Tuesday, November 5, 1996-- com: Health (20)

EVIDENCE

[Recorded by Electronic Apparatus]

Tuesday, November 5, 1996

.0907

[English]

The Chairman: Order, please. First of all, we would like to welcome our witnesses from the Canadian Pharmaceutical Association.

Whoever is in charge can start talking. Please introduce your colleague, give us a brief statement, and leave us some time to -

Mr. Martin (Esquimalt - Juan de Fuca): I have a point of order, Mr. Chairman. I put forth a motion -

The Chairman: Keith, if you look at the order of business, at 9 a.m. we're hearing witnesses. It says so very clearly. It's not fair to the committee or the witnesses to be -

Mr. Martin: I'd like to know, Mr. Chairman, when we're going to debate this motion I put forth last week.

The Chairman: The question can be put when we go into our meeting. We're now in a hearing.

Go ahead, sir.

[Translation]

Mr. Leroy Fevang (Director General, Canadian Pharmaceutical Association): Good morning. My name is Leroy Fevang.

[English]

I am the executive director of the Canadian Pharmaceutical Association. My colleague is Noëlle-Dominique Willems, director of government and public affairs for the association.

[Translation]

I will be making my presentation this morning in English, but my colleague,Ms Noëlle-Dominique Willems, will be happy to answer your questions in French.

[English]

The Canadian Pharmaceutical Association represents pharmacists from across the country. We have 10,000 members, in all provinces and territories, and we're concerned with the practice of pharmacy.

Pharmacists strive to provide pharmaceutical services in order to optimize the use of drugs, including both prescription and non-prescription drugs. Our mandate then overlaps with your committee's plan of action, which is to study substances that have the potential to cause harm when abused or misused.

Pharmacists are concerned with the increasing misuse of drugs and the lack of any coordinated, integrated national approach to deal with the problem of substance and drug misuse in any cost-effective way. We have developed a model or a proposal you have previously received a summary of, and now I understand you have a copy of the full document before you. We developed this as an approach to deal with the problem of misuse, overuse, or underuse of drugs.

Numerous studies have demonstrated that in Canadian society we have a real problem in this particular area. These are documented in the report here on page 9. Dr. Soumarai has indicated that with the restricted access the public has to drugs, adverse drug reactions are a common problem and they result in increased use of more expensive health care services.

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The report documents actual instances of problems that have been found in other Canadian studies. Often we rely on U.S. material for our references, but here we have Canadian studies that have demonstrated clearly that we have a problem in Canada. The Ontario Drug Programs Reform Secretariat and the B.C. Royal Commission on Health Care and Costs are just two of the studies that indicate the magnitude of the problem and the nature of the problem we have here in Canada.

Our brief goes on to state that 10% to 20% of our hospital admissions of the elderly in Canada are attributed to adverse drug reactions or medication misuse.

With that as an indication and demonstration that we have a problem in Canada, this document was developed as a potential solution to that problem by setting up a national coordinated approach to deal with drug use management in Canada. The approach was based on the definition of drug use that was proposed by the national pharmaceutical strategy in 1993. It's current in that respect. The balance of this report outlines in some detail how this plan can be implemented, the various characteristics of the plan, and the details for its development and implementation in Canada.

This plan was also presented to the policy consultations and the pre-budget development, so they're aware of this initiative from a financial perspective. At that time we indicated to them that the potential of setting this up might be around $2 million to $3 million but the savings that would result for Canadian society would far exceed that once it was implemented.

Before closing, I wanted to say we're very much in support of the report presented to the committee by the Canadian Centre on Substance Abuse by Mr. Jacques LeCavalier. We support their initiative and commend them for their work in these difficult times they are facing.

In recognition of the limited amount of time we have before you, I wanted just to make these presentations of the material before you. If you have any questions, we would be pleased to respond to them.

The Chairman: Thank you.

Mr. Dubé.

[Translation]

Mr. Dubé (Lévis): You have presented your brief rather quickly and I have not yet had time to read through it completely. First of all, I would like to know how you feel about the current situation in Quebec, particularly since the introduction of the new drug insurance program. Do you feel this initiative is consistent with your position or not at all consistent?

Ms Noëlle-Dominique Willems (Director of Government and Public Affairs, Canadian Pharmaceutical Association): This initiative is consistent with what we proposed, namely that the private and public sector programs be combined to form a universal program. That is why we support it. Unfortunately, deductibles were introduced. Recently, agencies such as Opération enfance au soleil have been freeing up a $100,000 fund to help people purchase drugs.

Our pharmacists often tell how some people, in particular seniors or welfare recipients, ask them which drugs on their list of prescription medicines are absolutely essential. These people cannot afford to buy all of their prescription drugs and must often chose between food and their medication. This is an impossible choice.

What we are suggesting in our program goes one step further. To our minds, health is not simply a question of having a diagnosis in hand; it's also a question of having the medication to treat the symptoms. Instead of witnessing cases of people taking advantage of the system, we are seeing more frequently people purchasing fewer drugs. This poses a serious problem since the cost burden is merely being shifted to another component of the system.

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Mr. Dubé: Bearing in mind the reservations that we have expressed, can you tell us if this kind of initiative has been introduced elsewhere? Have other provinces adopted similar initiatives?

Ms Willems: There are no initiatives exactly like it, with the exception of British Columbia which is adopting the same kind of system. The realization is dawning that cutting back on the amount of medication prescribed reduces the number of people who turn to other health services.

Other provinces such as Manitoba and Saskatchewan have introduced different types of drug programs which are more general in nature, but which, unlike Quebec, are not intended to be universal.

Mr. Dubé: I will now turn the floor over to my colleague from Portneuf.

Mr. de Savoye (Portneuf): In your brief, you alluded to the U.S. managed care model and you expressed some concern that this model would take over in Canada if we failed to react. Could you explain to us the extent to which a threat exists and the nature of this threat?

Ms Willems: I think the nature of the threat is fairly obvious. Since we have a private system where 45% of the cost of prescription drugs is covered, this means that 45% of our health care system represents some potential for U.S. companies or U.S.-style companies which will try to come in and privatize this component of the system. Companies like FoxMeyer, PCS and others are already attempting this.

This is the real danger that we currently foresee. Unless we stop this from happening and unless we establish a better framework, as was done in Quebec, we run the risk of ending up with a completely privatized system for at least half of all drug coverage in Canada.

Mr. de Savoye: Ideally, what measures should be taken, in your opinion, to guarantee to people that they will receive the proper medication at the right time?

Ms Willems: The Association's position since 1962 has been that drugs should be included in the country's health care system. The argument has always been that this coverage would prove too costly, but ultimately, it ends up costing us too much anyway because people who do not have access to drugs end up in the hospital and there, they are covered by the health care system.

Mr. de Savoye: We all know that the cost of generic and brand name drugs differs considerably. We also know that the patient relies a little on the pharmacist or on his own physician for assurances that he is paying the best possible price.

We also know that some insurance companies, our own among others, insist that we buy the least expensive drugs. This puts companies who do research in an awkward position since they pay for their research through the sale of brand name drugs, not the generic version.

On the other hand, manufacturers of generic drugs are doing the public a service since the latter does not want costs to get out of hand. How can we possibly strike a balance here? Where is the conventional wisdom?

Ms Willems: It will become clear when we review C-91, most likely around February.

We have to realize that the health care system is experiencing major fiscal constraints and that furthermore, drug costs are increasingly being covered by the private sector rather than by the public sector. Just think about the move toward more ambulatory care in Quebec and about the fact that people are spending less time in hospital. It is clear that someone else has to start picking up the tab and people are being pushed to turn to the private sector.

Consequently, as long as this continues, the pressure will be on to look to less expensive drugs. Canada has tried to strike a balance by introducing mechanisms to control the cost of patented drugs, but it must be said that the safeguards in place are equivalent to those in other comparable countries. Therefore, a balance of sorts has already been achieved.

Of course, we can always fine tune these mechanisms and see if there is some way of controlling the cost of generic drugs, since we know that our generic drugs are slightly more expensive than similar drugs in other countries.

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Perhaps there is some kind of balance to be achieved in this area. Within the framework of Bill C-91, we will have to look of doing just that.

Mr. de Savoye: Thank you, Mr. Chairman.

[English]

The Chairman: Mr. Szabo.

Mr. Szabo (Mississauga South): Thank you, Mr. Chairman.

I think it's kind of appropriate that you're here today because this is Pharmacy Awareness Week. Yesterday, I had -

The Chairman: My mistake, I hadn't realized -

Mr. Szabo: I'll be very quick.

The Chairman: For the record, I just want to note that it would normally be the third party's order.

Paul, then Grant.

Mr. Szabo: In the House yesterday I made a statement and highlighted some of the issues: 12,500 lives lost at a cost of anywhere from $7 billion to $9 billion. I think it's very important that the pharmaceutical industry play a lead role in trying to educate, and it looks like a very big part of the program. In fact, in your national program components on page 25, the very last item is standards for patient information. Too bad it's last, because it seems to me that the problem is between the proper use as prescribed and the understanding of that so that we have a proper health care outcome.

My question is on educational approaches, and there are many. There's no one simple solution. We have some pharmaceutical products that have warnings on them saying, for instance, ``Do not take this with alcohol''. Has the pharmaceutical industry done any research, or have you any basis for feeling that a warning on the product saying something like, ``Do not use this in conjunction with drinking alcohol'' would be effective? If so, do you think the reverse should also be true, that alcohol should have a label saying, ``Don't take this when you're taking drugs''?

Ms Willems: I think that would be right.

Mr. Fevang: Yes. Although we laugh, there is a lot of truth to that.

In the liquor stores they often have signs warning people not to drive when they drink, but they don't have any warnings indicating the danger of medication. The point is well taken. The more often you reinforce that message, the more likely it's going to be absorbed and understood, because it is at that point of individual usage where the problem really develops. The more educated and informed we are, the more likely we are to achieve our common objectives.

Mr. Szabo: Thank you, Mr. Chair. That's all I wanted to hear.

The Chairman: Grant.

Mr. Hill (Macleod): Thank you, Mr. Chairman.

As you know, we're studying the problem use of both legal and illegal substances. You've given us a fairly broad overview of the pharmaceutical industry and some suggestions. I always like to compare us with other countries. Is there another country that is doing better than Canada in the problem use of legal pharmaceuticals?

Mr. Fevang: That's part of the problem itself in that there's really very little documentation that would indicate the comprehensiveness of this problem from country to country. We have our different systems. Even in Canada, the percentage of hospital administrations is a very difficult figure to come up with, because at the point of admission they don't document the actual causes of whether it's an ADR or whatever it was that caused the admission. So it's very difficult to really compare. One would only be able to respond, I think, with a gut feeling that Canada and North America have a different system from the European one. I would hope the European system might have a different set of controls and a lower rate of incidence than we have here, but there's no documentation to substantiate that.

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Ms Willems: There are studies under way, because we realized there were problems in identifying how many actual hospital admissions were caused by drug interaction or drug misuse, etc. There are a number of studies that are under way at this point to try to identify that. But if there were a national system that would actually put in the data in the hospital, that kind of information would be very useful to everybody.

It's difficult to import that kind of data from other countries. We have to use American studies for a number of things, but, even then, the population is different, the ethnic components of the population are different; therefore it's very difficult to extrapolate.

Mr. Hill: You're talking about adverse drug reactions. That is really different from the mandate of this committee, which is to look at the problem behaviour that comes from the use of licit products. Is there no data that will give us an indication of where Canada stands on the problem use of licit substances?

Ms Willems: Let me give you an example - Gravol. We know there's a problem with youth overusing and abusing Gravol. In certain provinces it has been taken out of public access in the pharmacy. There is no strict documentation, province to province, to say exactly what the incidences are of problems with youth and Gravol. We simply know there have been instances where kids have taken it and have been very ill. In some instances, a couple have died.

I get calls from California asking, do you have problems with Dramamine? It's the same thing, but their system is also unable to track that.

We know there are problems with those kinds of drugs. We know there are problems with codeine in certain populations because codeine is easier to take and doesn't present the social stigma that you have when you take alcohol, for example.

Basically, there are problems. They are not documented. What we're proposing is a framework that would put all the players in place to try to track those instances. CIHI would be involved, CCOHTA would be involved, to really look at what the situation is and give us the tools to better understand and better address those issues.

Mr. Hill: To repeat then, it would be very difficult to measure the effectiveness of such a program when we don't have the data to say that a certain percentage of the population is -

Mr. Fevang: At this time, yes, but we are trying to set up the information databases through the system that would help to measure the effectiveness of the overall program. We're moving in that direction with all of the networks we have and the provincial databases that are established, for example, in British Columbia, Ontario and Manitoba. They're all starting to collect the data that would help to respond to your question.

Earlier on, you gave the impression that adverse drug reactions were a different part of the committee's mandate. I'd like to suggest that the adverse reactions are the result of the misuse, underuse and overuse of the drugs themselves. There is a direct tie-in and relationship between the two.

The Chairman: Mr. de Savoye.

[Translation]

Mr. de Savoye: Currently, pharmacists closely monitor prescription drug use by computer. However, some drugs can be purchased without a prescription and their use cannot be monitored in any way.

If, on the one hand, some way could be found to use computerized control measures, to ensure that people are legitimately buying the drugs they need and maybe even to ensure that they are buying them at the appropriate time, and if, on the other hand, we know that some categories of drugs cannot be subject to similar controls, what balance should we seek to achieve between control measures and education or prevention measures, to address the problem of abuse, forgetfulness or neglect? What kind of balance would you like to see achieved?

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Ms Willems: We have long believed that prevention and education are the best course of action and we encourage pharmacists to take a counselling approach, that is to provide better information not only about the prescription drugs they sell, but also about the drugs that can be purchased over the counter.

In Quebec, we have a reference work, the code of medicines, which helps people to identify over-the-counter drugs that can interact either with other drugs or with certain food products. We believe that education and prevention are absolutely indispensable components of Canada's health care system. Canadians must take responsibility for their own health, otherwise we will not see much in the way of change, even if controls are put in place. What we need is a real partnership.

I want to thank Mr. Szabo for mentioning Pharmacy Awareness Week which is part of our program. This year's theme is the sharing of health care by the patient and his pharmacist. We will try to emphasize the fact that we are equal partners with the patients and that we are there to ensure everyone's well-being. We therefore feel that it is important for prevention and education mechanisms to be in place before any controls are instituted.

We believe that the public is mature enough and that consequently it can make the right decisions, provided it has the right information.

Mr. de Savoye: We appreciate the fact that pharmacists do exemplary work in their field and that they make every effort to see that their patients understand the medication they are taking and why it has been prescribed to them. Could the pharmacists one day be called upon to play a more proactive role in the community? Do you foresee the day when information sessions could be held or groups of volunteers organized? Have any initiatives of this nature been attempted?

Ms Willems: Yes, many initiatives of this nature have been carried out. Increasingly, we hold information sessions for specific types of patients, such as diabetics, or for people who want to stop smoking or who suffer from high blood pressure. More and more, pharmacists are taking a proactive role. Through the National Coalition on Managed Care, we are also trying to educate employers and employees and we have organized specific workshops with this objective in mind.

This is the approach we advocate when it comes to seeing pharmacists take on an expanded role within the community.

Mr. de Savoye: Thank you.

[English]

The Chairman: Keith.

Mr. Martin: Thank you both for coming before our committee today.

One thing I've always been continually amazed at in working with people who have addiction problems, particularly in detox, is the enormous quantities of prescribed substances these individuals have. I was wondering if you are working with or have made suggestions to the provincial medical communities, and the provincial medical service plans, on how they can better monitor some of the prescribing habits, or, once they've found individuals who are pushing...working with the justice department to find individuals who are pushing substances such as the narcotics, the benzodiazepines, the amphetamine-like substances, Ritalin. These cause such a huge problem out there. Are you making any efforts to work with the provincial legal authorities, the provincial medical authorities, and have you made any suggestions to them on how we can get a handle on this, to cut off the supplies?

Mr. Fevang: Actually, we've concentrated most of our liaison at the national level with the Canadian Medical Association. We've been working with them for about the last eighteen months in the generation of a document to enhance the quality of drug therapy so pharmacists and physicians can work together. All too often we're practising in the two solitudes concept. By working together we can reinforce the expertise of both practitioners to enhance the quality of prescribing and the quality of drug usage.

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That's in general. More specifically, we're working again with the CMA on the development of guidelines on benzodiazepines, guidelines on the substance, on how to regulate their use, and on how to assist in taking patients off benzodiazepines after they've been on them for quite some time.

Mr. Martin: I'm mostly concerned about inappropriate prescribing practices. There are oodles of information out there on how to get your patients off benzodiazepines and what appropriate prescribing habits are for benzodiazepines, etc. Mostly I'm concerned about those very few individuals who choose to give 300 Tylenol 3s to an individual who has headaches on a weekly basis.

Mr. Fevang: That will be identified more easily now through the networks that have been established. We're keeping records to identify patients who are using inordinately large amounts. Through that identification the appropriate controls can be exercised about the prescribing and the dispensing distribution levels.

Ms Willems: Let me add that through the National Pharmacy Coalition on Managed Care, we're also doing drug-use reviews, and when we do those reviews we usually identify those types of problems and signal the pharmacists, who have to deal with the doctors. So there is a direct intervention - which is usually the best way - from professional to professional, rather than going through the legal channels. But if the behaviour doesn't change, we will indeed go through the legal channels.

Mr. Martin: That's great. Thank you.

The Chairman: Finally, we have a brief question from Joe Volpe.

Mr. Volpe (Eglinton - Lawrence): I want to follow up on Dr. Martin's last question.

I realize various provinces are looking at or have already introduced a smart card process, but you're suggesting that once the data is in for the dispensing, by both the pharmacy and the doctor, you'll be able to have some sort of self-regulation that will curb the kind of practice that's been described.

But many pharmacies already have data banks. For example, the ones near my place - and it's probably an inappropriate example - won't issue anything unless they see a doctor's signature on a prescription. Presumably, there's a data bank that tells them what a doctor prescribes, in what quantities, and in which frequency. Do you not have that already under control in some provinces?

Mr. Fevang: The data bank in a pharmacy really relates to the data within that pharmacy. They have very good records on what has transpired within the experience of that pharmacy, but they don't know if, for example, a patient has had a prescription dispensed at another pharmacy or at another one beyond that. You don't get that total global picture as to what's going on when there might be duplication of that medication. It could have been prescribed by another physician who didn't know what the first physician was prescribing. With the system we have now there's no integration of these records.

With the provincial networks that are being established now, they're merging the individual databases into one so that there is a global picture as to what is transpiring. The misuse and overuse situation can come to light. That element has been missing. To merge these various databases -

Mr. Volpe: Do you want to leave the supervision of that misuse and abuse to the professional organizations, the pharmacists' organizations and medical organizations?

Ms Willems: You know that pharmacy is a self-regulated profession. Therefore, there is a voluntary association, but there is also a college that is putting in the codes of ethics and guidelines, which are usually fairly stringent and fairly well applied, so I wouldn't be too worried.

It is a profession where there are abuses, as in other professions, but at the same time, when compared to the number of people who are practising it, I think it's been fairly well self-regulated. I say that because Mr. Fevang is a past registrar, right?

Mr. Fevang: Yes.

These problems come to light. Certainly, most of the experience shows that patients have a difficult time getting a prescription refilled if the time intervals are not right or if the authorities' approvals are not there. The same kind of professional responsibility applies when there's obviously a case of overuse or misuse.

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The Chairman: We're out of time.

I want to recognize the distinguished member from Kenora - Rainy River, who has joined us.

We'll take a moment to make the transition.

Mr. Fevang: Thank you very much for the opportunity to appear before you.

The Chairman: Thank you.

[Proceedings continue in camera]

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[Public proceedings resume]

The Chairman: Somebody just alerted me to an error we just committed in camera, but we can fix it really quickly. When we did the clause-by-clause on Bill C-202, we should not have done it in camera; we should have done it publicly. So let me call the motions on it again.

We're doing the clause-by-clause of Bill C-202, for a national organ donor day in Canada.

Shall the title carry?