Evidence of meeting #7 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was prescribing.
A recording is available from Parliament.
Associate Executive Director, College of Family Physicians of Canada
At our level, we're working at building consensus. We're working on connecting members electronically to help members themselves help each other make difficult clinical decisions about patient care when there isn't a guideline that applies or when too many guidelines apply.
So certainly, the linkage of colleagues across our college is part of it, and certainly as well, collaboration with specialist groups, many of which are involved in the production and dissemination of these guidelines.
President-Elect, Canadian Medical Association
Maybe to provide another little context around that, back in Kingston last night I was speaking about this with an emergency room physician I highly respect. He said that 20 years ago we used opioids to treat patients for palliative care or for cancer pain, and we did a really crummy job treating everybody with non-cancer chronic pain.
Over that 20 years, opioids and other drugs have emerged as legitimate therapeutic agents. The guidelines that have been referred to have been an attempt to define, I think, what that best practice would be, and I think they've largely done that. What we're talking about now is the unintended consequence of having successfully treated a large number of people with chronic pain; now we have the fallout, which hasn't been as well managed.
The guidelines I think are good, and the challenge is going to be in the knowledge translation, in getting them into practice, off the paper and into practice. One of the things we've done, working with a group based at McMaster University, is work to develop these knowledge-for-practice tools that can be used at the bedside. We've cosponsored an online education module based on those guidelines that is being developed by a group at Memorial.
So there's certainly a role, I think, for professional groups to participate in this kind of knowledge translation. There potentially could be a role for governments as well to assist in the dissemination of good information—information that we all agree is reasonable—and making sure that it translates into the way things really roll out on the ground.
Conservative
Chief Executive Officer, Canadian Nurses Association
If I may just add to that, I think I would say as well that you can translate the guidelines into tools, but tools that are not limited just to providers. There can be tools for family members, for them to have a better understanding of some of the implications, and fact sheets for patients and fact sheets for dispensers, so that you have easy-to-access, retrievable, and concise information that can be used on a day-to-day basis.
Dr. Maura Ricketts Director, Policy and Research, Canadian Medical Association
I was just wondering how many of you have ever read the instructions for your TV changer, one of those hand-held devices?
Clinical practice guidelines are worse than that. The point is that converting these things into tools that can be used at point of care requires that an effort be taken to do so. You need people who understand what's happening at the clinical setting, and they reorganize the information so it makes sense from the doctor or prescriber/patient interaction point. It takes a concerted effort to do those things and that's why resources are required for it.
I'll also point out that pharmaceutical companies use academic detailing because it works. Academic detailing is an excellent way to work with any prescriber to help them use the best practices in their clinical practice setting. But these things require resources, leadership, and an intent to make the entire system work better.
Conservative
The Chair Conservative Ben Lobb
Okay, thank you very much. That concludes that seven-minute round.
Ms. Fry.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
I want to thank everyone who came here today.
I think, with an exception, all of you are prescribers to some extent, so I wanted to focus on the fact that prescribers are one piece of the problem, issue, solution, or whatever you want to call it.
I think what we heard from you, and what I think some of us know, is that the first step is to provide the appropriate drug for pain, regardless of what the pain is, whether it is palliative care, cancer, post-operative pain, pain because of a broken bone, or something like that. I think that's the first thing. I know there are guidelines for doing this, but how do you track appropriate prescribing?
The second one of course is surveillance, which is the physicians surveying the prescriber. Who surveys the prescriber? How does that surveillance occur without making the person being surveyed feel like they are threatened? How do you do that surveillance? And are we talking about tools then so that you can look at those prescribing practices?
This is the first piece of it. I know that when addictionologists first started addictionology, when it first became a specialty, addictionologists were saying that before you give patient A a particular drug you should do a history and a family history to see whether that patient has a propensity or if there is some sort of history within their family of people who are addicted to alcohol or inappropriately use all kinds of substances, including smoking. That might trigger you to decide on what particular medication to give to that person that has the least ability to cause addiction. Most of these drugs are addictive drugs so I know that that's a difficult problem.
The second one is, and I know I've repeated this before and I don't know how many of you know, in British Columbia about 20 to 25 years ago they started something called a triplicate prescription. The triplicate prescription meant that every time you prescribed an opioid, a barbiturate, or a narcotic of any kind, you had to use that prescription pad. That prescription pad had three pieces, one kept by the doctor, one sent to the college of pharmacists, and one sent to the college of physicians and surgeons in the province. That way they were able to keep track of what doctor was prescribing what drug, how often, and whether it was an appropriate prescribing practice or not. It was also able to pick up double doctoring in that province, so doctors and pharmacists were sent a list every week of people to look out for, including their aliases, who came and asked for drugs.
If we had that across the country and one was able to therefore track—not only within the province but outside of the province for a patient who from comes from another province—would that be an effective way of monitoring appropriate prescribing practices, tracking, and surveillance? I think that might be an important piece. I'm sure Dr. Meuser knows that there's going to be a patient who walks into your office and says, look at me, man, I've had this accident, I've got this God-awful pain that's been going on for 12 years, and I can't move my back. My doctor in Saskatchewan has been given this to me for a long time. Unless you call the doctor in Saskatchewan, and sometimes you can't get a hold of the doctor at the time, or you refuse the drug to the patient, there is no way of knowing whether this person is bona fide or not. I wanted to ask those questions, because I want to get to the nitty-gritty of the tools that are necessary to appropriately prescribe in the first place, and to track and survey.
I'm open to whoever wants to start.
Go ahead, Chris.
President-Elect, Canadian Medical Association
These are very interesting questions about appropriateness, because, of course, appropriateness is very difficult to define.
You're well aware, I'm sure, of the Choosing Wisely initiative, whereby medical practitioners are trying to say upfront that we recognize that appropriateness is something that can be enhanced. It's one of those things you kind of know when you see them, but it's kind of difficult to define. Ultimately, I suppose the way forward is to have some sort of reduction in the practice variation we see, have some sort of unanimity around what constitutes good practice, and then have the outcomes be the measure.
So it really speaks to how this part of the problem has to be wrapped up in the bigger envelope of managing pain in Canada, because at the end of the day we want people to be in as little pain as possible, and we want to have as few people addicted as possible, and we want to have as much of the inappropriate prescribing disappear as possible. Those are the outcomes we're trying to reach, and if we reach those, we will have increased appropriateness by definition. The most powerful tools are those that measure these important outcomes and give us ways to access best practices and to assure ourselves and others that we are following best practices.
The idea of monitoring prescriptions, I think, has met with modest success in the past, but really I suppose it's a red flag. If you find that Dr. X prescribes 10 times as much as Dr. Y, does that mean that Dr. X is prescribing inappropriately, or does it mean that he has a different practice profile? It may be sort of a signal that we need to go in and look a little bit deeper. It may be the first pass, but it may not be the sole tool required.
President-Elect, Canadian Medical Association
It is a tool, and hopefully it would be electronic and not three sheets of paper anymore.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Dr. Meuser, did you have anything to add?
Sorry, Chair, I should go through you.
Associate Executive Director, College of Family Physicians of Canada
It's hard to argue against improved information, and I think we would all agree that the more information we have when it comes to making that prescribing decision, the better it is, both about the drugs we're prescribing and certainly about the individual patient and the risks they bring when they are on the receiving end of that prescribing decision.
Having said that, I think we in family medicine are used to making decisions—and important ones—based on incomplete information. We do it all the time. Unfortunately, uncertainty and ambiguity are our constant companions in the work we do every day. So I think the truth is that most of the difficulties we see in prescribing are based on decisions that are made with the best possible intentions. What we attempt to build in are certainly supports for the information we have when we make that decision as well as other kinds of supports to clinical decision-making.
In Ontario, for instance, there is an opioid prescribing mentorship network that has been created by the Ontario College of Family Physicians that links family physicians to others—pain and addiction specialists as well as other family physician colleagues—so that when they run up against a particularly difficult decision around this prescribing conundrum, they have a group of colleagues they can refer to on a relatively instant basis to help them make that decision.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you.
Dr. Bard, I wanted to ask you if you saw this as being some kind of cross-country thing?
Chief Executive Officer, Canadian Nurses Association
Just for the record, I think the report First Do No Harm has a good section and shows the cross-responsibility at the provider level, the government level, and the local level. I think I would advise the committee to really look at some of those surveys, because they are needed.
Conservative
The Chair Conservative Ben Lobb
Perfect. I thank you, and I'm sure our analysts are making copious notes here and have likely read it three or four times.
Mr. Hawn, go ahead for seven minutes, please.
November 27th, 2013 / 4:40 p.m.
Conservative
Laurie Hawn Conservative Edmonton Centre, AB
Thank you very much, Mr. Chair.
Thank you all for being here.
Dr. Simpson, first, you said that 898 out of 1,000 first nations youth fifteen and over have had therapeutic prescriptions for opioids. Is that 898 of 1,000 individuals, or is that 45 individuals getting 20 prescriptions?
President-Elect, Canadian Medical Association
That's 898 prescriptions per 1,000 individuals. That doesn't mean 898 individuals.
Conservative
Laurie Hawn Conservative Edmonton Centre, AB
Okay, thank you. I'm far less shocked now.
Now, just on that, or on tracking other prescriptions, and along with what Dr. Fry was saying, it seems to me that there's a problem with training and standards, not that anybody's training or standards are necessarily inefficient, it's just there's inconsistency and difficulty in tracking that. On the explosion of medical marijuana prescriptions, and that is an explosion from a disproportionately smaller number of doctors, and we've talked about it a little, is there anything you can add about effective ways to track that? I know we've talked about some in B.C., and that seems to be effective.
Is the CMA going to push for a standardization across the country for some of these things, which I think, as Dr. Fry said, would be a good idea?
President-Elect, Canadian Medical Association
Certainly, I think there's a role for professional societies to play in some of the knowledge transfer. I think there's also a potential role for levels of government, and the federal government, in particular, to play a leadership role, to work together with the provincial and territorial governments to help develop a prescription monitoring and data collection system.
I think this is the information that gives us all the power we need to make better decisions and then for monitoring the progress made on the problems. How are we going to know if we're getting any better if we can't measure it in some way?
Conservative
Laurie Hawn Conservative Edmonton Centre, AB
Is that sort of approach accepted across the medical profession, writ large? Would doctors buy into that? The tracking should be used to educate. Is there a fear that some of the tracking might be used to punish in some way?
