Health Committee on Nov. 20th, 2013

[The Chair, Conservative, Ben Lobb]

Good afternoon, ladies and gentlemen.

Welcome to the health committee. It is 3:30. We should get started.

I am very pleased to have here the Canadian Centre on Substance Abuse. You each have 10 minutes for your presentations, Mr. Perron and Ms. Robeson. Go ahead. If you need translation, it's there for you.

Mr. Perron, you're going to speak for 10 minutes. Go ahead, sir.

[Michel Perron, Chief Executive Officer, Canadian Centre on Substance Abuse]

Thank you. Good afternoon, Mr. Chair and members of the committee.

My name is Michel Perron and I'm the chief executive officer of the Canadian Centre on Substance Abuse, or CCSA as I'll refer to it in my remarks.

I'll extend my congratulations to you, Mr. Lobb, on your appointment as chair of the committee. Thank you for having us here.

I am joined today by Paula Robeson, one of CCSA's knowledge brokers and the lead on the prescription drug abuse file.

For those of you who are not so familiar with CCSA, we were created by Parliament to bring government, the not-for-profits, and the private sector into alignment on substance abuse issues. As a result, we have a federally legislated mandate to provide national leadership in reducing alcohol and other drug-related harms, and we have been doing so since our creation 25 years ago in 1988.

We are largely funded by Health Canada to perform the role of bringing together these entities. I think we have demonstrated our capacity to do so in areas such as alcohol treatment, youth drug prevention, and many of the issues that are important to you individually, to your ridings, and to this committee. It is therefore appropriate and relevant that CCSA initiated the process that brings many of us here today.

I want to tell you about the strategy titled First Do No Harm: Responding to Canada's Prescription Drug Crisis, which the centre launched last March in collaboration with many partners, including Health Canada. This strategy represents a unique approach in Canada to respond to the country's prescription drug crisis, which is an understandable source of concern for the government, as evidenced by the latest Speech from the Throne and this committee meeting.

Why develop a strategy? I know it has been circulated. I suspect the committee has heard some facts about the magnitude of the prescription drug crisis in Canada. Allow me to add to that, if I might.

Canada is now the world's second-largest per capita consumer of prescription opioids behind the United States. In Ontario alone, the deaths related to prescription opioids doubled from 1991 to 2004, and the mortality rate is now more than double that of HIV.

More recent data show that of the 2,300 drug-related deaths in Ontario between 2006 and 2008, 60% were opioid-related. The number of drug-related deaths goes as high as 74% in Nova Scotia. These are smaller numbers but nonetheless a very significant proportion.

Prescription drug use is a growing problem among young Canadians. A 2001 survey of Ontario students in grades 7 to 12 revealed that 14% reported the non-medical use of pain relievers. Among these, 72% said they got it from home and 6% got it from their friends. The abuse of prescription drugs by young Ontario students ranks third behind binge drinking and cannabis use.

It's clear that prescription drug abuse touches us all and requires a comprehensive pan-Canadian approach to deal with the issue.

“First Do No Harm”, the strategy we will refer to today, was launched in March 2013 by the CCSA, along with then Minister of Health Leona Aglukkaq and over 20 partners who were participating in the development of this strategy. This 10-year pan-Canadian strategy lays out 58 recommendations to address the devastating harm associated with prescription opioids, stimulants, and sedatives, in the interest of improving the health and safety of Canadian communities across the country.

This strategy is the result of over a year of work by the National Advisory Council on Prescription Drug Misuse, which included health professionals, patients, families, members of first nations, law enforcement representatives, regulatory bodies, the pharmaceutical industry and researchers. The council was co-chaired by Alberta's Coalition on Prescription Drug Misuse.

whom I know you will be meeting with in the weeks to come.

Also involved were the Nova Scotia Department of Health and Wellness and the Canadian Centre on Substance Abuse.

The federal government was represented throughout that process by a number of departments, namely Health Canada, Public Safety Canada, the Department of National Defence, and Justice Canada.

CCSA brought together those with a clear stake in the problem to help develop the solution. It was apparent to all of us when we initiated this process a year and a bit ago that the status quo could not carry on and that we needed to find a new path forward.

Following the first meeting we convened, all stakeholders called upon CCSA to take the lead in developing the strategy, as we have in other areas.

In answer to the question being considered by this committee, that is, the role of the federal government, there is a very clear one in addressing this national problem, but I wish to underscore as well that this goes well beyond any one level of government and well beyond government alone. We have, however, taken the liberty of drawing out all of the recommendations from the First Do No Harm strategy that recommend the involvement of the federal government, for your particular attention. I'd note as well that Health Canada was identified as a co-lead, alongside the Canadian Centre on Substance Abuse, and other parties, whether regulatory, professional, or the like. A copy of this has been handed to the clerk of the committee.

The following are the main areas in need of the federal government's involvement: preventing the harms associated with prescription drugs for individuals, families and communities; ensuring that the system can provide the affected individuals with effective and timely treatment; controlling and monitoring prescription dispensing, as well as the associated consumption, abuse and harms, at provincial, territorial and national levels.

Other aspects include ensuring that law enforcement has the tools it needs to prevent diversion and trafficking in prescription drugs and related criminal sanctions; reviewing federal and provincial and territorial legislation and regulations that govern all areas of our current prescription drug system; and finally, leading and contributing to enhanced research and knowledge exchange about the nature and extent of the prescription drug abuse problem in Canada.

On a separate but related note, I was very happy—delighted would be a better word, and perhaps even more—that the federal-provincial-territorial ministers of health recently turned their attention to this very piece of work, the First Do No Harm strategy, and committed to working in the areas of prescription monitoring programs and surveillance and prescriber education—again key recommendations that found their way into the strategy. That's to say that, along with the intentions and the actions of the federal, provincial, and territorial governments, there are many other activities already under way that are responding to the recommendations identified. We underscore that it's vital as we move forward that all of these efforts be coordinated in a strategic and comprehensive manner to avoid any duplication and to maximize the investments being made.

By the way, since the launch, eight months ago, of the strategy titled First Do No Harm: Responding to Canada's Prescription Drug Crisis, the centre has created two implementation teams whose mandate is to ensure that each of the 58 recommendations is carried out.

To put it bluntly, if I may, we are moving forward and we have a plan. We have a plan for Canada, and we have the right people at the table to realize the vision laid out in First Do No Harm and we are now working together to obtain the resources to make it happen.

Mr. Chair, while the committee should rightfully consider the role of the federal government in addressing prescription drug abuse, I would argue that the committee should also consider the role of CCSA, an agency created by an act of Parliament and responsible to Parliament, as part of that response.

To provide greater clarity to the members of the committee, I have brought copies of the relevant sections of the CCSA Act to show the purpose and scope of our intent and how that might be helpful in this regard. By definition, we have a legislated responsibility not only to have initiated the process of First Do No Harm, but also to see it through to completion.

Beyond this, it's imperative that the hard work and dedication of the great number of organizations that participated in the development of the strategy and committed to staying with it toward its implementation not be squandered. The fact that we have 58 consensus recommendations means that we have at the table—and prepared to engage in the process—all of the key organizations responsible for not only identifying the problems but also resolving them. That is more than only talk and goodwill; it's about putting real dollars, real investments, real professional practice, as well as their commitment, on the table for us, in a truly pan-Canadian approach to dealing with the issue.

Distinguished members of the committee, the strategy First Do No Harm: Responding to Canada's Prescription Drug Crisis is putting forward a strong call for action. It is proposing detailed solutions that encourage all of us to find a remedy to the problem of prescription drug abuse in Canada.

I am very happy that you'll be hearing from others who collaborated on the development of First Do No Harm, including Ada Giudice-Tompson, whose son died of an unintended drug overdose, and Dr. Susan Ulan of the Coalition on Prescription Drug Misuse, among others, who participated in First Do No Harm. I am sure you will hear a consistent message from them about what needs to happen now. Indeed, part of our role is to attenuate the noise on this issue and help you focus, as decision-makers, on the signal, and First Do No Harm is the signal.

To conclude, Mr. Chair, we urge special attention by this committee to three areas. The first is to prioritize the key functions that the federal government can engage in to address prescription drug abuse, consistent with the recommendations laid out in First Do No Harm. I would add CCSA to that as well.

The second is to underscore your committee's support for the structure and process going forward under First Do No Harm, which, again, is a true pan-Canadian strategy to address this issue.

Finally, the third is to commit to examining adequate resourcing for the strategy to move forward, including the role CCSA is expected to play in it now and in the future.

I want to thank the committee for its interest in this issue, which is of vital importance for the health and safety of Canadians.

I am very happy to take your questions at this time.

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Perron.

We're going to begin our first round. To begin the first round, Ms. Davies, for seven minutes, please.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much, Chairperson.

Thank you, Mr. Perron, and Ms. Robeson, for coming today. You've provided a lot of information.

The first question I'd like to ask—well, it's maybe not appropriate to you—is that I do find it a bit curious that we have this First Do No Harm strategy. I guess it was rolled out just in March of this year, so it's very new. It does beg the question why we're actually studying it, because it does appear that we actually do have a strategy.

Now, you've laid out some areas where we can maybe assist, but it begs the question why we're actually studying this. Nevertheless, I do have some questions.

I noticed that Nova Scotia is one of the provinces. In fact, it's the only province that's involved. I'm curious about that because I don't know if you remember, Mr. Perron, but when the Special Committee on the Non-Medical Use of Drugs did its report in 2001 or 2002, what I remember from that study across Canada was that in Atlantic Canada in particular, there was much higher misuse of and addiction to prescription drugs than elsewhere in Canada. I just wondered if you could give us any sense of this across the country. I know that in B.C. it was more around so-called illegal drugs, whereas in Atlantic Canada it was legal prescription drugs. Is that still the case? Is there a great variation across the country? That's one question.

The second question I have is this. I'm very interested to know if you will be investigating something, and I've been looking through the strategy here very quickly as you were speaking, to see where it is, if anywhere, and I haven't found it yet. I thought maybe it would be under monitoring and surveillance—that we would actually set up some sort of national system regarding the way pharmacies and dispensaries are operating to prevent people shopping around and getting double, triple, whatever, prescriptions. Is that part of the plan too? And if so, where would that happen?

And thirdly, I noticed that Health Canada is the lead on a lot of these things, which of course would naturally be so. I wonder if you could tell us if Health Canada has committed any funds to actually implementing this strategy at this point.

[Michel Perron]

Thank you. I'll try to treat these, and if I miss one, please move back to me.

First of all, I am delighted that you remember the committee of 2001, and it's important that we have that continuity at the table here.

[Libby Davies, NDP, Vancouver East, BC]

Oh yes.

[Michel Perron]

The first thing is that Nova Scotia took the lead in being co-chair of this process on behalf of the federal-provincial-territorial problematic substance use committee. They were our door into the PT process. The other co-chair was the College of Physicians and Surgeons of Alberta. So we tried to get the right elements participating at that level.

Second, I guess the question is, why are we here? Perhaps I think it was a bit rhetorical. But nonetheless, on the purpose of the CCSA, our role is to develop—and I go back to that signal-noise thing—and to try to provide for you a very clear understanding of where, collectively, those who are charged with accountability and responsibility for the system from all levels of government, the not-for-profit and private sector, think we should be spending most of our time. First Do No Harm does that. It is not a federal strategy, any more than it is a PT strategy, any more than it is a College of Physicians and Surgeons' strategy. I think everybody would associate it as being the vision of how we need to deal with this issue across Canada, and there is an understanding that to address this deeply complex and diverse problem we need to have a collaborative approach to dealing with the solution. First Do No Harm is really an articulation of the what and the how we wish to deal with that problem.

In terms of the variations of harm across the country—and I'll ask my colleague Paula to jump in at any point afterwards—there are two things I would say. One is that I don't think any jurisdiction is unaffected by the issue of prescription drugs, whether opiates, which have received a lot of the attention in the media these days.... Here I want to underscore that this deals with three categories: stimulants, depressants, and opiates. So while we have seen scores of reports pointing to the need to address this issue, the actual granularity of the data is varied across the jurisdictions. But it's safe to say that no jurisdiction has escaped the issue and that they're all committed to dealing with it.

In your province there are very good triplicate programs for how to manage these. That isn't necessarily the case across the country. Part of First Do No Harm is to try to equalize, I guess, the level of rigour that is present in the system.

[Libby Davies, NDP, Vancouver East, BC]

Can you tell me where that is in your strategy. What section does that come under?

[Michel Perron]

The prescription monitoring programs would be under the monitoring and surveillance section. You'll see that there are three elements there.

[Libby Davies, NDP, Vancouver East, BC]

You talk about a coroner's report, poison—

[Michel Perron]

Right. The initial challenge in this whole strategy was trying to figure out who should be at the table. The whole notion of having a prescription monitoring program—which gets to your other point about how dispensing and the whole supply chain is monitored and who is intervening at which point, whether it be for physicians who are perhaps prescribing it in a manner inconsistent with others to allow for a flag to be raised for the college to go in and ask why they are prescribing in this manner, to monitoring the actual transaction of the prescriptions, and on from there so to speak—is captured under monitoring and surveillance.

I'll go back to the point of not necessarily having the right data. Monitoring is about the prescription monitoring programs and the variability among the jurisdictions. Surveillance is about the broad prevalence data and some of the harm data that I was referring to earlier, which we frankly are still lacking in many of the jurisdictions.

The other point I would make, and then perhaps Paula can jump in, is that the pharmacies and dispensaries I think are well covered off. In fact, we had the National Association of Pharmacy Regulatory Authorities there. Again, we had them all at the table and they all indicated that this is something they want to engage in and be a part of.

In terms of Health Canada's role, I think our responsibility was to create a context in which the government could see where its actions should be focused. I think First Do No Harm gives that concentration of activities. As you pointed out, Health Canada is listed in a number of them along with other jurisdictions.

The good news for me is that we saw that it has now been included in the Speech from the Throne, which we thought was a significant accomplishment.

[Libby Davies, NDP, Vancouver East, BC]

But do you have a budget at this point to actually implement the strategy from Health Canada?

[Michel Perron]

Not that I'm aware of from Health Canada. Health Canada can respond about what they're prepared to put on the table for that, but I know they are very much engaged—and certainly on the first nations side they are very present. The fact that they are having these discussions with FPT ministers of health and that it's in the throne speech and has expanded the reach of the national anti-drug strategy to allow for the inclusion of prescription drugs, I think, bodes well.

So what all of that amounts to I can't speak to specifically.

[The Chair, Conservative, Ben Lobb]

Very good.

Thank you, Ms. Davies.

Next up for seven minutes is Ms. Adams.

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

Thank you very much for coming today and sharing your experiences with us.

I'm particularly interested in the First Do No Harm report that you have issued. Can you share with our committee some of the recommendations from that report, especially focused on knowledge gaps and our ability to strengthen the surveillance of prescription drug abuse.

[Michel Perron]

Among the knowledge gaps I think there are three areas in particular that we can focus on. This again was a subject of the discussion with the FPT ministers of health. One is on prescription monitoring programs and the understanding of what exactly is occurring across the country in that regard. The next is the surveillance and understanding of the extent, effect, and impact of prescription drug use and abuse. Third is around the area of prescriber education.

Not to focus singularly and solely on prescribers, that nonetheless certainly surfaced as part of the discussion in First Do No Harm as a significant component to this issue. That was one of the first challenges we had to wrestle with as a committee: what is prescription drug abuse? We clearly it as being on dual tracks. One is a purely therapeutic track, a medical track if you wish. The other is outside of that in illicit drug use—in other words using these drugs for purely illicit purposes.

Within the therapeutic track we determined very clearly that greater understanding and attention to prescriber education was necessary for all forms of physicians, in general practice and the other. This is from the physicians themselves. Also, there is the ability to understand, particularly around opiates, when opiate prescription is appropriate and when it is not appropriate and how best they can serve individuals with short-term acute pain in particular.

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

We're very early in our study at this point, but what seems to be quite consistent is the fact that there is a general lack of awareness of the extent of this problem and shortage of metrics quantifying how widespread this problem is.

Are you aware of anyone taking up that information, or where we might look to find this type of information?

[Paula Robeson, Knowledge Broker, Canadian Centre on Substance Abuse]

One of the six teams that have been put together for the implementation of the strategy is the monitoring and surveillance team, and there is a group working on bringing together the key data holders on this issue. They vary by province, and it's difficult to compare across provinces right now, but the lead of the committee to bring all the data holders together to talk about common metrics, similar data sources, and data collection methodologies is Dr. Beth Sproule of CAMH.

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

How far along are they at this point?

[Paula Robeson]

The strategy is in its fairly early stages in being put together, but we have a template for a meeting. We're waiting on some funds to bring that group together, but there are a number of key data sources and data stakeholders, including coroners across the country, various treatment databases, and poison control centre information. Lots of different sources need to be brought together.

We have identified those key players, and it's now a matter of bringing them to the table.

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

It clearly seems that critical work needs to be done.

[Paula Robeson]

Yes.

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

Do you anticipate that they will meet within the next six months, or what's the timeframe at this point?

[Michel Perron]

I can speak to the broader point of where we are at CCSA in terms of the implementation of First Do No Harm. As I mentioned in my remarks in French, we've developed action implementation teams composed of the same individuals and organizations that helped create the recommendation, and who are at the table helping with implementation.

The implementation teams are composed of the key custodians of these areas of expertise. In the area of monitoring and surveillance, we have Health Canada at the table and the FPTs. The process now is to help those entities determine what role they would like to play as part of the overarching implementation around monitoring and surveillance.

We have the signal from the FPT health ministers that they want to do something in that area. We look forward to seeing what it is in particular, but we're confident that as they look at that, they can contextualize their work as part of the broader whole, part of the first Do No Harm activities, respecting fully the role that governments want to play in that particular area.

At the same time, there are other data points that are non-governmentally related that will be coming to the fore so we can have a truly comprehensive picture of what is happening over time.

This is clearly an initiative that's going to take a significant amount of effort, number one, but it's time to move forward. The intent of first Do No Harm is again to minimize any duplication of effort or spun cycles that don't need to be spun that are being undertaken by others.

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

No, exactly. Nobody wants to do that.

Health Canada, Public Safety Canada, and Justice Canada all spoke to the fact that there really is a lack of awareness of how serious prescription drug abuse is. Could you offer any advice to us as to how we might practically raise awareness on this issue?