Thank you very much.
Mr. Chair, members of the committee, good afternoon. Thank you for letting me testify before you as part of your study on the government's role in addressing prescription drug abuse.
This is a serious issue. Let me begin by saying that the CMA shares the concern of governments and other stakeholders about the risks and harms associated with misuse or abuse of prescription medication.
The CMA is particularly concerned about the impact of the abuse and misuse of prescription medication on vulnerable populations, notably seniors, youth, and first nations. It's increasingly recognized that while prescription medication has an important role in health care, the misuse and abuse of controlled psychoactive prescription drugs, notably opioids such as oxycodone, fentanyl, and hydromorphone, are emerging as significant public health and safety issues.
Users of prescription opioids fall into two broad groups: those who use them for therapeutic reasons and those who use them for recreational purposes or because they are addicted. There is considerable overlap between these two groups. For many of those who misuse or abuse, their first exposure to the opioid was therapeutic. The routes for acquiring prescription opioid medication include legitimate prescribing for therapeutic purposes, double doctoring, diversion techniques such as prescription fraud and forgery, thefts, street drug markets, and even Internet purchasing.
What are the rates of prescription opioid drug abuse or misuse?
This is a very difficult question. It's generally acknowledged that national data on the abuse and misuse of prescription medications are lacking. However, there is evidence of misuse among vulnerable populations such as youth, first nations, and seniors.
For instance, 14% of respondents to the 2011 Ontario Student Drug Use and Health Survey said they had used opioids in the last year, making this the third-most common drug used after alcohol and marijuana.
A review of the non-insured health benefits program found that 898 opioid prescriptions were dispensed per 1,000 first nations individuals aged 15 or older in Ontario in 2007. The federal government has recently implemented a prescription monitoring program related to the NIHB.
While accurate data on the prevalence of the misuse of prescription medication among seniors are lacking, there is concern that with Canada's aging population, there will be an increasing number of seniors needing treatment for prescription medication-related harms, for example, medication interactions, falls due to drowsiness, or falls due to lack of coordination.
This is a snapshot of what is being described as an emerging public health concern.
The CMA is encouraged that federal, provincial, and territorial governments are committed to collaborating to address this issue. In our brief we outline three specific recommendations, which l would like to speak to.
First, in order to truly address the issue, the CMA recommends that federal, provincial, and territorial governments work with stakeholders to implement a pan-Canadian strategy to address the misuse and abuse of prescription medication.
To support quality patient care nationwide, such a pan-Canadian strategy must include the following:
an education and awareness-raising component that targets vulnerable populations, such as seniors, first nations, and youth, as well as health care practitioners; and the availability of, and access to, effective pain management and treatment programs.
Addictions treatment is a critical component of quality care. We need to address availability and access to addiction treatment and withdrawal management facilities as well as pain treatment and management across the country, particularly in rural, remote, and native communities. We see a patchwork of resources and approaches across jurisdictions and very importantly among regions within jurisdictions.
Surveillance and research are also needed—notably there needs to be a pan-Canadian interoperable system for real-time monitoring of prescription medication. We will speak more about that shortly.
Of course, we can't forget two other important components of health care: prevention and consumer safety. For prevention this means sustained youth social marketing and safe storage advice. For consumer protection we need slow-release formulations and other forms of tamper-proofing to reduce addiction.
Secondly, the CMA recommends that governments at all levels work with prescribers and the public, industry, and other stakeholders to develop and implement a nationwide strategy to support optimal prescribing and medication use. This strategy should include educational programs for health professionals, point-of-care practice tools and resources, special educational supports such as academic detailing or online communities of expertise to mentor prescribers and provide guidance, and public education to address prevention and safe use of medication.
CMA calls for this strategy in recognition of the challenges physicians face in assessing the condition of patients who request or may need the medication. Physicians assess whether the use is clinically indicated and whether the benefits outweigh the risks. The challenge is that there is no objective test for assessing pain and therefore the prescription of opioids rests to a great extent on mutual trust between the physician and the patient.
There has been progress such as the creation of the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain. While there have been efforts to advance the national guideline, more needs to be done to develop and advance point-of-care practice tools.
Thirdly, the CMA recommends that the federal government work with provincial and territorial governments, together with health professional regulatory agencies, to develop a pan-Canadian system of real-time monitoring and surveillance of prescription medication.
Limited access to information and resources is a key gap that physicians struggle with every day. Physicians simply do not have access, in real time, to the information they need at the point of care. A physician in Canada, with the exception of Prince Edward Island, does not have the ability to look up medication history to determine if the patient has received a prescription from another doctor, even in the same community. In some provinces, pharmacists are able to access a database for this information. But this is not true for every jurisdiction. Addressing the lack of information and resources is critical to eliminating a major barrier to effective treatment, and that requires establishment of a pan-Canadian real-time monitoring and surveillance that is interoperable.
It may be true that most provinces have prescription monitoring programs in place. But they differ widely and are not interoperable. Some are administered by regulatory colleges, others by government. They collect different information in different ways.
In addition, most of these programs focus exclusively on education and oversight of physicians but do not address patient needs.
The CMA is advocating a nationwide monitoring and surveillance system with common standards and protocols. It must be linked to electronic health record systems. And it must have the capability for use in enforcement by the regulatory colleges and for data gathering, research, and program evaluations.
As the Canadian Centre on Substance Abuse noted earlier this year in its groundbreaking report, First Do No Harm, “Existing activities to monitor the harms associated with prescription drugs in Canada are fragmented.” This must change. CCSA's report concluded that, “The data sources that do exist in Canada, such as coroner reports, poison centre records,…health data, losses and thefts data,…adverse events data, medication incidents and law enforcement records, are not part of any comprehensive national initiative”.
Let me wrap up by reiterating CMA's concern with this issue.
Canada's physicians are committed to optimal prescribing and working with governments to address the abuse, misuse, and unsafe use of prescription medication across Canada.