Health Committee on Nov. 27th, 2013

[Rachel Bard]

If I can answer from a nurse practitioner's perspective, evidently when you are in front of a patient you look at it in a comprehensive way. You look at the total care and the total aspect of the individual so you start to try to map out some of the different interactions or reactions that the person has experienced so you start to do some clinical analysis. Then you can try to adjust and also provide some education to the patient in terms of what to expect and what to flag. It is part of the total care of an individual. It's critical.

[Earl Dreeshen, Conservative, Red Deer, AB]

Ms. Ma.

[Jessica Ma]

It's a great question. I think that one of the pieces we try to work with, with our consumer advocacy, is to have a better understanding of medications and the link to illness. I don't think that piece is quite clear in the public eye. We could do a better job as health care practitioners in making sure that people understand the medications they're on and why they're on them, and that they can be part of the monitoring in assessment of these medications.

Yesterday I was at a research meeting on home care. There's a growing push to community care and having these patients manage their medications on their own. Their caregivers don't quite understand the implications of all the meds and how they put them together. As we increase our education to our consumers there will be better understanding of their medications and more information for their family physicians when they visit.

[Earl Dreeshen, Conservative, Red Deer, AB]

Dr. Simpson.

[Dr. Chris Simpson]

I think there are pockets of excellence in the country where some of these approaches are employed, and where there's a multidisciplinary approach that truly has the patient at the centre and that has all the follow-up and supports in place. It's telling that it takes that kind of a resource-intensive, complicated enterprise to do it well. It reveals what a complex recalcitrant problem pain management is. The difficulties in Canada of course are in the rural and remote areas, and in certain demographic groups that have particular challenges by virtue of their socio-economic status and other demographic differences.

Many family doctors in remote areas—and Jamie will no doubt expand on this—will tell you they don't have any multidisciplinary team there. They're it, and opioids are all they have. There's no physiotherapist or occupational therapist there. So there's this inequity of resources available to patients that we really need to get at if we want a national approach. If we want to introduce some sort of uniform assessment and treatment of some of these patients, we can't do that by simply focusing on what we are going to do differently about prescribing, but on what we are going to do differently about treating these patients in pain.

[Earl Dreeshen, Conservative, Red Deer, AB]

Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you, Mr. Dreeshen.

Ms. Morin.

[Isabelle Morin, NDP, Notre-Dame-de-Grâce—Lachine, QC]

Ms. Bard, I would like to start by saying how happy I was to hear you talk about the social determinants of health in your speech. As you mentioned, this goes beyond prevention; we have to have marketing campaigns aimed at young people. Other witnesses have said the same thing. Medications must be stored better. We must go to First Nations communities and educate them about the negative effects of prescription drug abuse. Housing is also a very important social determinant. I am happy that a group is sensitive to it. Yours is the first to have said so here.

Let me move to another matter. A 2009 report published by IMS Health revealed that Canada's pharmacists filled 453 million prescriptions in 2008. That is an average of 14 prescriptions per Canadian. That figure certainly struck me. Michel Perron, the Chief Executive Officer of the Canadian Centre on Substance Abuse, appeared before the committee last week. He told us that a good deal of the education that physicians receive after finishing their training is funded by the pharmaceutical industry. Unfortunately, I do not think that we are going to have anyone from the pharmaceutical sector with us for this study, but I have a question for Mr. Meuser. What is your position on that situation?

Let me tell you about an example from my personal experience. Previously, I was a French teacher. When publishing companies came to see us in order to sell their books, those were the books that the school bought for the following year. It has an influence, for sure.

Mr. Perron even told us that physicians receive less training than veterinarians and that the training they get comes from the pharmaceutical industry. Do you see a conflict of interest there? I would like to hear your opinion, and Mr. Simpson's.

[Dr. Jamie Meuser]

In our system of accrediting continuing education, we have built into that system very strong and strict safeguards against bias and lack of balance entry into the programs where you get credits. We're very stringent on ensuring that the evidence that's put in front of our members around the education they get on prescribing, among many other things, is based on science and not on marketing. That's a clear requirement that we have.

Dr. Simpson mentioned the success that pharmaceutical companies have had with detailing. I completely agree with him that we could take a lesson from that. One of the interventions that we know succeeds—and pharmaceutical companies have known this forever—is establishing a relationship with a prescriber in the context of education. The only reason we can't do that is resources. Resources need to be applied by us around presenting scientific rather than marketing to prescribers that would allow for a broad range of important clinical decision-making questions to be addressed with members of the health care team at all levels.

[Dr. Chris Simpson]

Certainly government investment in impartial continuing education and knowledge transfer, and some of the programs we've suggested in our brief is a way to disseminate that kind of information in a non-biased way.

I think it's fair to say in general that the health professional community has moved away from, more than at any time in the past, or has resisted influence by marketing individuals. Again, often in many communities and for many health professionals, the information that's disseminated by pharmaceutical companies is still too prevalent, so we'd be very supportive of what you said around that.

I wanted to add as well, I appreciate your comments about the social determinants of health. At the CMA this has been our top priority, particularly during our past president's presidency, Anna Reid, so we're certainly appreciative of those comments.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Ms. Morin, your time is up.

Next up is Mr. Lizon for five minutes.

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

Thank you very much, Mr. Chair. Thank you, everybody, for coming to the committee today. Thank you, Dr. Meuser.

First, doctor, I remember when I was growing up I never used to get a prescription for an ear infection. My grandmother and my mother used to look after that for all of us, if I remember correctly. I don't know where your comment about a mother-in-law comes from. I thought it was the opposite.

I wanted to start with what you mentioned about unintended consequences. It's not anything new. If you read the literature, there are examples of people getting hooked on heroin that initially was used to treat pain and they liked the experience. I don't know how we should assess why we haven't been able to learn anything from that, or whether it's something that was simply overlooked. Maybe you could comment.

[Dr. Jamie Meuser]

I'll start and I'm sure others will contribute to this. I think what you've put your finger on is really at the core of the problem.

We wouldn't prescribe these drugs if they weren't powerful, so these are powerful agents for good, but they are also powerful agents of potential harm. The problem is we can't look into the future and see with any degree of certainty whether any given prescription is going to cause more good than harm.

We can certainly, based on risk factors, based on genetics, based on past experience with this particular patient, try to predict that, but in fact the power of these medications for both good and harm is at the core of the issue that we're talking about today.

What we're emphasizing these days as a starting point for treatment, and I'm sure a few of our witnesses here today will agree with me, is non-drug treatments around all the conditions that people are up against. People working on diet and lifestyle questions, working on physiotherapy or rehabilitation measures that can help deal with pain, as the speaker before said, addressing some of the most important non-medical determinants of whether someone gets sick or gets better quickly is equally as important as writing the right prescription.

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

Thank you.

[Rachel Bard]

I think the only thing I would add as well is that the interdisciplinary team is essential. If you want to try to reduce the use of drugs, you need to reduce the wait time and really make services accessible in a reasonable timeframe, and connect the right professionals around the person. Approach it that way, so that you use the least invasive and the least intrusive approach first.

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

Mr. Chair, how much time do I have left?

[The Chair, Conservative, Ben Lobb]

A minute and a half.

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

Yes, go ahead.

[Dr. Chris Simpson]

Certainly, I'd support what has been said. I think at the core of this is the decision we make every day as health care practitioners, how do we balance the benefit against the risks? We and patients always accept some degree of risk in order to derive the benefit. The challenge going forward is finding ways to enhance that ratio and make that ratio as good as we can.

We can't lose sight of the good that these drugs have done. Any solution that we come up with can't sacrifice the good that has been done. It can't erase or reverse that good that has been done. At the same time we must acknowledge the harm that has come as well.

At the individual practitioner level, it's going to be putting tools in their hands that allow them to make decisions with their patients, confidently, that this is a risk worth taking, the benefits are what we're expecting, and we have an ongoing plan for follow-up to make sure that what we are expecting to happen, will happen.

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

I have just one quick question. I don't know if there's a quick answer to it. I don't think Canada is the only country where the problem exists. Therefore, is there a country in the world that has made some attempts to deal with and address the issue? Could we adopt their solutions here?

[The Chair, Conservative, Ben Lobb]

You have about 10 seconds to answer the question, and then I'm going to have to move on.

[Rachel Bard]

I mentioned that Switzerland did bring a program that was very effective. I think that is one country to look at.

[The Chair, Conservative, Ben Lobb]

Okay. Thank you very much.

This is the last round of questions for the afternoon.

Ms. Davies, you have five minutes, please.

[Libby Davies, NDP, Vancouver East, BC]

Thank you very much.

I'm going to follow up on the question that Ms. Morin raised, and that is the role of pharmaceuticals. First of all, I believe we are going to hear from Rx&D, because I happened to run into one of their representatives today and I think they are coming to our last meeting, so we will hear from them directly.

Who monitors what is being sent to physicians and whether or not the information is appropriate? Dr. Simpson, you talked about how in remote areas physicians are pretty well on their own; they don't have a multidisciplinary team or other colleagues who they can go to. I'm just curious to know. We're talking about a multi-billion dollar industry here, so obviously there's the issue of pushing new prescriptions. I've seen those books in doctors' offices. They're huge, and you sometimes see physicians flipping through them, but who monitors that? Is there any monitoring? Do we need to pay attention to that to make sure that it's not just a marketing thing, but that it really is centred on proper guidance about what an appropriate prescription is?

[Dr. Chris Simpson]

I wouldn't want to speak for them, certainly, but over the years there's been a significant change in the way that the pharmaceutical industry interacts with health care practitioners. They're governed, I know, by a code of conduct that's determined internally. The typical interaction in 2013 is usually, “Have you seen this paper that was published?”, “Have you seen these guidelines?” The influence is much more subtle, but of course it is still there. That's why they do it. That's why detailing works so well.