Thank you again, Mr. Chair, and members of the Standing Committee on Health.
As associate executive director of the College of Family Physicians of Canada, and as a practising family physician, I'm privileged to be here with you today, and I thank you very much for the invitation.
The College of Family Physicians of Canada, CFPC, is the voice of family medicine in Canada. We represent over 30,000 dedicated members. The CFPC advocates on behalf of its members to ensure high quality in the delivery of care. Education is a key element of our mandate. We establish standards for training, certification, and ongoing education of family physicians, and we're responsible for accrediting post-graduate family medicine training in all of Canada's 17 medical schools.
My remarks today will concern the role family physicians can play to address prescription drug abuse and misuse, and how we can work with patients to find the common ground required to resolve situations in which there is prescription drug misuse.
Prescription drugs are clearly an important part of management of disease, of curing illness, and of maintaining function. All of us at one point or another will likely require prescribed antibiotics, for example, for an infection. Some drugs are prescribed for the short term; some, such as pain management medications, for longer periods; and some are required for the duration of one's life, like thyroid hormone supplementation in the case of an under-functioning or surgically removed thyroid gland. Indeed, a 2007 Commonwealth Fund Survey found about half of all Canadian adults take at least one prescription drug on a regular basis.
Because of our place in the health system, family physicians are largely at the centre of prescribing. Prescriptions for the most common known drugs are usually written by us, but I would be remiss if I didn't note that prescribing decisions—what I mean by that is whether to prescribe, what to prescribe, how much to prescribe—can be the result of many complex factors. These include how a patient reacts or doesn't react to certain medications; the patient's history; other drugs the patient is taking; a patient's preference and income level, including what to do when a lower-income patient does not have a drug benefit plan; and what happens when a patient is prescribed a drug in hospital and then is discharged. All of these are common and predictable determinants of prescribing.
Complexity in family medicine may also be increasing. Aging patients, many with multiple chronic conditions, are a part of almost every family physician's practice. We are also seeing patients discharged sooner from the hospital, and the continuation of care, including the management of prescribed drugs and follow-up tests, become the responsibility of family physicians.
While there are numerous benefits to prescription medications, we're also aware of harms due to prescription drug misuse and abuse. Those harms include severe allergic reactions and a variety of effects related to the known mechanism of the drug's action and effect. For some drugs, the harmful effects can involve addiction; withdrawal; overdose, both intentional and unintentional; as well as suicide.
In a study of opioid drug-related deaths among Ontario drug benefit plan recipients in 2006, 40% of all single opioid deaths were due to a single drug—oxycodone, followed by morphine and heroin. One study also found that, in about two-thirds of opioid-related deaths in Ontario, the victim had been seen by a physician at least a month prior to death. In most cases, the coroner determined that the cause of death was accidental. In other words, we family doctors are implicated in these situations, and often in preventable ways.
In a 2011 study on Ontario primary care physicians' experiences with opioid prescribing, over 95% of family doctors reported prescribing opioids within the previous three months. A majority, 86% of those respondents, reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least one patient had experienced an adverse event related to opioids in the previous year, usually involving oxycodone. And 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events.
I'd like to share with you a story about a patient of mine with long-standing chronic and disabling pain. She was started on morphine with dramatic improvement in function. A few weeks later, I heard from her partner that she had undergone surgery for a bowel obstruction, presumably due to cancer.
When I finally caught up with her in hospital, there was good news and bad news. The good news was that there was no sign of cancer. The bad news was that the morphine I'd prescribed had caused profound constipation, resulting in the need for urgent bowel surgery. I had, in other words, succeeded at compassionate care—succeeded at helping in one way. I had enough knowledge and skill to do that, but not enough to prevent the complications, to prevent the predictable and unnecessary suffering that she underwent as a result of my prescribing. Clearly, I had some work to do—in fact we all had.
The CFPC has taken a position on oxycodone in particular. In November 2012, our board passed the following resolution:
The CFPC expresses profound concern that any changes that lead to an increase in the Canadian supply of sustained release oxycodone will contribute to further ongoing abuse of this drug and all of the accompanying negative health and social consequences. We call for a comprehensive approach to increase research and education initiatives surrounding appropriate and effective treatment strategies for patients who suffer from chronic pain.
The CFPC takes its role of social accountability seriously. We know that family physicians must take steps to assist in the reduction of prescription drug abuse and misuse. We recommend that this issue be addressed using the framework from the report, First Do No Harm: Responding to Canada's Prescription Drug Crisis. The CFPC was a member of the National Advisory Council on Prescription Drug Misuse and contributed to this report.
I'm going to spend a moment to focus on education for family physicians, adequate supports, and collaboration. Currently, gaps can easily be found in continuing education programs offered to primary care physicians regarding prescription drugs. By developing and delivering a curriculum for health care practitioners, we can educate prescribers and dispensers about the harms associated with the use of different medications. As family physicians, this is especially important because it helps us to open up a dialogue with one another in our local practice communities and with our patients by better informing them of the potential harms of prescription drugs. It also allows patients to participate in the shared decision-making process, which ensures that they're taking an active part in patient-centred care.
As family physicians, it's important for us to have access to unbiased education and support when assessing and managing cases of drug misuse, as well as to assess access referral pathways when a patient's problem becomes severe. Support models, such as the shared care and collaborative care models, involve local networks of pain, addictions, mental health, primary care, and other sectors. The collaborative nature of these models helps recognize the role and usefulness of team-based approaches. It also helps promote information sharing, dialogue, and teamwork exchange between health care practitioners and other service providers to address the stigma and fears linked to the use of these medications.
Having access to a network of experts—either physically or through the use of communication technologies such as webinars and telemedicine—can provide supervision, mentorship, and peer consultation to primary care providers throughout Canada. This is especially beneficial to embracing access to expertise in underserviced areas.
The CFPC is taking a leadership role through our model of care provision, called the patient's medical home. This vision for a family practice advocates for a team-based, patient-centred approach. By creating multidisciplinary teams, such as family health teams and primary care networks, we're able to provide a full range of treatment options related to pain, mental illness, and addiction.
Thank you once again for this opportunity to present a family medicine perspective on this issue, and I commend the Standing Committee on Health for undertaking this important study.