We don't have the time to do that in our society and that's why people turn to these medications. They don't perceive them as problematic. Yet they are hugely problematic as we've talked about. Whitney Houston and all of these people used benzodiazepines daily in their lives.

I'm sorry—I forget the rest of what you were talking about. I just get so upset about this.

But the other thing I wanted to say is that you heard from other speakers earlier on that there is a huge problem with opiates and benzodiazepines in our addicted population, and those are the cause, for example in B.C., of probably at least, I'm going to guess, about half of the overdose deaths that we see.

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

That's unbelievable.

We're looking at some of these statistics, and even the economic action plan cites, I think, one of the most compelling pieces. There's been an increasing rate of prescription drug abuse, which doubled amongst Canadians aged 15 and older in one year, between 2011 and 2012. This is an epidemic.

Dr. Persaud, apparently there are these tamper-proof medications being brought forward. I've been hearing reports that they're fairly easy to circumvent and that you can microwave them and then inject the substance. Are there ways to circumvent these tamper-resistant drugs? If not, don't addicts just switch to some other drug?

[Dr. Navindra Persaud]

Thank you for the question.

Yes, absolutely. As the president of Purdue pointed out, no formulation is completely resistant to tampering, and even the newest formulation, of course, can be altered so that it can be injected or nasally insufflated, nasally inhaled. But even aside from that, the pills are designed to be swallowed. One way to harmfully misuse opioid medications and other medications like benzodiazepines is simply to swallow the pills, to swallow more than the prescribed amount or to swallow pills that you are not prescribed. There are some studies of people who have died of overdoses suggesting that actually in only a small fraction of deaths from overdose is there evidence of injection or nasal insufflation of the medication. The inference is, in many cases, that individuals are simply swallowing pills.

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

While I certainly appreciate many of your comments, there was one that I took exception to. That was that you thought there was no good reason for samples to be distributed through a physician's office. I would just humbly suggest to you that I wouldn't want to throw out the baby with the bath water. There are many people who don't have drug plans, for instance, working-class people or small-business owners. So I think there might be many legitimate uses for samples.

But I think you were bang on in saying that continuing professional education should never be sponsored. Is the one certificate you brought with you an anomaly or is this something that is actually taking place across the country?

[Dr. Navindra Persaud]

Thank you for the question.

It's definitely not an anomaly. If you go to the annual conference of family physicians, you will meet with representatives of all of the pharmaceutical companies present in Canada. It's very common for continuing medical education events to be funded or sponsored.

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

Dr. Persaud, do they happen to be there at that conference or are they actually putting on the educational sessions?

[Dr. Navindra Persaud]

They host satellite symposia at conferences. They also host hospital rounds or sponsor hospital rounds presentations, just like the session I attended in 2010. This would be an hour-long presentation, usually in the morning, at which physicians meet to discuss a particular clinical topic. Those are commonly sponsored by pharmaceutical companies. They also happen at lunchtimes in clinics and they are sponsored by drug companies that often bring lunch. It's very common.

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

There's a sort of hospitality add-on.

Thank you very much.

[The Chair, Conservative, Ben Lobb]

Thank you.

Our next stop for seven minutes is Mr. Scarpaleggia.

Go ahead, sir.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Thank you very much.

Thank you to the witnesses for your presentations. I'd like to start by saying that we're disappointed with the decision of the chair to direct the clerk to disinvite Nova Scotia Minister of Health and Wellness Leo Glavine yesterday afternoon, overruling the witness list that was distributed to members on November 29 of last year as described in the Minutes of Proceedings of the November 27 meeting.

This is particularly concerning given the minister's unique expertise and work in the very field we are studying. We hope that this decision is not politically motivated since he is the only witness who was disinvited and the chair has substituted him with another witness who had requested to appear. He did this despite Minister Glavine being one of our top priority witnesses.

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

I have a point of order.

[The Chair, Conservative, Ben Lobb]

We won't eliminate your time but we have a point of order.

[Terence Young, Conservative, Oakville, ON]

That was his time.

[The Chair, Conservative, Ben Lobb]

No, the time used on the point of order.

Go ahead, Ms. Adams.

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

I have a point of order.

Mr. Chair, I don't believe this is actually pertinent to the discussion at hand. I think the witnesses who are and are not called are conceived of in a different manner. I would respectfully suggest to the member to direct his questions to the witnesses who have taken the time to join us here today.

[The Chair, Conservative, Ben Lobb]

Mr. Scarpaleggia.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

There are no specific rules apparently governing the nature of questions that may be put to the witnesses appearing before committees.

So if I may just continue with this I'll be done in a couple of seconds and I'll go on to my questions.

I would ask the clerk to invite Minister Glavine to submit his remarks to this committee so that members may review his testimony.

I'm new to this committee. I'm not normally a member of this committee. I'm substituting for Dr. Fry, and I find this study quite fascinating actually. So you'll have to excuse me if some of my questions appear rudimentary to those who have been part of the study all along.

I'm trying to get a handle on this notion of prescription drug abuse. I've been thinking about it a lot because of ads that have been running, at least in my province, and I imagine there are ads sponsored by the provincial government about this problem. I really wasn't aware of it in total until these ads started to appear. Now this follows up on these ads.

Perhaps you could explain to me, Ms. Strang, what is really involved. Are we talking mostly about opioids? When we talk about prescription drug abuse I imagine that people aren't stealing cholesterol drugs or what have you. We are dealing with painkillers. I guess that's what it's about.

[Lorinda Strang]

As Dr. Durnin also mentioned, we work together at the Orchard Recovery Center. We see, for theft and fraud, it's often the opioids but it's also benzodiazepines as well.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Would that be Valium?

In terms of the mechanics of this, how does it happen? I understand there can be theft and people can take too much of the drug that has been prescribed to them. But then they would have to renew their prescription and typically doctors give limited refills and so on. Of course, others in the household can raid the cabinet no doubt, but other than those methods how do people get their hands on these, other than, as I say, breaking into pharmacies and so on? You talked about requiring an ID to get a prescription drug from a pharmacy. Could you just elaborate on that because, as I say, I'm new to the study and I'm not familiar with all of it.

[Lorinda Strang]

There are two streams. There are people who are legitimately prescribed medication for a broken ankle or a surgery or whatever, or benzodiazepines for anxiety. There are people who can use those and not become addicted. Then there are people who become addicted to the medications after they have been legitimately prescribed them. At that point they become addicted and dependent on those medications. That is when they start to lie to their doctors. That is when they start to steal or change the prescription medications, adding an extra zero to the prescription will give them extra medication. There are a million ways that they are trying to circumvent the system.

Then there are people I've talked to who've heard that there's a whole generation out there right now that has just started to use prescription medications to get high. There's a whole culture among our youth who believe it's safer to get the medication from the doctor. They're mixing it with other things, they're crushing it and shooting it, they're lying and manipulating their doctors because they've become addicted to it.

So there are the people who are just using these medications to get high, and then there is another stream of people who were legitimately prescribed the medication, became dependent upon it, and then manipulated the system.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

In stealing it, you have to manipulate your doctor or lie to your doctor.

[Dr. Maire Durnin]

There's a huge street market for OxyContin and other opiates and benzodiazepines, and it comes from everywhere. It comes from over the border. You'd have to ask the RCMP, but it's out there. It's manufactured. We have pharmacy break-ins in British Columbia all the time. We have doctors who are over-prescribing.

You also need to remember that once someone becomes addicted, they need some kind of opiate. So when OxyContin or street OxyContin and now fentanyl become too expensive, they will turn to heroin. So our young people in this age group are now finding they can't afford the $500 to 600 a day to maintain their Oxy habit, and they will turn to heroin because it's more potent and cheaper. Then they inject—you get HIV, hepatitis C, and I see that now regularly in my practice. My colleague has a patient who's 16 years old, and I have several who are 18 or 19.