Health Committee on Oct. 18th, 2016

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you, Mr. Chair.

I'd like to thank the entire panel for showing up and for your service in all these different aspects.

I practised emergency medicine for almost 20 years, and as much as I agree that prevention is key, it doesn't change the fact that there's an ongoing crisis you have to deal with. Certainly in the emergency department when all the different problems roll in, you can't just stand there and say, “This should have been prevented.” I appreciate what first responders and paramedics have to deal with, because we see the looks on their faces when they bring these patients in. It's a horrific situation.

I support what my colleague Ms. Kwan said about harm reduction. I know from the data on it how important it is.

Dr. Blackmer, you talked about how burdensome the Respect for Communities Act is. What aspects of it, in particular, are causing problems in preventing more harm reduction strategies?

[Dr. Jeff Blackmer]

There are a number of aspects, particularly the number of hoops that communities need to jump through and the barriers that are put in place in terms of the letters of support and a number of the other procedures that people need to go through. I think we all recognize that input from the community is one aspect of that decision-making process. It's an important aspect, but obviously those letters of support from all of these layers and levels are burdensome in a way that outweighs the potential benefit to having input from that community. That's one example; there are others as well.

I would note that we recognize that harm reduction is one aspect of a full approach to this, but it's a very important one. We also know that in communities where these clinics have been established, whereas there may have been obstacles prior to the establishment, in fact, surveys done afterward showed that in many cases those communities came to see them as being very beneficial. There are a number of aspects to the bill that while important provide more obstacles than they need to.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

Mr. Bursey, perhaps you can answer this from the pharmacy's point of view. We were talking about the availability of opioids. Manitoba had one of the problems, which was noticed by the pharmacy community and the medical community. It had to do with Tylenol 1s. For background, Tylenol 3s and Tylenol 2s are of course available by prescription only. Tylenol 3s have 30 milligrams of codeine each. Tylenol 1s with eight milligrams of codeine apiece are non-prescription. In Manitoba they were noticing a lot of addicts, because they could get them over the counter, were taking a lot of them. Due to the amount of Tylenol it took to get high off Tylenol 1s, people were presenting at the hospital with liver damage, sometimes needing liver transplants.

As well, it turns out that there's a four-minute YouTube video that shows you how to extract pure codeine from Tylenol 1s.

In response to that, Manitoba has made Tylenol 1s prescription only. Would that be a strategy that would be at least somewhat helpful in removing one more source of narcotics from the street?

[Alistair Bursey]

I think it's a good strategy. In my practice we saw a lot of patients seeking Tylenol 1s, and it got to the point where we required a patient assessment by the pharmacist to see if it was an appropriate therapy, for example, for a migraine or abscessed tooth infection. Then the pharmacist would write a prescription as appropriate, and we would put it on our pharmacy system and it would be fed into the electronic health records so it could be tracked. The idea was that the appropriate patients would be taken care of, and the patients who were drug-seeking would no longer be able to gain access to it, and we would inform them of alternative therapies such as addiction services.

I can certainly say what we've done in our pharmacy has made a big difference, and I think what Manitoba has done certainly would. I do have concerns with those patients who are getting Tylenol 1s, codeine products, for appropriate therapies. If you do up-schedule it and pharmacists can no longer prescribe it after doing a thorough assessment, I think that could be concerning, but I do think there's an opportunity there to find solutions that take care of both parties.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

To clarify, Manitoba pharmacists can prescribe it.

[Alistair Bursey]

They can?

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Yes, they can prescribe it, but they have to do an assessment. They have to prescribe it, and it goes on the same electronic medical record that all the prescriptions go on, so as you say it can be tracked.

[Alistair Bursey]

Yes, and that's a great solution. I'm hopeful that more provinces can work together to move toward that solution.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Thank you.

You made a reference to commercial pill pressers. Now, there's a very alarming development, again in Manitoba. Some carfentanil made it into Winnipeg. I'm familiar with it from my residency. It is elephant tranquillizer. In residency, when I was doing my toxicology, I read that you would only encounter it if your hospital was near a large-animal veterinary facility like a zoo, because 20 years ago that was the only place you'd see that if there was an accidental exposure there. Times have changed, and it's shown up.

The form it showed up in in Winnipeg, unfortunately, was on paper blotters of the same form that young people will take other drugs like ecstasy, particularly at raves. There was nothing on it saying what was in it, but they had carfentanil, and the police found a fairly large shipment. There have been at least two carfentanil overdoses in Winnipeg in the last couple of months.

That being said, given that it's such an easy way to package fentanyl for consumption, would banning commercial pill pressers make that much of a difference, or would it just simply divert more of this to another form that makes it onto the street?

[Alistair Bursey]

As we said earlier, I don't think there's a magic bullet that's going to solve all the problems, but I do think we're going to have to use multiple different ways to find solutions. I think regulating pill presses is one solution. I think obviously there is some work to be done with this particular elephant tranquillizer, and I think as long as we try to deal in a multipronged approach, then we'll be able to start to make some progress on improving the situation of addiction.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

My last question is for the colleagues at the Vancouver Fire Fighters' Union. Again, I agree naloxone is a band-aid, but when someone's bleeding you need a band-aid. Some jurisdictions have started to use police services for different forms of first response. Some American jurisdictions have had police carrying external defibrillators in their cars, calling them on 911 calls to a collapsed person. There is also talk of training police in the use of inter-nasal naloxone. Would the participation of the police in this, particularly with our new law when police are not automatically giving possession sentences now, be helpful in dealing with this disaster until we can get it under control?

[Chris Coleman]

I think so, and that conversation was taking place at that meeting a couple of weeks ago where our chief said everything's okay. A police officer presented as well on that very subject, so that conversation is happening. If it's not implemented right now, I'm sure it will be.

[Doug Eyolfson, Liberal, Charleswood—St. James—Assiniboia—Headingley, MB]

Good to hear, thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we're going to go to five-minute rounds, and we're starting with Ms. Harder.

[Rachael Thomas, Conservative, Lethbridge, AB]

First off, I will join my colleagues in saying a very respectful thank you for coming and giving us your time today and sharing your expertise with us. We certainly appreciate it.

I'm going to direct my first question towards Mr. Blackmer.

I recently had a conversation with an aboriginal teenager in my community who was boasting to me—he was unfamiliar with who I was—about the prescription drugs, opioids, that he would get from his doctor, which he would then sell. He told me that depending on the drug, he would get anywhere from $10 to $25 per capsule. Basically, this is how this young man lives. He's going to his doctor, he's having these drug prescribed, and then he's functioning within an illicit market.

Clearly, his doctor is doing this continuously, and it would appear that there's no accountability. This teenager doesn't take them, so it is questionable whether or not he even needs them. I guess I'm just looking for your thoughts as to whether this is happening across Canada. Is this a common occurrence? How would we go about bringing a stop to this type of conduct?

[Dr. Jeff Blackmer]

I can't speak to specific statistics around that, but clearly this is a concern across Canada. The issue of patients selling prescription drugs is not unique to one jurisdiction. We've seen this for years. It speaks to some of the challenges that I was alluding to before at the individual patient-practitioner level. In conversation with a patient, it's very difficult for the practitioner to say, “Oh, this seems like the kind of person who would go and sell these drugs.”

You have to understand that the patient is presenting.... Some of these people are very good. If this is their livelihood, they become quite good at this. They present with a lot of pain. They present with a very convincing story, and sometimes they do this to multiple practitioners on the same day. Sometimes it's a primary care provider, but more often it's a walk-in clinic or an emergency room where there's not an established relationship and it's one-off meeting between that doctor and patient.

There are huge challenges for those health care practitioners to really get to the root of some of these problems and to understand how these medications are being used.

There are a number of things that can be put in place to try to mitigate that like prescription monitoring programs, so that a doctor can call up the history in real time and say, “Oh, they were just at the emergency department yesterday and they were prescribed the exact same medications they're asking me for now.”

They need more time to have those conversations and to screen for addiction potential, but also to screen for risk factors in terms of patients who might turn around and sell those drugs. Again, there's no perfect solution to this. There are a number of things that need to be put in place.

It is very challenging for front-line physicians and other health care providers to determine in very rapid sequence what will happen to those medications after they're dispensed.

[Rachael Thomas, Conservative, Lethbridge, AB]

It would appear to me, then, that it would make a significant difference if we were to implement a national databasing system with regard to the use of prescription drugs to tell us what's being prescribed, why it's being prescribed, and how often it's being prescribed—all of those things. Would you agree with that?

[Dr. Jeff Blackmer]

Absolutely, that would be hugely helpful. I think that's one important role that the federal government can play in this area. We know people can cross borders in Canada quite easily, and we know that drug seeking happens across borders as well, so being able to access that data in real time....

It's not enough for a doctor to find out two weeks later that the patient that they saw had been doctor shopping and had multiple prescriptions. That's helpful for future knowledge and changing practice, but in terms of being able to address the issue of the patient in front of them, they need access to all of that information in real time. We don't have systems like that in place now.

[Rachael Thomas, Conservative, Lethbridge, AB]

I recently learned that in places in the United States it's common practice for doctors to have a preconsult before prescribing. They'll actually bring patients in, sit down, talk to them, have a conversation with regard to why the prescription is being requested, then have a separate meeting with that same patient on another occasion to do the prescribing.

It's my understanding that this basically creates a bit of a lag period, if you will, which then allows the doctor to make a good judgment, but also creates a bit of a loophole for the individuals seeking the opioid.

Could you comment on whether or not you feel that this would be helpful in Canada?

[Dr. Jeff Blackmer]

I know that there are Canadian physicians who are doing that, who are having multiple consultations and meetings at different points in time. That also has its challenges.

For someone with severe acute pain who genuinely needs pain medications, asking them to come in for an appointment now and then for another appointment in three weeks—speaking to the access to primary care and access to physicians—can be really difficult. For some situations that might be very appropriate and for others it might be more challenging.

[The Chair, Liberal, Bill Casey]

Your time is up.

Ms. Sidhu.

[Sonia Sidhu, Liberal, Brampton South, ON]

Thank you, Mr. Chair.

Thank you to all the presenters. My question is to the Vancouver Fire Fighters' Union.

Are there any particular communities affected? As you said, it's not a drug issue; it's a mental health issue. What kind of education would you recommend and what kind of resources? What are your views about that?

[Chris Coleman]

At the risk of over-simplifying, I think it's a matter of housing and mental health support.

I'm sure you're familiar with the housing crisis in the city of Vancouver, and it gets no easier in the Downtown Eastside when a single-storey affordable bakery for the local residents is rezoned to 13 stories of condominiums with Starbucks as the anchor tenant.

[Sonia Sidhu, Liberal, Brampton South, ON]

For mental health issues, do you have any education perspective or any other resources?

[Chris Coleman]

I can't speak to that.