Health Committee on Dec. 4th, 2013

[Ada Giudice-Tompson]

I believe you said the third recommendation, correct? That's the abolition of specific marketing practices for prescription drugs with potential for abuse.

In the 1990s, Purdue Pharma conducted a massive campaign. They had the brand name OxyContin, but they promoted the use of opioids. Physicians never prescribed opioids for chronic non-cancer pain prior to this mass marketing campaign. The Federation of State Medical Boards in the United States—and I believe ours here in Canada, in Ottawa, is FMRAC—took all of this information from Purdue Pharma on the promotion of opioids, which was to use them because less than 1% of people would become addicted. This information was totally inaccurate, yet some people still use that language today. It was a massive marketing campaign right across the U.S., and Canada as well, with misinformation.

The marketing from industry to prescribers and to the public has to be curtailed. We need to put almost a firewall between industry and the prescribers and patients, because it was promoted as safe: less than 1% would become addicted and you wouldn't become addicted if you took it for pain. That was all untrue. It was a promotional campaign. People don't realize that, because it comes from your doctor so you think it's safe.

Have I answered your question?

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

Yes. Thank you very much.

[Dr. Susan Ulan]

Thank you for your questions.

My understanding is that you had two parts to this. Number one is what would be required from a funding point of view to support the work. Number two is the issue about the Ritalin and the sampling.

I think the most important thing is to first of all get some good data. There are two elements to that. One is prescription monitoring programs. There's a lot of good work being done in each province, but requiring and encouraging each province and territory to have a way of monitoring what is being prescribed, what is being dispensed, and who is being prescribed medications is critical.

Also, I think we need to learn from each other about initiatives being done in various locations, so that we don't redo and replicate work that has already been done. Creating a network of information regarding prescription monitoring programs is key, I think. That will allow us to mine that data so that we can look at national trends as well as identify the prevalence of medications like Ritalin. Until we have some information on concrete data, it's really difficult to look at why it's occurring when we don't even know how much it is occurring across a province and across the country.

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

Do you have an idea of how much money it would cost to do this study? Do you have a number?

[Dr. Susan Ulan]

I think the more important thing is to look at how much it would cost to put together a surveillance system and to standardize some of the prescription monitoring programs. Some of that work is occurring through the national prescription drug abuse strategy. They have an implementation team, of which I am actually a part, because it's something that I feel very passionate about.

I think one of the important things is to do a cost analysis, to make some decisions about what the priorities are, what key indicators we want to look at, and then to look at how we gather that data to be able to establish some dollars to it.

Until we really identify what it is that we need to have a good system, I think it's very difficult to put in a specific request.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Thank you, Ms. Morin.

Next up is Mr. Lizon, for five minutes, please.

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

Thank you very much, Mr. Chair.

My thanks to all the witnesses who are here with us in the committee room and those on by video conference.

Mr. Chair, first I would allow myself to make a comment to my colleague across. The issue was raised in the Speech from the Throne and I don't think the fact that we're engaged in this study can be viewed by anybody, regardless of their political side, as a negative thing. We are trying to address a very important and serious issue that exists in this country.

I'll be very honest. We've had several meetings on prescription drug abuse, and I have to admit that I'm confused. I understand how complex it is; however, I don't think I understand how extensive it is, and what the full scope of it is. So far, everybody who has come, all the witnesses, have focused on opioids.

Dr. Ulan, thank you for bringing up the other medications that people misuse or abuse.

Opioids are not new on the market. Morphine has been around for 200 years. However, I would assume that the fact opioids are very readily available is part of the problem. There are also current treatments that opioids were previously not used for.

Dr. Ulan, you mentioned that on a per capita basis, Canada is one of the countries where opioids are used the most. Why is that? Do other countries have other forms of treatments? Do people have a different tolerance for pain in other countries? Why do we use the most?

[Dr. Susan Ulan]

It's a very good question. It's an issue affecting first world countries. It does not happen in second or third world countries.

I completely agree with your reflection and comment that it's related to availability. As medications have become more available and physicians have become more comfortable with prescribing medications, specifically opioids, this increased availability has led to some harm. Yes, people with chronic pain have probably benefited, and many other people have, but there have also been some consequences as a result of that increased availability.

As you've seen from the discussion we've had, it's very difficult to draw a line between misuse and abuse. It's difficult to even collect data that might be relevant across the country.

I agree with you. I think the increased availability and access to medications has fuelled some of the trends that we're seeing right now.

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

Was there any research done on what percentage of people treated with opioids get addicted? During the First World War or Second World War, that was the only thing doctors had for the terribly wounded soldiers, if they had enough supply.

Percentage-wise, is there such research? What's the risk?

[Dr. Susan Ulan]

I think that Dr. Selby would be in a very good position to answer that. I'd suggest posing it to him, if that's okay with the chair.

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

Thank you.

[Dr. Peter Selby]

In Ontario, we have a youth survey of drug use. It has been going on for the last 15 or 20 years, and we're beginning to see the recreational use of opioids come in.

To answer your question about what determines whether people get addicted or not, it's not only availability. There's availability and there's the social norm about the use of it. We know that the drug itself, depending on the type of opioid, will have greater or lesser of what we could call abuse liability. The opioids that come into the system quickly, that can be injected and that leave quickly are the ones people will get into trouble with, because of the abuse liability.

If you want to look at the risk of getting addicted, opioids are less addictive than tobacco and more addictive than marijuana. That's where you would find it on the risk continuum, somewhere in there. Taking a look at prevalence, less than half a per cent of Canadians actually end up with illicit drug use problems, if you look at it compared with other substances. So availability does account for some of it, but it doesn't account for all of it.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Mr. Lizon. Your time has come and gone.

Next up is Mr. Marston, please.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Thank you, Mr. Chair.

I want to start off with Detective Harris, and perhaps Dr. Ulan, and Mr. MacPherson, you might want to come in on this.

I've used this several times in this committee since we first heard about it. Mr. Wallace from our prisons group came here and talked about the fact that 80% of new inmates come to the prison system already addicted or in trouble with medications. It just captured me, because I had a meeting with Chief De Caire, our police chief in Hamilton, and he was practically white the day he talked to me about this new drug, desomorphine, the street name of which is krokodil. We've had other people here talking about it.

When I looked at the mixture, the concoction is codeine mixed with gasoline, paint thinner, iodine, or hydrochloric acid. What's really frightening about this is that it's known as the flesh-eating drug, because the area you inject, you can wind up with a very messy situation. It's also called the “zombie drug”, so today with all the young people caught up in this zombie craze.... Now, people with common sense obviously can separate the fiction, but it's less expensive and far more hazardous than any version of heroin. It's more toxic, and the duration or action, the high, is even much shorter.

How did we reach this point? Is oxy to blame, the fact that it was there and then there's a real effort to pull back on it?

I have a couple of other questions, too. Does this desomorphine have a clinical usage? I can't imagine it does. Is it corporately manufactured, or is this something that's being concocted in some chemical lab in somebody's backyard?

[Det Collin Harris]

Thank you for the question.

The anecdotal evidence that we have that's currently out there is there have been no reported incidents of krokodil use in Canada.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

We had three last week in Niagara. They may have crossed the border from the U.S. I'm not sure. They got treated in our health care system.

[Det Collin Harris]

I think it's great that individuals are bringing awareness of this drug out there but do we have any evidence? Do we have any concrete evidence that drug has been seized? Where is the information coming from? Is it a third party who is stating that the individual has taken krokodil, or is it from a treatment provider who says that the individual said he had taken it? At this point in time, we haven't seen it.

I think we can almost say the same occurred with bath salts in Canada, where individuals have conducted heinous acts...very similar, where information from the media comes out that bath salts were used, but eventually down the road through analysis, none were ever found.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

My information came from our chief of police, and then just last week there was a report in our local newspaper that represents the Niagara area.

Just on the background, does anybody know if this has a clinical usage? Is it something that's manufactured by a firm?

[Dr. Susan Ulan]

No, it's not.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

No. Good. Thank goodness, because I couldn't even begin to imagine how we got to that place. There's been all kinds of...well, bathtub gin poisoned a lot of people in the prohibition era. I just won't ever forget the look on our chief's face when he explained this thing to me.

I'm going to take a brave step here, Giudice...I'm not even close. I'm going to call you Ada. That's much easier.

[Ada Giudice-Tompson]

Perfect.

[Wayne Marston, NDP, Hamilton East—Stoney Creek, ON]

Anyway, thank you again for being here. I certainly appreciate it. There's nothing like the first-hand story.

Currently, Health Canada is still okaying generic oxycodone. Now there are major efforts in the United States to try to get it off their streets. They've recognized that....

Why are we still approving it? In the paper you gave us, you referred to the sales pitch. They get a lot of this out there. Do you suspect that we've been taken into some degree by that? Our medical professionals are going that way, but even Health Canada?

[Ada Giudice-Tompson]

I believe so, I'm sad to say. Health Canada probably doesn't have the staff, but why do we need all this generic oxycodone when Health Canada has pulled from the formulary OxyContin? They've replaced it with OxyNEO, which is more tamper resistant. However, that doesn't mean it's less addictive. My son never snorted or crushed. He took his medication as prescribed, and he was started on Percocet. He died in his bed at home. The doctor had given him hydromorphone, and by the way, Canada is the top consumer worldwide per person of hydromorphone.

Getting back to your question, they've put out oxycodone generic. It doesn't make any sense to me why someone would do that. I think there are laws that protect patents and other business and economic laws that upstage the patient's safety and the drug safety aspect of it. That's what I've seen from my research across Canada and the U.S. There's been a lot of misinformation given to Health Canada. If you followed the lawsuits, they paint a picture for us, for Paxil, for Ritalin, for all of them, especially with Purdue Pharma. They were charged in 2007. They pleaded guilty, and yet we still have their products.

Why do we need so many opioids? We've been talking about monitoring, and databases, and naloxone. These are all great, but these are after the fact. We want to be preventing this harm. Our doctors have to have the information up front. These are life or death decisions. My son didn't have to die. This was just a big marketing scam, and it continues that way.

I'm sorry. I gave you a long-winded answer, but there's a lot of information on that.

[The Chair, Conservative, Ben Lobb]

Thank you.

Mr. Dreeshen, please.

[Earl Dreeshen, Conservative, Red Deer, AB]

Thank you very much, Mr. Chair, and to our witnesses, thank you for being here today.

To Mrs. Giudice-Tompson, thank you for giving us the testimony that you did today. Your last answer spoke volumes. Thank you very much for that.

I have a couple of other things.

Dr. Selby, you had talked about remote areas and the pain management procedures that would be perhaps taken in those locations. One of the things we heard a few days ago was that it would be more likely that they would use opioids in their prescriptions. I didn't see that as tying into what you had said. I think the reason they gave was that you wouldn't have a lot of these other auxiliary-type health services that would be there.

I'm wondering if you could clear that part up as we move on.