Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 5 - Evidence - February 5, 2014
OTTAWA, Wednesday, February 5, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:20 p.m. to study prescription pharmaceuticals in Canada.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[English]
The Chair: I'd like to welcome you to the Standing Senate Committee on Social Affairs, Science and Technology. My name is Kelvin Ogilvie; I'm a senator from Nova Scotia and chair of the committee. I'd like to start the meeting by asking my colleagues to introduce themselves.
Senator Eggleton: Art Eggleton, senator from Toronto and deputy chair of the committee.
Senator Chaput: Maria Chaput, Manitoba.
Senator Seth: Asha Seth, from Toronto.
Senator Enverga: Tobias Enverga, from Ontario.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Seidman: Judith Seidman, from Montreal, Quebec.
The Chair: Thank you very much, colleagues. We have two organizations represented today and, by agreement, I will invite the Canadian Centre on Substance Abuse to present first. I understand you're sharing your time, so I'll ask Robert Eves first, who is Director, Strategic Partnerships and Knowledge Mobilization. He is here with Paula Robeson, Knowledge Broker.
Robert Eves, Director, Strategic Partnerships & Knowledge Mobilization, Canadian Centre on Substance Abuse: Thank you. Good afternoon, Mr. Chair and committee members. I am joined today by my colleague, Paula Robeson, one of CCSA's knowledge brokers, who is the lead on our prescription drug abuse file.
For those of you unfamiliar with CCSA, we have a federally legislated mandate to provide national leadership and advancing solutions to reduce alcohol and other drug-related harms, and we've been doing so since our creation in 1988 as an act of Parliament.
Substance abuse is a problem too complex, too significant and too deeply rooted to be solved by one group or approach. CCSA's role is to bring together government, not-for-profit organizations and the private sector around substance abuse issues to achieve consensus on possible solutions and to take action. For the last quarter century we have ably demonstrated our capacity to do so in areas such as alcohol treatment, youth drug prevention and prescription drug abuse.
In March 2013, CCSA with then Health Minister Leona Aglukkaq, and 30 other partners, launched the First Do No Harm strategy to respond to Canada's prescription drug crisis. This 10-year pan-Canadian strategy lays out 58 recommendations to address the devastating harms associated with prescription opioids, stimulants, sedatives and tranquilizers.
CCSA brought together those with a clear stake in the problem to help develop solutions. It was apparent to all of us that the status quo could not carry on. We needed to find and agree on a path forward that would recognize the therapeutic benefits of certain prescription drugs while also reducing their potential for harms.
We are also doubly pleased to be appearing alongside one of the co-chairs in the development of the strategy today, Dr. Susan Ulan from the Coalition on Prescription Drug Misuse of Alberta.
I would now like to hand the presentation over to my colleague, Ms. Paula Robeson, to address the questions being considered by this committee today.
Paula Robeson, Knowledge Broker, Canadian Centre on Substance Abuse: Good afternoon and thank you for the invitation to address the committee and the questions being considered as part of your study.
First, with regard to the process to approve prescription drugs, First Do No Harm calls for a review of Health Canada's regulatory and related information requirements throughout the supply chain. This involves examining the practices and processes of manufacturers, distributors, as well as health care practitioners who prescribe and dispense these medications.
We also recommend a review of the drug approval process to examine vulnerabilities in the supply chain, to work with provinces and territories to access the necessary information and to strengthen regulations as indicated.
Further, the strategy calls for complete life-cycle surveillance and risk mitigation plans to be put in place for both branded and generic products before they are approved. These strategies would enable timely identification of risks and the required actions.
I'll now move on to the post-approval monitoring of prescription drugs. We recommend that if post-marketing surveillance identifies additional risks and harms, adjustments be made to product monographs which provide the necessary information for safe and effective use of prescription drugs.
We recommend changes to the labelling of prescription drugs. Patients need clear and easy-to-understand labels so they take what's prescribed to them in the manner and for the reasons they were given the prescription in the first place, and they need to fully understand the risks and benefits of the medications they take.
Mr. Chair, existing monitoring and surveillance activities related to prescription drugs in Canada are fragmented. Currently, information on the use, misuse and harms of prescription drugs is tracked by different federal and provincial agencies within their respective jurisdictions and in a variety of ways. While there are some relevant data available among existing surveys, there is no consistency in approach, collection or use of data. The ways in which prescription drugs are monitored differ across jurisdictions, and the data sources that do exist in Canada are not part of any comprehensive national initiative.
Furthermore, there's no single group dedicated to addressing the issue of information tracking, thus cross-sectoral collaboration is required. Therefore, in addition to ensuring that each province and territory has a strong prescription monitoring program, we also need to have a national group that pulls together all relevant data from multiple sources, including crime, fatalities, treatment, hospitals, coroners, et cetera. This would help determine the nature and extent of the problem, trigger change where it's required. The standardization of key elements of a prescription monitoring program and a Canadian drug surveillance system are required. Such a comprehensive system would generate baseline indicators regarding the harms associated with prescription drugs and could inform the evaluation of actions taken on the strategy recommendations and lead to more effective, evidence informed support, treatment and care.
These initiatives are all important parts of the First Do No Harm strategy and some activities are already under way. Moving forward, all of the efforts towards reaching these goals must be coordinated to avoid duplication and to build upon what already works and exists in Canada.
At CCSA we are moving forward. We have a plan; we have the right people at the table to realize the vision laid out in First Do No Harm; and now we need the resources to make that happen. To put it bluntly, Mr. Chair, CCSA needs financial support to continue our important work in leading the implementation of the First Do No Harm strategy with our key stakeholders and to fulfill the commitments we've made to Canadians.
We're hopeful that the government will reinforce its commitment made in last fall's Speech from the Throne to expand the national anti-drug strategy to include prescription drug abuse by providing additional resources for CCSA. We need support from the federal government, but in order to ensure progress on this issue we also need to ensure coordination, which will require support from other levels of government. We've seen leadership from provinces like Alberta in bringing financial commitment to the table, but it goes without saying that we need more.
In conclusion, I would like to thank the committee for your interest in this very important issue of vital importance to the health and well-being of Canadians.
Robert and I would be happy to answer any of your questions to the best of our abilities.
The Chair: Thank you both very much. I will now turn to Dr. Susan Ulan, Co-chair of the Coalition on Prescription Drug Abuse.
Dr. Susan Ulan, Co-chair, Coalition on Prescription Drug Misuse: Thank you, Mr. Chair and committee members. The Alberta Coalition on Prescription Drug Misuse — we refer to ourselves as CoOPDM — is very appreciative of the opportunity to present information to the committee and to let you know a little bit more about what we're doing in Alberta and we hope that this informs your study on pharmaceuticals.
CoOPDM was formed in 2008. We're a multi-stakeholder group in Alberta that represents physicians, pharmacists, law enforcement, government, and First Nations and Inuit Health Branch. We're a collaborative volunteer group that is looking at how to collectively address the issue of prescription drug abuse and reduce the risk of harm. Many of the groups at our table are people who see first-hand in our professional lives the impacts of prescription drug misuse in the communities and in our health care system.
Over the last five years, we've undertaken a number of research projects and initiatives to better understand the scope and complexity of the issue in Alberta and to look at what data is being collected and how better to move forward in that regard. Currently, we are working with the Alberta Chief Medical Officer of Health, Dr. Jim Talbot, to look at how to develop a better governance model in Alberta.
I'm a family physician by training and my role at the College of Physicians & Surgeons is with physician prescribing practices. This is a quality assurance, quality improvement program that looks at working with physicians from an educational perspective to address prescribing issues both individually as well as broad province-based interventions.
I practised for 20 years as a family physician in a very wide scope of capacities. I feel my skill set is quite well-suited to this. I've had the opportunity to act as Co-chair of Coalition on Prescription Drug Misuse, and I've had the distinct honour of being asked to act as Co-chair of the National Advisory Council on Prescription Drug Misuse to develop the national prescription drug misuse strategy First Do No Harm: Responding To Canada's Prescription Drug Crisis, which was led by the Canadian Centre on Substance Abuse, CCSA.
I thought I'd briefly outline some of the things that CoOPDM has learned over the years with our research and investigation in working with this issue. Prescription drug misuse and abuse affects everyone. It affects every community and every population, and it is not in marginalized populations only. The impacts may be experienced differently depending on the community and the culture, however, this affects everybody. It's critical that we look at this broadly and incorporate strategies that are applicable to a wide variety of circumstances.
As Robert has alluded to, this is a very complicated issue. Prescription medications are medications with legitimate medical purposes. Any strategy that is undertaken should not decrease the access for appropriate medical treatment. The tendency is to look just at opioids, which are in the media a lot, but we are also talking about sedatives, sleeping pills and stimulants. A variety of medications need to be managed in a similar manner.
Our experience has shown that if you work with a community and dramatically decrease the availability of prescription drugs, it does not make the issue of addiction go away. Our experience in Alberta has been a rise in alcohol-related incidents drifting to different medications to misuse and illicit medications, which has led to more criminal activity and violence. Any strategy that is incorporated has to be broad and deliberate. You can't just pick off a few items to address.
In a similar manner as the First Do No Harm strategy, there are recommendations in five different streams of action. It's important that actions are taken in a comprehensive way from multiple perspectives. It's not simply a matter of decreasing the availability of drugs.
We need to collect data. In Alberta we did a literature review. We had interviews with key stakeholders to see what data is being collected to inform this process. We found that a lot of data is being collected, but it's not being compiled and organized into actionable actions, so we feel that prescription monitoring and the surveillance system are critical.
We need improved access to treatment for chronic pain, addiction and mental health issues. The tendency is to think of these as sort of end results but, in reality, early access to appropriate treatment decreases the risk of harm and decreases the cost to the system in both people costs and health care costs. We can't address this by ourselves. CoOPDM is a volunteer organization with little influence or authority. We need the guidance of federal government and provincial government at all levels to bring this forward and to make this an issue of urgent public health attention.
Our recommendations are that we support the development of federal leadership to bring together the provinces and territories to work collaboratively with a common goal of addressing prescription drug abuse with input from multiple stakeholders.
We support the 58 recommendations of the CCSA's First Do No Harm in the five different streams. It's important that we set the goal to reduce the risk of morbidity and mortality of prescription drug abuse in Canadians. Some of you may know that in Canada, depending on the year, we're either the first or second largest consumer of opioids per capita in the world. We think it's important to set a goal to decrease and change that status.
Similar to Robert, we also believe that there needs to be a national surveillance system that can be adapted to each province. It needs to pull in information from multiple sources. Most important, that data needs to be monitored and utilized to influence policy and legislation and to create action. By having a surveillance system, we can quantify the issue and look at tracking our progress as we develop interventions.
The prescription monitoring programs across the country need to be standardized, and we need to find ways to share information. The legislation and privacy issues are barriers. Everyone operates with their data in silos. As a result, it's very difficult to move forward and share that data, even if it's aggregate, in a meaningful way because of privacy legislation. We need to review that and ensure that we can do the right thing to minimize the risk for public safety and individuals.
We need to advocate for national curriculum standards for both law enforcement and health professionals. As noted before, we need to improve access to mental health, chronic pain and addiction treatments; and it needs to be consistent and available across the country.
We need to work with First Nations groups. Although prescription drug misuse and abuse affects all populations, the impact on First Nation communities is greater for a variety of reasons. We need to work very closely with these communities to reduce the impact.
We need to develop a mechanism in the federal government to be able to make decisions when safety issues are identified for a medication that is currently on market so that when issues or circumstances arise, a mechanism is in place to manage that appropriately.
On behalf of the Coalition on Prescription Drug Misuse, I appreciate your time and interest in this issue. It is a critical public health and safety issue that is affecting our health care systems in our communities. I'm delighted that we're here and I am happy to answer questions.
I can speak on behalf of Coalition on Prescription Drug Misuse, but my experience as a medical regulator may also be included in some of our discussion.
Senator Eggleton: I'll put a couple of questions that either organization may answer.
The development of the report First Do No Harm called for a national strategy to address prescription drug abuse. You had a consultation with the Minister of Health, and perhaps that's what produced a notation in the Throne Speech last October that the National Anti-drug Strategy would be expanded to include prescription drug abuse and that Health Canada is committed to working with the Canadian Centre for Substance Abuse to determine the specifics.
How is that coming along?
Mr. Eves: It's coming along very well. We had a symposium hosted by CCSA and the Minister of Health on January 24, specifically to bring together key stakeholders. In this case, many were the regulatory bodies and associations representing health practitioners to talk about the key priorities in moving forward. We actually walked away from that with some pretty clear messages.
Specifically, we heard about prescription monitoring programs, as well as surveillance as a whole, in particular, as in your report, around post-approval monitoring of safety and effectiveness. The other main theme was education not only for prescribers but also for dispensers as well as consumers. We walked away with some clear messages. I'd have to say it was a success and it has helped to move the dialogue forward. We understand, however, that things take time, too.
With the budget coming up, we are hoping to see some room made for this issue and, hopefully, CCSA may have some part of that.
I think we have made definite strides since the launch in March of 2013.
Senator Eggleton: One of the key issues here — and I think both of you have mentioned it — is this surveillance system. The national advisory council recommended a pan-Canadian surveillance system. We find a lot of pan- Canadian issues are challenging, and one of the challenges I think you noted is the privacy laws in the different provinces.
Are there other challenges? Is this going to be part of the national strategy? Is this getting the kind of receptiveness from Health Canada that you need to see this happen in a pan-Canadian way? Is there any particular model? Is Alberta a model, for example, or is any other province a model for this surveillance system? Are there any other challenges aside from the privacy law? If you have any ideas of how to get around the privacy challenge, that would be helpful, too.
Dr. Ulan: There are two components to the data surveillance. There are prescription monitoring programs. About five or six of the provinces and First Nations have prescription monitoring programs set up a little differently. They track their prescriptions — that is, who the prescriber is and what the medication is. These are for monitored medications. Each province then determines, often with a regulatory body, what flags are in that system — be it multi- doctoring or high doses or high quantities — and how they are managed. That's the prescription monitoring piece.
The larger piece is looking more at the impact of the prescription drug abuse and misuse. That is looking at health care outcomes, such as overdoses, poison control calls, coroner's data, treatment facilities, and the type of medications that are being presented when patients come into treatment. The surveillance system needs to be much broader in capturing information from a multitude of different sources.
There are some good models in the U.S. for their surveillance system. The three main ones are RADARS, NAVIPPRO and a third one called DAWN. They each look at different sets of data. NAVIPPRO and DAWN use similar data together. They look at what's happening in the community and what's happening in hospitals and in poison control. There are two pieces of that.
The issues are, number one, the privacy legislation, and, number two, technology. Each province is quite different with prescription monitoring programs. In Alberta we are quite fortunate. We have an electronic health record. If a patient comes into my office, if I'm their primary caregiver and I'm in the circle of care, I have the ability to look at their provincial health record, which outlines all the medications, all their investigations, vaccinations and emergency records. Prescriptions are part of that. We've got that ability in Alberta, but other people don't. There are real significant technological barriers to be able to implement this.
Then, bringing together different regions, we want to make sure, with a pan-Canadian strategy and surveillance system, that there is an overarching principle and that it can be used in each province and territory, depending on circumstances. There are several barriers. It sounds quite easy to implement, but the reality is there are many challenges. It doesn't mean that we don't do it, but I think we have to be very realistic and strategic with how that moves forward.
Senator Eggleton: Is there any nudge we can give to the federal government on this issue that might help overcome some of these barriers?
Dr. Ulan: I had the opportunity to present at the House of Commons Committee on Health in December, and I was able to participate in the symposium. At both of those venues, it came through loud and clear that data and surveillance was a key part of it — not all of it, but it's a key issue. It needs to be sooner rather than later. So, we hope.
Mr. Eves: I could speak a little further to that. We know that one of the big pieces — and Susan alluded to this — is the collaboration or cooperation piece and then, also, the standardization. This requires a jurisdictional component as well. The investment of resources wouldn't only come from a federal body; it would have to be investments made on a jurisdictional basis.
We do understand that the ministers of health have made this a priority, in particular prescription monitoring, and are moving towards how they can work together on the issue.
Senator Seidman: Thank you for being here.
I wanted to ask you specifically about the psychoactive drugs, which we know have a very high potential for harm as a result of any misuse, abuse or addiction.
Specifically, if we're collecting data, we have to know how we define ``abuse,'' ``misuse'' and ``addiction.'' You've all alluded to the complicated aspects of these matters. Could you please help us understand the complications in trying to define ``abuse,'' ``misuse'' and ``addiction,'' also as they apply to different socio-demographic age categories?
Dr. Ulan: I can begin to speak to that. I agree with you. I think the differentiation and the clarification between ``misuse'' and ``abuse'' are very difficult. ``Misuse,'' by definition, is any use of a pharmaceutical for other than its intended purpose, whereas ``abuse'' is the non-medical use. It has to do more with intent, so sort of intentionally misusing the medication in a way to take advantage of the psychoactive properties. There is intent, and I think it's very difficult for somebody externally to try to guess as to someone's intent internally.
For instance, if somebody is taking a sleeping pill and one tablet of the pill isn't doing the trick, they may increase their dose to taking two at night. That could be perceived as misuse, whereas if that same patient snorted the sleeping pill, that would be abuse. Once again, it's very clear with that type of example where it's either/or, but there are a lot of grey areas.
Definition is critical. It may be that we need to blend the definition to more reflect the DSM. The Diagnostic and Statistical Manual V was just released in June and it has no longer separated ``dependence'' and ``addiction.'' It now sort of lumps them together as ``problematic substance abuse.'' It's then broken down to the different substances like opioids, alcohol, that sort of thing. There is clinical recognition that it isn't a clear-cut differentiation.
Ms. Robeson: It's also important that the First Do No Harm strategy focused on the harms associated with prescription drugs, whether misuse or abused. Part of the outcome data that we need to look at are the harms, regardless of whether the medication is taken as prescribed or if it's misused. It's important to get some of that data as well. Was it taken as prescribed by dose, route, frequency and person, and what are the harms regardless of whether it's abuse or misuse?
Senator Seidman: If we're going to collect the data, if we're going to do the work and the surveillance, what are the challenges that we're going to face in trying to develop the definitions? Is it merely pulling in line with the new diagnostic manuals? What would you say?
Ms. Robeson: We have received a CRISM grant from CIHR to bring a group of stakeholders together. They will be dealing with some of those issues. There was a previous meeting that looked at those definitions. Part of the concern was that they didn't arrive at real definitions, which makes data collection and analysis very difficult.
One of the goals of this surveillance group will be to land on key indicators — perhaps not specifically around those definitions — to monitor for whether the drug is taken by the person in the way it was prescribed, what the harms are, seeking treatment, whether there is addiction, treatment for addiction, wait-list times, overdose or death being some severe outcomes related to that. Focus less on definitions and more on key, specific indicators.
Senator Seth: Thank you for such an interesting topic. I see with the CCSA presentation that Canada has the second highest level of per capita prescription opioid use in the world. Which country is the largest consumer of opioids and which is the least? In the case of the least, what initiative has been taken by the government to give this low level of drug abuse?
Dr. Ulan: The U.S. is the number one per capita utilizer and consumer of opioids. The least would not be countries we want to emulate. This is a First World problem, so the countries low down on it are places where opioids are just not available for treatment, whether or not it is appropriate or inappropriate. If you happen to be living in India and you have terminal cancer, regardless of how painful it is, you may not have access to it. Being the lowest consumer per capita has more to do with availability than initiatives to limit the prescribing of it.
Senator Seth: What cities in Canada do you see with the largest consumption of misused prescription drugs?
Mr. Eves: We can't speak to that at this point, and that is part of the relevance of the work you are doing with the second report and, in particular, understanding what post-market surveillance looks like, post-approval. We can't actually say. We have statistics from areas where they do have some monitoring. Ontario is one of the most robust at this time. That doesn't mean it's the best collector, but the one that has so far analyzed the data publicly. At this point we don't have that information.
The Chair: Just to clarify that, let me make sure we understand. You are able to say Canada ranks very high in terms of the total opiate use, but you are not able to say which ones are, so you are dealing with some volume identified of purchase of opiates on an annual basis?
Mr. Eves: Yes.
Senator Seth: What segment of the population misuses that drug? Is it young people, old people, rich, poor? Which segment would you suggest?
Mr. Eves: I can say confidently all segments, just differently. If you took older adults for example, there has been a prescribing pattern for a long time where they are more likely to be prescribed to than other parts of the population, with the exception of women. They are more likely to have what Susan referred to as ``access,'' which then increases the chance of potential for misuse, abuse and other harms related to the use.
The segments of the population that have greatest access are the highest risk but, having said that, we won't necessarily conclusively know. There are drivers in each of those population groups that are different. In one it may be access through an actual prescription, but in the case of youth we know it is access in the home, for example.
We don't have statistics specifically that would show one segment of society has higher problems than another. It runs across all segments.
Ms. Robeson: We have some data provincially in certain jurisdictions which show, for example, that the treatment rate for women is rising at a greater rate than the treatment rate for opioid addiction for men. We are noticing that there are some variations among the population, but we have difficulty saying whether that compares across the country.
There has been a fair bit of media around the issue within First Nations communities that seem to be disproportionately affected as well.
[Translation]
Senator Bellemare: When you look at this problem, it is somewhat difficult to know what constitutes abuse of medications and what constitutes inappropriate use. Young people, for example, are a population at risk. They are often prescribed a series of medications to treat ADHD, like Ritalin. That was not previously the case to the same extent. I am so surprised to see how extensive this problem has become today. They get prescriptions for the problem. Very young children become used to taking drugs very early in life. Behaviours develop and they get worse as people get older.
We live in a world where innovation is everywhere. Pharmaceutical companies are producing a lot of drugs. When you go to the doctor, you very often come away with a prescription. That is how care is provided now.
If we want to solve the problem at the source, we have to watch out for that. But it is impossible. I have trouble understanding it. We can try to understand the extent of the abuse, but I wonder whether the source of the problem is rather in the relationship between the doctor and the patient and the way in which care is provided these days. In that context, perhaps we should be concentrating on understanding the effect of the medications when they are used improperly. Then we can provide information and come to grips with the problem in much the same was as we did with tobacco or alcohol use.
I would like your reaction to that. Could you also tell me if you have information about treating young people with prescriptions? Is it all really necessary?
[English]
Ms. Robeson: With regard to young people, we do know from a misuse and abuse perspective that in one particular study 72 per cent of those kids access some of the drugs of abuse from their parents and home medicine cabinets. There is information that we can give to families about safe storage and disposal of their medication that can help in this regard.
When we look at issue of prescribing behaviour and consumer behaviour, we need to help inform consumers that when they go for a health issue perhaps the best course of action is not medication. There may be alternatives to the treatment of pain, for example, like physiotherapy, acupuncture and lots of other alternatives that are not pharmacologically based. Part of the strategy is about the education of prescribers and dispensers of medication — physicians, nurses, midwives, dentists and others — to help work with those folks around appropriate prescribing for appropriate circumstances.
It's a bigger issue in that some of this is system-focused. It takes only a few moments of a physician's time, or any other practitioner's time, to write a prescription. They are not necessarily funded for a thorough assessment and evaluation, nor in some circumstances do the appropriate resources exist in communities for specialist care or even alternatives to pharmacological support like physiotherapy, massage and others.
It's bigger than any one piece of that, and part of the benefit of the strategy is that no one piece alone is going to change this. There must be a comprehensive approach that looks not just at the prescribers but also the consumer demand for some of these drugs, because there's an awful lot of marketing out there that suggests if we take a pill it's a wonderful panacea. However, we need also to inform consumers of the risks that they can face for some of this.
[Translation]
Senator Bellemare: You said it exactly, it is systemic. We have a system in which doctors write prescriptions and people want their problem solved quickly. They want a miracle pill.
In some of the documents you sent us, you say that you cannot solve this problem without leadership and direction from the federal government. What can the federal government do to change the system?
[English]
Ms. Robeson: All roads to this solution don't lead to the federal government or to any one government or any type of government. The federal government can be part of the dialogue and sit at the table. They can provide funding for some of those initiatives.
As legislative barriers — for example, the privacy issue — come to the fore, this can be part of the discussions around what legislative changes can be made. There can be strengthening of the post-market surveillance system and the appropriate responses that can come into play there and the federal government can be part of that solution.
It's important that while there is a huge role for the government in this, it is not only a government role. I think we often look solely to government as the solution for all of this, but being part of the table and providing the funding in their legislative arm is a key to this strategy.
Senator Cordy: Dr. Ulan, you spoke about a lot of data collected, but it's not being compiled. Could you just expand on that?
Dr. Ulan: In Alberta, as part of CoOPDM, we did a literature review of the different prescription monitoring programs and surveillance systems available across Canada. We looked to the U.S. and internationally at what kind of systems were available, so we have some information as we begin to look at how to improve management of this in Alberta.
The second piece was looking at having interviews with key stakeholders in the province to look at what data they collect, whom they share that data with and what's done with that data. We looked at RCMP, municipal police, the College of Physicians & Surgeons, coroners' data, Alberta Health Services and First Nations. We realized there's actually a lot of really good data being collected. How each of our organizations utilizes that data is often not as robust as it could be and we don't have a mechanism in place to be able to share that data to get a bigger picture of what's happening provincially.
Putting that data together to get a better idea about what's happening on a global basis is very important, because it allows us to not only quantify the issue, to develop strategies to be able to deal with the issues that are identified, but it also allows us to track our progress. That kind of information is well positioned to influence policy and legislation. Unless there's good information available, it's very difficult to put together a compelling argument about why changes to the system need to occur.
Senator Cordy: Some of the information that provinces or organizations are gathering is who prescribes and how much medication a patient is taking. A few years ago I think most provinces were very much aware of the double doctoring, in some cases triple or quadruple doctoring, with people going from doctor to doctor and pharmacy to pharmacy. A lot of that has been dealt with, at least I hope so. What about individual doctors?
A friend of mine had surgery and got a prescription for 50 OxyContin pills and he was flabbergasted. Maybe the doctor felt this person would never abuse it, but there is no stereotype about who abuses prescription drugs. People have the stereotype in their minds about someone on the street and that's not the case, particularly with prescription drugs.
Do we have data in terms of to whom doctors are prescribing and the amounts? A single dose of 50 OxyContin seems to me to be extreme.
Dr. Ulan: I am happy to speak about that. That's my job, basically.
In Alberta we have a triplicate program and that's been in operation since 1986. It's a prescription monitoring program that initially was utilized to identify multi-doctoring. If a patient saw more than one practitioner in a certain period of time, a letter was sent to all the practitioners that were prescribing. Over the years we've got a huge database and several years ago — probably about six or seven years ago, at least — the college, in addition with other partners that operate the triplicate program, evaluated the way this data was being utilized and felt we could improve on that. We invested quite a bit of money into data mining so we could more appropriately identify high risk patients or physicians and interact.
My job at the college is to interact with physicians who are high prescribers and identified through our triplicate program or through the complaints process, or because of notification from a colleague or a family member. I've got data that I can present to the physician; I get some information about their practice and work with them from an educational perspective to improve their prescribing practice.
We have some broad education that we provide to all physicians in the province, but really the role of the college as medical regulator is to identify high-risk prescribing and to manage that. We tend to prefer a more educational approach because it's cheaper, quicker and less adversarial.
The complaints process is also utilized. Everyone's got the option to file a complaint against their physician and that's certainly an option, but if a problem has been identified, if at all possible, we'd like to work with a physician from an educational perspective and we can rein them in.
I agree, that is an important role of medical regulators to identify not only high-risk patients and inform the prescribers but, as importantly, to identify high-risk physicians.
Senator Cordy: Ms. Robeson, I thought you spoke very reasonably about the consumer demand for prescriptions from doctors when you go to a doctor's office and people aren't necessarily taking into account the side effects of prescription drugs. Certainly the reading I've been doing recently is that this is becoming a concern. There is a demand by the consumer for medications when in fact they're not going to help. If you've got a cold, liquids and rest, the old- fashioned remedies, are best, yet people are demanding prescriptions for things where prescriptions really will not do anything and every prescription, as we know, has some kind of side effect.
I think you spoke also very well about other non-prescription remedies, like massage, physiotherapy, whatever, that would be better and there are no side effects from those.
With an anti-drug strategy that would include prescription drugs — hopefully money for that will come in the budget — would you include education in that public awareness? Would that be a major part of the strategy in terms of prescription drugs? I'm not sure people necessarily take it as seriously as they should.
Ms. Robeson: I would say it must be an important part of the strategy for all of the reasons that you've just outlined. Part of what we've done so far is a scan across the country as to what public education campaigns and other initiatives exist around this issue and exactly what they're offering. Some are specific to safe storage and disposal, whereas others are about informed consumerism of health care services specific to the prescription drug issue.
We're in the process of analyzing that scan to see what is out there, but I think that that will then inform whether we need to develop something new, update what is existing, or spread out some good practice. Yes, it has to be part of the solution to this, because consumers are part of the issue.
Senator Segal: I just wanted to make sure that I understood your answer to Senator Seth. As I understood your answer with respect to the distribution of the problem across the population, if you had 10,000 people in Alberta or any other province who had a post-secondary education and were earning in the top 5 per cent of the income cohort and you had 10,000 people who were in the lowest economic cohort, with less education and living at the poverty line or beneath, the exposure to this problem and the uptake in terms of the misuse or abuse of drugs would be no different among those two groups Did I understand your answer correctly?
Dr. Ulan: The reality is that we don't have good data about that.
Senator Segal: So we don't know?
Dr. Ulan: So we don't know.
Senator Segal: The second question really follows on my colleague Senator Cordy's question.
If you think about 35 years ago, drinking and driving, for example, if you think about smoking, if you think about where we are socially and in terms of uptake and substantial progress in terms of percentages of the population not as deleteriously affected, as was the case in the past, as I recall those efforts, there were regulatory innovations, there were memoranda of enforcement for the police in terms of how they engaged, and there was a lot of advertising and public relations done aimed at all levels of the population. It wasn't just government. Government helped, but there were a lot of private sector, not-for-profit and other groups in the mix.
Is there anything, in your judgment, that we can learn from that that government — or you — could provide some assistance or leadership on to allow us to move this ball down the road a little faster than we appear to be able to do in the kind of clinical approach which, understandably, we are now focused on?
Mr. Eves: You make an excellent point, and that's actually written directly into the recommendations of the First Do No Harm strategy, to actually build on the success of other long-term campaigns to curb and change behaviour. And you're right; there are a lot of lessons there, too.
The thing we can't take out of the equation, though, is it will still take time to get us to where we want to be. Will it take as long as smoking or wearing seatbelts, as an example? Maybe not, because this issue does have an urgency to it that may not have been there for others, where we're seeing the effects, outcomes and the harms related to prescription drug misuse occurring in much more dramatic ways.
I expect the time will be less, but it will still take some time. We will be building on the success of other campaigns.
Ms. Robeson: We can learn from a lot of those strategies because of the multifaceted approach that turned out to work, that we finally discovered worked.
What's different about this issue, however, is that these are also medications that have legitimate therapeutic benefits. So, being able to ensure that people have access to appropriate treatment using these medications when it's appropriate and when other strategies have been tried and were either unsuccessful or required some supplementation, that's what's different about this strategy. It's a little more complex, but I still think we can learn a great deal from all the other approaches that can work.
We know from putting this strategy together and from the experts that came together that it requires legislation. It requires public education and other prevention initiatives. It requires education of all key stakeholders, including prescribers and dispensers. The ways in which other communities and organizations went about doing that kind of work in the area of tobacco, for example, will greatly inform this, but it's just slightly more complex. That's not to say it's insurmountable, but it's just a little bit different as well. We have to adapt some of that.
Senator Enverga: Thank you for the presentations. Many of my questions have been answered.
However, one of the underlying causes of prescription drug misuse in Canada is the lack of awareness. With regard to that, do you have any strategies for prescription drug use? Please comment on non-prescription drugs as well, such as over-the-counter drugs.
The Chair: Stay away from over-the-counter. We're looking entirely at prescription drugs here, so we don't want to get into the alternate medications.
Senator Enverga: That's fair.
Mr. Eves: Something that's also reflected in your report, which is better communication and more effective communication, labeling is a good example of how we can get consumers the information they need when they need it. There is also the black box or black triangle methodology, which can let people know right away that this is a medication that may have some considerations that you need to be aware of, right through to the monograph and standardization of the monograph and what information is shared at the time the prescription is dispensed.
I think those are things that would empower consumers and give them the knowledge they need to know there is a potential for risk when they're taking this substance and alerting them to that.
Dr. Ulan: I'd like to expand on that a little. I think the education piece is critical for all health providers, not just physicians and pharmacists, but nurses, dentists, even vets. In Alberta, our Triplicate program also tracks veterinary prescriptions, and we're finding that patients are using their pets and their veterinarian appointments as a way of obtaining prescription medications that they're misusing for their own purposes. So, education of all professionals, both undergraduate as part of their training but also post-graduate, is critical and it is not just for physicians.
I couldn't agree with you more; I think the education piece is under-utilized at this point.
Senator Enverga: From what I see, it's a lack of awareness because of misuse. However, awareness causes abuse, the way I hear it from you.
Have there been any lessons learned in this regard? Do we have to put some kind of label on prescription medication as we did for cigarettes, to make risks more visible so this will not happen again? What do you think about that?
Dr. Ulan: I think there are a couple of things. Once again, on your point about being able to identify when there's abuse, I think physicians and other treatment providers are poorly equipped and poorly educated to identify when a patient is running into problems, when they're using more than they should, or when they're starting to show some high-risk behaviours.
As physicians, we aren't very well trained at identifying those symptoms and what they might mean and how to deal with the management of that patient so you can set appropriate boundaries and tighten up your control, as well as learning about resources in your community and how to get help for that patient. I think that's a big piece that we aren't well trained on as either medical students or graduate physicians.
I agree with you. I think labeling is very important because, with respect to opioids, often family members and the people close to people who are using opioids underestimate the power and the potential risk of those medications. If they were more appropriately labeled, it would be easier to minimize some of the risky behaviours and perhaps encourage people to store those drugs more appropriately.
Ms. Robeson: That level of awareness would also empower consumers to actually ask the questions of whoever is prescribing their medication, so instead of asking for the medication, to be able to ask about dosage. Do they really need this number of pills? I could repeat a number of similar stories about the volume of pills dispensed, for example.
Maybe we also need to work with dispensers, that if a prescription comes in for 50 tablets, only a certain number are dispensed, with the option that people, if they continue to need that medication, come back for more. There are a number of changes that we could make without a whole lot of legislative requirements in that regard.
Consumer empowerment is one key piece. As Susan alluded to, in terms of recognizing signs and symptoms of substance abuse and other risk issues, the amount of education that prescribers — for example, physicians or nurses — get during their undergrad or in their postgraduate training around pain management is fairly low. In fact, of all the groups Susan mentioned, including veterinarians, veterinarians get the most of all of those groups in terms of pain management education as part of their training to be the health providers that they are.
Undergrad curriculum or pre-certification curriculum, as well as continuing education, are also part of that.
Senator Enverga: Just a quick question: Do we think we should criminalize some aspect of abusing drugs?
Dr. Ulan: It's very difficult to criminalize something that has appropriate indications. It's not like heroin or cocaine; these are medications that are important to be available for appropriate medical conditions. It's very difficult.
There are already mechanisms to criminalize trafficking, diversion and double doctoring, but to criminalize possession of something that is therapeutic would be quite challenging to do. However, the criminal activity using that as a substrate should be considered to be strengthened.
[Translation]
Senator Chaput: The national advisory council on prescription drug misuse recommends the establishment of a Canada-wide monitoring system. How can we establish a Canada-wide monitoring system when data and information is incomplete for Canada and for the various provinces, as you mentioned? How can we monitor the scope of the misuse and abuse if we do not have sufficient information? How can it be done? Are there other tools that can be used to measure it?
[English]
Dr. Ulan: What we do is start off with what we have access to as far as data goes.
In Alberta, we looked at starting to work with other stakeholders — looking at the government, the coroner and law enforcement — and putting the data we had together in a composite and aggregate way so that we aren't identifying any particular information about either a patient or a physician, but looking at an aggregate picture, just with what we have to get a better idea about what the current situation is. As things move on and as we start to develop better governance, legislative structure and work through some of the privacy issues, then we can kind of build on that.
You have to start off simple and take a look at what you have to begin with. It may not be perfect, but at least it's something, and it helps inform your process and gives you a baseline.
You can do that fairly simply using existing data, recognizing that it may not be applicable for all provinces, territories and all locations within a province, but at least it's something. Look at the data that's currently already available.
Ms. Robeson: One of the recommendations in the strategy is to put in place in each province and territory a prescription monitoring program similar to the one Susan is referring to. We're hoping to do that by having those jurisdictions that have those prescription monitoring programs work with other jurisdictions to enable them to understand how to set one up in their jurisdiction.
We're in the process of a review of the evidence — the research — on what are the core components of effective prescription monitoring programs to know what ought to be in place in each of these jurisdictions. Then we would work with those jurisdictions to identify, as Susan said, those data sets that already exist, identify gaps, and work together to try to address some of those gaps. Different jurisdictions may be collecting different data right now.
Over time, having those data sets able to communicate or be comparable to other data sets in order to understand the picture nationally does not necessarily mean that a national system is required. But it must be a system that's jurisdictionally based such that we can compare across jurisdictions, as well. That would be helpful.
[Translation]
Senator Chaput: So we are using what is already going well as a model from which to develop a Canada-wide system. Thank you; I am happy to hear that.
[English]
Senator Stewart Olsen: I have so many questions, because I'm not sure that I understand the scope of the problem.
I see in the data here you quote the billions of dollars and the loss, and yet you tell us that we're not collecting the data, and so we don't really know.
Perhaps, Dr. Ulan, you could tell me. You started with something simple. It's not that I'm questioning there's a problem; I'm questioning perhaps your suggested solutions.
Trying to put in place these massive monitoring programs is not going to deal with the problem that, if this is true, needs an urgent first start or first steps. I don't think we're going to get there quickly for sure.
I'd go back to the public relations campaign and going to the prescribers.
These are not brain-trust solutions; these are pretty simple, basic solutions that we can understand and work from there. Yes, I understand the need for collecting data, but I think that, if you're right and that this problem is so enormous, then maybe we should start with the simple. I just think it's a really difficult thing to ask. I'm not sure how it would be accomplished. I'm not sure I'd like my prescriptions across Canada in today's world. Do you know what I mean?
Ms. Robeson: The First Do No Harm strategy talks about those 58 recommendations. We're talking about various single recommendations across that strategy.
It's a 10-year roadmap because it can't happen overnight. We have identified short-term strategies that will help us get toward those recommendations, and some of that includes identifying what the core components of an appropriate process are and identifying what data exists jurisdictionally so we can understand what does exist and what we do need. But data alone are not the solution. We've done a scan of what educational offerings exist for prescribers and dispensers, so we know what exists now and how that relates to the most current evidence of what ought to be offered, and then we can look at the gaps to address that as well.
For example, we partnered with the Canadian Association of Chiefs of Police and Public Safety on National Prescription Drug Take Back Day as a way of informing the public of the importance of this particular issue and what they can do to address it in their own homes, like safe storage and disposal, for example, and providing them with a way of bringing unused medication back to prevent poisonings among children, diversion to the criminal system, as well as use and misuse by their own family members. That's in place already; in fact, the last one was last May and we're having another one this May.
There are things that can be put in place along the way, and what we're talking about in terms of a national system or even jurisdictional systems is not those short-term initials, but we can take steps along the way as part of a much more comprehensive approach to move toward recognizing it. It is a crisis and we need to act now, but the solutions for it in a comprehensive way are going to take time.
Senator Stewart Olsen: Do you have any data on the scope of the problem in Alberta? I ask specifically, because your program seems to be up and running. It is just to gain an idea of the scope of this.
Dr. Ulan: We've got data on each of the individual parts that touch on this issue, but we don't have a data set that looks at compiling it to get a better sense.
That's important because when we have initiatives and interventions that look at addressing one part of the issue, there are unintended consequences. I'll give you an example of this. The College of Physicians & Surgeons was approached by four different First Nations communities in Alberta asking for assistance with addressing high prescribing in their communities. We worked very closely with the physicians and changed the prescribing for opioids and sedatives quite substantially. Three things happened.
First, I knew the work we do could influence physician prescribing. Those patients ended up going to different physicians where they could obtain medications from different doctors who were less strict about how they were prescribing.
Another thing happened that changed my approach. I got a call from a provincial director of women's shelters. She contacted me to say, ``I understand that you've been working with the doctors in this community. I have to let you know that the number of women showing up at our shelter who have been beaten by their partners and family members has gone up substantially. There is more alcohol and more violence against women. I just want you to be aware of that because we think it is probably tied in with your prescribing intervention.''
That's where I think the surveillance is important. If you are going to make a change to one aspect of the puzzle, you need to be prepared for potential unintended consequences. Look at identifying when something is changing and happening, but more importantly perhaps anticipate that there might be some unintended consequences and look at how to address them beforehand. That's where the importance of surveillance comes in.
The other important piece is to look at how to change the whole system, not just one part of it.
Senator Stewart Olsen: I see. Things have changed a lot. There used to be much more scrutiny over the number of prescriptions issued. People would question that. In emergency rooms, if a doctor said, ``Give them a dozen pills to go home,'' a nurse would say, ``I think two might see them through.'' Things have changed a huge amount, and I'm not sure where you go to bring it back to where there's more oversight, responsible prescribing and handing out of these drugs. I'm not sure.
Dr. Ulan: It's a multi-pronged approach. We also have to look at the role of the pharmaceutical industry. I was in practice when the chronic pain management was being marketed to physicians. Previously, people on a prescription higher-potency opioid usually suffered from a malignancy or severe trauma. The chronic pain world and the pharmaceutical industry began to capitalize on that and marketed to physicians that a more liberal use of these medications was appropriate and supported by evidence. That was a big driver.
We underestimated the power of the pharmaceutical industry. It has made us review how medications are approved and monitored and how physicians are receiving their education. Receiving education from pharmaceutical representatives is not the most appropriate way to get educated. Their motivation is different. It's financial and to sell a drug. That has made a dramatic change in many institutions in terms of how research is done and medications are marketed. That was a bit of a tipping point.
The Chair: At this point I want to come in and pick up on some of these things, including your comments to Senator Stewart Olsen.
Over a number of studies, we have been dealing with the issue of the lack of electronic information in this country with regard to the medical system as a whole. In some areas, many of us find it inexcusable that we are not where we should be today in these areas.
Senator Stewart Olsen also mentioned the issue that she didn't want her information going elsewhere. If Google can tell you what suit you're going to buy next week, what it's going to look like and where you're likely to buy it without anyone else in the world knowing, we can deal with a system that monitors our prescriptions in this country while protecting the individual. What we really need in the data are the things you have indicated: age range, dosage, indication and frequency. There needs to be no individual identifier related to that kind of information.
There is the issue of pharmaceutical companies in this situation. We hear of physicians, and in our neck of the woods in the Maritimes we read about in the newspapers regularly, prescribing 50 to 60 OxyContin pills in a single prescription. I don't think there is any blame on an external agency because somebody wrote the prescription for those pills.
It seems that in this area we are dealing with today it is fairly well understood what dosage and frequency will likely to lead to addiction. We understand that it ranges, that there are sub-sets of the population and that nothing is absolute. We know that within certain large parameters you can be reasonably concerned that a lengthy duration of a certain level dose is likely to have an impact in terms of long-term dependency.
You have spent a lot of time on the fact that these opioids get out and are used as an illicit drug; but in actual fact many people get hooked on these drugs through prescriptions that are written on an ongoing basis. I suspect that many people in this room know people in that category. There is not only the issue of dealing with the illicit use of prescriptions, but also the unintended consequence of what normally would be seen as a legitimate prescription leading to addiction. You have made a very strong point today that in order to develop educational approaches, guidelines and so on — all of the non-threatening forms of intervention — you need information.
That comes back to the need for electronic databases. Data is valuable in these areas. The one link that we have seen come up in these areas over and over is the pharmacist, not in terms of authorizing or whatever, but in terms of being aware of what is going out and often very aware of the nature of the patient they are filling the prescription for. Pharmacists tend to be much more practically aware of the total number of prescriptions that the individual is getting and the variety, et cetera.
In our previous reports, we strongly urged that Canada move much more deliberately toward an understanding of what is going on and, at the other end of the spectrum, give the electronic health record to patients so they can take it from jurisdiction to jurisdiction because people move around. Some jurisdictions are further ahead in electronic health records than others. I suppose it's an electronic medical record, because it is a record in a doctor's office and not a health record, which is a record across the country. That is ultimately the most valuable one. There are many examples of medical records, but not so many of the total health record. We have been pushing very hard in these areas.
I want to make the point that the addictive nature of these drugs isn't just a problem for those who are already addicted and seeking. It's also a problem for people who have no dependency and didn't want it at the outset but, because of the duration and frequency of their prescriptions, ended up developing a dependency. If suitable data were collected, it would not be unreasonable to expect that guidance could be given to physicians and pharmacists with regard to the number of pills of a certain dosage considered reasonable to cover the first prescription in most circumstances.
I want you to comment on that in a minute, but I want to go on with some other issues.
You have referred, as well, to collecting data, and I appreciate that, in the cases you are dealing with and the issues you are looking at, you're looking at sources of data, as you have indicated, that are different than the ones we have normally been looking at. You're looking at police records, coroner's reports, and so on, because you're looking at the impact out there, whereas we have been so far largely concentrating on the prescription end of things in that area. What I'm saying here is that I appreciate the fact that you say it is more complex for you than it seems because of the number of sources that you want to get information from.
Let us suppose that there was a reasonable system in each province for the collection of a reasonable amount of the useful data. The value of that data is the data in total with regard to the national behaviour because it moves, it changes. What organization would you say, or could you say, would be the best to collect that data and then make it available to the other organizations that need and use that data? Is it Health Canada? Is it one of your organizations? You can't just say we need to collect data. Data doesn't collect on its own and it doesn't get distributed on its own.
We are a balkanized country, due to our federal-provincial structure. We can't change that, but we should be able to identify a mechanism that is logical and reasonable, where the data could be collected nationally and then remade available to all of the organizations that use it.
I guess I'd like you to comment on that issue and then just speculate a bit on the earlier issue I raised. Do you think it will be possible, if sufficient data is collected, to be able to give far better advice to physicians and pharmacists — and I say pharmacists because they actually could be a gatekeeper with regard to this — with regard to pharmaceuticals that are known to have significant, long-term effects? We're talking addiction here specifically, so we will stick to addiction in this case.
Would you any of you like to comment?
Dr. Ulan: I can start. In Alberta, when we began to look at where it would be most important to have data surveillance housed, we felt it should be with Alberta Health because they were partners with the triplicate program and had access to that data. They were also the payers and funders for many of the data sets that would be appropriate to collect. In addition to that, they also had the authority to mandate the requirement to submit data, so it won't be an optional thing.
In Alberta we felt it would most likely reside in Alberta Health. In looking at the governance structure, they found that within Alberta Health there were several departments that also had bits of information and data that they actually weren't compiling and integrating within their own organization. That's what we felt would be most appropriate. That may be different in different provinces; that may be different from a national surveillance system. Within our province, it made most sense to look at Alberta Health.
With respect to your other questions about the prescribing data, I'm not sure I completely agree that there is a specific quantity or dose above which somebody should not dispense or prescribe. That data is actually not clear. There is a tremendous variation in prescribing appropriate doses and it is not necessarily based on diagnosis, or age, or gender, or anything like that.
Medications, and particularly the risk that comes with opioids, is not related necessarily to the quantity or the dose; it's often the whole context of the rest of the patient. Are they somebody who consumes alcohol? What other medications are they on? What's their underlying condition that the medication is being prescribed for? What's the function of their liver and kidneys? There isn't a magic quantity or dose that we can apply. I wish there was. It would make my job tremendously easier, but that's not the reality.
There have been times when I have reviewed the prescribing and clinical records for a patient that seemed to be an unusually high quality and there are absolutely no problems; it was quite appropriate. This person had an unusually high tolerance and there was no risk of harm coming from it or indication that they might be at risk.
The other thing that is difficult to determine is who is going to run into problems with medication. You can take 10 different people, put them on the same medication, the same dose, and you are going to have 10 different responses. Being able to identify who is the most likely to run into problems, either addiction or dependence or overdose, is a million-dollar question. I think there does need to be more information so that we can better proactively identify who is at highest risk. We have some crude tools looking at previous medical history, family history of dependence, and whether or not there is any psychiatric history. We have some general measures, but those tests haven't been well validated to ensure they are clinically appropriate. However, it gives you an idea that if you have a patient in front of you and they come from a family history of alcoholism, they struggled with an abuse issue — either alcohol or prescription drugs — previously you better be very careful with that patient and how you dispense and prescribe those medications, because they may be more likely than somebody else without a family history to run into problems.
There isn't any magic to it. I truly wish there was. It may be, over time, that we determine that or have ways of better identifying risk, but right now it's quite crude.
The Chair: That's very helpful. Would you either of you like to come in on this?
Mr. Eves: On the issue of where the data would be appropriately housed — and this is more a Canadian thing than anything — but I would defer to jurisdictional government as well as potentially how that connects to a national level through Health Canada. That's probably based on my experience.
If I look south of the border to the U.S., we had presentations during the course of the development of our strategy from two different groups, the RADARS group and the inflection group, which NAVIPPRO is part of. Data there is held privately and it is funded through third-party arrangements through pharma industry. It has been very effective in collecting data.
To the second part of your question, what can it tell us? It can tell us, for instance through the inflection group, why people are coming into treatment and how they are acquiring the drugs they are misusing in the first place. They can be very accurate, right down to the fact that they can tell you how much it costs on the street corner in New York City between Third and Main. There is some new, amazing, nuanced data that does require significant resources, but I'm not sure we could necessarily pull those resources from our jurisdictional government, our federal government. I think there are advantages to both.
Ms. Robeson: No such system currently exists in Canada, although, as you can imagine, they are interested in making headway here.
We do also have organizations like CIHI, the Canadian Institutes for Health Information, who might be a resource to compile some of that data, but currently this is not part of the issue that they're looking at. There may be some combination, but, whatever it is, I don't think it exists just yet here.
The Chair: I think we can probably agree with you. I fully expected you would say the provinces are collecting and doing a lot in that regard, but at 36 million we are smaller than some states, so it would be useful perhaps to have that. Thank you very much for that.
Senator Seidman: I think that what we've learned from you today, and what we've heard from previous witnesses, is that there is no question that prescribing practices are pretty critical in this. There's no question that all of us know, when we turn on the television set every day, that at least every second commercial is a commercial for a prescription drug and it says, ``Ask your doctor if it's right for you.'' I can almost hear that echoing in my ears over and over again.
I'd like to know if, in your experience, and in the studies that you have done, a monitoring system has any effect on prescribing practices of physicians.
Dr. Ulan: I can speak to that from Alberta and, as I alluded to earlier, we know we can influence physician prescribing both individually as well as more broadly. What we aren't able to do as medical regulators is influence patient behaviour.
In several of the initiatives that we've undertaken in Alberta, we've done started off with broad-based education to the physician community as a whole and then after a period of time in monitoring whatever indicator we're looking at, we do a targeted intervention. We would look at the data and identify the outlying prescribers and then work more comprehensively and intensely with those specific prescribers. It is very effective. I can influence prescribing quite significantly and quickly.
The other side of that is that I can't influence what the patients do. So, as I said, with other First Nations communities — and we have seen this replicated in other populations we have worked with in the province — patients tend to drift to either the next community or another prescriber that they know is easier to obtain medications from.
It's a matter of once again going back to the multi-pronged approach. We need to educate the public, have better access to pain and addiction treatment, better education of prescribers. We need to enable physicians and pharmacists to have real-time access to that patient's data so that if this patient goes to one physician and the physician says, ``No, I'm sorry, I'm not going to give you that medication,'' and they go to another physician down the street, that doctor can look — in our province, it's called Netcare — and say, ``You just got that prescription from somebody yesterday. I'm not going to prescribe that medication for you.'' It's a multi-pronged approach and changing prescribing behaviour is an important piece of it, but by itself it's not going to change it in a comprehensive way.
Senator Seidman: I will take that at face value for now, but I'll present to you an example we heard about seniors, polypharmacy and growing concerns about a different approach to prescribing medications to seniors, for example a regular review of the numbers of medications they are taking. They are consistently, with many chronic diseases, prescribed many medications, perhaps by different physicians, specialists, with no one really managing. So they just have medications added to medications.
The other thing that has been proposed is de-prescribing because once a medication is prescribed, it's never taken away. I'm referring to physician prescribing practices and whether a monitoring system would have an impact on that or if it is just a cultural change for physicians.
Dr. Ulan: I think it's probably both because with prescription monitoring programs we are only monitoring controlled medications with abuse potential. It is opioids and, depending on the province, benzodiazepines, some of the stimulants. We are not looking at antidepressants, anti-psychotics, antibiotics, other medications. There must be a more comprehensive plan because that requires clinical judgment. It is possible create to systems.
In one of hospitals I used to work at, they had funding to do a project several years ago where there was a review from an independent group of pharmacists that reviewed the medications being prescribed for a particular patient. They had access to all the clinical data so they could work with the physician to look at how to decrease the prescribing and the risk of drug interactions. Those are clinical decisions as well, so that piece has to be part of it, and that takes time and money. But I think there are certainly solutions to it.
Senator Seidman: Now we get into what you started with and the complication of defining what we are dealing with in terms of abuse or misuse.
Dr. Ulan: And polypharmacy doesn't mean abuse or misuse.
Senator Seidman: Exactly.
Senator Bellemare: When you say ``we in Alberta,'' who are you talking about? Are you talking about a provincial agency or CoOPDM?
Dr. Ulan: I'm talking about my role as a physician, with Physician Prescribing Practices of the College of Physicians and Surgeons, so it's more of the regulatory body role that I'm bring to this conversation. We do partner with other organizations. Our prescription monitoring program is operated by the college on behalf of partners including Alberta Health, dentists, vets, the Yukon Medical Association, and pharmacists. We have interventions. Some of the interventions are solely with physicians; the others are done in conjunction with the Alberta College of Pharmacists. When we identify a high-risk patient, we communicate with the physicians in my organization and the Alberta College of Pharmacists will communicate with the pharmacists in their organization.
Some of the other programs that we are talking about are looking at data surveillance and pulling data together from different sources. That's more referable to the Coalition on Prescription Drug Misuse because at that table we have law enforcement, Alberta Health, pharmacists, municipal police services — some of the broader programs that involve multiple stakeholders. That would be with the perspective of CoOPDM.
Senator Bellemare: Who financed the coalition?
Dr. Ulan: The coalition was funded initially by an AADAC, which is a government arm for addiction and mental health services. They were folded as Alberta Health Services went through some restructuring. We have been operating through an initial seed grant from 2008, basically a government grant. We are in the process of applying for another grant to keep operating.
Senator Bellemare: Do you think it could be that the body will monitor and do the surveillance you hope for?
Dr. Ulan: I don't think we have the authority to do that. We represent many different perspectives and I don't think we have that legislative authority to be in the position to do that. I'm not sure it's appropriate for us to house it within our group, but we would certainly like to be a part of and a voice as part of an advisory body on how that looks.
Senator Bellemare: Even though you have provincial people on the board, you don't think that it could work?
Dr. Ulan: When you are looking at data, where data is housed, who has access to it and responsibility for it, there are a lot of other issues that have to be addressed and we don't have a standalone body that is embedded in legislation and with privacy regulation around it. We each operate under different privacy legislation, so I don't think it would be appropriate for us to do it.
The Chair: Thank you all very much. This has been tremendously interesting.
One of your answers to my question, when you talked about knowing what individual patients are all about in terms of their character and so on, and moving us into the personalized medicine issue that we have been dealing with in other studies, but that changes the whole approach to medicine, doesn't it? Particularly when you start at the general practitioner and the time they have available, the payments schedules and so on, it starts looking at major structural changes as we move forward in those areas. But it is critical, as you say, Dr. Ulan, in terms of understanding how any given prescription may operate in any individual.
Thank you for the thoroughness and clarity of your answers and, to my colleagues, for the breadth of their questions. With that, I declare the meeting adjourned.
(The committee adjourned.)