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37th PARLIAMENT, 2nd SESSION

Standing Committee on Health

EVIDENCE

CONTENTS

Thursday, October 2, 2003

0905

The Chair (Ms. Bonnie Brown (Oakville, Lib.))

Dr. Noralou Roos (Director and Senior Researcher, Manitoba Centre for Health Policy)

0910

0915

The Chair

Dr. Anita Kozyrskyj (Assistant Professor, University of Manitoba, Manitoba Centre for Health Policy)

The Chair

0920

Dr. Alan Katz (Associate Professor and Associate Department Head, Department of Family Medicine and Manitoba Centre for Health Policy, University of Manitoba)

0925

Mr. Svend Robinson (Burnaby—Douglas, NDP)

Dr. Alan Katz

0930

The Chair

Dr. John Wade (Former Chair, National Steering Committee on Patient Safety)

0935

0940

The Chair

Mrs. Deb Kostyk (Seniors and Addictions Prevention Education Consultant, Addictions Foundation of Manitoba)

0945

0950

The Chair

Mrs. Deb Kostyk

The Chair

Mr. Rob Merrifield (Yellowhead, Canadian Alliance)

0955

Dr. Alan Katz

Mr. Rob Merrifield

Dr. Alan Katz

Dr. John Wade

Mr. Rob Merrifield

Mrs. Deb Kostyk

Mr. Rob Merrifield

Mrs. Deb Kostyk

Mr. Rob Merrifield

Dr. Alan Katz

Mr. Rob Merrifield

Dr. Alan Katz

1000

Mr. Rob Merrifield

Dr. Noralou Roos

Mr. Rob Merrifield

Dr. Alan Katz

Mr. Rob Merrifield

Dr. Noralou Roos

Mr. Rob Merrifield

The Chair

Mr. Greg Thompson (New Brunswick Southwest, PC)

Dr. Alan Katz

1005

Mr. Greg Thompson

Dr. Alan Katz

Mr. Greg Thompson

Dr. Noralou Roos

Mr. Greg Thompson

Dr. Noralou Roos

Mr. Greg Thompson

Dr. Noralou Roos

Mr. Greg Thompson

Dr. Anita Kozyrskyj

Mr. Greg Thompson

Dr. John Wade

1010

Mr. Greg Thompson

The Chair

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.)

Dr. John Wade

Mr. Stan Dromisky

1015

Dr. Alan Katz

Mr. Stan Dromisky

Dr. Anita Kozyrskyj

Mrs. Deb Kostyk

Mr. Stan Dromisky

Mrs. Deb Kostyk

Mr. Stan Dromisky

Dr. Alan Katz

1020

Mr. Stan Dromisky

Dr. Noralou Roos

Mr. Stan Dromisky

Dr. John Wade

The Chair

Mr. Svend Robinson

Dr. Alan Katz

Mr. Svend Robinson

1025

Dr. Noralou Roos

Mr. Svend Robinson

Dr. Noralou Roos

Mr. Svend Robinson

Dr. Noralou Roos

Mr. Svend Robinson

Dr. John Wade

Dr. Noralou Roos

Dr. John Wade

Mr. Svend Robinson

Dr. John Wade

Mr. Svend Robinson

Dr. John Wade

Mr. Svend Robinson

Dr. John Wade

Mr. Svend Robinson

1030

Dr. John Wade

Mr. Svend Robinson

Dr. John Wade

Dr. Alan Katz

Mr. Svend Robinson

The Chair

Ms. Michele Fontaine (Vice-President, Coalition for Manitoba Pharmacy)

Mr. Greg Skura (Secretary, Coalition for Manitoba Pharmacy)

1055

Mr. Lothar Dueck (President, Coalition for Manitoba Pharmacy)

The Chair

Mr. Ronald Guse (Registrar, Manitoba Pharmaceutical Association)

1100

1105

1110

The Chair

Mrs. Marian Kremers (President, Manitoba Society of Pharmacists)

1115

1120

The Chair

Mr. Rob Merrifield

Ms. Michele Fontaine

1125

Mr. Rob Merrifield

Ms. Michele Fontaine

Mr. Rob Merrifield

Ms. Michele Fontaine

Mr. Rob Merrifield

Mr. Greg Skura

Mr. Rob Merrifield

Mr. Lothar Dueck

Ms. Michele Fontaine

Mr. Rob Merrifield

Mr. Ronald Guse

Mr. Greg Skura

Mr. Lothar Dueck

1130

Mr. Rob Merrifield

Mr. Lothar Dueck

The Chair

Mr. Rob Merrifield

Ms. Michele Fontaine

The Chair

Mr. Ronald Guse

Mr. Rob Merrifield

Ms. Michele Fontaine

Mr. Rob Merrifield

Mr. Ronald Guse

1135

Mr. Rob Merrifield

Mr. Ronald Guse

Mr. Rob Merrifield

Mr. Ronald Guse

The Chair

Mr. Greg Thompson

Mr. Ronald Guse

Mr. Greg Thompson

Mr. Ronald Guse

Mr. Greg Thompson

Mr. Ronald Guse

Mr. Greg Thompson

Mr. Ronald Guse

Mr. Greg Thompson

1140

Mrs. Marian Kremers

Mr. Greg Thompson

Mrs. Marian Kremers

Mr. Greg Thompson

Mrs. Marian Kremers

Mr. Greg Thompson

The Chair

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

1145

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

Mrs. Marian Kremers

Mr. Stan Dromisky

1150

Mrs. Marian Kremers

Mr. Ronald Guse

The Chair

Mr. Svend Robinson

Mrs. Marian Kremers

Mr. Svend Robinson

Mrs. Marian Kremers

Ms. Michele Fontaine

1155

Mr. Ronald Guse

Mr. Svend Robinson

Mr. Lothar Dueck

Mr. Svend Robinson

Mr. Lothar Dueck

Mr. Svend Robinson

Mr. Scott Ransome (Executive Director, Manitoba Society of Pharmacists)

Mr. Svend Robinson

Mr. Scott Ransome

Mr. Svend Robinson

Mr. Ronald Guse

Mr. Svend Robinson

Mr. Ronald Guse

1200

Mr. Svend Robinson

Mr. Ronald Guse

Ms. Michele Fontaine

Mr. Svend Robinson

Mr. Greg Skura

Mr. Svend Robinson

Mrs. Marian Kremers

Mr. Svend Robinson

Mr. Ronald Guse

Mr. Svend Robinson

Mr. Ronald Guse

1205

Mr. Greg Skura

Mr. Svend Robinson

Mr. Greg Skura

Mr. Svend Robinson

Mr. Greg Skura

Mr. Svend Robinson

Mr. Greg Skura

Mr. Svend Robinson

Mr. Greg Skura

Mrs. Marian Kremers

The Chair

Mrs. Marian Kremers

Mr. Ronald Guse

Mr. Greg Thompson

The Chair

CANADA

Standing Committee on Health

NUMBER 055

2nd SESSION

37th PARLIAMENT

EVIDENCE

Thursday, October 2, 2003

[Recorded by Electronic Apparatus]

¿ (0905)

[English]

The Chair (Ms. Bonnie Brown (Oakville, Lib.)): Good morning, ladies and gentlemen. It's my pleasure to welcome you to the Winnipeg section of our travelling consultations on prescription drugs. We're anxious to hear your comments on the subject we're studying.

This morning we have representatives from the Manitoba Centre for Health Policy, the Department of Family Medicine, the National Steering Committee on Patient Safety, and the Addictions Foundation of Manitoba.

We'll begin with the Manitoba Centre for Health Policy, with Dr. Noralou Roos, director, and Dr. Anita Kozyrskyj, assistant professor with that organization.

Ms. Roos, would you like to begin?

Dr. Noralou Roos (Director and Senior Researcher, Manitoba Centre for Health Policy): Thank you very much.

I would certainly like to commend those of you involved in this effort for focusing on what I believe to be absolutely critical questions facing Canadian medicare over the next decade.

To get to my bottom line first, there are four areas I would urge you to focus on in your deliberations. One, which is from my perspective extraordinarily important, is to create the capability for reviewing and funding research on the cost-effectiveness of drugs--and here's the kicker--at arm's length from the pharmaceutical industry, both generic and patent.

Second, I think it's extraordinarily important for you to come up with mechanisms for aggressively prohibiting direct advertisement to consumers. The legislation is in place; the enforcement of it is somewhat problematic.

Third, I think it's very important that the nascent efforts to develop means of collaboration across the country among the provinces on both the listing and purchasing of drugs be supported.

Fourth, I would urge you to look very critically and skeptically at the proposal that we really don't need to be that concerned about rising pharmaceutical costs, that this is really another form of industrial development, economic spending, which might be seen as an engine of economic growth. This is an argument we're hearing more frequently and it's something that needs to be examined very critically.

First of all, the focus on the arm's-length research is an extraordinarily important thing, which really is not happening. Without having research into drug effectiveness, into public interest research questions about the use of drugs and compliance with the recommended use patterns, the right questions just don't get asked. The evidence that is produced--we have several studies showing this--tends to be very optimistic about the drug effectiveness. The research often ends up in some sense having critical biases.

My colleague, Anita Kozyrskyj, who is a pharmacist and is appointed in both the faculties of medicine and pharmacy, will speak to some research we've done at the centre focusing on why it's critical to introduce this public interest perspective on cost-effectiveness into drug research.

The critical question that always comes up is that it may be important, but how do we fund it? What I would point out is that as part of the patent legislation, companies are required to devote 10% of sales to research and development in the country. They've achieved this target.

While some of this goes into basic research, in the latest report that I read from the Patented Medicine Prices Review Board, only about 16% was going into basic research. The big bulk of these funds is going into clinical trials and into post-trial marketing.

If only one-quarter of this 10% of sales, which is their commitment, went into arm's-length research, this would basically transform our ability to assess the cost-effectiveness of drugs in this country.

So what's the problem with the existing approach to research?

I think the most compelling evidence of how serious these problems are is represented by the statements that the editors of the leading medical journals made a couple of years ago when they came out with recommendations based on their experience of the problems they were having with the manuscripts they were receiving--asking for full disclosure of the sponsor's role in research; asking for assurances that the investigators were independent of the sponsor; ensuring that they were fully accountable for the design and conduct of the trial; ensuring that they had independent access to the data; and, importantly, ensuring they had control over all editorial and publication decisions.

¿ (0910)

So it's a concern that they felt they had to make these requirements, but what's even more of a concern is that they did a study in the U.S that found the vast majority of contract research done in the U.S didn't even come close to meeting these requirements.

A similar study is being undertaken by the Canadian Institutes of Health Research in Canada, which will be starting, I believe, in the winter or early spring, and we have no reason to expect the situation in Canada is any better than this. The situation is very serious.

I mentioned the importance of cross-provincial collaboration. I think, if you haven't done it already, looking at what's going on in New Zealand and Australia around mass purchasing, around coordinated review of what gets listed, is very important.

In regard to the prohibition of direct-to-consumer advertising, again the evidence suggests that what happens is you drive up physician visits and drug costs through direct advertising to consumers, and the results are very interesting. Physicians are very likely to prescribe drugs when asked by patients.

However, when physicians are asked if they think it was a good idea that such a drug be prescribed, in more than half the cases they said had they made the decision independently and not been asked by the patient, they would not have prescribed this drug. So this again is a very problematic situation.

Finally, in the area of drug costs as an engine of economic growth, the health economists who have worked in this area are very concerned that unless there is a strong commitment to arm's-length assessment of drug research, the expansion of the pharmaceutical industry in Canada will lead directly to a marked escalation in drug costs.

The big concern is that the way this initiative is being pushed is to ask for quid pro quo. The public policy forum document, which was one of the first places.... This was a meeting held in Montreal, not this last summer but the previous summer. It made the statement that Canada's research-based pharmaceutical industry is ready to entertain significant investment commitments under certain conditions.

The conditions they're looking for would essentially make even some of the somewhat effective policies in place, including the reference-based pricing initiative in B.C. and the mass purchasing or the extended use of generic drugs, which one finds both in B.C. and Saskatchewan, much more difficult--if this quid pro quo approach to increased investment were accepted.

In summary, from my work and my look at this, I would urge you to look very carefully particularly at this arm's-length funding of research. I think some of the work we've done at the Manitoba centre--which Anita will speak to shortly--reinforces the importance of this policy.

Thank you.

¿ (0915)

The Chair: Dr. Kozyrskyj.

Dr. Anita Kozyrskyj (Assistant Professor, University of Manitoba, Manitoba Centre for Health Policy): We provided you with an example of the research done at the Manitoba Centre for Health Policy in the area of appropriate use of pharmaceuticals, effectiveness of use, cost-effectiveness. The example we've provided is in the area of anti-hypertensive drugs. We released a report last year that compared two kinds of drugs, the ACE inhibitors and the A2RAs, which are considered therapeutically equivalent. At the time we evaluated their use, there was a recommendation that the A2RAs be used only after a trial of the ACE inhibitor. The A2RAs are a newer class of drug and they're more expensive. We found that 60% of individuals who use this new class of drug had not in fact received a previous course of the ACE inhibitor. So this was a test of evidence based on the literature, and also of clinical practice guidelines at the time. This was in 1999.

Since the release of the report, of course, time has passed and the clinical practice guidelines have been changed. In this year this new class of drug now has appeared as a first-line alternative to the older class of drug. This is of interest, because when you actually read the clinical practice guidelines, there are statements relating the background material that was used in the production of them, that the evidence is based on clinical trials, and it does not include any consideration of public health considerations or cost-effectiveness. So the clinical practice guidelines are based on evidence, but not based on cost-effective evidence. Our research shows that it's important to consider the appropriateness of use and the effectiveness of use. I guess this evidence complements the efficacy or the clinical trials evidence. We will be releasing a report that shows cost savings if you actually do follow the practice of using one drug before the other as an approach to prescribing.

I just wanted to bring to your attention that there are various influences involved in the creation of these guidelines, and cost-effectiveness and public health considerations may not be among them.

The Chair: Thank you, Dr. Kozyrskyj.

We'll move onto the Department of Family Medicine and the Manitoba Centre for Health Policy at the University of Manitoba. The representative is Dr. Alan Katz from the Department of Family Medicine.

¿ (0920)

Dr. Alan Katz (Associate Professor and Associate Department Head, Department of Family Medicine and Manitoba Centre for Health Policy, University of Manitoba): Thank you.

I have three major messages that I'd like to address. The first one is with regard to the approval of new drugs and the mechanism therewith. The second is with regard to funding for clinical trials. The third is with regard to accountability for prescribing of drugs.

I think there are currently significant problems with the system Health Canada uses in the approval of new drugs. This is because there are two very strong conflicting interests at stake here. The one is the safety of the public who are to use these drugs, and the other is the pressure from interest groups, disease groups, such as HIV/AIDS, where we saw a significant change in the number of drugs that went through a rapid approval process because of the activism of that group, and from industry, which frequently comments on the millions of drugs that are lost on a daily basis as approvals for drugs are delayed.

I think the solution lies in a differentiation in the process of approval. There's potential to recognize that very few of the drugs that come before the approval process actually lead to dramatic improvements in either quality of life or survival. It's a small fraction of the drugs that are approved that actually make a dramatic difference. For those drugs there needs to be a process that recognizes that, that allows a much more rapid approval process, but part of that needs to be compulsory surveillance. So a drug can be approved for use much more quickly, with a less rigorous approval process, but built into this is that it's an approval with a caveat that surveillance of all use of this drug is compulsory.

I mention this for addressing safety, but I think there's an added spinoff value, in that our current system does not encourage physicians to be involved in surveillance of safety of drugs. Currently, the adverse effects reporting system is dramatically underutilized. I think it's voluntary. Maybe it's compulsory, but I'm a practising physician and I can tell you that none of my colleagues fills in those forms; none of my colleagues sees it as part of their responsibilities in a busy day of seeing multiple patients to go and fill out a form that a patient had a reaction to a drug. We need to change that. One of the ways of changing it is by instituting a system with a small, select group of high-impact drugs, so you know if you prescribe that drug you have a responsibility for surveillance. And surveillance in that context doesn't just mean adverse effects; it means good effects too. So it becomes part of the process.

So I see a differential system based on the potential impact of the drug. The vast majority of drugs will go through an extremely rigorous process, with a few drugs going through the more rapid process.

The second issue I wanted to address is the funding of clinical trials primarily, but other research as well. There was a recent paper published in the British Journal of Medical Ethics by an ethicist from Manitoba who made a fairly cogent argument that no clinical trials should be funded by industry at all, based on a number of ethical arguments and some examples of places where things have gone wrong. I don't believe that's realistic, and I don't believe you will accept that as being realistic, but I do think there is potential for a middle of the road situation. I want to draw your attention to some of the work we've been doing in the Department of Family Medicine through our primary health care research unit in combination with industry. I think there's a place for partnership between industry and academia.

One study in particular I want to tell you some of the results of. It's called the Manitoba appropriate anti-inflammatory utilization intervention study. We found a neat acronym, MAAUI, for the study and we've got some interesting findings.

¿ (0925)

It's a study where there's a partnership between industry, academia, and provincial government, and I think it is a potential model for collaboration and partnership. It certainly, in my view, is a great improvement on the current situation, where the vast majority of research is funded by industry, with no input from academia or governments. I think that's a sad situation and doesn't serve us well.

I must tell you that our experience in this kind of model has not been universally positive. There is a tendency for industry, depending on your industry partner, to want to dominate the process. So we have learned that some partners are better partners to work with. But I think we have found, certainly in the MAAUI project, partners who understand where we're coming from, and it works extremely well. So it can be done.

The third comment I wanted to make concerns accountability for drug prescribing and the monitoring of prescribing practices. There is, in my view, currently no accountability for those who write a prescription. Errors are made. Pharmacists, unfortunately, work in an environment where the more prescriptions you fill, the more you earn, as with the majority of physicians, who work in an environment where the more patients you see, the more you earn. So errors slip through. There is no current incentive for either the physician or the pharmacists to pick up those errors and to monitor prescribing practices in respect of interaction of drugs.

In Manitoba we have an electronic system that sends an immediate message to the pharmacist whenever there's a potential interaction of two drugs that the patient is on as part of the dispensing process. Since that's been in place, I think 10 years now, and I have not once received a phone call from a pharmacist telling me of a potential interaction. I know I've prescribed drugs where there have been potential interactions, but the current system allows an immediate override. You hit the button and it just goes away. The assumption on the part of the pharmacist is that I know that. I can tell you that's a false assumption. Most physicians do not use information technology to its potential and are not aware of those interactions. So there currently is no accountability in the system.

Mr. Svend Robinson (Burnaby—Douglas, NDP): Does that warning go to the pharmacist or to physician?

Dr. Alan Katz: It goes to the pharmacist. When the pharmacist enters a drug into the current provincial system, that system automatically looks through the drugs that patient is already on. And this is a compulsory system that all pharmacies in Manitoba have. But the same does not apply to family physicians' offices. Probably 10% of family physicians have electronic health records and have a system that has that potential.

So one of the things we need to do is support information technology that allows the point of prescribing, the physician's office, to have this potential. But I would suggest that we need to go a step further. I spoke about surveillance for high-risk drugs. We need to build a culture of accountability where physicians have a sense of accountability not only to themselves and individual patients but also to the system.

I think they've seen a number of initiatives in the U.K. in this regard, where primary care reform over the last 10 years has recognized the need for accountability, has put money into the system to build a system of accountability, to build research into that, that allows accountability to be measured. In Australia as well, significant resources have been put into primary care research, specifically recognizing the high percentage of our health care that happens at the primary care level, recognizing the fact that if you look at the distribution of research dollars currently, primary care is dramatically under-researched. And accountability is one area where I think research is necessary.

One example of the work we've done in this area is with regard to anti-inflammatory medications, where development of the COX 2s or coxibs group of drugs is recommended. In Manitoba reimbursement is provided only if these drugs are prescribed to high-risk patients.

I also presented in my written submission the results of some of the work we've done in the MAAUI project. Out of high-risk patients, the majority of them, 53%, receive the old anti-inflammatory drugs, which they should not be receiving, so there is underprescribing in that group, and 47% receive appropriate prescribing. In low-risk patients, a much smaller group, there is overprescribing in about 3,000 patients.

So some low-risk patients are receiving drugs they don't need, but the majority of high-risk patients are not receiving the protection they need. There's a lot of potential for improvement there, as the study shows.

While the conventional wisdom is that the pharmaceutical industry is dramatically successful in their marketing, and that everybody is getting the most expensive drug...I think they are successful, and I think there needs to be balance in that marketing process, but I think there are as well a number of patients not receiving the potential good that they can receive.

In my written submission I also mention the work I did at the Manitoba Centre for Health Policy with regard to beta blockers, drugs that have been shown to have a 14% reduction in mortality after myocardial infarction. Only 59% of Manitobans are on beta blockers after myocardial infarction. So there would be fairly dramatic potential in terms of mortality if there were an increase in beta blocker usage, but to be honest, the pharmaceutical industry does not promote beta blocker usage because there's no money in it. These are drugs that have been on the market for 10 or 20 years, and in the last 10 years I can't remember having seen anything from industry supporting the use of beta blockers after myocardial infarction, because there are so many on the market and these are not expensive drugs.

So we have potential here for dramatically improving outcomes with a very simple use of a drug that's freely available on the market and relatively cheap.

¿ (0930)

The Chair: Thank you, Dr. Katz.

Our next witness is the former chair of the National Steering Committee on Patient Safety, Dr. John Wade.

Dr. Wade.

Dr. John Wade (Former Chair, National Steering Committee on Patient Safety): Good morning, and thank you for inviting me.

You probably don't know me, but I've been described as a paleoanesthesiologist and as a has-been in recovery from being a deputy minister of health for a few years. I want to speak about patient safety, which I think will be a really major issue in this nation over the next couple of months, never mind years.

My background in this goes back to the days in anesthesia, in the late sixties, when we were concerned that the death rate from anesthesia in Canada was probably one in 500. We pursued some outcome studies, with the assistance of the Centre for Health Policy and others, documenting the problems. Then we wrote the guidelines to practice for the Canadian Anestheiologists' Society. Those are now in place. They are upgraded every year. The outcome from anesthesia now, the death rate, is only one in 250,000. Well, I say “only”, but even that isn't good enough.

We've also gone from the highest CMPA medical legal fees, up there with obstetricians and neurosurgeons in the seventies, to a very low level as a result of paying attention and documenting and doing research and acting on patient safety and outcomes.

I think the patient safety institute...and I don't know whether you've read our study. I've given you a copy. It arose out of a meeting of the Royal College of Physicians and Surgeons in 2001 in Ottawa. Out of that, the Americans and others said that “to err is human”, that there was something in the neighbourhood of 80,000 to 100,000 deaths in hospitals in America every year, at least 50% preventable. That alerted many people in this country. We had no study. There was no coordination. So that group, comprised of lay people, physicians, nurses, pharmacists, ministers of health from Alberta and Nova Scotia, and Health Canada formed a steering committee, which I chaired. Our message was to bring back a plan within a year. We did that.

The other thing we insisted on was, “Government, hands off. Let us do it.” We did not think, with the current state of federal-provincial...whatever you want to call it, that it could be done through the political process.

So that's what we did, and we formed five working groups. Those working groups were in the areas of measurement and evaluation and education systems. We now know that most adverse events are not caused by individuals but by systemic failure. As well, with regard to the legal and the regulatory, if we're ever going to have reporting, we need to look at the provincial regulations and the legislation in terms of privacy, confidentiality, and privileged communication.

That's best exemplified by the tragic death of the young child in British Columbia who had an injection of a chemotherapeutic cancer agent into her spinal cord at the children's hospital. It was only supposed to be administered intravenously. When her death was looked at, it turns out there had been three other incidents in Canada that had gone through coroners' inquests, but that information was not shared across the nation. As a result, we had the fourth preventable death.

So the legal and regulatory are critical. We need to have a new form of multidisciplinary education of our nurses, pharmacists, and others, with systemic reviews, the accreditation process.... Things like wrong-limb surgery, etc., can be handled that way. We need measurement and evaluation. As well, we know from what's going on in the United States that the public needs to be informed and physicians need to be informed. The public says, ”That's low on our list, because we're more concerned about getting our hip done and our MRI.” Physicians say, “Well, that may be true for some other doctors, but not me and not in my hospital.” And we know that's not right.

Medications are an important part of adverse outcomes and deaths, probably amounting to 40%, but they are also part of the systemic problem in that when you see adverse events with medication, certainly in the institutions, it indicates a failure and breakdown with other people within the system as well as with the medication itself. So they are part of a greater problem, and they need to be addressed in that manner.

¿ (0935)

Our report has gone in. We had 19 recommendations. We presented to Mr. Romanow and to the ministers of health...in the latest federal budget there is $50 million allocated to patient safety, or $10 million a year for five years.

There's an interim group looking at setting up a Canadian patient safety institute, which I think needs to proceed very quickly. I think the pressure is going to come from what's called the Baker-Norton study. CIHI and CIHR have funded a study to look at adverse events and outcomes in Canadian hospitals. That study will be published late this year in peer review journals. It's coming down the track.

I would be very surprised if there are not 10,000 deaths in Canadian hospitals annually, 50% of which are preventable. As politicians, if you're not ready for this...because I think the Canadian public is going to be very concerned about what's going on in our health care system.

That publication is going to be out...I'm not sure when, but probably later this year. It will be published in a peer review journal, something like the CanadianMedical Association Journal. So there is some urgency for the Canadian patient safety institute to get set up, get organized, and get busy, because I think it's in the best interests of the health of all Canadians.

I should say, too, there's a tremendous economic spinoff. If you increase, through adverse events, the length of stay in hospitals or legal fees or any of those things, we're talking about millions, if not billions, of cost to the system. Although that shouldn't be the primary driver, there is a strong economic driver to it as well.

So I would urge you to have a look at our document and to do whatever you can to help facilitate the establishment of a permanent Canadian patient safety institute that would coordinate, facilitate, and stimulate patient safety in our country.

Thank you.

¿ (0940)

The Chair: Thank you, Dr. Wade.

Our next witness is from the Addictions Foundation of Manitoba, Deb Kostyk, seniors and addictions prevention education consultant.

Ms. Kostyk.

Mrs. Deb Kostyk (Seniors and Addictions Prevention Education Consultant, Addictions Foundation of Manitoba): Thank you very much for the opportunity to speak to you today.

I will be focusing on seniors, as my specialty is seniors and substance misuse. I've been doing this for about 20 years, and hopefully I'll have some ideas to share with you at the end of the presentation as well that might be helpful.

One of the things in terms of adding a seniors flavour to this today is just to let you know, if you're not aware at this point, that in Canada, seniors 65 plus comprise about 12% of the population. Manitoba actually has the second highest proportion of seniors across Canada, at 13.6%. And we've been hearing over the years about the baby boom, about the bust and echo that's going to be happening. Definitely we will be seeing a dramatic rise in the proportion of older adults in Canada over the next 40 years. So in terms of the seniors population, that's what we're looking at.

If we add the whole thing of older adults as prescription drug consumers, that also adds another dimension to it. People over the age of 65 spend about four times more on prescription drugs than do younger age groups. As well, in Manitoba, from 1996 to the year 2000 there's been an increase among older adults of a greater proportion of dispensed medications. They're taking more medications as time goes on.

As well, when we look at older adults, we've found that people over the age of 65 take an average of five prescription medications. So they definitely are high users of medications.

The other thing is that when we talk “addiction”, I tend to prefer the term “substance misuse”. That helps me in that I can get away from the whole thing about whether they're using it intentionally or unintentionally. It's misuse all the way across the board.

The definition that I find helpful actually comes from a network that is slowly growing in Manitoba, called Partners Seeking Solutions with Seniors. Our focus is looking at substance misuse in Manitoba with seniors. What we've come up with for a definition is looking at the overuse but also the underuse or inappropriate use of drugs or alcohol that results in personal, social, or health problems for the user. But to me it's also systemic; it creates problems not only for the person who's consuming the drug but also for the system at large.

When we look at older adults and their use of medications, what's happening is that any drug can be misused, as has been highlighted already. What we're looking at in terms of misuse is that it can be getting a prescription without appropriate indications; taking the wrong drug for a certain condition; taking too little of it; taking too much of it; or taking it for too long. So it's the counter-indicated use of medications, and not only for older adults but for the system at large. It's a system issue.

One piece of information to support this is that 12% to 46% of prescriptions dispensed were found to be unnecessary or inappropriate. This was with older adults particularly. So any drug can be misused.

¿ (0945)

We're also looking at, from an addictions point of view...and when I look at this, my favourites basically are those drugs that are psychoactive in nature, particularly those that are benzodiazepines or opiates. Those are the ones I tend to look for with older adults in terms of use. And it's actually quite alarming when we look at the numbers of older adults using those particular kinds of drugs. What I can tell you is that a number of years ago--I suppose this dates me a bit--we did a study in a Winnipeg hospital, in emergency, looking at possible drug dependency with opiates and benzodiazepines. What we found was that 17% of people over the age of 65 were possibly drug dependent on benzodiazepines or opiates. When you look at the population of older adults, that's quite an alarming number who had just been taking medications for, again, too long, inappropriately, beyond the therapeutic use, beyond its usefulness.

We're also looking at the fact that the older a person gets the more likely they are to be prescribed benzodiazepines particularly. I hear older adults referring to benzodiazepines as sleeping pills or nerve pills, but the older you get the more likely you are to be prescribed these particular drugs. And because of the aging sensitivity, because the aging body changes in many ways, there's increased fat content, decreased muscle content, decreased water content, all of those kinds of things that happen, which leads to greater sensitivity for these particular kinds of drugs, or any drug for that matter.

But from my perspective, looking at benzodiazepines and opiates, what you get from this, from using these particular drugs inappropriately, are unsteadiness, fatigue, increasing cognitive impairment, and difficulty concentrating, which can, in many ways, create a lot of difficulty for an older adult, who may possibly be compromised physically and mentally in some ways anyway.

Also, another thing we'll see in terms of prescription drug use that makes this a bit complex with anyone, but also for older adults, is not only the prescription drug use but also what they're mixing that prescription drug use with. I have an alarming piece of information: alcohol has a negative effect on over 150 medications. The other thing is--this information also really blew me away--that 20% of people over the age of 65 who use multiple medications are also daily drinkers. So again, the therapeutic effect and the possibility for adverse drug reactions becomes quite high for this particular population.

If we also add over-the-counter drugs, some of them also have opiates, codeine, in them, they have alcohol in them, and for an older adult who's also taking a benzodiazepine or an opiate, you increase the sedating effect without older adults even being aware of it. Herbal remedies can also have a definite dramatic impact on prescription medication, and older adults are using a lot of herbal remedies.

So it complicates the whole issue about use of prescription drugs, in terms of what they're mixing this with, which then can increase the incidence of adverse drug reaction, and adverse drug reaction is definitely the worst possible consequence of prescription drug use for older adults.

The other alarming factor about prescription drug use, particularly benzodiazepine use, among older adults is that falls are the sixth leading cause of death among older adults, and consistently in the literature benzodiazepines have been mentioned as one of the factors in creating the incidence of falls.

¿ (0950)

The thing about using benzodiazepines and opiates is that it is about the patient-doctor relationship. It's about older adults looking for a quick remedy for symptoms, usually sleeplessness, anxiety, and chronic pain. We all like to have relief of symptoms, and also then physicians feel compelled to provide some answer to those remedies.

So some of the factors relating to substance misuse among older adults, when we look at the system per se--I would agree with the panel--are due to a fragmented health care system, particularly when we have family physicians, pharmacists, and other service providers to older adults who tend not to communicate with each other, and also you have an older adult who may or may not know what to say, what to report to their health care providers, and the time to do it.

Also, I was involved with the elders health program. We got three-year national funding a few years ago, and we found that when we identified an older adult who had been on benzodiazepines--and it was common for us to find someone who'd been on benzodiazepines for 10 to 30 years, regularly using them--and who was interested in tapering off those kinds of medications, we made a phone call to the physician, and physicians, given the support, were actually ready and willing to collaborate in whatever way was going to be effective for the patient. It would also in many ways increase health benefits for that patient if they were tapered off appropriately.

We found quite often that it's support. If you can provide support to physicians, to pharmacists, and provide intersectoral cross-system support and connect this in a case management way, there can be definite health benefits that can really assist not only the older adult but the system at large.

Another of the factors about substance misuse that relates to this is the training: training in geriatric care; training in addictions; training in grief intervention, what to say, what to do. A factor in this system is the lack of prevention initiatives. What kind of message is getting out? We've also talked about marketing, not only messages getting out to physicians and pharmacists, but also to the public.

The Chair: You are well over your time. Can you just wrap up, please?

Mrs. Deb Kostyk: Some of the solutions we see in Manitoba include a medication information line to older adults, and that's a toll free number that people can use. It's a well-accessed program. There's intersectoral community collaboration, Partners Seeking Solutions with Seniors, going on right now. We also really need age-specific substance misuse programming. Older adults are not going to traditional addiction services. They're not speaking to physicians. They need age-specific programming that can work between systems.

Thank you.

The Chair: Thank you very much.

We'll move on to the second part of our meeting and begin with Mr. Merrifield.

Mr. Rob Merrifield (Yellowhead, Canadian Alliance): Thank you for coming in and sharing with us what you've seen and what you recommend. It's interesting, but it's so broad and we have very little time to ask the questions. First you have to discern how big of a problem we have out there, and I appreciate Deb's remarks, and, John, I think you've done quite a bit of work on this.

There's no question from the research I've done personally on it that I would concur with everything you're saying. We have a very serious problem out there, and some of the numbers we heard from our witnesses the other day were that 50% of the patients within our facilities have the potential for being mis-prescribed, or for having addictions and adverse reactions.

Maybe I'll ask the doctor this. Would you say that number is perhaps false, or would you confirm it?

¿ (0955)

Dr. Alan Katz: I don't know of any evidence either way yet. I know the study Dr. Wade referred to will answer that question in terms of the actual numbers, but in terms of experience it doesn't surprise me.

Mr. Rob Merrifield: That's what I'm asking. You have personal, hands-on experience, and you get a sense as to whether that is practically true or not, but you're saying to us that it's probably true.

Dr. Alan Katz: One of the issues you face with seniors in particular is the issue of drugs being prescribed for symptomatic reasons. Many times we know the drug is not going to cure a disease, but as you get older you develop multiple diseases that interact with each other, and as a result, patients come in with multiple complaints. The natural response is to want to help your patient, which means you're prescribing a drug for A and B. Each time it's a different drug, and the more drugs you prescribe, the more potential there is for interactions. In fact, that's how people end up in hospital with drug problems.

Dr. John Wade: I think the data are pretty clear from other countries, and I doubt that Canada is any different. Those numbers are probably right.

I would also say that Canada has an amazing opportunity to change that with Health Infoway. You funded that to $3 billion. They're looking to create electronic health records for all Canadians within the next five years. That will do two things: one, it will give us a database we've never had before to pursue further, drill down on, some of the data we need, but also combined with the pharmacare systems that are in Manitoba, the DPIN system here and others, you will have electronic subscribing--probably interactive and tracked--and that's an amazing opportunity. No other country could do that because no other country has a single pair and--

Mr. Rob Merrifield: It seems like each province is doing their own thing on this one. I know Alberta has the Alberta Wellnet program. They're looking at their electronic records falling within the next 12 months. There will be an interesting pilot in that province to see if that can be applied, but there's no question we have a unique opportunity in Canada to make....

Hopefully, Infoway will allow all provinces to talk together nationally and will work its way through. I would agree with you.

I'll really be looking forward to your report and being able to read your 19 recommendations and some of the work you've done, because I think you're ahead of the curve. When we talk to the department we hear that very little work has been done in this area. So thank you for your work and for what you're doing with it.

I have one question before we get on to some of the other solutions. You talked a lot about the problem with the benzodiazepines. When you find that an individual has been addicted to benzodiazepines, how difficult is it to get them off that?

Mrs. Deb Kostyk: It's quite possible. The elders health program successfully tapered older adults off benzodiazepines, with support and by promoting other behavioural therapeutic alternatives, which is really key. There are tangible behavioural alternatives to offer that allow people options in terms of managing their symptoms.

Mr. Rob Merrifield: How long does it take to get them off?

Mrs. Deb Kostyk: It varies. With brief intervention, I have seen some older adults--in some ways it's a bit scary but they're doing it--tapering themselves off in a matter of a few weeks to a few months. Others I've seen require about one to two years.

Mr. Rob Merrifield: So it's a long process.

Getting back to the doctor--because I know my time is limited here--in terms of some of the solutions, you're saying that academia and industry are not working in a collaborative way for some of the studies on drugs right now and you're recommending that should be taking place.

Dr. Alan Katz: The vast majority of studies that are currently taking place are funded by industry through research organizations. Some academic people will be participating in them, but the studies are controlled by industry.

Mr. Rob Merrifield: So you're talking about the control of it, not necessarily that you're working together collaboratively.

Dr. Alan Katz: Yes, the model I'm talking about is a steering committee model where the actual data is kept within the academic environment and the publication is not controlled by industry--that kind of thing.

À (1000)

Mr. Rob Merrifield: Yes, I would concur. I don't have a problem with that.

Right at the beginning we were talking about the recommendations on research into direct-to-consumer advertising, listing of purchasing drugs and using it as an engine of growth, but I'm wondering what your thoughts are on faster approvals being safer and cheaper. How important is moving to the faster approval of drugs when you relate that to your comments on the economic engine and the growth driver?

Dr. Noralou Roos: I think Alan's comments are pertinent here. When they reviewed the 1,000 drugs that had been approved in the last 10 years, what they found was that 85% were marginal improvements on what had been available before. So the argument about the need for faster approval applies only if you're going to focus on identifying where there's this promise for the very small minority.

Mr. Rob Merrifield: Do we know that beforehand?

Dr. Alan Katz: We should, because part of the process is that people have to make submissions with evidence, and when they file other drugs in the same category--

Mr. Rob Merrifield: Isn't that happening to some degree now?

Dr. Noralou Roos: No.

Mr. Rob Merrifield: Okay, fair enough.

The Chair: Mr. Thompson.

Mr. Greg Thompson (New Brunswick Southwest, PC): Thank you, Madam Chair.

I want to pick up on what Dr. Katz and Ms. Roos had to say about the approval of drugs and some of these marginal drugs that are approved. It goes back to part of the testimony we heard from Dr. J.D. Bury, who in one of his publications on reducing drug prices talks about irresponsible prescribing. It fits in with what you people are saying about some of these new drugs that come on the market. He's talking about drugs that cost 100 times as much as some of the first-line drugs that are doing exactly the same thing. One of the examples he draws is in the area of hypertension.

Yesterday one of the things I suggested to him, which we've heard actually from the Minister of Health for the Province of Saskatchewan, was the idea of a clinical trials registry. I just want to hear your comments on that. What identifies some of those marginal drugs, so that we wouldn't be in such a rush to push some of these onto the market? We're talking about the high cost of prescription drugs, and a lot of that could be avoided. We bring on these wonderful cures that do absolutely nothing new, only to find that it's costing either the government or individuals much more than it should.

I'd just like to hear you speak on that, Alan, specifically in regard to a clinical trials registry, whether or not that could work. Would it in fact help? Ms. Roos, maybe you could pick up on what Alan has to say.

Dr. Alan Katz: I don't believe the answer lies in a clinical trials registry necessarily, because the results of clinical trials are generally published anyway. They may be a little bit more difficult to find, but they're out there.

The issue of not approving the more expensive drugs is a complex one. Ultimately, the problem isn't that the more expensive drugs are used at all; the problem is that they're used unnecessarily in a majority of patients. There is a place for the more expensive hypertension drug, but it's not in the majority of patients. Maybe 60% or 70% of patients should be taking cheap diuretics that cost pennies a day rather than the drugs that cost $2 a day. But there's still a need for the more expensive drugs in patients. I don't think it's wise to suggest that those more expensive drugs should never be approved. I think it's how they're used by physicians that we need to look at. Clinical trials will not address that issue; it's a marketing issue, an issue of balancing the influence on prescribing patents.

À (1005)

Mr. Greg Thompson: In regard to clinical trials, you can compare quickly, I guess, the results of one drug over another with respect to how the process unfolded. Would that be helpful?

Dr. Alan Katz: The problem is that clinical trials comparing diuretics that cost pennies a day and the drugs Anita referred to are not done, because the people who fund clinical trials are the pharmaceutical industry, and there's no advantage in comparing pennies to dollars. So it's not so much a registry of what's being done; it's influencing the process initially. Rather than keeping a registry of what's being done, it's influencing it and developing partnerships with industry that actually help make the decisions about how these trials are done.

Mr. Greg Thompson: So you're saying some of the evidence in clinical trials is skewed from the get-go because the person who's conducting the trials is the person who's going to benefit.

Dr. Noralou Roos:

They design the trials very deliberately, ensuring that they pick a drug for comparison such that they can anticipate that they'll show advantageous results.

Mr. Greg Thompson: Ms. Roos, is there an area that we can go to beyond the clinical trials for practical evidence, provided by, for example, the medical profession, on the success rate of a particular drug or the ability to cure an ailment?

Dr. Noralou Roos: This is really why I'm a very strong believer in setting up significant investment in arm's-length evaluation, a public-interest-driven questioning. There needs to be funding out there to ensure that there is broad distribution. How do you counter the marketing, which the drug companies are very effective at, ensuring that you potentially review how physicians are prescribing in a very public way and that information gets communicated broadly to the public on the cost-effectiveness issues Anita was describing?

Mr. Greg Thompson: That fits in well with your position on advertising as well.

Dr. Noralou Roos: Absolutely.

Mr. Greg Thompson: That was just another opportunity to exaggerate the claims of drugs, whether they're effective or not. We've had many examples of that.

Dr. Anita Kozyrskyj: If I may add, on the issue of the clinical trial evidence and the choices I made in terms of which drugs were compared, this evidence is then incorporated into clinical practice guidelines. We don't have additional evidence in terms of the effectiveness of these drugs once they're released onto the market. The example we gave of the population-based studies we do at the Manitoba Centre for Health Policy would give the opportunity to make comparisons of drugs that are more expensive, less expensive, and as effective, and would contribute to this evidence. So this is evidence in addition to clinical trial evidence. If it were available, there would then be the opportunity to incorporate it into clinical practice guidelines.

The clinical practice guideline is the guideline by which physicians practice, so once this evidence is incorporated into the guideline, it's very difficult to make substantial changes.

Mr. Greg Thompson: Then we should be able to share that information quickly and worldwide, because a lot of that evidence.... I guess what I'm saying is that it's okay for Canada to adopt that system--it would be fine--but that type of system would have to be international, if you will. Is that correct?

Dr. John Wade: No, I don't think so.

I think you have a wonderful opportunity in Canada with the new Infoway on drugs to put that in every doctor's office. One of the reasons that clinical practice guidelines haven't worked is that they are too complicated for the person. I was a GP and have been on the firing line; you don't have time to be looking up clinical practice guidelines, etc. But if you had that on your computer in your office, where you could see it and interact with it, etc., and prescribe that way—which should be entirely possible in this age, as you see it at McDonald's every day—it would really go forward.

I'd just like to comment on clinical trials. Number one, they're the biggest marketing that drug companies have. What they do is go out and recruit people—me being one of them, having introduced Forane in terms of anesthesia in the United States and Canada—who go to talk about it on some platform. That's the best advertising a drug company can have. So you have to look at clinical trials as marketing for drug companies.

Secondly, Canada has not funded good clinical research. So many clinicians have had to resort to clinical trials to get some money to do research—or often for other things. As they said in my first profession, “You always skate to open ice”. Well, the only open ice that clinical investigators have had has been from the clinical trials and funding that way, because government or provincial funding hasn't supported that.

So you've got this problem. I agree completely with Noralou that if you took a certain percentage of money that is now being used in clinical trials and put that towards a stand-alone evaluation and communication strategy, we'd be miles ahead. And the good drug companies, who have good products, would benefit from strong peer-reviewed research showing the benefit from their drugs. But they have to be convinced.

À (1010)

Mr. Greg Thompson: Thank you, Madam Chair.

The Chair: Thank you, Mr. Thompson.

Mr. Dromisky.

Mr. Stan Dromisky (Thunder Bay—Atikokan, Lib.): Thank you very much.

Through all these hearings and so forth, and the more we read about and listen to the kinds of problems related to this area, I could draw an analogy. It's much like a symphony orchestra. We have a large number of very, very talented people who are well educated, very bright, and even creative, but they're all playing a different piece of music at the same time. That's the way I see it.

Now here we have a doctor who says he's too busy. We have a huge problem regarding the adverse effects of drugs in our population—not just for seniors—but doctors are too busy. Well, how are we going to find out when the vast majority of people affected maybe don't know what they should be doing? They turn to the doctor. After all, the doctor prescribed it. They don't go running to the radio station; they don't go running to the press; they don't go running to Health Canada. Where do they go? How are we going to find out? That's the big problem.

So what suggestions would you have as professionals to make that system work, so that we get the information pertaining to adverse effects?

I talked to a doctor the other day. He's fading out of the system or out of his practice. He's only working half-time now, so I asked him, “How many patients do you see in a day?” He said, “Well, I try to keep it to 40.” I can appreciate and understand what he's going through, and what all doctors are going through in this country, with the pay system and everything else.

Do you have any comments pertaining to what I just finished saying?

Dr. John Wade: Instead of working harder, we have to play smarter. I don't think you'll ever change and do it right until you change the funding system for physicians.

People have talked about multidisciplinary reform, etc. I've heard it for 25 years. So why hasn't it worked? It's because most Canadian physicians are still on fee for service. If you're really interested in primary care, change the funding system and allow the payment of other providers and what I'll call health access centres--pharmacists, physiotherapists, etc. Give people the technology they need that's now out there.

It takes fundamental guts to change the system and to do the things that are necessary, but we'll be talking about this for another 25 years unless you make the fundamental decision to change the funding system and provide physicians and other health care providers with the support they deserve and the technology that's now present. We just have to get on with it; otherwise we'll still be talking 25 years from now.

Mr. Stan Dromisky: It's because we're directly related to the work ethic. The harder you work, the more money you should get. That's what we've been teaching our children for years and years--and for centuries maybe, I don't know. But it definitely is in our society. So the more people you see in a day is a good indicator to me that you are working harder than the doctor who sees fewer patients in a day; therefore you should get more money than he does. But the care you're giving is lousy; we know that.

In this part of the country, in Alberta, Saskatchewan, and Manitoba, you have large collections of certain ethnic groups. From your experience, are herbal medicines or other kinds of “treatment”--that's the word I'm going to use--more prominent with certain ethnic groups than with others? Do you find that certain ethnic groups stay away from pills as much as possible compared to others? Is there any evidence whatsoever...?

I'm just thinking of certain ethnic groups in the city of Thunder Bay. I know what they believe and preach to each other pertaining to hospital services. As an example, they say, “Hey, if you go into the hospital you're never going to come out, so stay away from the doctors and stay away from those kinds of places, because once they put you in there you're finished.” We still have people who think that way.

À (1015)

Dr. Alan Katz: That's unfortunately true for some people.

Voices: Oh, oh!

Mr. Stan Dromisky: Yes, and that was the information we just got from Dr. Wade.

Dr. Anita Kozyrskyj: We really haven't done very much research in that area, but one bit of research we have done relates to variations in prescription use according to neighbourhoods in Winnipeg, for example.

There are some very interesting patterns. In one that I recall, a certain neighbourhood that had a large proportion of new immigrant families had the lowest rate of use of antidepressants, for example. This is probably as close as we can get in evidence relating to certain cultural groups and differential use of the health care system. It is an interesting question.

Mrs. Deb Kostyk: It's definitely anecdotal--

Mr. Stan Dromisky: Yes, that's what I'm referring to.

Mrs. Deb Kostyk: We hear stories. I just met with a man from the Filipino community who is a senior. He talked about how there were certain beliefs about medications and alternative health care practices in that community. He finds them quite effective, thank you very much.

Mr. Stan Dromisky: Could I have one more question? This is switching the topic.

It's marketing we're talking about. The drug companies want to make big bucks. When I take a look at the whole system, it seems to me we're all players, but the whole industry is being controlled by the pharmaceutical companies. They seem to be able to get away with anything they want.

I would be very suspicious of any results they published pertaining to any new kind of trial or research they were doing on a new drug. I'd be very cautious, there's no doubt about it. But they've gone through the experience and spent millions of dollars. I've visited pharmaceutical factories--I call them factories--in Montreal. I've gone to every one of them. In one of them they had 170-some professional people with PhDs--post-graduate studies--doing all kinds of research costing millions and millions of dollars. We know that story.

But how do I get my drugs out? I would like you to be very honest and tell me how you are enticed to pass on their drugs over someone else's drugs, to give the more expensive drug instead of the cheaper drug. What are the kinds of things the drug companies do to entice and encourage you to market their products, sell their products, or pass on the recommendation that their products should be used, instead of using your own common sense, intelligence, and judgment? There must be things being done for that to happen, because I hear all kinds of stories. I would like to gather more information before this committee.

Dr. Alan Katz: As a practising physician, let me speak first and tell you about an experience I had ten years ago when I took my rental car back to Avis, Hertz, or whatever. The fellow came into the parking lot with a handheld device, recorded my mileage immediately, and gave me a receipt on the spot within 15 seconds. That kind of technology still does not exist in the medical system. It has existed in private industry for years. So my point is that we're dealing with private industry that has access to millions of dollars and incredibly sophisticated marketing procedures.

The simple colour ads in the premier medical journals are the tip of the iceberg. I am probably not aware of some of the ways I'm being influenced by the industry, and that's their right. They have sophisticated marketers, and they're doing that because this is a free enterprise society. I think that's fine, but we need to try to balance that.

In my written submission I said we needed to try to support good evidence-based information getting to physicians through alternative means that are currently available, not through the industry. Yes, there are dinners, gifts, trips, and academic lectures sponsored by the industry. All those things are out there, and there are other more subtle things.

When someone from the industry comes into a physician's office in the morning and gives them details about a drug, that person often has information on the amount of their drug the physician has prescribed. There's a system out there where they buy information from pharmacies about your prescribing habits. A few weeks after they've been to your office, they get the data back and see that you're prescribing more.

So there's an enormous sophisticated system out there that currently is not balanced by evidence or academia. It's purely driven by the industry.

À (1020)

Mr. Stan Dromisky: In the future, do you think the profession can really govern itself without the interference of government or other agencies regulating your lives, as far as drugs are concerned? Will you ever reach that point?

Dr. Noralou Roos: Are you talking about the pharmaceutical industry governing itself?

Mr. Stan Dromisky: No. I'm talking about the medical profession and personnel who are involved in the prescribing of drugs.

Dr. John Wade: If you want to kill the health provider professions, then have the government regulate them. I wouldn't tolerate that. I think the professions, by and large, are doing an increasingly better job of regulation themselves. I've been in the bureaucracy, and there's no way it would work if they tried to regulate the professions.

They can support regulation, help with that, and provide the tools, etc., but if you put that into the bureaucracy, forget it. I guess I'd feel very strongly about that, and most of my colleagues would. That's not to say we're doing a good job as health providers; we could do a lot better. But why not support us in getting the technology, funding, and things necessary to do it? I think the professions would do it. I'm saying “professions”, not medicine alone.

The Chair: Thank you, Mr. Dromisky.

Mr. Robinson.

Mr. Svend Robinson: Thanks very much, and thanks to all of our witnesses for your evidence this morning. It's been very helpful.

I must say, the more I listen and the more I read in this area, the more convinced I become that a system based fundamentally on maximizing corporate profit in this area is one that leads to all sorts of outcomes that are just fundamentally at odds with the public interest and certainly at odds with maximizing the prevention of illness and the treatment of illness. That's the overall perspective I come at this from.

I was interested, Dr. Katz, in your reference to an article--I'm not sure if it was by one of your colleagues--with respect to clinical trials and taking corporate interference out entirely. It makes a lot of sense to me. What's the name of that particular clinician?

Dr. Alan Katz: Arthur Schafer wrote the article.

Mr. Svend Robinson: I wonder if our researcher could get the information on that article so it can be circulated to members of the committee.

I just have a couple of follow-up questions. You're at the University of Manitoba, and I gather the Centre for Health Policy is associated with the university as well. Does the University of Manitoba have any particular policy or guidelines with respect to confidentiality agreements for clinical trial outcomes or research that is being done?

Frankly, I think it's outrageous that in too many instances researchers who are conducting research that is paid for by corporations sign agreements that effectively muzzle them and silence them. I'm thinking of Nancy Olivieri and a number of other examples you're well aware of. What about the University of Manitoba?

À (1025)

Dr. Noralou Roos: This is a very good question. Dr. Katz and I were smiling at each other because several of us--and he was formerly the chair of the ethics committee--have been very concerned about precisely this issue and have been working with the administration to try to develop a series of guidelines.

Actually, much is based on the recommendations of the medical editors to ensure that research is reviewed in a systematic way and to ensure that contracts that are contrary to publication rights, etc., are not signed. However, it's recognized that it's a very uphill battle. Universities across the country are faced with exactly the same issues, and there's no expectation it's going to be solved quickly.

Mr. Svend Robinson: I'm not sure if Dr. Katz wants to add anything, but basically the University of Manitoba, then, has not changed its policy in this area.

Dr. Noralou Roos: It's in the process of developing a policy that fundamentally deals with patient safety issues and publication issues. As to how this gets implemented, most of the contracts with pharmaceutical companies are in fact signed not by the university, because university researchers don't drive the design of this research, but by the hospital research foundation. The contract officers are basically charged, because they get overhead from these contracts, with bringing in as many contracts as feasible, because this supports much of what goes on in these organizations.

Mr. Svend Robinson: It takes money.

Dr. Noralou Roos: Exactly.

Mr. Svend Robinson: This is clearly an area that as a committee we're going to want to look at carefully. Universities are publicly funded institutions. Frankly, I think it's outrageous that a publicly funded institution should be prepared to be a party to this kind of agreement.

Dr. John Wade: Can I comment? I used to be a dean.

I don't think what happened with Ms. Olivieri would have happened at the University of Manitoba. There you had primarily a hospital-based research institution that had a contract; it didn't necessarily go through the University of Toronto. Here, hopefully, that would have gone through the faculty first and then to the central university. That should--

Dr. Noralou Roos: No, it wouldn't.

Dr. John Wade: Well, it would have when I was there.

I want to make a different point, though. The universities are one problem, but what you're seeing now is a bunch of clinical trials coming up in the community that do not have the scrutiny of research ethics committees or whatever. I think that's a far greater problem than universities. What you're seeing out there are people in private practice doing clinical trials for drug companies and getting paid for it without training in education and research and without the scrutiny of an ethics committee.

Mr. Svend Robinson: That's another problem.

Dr. John Wade: That's a far greater problem.

Mr. Svend Robinson: I'm not sure it's a greater problem, but it certainly is a serious problem as well.

You made reference, Dr. Wade, to a study coming out later this fall that is really quite shocking; I think Canadians should be deeply concerned about that. To the extent that we as a committee are able to make recommendations in the pharmaceutical area, at least, because not all these 10,000 deaths are related to pharmaceuticals, of course, but--

Dr. John Wade: That's just in the hospitals. That doesn't include deaths in the communities.

Mr. Svend Robinson: No. I understand.

Dr. John Wade: That's a far bigger problem, one more difficult to study and not easily compared with the studies that have been done in other countries. That's why this is simply only hospital data.

Mr. Svend Robinson: I understand that, but I'm saying I very much appreciate your reference to that. Certainly, I'm sure that as a committee we're going to be looking very carefully at the results of that study and also at what recommendations we might make, hopefully, flowing from that study.

I just have one other question, and that is with respect to the issue of patent protection. I read a study recently--I think it was in The New England Journal of Medicine but I can't remember exactly where it was--that was pretty radical. It suggested that maybe as a society we should be asking the most fundamental and basic question: why is it that we have to basically bribe big pharmaceutical companies trying to make money to do research in splendid isolation? Of course, they only do research on stuff that makes money. If it's sleeping sickness that affects millions of poor Africans, they don't want to go there. What about--and I don't know whether any of you want to take this on--the suggestion that instead of funding research through corporate bribery and patents, we publicly fund it?

À (1030)

Dr. John Wade: We've underfunded research, including clinical research. Even with what's happened at MRC and CIHR, we're probably only at one-third of what the Americans spend per capita. We're really low, but don't forget, some of this research is the creation of new chemicals, etc., and I'm not sure if that's funded even in the United States, through NIH.

You have to have some mechanism to fund really early research, and right now it's the drug companies--and it's fair if they get some profit from it. We just underfund research, especially clinical research, in this country.

Mr. Svend Robinson: There's nothing at all that would prevent some of our fine young researchers from dedicating themselves, with public support, to doing the kind of research you're talking about as well.

Dr. John Wade: They would do it.

Dr. Alan Katz: Well, they would do it, but in fact the problem is much bigger than that, because currently the tendency is for our public institutions, our universities, to patent everything they do. You can criticize industry, which is openly in it for the money, but the current trend is for any significant findings in universities to be patented. The SARS virus genome has been patented by the University of British Columbia, etc.

So the extent of the underfunding of pubic research in universities has reached the stage where, for their survival, universities have industry liaison officers and patent offices. To survive and promote research they're patenting all these things, which I think is not necessarily in the best public interest.

Mr. Svend Robinson: Thank you.

The Chair: Thank you.

On behalf of the committee members, I want to once again thank our witnesses for coming forward. It's been a very valuable morning, and we've had a look at some of this from a different angle than we've had up to now. Thank you very much.

We look forward to anything you have to send us with respect to publications, new information, or anything you think might follow up on some of the questions you've heard today.

We'll take a 10-minute break.

À (1032)

À (1050)

The Chair: We're called back to order, and welcome to our next group of witnesses at our hearings on prescription drugs.

This morning we have representatives from the Coalition for Manitoba Pharmacy, the Manitoba Pharmaceutical Association, and the Manitoba Society of Pharmacists.

From the coalition we have three witnesses, Mr. Dueck, Mr. Skura, and Ms. Fontaine. One of you, I think, is going to lead off.

Ms. Michele Fontaine (Vice-President, Coalition for Manitoba Pharmacy): Good morning.

I am currently a community pharmacist in Winnipeg and vice-president of the Coalition for Manitoba Pharmacy. On behalf of my colleagues with the coalition, I would like to thank the committee for the opportunity to address you today.

As the committee gathers evidence from Canadians regarding prescription drug prices, availability, prescribing practices, and adverse events, it is critical to closely examine a new and dangerous trend that is growing across Canada, but is currently most serious in Manitoba. The primary concern of the Coalition for Manitoba Pharmacy is the rapidly growing cross-border Internet pharmacy export business. The coalition believes this trade is illegitimate, unethical, and causing significant harm to our health care system.

I would like to begin by speaking to a frightening development I have seen in my pharmacy that has also been reported by community pharmacists from one end of Manitoba to the other: increasing shortages of urgently needed prescription drugs. By their own reckoning, Internet pharmacy companies are diverting at least $1 billion worth of Canadian drugs to the United States. This is against U.S. federal law. In order to fill orders south of the border, Internet pharmacies have shown no regard for Canadians who need prescriptions, but rather have created an illegitimate underground network to buy Canadian medication at Canadian controlled prices and then turn around and resell those drugs at significant profit to Americans who can pay more.

My pharmacy is located adjacent to the Winnipeg Health Sciences Centre, and we process a significant percentage of the outpatient cancer prescriptions in Manitoba. In my practice I have recently seen more shortages than in my entire professional career, and some of the drugs that have been short are life-saving cancer drugs. On several occasions drugs for conditions such as brain tumours and adult and childhood leukemia have been simply unavailable through legitimate distribution networks in Manitoba. On those same days I have found the same cancer drugs listed as available to U.S. customers through Manitoba Internet pharmacy websites.

It is not acceptable for Americans with money to pay more for our drugs, to have access to medications that I can supply to my patients only through literally days of frantic sourcing, sometimes receiving only a single bottle of emergency drug supplied from the manufacturer. Internet pharmacy companies are claiming that increasing widespread shortages reported by community pharmacists are not their fault. They blame wholesalers, they blame manufacturers, they claim it's a coincidence. It is no coincidence. When you make it your business to divert to the U.S. as much of Canada's drug supply as you can sell, you create shortages for Canadians.

Mr. Greg Skura (Secretary, Coalition for Manitoba Pharmacy): Good morning.

I'm a pharmacist and partner at Super Thrifty Drugs Canada, the only pharmacy chain based in Manitoba. I'm also the secretary of the Coalition for Manitoba Pharmacy.

One of the most serious concerns regarding Internet pharmacy is how this commerce is creating a severe shortage of pharmacists in our province. Recently my company was forced to close the doors of our profitable pharmacy in Winnipegosis. This was the only drug store within a radius of 70 kilometres, and it also served the hospital and nursing home. This was the first time in 35 years that I've had to shut down a pharmacy. The reason is that there are simply no pharmacists available to work at our Winnipegosis store. Why? Cross-border Internet pharmacy, through the huge profits they make by selling Canadian drugs to the U.S. at higher prices, can lure pharmacists from our communities and hospitals with promises of huge salaries, bonuses, and a cut of the profit. As a result, approximately 20% of the pharmacists in Manitoba now work in the Internet pharmacy trade shipping Canada's drug supply to the U.S. rather than caring for Manitobans, who are less profitable.

Pharmacists have been in short supply before in Canada and Manitoba, but not like this, and it is the quality of pharmacy care to Manitobans that is suffering. My company has three more rural drug stores that are on the edge and are struggling to remain open, with no relief pharmacists available and an inability to hire new pharmacists. Internet pharmacy companies say the severe shortage of pharmacists in Manitoba is not their fault. They blame pharmacy chains; they say it is a coincidence. It is no coincidence. You can't take 20% of the pharmacy professionals out of Manitoba's communities and hospitals to serve the U.S. cash market and not harm pharmacy care at home. How many rural pharmacies will have to be shut down, putting access to medicine and pharmacy care of Manitobans at risk, before government takes action to stop the diversion of Canadian drugs and pharmacy care to the U.S.?

À (1055)

Mr. Lothar Dueck (President, Coalition for Manitoba Pharmacy): Hello.

I'm a community pharmacist in Vita, a small rural community, and president of the Coalition for Manitoba Pharmacy. I'd like to talk about how cross-border Internet pharmacy is driving up the price of prescription drugs and the risks if this continues.

Recently drug manufacturers have begun to raise prices of their products in Canada, for the first time in many years. One manufacturer raised its price by 4%, for the first time in four years. Others also have raised prices by 4%, for the first time in 10 years or more. We believe this is a reaction to the massive volume of drugs meant for Canadians that is now being shipped to the U.S., and Canadians are the ones who are forced to pay more so that Internet pharmacies can make money in the U.S. market. If Canada's governments allow this trade to continue, we believe the result will be an end to Canada's price-controlled drug regime that allows us to pay much less than Americans do for their prescription medicines. Canada's drug prices will rise to match those paid in the U.S.

The coalition is not alone in its ethical and professional opposition to cross-border pharmacy. The Canadian Pharmacists Association, the Canadian Medical Association, the Association of Deans of Pharmacy of Canada, the Manitoba Society of Seniors, and many other professional and consumer groups have made their concerns very clear.

As we have outlined in our submission to the committee, it is time for the federal government to act. Shortages of medicines, shortages of pharmacists and pharmacy care, and rising drug prices for Canadians are no coincidences. These, we believe, are the product of the cross-border Internet pharmacy trade. Canada's health care professionals are asking for your help. Canadians need more care, more involvement from pharmacists here at home, not less. We appeal to the federal government to take immediate steps to protect Canadians and to stop the export of Canada's drug supply and our pharmacy care.

The Chair: Thank you very much.

From the Manitoba Pharmaceutical Association we have the registrar, Mr. Ronald Guse.

Mr. Ronald Guse (Registrar, Manitoba Pharmaceutical Association): Thank you, Madam Chair.

I appreciate the opportunity to speak to the committee this morning. My name is Ron Guse, and I am the registrar with the Manitoba Pharmaceutical Association. Just for clarity, the pharmaceutical association represents neither the pharmaceutical industry nor the pharmacists. Our role is primarily protection of the public. I'm sure you're familiar with the College of Physicians and Surgeons throughout the country; our role would be similar to theirs, except we deal with the practice of pharmacy, not the practice of medicine.

We prepared a brief that was circulated ahead of time to the standing committee, and most of my comments will be directly from that brief for your ease.

Although this committee is stressing many issues, I'd like to focus on a certain number of issues that were listed in your mandate, certainly the rising cost of prescription drugs. With regard to prescription drugs in Canada, you really cannot speak about patented medicines without referencing the Patented Medicine Prices Review Board. I won't explain that board to you because I'm sure you're well aware of its responsibility.

In the 2002 report from the Patented Medicine Prices Review Board, it shows this is the first year that patented medicines in Canada were 1% higher than in the other jurisdictions they use for comparison. I believe Canada's market introduction of patented medicines and subsequent price increases being regulated by the PMPRB, the Patented Medicine Prices Review Board.... They do a phenomenal job for the Canadian public in regulating those prices.

One of the areas of prescription medications not regulated by the Patented Medicine Prices Review Board is products that have gone off patent--and some of them were never on patent because they predated that process. We commonly refer to them as generic products in Canada. Although the overall health care costs in Canada are somewhat lessened by having generic products on the market, the generic products, by and large, set their prices in relation to the patented products on the market, and they don't necessarily have anything to do with their cost of development.

What we've seen recently, in the last couple of years, in the formulary in Manitoba--and the formulary in Manitoba is not unlike formularies in other provinces that indicate what products are interchangeable and the prices of those products--is that with respect to the generic products, there's been a substantial increase over the last two years. Products that would have cost less than a penny per tablet have now increased to over 6¢ per tablet. It doesn't sound like a lot of money when you say 6¢ per tablet when you look at some of the products costing in excess of $1, $2, $3, or maybe $10 per tablet, but if you look at the percentage increase, you're looking at over 750% in price increases.

As mentioned in the previous presentation, there's been phenomenal growth in pharmacies across Canada. They're selling mostly patented medications to patients residing in the United States. Often this term is called Internet pharmacy. The Manitoba Pharmaceutical Association that licenses the practice of pharmacists and pharmacies in the province has identified these pharmacies as international prescription service pharmacies--IPS pharmacies. Frankly, as much as it's called Internet pharmacy, it really is a mail order system, and the Internet is used for advertisement and to gain access to larger numbers of population.

However, this unforeseen and unintended diversion of medication from Canada's price-protected system will--and has--result in a more rapid cost increase of our once economically priced drug system.

To date, provincial governments have supported the selling off of Canadian preferentially priced products to the American patient. This support has caused the manufacturers to examine their voluntary participation in the Patented Medicine Prices Review Board. The reason I say voluntary is if they're going to market their product in Canada, they have to have it reviewed by the Patented Medicine Prices Review Board, but realize there's no obligation for them to market their product in Canada. That's why I use the term “voluntary”.

Á (1100)

We've had two recent examples where two of the major international manufacturers have put price increases on the Canadian public--price increases that they haven't put forward for probably about 10 years. There may be many reasons for their responses, but I think if you look at the large disparity between the prices for American products and the prices for the same Canadian products, likely what they're leaning toward is more of a North American price. The indication we've seen, looking at the prices on both sides of the border, is that the tendency is for the Canadian prices to increase as opposed to the American prices decreasing.

The Pharmaceutical Association has some grave concerns that increased prices or the lack of manufacturers' voluntary participation in the Patented Medicine Prices Review Board will cause diminished access to medications in Manitoba.

With regard to a mechanism for controlling prices, again, the PMPRB does the best job possible within their mandate to review patented medication prices in Canada. But I think there also needs to be a review of the generic prices being established in Canada. If you look at our prices compared to other markets, the prices we're subject to in Canada are considerably higher. That's really because there's little competition for generic products, and once the major manufacturer moves its product off the formulary, typically the generic prices increase. I alluded to that earlier.

I'd also like to speak briefly about direct-to-consumer advertising. I won't go into details, because I'm sure you're well aware of the controls on direct-to-consumer advertising in Canada for prescription products. But the American market at one point in time would not allow direct-to-consumer advertising. That was changed recently. As we all see, there are many advertisements going on in American television and radio for prescription products.

Typically, the advertisements for patented products are trying to encourage a switch from a patient's existing treatment plan to a treatment plan involving the product advertised. Again, typically, the patient might be stabilized on an economical, therapeutically effective program and the influences try to switch them to the product being advertised.

I think Canada can take the opportunity to learn how or whether this form of advertising has advanced patient care and enhanced the treatment of diseased conditions. Because it came from an area that prior to this had no advertising and now has a large amount of advertising, I think Canada could learn from that. If this has enhanced patient care, then it's something that would be welcome in Canada. But if it hasn't, what components of that enhanced information to the patient would enhance patient care in Canada?

The other thing that has to be considered is Canada has a different social health care system. In the United States there are more private payers for the program. The patient is somewhat restricted to certain physicians that they can see, because of the payers of the program. In Canada, under our social health care system, the patient is really unrestricted as to the number of physicians they can see. Now certainly there isn't an abundance of physicians and there are some restrictions on access, but if a patient were influenced to the extreme of wanting a particular product and wouldn't take no for an answer, it's not inconceivable that he could attend enough physicians until he found one who would prescribe the product for him.

I want to also address the issue you've identified in marketing to and lobbying prescribers and pharmacists.

Once physicians or health care professionals graduate, it's a challenge for them to maintain current knowledge about recent treatment plans and medications. We've developed a program in Manitoba--and it's not unique to Manitoba; there are programs in the country--that takes recent information to the prescribers, basically dealing with best practice issues. We believe that's something that has to be welcomed by governments so practitioners would be able to understand and have knowledge about the best practice models, not necessarily what's being advertised most often.

On consumer access to health professionals and access to drugs, there are three issues I've addressed in my brief, and I won't go over them in detail. I think we have some major challenges in northern or remote communities in Canada that currently are not being addressed in a universal and wide application.

Secondly, as I mentioned earlier, access will be diminished by sending Canadian medications to the United States.

Á (1105)

Third, I think we need to involve the pharmacists more in a role to enhance patients' access to medications. We recently presented a four-point proposal to the Manitoba government showing how enhancing the pharmacist's role in patient care would enhance the patient's care and their access to medications. Further details on that four-point proposal can be made available to the chair if she wishes.

The second last thing I'd like to address is misuse, abuse, and addiction within the general population. I saw that you had a presentation by the Addictions Foundation of Manitoba. My proposal for misuse is not necessarily related to addiction but when there's an unintentional misuse by the patient. That's typically because they don't know how to use their medication properly or other medications they might be using. Approximately 15% to 25%, depending on which report you follow, of admissions to hospitals are as a result of medication mishap. I think that's a serious issue. The problem is not that they don't have access to the medication, but that access to the medication has led them to drug interactions and medication mishap. Those problems, by and large, could be addressed by enhancing the role of pharmacists and bringing the pharmacists into the health care team for patient care.

I also want to address what is not a prescription item in Canada but is in many other countries. If I'm not mistaken, Canada is probably the only country that has codeine available without a prescription. Codeine is a narcotic. Under section 36 of the regulations of the Controlled Drugs and Substances Act a patient can purchase small amounts of codeine from a pharmacist without a prescription. Although there may be some therapeutic value for codeine as a cough suppressant, 8 milligrams of codeine is very much sub-potent as an analgesic. The problem is that in section 36, in order for codeine to be available without a prescription, it has to have other products with it in that dosage form. Typically, an example would be codeine with acetaminophen and caffeine. Those individuals who are using or misusing the product for the codeine content are causing themselves irreparable damage from the acetaminophen, the product that comes with the codeine.

So I'd like to raise this issue with the committee. I know you're speaking on prescription medications only, and this is a non-prescription item in Canada. The registrars from across the country challenged Health Canada a number of years ago to review this product and, if it had therapeutic value, to work with us to develop proper access. If it doesn't have any therapeutic value, and I think that's more the case, the product should be removed.

The last thing I'd like to leave the committee with--and I apologize for the length of this--is the international comparisons you've asked about. Through the National Drug Scheduling Advisory Committee set up by the National Association of Pharmacy Regulatory Authorities and participated in by Health Canada, they've identified some 35 prescription medications that are now moving to non-prescription in other countries and likely will be moving to non-prescription in Canada. I know your mandate is prescription medications, but it's very difficult to speak about that issue in isolation from the non-prescription market. I think the committee ought to look at where international movement of medications is going, prescription to non-prescription, and be cognizant of some issues on patient access and patient care in that regard.

Thank you very much.

Á (1110)

The Chair: Thank you, Mr. Guse.

Our next witnesses are from the Manitoba Society of Pharmacists, Marian Kremers, the president, and Scott Ransome, the executive director.

Ms. Kremers.

Mrs. Marian Kremers (President, Manitoba Society of Pharmacists): Thank you, Madam Chair, and thank you to the standing committee for this opportunity to present the focus of the Manitoba Society of Pharmacists--which is the interest of our working colleagues--their conditions, and the negotiations for remuneration with the government agencies.

As I can see today, this certainly recognizes the fact that the standing committee knows that you cannot effectively study prescription drugs without involving pharmacists. We are the drug experts; we have more training in drug therapy than any other health professionals. Pharmacists are trained to understand the chemical makeup of prescription drugs and their effects and how medications interact with one another and within the patients themselves.

As we see today, the rising cost of prescription drugs is a topic that garners significant debate. They're a multifaceted cost required by a lot of different factors. To put it simply, rising costs are a product of pricing and increased utilization. The pricing of drugs is clearly important. However, greater attention must be given to the utilization, specifically the inappropriate utilization, of prescription drugs.

The three most typical examples of utilization error are: underuse, or therapies that could make a difference and are maybe not applied; overuse, the use of therapies that do not work; and misuse, therapies that could make a difference but are misapplied, either by wrong dosage or the wrong format, etc. Antibiotics are a really good example of this. One of my colleagues said, “Where have all the prescriptions for amoxicillin and septra gone?” Formerly, these were the mainstay of therapy. The norm is now Ciprofloxacin and Zithromax. These are highly potent, broad spectrum antibiotics, which I would venture to guess are misused and used inappropriately 50% of the time.

Effective medication management must become a reality. By more fully involving pharmacists, improvements can be made to the efficiency and effectiveness of drug therapy; this will reduce costs and enhance patient care. Reducing costs and improving patient care are two of the most important goals of health care reform.

In order to provide the standing committee with a tangible example of just one of the real opportunities that exists for reducing costs and improving the health of the population, I'd like to take the opportunity to highlight the findings of one recent study that brings into perspective the practical solutions that pharmacists can bring to an improved health care system.

The high-risk patient intervention program, done by the Institute of Health Promotion Research in October 2001, is a study that involved a randomized controlled trial to test whether a pharmacist and nurse home care team could reduce hospital re-admissions of seniors discharged from hospital who were taking six or more medications. The study involved 255 seniors, and the outcome measures included the number of emergency visits to general practitioners or specialists; the number of non-emergency visits to general practitioners or specialists; the number of pharmacare prescriptions written; the number of times the person was hospitalized via emergency departments; the number of times the patient was hospitalized for a 24-hour period when admitted via the emergency department; and whether the senior received long-term care service. So there were a lot of factors that measured whether this was going to be successful or not.

Between September 1999 and October 2000, the intervention teams made home visits to seniors in the experimental group. They conducted a thorough needs assessment and went through patient medicine cabinets. What they found were lots of outdated medication; drugs that didn't go together; and medication that was prescribed in too high or too low a dosage—which speaks to the aforementioned inappropriate use. In these cases, the pharmacist would contact the patient's physician to get things straightened out; in other words, they would make needed dosage adjustments and/or increase or decrease the medication. The intervention team also developed plans, each with a monitoring component to ensure that every senior in the experimental group received optimal medication therapy.

Overall, the intervention team contacted the seniors' physicians 136 times and made 255 medication-related recommendations, of which 206, or 81%, were accepted by the treating physician.

Á (1115)

Among the recommendations were: changing medication; discontinuing a medication; adding a treatment; or increasing or decreasing the dose.

The team also made changes in how the medication was delivered; they removed outdated or unused medication; contacted community services; provided a booklet where seniors recorded their medication; changed the way medication was packaged; furnished a list of medications; and supplied the written information to various people who were concerned with their therapy; provided medication schedules; and changed the times the drugs were administered. Overall, it simplified the total drug regimen. This is what pharmacists refer to as pharmaceutical care; non-pharmacists often call it appropriate medication management.

To date, in the pharmacy care field—and Michelle Fontaine could probably back me up on this—the value-added care provided by pharmacists at the moment is given with no remuneration. This quality tax on professionals cannot continue. As the representative of our pharmacists who is negotiating for appropriate remuneration, I make the committee aware of this problem.

The study I was referring to showed that seniors experienced significantly fewer hospitalizations and used other costly medical services less often. After the cost of running the program and all other costs were deducted, there was an average net saving of $680 per person in this experimental group. So not only did it save the government money, but we were also looking at extremely much better treatment of the patient. Is this not ultimately our goal in the health care system?

The study is hardly unique. A multitude of studies exist supporting the proposition that pharmacists can improve health outcomes by achieving optimal patient medication use. The Manitoba pharmaceutical care project demonstrated similar findings. An expansion of this service could encompass positioning of pharmacists at sites of prescribing. We have a few pilot projects going on right now, where pharmacists are actually in family physicians' offices. This could also include employing pharmacists to develop evidence-based prescribing guidelines, which provide feedback for prescribers.

Unfortunately, pharmacists are really underutilized members of the health care team, and the underutilization is one of the largest barriers to achieving optimal pharmaceutical care for our citizens in Manitoba.

We have a report from Dr. Colleen Metge, an associate professor at the Faculty of Pharmacy, University of Manitoba. In her submission to the Romanow Commission, she presented jointly with fourth-year pharmacy students the ABCs of pharmaceutical use and the role of pharmacists in the provision of primary health services.

“A” is for assessment: is the drug chosen for an individual the most appropriate and the cost-effective one at the moment?

“B” is for bottling: is the right drug given to the right person at the right time in the right dosage for the right duration? We refer to this now as traditional dispensing, a role we can delegate to other people.

“C” is for counselling or consultation: does the individual understand how to take their medication? Do they know why and what they should expect? Does the pharmacist have the time to consult with the individual's physician about what are the desired outcomes? Will the physician consult with the pharmacist about the desired outcomes?

And “s” is for surveillance or follow-up: is the drug actually doing what it's supposed to do? Pharmacists are the ones who see the patient the most often. Is somebody looking to find out whether the individual has the desired outcomes and is having minimal side effects?

Dr. Metge points out that the while pharmacists do a good job at “B”, the bottling, they've been overtrained to utilize that as their sole service to society. To improve the health of Canadians and achieve cost savings in the health care system, pharmacists need an expanded role.

The Commission on the Future of Health Care in Canada reached a consistent conclusion about the role of pharmacists, and I'd like to ask the committee to carefully consider recommendation 39 of the Romanow report, which states:

A new program on medication management should be established to assist Canadians with chronic and some life-threatening illnesses. The program should be integrated with primary health care approaches across the country.

In support of this recommendation, Romanow noted the following:

Part of the management would be effective use of prescription drugs and other medications. It also means that pharmacists can play an increasingly important role as part of a primary health care team, working with patients to ensure they are using medications appropriately and providing information to both physicians and patients...monitor patients' use of drugs and provide better information and communication on prescription drugs.

This would affect the types of savings we can see over and over again in studies that involve a comprehensive treatment of our patients in Manitoba and across the country.

Thank you to the committee for hearing us.

Á (1120)

The Chair: Thank you very much, Ms. Kremers.

We'll begin the questioning with Mr. Merrifield.

Mr. Rob Merrifield: Well, we again have quite a panel. Thank you for coming in. It goes right from Internet to pharmacy and everything in between.

Let's start with the Internet pharmacists, who I understand two years ago were about a $400-million-a-year business and $1.2 billion last year, I believe. Therein lies your concern, and probably the stress it has put on you as far as the 20% reduction in available pharmacists. That's really what you're saying, that there's a shortage of pharmacists.

I'm concerned also with what you're saying about the shortage of drugs. I'm a little puzzled as to why that would be. Do you not have any kind of a priority to them, or is it because they buy them in more bulk that they're able to get the drugs ahead of you? Can you explain what's actually happening on the manufacturers' side of it, to describe what's going on there?

Ms. Michele Fontaine: What we believe to be true is that the manufacturers are aware that they are exporting a lot of the medications to the United States. They have stopped allowing purchase by these companies directly from the manufacturers. They try to limit distribution through the wholesalers as well. They're watching for irregularities in large bulk buying that haven't occurred so that they know what's being drawn out.

We believe there's a large illegitimate underground supply. We do have some evidence that the Internet companies are also contacting other community pharmacies asking them to purchase drugs for them, paying them extra for that drug, and then taking it and exporting the drug to the U.S.

Á (1125)

Mr. Rob Merrifield: So they're actually using some of the pharmacists.

Ms. Michele Fontaine: Yes.

Mr. Rob Merrifield: That's how they're getting the product.

Ms. Michele Fontaine: Mrs. Michelle FontaineThey're illegitimately bypassing--

Mr. Rob Merrifield: Which is what you meant by “illegitimate underground supply”.

Mr. Greg Skura: Let me add to that.

When a drug is introduced to Canada.... If Canada is only 2%, say, of the drug utilization, the U.S. takes up 40%. So the companies determine how much drug is going to be released to Canada, how much is going to be released to Manitoba. In a lot of these cases where the Internet pharmacy is using this drug, there's only so much available right now, because the companies have said that's all that's going to be released on a monthly basis.

So this is where they're having a problem. They're expanding their business and they can't get enough drug, so they're looking for alternative ways to obtain the drug. And because we have to buy it through the wholesaler, now we're having a shortage of drugs with which we have to service our Manitobans.

Mr. Rob Merrifield: It just seems odd to me.... I've had pharmaceutical companies in my office, talking to me about this problem, and the brand name guys are saying they don't like this any more than you do, and they're having a problem with this. But they even know which doctors are prescribing how much of the product, so I can't believe they can't trace and find out where it's being bought. It just doesn't make sense to me.

So with this underground trade, are they looking the other way when it's happening? Can you tell me how you feel they are able to get away with that and honestly, legitimately say they don't know who's doing it?

Mr. Lothar Dueck: The issue of shortage just means the demand exceeds the supply. As a pharmacist looking after Manitobans and Canadians, we feel it is a serious challenge to our health care system that these drugs are being diverted. We don't have the answer to that. We see the problem. We get solicitations. And because of the nature of the business, we have to pay a lot higher salaries for our pharmacists. Some pharmacies are getting into that business to supplement their expenses so that they can afford to keep on serving Canadians, Manitobans in particular.

Ms. Michele Fontaine: I'd like to add something, please, if I may.

The coalition is an ad hoc committee. We have no budget. The burden of proof should be on our provincial government and perhaps our federal government. We don't have the resources to investigate how the shortages come about.

All I can tell you is that when I need Purinethol for my pediatric leukemia patient and I have to spend five hours on the phone sourcing enough drug until it's released again, and I go home and it's listed as available on Internet sites, that poses a question. I don't have the resources to answer that, but I would like somebody to, and I believe the burden of proof should be on the government.

Mr. Rob Merrifield: That was my second question. What kind of lobbying should be done with regard to the provincial government here in the province, and where are you going on that front?

Maybe Greg Skura would be the person to talk about that.

Mr. Ronald Guse: I'll let Greg speak first, and then if I can provide some additional clarity, I'll do that.

Mr. Greg Skura: We have tried to get an appointment with the health minister of the Manitoba government and we haven't been able to achieve that. From what we understand, the Internet pharmacy is supplying a lot of jobs, and that's the major benefit, say, that they can see. They're not looking at increased drug costs, the shortage of pharmacists, or the quality of care that pharmacists can give.

The Internet pharmacy is not concerned about Canadian health at all. They're not giving free clinics. They're not available for consulting on a child who has a rash, or a child with a croupy cough, or whatever. I think everybody's had occasion to go into a drug store and ask a pharmacist for advice. And advice is always there. There's no charge. The pharmacist is always available.

One of the things the Internet says is, well, chains are always opening up. Yes, Shoppers is open until 12 o'clock, and isn't that convenient? I can see my pharmacist until midnight about a health problem. The Internet is not available for those types of problems.

Mr. Lothar Dueck: On the federal level we have met with Health Canada to discuss our concerns about Internet pharmacy. We've talked to Mr. Rock and to Pierre Pettigrew's office as well. It doesn't seem to be an issue at this time.

Á (1130)

Mr. Rob Merrifield: You're not getting support from the provincial government. Is that what you're saying?

Mr. Lothar Dueck: Not the provincial government; not either.

The Chair: We're going to have the provincial health minister here this afternoon, so perhaps we can ask him.

Mr. Rob Merrifield: We may ask him on your behalf.

Ms. Michele Fontaine: Pardon me for interrupting. The response we have received from the minister, and I believe from MaryAnn Mihychuk as well, is that it's an issue that perhaps we have thought of in our heads, I suppose, because no Manitoban has been denied drugs.

I don't know how they can say that. Tapazole is not available. We can't get any. But we don't phone the minister every day to tell him that we weren't able to supply that drug. We'll go to great lengths to buy it.

I've bought drugs from an Ontario hospital for a brain tumour patient because that was the only place I could get it. We phone the doctor. We find an alternative. We make sure the patient, the bottom line, is looked after.

So maybe no one has been denied drugs, exactly, where they're out in the cold. We would never do that to a patient. We will go to great lengths to ensure that their safety and their health is looked after. So I find that an inappropriate response, and that's the only significant response I can say.

The Chair: Mr. Guse would like to comment on that question as well.

Mr. Ronald Guse: We could spend a good amount of your time discussing this issue, because there are questions still to be answered about the legality of it and the patient safety. There are certainly a lot of political issues that need to be addressed on both sides of the border, by the state board and provincial governments and also the federal governments on both sides. It's a very interesting topic, to say the least.

With respect to the provincial government, the direction we've seen from the government seems to be that taken by the Minster of Industry, Trade and Mines, Minister Mihychuk. It is disconcerting that we haven't heard directly from our minister. Certainly we're working on that, and I guess others are working on that as well.

What we're hoping to get from the minister and from the government is some big picture analysis, because as much as it might be a boom for industry in Manitoba and jobs, you can't have such a phenomenal increase in something without having something else suffer. The concern is clearly that the something else that might suffer is Canadian access to medications.

The Manitoba Pharmaceutical Association, as a regulatory authority, has said if this is done safely, legally, and Manitobans are placed first, it's something that the pharmaceutical association could certainly endorse. I don't think any one of those subjects has been addressed.

Mr. Rob Merrifield: As to how hard you're having to look for new drugs, you've mentioned a couple, two or three of them. I'm trying to get a handle on the scope of this. Is it chronic? Is it periodic? Is in increasing? Is it stabilizing?

Ms. Michele Fontaine: The number of shortages is increasing. As far as the question, is it chronic, is concerned, there are some that are chronically short. Chronovera, 240 mg, the manufacturer has said, will not be available until January 2004. That is listed as available on at least 15 websites.

Other ones are short term. Sinemet CR was short for a while. It comes in and there are a few bottles, and then they're gone again.

So it is both.

Mr. Rob Merrifield: Maybe you don't know the answer to this, but are you having shortages right across Canada from pharmacists and your colleagues in other provinces? It's not just a problem in Manitoba; this is happening in other provinces as well, and the supplies could come from other provinces, for sure.

Mr. Ronald Guse: If I can speak to that briefly, I believe it is a national problem. I can't speak on behalf of the coalition, but I know that's why we touched on it.

I know why the coalition has spoken on that clearly this morning. It is a national problem.

It might be centred, in some people's perception, in Manitoba. There are other reasons for that, and I could go into that in detail, but it is a national problem.

International prescription service pharmacies are located in Manitoba, Saskatchewan, Alberta, British Columbia, Ontario, and east. Has each of the provinces experienced the shortages that are being reported here?

Because some of the manufacturers can't quite get a handle on it in other provinces, just by the way the pharmacies are licensed, they are having more difficulties in addressing this situation. Not to speak on behalf of the manufacturers, but they have some liability issues. Their product is marketed for Canada, let's face it, and they have some concerns about their product being shipped to the U.S. market.

Overall, what we see or hear from the licensing body is that typically the drug supply chain in Canada was, and for the most part still is, phenomenal. A pharmacist in Manitoba could sell the last bottle of a product on their shelf to their patient and have that bottle replaced later that day, if not the next morning. That's the way things were.

I can tell you that the general uneasiness with pharmacists, not only in Manitoba but across the country, is that if they sell that last bottle from their shelf, they don't know when it's going to be replaced.

Á (1135)

Mr. Rob Merrifield: Is it generic and brand, or just...?

Mr. Ronald Guse: Typically the products going to a U.S. market are patented brand name medications, not generic. If you look at the generic prices, one of life's ironies is that generic prices in the United States are considerably cheaper than in Canada.

Mr. Rob Merrifield: There are no shortages there then.

Mr. Ronald Guse: It appears not.

The Chair: Thank you, Mr. Merrifield.

Mr. Thompson.

Mr. Greg Thompson: Thank you, Madam Chair.

I want to again talk about the Internet pharmacy, or, as Mr. Guse called it, the mail order pharmacy. Mr. Guse, I'm looking at your presentation representing the Manitoba Pharmaceutical Association and your mission statement. I'll just put it in those terms. You identified it as being similar to the Canadian college of physicians, and so on. You said that the MPA was for protection of the public. Reading from your presentation you said, “This provides a wide scope of responsibilities that include licensure, establishing and auditing compliance of standards, complaint investigations”, and so on.

It seems to me that your pharmacists are being rewarded for bad behaviour. You have a group of pharmacists over here talking about a problem. You're sitting at the other end of the table, and it appears as if you've got some power over those pharmacists who are creating the problem that these people have identified, but you're doing nothing.

Then we hear about getting the provincial government to do something--maybe the federal government. But don't you have the responsibility yourself to shut down those types of operations when you know the public is being endangered?

Mr. Ronald Guse: The authority of the Manitoba Pharmaceutical Association does come from government. I have to operate under a provincial act, the Pharmaceutical Act of Manitoba, and the regulations that support that act.

Mr. Greg Thompson: But you're saying protection for the public in your statement here. That's not accurate then. In other words, you don't have any power or teeth.

Mr. Ronald Guse: I would probably agree with that when it comes to this issue, frankly. We need additional investigative powers to not only discover the information, but to share the information with those who need it.

Mr. Greg Thompson: I often hear this type of code language when I start talking to certain groups. You know the problem is there and then you try to codify it so we don't really know what it is. Then if we try to do something about it you get into this kind of fuzzy language, but it's not very strong or authoritative. It seems like the problem just goes on and on.

Maybe some of the other members can pick up on it, but I don't want to dwell on that totally. I think we're onto something here. I'm sure Mr. Robinson and others will want to pick up on it as well.

There's just one thing you mentioned that I want some clarification on. You talked about codeine--and this is very specific--being sold off the counter, with no prescription necessary. Tylenol 3 has codeine, and that's one of the reasons why it can only be purchased with a prescription. Is that correct?

Mr. Ronald Guse: That's correct.

Mr. Greg Thompson: But how much codeine is in Tylenol 3, versus what you can buy off the shelf? In other words, I'm wondering if that amount is excessive in Tylenol 3.

Mr. Ronald Guse: Tylenol 3 has 30 mg of codeine. The product you can buy without a prescription has a maximum of 8 mg of codeine.

Mr. Greg Thompson: Okay. That's just a specific one. Time is the problem here, and I'd like to talk with you more on that one.

But I think Marian was speaking in code about the expanded role of pharmacists. I understand the team approach and how much more involved pharmacists could be. In other words, I have a problem when I'm standing there watching someone as highly educated as yourself or the other pharmacists counting out pills, one or more at a time. Greg Thompson could count out pills with no training at all, if you will.

I understand the need for an expanded role, and I understand the team approach. We've heard some evidence to suggest that approach does work. But when I hear this codified language, it appears to me that some groups within the pharmaceutical industry business, if you will, are suggesting that the person who sells the pill should be prescribing the pill. In other words, I want to sell the pill and prescribe it in one fell swoop, so let's move into that area. I feel that and sense that, and I just want your comments on whether or not pharmacists should be writing prescriptions as well as selling them. Do you see a problem with that?

Á (1140)

Mrs. Marian Kremers: At first glance, it would seem there's a conflict of interest there, but actually, the system we have right now creates more conflict of interest, because the pharmacist is rewarded monetarily by selling a product. If we choose not to fill that prescription, it means our monetary reward is not there under the current system. Should we be practising pharmaceutical care, as professionals, we would be able to recommend that a specific medication be discontinued without it being monetarily punitive to us, in order to make for the best care for the patient. So the prescribing of the medication would not necessarily be done by what you're traditionally seeing as a pharmacist in a community pharmacy setting, but it may be done by a pharmacist paid for through a government agency or in whatever way for their prescribing expertise. That pharmacist perhaps would not end up filling that prescription at all, would have no connection with a commercial pharmacy.

Mr. Greg Thompson: Well, we see all kinds of bad behaviour being rewarded in the industry. I'm just--

Mrs. Marian Kremers: I take exception to your calling it an industry. It is a profession, Mr. Thompson. The industry we typically think of as the drug manufacturers.

Mr. Greg Thompson: We're getting into semantics, but I think the sense of bad behaviour being rewarded is pretty evident within the profession of pharmacy itself.

Mrs. Marian Kremers: As president of the Manitoba Society of Pharmacists, I see all the time the frustration of our members who are not being rewarded adequately for the services they do supply to the residents of Manitoba versus the ones who seem to be rewarded by the Ministry of Industry, Trade and Mines.

Mr. Greg Thompson: I'm being shut off, but thank you. Maybe we'll have a chance to continue in another round.

The Chair: Thank you, Mr. Thompson.

Mr. Dromisky.

Mr. Stan Dromisky: Thank you very much.

On a positive note, my own experience with pharmacists is absolutely outstanding. I stand and watch while they serve other customers. There's a lot of counselling going on, information passed and shared, and so forth. I'm talking about the manner in which the relationship has been enhanced between the druggist and the customer over a period of years. They are truly professional in my community, where I have been dealing with them for years.

Mrs. Marian Kremers: It's very good to hear that.

Mr. Stan Dromisky: That's very positive.

In the relationship this person has developed with the pharmacist, they begin to tell what you might call family secrets, become very personal, and they'll pass on information pertaining to the drug they have been prescribed by some doctor. Often you will hear that things are just not going well. In other words, the pharmacist picks up information about adverse effects of a certain drug, and my question is related to that. Do you in Manitoba have some network or some way of sharing that information you pick up, even though it's anecdotal, with the doctor who prescribed the drug or with other pharmacists? Do you have some network to share it with the manufacturers, or even with other patients who have come to you and are receiving the very same drug? Is there some follow-through?

Á (1145)

Mrs. Marian Kremers: Yes, there are many mechanisms. One of them, of course, is the long route, and that's the Canadian adverse drug reaction reporting.

Mr. Stan Dromisky: Through Health Canada.

Mrs. Marian Kremers: Through Health Canada.

Mr. Stan Dromisky: I know they don't do anything with that.

Mrs. Marian Kremers: I tend to agree with you. Only recently have they accepted submissions from pharmacists, by the way. It's always had to come through medical practitioners.

The aspect of sharing the information with the physician, of course, is always there, and it is the pharmacist's duty to do that when we uncover adverse effects. That's how we can contribute to improved care for patients, by making the physicians aware that there is potentially a problem.

Mr. Stan Dromisky: That's when you're not too busy to contact the doctor.

Mrs. Marian Kremers: That is part of the problem--and sometimes getting the reply. However, that's not part of this discussion, but that part is definitely there.

We anecdotally share information with colleagues, of course. It does not become part of an official notation, so it's available across the network. I don't know how you address that and still keep some confidentiality in the system.

Mr. Stan Dromisky: My next question pertains to something Mr. Thompson has already introduced, and the committee has sort of been introduced to exploring such a possibility. You know that we have nurse practitioners? Now, nobody knows as much about the chemicals and the drugs as you people do. Doctors know very little--I'll be very honest about it--and they rely very heavily upon your information, your guidance, and so forth.

Mrs. Marian Kremers: I wish they relied a little more.

Mr. Stan Dromisky: Yes, possibly.

We have a problem in many of the isolated communities and many of the smaller communities, and the problem is being aggravated here by this cross-border trade. You're losing a lot of pharmacists. I don't know if there's been any thought given to having an integrated program, with some type of harmony between a medical program and a pharmacist's program on university campuses. A pharmacist could pick up additional credits and courses in order to become a pharmacist practitioner in a community where there is a great need for someone to do some of the preliminary work for customers where there might not be a doctor. Or there could be a pharmacist who visits, because we do have pharmacists visiting various centres throughout northwestern Ontario and other parts of the country. Has any thought in your profession been given to such an enhancement of your role, if you want to use that term?

I see it that way. I think you could enrich the quality of life by doing more than just giving out drugs, with more counselling and guidance. I know that's happening already in my riding. The pharmacists are taking a very active role in counselling customers, but I would love to see something done more professionally.

Mrs. Marian Kremers: On a national basis, the Canadian Pharmacists Association has approached government on many areas, one of them being pharmacist prescribers, a practitioner as you're defining it, as well as nurse practitioners, people who would take extra training. The people we are graduating out of the university right now, however, probably could handle that role quite effectively.

Mr. Stan Dromisky: Who is being graduated, the pharmacists?

Mrs. Marian Kremers: The recent pharmacy graduates are more than capable of taking on that role.

Mr. Stan Dromisky: How come more today than they were 10, 15, or 20 years ago? Is there something new in the program?

Á (1150)

Mrs. Marian Kremers: Absolutely. Twenty years ago, quite frankly, I could never have done that. The programs have changed drastically in the last 10 years.

Mr. Ronald Guse: If I could, I'll just speak to that for a moment. The program is now a five-year program. In the past, when Marian and I graduated, it was four years. In that additional year there's a lot more critical involvement of the pharmacist. The medications are phenomenally more complex. There are different areas of study regarding pharmacokinetics, which was just starting when we were graduated, so there is more complexity and the pharmacists have been trained phenomenally to do that.

We would echo Marian's and your thoughts that the pharmacist could be challenged and charged to do the tasks you described. It's one of those interesting issues of--and there are many of those issues--where does the federal government leave off and the provincial government take something on? While prescription drugs are approved by the federal government, the issue of who can prescribe those products is for the most part dealt with by the province.

As mentioned earlier, we have a proposal in front of the provincial government now to show how pharmacists can enhance patient access to prescription medications. I don't think we're here to say that a pharmacist is an expert or may very well become an expert, a diagnostician who can say what exactly is wrong with a patient, but for some minor ailments the pharmacist could do that.

It still requires, obviously, a physician to diagnose. But when it gets into the area of which is the best medication to treat an illness, that's when I think the pharmacist can work along with the physician. As to the treatment goals identified by the physician--I have a patient and I want to get that patient to this area for their well-being--if it involves medications, and often it does, the pharmacist can do that.

The Chair: Thank you, Mr. Dromisky.

Mr. Robinson.

Mr. Svend Robinson: Thanks very much to all the witnesses for your evidence this morning.

I have questions in two areas.

We heard evidence earlier this morning in the first panel from a practising physician, Dr. Katz, with respect to a computerized program here in Manitoba that basically, when an individual receives a prescription for a particular drug, gives you the history of other drugs they have been prescribed, and if there is a potential for a conflict or a problem with the interaction between those drugs a red light goes on. There is a warning. What we also heard was that this isn't working. According to Dr. Katz, at least, pharmacists are not communicating to the physicians when there is a warning received about a potential adverse effect from an interaction of drugs. He said that in the 10 years he's practised he's never had one, and yet there have been circumstances in which there clearly was a potential for an adverse result from the interaction of drugs.

I want to give you the opportunity to explain why we're hearing that and why the system doesn't seem to be working.

Mrs. Marian Kremers: Perhaps Dr. Katz isn't very available to receive his calls.

Mr. Svend Robinson: He said he hasn't gotten any calls.

Mrs. Marian Kremers: I have absolute faith in pharmacists solving the problem. Perhaps they could solve the problem without contacting the physician. I find it very peculiar that in his position Dr. Katz would not have received any calls. As a former practising pharmacist, I was on the phone many times to physicians. I don't understand why Dr. Katz would not have been contacted. Maybe Michelle or some of our more recently practising pharmacists can answer the question.

Ms. Michele Fontaine: Some of the time the interactions show up as codes. There's ME1, ME2, ME3. There is a series of MY, MZ, MW, and I think perhaps sometimes they're missed just because of the abundance of codes that are presented. It is very good that you have to look, but it could be missed. If it's ME1, that means the highest level of an interaction. That's where you should contact the physician. Sometimes it's a short period. You may have resolved it so that they don't take their Lipitor while they're taking their Erythromycin for that period of time.

I think initially, when it first started, it was pretty overwhelming for the pharmacists to see all of the codes and to identify them and be able to act on them. I believe that process is improving. The newer graduates who are coming out are more trained to use the system. The codes have been simplified. It is probably improving. I don't know if it is ideal, but I'm sure it helps.

Á (1155)

Mr. Ronald Guse: Dr. Katz's example might be the exception as opposed to the rule. I think if you spoke with a number of physicians they would be complaining on the other end, saying the pharmacists are always bothering them--in a kind way, I hope--with this type of information, because it's ongoing.

Mr. Svend Robinson: I would hope if that alert came up you would be the first people--and you are professionals. I would assume that would be happening, but you will understand that when we hear this information it gives rise to concern.

My other area of questioning is on the Internet pharmacies. I want to try to understand this.

First, why is there a Coalition for Manitoba Pharmacy that was created in June of this year? There is the Manitoba Society of Pharmacists, and I would have thought that if the Manitoba Society of Pharmacists was concerned about this you wouldn't have to create a separate body. I have so far heard silence from the representatives from the Manitoba Society of Pharmacists on this issue. I would ask the Manitoba Society of Pharmacists directly, have you taken a strong stand on this issue? Why is it necessary for there to be an ad hoc coalition?

You mentioned you have no budget. Do you receive any funding at all from the pharmaceutical industry for your coalition?

Mr. Lothar Dueck: We have no funding right now.

Mr. Svend Robinson: You have no funding at all.

Mr. Lothar Dueck: We have no funding. We're working as volunteers.

Mr. Svend Robinson: Then over to the society.

Mr. Scott Ransome (Executive Director, Manitoba Society of Pharmacists): The Manitoba Society of Pharmacists represents all pharmacists. That includes, as referenced earlier today, that there could be as much as 20% of practising pharmacists currently in Manitoba who are practising in international pharmacy. We represent them as well as pharmacists who work in hospitals and pharmacists who work in community pharmacies. We're an organization that represents all pharmacists, and clearly a good piece of our membership works in international pharmacy.

Mr. Svend Robinson: Are you not also concerned about some of the ethical questions that have been raised with respect to those people who you do represent and the prescriptions that are going out without direct contact between physician and patient?

Mr. Scott Ransome: Clearly we're concerned with that. We have a formal position with respect to this matter. I'd describe the position as being quite balanced, but one of the things we point out to all practising pharmacists is that they have to comply with all provincial legislation, all federal legislation, all international legislation, and the code of ethics--code of conduct here in Manitoba. We are not in any way advocating that anyone ignore their professional responsibilities.

Mr. Svend Robinson: Let me deal with the issue of the relationship between physician and patient.

According to the brief of the coalition, here in Manitoba doctors can't sign off on these prescriptions. So in order to get the prescription they have to find a doctor from another province, as I understand it. The obvious question is, what on earth are doctors in other provinces doing signing off on a prescription for a patient they've never seen? Are there not similar codes of conduct in place in those other provinces that would say, look, you do that and you lose your licence to practise medicine?

Mr. Ronald Guse: I would love to answer that question for you, if I may. I'll try not to speak in codified language.

When we have that information in our possession, our provincial act, the Pharmaceutical Act of Manitoba set up by the Government of Manitoba, prevents me from sharing that information with licensing medical authorities in other provinces. So I can't sit here and say to you that it is occurring, because even if I told you that--as was raised by the coalition--I couldn't even confirm that that in fact is occurring. I can't even confirm to you that pharmacies who ship medications to the United States are in fact using physicians from other provinces.

Mr. Svend Robinson: You can't confirm that?

Mr. Ronald Guse: I cannot confirm that to you because if I confirm that, it might be information I've discovered by doing on-site audits, and that information is private.

We just went through a process of having a prosecution against me personally--against the Manitoba Pharmaceutical Association as a whole, but it was directed at me personally. I didn't break the act. By their interpretation it was perceived that I broke the act, but I did not. It started a long legal process to silence the Manitoba Pharmaceutical Association and me as registrar.

Â (1200)

Mr. Svend Robinson: I think it's outrageous. If you people are able to identify physicians from other provinces or territories who are signing off on these prescriptions in breach of their ethical responsibility.... You're on the front lines. Why shouldn't you be in a position to report this directly so that there can be follow-up action in those jurisdictions so that those doctors aren't allowed to get away with it?

I don't know if you want to comment on that, but to me it seems like a no-brainer.

Mr. Ronald Guse: In plain language, welcome to my nightmare.

Ms. Michele Fontaine: If I can speak, what I'll say should partially answer one of the questions Mr. Thompson asked. The coalition was formed in response to the MIPA, the Manitoba InternationalPharmacists Association, and the MPhA's mediated agreement.

You asked why the MPhA has no teeth. The MPhA, in my understanding and in my opinion, was doing their inspections and they were trying to come up with some sort of--they are a regulatory body--regulations. The Manitoba government allowed MIPA, or the Internet guys, or whatever you want to call them, to come in and speak to them, and all of a sudden our regulatory body had to go into a mediation process, wherein, in my understanding, they were made to come up with an agreement that would allow Internet pharmacy to exist, thereby taking away any teeth they had.

The agreement was reached--and these guys can help me with the dates--but what it came up with was they were told not to tell the pharmacists' body for about a month. It was released days before the election, and the pharmacists had one week of this information to go to the vote, to vote on whether or not we agreed with this mediated agreement.

We had 300 pharmacists in a week sign a petition asking for it to be delayed so that all the pharmacists could actually read the agreement and see what it said and see if we could come up with an understanding. That wasn't granted. Then we had 307 members, out of 1,000 roughly, vote against the agreement.

Why does the MPhA have no teeth? Maybe ask Mr. Chomiak.

Mr. Svend Robinson: I think we're going to have a number of questions for Mr. Chomiak.

Mr. Greg Skura: If I can add to this, as Ron said, there's a lawsuit against him. There were several lawsuits. The government was promoting international pharmacy and they said to our association--Ron is the registrar--make this work. Ron had no choice. He had a personal lawsuit, other lawsuits. They have a war chest of $1 million for just legal matters.

Mr. Svend Robinson: Can I ask one very brief final question? I'm sorry to take your time, but this is an important issue I think for us to flesh out.

Just to understand how it works, when your members, the 20% of Internet members you're also representing--which is why you're a little cautious about this stuff--receive a prescription signed by a physician in Alberta or Saskatchewan, for example, and they see it comes from a person who they recognize is an Internet pharmacist maybe making repeat purchases, for example, there's nothing at all that can be done? I suppose they don't want to do anything because this helps their business, but is there nothing at all that can be done by either of your two bodies in these circumstances?

You're saying your hands are completely tied, that even if you really know what's going on here.... Presumably you know who the people are who are your Internet pharmacist people. You well know who they are. They come in and they have a prescription signed by a doctor in Saskatchewan. So you know what's going on; you have to know what's going on. But you're saying there's nothing you can do.

Mrs. Marian Kremers: No, there's nothing that MSP can do because we are not a regulatory board, but--

Mr. Svend Robinson: I was directing that more to--

Mr. Ronald Guse: According to the legislation, I have the ability to share information with my colleagues, the pharmacy licensing boards, colleges, and associations across the country. I have the ability to share information with the medical licensing body in the province of Manitoba and that's it.

Mr. Svend Robinson: But if you shared it with the medical licensing body, which is the College of Physicians and Surgeons, do they not have the authority then to raise concerns with their counterparts in other jurisdictions?

Mr. Ronald Guse: Our legal advice--and I can tell you that our legal budget in 2001 was $6,000; we're now at $91,000 and we're not quite done this year yet--is, and he's used these terms so I can understand it, you can't do something through the back door you're not allowed to do through the front door. So if I share it with someone who.... I can share it from point A to point C. They won't allow it to be point A to B and B to C. That just won't be allowed.

Â (1205)

Mr. Greg Skura: May I answer that briefly.

I know the medical association of physicians of Manitoba sent letters to all the physicians saying, no, this is not a good practice. You're not meeting the person face to face. It's up to the physician whether they want to sign these prescriptions. They're getting paid $10 to $15 for every prescription, so all of a sudden here is another revenue for physicians.

If Internet pharmacy isn't stopped, we're going to start doctors--

Mr. Svend Robinson: You say in your brief it's been banned. They can't do that in Manitoba now.

Mr. Greg Skura: In Manitoba. But they can do it without anybody knowing they can still do it.

Mr. Svend Robinson: A Manitoba doctor?

Mr. Greg Skura: Yes.

Mr. Svend Robinson: So they'd be breaking the law?

Mr. Greg Skura: They'd be breaking the law. But they're not going to be.... This is the part where we can't notify anybody if...and we're not Internet, so I don't see any of the doctors who sign it. Internet has signed their own agreement among themselves, because this is such a cash cow that they're not going to give this information to anybody.

Most of the doctors--I shouldn't say “most” because I'm not part of MPhA. A lot of doctors are coming from the Maritimes, New Brunswick, some from B.C., or whatever, because there are some doctors there who have their own Internet set-up and they just do Internet. I think there are three of them. It was written about in the Globe and Mail about four months ago. But everybody's making money off it.

I know of one physician in northern Manitoba who was offered $15,000 a week just to sign Internet prescriptions, and this was just three months ago. This is even though it's against the law. There's money to be made--

Mr. Svend Robinson: It's pretty tempting.

Mr. Greg Skura: It's tempting, that's it, yes.

Mrs. Marian Kremers: The real flaw is in the Manitoba Pharmaceutical Act, and it is the fact that the practitioner is defined as any registered practitioner in Canada, whereas in most other provinces it is restricted to their own province.

The Chair: So that minor change could eliminate these out-of-province practitioners from signing?

Mrs. Marian Kremers: I wouldn't go so far as to say that. It could go a long way to helping to regulate it, though.

Mr. Ronald Guse: Madam Chair, I just want to clarify this too.

If my lawyer were sitting with me today, he would say there is information we can share with medical licensing authorities in other provinces, but the information they would need in order to act is information we cannot share.

So we can take it to a certain level, but once we get their interest piqued, we can't take it to the next level.

With regard to prescribing and who's defined as a prescriber, I said earlier it's a situation where the federal government goes so far and the provincial government takes over. Our law is that a prescription is valid if it's prescribed by someone who's licensed in any province in Canada.

Now, when that law was put in place, it was well before there was anything known as the Internet, and the law, I would suspect, was put in place to facilitate Manitobans going to another province to receive care. We're like any other province. We have border towns, and patients will fly across the border to Ontario or Saskatchewan to receive care. Obviously, that's in keeping with good medical practice and good patient care, so the prescription needs to be filled. It didn't anticipate Americans having prescriptions signed by physicians they've never met, nor was it to facilitate their access to our less expensive products in Canada.

Mr. Greg Thompson: Madam Chair, could I just have one word, and this is just a comment.

I think the code's been broken. I really appreciate your testimony here today, and I know the chairperson will probably want to say that as well, but this has really been helpful, and I do thank you very much.

The Chair: It's interesting. At the coffee break Mr. Dromisky and I were saying the one thing we've learned today is that Manitobans are so honest, and we didn't have as much code as we've had in other places. So thank you very much for your frank appraisal of the situation and for alerting us to these problems, which have been highlighted more in Manitoba than in anyplace else. You've given us some understanding of it, at least to the best of your knowledge.

Thank you very much.

Ladies and gentlemen, we will now break until 1 o'clock.