Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 10 - Evidence - April 2, 2014
OTTAWA, Wednesday, April 2, 2014
The Standing Senate Committee on Social Affairs, Science and Technology met this day, at 4:50 p.m., to study Bill S-213, An Act respecting Lincoln Alexander Day, and to give clause-by-clause consideration to the bill.
The committee also continued its study on prescription pharmaceuticals in Canada.
TOPIC: The nature of unintended consequences in the use of prescription pharmaceuticals.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I will start the meeting by asking my colleagues to introduce themselves.
Senator Eggleton: Art Eggleton, Toronto, deputy chair of the committee.
Senator Merchant: Pana Merchant, Saskatchewan.
Senator Stewart Olsen: Carolyn Stewart Olsen, New Brunswick.
Senator Enverga: Senator Enverga from Ontario.
Senator Seth: Asha Seth, Toronto.
Senator Nancy Ruth: Senator Nancy Ruth, Toronto.
The Chair: Thank you, colleagues. I'm going to explain that we have agreement of the steering committee to be able to accommodate our two sessions today, given that some of the witnesses on the next panel have come from some distance. I appreciate my colleagues on the steering committee agreeing to the following process: This first session will last 30 minutes. We hope the discussion part will finish in approximately 15 minutes. We will then go into clause by clause, winding up with a total of 30 minutes. We will then change over quickly and go into the second session, which we hope will end at 6:15 but we have agreed that it might possibly extend to 6:30.
Does everybody understand the procedure?
Hon. Senators: Yes.
The Chair: So as not to delay any further, I want to welcome our guests to our first session here, which is on Bill S- 213. Our witnesses are the sponsor of the bill, Senator Meredith, and we have Rubin Friedman, Spokesperson and Member of the Board for the Canadian Race Relations Foundation.
At the end of presentations, I will open things up quickly for questions, and we will proceed.
Hon. Don Meredith, sponsor of the bill: Honourable senators, I am pleased to be here this afternoon to speak about a true Canadian hero, the Honourable Lincoln MacCauley Alexander. He is one the most outstanding, accomplished citizens of our time. He loved this country. And with hard work and strength of character, he rose above prejudice, embraced public education, committed himself to service and became a master of his own destiny. Lincoln Alexander is known to most of you, a golden product of Ontario. He's made history as the first African-Canadian elected to the Parliament of Canada, the first African-Canadian federal cabinet minister, and the twenty-fourth lieutenant-governor of the Province of Ontario — the first African-Canadian viceregal representative in Canada. He's a role model for me.
So it is with great appreciation that I appear before you with the hope of earning your support for the celebratory Bill S-213 that recognizes January 21, the day of his birth, as Lincoln Alexander Day across this magnificent country of ours, which we love. I ask you not only for your support but also for your good partnership in moving forward this bill that offers due recognition, not only to the outstanding example of a life of service, but equally to the greater dominion of aspiration and promise that Canada offers all citizens. The bill is good legislation, not only because of the great Canadian after which it is named, but also because it is grounded in the core themes that already empower Canada: civic duty, education and diversity.
First, Lincoln Alexander Day would offer us an opportunity to reflect and strengthen our commitment to civic duty, giving selflessly of ourselves and supporting our communities, friends and family. Second, it would offer us an opportunity to reflect on our commitment to education and lifelong learning. Third, Lincoln Alexander Day would offer us an opportunity to reflect on our own commitment to a diverse Canada.
Before I expand on these important themes in the brief time I have with you, it is important that, on this particular occasion, I remind honourable colleagues that Lincoln Alexander Day would be good for Canada. Like some of you here, I had the privilege of meeting Mr. Alexander on several occasions.
His was an endearing Canadian story. He was born in Toronto to hardworking and religious West Indian immigrants. When I first met him as a young man, he left me with a lingering sense of inspiration about the good to which we can aspire as individuals. I was inspired by his embrace of the value of good education and the grateful manner in which he excelled at all levels. I was inspired by his courageous response to a call to serve during World War II. He was well decorated by the Royal Canadian Air Force. I was inspired by his pursuit of a law career and how he overcame racism to graduate among the top performers of the prestigious Osgoode Hall Law School. He later became Queen's counsel. Many Canadians, regardless of race, were inspired by his service, including as Canada's first Black member of Parliament; first Black cabinet minister; and the twenty-fourth Lieutenant-Governor of Ontario, the first member of a visible minority to hold this position.
Honourable senators, strength and resilience were the hallmark of his approach, but in true Canadian style, he took on otherwise sensitive circumstances with measured grace and quiet strength.
What would Lincoln Alexander Day mean to Canada? How would we as a nation benefit — mothers and fathers, civic and community leaders and stakeholders, seniors and youth, military servicemen and -woman, public servants and volunteers, and everyone in between?
What would he mean to us as we strive to build a more perfect Confederation? First, the day would offer us an opportunity to reflect on our own commitment to public service. Lincoln Alexander believed in public service. Most of you will agree it is an essential part of our evolving and maturing democracy. Through this lifelong contribution to community in so many different roles — from grassroots engagement to military service to the highest office in the land — Lincoln Alexander set values as the standard of good citizenship.
Today, there are millions across this great country, from coast to coast, whether paid or volunteering, who walk in his example and are making a difference. Lincoln Alexander Day would help to celebrate and recognize all who give of themselves.
Second, Lincoln Alexander Day would offer us an opportunity to reflect on our own commitment to education. Lincoln Alexander understood the strong and direct relationship between investment in education and educational attainment and the economic growth, especially in the age of a global economy. His mother continuously exhorted him about the value and power of a good education, and with the same name with which he later titled his memoir, she would say to him ``Go to school, you're a little Black boy.''
Lincoln Alexander Day would allow each of us to reflect on our own commitment to education. Every child deserves the best and equal access to opportunity, and education offers that. As a part of the education will be the story of Lincoln Alexander: How, through his value of the public education system, he rose to a place where he could make a difference for all Canadians.
Honourable senators will agree it will be more enlightening to understand Canada's history when students learn about the service of this great Canadian hero in their schools. Students will learn not only about his passion for service to his country but will see the example that, with hard work, good character, strength and purpose, anything is truly possible in this country.
Honourable senators, Lincoln Alexander Day would offer us an opportunity to reflect on our commitment to diversity. Lincoln understood the strength and value of Canada, where all citizens sense if they put in hard work they will be assured fair access to work and opportunity to contribute to Canada. Lincoln Alexander's profound respect for our country was evident in his everyday life, a role model for young people of every colour and race. All through his lifetime, he noted the notion of equality and evolved for the better. He bore witness to the evolution of the forceful collection of laws and policies from the 1982 Charter to the Canadian Human Rights Act, all working to ensure equality under the law. Lincoln Alexander Day would give us another reason to highlight Canada as one of the best countries in the world, recognizing that Canada is still progressing as a nation but interested in rallying around that which unites us rather than which divides us.
Honourable senators, it is with these comments that I humbly ask for your support as we move this bill forward to honour a man who will be recognized in history in this country. The United States has Martin Luther King Day. You would be lending your support to history in this country by allowing this bill to go forth from this committee back to the chamber.
Rubin Friedman, Spokesperson and Member of the Board, Canadian Race Relations Foundation: Senator Meredith, I estimated correctly that you would do a lot of the heavy lifting, and I wanted to add our brief comments to what you have said.
Honourable senators, on behalf of the Canadian Race Relations Foundation, I thank you for the opportunity to speak in support of this important initiative to recognize and honour the contributions of Colonel the Honourable Lincoln MacCauley Alexander to his country. He was a man of many firsts, which have already been enumerated by the Honourable Don Meredith and others. Many of these have to do with being the first Black person serving in significant capacities, such as member of Parliament, federal cabinet minister, Chair of the Workers' Compensation Board and Lieutenant-Governor of Ontario. He always characteristically emphasized his intention to serve all Canadians, whatever issues landed on his desk. He did so with distinction in every position he held, from his service in the Armed Forces to his career as a lawyer to his record of being the longest-serving Chancellor of the University of Guelph.
Lincoln Alexander received many honours and accolades throughout his life including, in 2003, the inaugural Canadian Race Relations Foundation Lifetime Achievement Award for his contribution to the advancement of harmonious race relations in Canada. Indeed, it was in recognition of his achievements in this area that he was appointed the first Chair of the Canadian Race Relations Foundation from 1996 to 2003. He led his board in establishing the first governance structures, goals and strategies of the foundation, with a view to promoting a Canada wherein all can participate fully without discrimination based on race, religion or ethnicity.
He was a proud Canadian, yet one who from his own experience as a Black person growing up in Ontario was keenly aware of the many discriminatory barriers that had to be faced and fractured in his lifetime for him to achieve what he did. His pride in an ever-expanding and ever-changing Canada full of diversity never left him blind either to the racism of the past or the ongoing need to address issues related to race and ethnicity as they arose.
He ensured that the foundation was at the forefront in raising awareness in many sectors of the key issues that we all had to deal with as Canadians. Under his leadership, the foundation called together chiefs of police to address the thorny question of profiling and worked diligently to promote the inclusion in schools and centres of higher learning the need to deal with matters of race, religion and ethnic origin. The foundation undertook initiatives to promote more representation of visible and other minorities in all professions and fields of endeavour to more accurately reflect Canada's population. Above all, he was kind and principled. He had the capacity to reach out to both ordinary Canadians and those in positions of power to change things. He stressed that human dignity and opportunity for all were in the interests of the country and that it would advance our economic, cultural and social well-being.
The foundation today is proud to continue and to enhance the tradition of Lincoln Alexander in bringing Canadians together to explore and find solutions to ongoing and newly developing barriers to participation and contribution to the life of our country. We continue to hold round tables across the country on new and emerging issues. We gather data on and support studies regarding the status of race relations in Canada. Through our sharing of resources and programs, we promote awareness of what can be done both individually and collectively to combat racism and hatred of any kind. We facilitate the meeting of diverse communities and interests to build a common approach to a strengthened and responsible sense of Canadian citizenship with its inherent rights and obligations. We do all of this in support of one overarching goal: to build a stronger Canada where racism and racial discrimination have no place.
The Canadian Race Relations Foundation wholeheartedly supports the subject and spirit of this bill: the creation of Lincoln Alexander Day, a well-deserved recognition of Colonel the Honourable Lincoln Alexander, because we share your recognition of his myriad achievements and the vital role he played as a national icon, pioneer, leader and inspiration to others in achieving the overall goal.
The Chair: We will go quickly to questions.
Senator Merchant: I thank the committee for allowing me to take part in this part of its deliberations. I want to congratulate Senator Meredith, welcome Mr. Friedman and say how supportive I am of this bill because I served with Lincoln Alexander in the CRRF from 1996 to 2002. Everything that you said about him is absolutely correct.
He always spoke about champions when we were together in the foundation. He always thought the champions were the people that we look up to and try to emulate and that in doing so we were building a stronger Canada and helping our people to aspire to excellence. He was a great champion. For that reason, I add my words of support and say that Lincoln Alexander Day is a terrific idea. It will promote public service and excellence and for that I am very pleased.
Senator Eggleton: Mr. Friedman said that Lincoln Alexander was a man of many firsts, and certainly that's true. He was the first Black man in many areas of the Parliament of Canada and in many institutions of governance in this country. I don't think it's important enough just to be first. It's what you do when you are first that's important. He took every position that he held and used it to the maximum benefit of the people of this country. He continually did that through his many years in these very different positions. He did it with great humour, warmth and kindness and shared that with all the people that he met.
I knew him for many years. In particular, he and I served in many different community functions in and around Toronto when he was the Lieutenant-Governor of Ontario and I was the Mayor of Toronto. Beyond that, we developed a friendship that lasted for the rest of his life. I'm very proud and pleased that I had the opportunity to know Linc, as his friends called him, and that I had the opportunity to know and work with him in many respects and to see the kind of impact he had on many people in this country. He made his mark in this country, and I think it's deserving of recognition.
The Chair: We will now move to clause-by-clause consideration. I will let you know in advance that there are two amendments that will be introduced at the appropriate time during clause-by-clause discussion. Those amendments are being circulated now in both official languages. You will have them in a few seconds.
Senator Eggleton: The sponsor is aware of these amendments?
The Chair: Yes. These have been fully understood by the sponsor and, it was my understanding, agreed to by the sponsor of the bill.
Senator Meredith: Yes.
The Chair: Honourable colleagues, we will now move into clause-by-clause consideration of Bill S-213, An Act respecting Lincoln Alexander Day.
Is it agreed that the committee proceed to clause-by-clause consideration of Bill S-213, An Act respecting Lincoln Alexander Day?
Hon. Senators: Agreed.
The Chair: Thank you, colleagues. It's agreed.
Shall the title stand postponed? Is that agreed?
Hon. Senators: Agreed.
The Chair: Thank you. Shall the preamble stand postponed?
Hon. Senators: Agreed.
The Chair: Shall the short title in clause 1 stand postponed?
Hon. Senators: Agreed.
The Chair: Thank you very much.
Shall clause 2 carry? It's at this point, I believe, the first amendment is to be brought in. Senator Stewart Olsen?
Senator Stewart Olsen: Yes, I move that Bill S-213, in clause 2, be amended by replacing in the French version, line 1, on page 2, with the following:
[Translation]
``Le 21 janvier est, dans tout le Canada,''.
[English]
The Chair: Essentially, it is correcting the date on that section to bring the two in line. It is a technical amendment.
Colleagues, is it your pleasure to adopt that amendment?
Hon. Senators: Agreed.
The Chair: Thank you very much. The motion to amend is accepted and I shall now ask again, shall clause 2 carry?
Hon. Senators: Agreed.
The Chair: Clause 2 is carried, as amended. That's understood.
Shall clause 3 carry?
Hon. Senators: Agreed.
The Chair: Carried.
Now we are back to the deferred clauses. Shall clause 1 carry?
Hon. Senators: Agreed.
The Chair: Carried. Thank you very much.
Next is the preamble. It's my understanding that the next amendment occurs in the preamble.
Senator Stewart Olsen: I move that the preamble of Bill S-213 be amended by adding after line 13, on page 1, the following:
Whereas Colonel The Honourable Lincoln MacCauley Alexander was the first Black Canadian to be elected as Member of Parliament in the House of Commons, to be appointed as Cabinet Minister and to be appointed as Lieutenant Governor.
The Chair: That is moved by Senator Stewart Olsen. Is that amendment agreed?
Hon. Senators: Agreed.
The Chair: Thank you very much. I will then ask you, shall the preamble carry?
Hon. Senators: Agreed.
The Chair: Carried.
Shall the title carry?
Hon. Senators: Agreed.
The Chair: Carried.
Shall the bill carry?
Hon. Senators: Agreed.
The Chair: Carried. Thank you.
Is it agreed that I report this bill, as amended, to the Senate?
Hon. Senators: Agreed.
The Chair: That's agreed. Thank you very much, colleagues. That completes our work. I congratulate the sponsor on this. We will get it into the Senate as soon as possible — hopefully tomorrow, but as soon as possible. Mr. Friedman, we thank you very much for having joined us today.
Senator Merchant: Mr. Chair, I would like to have it noted that I am now going to leave the committee. I thank you all very much.
The Chair: Thank you very much, Senator Merchant.
Senator Meredith: I want to thank honourable colleagues and senators for making history in moving this bill forward. I thank you for that support. I'm confident, senators, that the family will be ecstatic in terms of this seeing this come to fruition. Again, thank you for your consideration of this bill.
The Chair: Thank you very much.
I now want to welcome our witnesses for our second session this afternoon. I remind honourable senators that we are dealing with prescription pharmaceuticals in Canada. This is the fourth part of a four-part series on this subject and we are dealing with the nature of unintended consequences.
Today we have representatives before us who may speak to several of the issues that we have on our agenda in this particular section of our study. By initial agreement, I'm going to invite Mr. Sholom Glouberman, President of Patients Canada, to present first.
Sholom Glouberman, President, Patients Canada: Thank you very much for inviting me; I appreciate being here. I learned a lot from the last session that you had. Watching it was really interesting and I appreciate of the civility of all of this.
I think the most important thing about prescription drugs is that the morbidity of the Canadian population has changed dramatically over the last 50 years. When we started to have publicly funded health care in Canada, most people were dying of acute diseases, sudden diseases, heart attacks, if you will remember, and extreme cases of cancer. We now have the situation where most people don't die of acute illnesses; they die over a long period of time of chronic disease. As a result of that, people are medicated for long periods of time, and we have a huge use of medication.
To a certain extent, the result of this and trying to catch many of these chronic conditions early has resulted in earlier and earlier medication of people. You have pre-diabetics who are medicated and people with hypertension who are medicated early and we're discovering that there is quite a lot of overmedication of the population and not medication that really is necessary at times. In Canada, as a result of this, we are the second most medicated population in the world. The United States is the first and we come second. We pay an average of over $900 a person a year on drugs. That probably is the biggest issue. It's a very difficult issue to figure out how to properly medicate the population and to make sure that people's chronic conditions can be dealt with without medication; for example, by changing diet and increasing exercise, or changing some aspects of lifestyle.
The other big consequence of prescription drugs that is unintended is the overuse of drugs prescribed to people who at times don't need them. People become addicted to opioids, for example, and the whole issue of opioid addiction is one that affects large parts of our population, especially people from the native community. That issue is one we have to bring to the attention of the public and make sure that we understand how the abuse of prescription drugs can be better controlled.
To a certain extent, that can be done by knowing who takes them, who prescribes them and having that information spread more widely. We still haven't been able to do that in Canada, because the way in which we deal with our electronic medical records and electronic prescription records is that they aren't widely shared, and they aren't shared amongst the various prescribers of drugs.
The third unintended consequence in terms of over-prescription is the way in which our health care system is structured. Patients very often don't know exactly what drugs they are given and why they are given those drugs. They don't understand and aren't given to understand what some of the consequences are of taking drugs over a long period of time — at times unnecessarily.
It has to do with the way in which doctors are paid, to a certain extent. Doctors are paid per visit and, as a result of that, they want to try to get everything done within the time of that visit. One of the easiest ways to do that is to prescribe drugs. So one of the things that can sometimes happen as a consequence is a kind of collusion between the doctor and the patient to over-prescribe and to prescribe drugs that may not be necessary at the time.
That's probably enough to get us going.
The Chair: I now want to welcome Colleen Fuller, Chair of PharmaWatch, who is appearing before us via teleconference. We very much appreciate your willingness to join us today, Ms. Fuller. Please go ahead.
Colleen Fuller, Chair, PharmaWatch Canada: Thank you to the committee. I heard quite a bit from colleagues about the work you're doing, and it's very impressive. I'm very glad that PharmaWatch is being given an opportunity to assist in your deliberations.
I'm going to address the important role that reporting plays in our understanding and knowledge of unintended consequences. Adverse drug reactions come in many shapes and sizes; some are mild, short-term and actually acceptable consequences when weighed against the benefits the person might derive from the use of a prescription drug. Some last for a brief moment, but others can persist for many years.
Often the experience people have with adverse side effects is confusing, mainly because people don't know that they're experiencing an adverse drug reaction; they don't often know what an adverse drug reaction is. Many more people, as Mr. Glouberman said, are taking more than one prescription drug, so it's kind of difficult to attribute a particular side effect to a particular drug. Often the adverse drug reaction mimics the condition that is being treated.
Some ADRs are traumatic and life-altering experiences, and that's mainly what I'm talking about here. About 80 per cent of all ADRs reported to Health Canada are considered serious adverse drug reactions, and that would include fatalities. As I'm sure you know, adverse drug reactions are a leading cause of death in Canada. Drugs can both enhance the quality of life and literally rob a person of life altogether.
From my perspective, there are three factors that contribute to the severity of the experience related to adverse drug reactions. One is the lack of knowledge that so many people have about the potential harm associated with prescription drugs. The second is that most people don't know what to do when they actually experience a serious adverse side effect. The third reason is the isolation that comes from that lack of knowledge. Often you believe and actually are told by your physician that your experience is unique, and that is often not the case.
There are also a number of things we can do to decrease both the number of adverse drug reactions as well as the trauma that may result from prescription drug use. PharmaWatch has worked with many people across the country who have had really serious adverse drug reactions. One tool to help them deal with the experience is to provide them with the ability to tell somebody about it and to enable them to feel that they are helping others to avoid what they went through. That is a major motivation in terms of reporting adverse reactions; people don't want anybody else to experience what they experienced.
That's where the regulatory Health Canada comes in. It's their job to facilitate that storytelling and sharing of information and to support consumers to report directly, rather than having their experiences filtered through physicians and other health professions who are notoriously not reporting adverse side effects. That sharing of information does two things: First, it increases our knowledge of adverse drug reactions — knowledge that is always evolving and expanding the more we know about consumer experiences — and, second, it can help people avoid adverse drug reactions or some of the more severe experiences.
PharmaWatch campaigned for several years in support of direct-from-consumer reporting of adverse drug reactions to Health Canada. We were founded in 2001. And in 2003, Health Canada changed the rules so that people could report directly rather than having to go through a physician or a manufacturer. In part, as a consequence, the number of reports that originate with patients has increased from 331 in 1997, which was about 7 per cent of all ADR reports, to over 16,000 today, which is about 31 per cent of the total. That compares with 25 per cent of ADRs originating with the physicians and about 10.5 per cent from pharmacists.
Knowledge is a recovery tool and it is also a prevention tool. Consumers both want and need to make a contribution to our knowledge of unintended consequences, and it's Health Canada's responsibility to facilitate that. This is what supports informed decision-making and makes a contribution to less harm from prescription drug use.
Thank you. I'm happy to answer questions.
The Chair: Thank you both. I'm now going to open up the floor to questions from my colleagues.
Senator Eggleton: Thank you for being here and being part of the input for our study on pharmaceuticals.
The 2014 budget included about $45 million to be invested over five years to expand the focus of the National Anti- Drug Strategy. Up until now, we have been dealing with illicit drugs, but now they also feel that addressing prescription drug abuse should be part of it. Were either of your organizations consulted and, if so, is it evolving the way you expected? If you haven't been consulted, how do you think that $45 million should best be spent to help in terms of cutting down on drug abuse, misuse, overuse, et cetera?
Ms. Fuller: In the last five years or so, the engagement of Health Canada with consumer organizations such as PharmaWatch has declined quite significantly. I am on the Expert Advisory Committee on Vigilance. I was appointed in mid-2012 and the committee has met one time since then. I'm not sure what's happening with the committee at this point. There is definitely less engagement by Health Canada — there is no doubt about it.
Our organization is really focused on the need to enhance consumer involvement in the regulatory process. So the $45 million — I wasn't quite clear what you are saying. What is that $45 million going to over five years? You said anti- drug. Do you mean anti-drug abuse?
Senator Eggleton: They are expanding the National Anti-Drug Strategy. Up until now it has been illicit drugs, and they are saying they will now include legal, prescribed drugs that are being abused, overused or whatever. That $45 million over five years is $9 million a year.
Ms. Fuller: Yes. The term ``drug abuse'' is often used inappropriately in my view to address people who are addicted to medications. Of course, addiction involves a lot of behaviour that is described as abusive. I have a personal problem with that. I would like to see the money used to enhance Health Canada's engagement with organizations that are membership based, involved with their members to counsel or support them in the appropriate use of prescription drugs. Also, from our perspective, there needs to be a much bigger investment in supporting the reporting of adverse drug reactions.
Mr. Glouberman: I agree entirely with the other person. It's really important that people who take the drugs know more about them. Strengthening consumers in Canada is a really important issue and one that both of our organizations feel strongly about, and we are working toward that. Patients have to play a role not only in their clinical care but also in the development of policies and practices related to health care. They have the experience and those experiences are the foundation for changing services, making them much more consumer friendly and ensuring that things like the drugs they use are better understood by them. Labelling is a huge issue in drugs and not providing enough information about adverse reactions is another huge issue in the case of prescription drugs.
More money for organizations like ours to do that and to prepare consumers for it would be welcome. The growth of consumer movements in Canada is an important issue for all of us.
Senator Eggleton: It has been suggested at the table that there need to be periodic medication reviews as a means of reducing potential drug-to-drug interactions, overuse and misuse, et cetera. This would be between the physician and the patient.
How do you think that might be done? What is your thought about that? Should we encourage the colleges of physicians and surgeons to get this done by their members? Of course, there is also the problem that some people go to more than one doctor but you would need to have all the information in the hands of one doctor to do a proper review. What is your opinion about a periodic review by physicians with their patients?
Mr. Glouberman: This is especially true about the use of opioids as their use in Canada has expanded. It turns out that the opioids prescribed are very close to illegal drugs. They are one molecule away. One thing we have to think about in Canada is allowing the use of these opioids and thinking about whether we want to continue to allow their use in the same way because they are incredibly addictive. It's hard to blame the victim because these drugs have been made legal by our government — we've passed and approved them through Health Canada. I'm thinking about how we think about opioids and how we deal with them is a difficult problem. The most important thing is to make people aware of the extent to which these drugs are tremendously addictive and to be aware of their use. We don't do enough of that.
The other thing you are saying is also true. We have the technology to know when somebody is getting multiple prescriptions for a drug. We have to begin to make use of that technology. After several years, I am sure it will be possible to track individual use so we know that people are not being overprescribed in that way.
Ms. Fuller: I'm on the board of directors of a community health centre in Vancouver. We have a multidisciplinary team, which is one of the best ways to conduct some of these medication reviews that you're talking about. One thing mitigated in a multidisciplinary environment is the overprescribing of medications. We have a system in British Columbia whereby we can track people's prescriptions, which are in an electronic medical record that pharmacists and physicians haves access to. We have been able to address some of that. Ontario, of course, is a leader in the country with regard to multidisciplinary environments. That's one thing that should be utilized in this way.
I have not read evidence showing that that is the case, but I know that based on our experience in a multidisciplinary environment where the pharmacist is engaged with the doctors, some of these issues are more easily addressed.
Senator Seidman: I'm particularly pleased because you both represent patient advocacy groups in one sense or another. There is no question that there is a role for Canadians as consumers of the health system. They are dependent on health care providers in so many ways. My question for you concerns your role in outreach, specifically in education. Perhaps we could address two of the very big issues that we've talked about: loss of effectiveness of anti- biotics because of over prescribing and polypharmacy in seniors. I would like to know how you deal with those two issues in terms of educating the patient population.
Ms. Fuller: Our organization was founded specifically to do public education on adverse drug reaction reporting and the role of Health Canada in monitoring drugs once they've been approved and are on the market. I'm not sure that I'm able to address both points raised. However, we have conducted focus groups across the country on more than one occasion. The lack of knowledge and information that people have about the issues you've raised is concerning.
In particular, older people don't like drugs being overprescribed. They're concerned about the drug-to-drug interactions and are raising more questions about the beginning cascade of prescribing. Often the drugs prescribed are to counter adverse drug reactions to the drugs that came first or second. People want more information, but it's difficult to get. As I said, we focus on reporting adverse drug reactions.
Mr. Glouberman: Our organization largely works from patients' actual experiences. We hear patient stories about what happens to them. We try as a group to develop ideas about policies and practices that could start to turn this around, to a certain extent.
There are many policies that can be changed, in both the colleges and the government about how drugs are dealt with. They include such things as much clearer labeling and information about the drugs. Another thing is true that will be difficult for us to deal with: Because most people who are very old have multiple chronic conditions, they have to go to different medical specialists for their various conditions. As a result, they are prescribed different drugs by the specialists, and the interaction between the drugs is not understood clearly by the specialists and by the patients.
Our medical education system tends toward specialization rather than toward trying to work across these various specialties. This problem is especially prevalent among older people who have multiple chronic conditions. To have people who can work across those chronic conditions means we need more generalists or people who work across the boundaries. We have very few geriatricians who work across the boundaries. We have few properly trained geriatricians for the state of our population. We need more of them. We need more people who are boundary crossers, as it were in their training, in medicine. Part of the problem is on the provider side. The other problem is on the patient side, namely that the kind of information people can get is limited. It's not just that people don't want to get the information, it's that it's hard to find and receive. Part of it is a matter of education but part is being able to get the right information and making sure you can use it even if you have the capacity to gain it. All of those things are necessary.
As far as the health care system is concerned, patients are considered to be a free good. Patient organizations like ours find it difficult to get funding and to be properly funded in order to do the work we do. That funding and those connections are constantly being worked on. We get researchers, for example, who get quite a lot of funding to do what they do but the patient organizations and the consumer organizations that we need at this point really need more funding as well.
Senator Seidman: Ms. Fuller, I also appreciate your comments on seniors; Mr. Glouberman referred to that as well. Your association was created to encourage adverse drug reaction reporting by consumers and to advocate for improved post-approval monitoring of pharmaceuticals, if I understand correctly. You are also concerned about the increased consumption of prescription drugs in recent years.
Would you be taking any role in encouraging seniors to report adverse reactions or helping them figure out how to go about doing that?
Ms. Fuller: Yes, that's exactly what we do, actually. We have spoken to seniors' organizations and to people who are in long-term care facilities about the role they can play to increase safety. That's one of the things we do.
One of the problems, I think, that Mr. Glouberman has referred to is the lack of support and funding support. It's very difficult to get funding to do this. It is, of course, very labour intensive. When we were first set up, Health Canada did not allow consumers to report directly. We had a database set up at Memorial University and we were funded by the University of Victoria to set up a phone line where people could report adverse drug reactions to us. That funding lasted for three years.
In the meantime, Health Canada moved to accept consumer reporting. So our funding, as I said, came to an end. We switched to do a lot of consumer education. We were funded from time to time by Health Canada to be able to do that, but that has now come to an end. There are a lot of patient advocacy groups who, because of the lack of public funding, have to rely on the pharmaceutical industry for funding. They have to do that or else they do not get money. We have made the decision not to rely on pharmaceutical funding — and I doubt they would want to give us money any way — but that limits the ability to provide people with information. It's a big problem in Canada.
In other countries, they do actually fund consumer organizations to undertake this type of education.
The Chair: I will remind my colleagues to be efficient in their questions.
Senator Eaton: I will be extremely efficient. This is a question I asked last week. I think. Mr. Glouberman, you were talking about the loss of effectiveness; ``chronic disease'' meaning long-term drug use.
Mr. Glouberman: Yes.
Senator Eaton: I asked this question last week and nobody could give me an answer: Why are people not coming up with alternatives?
Mr. Glouberman: I can answer that. That's historical.
Senator Eaton: I don't mean lifestyle or diet.
Mr. Glouberman: No, I don't mean lifestyle or diet; I mean other things.
First, we are a friendly organization, it turns out, because we also don't accept money from drug companies. It's really important for you to know that. We do that because of the perception people will have about our organization. We are patient-led and patient-governed and try to keep ourselves that way.
The history of the Canadian health care system goes like this. We got funding for hospitals. That was the first part of the publicly funded system. That happened in 1947, before the NHS was funded. The next piece of funding we got was in the late 1950s, and that was for doctors. So we have funding for hospitals and for doctors in our publicly funded health care system, historically. Other health care systems have funding for a lot more services that are in the communities and that support people in the community. That is what we don't have. So we don't have enough publicly funded physiotherapy or other kinds of therapies that people could use to deal with chronic conditions. The consequence is that we only have doctors and hospitals by and large. Everything else is funded sometimes by health insurance, sometimes privately.
Senator Eaton: I'm also thinking of drug alternatives. Listen, I wish everybody would walk every day, go on a diet and have a healthy lifestyle. Short of that, if you are talking about chemotherapy being less effective as it goes on; opiates being far less effective as their use continues; and sleeping medication, why aren't we thinking of alternative plans for pain-killers — that is, alternative ways of dealing with the same condition?
Mr. Glouberman: Largely because our health insurance doesn't cover it, if we have health insurance; and our publicly funded system doesn't cover it. In Germany, if you're sick and old and not feeling well, you can be sent to a spa for two weeks on the government plan. It's really interesting. Isn't that a nice idea?
Senator Nancy Ruth: That's a wonderful idea.
Ms. Fuller: May I respond to this as well?
Part of the work that I do also is with union members. My colleague and I consult with unions about negotiations for their benefit plans very specifically where we talk to them about the formulary that is attached to the benefit plan. There are a lot of problems. About 60 per cent to 70 per cent of the cost of any benefit plan in Canada is for prescription drugs. Of course, drugs are a major cost driver for private employer-sponsored benefit plans. So there is some push-back at bargaining tables to decrease the cost of these plans. Often what happens is that they begin decreasing the amount of money going to nondrug parts of the plan. This is for lots of different reasons, including that union members consider it to be a giveaway to the employer if there are fewer drugs listed on the formulary.
Pharmaceutical companies are talking to employers. In British Columbia, pharmaceutical companies are talking to unions to ensure that their drugs are covered on the formulary. Private benefit plans are a kind of last bastion for full coverage or for a complete formulary of the newest drugs, the most expensive drugs, and so on, that public plans are often now reluctant to cover.
There is a dynamic that is set in place here that consumers are involved in through their negotiating unions. Employers are engaged with insurers, and 25 per cent of every dollar spent on the benefit plan goes into the pocket of the insurer. You have all of the invested parties and it's very complicated.
Senator Seth: Thank you for your description. That was interesting.
Ms. Fuller, in the report you provided to the committee you conclude that the current system of pharmaceutical surveillance does not serve any Canadian well. It puts women at the most risk of unintended consequences. I would like you to explain to me why women stand to be more vulnerable to the unintended consequences of prescription drug use than males.
Ms. Fuller: It's not completely understood why that's the case. There are physiological reasons. The most obvious answer is that women tend to use more prescription drugs than men do, so the number of reports of adverse drug reactions coming from women is higher for that reason.
Women also react differently to drugs than men do — not always, but sometimes — and that is not very well understood. One of the reasons is because women are under-represented in clinical trials. Even though women may be the intended market for a drug, not very much is known about how they will respond to a drug. The same is true with other specific types of populations. Older people are often not included in clinical drug trials. People who are supposed to be using the drug are often not included in the clinical trials. That's a problem that undermines our ability to predict what the response will be.
Senator Seth: It could be common, because they are taking more drugs, more sleeping medications. They tend to take more than men. Is it possible?
Ms. Fuller: Yes, that is one contributing factor. There is a growing body of literature that is looking at reasons other than the fact that women are more likely to use a prescription drug, especially in certain classes of drugs. There are reasons that we don't clearly understand why women are reacting differently.
Senator Seth: Is our government doing anything to avoid these unintended consequences, or are we doing anything more for the investigations in regard to that?
Ms. Fuller: Well, from my perspective, Health Canada is not doing enough. One of the discussions we have had — and I know that a number of other people, including Terence Young and other people who have been involved in the discussion for some years — one of the ideas that has been discussed is an arm's-length agency to do adverse drug reaction monitoring, because many people, myself included, feel there is a degree of conflict of interest within Health Canada because they are approving drugs, and their job is also to monitor for adverse side effects. So there is a kind of dual role that sometimes may come into conflict.
Senator Seth: There is no trial or something going on to avoid this? Do we require that, any trial?
Ms. Fuller: To avoid adverse drug reactions?
Senator Seth: To avoid why females get more unintended consequences.
Ms. Fuller: No. Again, I have to say the funding for Women and Health Protection, an organization that was funded by Health Canada to report to Health Canada on drug policy through a gender lens, from a gender perspective, ended in 2011. We provided a lot of information, and wrote a lot of reports to Health Canada, about what was going on, including what was going on both in pre-market and post-market experience with drugs.
Senator Seth: Thank you. Mr. Glouberman, you mentioned that Canadians are the second highest medicated by population.
Mr. Glouberman: Yes.
Senator Seth: Do you consider Canadians overmedicated, or is it because they have access to more prescription drugs? Why is this so?
Mr. Glouberman: Why are they? I think that is also historical.
You were asking about the services that are not funded. There are a large number of services not funded in Canada that can help people with long-term conditions, and some of these things are things like naturopathy and homeopathy and alternative kinds of health care. Some of that is useful to some people, but that is all privately funded. Also, one of the things that happens with them is that the medical profession does not lead people to them and does not know a lot about them.
There are alternatives, and they are growing quickly. One of the things that is happening in Canada is that naturopathy and homeopathy and alternative treatment is growing quickly. You can see organic foods in your supermarket. Vitamins and minerals and things that are not prescription drugs are there. That part of the health care world is growing and isn't very visible to the formal part of the health care system.
Senator Enverga: Thank you for the presentation. It's nice to know that both of you represent or advocate for patients.
One of the recommendations is to make an electronic database for all patients. Do you have any concern about what kind of information we should have that will be available nationwide? Do you have any concerns about privacy?
Mr. Glouberman: My sense is that the issue isn't so much about privacy as far as patients are concerned. I think that most patients would like the information about them to be accessible to all the doctors that they see. Patients who are addicted and trying to abuse drugs don't want that, but everybody else would like to ensure that the doctor knows about all their drugs and that there is proper conciliation, proper connection between the drugs they take. That requires that doctors know about drugs other than the ones that they prescribe. It also requires that pharmacists play a bigger role and understand about the reconciliation between the various drugs.
I think having that information available to everybody who prescribes drugs for a person is something that most patients would want. They would also want to have access to that information themselves, because sometimes they don't now.
Ms. Fuller: The experience in B.C. has been fairly positive, and it supports the role of pharmacists. That's one of good things about it.
Often, as Mr. Glouberman said, the patient is going from one doctor to another, because they are seeing a number of different specialists. They're prescribed drugs by different doctors. It's not that they are doctor shopping. It is just the nature of various illnesses they may have.
These doctors may not be communicating with one another, but the pharmacist will have access to an electronic database that includes the list of drugs that you've been prescribed. The pharmacist has knowledge, obviously, about drug interactions and so on.
I think most patients would support this idea. There are communities that have different concerns. The HIV community may have different concerns about information going into a database like that, but I think generally the response from the public would be fairly positive.
Senator Stewart Olsen: Thank you both for being here. I want to go back to the adverse reaction reporting.
I'm uncertain as to where people report these incidents. You're saying Health Canada. That's pretty removed from where the actual patients are. In hospitals adverse drug reactions are taken very seriously. Reams of incident reports are filed.
Are you speaking mainly of general practitioners? Is that where this concern is coming from, that the general practitioners are not reporting and that patients themselves do not understand what an adverse drug reaction would be?
Ms. Fuller: The estimate on physician reporting or general reporting of adverse drug reactions is about 5 per cent to 6 per cent. Five to 6 per cent of adverse drug reactions are reported in Canada. What this means is that much more has to be invested in a variety of strategies to support increased reporting.
Reporting adverse drug reactions is so important for a lot of different reasons. That includes when a drug comes onto the market. We normally don't know that much about it, because the period of clinical trials seems to be getting shorter and shorter, and a lot of the drugs that do come onto the market are intended for long-term use. Episodic use is one thing; if a drug is being trialed for four to six months, that's one thing. But if a drug is intended for long-term use among a population with chronic conditions, that's something quite different.
Doctors are notoriously poor reporters for a number of different reasons. It goes right back to their medical education, actually. Health Canada needs to develop a variety of strategies to increase reporting from all sources, not just consumers. We work with consumers, so that's the focus of PharmaWatch. However, Health Canada has to develop strategies for all groups to increase reporting.
As the chapter I submitted to the committee shows, there are certain groups that are more likely to report. One of those groups is women; they report on their own behalf and report on behalf of a parent, child or spouse. They are more likely to report than men. That should give Health Canada some idea of how to develop a communications strategy to target certain populations in certain settings to encourage them to report adverse drug reaction.
Our experience at PharmaWatch is that people don't like to report online, which is the key tool currently used by Health Canada. People don't like to do that — at least consumers don't. They want to talk to somebody and give information, and they also want to get information about adverse drug reaction.
Mr. Glouberman: In all of this, the idea of how you collect adverse drug reaction is really interesting. When you talk about these being reported in hospitals completely, what you're really talking about is giving the wrong drug to somebody; that's the adverse event reported in hospitals in great detail. Adverse drug reactions are not so well reported in hospitals, necessarily, but if you give the wrong drug, that's called an adverse event, and that's carefully reported.
One of the things that occurred to me while we were talking is that one of the reasons men don't report is because men don't take their drugs. That's one of the reasons you don't get as many adverse drug reaction reports. They are not as compliant and not as careful about taking their drugs as women are. That may be one of the things. But I don't know how many studies have been done on that.
Senator Stewart Olsen: That was helpful.
Senator Cordy: Congratulations on the principled decisions your organizations have made to not accept funding from pharmaceutical companies, because it would be easy money to get. So I congratulate both of your organizations. That's a very important decision. When I see drug ads on the websites of national organizations like the MS Society, sometimes I have to shudder and wonder whether their consumers are getting truly accurate information.
I would like to talk about an issue that neither of you spoke about: the counterfeit drugs that are out there. You go online and you can get just about anything — a counterfeit drug for most anything. You see newspaper ads, certainly in the United States, on ``Canadian drugs'' in the heading, so Americans think they're getting good drugs because they're Canadian, yet nobody knows what's in these drugs. We've heard testimony that there are a number of Canadians who can't afford to buy drugs, so if they have these counterfeit drugs at a much cheaper price, they are more likely to go to them rather than a pharmacy, even though we have no idea what's in them.
Are you coming across any of that with the consumers you deal with?
Mr. Glouberman: Not very much. The issue of counterfeit drugs is one that is much more of an American issue than Canadian, as far as I can tell. In most provinces now there is some help for people who can't afford drugs that help comes from the government.
One of the things that is really interesting in Canada is how much variation there is across the provinces in terms of drug coverage. In Quebec, there is pretty complete drug coverage. In Ontario, you can go to Trillium and get money if you can't afford an expensive drug. In other provinces, there are protocols for people to get drugs they otherwise couldn't afford. So there is some drug coverage for people who don't have enough money in Canada. In general, we have a fairly good safety net.
Senator Cordy: So you are not hearing about that in your organization?
Mr. Glouberman: I'm not hearing about that.
Ms. Fuller: I don't hear about it, either. But from people who we've been in discussion with in the United States, there always has been quite a lot of interest in the U.S. coming over the border, though I think that's less so now than it was five or ten years ago, in part because our drug prices are rising. A national pharmaceutical drug strategy in Canada is one of the ways to ensure that type of thing doesn't happen as frequently.
Senator Cordy: And we've heard that before from witnesses.
Mr. Glouberman, you said that patients don't always know why they are taking a drug. Ms. Fuller, you said that most people don't know what to do if they have an adverse reaction. What should Health Canada be doing? Ms. Fuller, you mentioned it shouldn't be online and that women are more likely to report than men are. First, you said they know why they're taking it, but I'm not sure people even recognize they're having an adverse reaction unless it's extremely serious.
Mr. Glouberman: A lot of that has to do with all kinds of information that's available about drugs. The interaction between doctors and patients and the explanation of why they're taking a drug and what the drug is can be improved. The labelling of drugs can be improved.
If you look at any drug that you are taking and look at the labelling and information that comes with that drug, you'll find that the print is too small to read most of the time. Improving labelling and improving the kind of information that drug companies have to give, and improving adverse drug reaction reporting — all of these things are part of the process, and they all could use quite a lot of change in Canada.
The Chair: Just before I go to my questions, Senator Eggleton, did you have a quick question that you wanted to ask?
Senator Eggleton: Yes, I want to follow up on what Senator Cordy talked about, counterfeit drugs. We are also hearing about substandard drugs; they are not counterfeit, per se, but they may be quite substandard, though some of them may be counterfeit. I've been reading a lot of articles about the FDA in the United States banning some of these substances that largely come from India, China or Brazil. A number of the factories in India have been barred from exporting medications into the United States.
I'm not aware that Health Canada has done anything to bar these medications in this country. One of the biggest companies is Ranbaxy Laboratories, which is a major supplier of many drugs into this country and the United States. Are you hearing concerns about this, and do you have any suggestions as to how we should be dealing with this?
Mr. Glouberman: I would like to turn that question upside down. One of the things that's been happening is the other way around; namely, that big pharma has been talking about the fact that generic drugs are substandard. They would encourage people to take the non-generic drugs — the ones they produce that are more expensive — because the generic drugs, which are exactly the same as theirs, supposedly, are not exactly the same and have different consequences and side effects.
There is a move to a certain extent by the large pharmaceutical companies that have the high and careful standards, supposedly, not to allow anybody else into the market. That is one of the reasons these things happen.
I don't know to what extent the drugs from other countries are below standard; I don't know the answer to that, because I am not in the FDA. I imagine there are counterfeit drugs produced, and that is a big issue. But I think there is also an issue about the large pharmaceutical companies trying to control the drug market.
In Canada, if you are given a particular drug and you want to take the generic version, the drug companies will give you the non-generic drug at the same price with coupons. That encourages the drug companies to charge the insurance companies a higher premium for their non-generic drugs because people want to take them. A lot of advertising and marketing go into this that have to be thought about and that we don't regulate.
Ms. Fuller: Canadians actually consume a lower percentage of generics than Americans do. I'm not sure about the reasons for that, but I do know that the provinces are trying to address it with some success. Where we see the problems are with the private drug plans. Most people think the best drug plan is one that has every drug that has ever been approved and that the choice is left to the doctor, the prescriber and the patient to decide which drug to choose.
One thing I would like to point out is that we used to have a lot more control over this situation when we had a Crown corporation that was manufacturing generic drugs. Connaught Labs manufactured both generics and vaccines in Canada and provided them at a cost-effective rate to the provinces to include in the formularies. That is no longer the case. I'm sure you know the story about Connaught. This has increased our dependence on the importation of drugs. For example, insulin was discovered in Canada under the roof of Connaught Labs at the University of Toronto. Today, we don't produce a drop of insulin in Canada; it's all imported. The fact that we don't have this type of manufacturing base is making us more vulnerable to the problems you raise.
The Chair: The issues that you have addressed here today are ones that we have been seized of throughout the four parts of our study. You have added some new dimensions to these from your personal and practical experience on the ground with real patients dealing with this. To take the issue of adverse drug reactions, for example, we've made some significant recommendations in our earlier reports. We have recognized that one of the great difficulties is getting people to know they can report and to do it in some manner. We know that the reporting system gets truncated in that a patient may speak to the physician but it may not get passed on.
Ms. Fuller, you referred to the issue of Health Canada, but there must be some body that ultimately collects all of the information because if it's reported to a hospital and it stays there, then the greater benefit of that knowledge doesn't get out. Fortunately, the medical system is encouraged substantially to report adverse drug reactions. In spite of that, we know from witness testimony over these four sections that the reporting of the actual number of adverse drug reactions is very low. Some estimate it at less than 1 per cent of the total adverse drug reactions.
Again, for reasons that you have indicated, in particular when you spoke about women not being prevalent in clinical trials, the reality is that the subsets of the population that you referred to are clearly identifiable groups not often included in clinical trials. Once a drug enters the human population, it is entering the greatest of the clinical trials. Our position in recommendations at this point is that we need to find better ways to collect that information to make it easier for people to report. You've given us some insights into some of the things that influence people against reporting. We need to build on that to build further recommendations because it's absolutely essential, as you have pointed out, that those reactions get collected in a manner that can lead to advice to physicians and pharmacists with regard to the nature of those reactions.
You also touched on the electronic record system, which we have strongly recommended in earlier reports. In fact, we have seen it as potentially an enormously beneficial thing to individual patients. This goes back to a point you made, Mr. Glouberman: A patient with a serious illness will see several different specialists who may not be connected in any way, which means that the patient is not the centre of focus. We've had recommendations and submissions to our committee in earlier reports that medicine must get back to being patient-centred as opposed to specialist-centred in terms of information and distribution.
You added a very important and real sense to these matters that we have been dealing with over time. On behalf of the committee, I thank you very much for being with us today and for the clarity and experience you brought to the answers given to us today.
I thank colleagues for their questions that elicited the kinds of information we received today. With that, I declare the meeting adjourned.
(The committee adjourned.)