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37th PARLIAMENT, 1st SESSION

Special Committee on Non-Medical Use of Drugs

EVIDENCE

CONTENTS

Tuesday, August 27, 2002

0935

The Chair (Ms. Paddy Torsney (Burlington))

0940

Mr. Jeff May (Past President, National Association of Pharmacy Regulatory Authorities)

Ms. Barbara Wells (Executive Director, National Association of Pharmacy Regulatory Authorities)

0945

Mr. White (Langley—Abbotsford)

Ms. Barbara Wells

0950

The Chair

0955

1000

Ms. Shelley Stepanuik (Vice President, Canadian Pharmacists Association)

1005

The Chair

Mr. White (Langley—Abbotsford)

Ms. Barbara Wells

Mr. White (Langley—Abbotsford)

Mr. Jeff May

1010

Ms. Shelley Stepanuik

Mr. Randy White

Dr. Barry Power

1015

Mr. White (Langley—Abbotsford)

Dr. Barry Power

Ms. Shelley Stepanuik

The Chair

Ms. Barbara Wells

The Chair

Mr. Bernard Bigras (Rosemont—Petite-Patrie, BQ)

1020

Ms. Shelley Stepanuik

Ms. Barbara Wells

Mr. Jeff May

1025

Mr. Bernard Bigras

Dr. Barry Power

Mr. Bernard Bigras

1030

Ms. Shelley Stepanuik

Mr. Jeff May

1035

The Chair

Mr. Derek Lee (Scarborough—Rouge River, Lib.)

Dr. Barry Power

Ms. Barbara Wells

Ms. Shelley Stepanuik

1040

Mr. Derek Lee

Mr. Jeff May

Dr. Barry Power

1045

Ms. Shelley Stepanuik

The Chair

Ms. Shelley Stepanuik

1050

The Chair

Ms. Shelley Stepanuik

The Chair

Ms. Shelley Stepanuik

1055

Mr. Jeff May

The Chair

Mr. Jeff May

1100

The Chair

Ms. Shelley Stepanuik

The Chair

Ms. Shelley Stepanuik

The Chair

Dr. Barry Power

1105

Ms. Barbara Wells

The Chair

1115

1120

1125

1130

Ms. Kathryn Raymond (Manager, Health Care Education, Purdue Pharma)

1135

1140

1145

The Chair

Mr. White (Langley—Abbotsford)

1150

Mr. Andrew Darke

Mr. Randy White

1155

Dr. Roman Jovey (Individual Presentation)

Mr. White (Langley—Abbotsford)

Dr. Roman Jovey

Mr. White (Langley—Abbotsford)

Dr. Roman Jovey

1200

The Chair

Ms. Kathryn Raymond

The Chair

Mr. Bernard Bigras

Mr. Andrew Darke

1205

Mr. Bernard Bigras

Mr. Andrew Darke

Mr. Bernard Bigras

Mr. Andrew Darke

Dr. Roman Jovey

1210

The Chair

Dr. Roman Jovey

The Chair

Dr. Roman Jovey

The Chair

Dr. Roman Jovey

The Chair

Mr. Derek Lee

1215

Dr. Roman Jovey

Mr. Derek Lee

Dr. Roman Jovey

1220

Mr. Andrew Darke

Mr. Derek Lee

The Chair

Mr. Andrew Darke

1225

Mr. Kevin Sorenson

The Chair

Mr. Andrew Darke

1230

Dr. Roman Jovey

The Chair

1235

Dr. Roman Jovey

The Chair

Dr. Roman Jovey

1240

The Chair

Ms. Kathryn Raymond

The Chair

Mr. Andrew Darke

The Chair

CANADA

Special Committee on Non-Medical Use of Drugs

NUMBER 052

1st SESSION

37th PARLIAMENT

EVIDENCE

Tuesday, August 27, 2002

[Recorded by Electronic Apparatus]

¿ (0935)

[English]

The Chair (Ms. Paddy Torsney (Burlington)): We are the Special Committee on Non-Medical Use of Drugs. We were struck pursuant to an order of reference adopted by the House of Commons on Thursday, May 17, 2001, to consider the factors underlying or relating to the non-medical use of drugs.

¿ (0940)

Furthermore, as of Wednesday, April 17, 2002, we were referred the subject matter of a private member's bill, Bill C-344, an act to amend the Contraventions Act and the Controlled Drugs and Substances Act regarding marijuana. The bill came to our special committee.

The committee has travelled across the country, down into the United States, and into Europe, and has been talking to stakeholders and people involved in research, interdiction, education, and rehabilitation. We've talked to addicts. We've talked to people to find out what's really going on in our communities and what things are working well.

We also of course have had a lot of meetings in Ottawa. We are very pleased to have with us this morning, from the Canadian Pharmacists Association, Dr. Barry Power, who is director of practice development, and Shelley Stepanuik, who is the vice-president of the organization. From the National Association of Pharmacy Regulatory Authorities, we have with us Jeff May, past president, and Barbara Wells, executive director. I understand that the national association is going to speak first.

I'll turn it over to you. If we could have about five to ten minutes from you, I'll give you a signal when it's about nine minutes and if you're wrapping up that's great. If you need a lot more time we'll figure out what to do then. Then we'll have an opportunity for questions and answers. This session will go until eleven o'clock.

Let me also say that we have representatives from various political parties around the table, and while not everyone is here given that we don't usually do committee hearings in the summer, everyone will have access to the transcripts. Some people may arrive during the meeting.

Over to you, Mr. May.

Mr. Jeff May (Past President, National Association of Pharmacy Regulatory Authorities): Thank you, Madam Chair.

We appreciate the opportunity to speak to this special committee as you consider factors related to the non-medical use of drugs in Canada. Preventing the abuse and intentional misuse of drugs is a major priority for NAPRA, the National Association of Pharmacy Regulatory Authorities, and its members.

I'm a pharmacist and NAPRA's immediate past president. I'm also national director of regulatory and professional affairs for Shoppers Drug Mart. With me is NAPRA's executive director, Barbara Wells, also a pharmacist.

NAPRA is a voluntary umbrella organization, an association of Canada's provincial and territorial pharmacy licensing bodies. We were established in 1995 and are based in Ottawa. Our association is funded almost exclusively through a portion of the licensing fees that pharmacists pay annually to their regulatory bodies. That averages out to about 6% of provincial fees. We receive no government funding.

Like you, our members are mandated to protect the Canadian public. Our members regulate the practice of pharmacists, the sale of drugs, and the operation of pharmacies in Canada. In doing so, they enforce provincial, territorial, and federal legislation relevant to pharmacy. We are also here with our colleagues from the Canadian Pharmacists Association, who represent the professional interests of pharmacists.

NAPRA was formed by regulatory authorities primarily to develop and harmonize standards for the sale of drugs and practice of pharmacy across Canada. Another of our objectives is to represent the views of member licensing bodies, both nationally and internationally, and liaise with the federal government on their behalf.

This morning, Barbara and I will be outlining for you two major roles that NAPRA and its members play within the framework of Canada's drug strategy and providing a number of recommendations for your consideration.

I'll now turn it over to Barbara.

Ms. Barbara Wells (Executive Director, National Association of Pharmacy Regulatory Authorities): Good morning.

One of NAPRA's major responsibilities is that of maintaining a national classification system which supports the appropriate use of drugs, including drugs that often are used for non-medical purposes. As you know, when a drug is approved for use and sale in Canada, the government decides whether or not it requires a physician's prescription to be available to the public. For those drugs deemed federally to be non-prescription, the provincial governments then have the authority to mandate further conditions for distribution within their jurisdictions. These conditions commonly include supervision or intervention by a pharmacist or other health care professional, special labelling, and, in some cases, even prescription status.

This secondary provincial safety net, if you will, was historically developed independently. Each province developed its own system. This resulted in a patchwork of rules, standards of practice, and even public access to drugs across Canada.

One of our first tasks was to develop harmonized conditions for the sale of all drugs on the Canadian market as well as the standards of practice expected of pharmacists distributing them. Our model was completed in 1997 and I am pleased to report to you today that Canada's national drug scheduling system has been adopted by nine out of ten provinces.

Our system consists of three schedules, if you will, of drugs, plus an unscheduled category. All three schedules include some drugs that have varying degrees of non-medical use. Our corresponding national standards of practice for pharmacists include a requirement that, and I quote, “pharmacists recognize and address patterns of inappropriate use of drugs”, and that they “detect and respond to activities which would divert drugs from their intended legitimate use”.

These are standards that are required of pharmacists.

We have a national drug scheduling advisory committee, which makes decisions on the placement of drugs within the model. Our committee is composed of seven independent experts and a representative from the Consumers' Association of Canada.

¿ (0945)

Mr. Randy White (Langley—Abbotsford, Canadian Alliance): Excuse me. I'm sorry. Could you just repeat that? I was writing it down and you were going a little fast: “Pharmacists recognize--

Ms. Barbara Wells: Yes: “and address patterns of inappropriate use of drugs” and that they “detect and respond to activities which would divert drugs from their intended legitimate use”. These are incorporated in the national standards of practice.

Decisions are made about scheduling on an objective, scientific, and transparent basis, with public health and safety the number one goal. Our aim is to support public access to important drug therapies while at the same time ensuring that threats to consumer health and safety are minimized to the fullest extent possible.

For classification, a drug is assessed against three sets of factors, each corresponding to a particular schedule. We use a cascading principle of assessment until the best fit, if you will, is arrived at. Abuse, addiction, and potential for non-medical use weigh heavily in these factors.

Schedule I drugs require prescription for sale. Those with federal prescription status are included, along with others deemed to require the advice of a physician for optimal use. Our schedule II and schedule III drugs are non-prescription. Schedule II drugs can be obtained only upon a pharmacist's direct intervention and approval. This category includes, among a number of entities, analgesics and cough suppressants with small, permitted amounts of codeine. You might recognize a trade name such as Tylenol 1 or Robitussin with codeine, and various house or generic brands. We know that there is some non-medical use of these drugs and therefore hold pharmacists directly accountable for their sale. These drugs cannot be self-accessed by patients. Professional interventions, including counselling, monitoring, the provision of information, and, where appropriate, refusal to sell and/or patient referral, are the expected standards of practice for pharmacists.

The public can self-select schedule III drugs in pharmacies, but again pharmacists are expected to be available for consultation and oversee their sale. Dimenhydrinate, or Gravol, and dextromethorphan, which you may recognize in DM cough syrups, are examples of schedule III drugs that we know are sometimes intentionally misused. Schedule III drugs must be placed in an area of the pharmacy that is adjacent to the dispensary and able to be visually controlled by the pharmacist. Again, we expect pharmacists to intervene when necessary, provide information and counselling, and, when warranted, exercise a higher level of control.

Unscheduled drugs can be sold without restrictions and you will often see these in gas stations, supermarkets, and other retail outlets. In some cases, the philosophy of harm reduction has dictated that a drug be made more accessible to the public. An example of this was the committee's decision to assign unscheduled status to nicotine replacement therapies.

I think most stakeholders would agree that to date the national system has been an outstanding model of cooperation among the public, provincial governments, the profession, regulators, and retailers. However, the benefits of this system to help reduce the non-medical use of drugs could be enhanced.

First, federal support is needed for a public education campaign on the rationale for our scheduling system and the purpose of pharmacist intervention on non-prescription drugs. Moreover, the public must be educated to expect it and demand it of pharmacists.

Second, we could do a better job on making sure that pharmacists are fully informed about the abuse of certain non-prescription drugs that we schedule. For example, if a drug is assigned schedule II status due to reports of its non-medical use, we need to make sure that pharmacists are fully informed about the specific nature, and even existence, of this abuse. Again, this is a resource issue.

Again, we're not talking here about simply restricting sales. We're talking about pharmacists offering referrals to patients where necessary.

Third, our drug scheduling system is for the most part funded by our member licensing bodies with direct meeting costs offset on a cost-recovery basis by our clients, which usually means pharmaceutical companies. A degree of underlying federal sponsorship would make the system more accessible to the Canadian public and enhance our efforts to identify and respond to new reports of abuse and misuse.

¿ (0950)

Our second area of interest is, as Jeff mentioned, the pharmacy licensing authorities' role in enforcing both federal and provincial legislation related to the sale of drugs, such as the Controlled Drugs and Substances Act. Our members inspect pharmacies and monitor pharmacists' practices for compliance with laws and standards. Since the beginning, our licensing bodies have counted on support from federal inspectors and field officers, not just in sharing responsibility for pharmacy inspections, but for advice, information, interpretation of federal laws, and general collaboration.

Some years ago, decisions were made by the government to stop conducting routine pharmacy inspections and there were corresponding cutbacks to field resources available to our members. Pharmacy licensing authorities have been severely affected by this, and all, from smallest to the largest province, report that losing this federal resource at the local level has had a substantial impact on their ability to effectively enforce federal legislation related to drugs. We are also seeing less and less coordination between the existing field staff and the Ottawa government when it comes to policy guidance and interpretation of federal legislation.

If our members could be here today and could deliver one message to you about this it would be this: please bring back these field resources. The pharmacy regulatory bodies need the support and assistance of the federal government to enforce your drug legislation. We need to work together with you to reinstate this support, modified if necessary, to be cost effective and mutually beneficial.

Thank you very much for this time. We wish the committee well in its deliberations.

You can access our standards and documents through our website at www.napra.org or also, of course, by contacting me. Thank you.

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

Dr. Barry Power.

[Translation]

Dr. Barry Power, PharmD (Director of Practice Development, Canadian Pharmacists Association): Ms. Shelley Stepanuik, who is Vice President of the Association, and a community pharmacist, is with me this morning.

[English]

By way of brief background on our association, CPHA has been representing the interests of Canada's pharmacists since 1907. Our members include hospital, community, consultant, government, and industrial pharmacists. We do not represent or speak for the pharmaceutical industry. Rather, we represent the profession of pharmacy in all practice settings.

I would like to begin by thanking the committee for giving us this opportunity to provide our perspective and thoughts on the issue of abuse and misuse of prescription and non-prescription drugs in Canada. The committee has heard repeatedly, and Canada's Auditor General noted in chapter 11 of her 2001 report, that there is not a lot of data on drug abuse in Canada, whether it's licit--prescription or non-prescription drugs--or illicit drugs. Committee members have heard that there is a problem of this type of abuse and we, as pharmacists, see it on a daily basis.

Ms. Stepanuik and I will be sharing our presentation time. We will try to keep our remarks brief to allow for more opportunity for your questions.

The main types of prescription drugs pharmacists see being abused regularly include painkillers, sleeping pills and anti-anxiety medication. There are others, but these are the main classes. They're the most common targets of diversions, forgeries and thefts.

The committee has already heard about some of the problems of prescription drug abuse from a number of witnesses, particularly when you travelled to Atlantic Canada. The committee has also heard about a variety of controlling and monitoring measures in place in various provinces.

As a pharmacist who has practised at the community level, as a consultant pharmacist, and at Health Canada, I have witnessed a number of problems associated with misuse of prescription drugs from a number of perspectives.

In terms of trying to address and find solutions, it is important to differentiate between those individuals who misuse pharmaceuticals to the detriment of their own health and those who misuse the health care system to obtain pharmaceuticals that they sell for profit.

When the committee heard from Shaun Black, a pharmacologist in Nova Scotia, he raised a very valid point about the need for greater education of pharmacists and physicians regarding addictions.

I would agree, and I will add that greater education on the dangers associated with addictions to and dependence on prescription drugs should go beyond prescribers and pharmacists to the community at large. Very little attention is paid to proper use of narcotics in pharmacy programs, although the curricula are improving.

Much of the attention given narcotics is negative and reinforces stereotypes that all people who take narcotics are addicted. The public is very poorly informed about narcotic drugs and their benefits. This unfortunately becomes very apparent in patients with cancer, who would benefit greatly from proper use of narcotics but are afraid to use them.

Codeine is a good example to illustrate the point that aside from the need to educate Canadians about the potential dangers of addiction to and dependence on narcotics, it also underlies the need among health care professionals for better understanding of pain control. In 2001, Tylenol 3 was the fourth most prescribed product in Canada, yet Tylenol 2, which at 15 milligrams is half the strength of Tylenol 3, was the eighty-eighth most prescribed product in Canada.

The amount of Tylenol 3 prescribed raises two questions: first, are Canadians receiving too much codeine and would they be better served with a less potent product such as Tylenol 2 or even less potent products that are available over the counter, and, second, are Canadians being poorly treated by the use of codeine instead of more potent drugs such as morphine? A great deal of fear is associated with the stronger narcotics, both on the part of health care professionals and the public. This fear may result in pain being poorly managed.

In Canada, we have had successful campaigns highlighting the dangers of smoking and alcohol consumption. We would recommend the development of a national campaign to explain the possible dangers of abuse and misuse of prescription drugs. Prescription drugs are now the medical intervention of choice, and usually for good reason, as they provide tremendous health benefits. People are under the impression that prescription drugs have no ill effects and can do no harm. A campaign should sensitize Canadians to the fact that while a drug is prescribed for a good reason, some drugs can lead to dependence and addiction and do not achieve their goals if taken improperly. The campaign should also provide people with information on what to look out for and whom they should be consulting when questions arise about their medications.

¿ (0955)

Pharmacists, as drug experts and the most accessible health care professionals, already provide important drug information to patients every day. We hope the committee would consider a national campaign using pharmacists, addiction workers, and others to go into elementary schools to sensitize children early on to the benefits and potential dangers of prescription drugs. Unfortunately, our busy society and health care system don't always allow physicians and pharmacists to spend the necessary time with patients to truly ascertain the causes of pain, the best methods of pain control, and awareness of potential for addiction and dependence. Deficiencies in medical and pharmacy education also help to prevent professionals from investigating these factors well.

I'll now turn it over to Shelley Stepanuik.

À (1000)

Ms. Shelley Stepanuik (Vice President, Canadian Pharmacists Association): Good morning.

I'd like to spend some time talking to you about some of the problems of abuse and misuse of pharmaceuticals I have seen in my time as a community pharmacist, as well as some of the potential solutions. I have practised as a community pharmacist in Saskatchewan and Manitoba, and I am currently in Smiths Falls, Ontario. I have seen a number of similar problems and a number of approaches to these problems.

Our recommendations calling for a national education campaign on the potential dangers of prescription drug abuse ares certainly supported by a call for a national real-time pharmacy network that would allow pharmacists and physicians to minimize abuse. These recommendations come directly from problems I and many other pharmacists see and deal with every day.

A common scenario supporting the need for a national real-time electronic database involves an elderly patient who has started on a benzodiazepine to help him or her sleep. The effect of this drug generally wears off after several weeks of use, so the end result is that the patient is no better off than they were prior to taking the drug. However, if the patient tries to stop the drug after a month or so, they will have rebound insomnia and will be convinced that they need the drug to sleep. In some cases a second sleeping pill may be prescribed, and the patient may have a supply of both drugs. If they are filled at the same pharmacy, the pharmacist can discuss the duplicate therapy with the patient and the physician. If they are not filled at the same pharmacy, the duplicate therapy would go unnoticed for the majority of Canadians. In B.C. and Manitoba the pharmacist would have access to the patient medication record and would be able to discuss the duplicate therapy with the physician and the patient.

A second example concerns people who abuse the health care system for profit by selling their prescription drugs to others. They are well versed in the weaknesses in the system and in ways to avoid detection. I have seen examples where pharmacists have been threatened by these abusers. In one example a patient was adamant that he did not want his narcotic prescription to be registered with the Manitoba central processing system, and we suspect it was in order to avoid the detection of double-doctoring or overuse. If every prescription had to go through a national processing system, problems of this nature could be avoided, because the information would be at our fingertips.

A real-time database would provide health care professionals and policy-makers with access to reliable and up-to-date data to determine the scope of the problem. The committee has already heard from witnesses from a number of provincial adjudications and prescription monitoring systems. In Manitoba I have worked with the DPIN system. In British Columbia the PharmaNet system is another tool which electronically and securely links all B.C. community pharmacies to central databases. These systems allow the pharmacists to gain secure access to patient medical profiles if they need to confirm issues with narcotics or prescription drug abuse or misuse. I should note that there are confidentiality stipulations in place for that, and the data we see are actually quite limited, but are enough for us to help assess the problem. Such a system on a national basis would ensure a uniform level of health care delivery for all Canadians.

Another tool that health care providers use to stem abuse in areas without real-time systems is a multiple prescription program, sometimes referred to as a triplicate drug program. The aim is to decrease the number of prescription forgeries and alterations and double-doctoring. There are variations of this type of program across the country, but they all follow a basic approach. A prescription is made with multiple copies that must be presented by the patient in order to receive a drug covered under that program. The form consists of the original prescription with an identical copy or copies attached to it. The order is only valid for a fixed number of days once it has been written. The original prescription is filed at the pharmacy where it is filled. The attached identical copy is then forwarded to the program managing body, such as the provincial medical regulatory body, within a fixed time after filling of that prescription. The third copy of that prescription form remains in the doctor's office, affixed to the patient's chart. The program requires that all prescriptions for drugs covered by the program be on this multiple prescription form. Only one drug can be prescribed on each form, and the prescription pads are personalized and numerically recorded for each prescriber.

À (1005)

These programs have had some impact in lowering the number of prescriptions written for included narcotics. Provincial prescribing rates for narcotics tend to be lower in those provinces where these programs are in place. The weaknesses of this system are that they are not real-time and little follow-up does occur with prescribers and pharmacists, but all systems have weaknesses. The multiple prescription program does have weaknesses, but has met with success.

In conclusion, Madam Chair, we would like to thank you very much for this opportunity. As my colleague mentioned, we feel there is much to be gained by leaving more room for questions. Certainly, I would welcome an on-site visit by anybody who wants to witness what we see day-to-day, but at this time we would be happy to answer any questions you may have.

The Chair: Thank you very much. And I can assure you, we've all been asking a lot more questions in our doctors' offices and pharmacies and everywhere else. We've had our eyes opened as we've studied this issue.

I'll turn now to questions. Let's do ten-minute rounds and see how many we can get in.

Mr. White.

Mr. Randy White: Thank you, Madam Chairman, and thank you, witnesses, for coming. I can assure you that the pharmaceutical profession is still highly valued among Canadians, and as far as I'm concerned, it does a very good job.

You had some very interesting statements, and I know the security of the whole infrastructure of pharmaceuticals is very prominent in your minds. The statement that I interrupted Barbara on and wanted her to repeat stuck in my mind, that pharmacists recognize and address patterns of inappropriate use of drugs. And as well, you're looking at visually controlling drugs, in drugstores I guess. To me, neither of those comments means a lot if you have five, ten, fifteen drugstores in a community and a person is going from drugstore to drugstore. I'm not sure how you manage that.

I've talked to a lot of addicts, but a particular number say they've had as many as four to six doctors on the go. They say they can maintain or support an addiction on prescribed drugs. I know people in prisons maintain habits on prescribed drugs. I wonder if you could give me an account as to how on earth it is possible for a drug addict to come to me and say, look, I've got doctors on the go; I just go into a drugstore and the next drugstore and the next drugstore, and hey, I've got myself a habit here, and those I don't use--because I don't need them all--I sell. How is it possible that this is still going on with all these controls?

Barbara.

Ms. Barbara Wells: Well, our standards also include a necessity for pharmacists to have a relationship with their patients, to know their patients. We know that double-doctoring goes on all the time, and we would expect pharmacists to assess a prescription, if we're talking about prescription drugs, and check for double-doctoring, to know the patient, to know the physician who is prescribing for the patient. That's part of knowing the patient, knowing their medical needs, being familiar with the relationship, and making sure the patient also has a relationship with the physician. So it's a sort of triangle. That is part of our standards as well.

Mr. Randy White: How do you do that if an individual is going beyond double-doctoring? I 've been told they go to a doctor, they know the story to give the doctor, and they know pretty well what kind of drug is going to be prescribed. They may have a relationship, therefore, with a doctor and another drugstore and another drugstore, and across town another doctor and another set of drugstores. Unless all these drugstores are talking to one another through a data system, how on earth do you catch these people? They're very professional at it.

Mr. Jeff May: I think, to pick up on Shelley's comments, the need for a truly integrated health and pharmaceutical information network is very critical. Many of our members are active in their provinces working with provincial health information networks; in British Columbia the PharmaNet system, the proposed pharmaceutical information network in Alberta, the DPIN system in Manitoba are three examples. We're actively working with those groups to facilitate the evolution of technology so that we can talk to pharmacies. As Shelley indicated, in British Columbia, if a pharmacist can see an entire drug profile, regardless of whether the prescription was dispensed at store A, store B, store C, or store D, we can see that information and make the appropriate interventions. In our traditional system the accountabilities of the pharmacist are the individual relationship that occurs at that store and the awareness of the broad access that a patient has. It's very difficult to pick up.

So I would echo support for the recommendation of CPHA to further a more integrated health and pharmacy information network.

À (1010)

Ms. Shelley Stepanuik: Absolutely, there is a way to abuse the system. I was really disappointed when I moved to Ontario to find out that we did not have access, because I got so used to that in Manitoba. My understanding was that there was a concern of confidentiality, and this was why we couldn't have that information. In Manitoba, just so you know, it was not just random access. I wouldn't be able to take my neighbour's health card number and just get nosy. I had to document, with my licence number somewhere, why I accessed the system, and I had better be prepared to answer for it every time I did.

If I felt there may have been abuse, that's all I would have to record. It would allow me into the system and show me what day, what was prescribed, how much was given, in a quantity and a day's supply. It would not tell me the doctor, it would not tell me where it was filled, and it would not tell me the price. By seeing day's supply, I can figure out what the probable instructions were, enough to see if it was similar to what I had or different from what I had in front of me.

When I was in Manitoba, we refused it many times. These were people who were abusers, but not the smartest abusers. You just had to be very blunt with many of them and say, you only got this four days ago; go away and come back in a week. Most of them couldn't argue, because they didn't know how we knew, but we knew, and they had got it somewhere else. Here we get certain early warning flags, but the information that comes across our screen is simply a date, the drug, and a quantity; it doesn't tell us the duration of days. So a person who is taking eight Tylenol 3 a day will run out more quickly than a person who was told to only take two tablets a day. So it's not enough. It only tells us the last time it was prescribed, not the time before, and not the time before.

Mr. Randy White: With the homemade drug, ecstasy for instance, the components of those kinds of drugs and drugs we haven't even heard of today that are being developed in somebody's basement or garage, I presume most of the components come from drugstores, department stores, you name it. Can you give us an idea of the more notorious components of some of these drugs like ecstasy and where they are coming from? You are a pharmacist, you should know this.

Dr. Barry Power: Some of the precursor molecules, as they are known, are non-prescription products. There has been quite a bit of attention paid in the United States to pseudoephedrine, which is a very common decongestant in many cough and cold preparations. It can be used to make a type of amphetamine, ecstasy, and other products. So it's widely available. There are other precursor molecules that are restricted through various laws, so that anybody who requires them has to be registered through a number of processes. With the ones that are readily available, you have to look at the potential for abuse versus the potential for harm by restricting access to them. Is it fair to restrict access to pseudoephedrine for every Canadian because some people are using it to make illicit drugs? There has to be a balance between the two.

One thing I have seen in one of the communities I worked in is that the police would alert us to any sort of precursor molecules that were becoming the current favourite of the bathtub labs. As a result, many of the pharmacies would remove these products from public access areas. They would still be available for sale, but they would be behind the counter, so people would have to request them. If people were requesting large quantities, you could alert the police to this.

To go back also to your previous question, there are systems in many communities where pharmacists have got together to set up early warning systems, so that if there is a forged prescription going around town or if somebody is known to be double-doctoring, within a few minutes every pharmacy in town will know about it, because one pharmacy will phone two pharmacies, and they will phone two more, and so on. Within a few minutes everybody has a description of the person, the names they are using, the drugs they are seeking, and the physicians they have been to. It's not a perfect system, but in areas where there is no electronic access to prescription records, it is somewhat effective.

À (1015)

Mr. Randy White: Where are the large amounts of prescription drugs coming from? They can't be just coming from drugstores. In some cases there are large deposits of these drugs kicking around out there. Where are they coming from?

Dr. Barry Power: There could be diversion at many levels. There could be people who are having prescriptions filled in pharmacies for large quantities. There could be diversion at the wholesaler or the manufacturer level. Anywhere somebody has access to narcotic medications, there is potential to have diversion. You could be getting large amounts being diverted at various steps. There are safeguards in place virtually every step of the way. The farther from the manufacturer you get, probably the easier it is to divert, because it's generally smaller quantities. So if you had somebody who was trying to divert, for example, 1,000 tablets of morphine from a manufacturer, that would probably be noticed, whereas if you had somebody who was trying to divert 5 or 10 tablets here and 5 or 10 tablets there from a pharmacy, that might not be noticed.

Ms. Shelley Stepanuik: If I can just add to that, one of the really sad things that did happen was the loss of the narcotic inspectors to the pharmacies, partly because it kept everybody accountable, but when you have a lot of different people working in the pharmacy, if somebody is walking by and helps himself to five morphine here, five Demerol there, it may go unnoticed, and you don't have to do the same sort of recording of your on-site inventory today compared with what you've purchased and what you've sold. That was one of the things that was really good about the inspectors. You knew they were coming, you knew you had to be a little tighter with who had access and all the rest. That is not to say that it's got loose, but it's just a component that was very helpful to employers, I believe, for them to also see.

The other part that was really good with the inspector coming into the store was that they got to see patterns of prescribing. I don't believe there is anything right now that shows patterns of prescribing. Some physicians may be more reluctant to prescribe the hard narcotics, but they give Tylenol 3 out as if it were candy. They have nobody watching what they're doing, whereas when the narcotic inspectors came in, they were literally thumbing through days and days of prescriptions just to see. And you can see a pattern fairly quickly when you start looking through hard copies of things. That doesn't happen any more.

I don't know if there is mandatory charting required for physicians of prescriptions, but at least when we had that inspection going on, we knew that bureau had an accountability to the federal government with respect to physicians and pharmacists, it wasn't pharmacy-specific. That was a loss, and it would be great to have it back.

The Chair: Thank you.

Did you also have comments?

Ms. Barbara Wells: I also just wanted to mention, in response to your question about where these prescription drugs are coming from, that there is some degree of illegal importation occurring. That could be another source.

The Chair: Thank you very much.

[Translation]

You have ten minutes, Mr. Bigras.

Mr. Bernard Bigras (Rosemont—Petite-Patrie, BQ): Madam Chair, in light of the Committee's study regarding the abuse of prescription drugs, I believe we may come to two conclusions.

The first conclusion is that there is a flagrant lack of education regarding the risk of prescription drug dependency and the impact of substance abuse. The second is that supervision and control are simply inadequate.

I would like to put the emphasis on the second part of my first question, namely the lack of control. I understand why there is talk about a so-called information database, specifically to avoid the multiple prescriptions that you have probably noticed all too often, and that you have just told us about. I think it is an excellent idea.

I would like to point out to you another phenomenon, and I would like to know if you have given any thought to the following case. Many people get a prescription, go to their pharmacist, obtain the medication, and often do not entirely consume the drug, only to re-sell it on the black market. We therefore have two distribution systems, your system, which is legal, and another system which is not, and very often both systems compete.

So, have you thought about this problem, that is, a computerized database would indeed help solve part of the problem regarding multiple prescriptions, but that it would not solve what happens with the drug once it is no longer under your control and is placed on an uncontrolled market.

À (1020)

[English]

Ms. Shelley Stepanuik: One of the things some provinces have instituted is a trial prescription program. In certain cases where you have items of abuse, especially anti-anxiety sleeping pills, somebody using one for the first time goes through only a seven-day supply. A lot of the time now patients are receiving a 30- or 60- or 100-day supply, with the hope that they will see their doctors in a couple of weeks to assess how things are going. A lot of medication is not completed, as you say. A lot of it will stay in the home until another day, when somebody else comes along and decides, that's what I need, I'm having stress. They take it, and it could be expired. It could be very inappropriate. That's a whole other public health issue.

The trial prescription program is, in some respects, labour-intensive. It does require secondary visits to the physician, but I would say that we see a lot of wastage and a lot of potential for redistribution when people get quantities that are absurd. One of the things that really surprised me in Manitoba was that blood glucose strips, of all things, became the product of abuse by people who had drug plans that paid 100%. They would get more than they needed because they knew that the person they sat next to on coffee row did not have a drug plan and had to pay $90 a box, while they didn't pay anything. So they would make sure they had a double supply and sell it for $30 or $40. You wouldn't know how much somebody was supposed to go through, because the quantities they were purchasing were quite normal. There would be no safeguards against something like that.

I feel very supportive of physicians who have been scammed, because these people who want it know how to say the right things. They know what allergies to profess. They know what sensitivities to say--sore stomach, I get headaches, or whatever. That's why I'm on the other side. I wouldn't want to be the physician dealing with that. It would be very difficult.

Ms. Barbara Wells: I also want to mention a variation on what you've described, and that is where legitimate patients, particularly seniors, receive legitimate amounts of narcotics and so on and are coerced or somehow intimidated to supply those to relatives, neighbours, or whatever. We've heard a lot of reports of that as well. I think that's an issue. Again, I'm not sure how you would respond to that. It comes with a network in the community of support for seniors and that kind of thing.

Mr. Jeff May: Also, I think the issue you are addressing is one of balancing need of the patient against appropriate prescribing and appropriate quantities. The provincial registrars of pharmacy, the provincial colleges of pharmacy, our member organizations do work very closely with the colleges of physicians and surgeons in their provinces to discuss aspects of appropriate prescribing, prescribing practices related to quantity and need. The situation you describe is a very difficult one to tackle, because it deals with a public that is intentionally trying to manipulate the system. Awareness of trigger factors, behaviour among not only prescribers, but pharmacists as dispensers and with our collective role in patient education, also awareness of appropriate and proper prescribing practices are really critical to reaching a solution to the issue you speak of. It's a very difficult one.

À (1025)

[Translation]

Mr. Bernard Bigras: I would now like to talk about information. This is my second question, and in fact it is the second problem that was identified by the Committee, namely education.

Mr. Power, I am worried by what you said, that in the matter of awareness and informing the patient, you don't have enough time to adequately fulfill this role. I have always thought of prevention as a part of the solution.

My question is this: in addition to saying that it would take more time to provide information to the public, what tool, what method, what process could be implemented to improve public awareness? You can't simply be purveyors of drugs, you must also inform people of the drug's impact.

I would therefore like you to expand on what you told us earlier. You have little time, I agree and you are probably right, but what can you tell us regarding what can be done to better inform patients regarding the dangers of abusing prescription drugs?

[English]

Dr. Barry Power: The profession of pharmacy at the moment is undergoing an evolution, and one thing we are attempting to encourage pharmacists to do as much as possible is give up the technical aspects, the distributive aspects, so that you don't have a pharmacist counting pills instead of speaking to a patient. That is one way we can get more time to discuss medications with the patient. It's a very serious problem in some situations, and it also is dependent on the pharmacy. Obviously, a pharmacist who works in a pharmacy that is filling 100 prescriptions a day will have more time to spend with patients than a pharmacist who is filling 400 prescriptions a day. There are standards in most provinces that require pharmacists to counsel patients on a minimum amount of information. With respect to narcotics, it may be that the minimum amount of information is not sufficient to help the patients to appropriately understand the benefits and risks of the medications.

I think we also need a public education campaign, because there are drugs that are being abused by people for whom they have not been prescribed, as Barb and Jeff mentioned. Every pharmacist in the country is familiar with situations where medications have been stolen, somebody has walked into their house and taken a few tablets of an anti-anxiety medication or a narcotic out of their vial. It's usually somebody they know well. It's often a family member who has a drug dependence problem.

So it needs to be a two-pronged approach. It needs to be a public education campaign, it also needs to be a campaign to encourage pharmacists, physicians and nurses all to spend more time with patients who are receiving narcotics, so that it gets rid of some of the fears that are out there surrounding narcotics, so that people who actually need them will benefit from them, but also so that they aren't treated casually, so that people aren't running to the doctor for a Tylenol 3 because they've had a minor pain for a short period of time. There are many non-prescription products that can be used instead of some of the narcotics that are prescribed very freely.

[Translation]

Mr. Bernard Bigras: Would you agree, for example, with a directive that would be part of a process where the pharmacist would be obliged to inform the patient on the impact and possible dangers involved in abusing certain drugs? You will maybe tell me that this is already being done, and that such an obligation already exists. I don't know, and that's why I'm asking the question. Would you agree on this type of obligation, for the pharmacist to inform the patient: "if you take this drug, these are the risks involved"?

À (1030)

[English]

Ms. Shelley Stepanuik: One of the things I have incorporated in my own practice is that when I see a patient getting a potentially abused product for the first time, I will find the time to spend that extra few minutes to say, watch out, you are getting something that is highly addictive, and if you use too much too quickly.... As a matter of fact, I just had this last night with a lady, who then broke down in tears telling me her 42-year-old brother just died. You never really know the circumstances for somebody's getting something, but the look on their face when they say, I didn't realize that I could become dependent, is worth my having taken that time. I don't know so much about the compulsory side of it. I am addressing my obligation to council by saying this, and I will generally do that as best I can.

There comes a point where you can't say any more, where in your day-to-day counselling you can only address the problems in front of you for that prescription at the moment, and that becomes a time factor. Some pharmacists in the country have started to implement a new way of practising, where they are doing sit-down consultations. This is a different service. They are charging people cash for it; it is not as if I can take an hour from my day, because it means somebody else has to be in the dispensary. This is where a pharmacist is sitting down for an hour and saying, bring everything you've got out of your house and let's go through it all. And you walk through one by one, what they have from your store, what they have from another store, what they have from the herbal store. And it is all assessed to the point where you can say, do you even know why you're taking this any more? Do you remember what this was for? Did you know you're taking this one because the first one is causing you that side effect? A lot of times those kinds of reviews can make a huge impact on people. We took a lady about two weeks ago who was taking 15 medications in her dosette every week and cut it back to eight. That's a massive impact.

The other part I would fully support is giving physicians the ability to bill for consultation only. I get the impression right now that they are very pressed for time with people, and there needs to be--I could be wrong on this--some sort of procedure for it to be a billable time. Let the doctor bill for 15 minutes of talking only, because some people just need to talk it through.

The other side that may have merit--and this is a little bit out of the range of pharmacy--is making psychologist help available for people who need grief counselling and who are started on anti-depressants because they are just going through menopause and they don't understand and they just need someone to talk to. If you don't have an employee assistance program, you have to pay for that out of pocket. That's very unreachable for many people.

Those sorts of things, I think, can help curb some of the problems that arise when people don't even realize they have become dependent on something, but having tried to stop it, they go through withdrawal symptoms. It's a different way of practice. For those who have an ability to take advantage of that, it's helpful, but that's not always the case.

Mr. Jeff May: The standards of practice that are in place on a national level, plus individual provincial standards, do address the requirement for the pharmacist to educate the patient on the use of the medication, but also on potential adverse events and the potential, as Shelley said, for dependency further down the road. The additional requirements for education on abuse and misuse I think are well covered in the standards, but what is, I think, particularly critical is awareness of any specific aspect that 's happening in a community. There are multiple forms of misuse of medications, prescription or non-prescription, and there could be a greater degree of collaboration, not only with the medical community, but also with law enforcement, to be aware of what's happening in a community and any other health care professional who is involved in addiction, misuse, abuse treatment, so that collectively, health care professionals have an understanding of current trends in the community, as well as the ability to communicate. With an awareness of those issues, pharmacists, I think, are very well positioned to deal with the issues you speak of.

À (1035)

The Chair: Merci beaucoup.

Mr. Lee.

Mr. Derek Lee (Scarborough—Rouge River, Lib.): Thank you.

Your evidence here today has been very helpful. Clearly, you're all professionals representing a piece of what we would regard as the drug spectrum. What's driving the problem we're focussing on is someone who has become addicted, someone who is determined to acquire the drug that they're seeking, whatever that is.

What we have is a very leaky system. You've pointed out the various diversions that take place. We may not have hit all of them here today, but you've covered most of them. There are tons of diversions, but what's driving it is that one person at the end of the supply chain who demands to have a drug because he or she is addicted to it. As professional as you and as your colleagues are, you're dealing with the regulated part of the drug spectrum; we haven't even got to the black market yet, folks. We can't seal up and make the regulated system work, because there is a consumer down there who, one way or another, is going to get his or her hands on the drug they've become addicted to.

You've made some suggestions and I'm going to be a kind of devil's advocate. Why should I, as a legislator, divert many more millions of taxpayers' dollars? Or why should I pass a law that would cause consumers to spend many more millions of dollars to patch up, to band-aid, the system we have now when, at the end of the day, if we even succeeded in patching it up 99%, there is still the 1% we haven't patched up and there is still the black market that will serve the person who is going to have the drug come hell or high water? Why spend more money on police and inspectors and systems and computers and databases? Couldn't we just find the addicted person and do our best to deal with that person within the health system and then spend more money on education to try to prevent people from becoming addicted, as you have made reference to? Could I address that to the regulated drug side?

The Chair: Dr. Power.

Dr. Barry Power: Just briefly, many of the things that we have suggested would end up being prevention. By spending money on some of these systems you will prevent some people from becoming addicted or dependent on prescription drugs. We have always had, and we probably always will have, addicts who will do anything they can to get whatever they're addicted to. You can have the best system in the world, but somebody is going to find a loophole through it if they are truly addicted.

I see it as a spectrum. You can implement prevention at various steps. A lot of the things we're suggesting are partially reactionary. They will stop some people who are addicted, but they also may help some people who are not yet addicted but are at risk of becoming addicted.

Ms. Barbara Wells: If I might add to that, the system we are faced with today, while not perfect, does put the pharmacist in a position to detect abuse and addiction and to help refer these people for assistance. Not only is there prevention, but there is also the detection element as well.

Ms. Shelley Stepanuik: May I just make a comment? I think it's important to identify that the abusers may not be who you think they are. We are very well aware of the people who may be on income assistance, who may have some disability of some sort and who have just taken up the system the way it is. They have fallen into this trap. They are just comfortable with that. They need to feed this addiction. I can tell you that most of the people we run into who have problems are senior citizens. In their opinion, they are not addicted to anything, but they can't do without their sleeping pills. They don't see that as an addiction. They don't understand that that's what it is. In many cases they may have started out in a depressed mode and have been given something like a sleeping pill. It should have been for a temporary timeframe, but it became kind of nice to sleep all the time so now they can't live without it. I think that is one side.

I would suggest that for the most part the people who are abusing don't believe they have a problem. They don't believe there is an abuse there, so to sit down with them to try to say let's take care of your problem.... They don't see it. They don't understand that this Tylenol 3 has made them drowsy, has made them fall, has ended them up in a hospital. It takes some real education at some level.

I think prevention can be key, which is why I really support the idea of letting physicians talk to people before they give them something that could become potentially addictive, depending on the person's personality and so on.

À (1040)

Mr. Derek Lee: I'd love to have people like you in all of our pharmacies, drugstores, and pharmaceutical companies. That would be a big help, but we're not going to get people like you in all these places. We're going to end up with a cross-section of society. What Ms. Stepaniuk just referred to was people who weren't in the category of non-medical use of drugs; they were simply the senior citizens who are addicted to the sleeping pill. Pardon me if I don't have the paradigm exactly right from a technical point of view, but that's a medical use of drugs. It may be an inappropriate medical use, but it's medical.

We're not even concerned with that here directly, but the education piece, as part of the prevention piece as part of the societal management of drugs from alcohol to nicotine to sleeping pills to all the legal stuff to all the illegal stuff--provided we continue to make it all illegal--is the bigger piece that I see out there.

You see the need to educate the professionals that you work with, or at least I think you see that. Are your professional organizations able to undertake that challenge of educating your crew, your piece of the spectrum, or do you need help from government in doing that? Do you need more provincial or federal regulatory clout to require the professionals you work with to be better educated and “continuing educated” or refreshed on how they can serve the public better?

Mr. Jeff May: I think that pharmacy organizations across the country, be they regulatory or advocacy associations, are actively involved in continuing pharmacy education programs of many sorts. Historically there have been programs involved with the street use of drugs, awareness of issues, and non-medical use of drugs. I think the issues you've identified for us are areas that require not necessarily a base education but certainly an awareness of what is really happening in the community.

I spoke earlier of the need to have health care professionals who are involved in addiction treatment communicate more, so that rather than focussing on simply the medical use of drugs and educating patients on what to do and what not to do, we pick up on Barbara's comment of being in a position where we are an end source of supply, if you will, where we are the professionals that do provide drugs to patients. The opportunity to intervene is there. The awareness, the issues in the community, need to be better understood, I believe, because it does vary among professionals, but there is a willingness and a capacity to be able to deliver educational programs to professionals within the existing pharmacy framework. There are many examples of that activity that have happened across Canada. I would say that the willingness is there and the capacity is there. It's a matter of increasing the awareness of what the issues are.

Dr. Barry Power: The Canadian Pharmacists Association is currently in the process of working on a program to raise awareness amongst pharmacists of drug diversion techniques. We're doing it in conjunction with a pharmaceutical company that manufactures a lot of narcotic products. They obviously have a vested interest in making sure that their products are used appropriately.

Programs are out there. Addiction and drug diversion are not necessarily the most well-attended continuing education programs that we have, because it's really not seen as a huge issue by a lot of pharmacists. I think the first step we have to take is to raise awareness amongst the health care professions of the problem you've been investigating.

À (1045)

Ms. Shelley Stepanuik: May I make a final comment? I think we can only do so much at our end when we have a legitimate prescription on our side, and we can help people as much as we can. I'm not going to profess to be anti-doctor, because I'm certainly not, but there are certainly doctors who are a lot easier to access things from than others. This is part of why the inspector was such a good thing, because we can't report this to anyone without creating a really devastating relationship within a small community by saying, “This doctor is a problem. Will you please look it over?”

I don't know exactly where to take that, except that the doctor ultimately is prescribing it, and has a record, I hope, of what they have prescribed week to week or month to month, however often they see someone. Someone may get a regular prescription from the physician and go to emergency and get more. We can stop that. We can call the doctor in emergency--and we do every weekend--to say, “By the way, did you know this person just got this two days ago and they have 50 tablets on hand?” That emergency physician will almost always say, “Don't fill it. They just got it. They don't need more. Give them the other antibiotic or whatever, but don't give the painkiller.”

We will intervene and do that a lot when we are aware of it, when it's in front of us, but that is basically an emergency room physician not knowing what the regular prescription use of that person is.

I would like to see something more on the prescribing side. I don't know what it is. I do know that in our community those physicians who use electronic prescribing seem to have a much better handle on what is leaving their office every day, possibly because their charting is immediate and not paper based. I don't know how often charts have to be updated or get updated in an office, but every pharmacist knows which doctor is a problem--or doctors. There's not a lot that can be done other than this: I can tell you that when a drug plan restricts payment on something, it becomes a bit of a “Whew!”, to us, like, “Oh, good, we have something to tell them why they can't get it.” Because most times they won't be able to afford it, but that's not a good reason to stop someone. It's just a piece of the answer, a very small piece.

The Chair: Before I turn to Ms. Allard, what's the process? The person has an addiction at this point. We heard about people, particularly in Nova Scotia, who had been prescribed pain management drugs while they were in a hospital setting, perhaps because they were the cheaper drug to prescribe but were extremely potent. They were sent home from a hospital on a Saturday with an addiction. Frankly, they need something to bridge them out of that situation, so not filling the prescription isn't necessarily the answer. Referring them to somebody who can identify and manage what is now an addiction is a better way to go.

In the case we heard about in Nova Scotia, by Monday the guy was back in emergency and it was, “Oh, there must be something wrong with your surgery, you're in an awful lot of pain, let's put you back on this drug”, when really he was just going through withdrawal--and not “just”; it was quite devastating. That was the guy we met who was in a methadone maintenance program. That's seven years later after a nice little injection habit and hep-C and God knows what else.

Where is the responsibility, and where are the pieces in between you and the physicians, to say, “Let's manage your pain. Let's figure out what's going on. You don't have to wait six months to get into the university pay management clinic. Let's figure out how we're going to handle this problem.”? Is there anything?

Ms. Shelley Stepanuik: There needs to be a desire from the patients' standpoint and I would argue that sometimes they don't care. The pain that they're having is the withdrawal pain; that's all it is. In some cases, they would welcome the help. In other cases, they just want to keep from having that withdrawal pain. They probably had legitimate pain to start with, but it grew from there. They may have problems financially. They may have problems in their social life or in their intimate life, or whatever the case may be, that just feed this need for more painkillers, either to mask the pain or to make them forget about it for a while.

À (1050)

The Chair: Also, after a while they will have all those other problems because their addiction is creating them.

Ms. Shelley Stepanuik: Yes. It's a very vicious cycle. If there were a way to stop them in the first place, that would be great. As for the people who are there, we see the same people every week. Their physicians make them come back every week because that is one way a physician will have control of the quantity being given out: by making sure they only get so much per week. It doesn't necessarily stop them from going to emergency and asking for more, but at least this is one physician's way of controlling it. It's a very good question.

The Chair: Carole-Marie.

[Translation]

Ms. Carole-Marie Allard (Laval East, Lib.): I would like to thank everyone; doing this in August is not easy, even for us.

Ms. Stepanuik, I find your comments very refreshing, and I think that you have reassured me very much regarding your social involvement in your community. Keep up the good work.

I would nevertheless like to look at a broader question. You mentioned the database that would be required, and that there is one in British Columbia and Manitoba. You also mentioned inspectors who could do some monitoring of the file, to see which doctors are prescribing too many drugs.

Wouldn't there be a third element, which would be to provide the pharmacist with the patient's file, providing a complete picture of the person requesting the drug? How do you see processing the patient's file within a process targeting better service for people going to the pharmacy? Are you looking at the medium term impact of providing a smart card, for example? Are you preparing for this?

[English]

Ms. Shelley Stepanuik: In Manitoba, when we did access the patient file, most of the time we turned right around to that patient and said, you just had this filled three days ago. Sometimes they would argue and sometimes they would not. When they didn't argue, the next question became, how were you told to use it? Then we could assess if this was early or if there was a legitimate reason. They are not going to tell us their sister and brother took half their supply and they need some more. They're not going to tell us they took more than the doctor prescribed, because, quite frankly, the doctor doesn't know what he was doing, and they do. So the only intervention we had was to question them and, in some cases, prevent them from getting it that particular day.

It was not without its faults. It was certainly not without its threats. There were pharmacists who didn't want to have that information, because, quite frankly, they were afraid to tell somebody they couldn't have it. The one thing it flagged more than anything was the same product being prescribed. The one area where we would have be better placed for helping people was when something different was prescribed, and in some cases we were able to stop them and say, did you know this is the exact same thing? It may not even have been narcotics, it may have been something like an anti-inflammatory, and the patient was getting a duplicate therapy and would have an ulcer in less than three days. Having that information allowed us to intervene and say, wait a minute, did you know what you got from the other doctor is actually the same thing he's giving you today? There was a lot of value in having that in front of us.

We do our profile checks right now within our own store, but it's only our own store, so that doesn't include everything.

[Translation]

Ms. Carole-Marie Allard: I guess my question goes even further; it would be the possibility of having each Canadian carry a card that would contain all that person's diagnostic health information. The patient would go to the pharmacy and the card would show that the doctor has diagnosed a disk herniation. The pharmacist would therefore have a better idea of the patient's problem.

Is this something that would help you? You mentioned the database and the inspector, but this would more target the safety of the patient who is going to the pharmacy.

Have you considered this possibility?

À (1055)

[English]

Mr. Jeff May: There have been discussions on exchanging health information for many years in Canada. A key point is the inability to see the diagnosis or the intent of treatment for a particular product or to understand some of the other subtleties related to the individual's care, particularly if it's a situation of pain management or where the person truly has an addiction.

Health care information, in a lot of ways, rests in silos, depending on where you are in the health care system. Historically, the gatekeeper is the physician, but as the public expands across the health care system, you have bits of information here and bits of information there. Regulators have identified a critical need for pharmacists to be able to secure this information in order to provide the type of care that we're advocating as part of our standards of practice, in order to take that practice to a higher level.

So we are very supportive of a system whereby pharmacists could see not just treatment intent, but potentially, lab values and other subtle aspects of patient care that relate to the issue we're talking about today. We could also contribute our information to the health care system as a collection of activities or drugs that are dispensed and discussions that have been held between a pharmacist and a patient with relation to proper drug use, but also potential for misuse of drugs or other warning signs we may see.

The pharmaceutical information network in Alberta, the Wellnet system, a lot of the factors you talked about are there on the map. It's just a matter of having the willingness and the ability or access to the technology to move forward. What you speak of is something that we believe is a positive step for pharmacists to have a greater contribution and deal with some of the issues we're talking about today. So whatever support we can provide behind a national health network, be it a smart card or a database system, we lend that support, not only in the provinces, but federally as well.

[Translation]

Ms. Carole-Marie Allard: Thank you very much.

[English]

The Chair: I find it interesting that a couple of provinces you have mentioned, Miss Stepanuik, you've practised in have very good systems, and particularly in Atlantic Canada--and I'm not picking on Atlantic Canada--it was shocking that the privacy issues were of such great concern that they hadn't networked information. You describe pharmacists calling two people, two people, two people, a very informal and perhaps less secure network of personal information being exchanged. I'd much rather have some kind of system where there are checks and balances, making sure you're not calling in your neighbour because you're angry with them or something, a legitimate process.

Is there movement? Are the provinces coming on side? Should we expect that within six months every province will have something? Or is it just not going to happen?

Mr. Jeff May: We have seen movement on interprovincial discussions with respect to networks. There's the western health information collaboration. The Atlantic provinces are talking about it. We have activity in both Quebec and Ontario as well in regard to integrating networks. Pharmacy, historically, has already operated on a very sound technological base, particularly with systems for payment of prescriptions. We do have the infrastructure to be able to move to the next level very quickly.

The willingness, I think is there, but we need more an ability to adopt and pay for the technology to network the systems. I would love to be able to say that we could adopt our systems within six months or a year. I don't know the answer to that question, unfortunately, because of the fact we're dealing with multiple stakeholders. But our members, our regulators are speaking with these groups, in collaboration with other health care professionals, to truly identify the need as it applies to patient care and protecting patients against harm.

Á (1100)

The Chair: Ms. Stepanuik.

Ms. Shelley Stepanuik: In Saskatchewan we had a network that was a bit archaic, so when it was the year 2000, it needed to be disbanded, so they could start with something new. In the year 2000 all the systems became Windows-based across the province. It was hugely expensive for the pharmacy to do it, but it was mandatory and everybody had to get on board. If you have not spoken to the Province of Saskatchewan about their systems, it would be, I think, very worth your while to hear what they've done.

Part of the integration included e-mail access among pharmacies, not for the purposes of fanning out information, but more for transfer of files or whatever the case may be. The other component they were trying to integrate into that was for the hospital to have some access to information. There were some debates back and forth, because while the hospital was getting access to perhaps the drug plan to be able to see somebody's full profile, the pharmacies were not being given access to diagnosis. And so there was a little less give-and-take, it was a little more one-sided.

That was in the pilot stages, which is going back a couple of years. I'm not sure where it has gone since, but certainly, the information capability is there, and Saskatchewan is small enough that they have been able to get their small number of stores on side to do this. Only the drug plan of the province has the full database of everybody, and you can't see that in Saskatchewan unless you have means through a hospital or whatever the case is. I would suggest that you do ask them about it, if you haven't already.

The Chair: We're going to hear from the over-the-counter people as well, but it seems to me that there's a massive potential for negative interreactions, antihistamines, Robaxacet, Gravol--apparently, Gravol is a party drug in certain communities. You can get those substances on your own, without discussing anything with a pharmacist. Certainly, if you're on a prescription drug and you're taking those things, there can be some negative reactions.

There are also, of course, people who are using illicit drugs and mixing them with prescriptions. Is there a discussion amongst pharmacists on how to say, you know, this doesn't really go well with pot? Obviously, alcohol and legal drugs people talk about, but illegal drugs you don't talk about, and when someone's filling their prescription and they're wanting to cash out all the rest of the stuff, you could say, wait a second, you've got Tylenol and you've got Gravol--those things don't mix. Is there a process where you encourage people to discuss those kinds of reactions and interreactions?

Ms. Shelley Stepanuik: When you can, you do. When we see somebody grabbing a sleeping pill off the shelf and you know they're getting something potentially dangerous, we talk about it, but it's really hit and miss. A former CPHA board member who works in a store on a campus was telling me how somebody came up to him and he said, do you take any other medications? And he said, yeah, ecstasy once or twice a week, and he was picking up an anti-depressant at the time. He was so stunned by this guy's honesty that he was actually able to work with him and tell him the potential ramifications of continuing the prescription drug and taking the other--are you sure you want to keep taking the ecstasy? It was interesting, because very rarely will you have people come right out and tell you. I asked a gentleman once if he had any allergies, and he said, no, I love them all. When you get people like that, you know you could probably expand your dialogue a little bit, but I don't believe most people find that they're volunteering that information.

The Chair: Most people don't realize some of these things are drugs. They're given by a doctor and they come in pretty packages, so they must be good for you.

Dr. Power, and then Ms. Wells.

Dr. Barry Power: In a few communities where I've worked and Gravol abuse has been a problem, although Gravol can be sold in the front area of the pharmacy, where there is public access, we elected as a community of pharmacists to put it behind the counter, so that people had to request it. At the store where I worked we actually elected to stop carrying the larger size Gravol as well, so that it was only available in small doses. There were a few people we knew were using it legitimately we would carry the larger size for, but most people would only have access to the smaller amounts. Did it solve the problem completely? No, it didn't. But we believe it did cut down on some of the abuse, and at the time most of the abuse of Gravol was among high school students. There is a great need for education amongst high school students about the potential dangers of drugs, whether they be prescription or non-prescription

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Ms. Barbara Wells: I also just wanted to point out again that our scheduling system is set up in such a way that the interaction between a pharmacist and a consumer is facilitated. You mentioned Robaxacet and Gravol and so on. Those items, again, are to be kept within the sight and sound of a pharmacist. That is meant to facilitate the kind of discussion Barry talked about.

The Chair: On behalf of all the committee members, I thank you for coming before us today and for the work you do in our communities. I always like to ask my pharmacist questions, because pharmacists are full of information. I hope more Canadians pick up on that and do the same, because you really do have great knowledge and education to share. Thank you very much.

I will suspend for three or four minutes, so we can get the next witnesses before us.

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The Chair: I'll call this meeting back to order.

Our next witnesses are from Purdue Pharma. We have with us Dr. Andrew Darke, vice-president of scientific affairs, and Kathryn Raymond, manager of health and education. I'm also pleased to inform committee members that Purdue has brought also Dr. Roman Jovey, the author of Managing Pain. He is available to answer any questions, should we have them.

I think we have some slides you have distributed to us for your presentation.

Welcome. I'll turn it over to you.

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Mr. Andrew Darke, PhD (Vice-President, Purdue Pharma): Thank you, Madam Chair and committee members, for inviting us to discuss with you. You've asked us to talk specifically about OxyContin and we are certainly more than interested in doing that. OxyContin has become a subject of media discussion in terms of abuse and this is of great concern to the company. Certainly when one reads of the disastrous consequences of abuse of any drugs, including our own, it's of concern to us and we seek to take steps to correct that problem.

As you've cited, I'm responsible for scientific affairs within the company. With me is Kathryn Raymond, who is responsible for our health care education activities.

While we are going to focus on OxyContin, I just want to give a little bit of background in terms of Purdue Pharma's activities in the research and development of analgesic products, which actually started in the 1980s and culminated in 1986 with the introduction to the market of MS Contin.

I believe it's true to say that at that time there was an ongoing evolution within the medical profession in terms of: how patients with cancer who were near the end of their lives were treated; whether their pain was adequately managed or not; and, in fact, their right to have their pain adequately managed. We believe that the introduction of MS Contin at that time made a significant contribution to what was essentially a palliative care revolution that started in the 1980s and continued into the 1990s. There have been major strides in the care of patients dying in pain.

To move closer to the subject of OxyContin, it's quite clear that severe forms of pain can exist outside of cancer. Just as an example, the International Association for the Study of Pain held their World Congress on Pain in San Diego last week. One of the papers presented at that conference was presented by two Canadian neurologists who are at the forefront of research in treatment of pain.

They presented a paper about patients with painful diabetic neuropathy who were treated with OxyContin. Diabetes is one of the diseases that can result in pain by virtue of the influence of the high blood sugar levels on nerve endings. Those high blood sugar levels produce damage to the nerves, which can in fact result in a rather unpleasant pain that some people describe as a burning pain. Some people describe it as a pain like an electric shock. Other people describe it as a pain that occurs even when they are given a light touch on their skin.

This is a pain that historically has not been very well treated. In fact, opioid drugs have been thought to not be particularly effective in this non-cancer pain condition. The study that was presented at the World Congress on Pain was supported by Purdue. It did demonstrate that OxyContin was in fact very effective in the treatment of this pain. It's research like this, which our company has been involved in supporting over the last 10 to 15 years, I think, that really provides much of the research foundation for our current understanding about the treatment of both cancer and non-cancer pain.

To talk a little more about OxyContin specifically, and just to clarify, OxyContin is a controlled release formulation of oxycodone for the treatment of pain. OxyContin is our brand name, if you like. The generic name for the active drug that it contains is oxycodone, and that's an important distinction. Often in the media we see the two terms confused, and one is never quite sure whether they are talking about the drug product, OxyContin, or other forms of oxycodone. The most familiar forms of oxycodone go under the names of Oxycocet or Percocet, for example.

Oxycodone is a semi-synthetic opioid. It's similar in chemical structure to morphine, hydromorphone, and codeine. In fact, the differences in the chemical structure of those drugs are actually quite minor.

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They are also related to other drugs such as Demerol, which you may have heard of, which is a meperidine. They are also related to fentanyl, which comes in a transdermal formulation, Duragesic. All of these drugs have very similar properties in terms of their effects, both on pain and on other body systems.

Controlled release formulations--and OxyContin, as I have said, is a controlled release formulation of oxycodone--contain the active ingredient, the active drug, together with various other ingredients in the tablet that actually slow the release, the rate at which the drug is released from the tablet. The graph that I've included in our presentation will explain what I mean by slowing the release of the drug from the tablet. There are two lines on the graph. The one that is actually a diamond in terms of the symbol represents the concentrations of oxycodone in the blood following a single dose of OxyContin. The other line represents the concentrations over time--a 12-hour period--of oxycodone in the blood following two doses, which are the two peaks that you see, of an immediate or non-controlled release formulation of oxycodone. So when we talk about slowing the release of the drug from the tablet, we're actually talking about slowing the rate at which the drug is absorbed into the body, and the period of time over which active levels of the drug persist in the blood is extended.

Looking briefly at the question of opioid abuse and addiction, I've made a number of points in very general terms. All opioids with analgesic properties have addiction potential. This statement is true for morphine. It is true for hydromorphone. It's true for oxycodone, codeine, and fentanyl. All of them with opioid properties in terms of analgesic effect also have addiction potential.

However, in patients who legitimately have pain that is being treated with opioids, the data suggests that the incidence of addiction is actually rather low. Some studies have shown this to be a fraction of 1%, in fact, but authorities would probably accept that the incidence of addiction in patients with pain legitimately treated with opioids is probably no higher than the incidence of addiction in the general population, which is around 6%, according to the data we've reviewed.

The problem with abuse of controlled release formulations, specifically OxyContin, or any of the other controlled release formulations that we or other manufacturers have available, is that the preferential methods of abuse often involve crushing the tablets and then either swallowing, inhaling through the nose, or injecting the drug once attempts have been made to dissolve it. This is dangerous for two reasons, particularly when given intravenously.

It is dangerous because the crushing of the tablet disrupts the engineering, if you like, within the tablet that actually controls the rate at which the drug is released. If you crush the tablet and swallow it, the drug will get absorbed faster and the concentrations in the blood will be higher. Similarly, if you inject the drug, you obviously get a very rapid rise in concentrations in the blood and in the brain, which is, of course, the reason that the hard-core users will preferentially seek to inject the drug intravenously.

Not only is the concentration of drug in the blood of significance in terms of a health hazard, but also, particularly with controlled release formulations, a number of the ingredients that are used to control the rate at which the drug is released from the tablet are insoluble, so there is a risk of injecting particulate matter in association with the drug itself. There are pathologies that are identified in association with insoluble ingredients within these tablets that have been injected during drug abuse.

To look at the use and abuse of drugs in Canada, we've started with a table that shows the number of analgesic prescriptions in Canada last year and up to March of this year. I will use this as background for the information that we'll discuss further, I'm sure, in terms of the extent of abuse of different opioid drugs.

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You can see that in the year 2002 we are at close to 12 million prescriptions per year for all opioid preparations, with 60% or so of that represented by formulations of codeine, often in combination with acetaminophen. The most common name that you may be familiar with is Tylenol 3. Representing 11% or 12% of the total prescriptions are combinations of oxycodone with acetaminophen. These are combinations that are not controlled release, so they're not similar to OxyContin in that regard. Again, the most familiar name there may be Percocet. At 3% or 3.5%, we have Dilaudid, which is hydromorphone, an immediate release formulation of hydromorphone, and its related generic products. Following that, at 3%, is MS Contin, our product, which is controlled release morphine. Other forms of controlled release morphine are listed there at around 2% also.

OxyContin itself is at 2.4% in the current year compared with 1.6% in the previous year. It is increasing in terms of the number of prescriptions, but is obviously a small percentage of the total opioid prescriptions. Duragesic, which is transdermal fentanyl, is down at 1.5%. Two other products, which are both our products, in fact, Codeine Contin and Hydromorph Contin, and which are, respectively, controlled release codeine and controlled release hydromorphone, are at around 1%.

One of the things we attempted to do was look at the relationship between this pattern of what we presume to be legitimate utilization and the patterns of drug abuse. In order to do that, when we first became aware that OxyContin was becoming a problem for abuse in Canada we undertook some discussions and in fact made presentations to a number of organizations and agencies that we thought would be able to give us information on the patterns of drug abuse in Canada.

The agencies that we talked to are listed in our presentation: the Office of Controlled Substances and the Therapeutics Product Directorate, both at Health Canada; Canada Customs and Revenue Agency; the Canadian Centre for Substance Abuse; and the Canadian Community Epidemiology Network on Drug Use, which is actually managed through the Canadian Centre on Substance Abuse.

In fact, we initiated at that time some discussions with the Canadian Community Epidemiology Network on ways in which we could partner with them to establish a greater degree of efficiency and effectiveness in the collection and assessment of data on drug abuse in Canada. Those discussions are ongoing.

We also participated in a national video conference with the RCMP Drug Awareness Service. We spent time making a presentation to the Canadian Association of Chiefs of Police Committee on Drug Abuse. We also spent a long time talking to, making presentations to, and hearing presentations from the Ontario Provincial Police Drug Awareness Section. The Ontario Provincial Police, to our knowledge and as told to us by members of this drug section, is the only police force in Canada that has a force or a subsection specifically devoted to prescription drug abuse.

I have summarized what we concluded based on those discussions with those various agencies. The first point is that there was no coordinated source of information on the extent of prescription drug abuse in Canada. That in fact was one of the reasons why we proposed to the Canadian Centre for Substance Abuse that we should look at ways in which we could facilitate installation of a system that would provide information along those lines.

Also, based on the discussions, particularly with the police forces that we talked to, there was little indication of a significant level of abuse of OxyContin. Really, a significant level would be in relationship to the abuse of other prescription opioids, prescription narcotics, and particularly in relationship to the abuse of illicit drugs, which of course is a major preoccupation, and they frankly told us so: prescription drugs were very much lower on their list of priorities than were illicit drugs.

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Then, based on data collected by the Office of Controlled Substances at Health Canada, we also looked at this data in reasonable detail and essentially concluded that the prescription opioids that are the most frequently stolen or the subject of forged prescriptions are those that are most frequently prescribed. So the conclusion would be that the more a drug is prescribed--again, for legitimate purposes--the more likely it is to become available for diversion for illicit purposes. So, for example, as for thefts of opioids in Canada, the most commonly stolen opioid in Canada, at least at the time we looked at this data, was in fact combinations of codeine and acetaminophen.

We also discovered that in terms of this particular data set, which is thefts and losses of OxyContin, they were not actually the major percentage of the total thefts and losses for preparations containing oxycodone.

Now, this is not to say that as the prescription base for OxyContin continues to increase it will not increasingly become the subject of theft or forgery or any other mechanisms for diversion and, ultimately, abuse. For that reason, we are certainly not ignoring this problem by any means. One of the things that is a major focus of our activities to prevent this becoming the major problem that it has appeared to become in the States is our educational activities with health care professionals. Kathryn Raymond will discuss that.

Ms. Kathryn Raymond (Manager, Health Care Education, Purdue Pharma): Thank you, Andrew.

Thank you, Madam Chair and committee members, for the opportunity to be here today and for me specifically to address the educational programs that Purdue has for physicians, nurses, and pharmacists.

It is clear that with many different types of patients there are many different types of pain, and there are also many different treatment options that physicians do need to be aware of as they assess and treat patients. These are both pharmacologic and non-pharmacologic.

Clearly, our programs are always focused on a goal of preserving the availability of opioid analgesics for patients who are legitimately in need of pain control. Whether they need it for cancer pain, whether they need it for non-cancer pain, whether they may need it for a shorter or a longer period of time, it is key to health care educational professionals that the appropriate use of all drugs is important, as is, particularly from Purdue's point of view, the appropriate understanding and use of opioids. This is the cornerstone, we believe, to reducing the abuse of prescription drugs.

As for the educational objectives we have--and all of our programs are listed on the next page of our presentation--clearly, the vast majority of patients who go to a physician for treatment of pain, and some experts say up to 98%, are seeking relief of pain. Consequently, we need to ensure that we offer physicians, nurses, and pharmacists the opportunity to acquire, maintain, and upgrade their knowledge, skills, and attitudes so that they can improve the quality of the care they offer their patients. That is what the patients want and that is what physicians want as well. It is our job to do our best to ensure that they have the most up-to-date information to do that.

Identification, risk assessment, and the management of patients who have risk factors for addiction are also very important. It is this group of patients that needs the most help, the help we are offering to physicians to continually upgrade them on new evidence, new indications, and new strength of medications, all of which will offer them the opportunity to customize a particular patient's prescription treatment, especially if an opiate is involved, but clearly if it's involved with a combination of any other treatment patterns. You heard the pharmacists say that patients often have a lot of medication that they need to be on, and it's very important that we offer the most up-to-date information so that the physician can counsel the patients appropriately.

As you see in our point three, I think one of the things that's very important, which we include in all of our programs, is to ensure that nurses and physicians, etc., are all on the same page and understand definitions. It's important that they understand that abuse is not equal to addiction, that dependence is not equal to addiction, and that tolerance does not equal addiction. We spend considerable time in many of our presentations discussing these actual definitions and how they relate to symptoms that the patients may present with so that the physicians can better understand their next steps in counselling that patient and offering treatment or adjusting treatment, whatever is required. These patients are not necessarily the norm. Patients who are seeking addiction, as you heard Andrew say, are not the norm of patients. Most of the patients want relief of pain and that's what we want to make sure they can have.

The last objective we have is that of applying existing guidelines to the use of opioid therapy. It's clear that guidelines come up frequently. It is up to us to be aware of the new ones as they come along, to make people aware through our programs, and to adjust our programs annually to make sure they are current and up to date, so that the education we are offering physicians and nurses is as current as possible and their decisions can be current. This will reduce their risk of inappropriate prescribing. It will also ensure that the patient gets the best that is possible for them, and within the regulatory guidelines as well.

Next we have listed a number of different topics that we include in the content of our programs. I'm not going to go over each one specifically--you can see that they are on slide 10--but I'll just let you know that the scope of the workshops covers a number of different items.

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It's very important to well round what the physician is hearing because that's what the patients will require of them when they go to get treatment. It's a logical process of assessing the patient and going through risk factors using tools. It's very important that physicians have tools so that they can ask, “Have I done this? Have I asked them that? Have I done everything that's required?” The next important step is chart documentation: what have I asked them, what did they want to achieve, what am I going to do, and what do we expect to get out of this treatment or this therapy? Then when you follow up with patients the next time you see them you can also chart that. It's a very good record of why you've done something and what you expected to get. This is also covered in our workshops. It's been continually updated. Just as a note, it's been covered in our workshops since we started doing them. More than seven years ago we started working with Dr. Jovey and other physicians to develop what was important for physicians' needs.

I'll just touch on one more thing that's very important, that is, tamper-proofing your prescriptions. Physicians need to safeguard their prescription pads like you and I would our cheque books--if we still write cheques. It's important not to leave them on the desk if you go out of the room. You should keep them with you at all times. There's a whole series of ways to write out a prescription which will ensure that the physician has written the prescription, that the patient will get what the physician has written, and that only that patient will get the amount that physician has written for them. That's also covered.

There are a couple of other addenda that have come up in the last couple of years. I believe they are recommendations from the CPSO. You can fax prescriptions. You can call a single pharmacy to let them know. You can have a discussion with the pharmacist, saying that this patient is coming in, this prescription is coming, and please make sure that this patient gets this medication. You've opened up dialogue, and that's good for the pharmacist, as you heard them address with you.

I have a summary on our next page of some of the numbers of programs that we have done, just for the last three years. We have different types of programs if they're looking for information on non-cancer workshops or if they want information on cancer workshops. The audience that attends them depends on what the need is. We aim to reach the right physician with the right message based on what their patients in their practice are requiring and at the right amount of time.

Just as a note, you can see that in 2002 the projected numbers of attendees at both these workshops are going to be lower than in previous years. The reason is that we are now encouraging our representatives to go into more rural settings, where the numbers of physicians and nurses may be smaller but their need for education and appropriate prescribing for patients is just the same. When you go out to smaller communities you have fewer people in your audience, so the numbers will likely be smaller.

The other thing that's important to understand is that these programs are just a small portion of what we do. There are national programs running in different provinces, but not noted in our presentation are additional programs that our representatives will run as well. A physicians' group will ask if they can talk about such-and-such and our representatives will get them together to talk about it. They'll bring in a speaker as required, or someone will do it and chair the session over a lunch session. These programs are not captured in our list.

There are conventions, national conventions for specialists, for family physicians, etc., where Dr. Jovey has been very kind and has offered workshops and plenary presentations where they have been asked for, reaching large numbers of physicians. They also are not captured on our list. We also have initiatives with universities and associations that are over and above this as well.

The other thing is that we are not the only company offering education on pain to physicians. This is our portion of it, but we also are just part of the picture.

For the most part, we reach family physicians because they are the first medical people that patients will contact in their quest for pain control. We do not discriminate, though, and certainly other physicians such as anesthetists, rheumatologists, orthopedic surgeons, and family physicians who work in the ERs are also invited. Again, we try to ensure that the program we invite them to is appropriate to the needs of the patients they will be prescribing for so that they will be able to go back in their practice and, starting the next day, use what they have learned.

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There are just a couple of other initiatives on our next page that I wanted to mention to you because they are new for us this year. It's important to expand what we have done from a national CHE point of view. There are three that I will mention here.

The Chair: What does CHE stand for?

Ms. Kathryn Raymond: CHE stands for continuing health education. In the physicians' world, they often refer to it as CME, continuing medical education, but because we branch out and include nurses and pharmacists we call it health care.

We are just embarking on developing a pilot workshop, a working title being “Challenging Patients: A Framework for Pain Management”. What has happened so often in the past is that our programs have been geared to the 98% of patients who do well, who come in, require treatment, are monitored, and do go off when their pain is reduced, but there are some patients who are challenging, as you've heard from the pharmacists' group before us. Setting up a process such as this boundary workshop will address offers an opportunity for physicians to begin a treatment process universally, the same for everyone, so that if patients do come back exhibiting symptoms that are a bit unexplained, challenging, or unsure, it will allow the physician to: (a) recognize them, and (b) not make assumptions, but (c) be able to put a plan in place so that patients can get appropriate assessment and further treatment as required. We're piloting them in the fall of this year and intend, pending appropriate evaluations, to run them into next year.

Interestingly enough, I heard Dr. Power refer to a program that they have embarked upon with a pharmaceutical company in a pharmacy-specific initiative. The one he was referring to, I believe, is this brochure that has been developed and endorsed by the Canadian Pharmacists Association. We have recently sent it to all pharmacies across Canada. You have it in front of you. It is on how to prevent drug diversion and protect your pharmacy. This is a very important part of what we also do: educating the physicians on protecting themselves and giving patient education materials for the patients on how to protect themselves and their product, but also including the pharmacist in that role.

Not the least of this is a pharmacy workshop, which is just in the final stages of development at this point. The workshop itself is focused on pharmacists and education on opioids. There is a subsection on how to protect your practice and reduce risk. This was actually developed because of collaborations we have had with pharmacists who have said they'd like to know more about the role of opioids in pain management and how they can protect themselves. So we have developed these two programs.

Last, you also have in front of you, I believe, a copy of the book Managing Pain: The Canadian Healthcare Professional's Reference. We have it in English and in French. This particular book, of which Dr. Jovey was the editor--and who is available to answer any questions for you from the medical side--took approximately two years to develop. You'll see that it has one editor and multiple authors from across the country. We've been very pleased with this. Since it was launched at the beginning of this year it has received tremendous accolades from all levels of community physicians, nurses, and pharmacists. People want more of them and we're very delighted about that, because they obviously want to utilize it as a reference guide, which was exactly what it was intended for.

In summary, Purdue CHE is our last slide. Over the past seven or eight years we have offered presentations and workshops to health care professionals to ensure that we are educating on the appropriate use of opioids in general and specifically since 1996, which is where OxyContin education has come in. The evaluations we ask the nurses and physicians to complete at the end of the program are invaluable to us, because it is with that information that we go back and review the content to ensure that it is up to date and is meeting the needs of physicians and nurses who treat patients. It helps us to guide our content updates as well.

You'll notice that when I say the programs are updated, they're offered by physicians to physicians. The programs are not Purdue saying to the doctor, “This is how you use the product.” It is Purdue working with physicians and nurses to develop material that they can then take out and use to educate their peers about appropriate use. It's important that we work with physicians who are leaders in their communities, who are interested in improving the health of all Canadians, and these are the physicians who give us counsel on how to upgrade our programs.

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In the future we're expecting to continue and expand our audiences. We invite them to come together to learn from workshops because it is this time of interacting with each other when they learn from each other. It's invaluable for them to be taking back information and putting it into practice in their community.

You will also notice that on the final page of your handout, we have--and I believe this part is in English only--a copy of the joint statement from 21 health organizations in the U.S. It is new this year, and was just put out in February of this year, I believe, with an interesting title, “Promoting Pain Relief and Preventing Abuse of Pain Medications: A Critical Balancing Act”. I think it has some very important points. I suggest that you may wish to have a look at it as well.

I am going to end this and thank you for your time, but I'm going to also introduce Dr. Jovey, whom we invited to come with us today. He has worked with us as a tireless developer, adviser and facilitator of workshops for the last seven years. He is physician-director at the alcohol and drug treatment program, and a complex pain consultant, working out of Credit Valley Hospital in Mississauga, Ontario. I know he would be pleased to answer any questions on the medical aspects of pain management.

I thank you for your attention and for the opportunity for being here. Merci. We will entertain questions now. Thank you.

The Chair: Thank you.

Randy White.

Mr. Randy White: Thank you.

Welcome to the committee. This committee is an important committee for the House of Commons, in that drugs really haven't been studied to this level of detail since the 1970s. We have to make some recommendations to the House of Commons, and I sincerely believe that your presentation will show up some place in our recommendations.

I do have some questions. I have some questions about the whole industry, to tell you the truth. A person who has back pain today seems to go to a doctor and walk out of the doctor's office in very short order with a prescription for 222s or whatever else you seem to want. If you're not happy with that after the pain persists, you can go to a chiropractor who won't give you pills but who will bend your back in so many ways that oftentimes I'm not sure whether the assistance was as much as you had hoped for. Then you could go to physiotherapy, which seems to be a different method altogether, and they're adamant that no pills be involved, it seems.

The reason I open with this is that I am quite appalled by the success of ecstasy in our society, with the number of pills being produced and the reasons why. I believe the main reason is that young people don't see a pill, no matter how harmful it is, as being that harmful. We grew up with television suggesting that you should take Tylenol or Aspirin, one's better than the other, and that you should take this pill, take that pill. Everybody takes pills.

I'm wondering if today there is anybody in Canada or North America who hasn't taken a prescription pill. I'm wondering if we in fact have become a society addicted to pills developed by an industry that makes a profit from them and by doctors who get money by prescribing pills and so on and so forth. Are we not an addicted society?

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Mr. Andrew Darke: In the very strict sense of your term “addicted society”, I don't think I would agree that we are an addicted society. Certainly there are individuals within our society who are addicted to many substances, including, in some cases, prescription pills.

It is true that the pharmaceutical industry operates to develop, to research, and to discover, actually, products, drugs, that will treat diseases, ailments, and symptoms that we believe we should be attempting to manage. So to imply that the way to deal with drug abuse is to somehow change the outlook of society with respect to the appropriateness of taking pills ill advisedly, I think would put us in the very difficult position of saying that innovation in terms of human health is not a place where we want to be. I think that's the dilemma: in attempting to manage a problem of abuse of drugs, or even misuse of drugs, we have to deal with the dilemma of how we also manage that alongside maintaining innovation for those diseases and conditions that I think we would all want to see addressed.

Certainly for those of us who have experienced any significant periods of pain, I don't think that we would be in a position to say that really we should be attempting to manage without those drugs that effectively manage pain. Just as in the example I gave, I'm sure the patients with pain arising from nerve damage with diabetes would say that they are pleased we were able to find a drug that controlled this pain.

I realize that yours was a very general question. It's a difficult one to address in a comprehensive way.

Mr. Randy White: The more I talk to people the more I believe that today everybody believes there are just too many pills in our society, too much common use of them. That was my point.

I would like to ask Dr. Jovey whether or not he feels that physicians are really qualified. How well qualified are they to be issuing prescription drugs today? The reason I ask this is that I am aware of people who become drug salesmen on behalf of pharmaceutical agencies. I happen to know a few, and I didn't really think they were very well qualified to be selling the drugs. Some I know who do sell know a lot about the drugs they sell, but then these individuals go into a doctor's office and say, “Ours is the best”--I've never been there, but I presume they say theirs is the best--“here's some. Try this on your patients. They'll like this better than the ones you're giving.” It's that sort of thing.

How is it possible for a doctor to keep up with the right levels, the right doses, and the right types of drugs when they are getting their information from salesmen who are really motivated by what you say in chapter 9 of your book: “Drug seekers who sell their drugs on the street are motivated by the desire for financial gain”? Well, so is the legitimate drug salesman.

I just wonder: how does a doctor really tell how best to deal with the situation and what drug is best to give?

Á (1155)

Dr. Roman Jovey (Individual Presentation): The answer is that there's no easy solution. I was trained 21 years ago, as you can tell by my hair. The amount of time that my medical class was exposed to the whole topic of pain management was probably less than the number of fingers I have on one hand. So there is a knowledge gap for sure.

At the last World Congress on Pain, not the one last week in San Diego, which I attended, but in Vienna, one of the keynote speakers stood up and said that the pain field is moving so quickly that “we are learning more by the month”. That's a direct quote.

The pace of change in medicine in general, and especially in the pain world, is so fast and is occurring so quickly that it's difficult or nearly impossible for any one physician to try to keep up, hence the importance of ongoing education programs.

As Kathryn has mentioned, I've been treating chronic pain with medication, or pharmacotherapy, for about 11 years now and have been speaking and educating for the past 7 years. There still is a lot of work to do. We've reached only a percentage of physicians, often preaching to the converted, and there is still a large number of physicians who require education. That's always been a challenge in medicine. How do you reach those physicians who think they know it and think they don't need to have education upgraded?

I'll tell you what the California solution is. In San Diego last week I heard from physicians there that the regulators in California have decreed that all physicians in California have three years to obtain a certain minimum number of education hours--and the number was either 12 or 16 hours--in the next three years about pain and opioids. It's legislated by their regulators. In the future that may be one tactic that's required. I'm not advocating that necessarily, but I'm giving you an example.

Mr. Randy White: A doctor in his office sees so many patients in the run of a day, I don't know how they get time to take off and go and look at these various drugs. How does a doctor differentiate between best drugs, the best effects of certain drugs? Do they not get incentives from drug companies to use their drugs? Do they not get a certain dispensary fee for dispensing prescriptions and so on and so forth?

Dr. Roman Jovey: No. That's incorrect, unless you are a dispensing physician who works in a very remote rural area, in which case you act as the pharmacist and physician. That would be less than 1% across the country. For most physicians, the only type of incentive you may get is that certain medications are sampled. Anti-depressants, as an example, may be given as samples, but certainly never opioids. It would be illegal. So no, this is not the case.

Mr. Randy White: So how does a pharmaceutical manufacturing firm sell its drug to a doctor? That's where you really have to sell it, isn't it? It's not to the patient; it's to the doctor. How do you go to the doctors and say “ours is better than the others, so therefore buy ours”? How do you convince Canadian doctors to do that?

Dr. Roman Jovey: We, all physicians, are now in an era of so-called evidence-based medicine. In this process, we've actually begun to re-evaluate practices in medicine that we've been doing for decades. We're questioning whether this is really appropriate.

You mentioned, for example, chiropractic and physiotherapy as modalities to treat pain. I can tell you that the evidence currently is that chiropractic manipulation has a small role to play in acute low back pain, but frankly there is no evidence that it has benefit in the long term for any other type of pain.

Similarly, physiotherapy was reviewed last year by an expert panel at McMaster University in regard to the treatment of chronic spinal pain, that is, neck and back pain, and found to be without long-term benefit. That flies in the face of what we assume is common sense, which is that it's better not to take a drug and to take a non-drug treatment, but the fact remains that there is no evidence.

So the way that companies now are trying to educate physicians is by reviewing the evidence, summarizing evidence, and by conducting clinical trials that will generate more new evidence that these treatments are in fact effective.

Â (1200)

The Chair: Thank you.

Ms. Kathryn Raymond: I will just add to that, if you don't mind, Randy. Dr. Jovey is absolutely correct. The evidence is crucial. In the program handouts we offer to physicians, if a clinical trial has been referred to in that presentation we make available a copy of that clinical reprint in the handout, because the physician's knowledge of that evidence plus the experience that they now have in their own practice or the experience they gain from talking to their colleagues about what has worked.... These are the questions they challenge their colleagues on: have you seen this side effect or have you seen this efficacy? The evidence plus their experience is what we ask them to review to make an appropriate decision, again based on their assessment of that patient and their patient's requirements. It's ongoing assessment, too. It's not just that we give it once and they come back in three months. We recommend routine follow-up, as I mentioned, and documentation. That's why we upgrade our programs on an annual basis: to make sure that we are giving them the latest in evidence so that they can make that decision. I hope that answers your question.

Mr. Randy White: Yes.

Ms. Kathryn Raymond: Excellent.

The Chair: Monsieur Bigras.

[Translation]

Mr. Bernard Bigras: Madam Chair, my questions will address knowledge and research.

This morning, I presented a list of organizations that are concerned with drug abuse in Canada, and I will name just a few: The Canadian Centre on Substance Abuse, The Canadian Institutes of Health Research, Correctional Service's Addictions Research Centre, The National Resource Centre on Substance Abuse, The Canadian Substance Abuse Information Network, The Canadian Community Epidemioliogy Network on Drug Use, and the Substance Abuse Research Centre, which just opened its doors in May 2001. Some witnesses have informed us that they would like to see a research institute entirely devoted to substance abuse.

My question is this: does the model that we have developed up to now allow us to optimize managing research, monitoring and dissemination of knowledge in Canada? Are you open, for example, to creating a research institute that is entirely devoted to substance abuse, or do you think that there are certain improvements that can be made in Canada to better handle information?

[English]

Mr. Andrew Darke: I think one option for increasing our knowledge about the factors contributing to drug abuse and addiction and methods to treat them is to focus the question on an institutional model. But that said, there are many institutions throughout the country that are not necessarily networked into a formal institute, but do, nonetheless, act through research and exploration of patient treatment modalities in this field. We have had discussions with a particular pain clinic in Toronto, for example, that has an interest--and Kathryn Raymond referred to this--in advanced techniques, if you like, that would allow pain to be treated in patients who are perhaps at greater risk of abuse of prescription analgesics than others. We have talked to that pain clinic about implementing some research that will allow us to evaluate techniques that will improve the treatment of patients who are indeed at risk. That is not to say that if, under the auspices of the Canadian Institutes of Health Research, a centre of excellence could be created to look at the question of drug abuse and addiction, it that would not be a good thing. I'm sure it would be.

Â (1205)

[Translation]

Mr. Bernard Bigras: Should I take it that if you prefer, as you have told me, and I quote, (translation) "preferably, an institutional model", you are telling us that you are in favour of creating a research institute devoted to substance abuse in Canada? Is this what I understand?

[English]

Mr. Andrew Darke: I'm not necessarily saying one model is preferable to another. However, I think, as a research society, if you like, in Canada, we recognize that the Canadian Institutes of Health research model is one we will use to address problems that society, in a general sense, regards as the most important. So if we regard substance abuse and addiction as a high priority for this nation, it would be appropriate to argue for the Canadian Institutes of Health Research to establish such an institute.

[Translation]

Mr. Bernard Bigras: I have another question regarding research funding. I was surprised to learn, for example, that for the period from 1998 to 1999, the United States spent six times more on substance abuse research. This is rather surprising, when we know that there is a lack of reliable data regarding the consumption models. Also, Health Canada informed us that there were no funds for monitoring the rate of consumption of illegal drugs in Canada. Therefore, we seem to have some gaps in reliable data that is currently available, and some data is simply not available at all.

Can you identify the areas where there is no data available, where this would be required in Canada to fully accomplish your work? Are there areas that you could identify that are not currently funded in Canada, or insufficiently funded, that could help you improve your working conditions, if I may call it that?

[English]

Mr. Andrew Darke: I would like to ask Dr. Jovey to comment on this too, but I do want to refer to one of the points we discussed in our presentation, which was that in talking to a variety of agencies, we were surprised to find there was no coordinated, whether central or distributed, source of information on the extent of abuse of different drugs in Canada. We were particularly interested to determine whether there was current abuse of OxyContin and how that abuse rate related to that of other drugs. We found that the information simply was not there.

In the United States there are a number of ongoing networks that are able to collect information on drug abuse and a number of ongoing surveys that are done on a year-to-year basis that provide systematic data on trends in drug abuse. I think Canada is certainly behind the United States in that regard, and that would be a major area of priority I think we should adopt.

Dr. Roman Jovey: I fully agree.

In answer to your question whether it would be a good idea to fund more research in addiction, absolutely. Addiction has traditionally been an underfunded, underserviced domain, if one would call it that.

As an example of existing statistics that the Americans have and we don't, the U.S. Substance Abuse and Mental Health Services Administration every three years conducts a huge survey involving some 70,000 randomly selected people. The surveyors go out into the field, so that they include places like shelters, for example. They ask patients about a whole range of health behaviours, but particularly focusing on drug abuse. One of the questions they ask is, “In the previous month have you used a narcotic or opioid medication for anything other than the treatment of pain?” In response to that question, 1.2% will answer that they have. Does that mean 1.2% are addicted? Absolutely not. There are many people who may occasionally use a medication for unsanctioned purposes. This occurs, for example, in patients with cancer pain, who will occasionally use an opioid for its anxiety relieving components or to help them sleep. So 1.2% is probably the worst it gets. The actual number of people who are addicted is probably much less. I'm sure you've been presented with statistics for Canada on the rate of heroin addiction, which is somewhere between 3 in 1,000 and 3 in 10,000, to give you some sense of how big a problem this is. Is this, in fact, a bigger problem than the undertreatment of pain? I would suggest to you that it is not.

Â (1210)

The Chair: Could I just ask you to repeat that. You have 1.2% of people--

Dr. Roman Jovey: Who admit that in the past month they have taken an opioid medication for a reason other than pain, in other words, euphoria. You would define that as drug abuse.

The Chair: Okay. What is the other number on heroin?

Dr. Roman Jovey: It is my understanding that the statistics in Canada show the total number of heroin abusers at somewhere between 3 in 1,000 and 3 in 10,000. Those statistics are, again, very difficult to obtain.

The Chair: Right.

Dr. Roman Jovey: In one sense, one can consider the heroin abuser as the end stage. somebody who begins to abuse opioids and progresses along that continuum of addiction, in much the same way we look at cirrhosis of the liver as an indicator of the amount of alcohol in a population. There are correlations. We could consider the heroin addict as the end stage of opioid abuse, and they are quite rare. I understand that it's a regional issue, and I understand that if someone from Vancouver were here, they would say, no, no, no, but if you look at the whole country, heroin abusers are actually rare.

The Chair: Mr. Lee.

Mr. Derek Lee: I think those are fair statements. I want to thank you for being here today. I have found the presentation very helpful in understanding at least the way your outfit deals with a real drug and your continuing health education investments.

For me, this book is really quite good, the book on managing pain edited by Dr. Jovey, and I want to get right to that. Although OxyContin has come up in discussions about abuse of drugs, your company isn't any more responsible for diversion than General Motors is responsible for use of one of its cars as a getaway car in a bank robbery. You have a good drug, it does the job. But buried in the middle of this book, Managing Pain, there's a chapter actually written, I think, by Dr. Jovey. I'm just going to read it, so I can get it on the record, because I think it's really important. It's in chapter 8, the subject being Opioids, Pain and Addiction, page 64, the second full paragraph. It says, talking about addiction:

However, the most influential risk factor by far appears to be biogenetic predisposition. Basic science and clinical research are increasingly identifying the altered neurochemistry of biogenetically vulnerable individuals as having the primary role in the development of an addictive disorder.

So we're talking about the non-medical use of drugs where the biggest piece of that is addictive disorders. It's addicts going out there and getting drugs however they can.

Dr. Jovey, when a doctor deals with a patient, I'm pretty sure one of the rules, one of the fundamental pieces of the relationship, is that you've got to know your patient. Know your patient, know your client. Ninety-nine per cent of doctors do that very professionally. But the statement you have here in this chapter I regard as the pharmacological equivalent of realizing the world is not flat. If you've got to know your client, if you've got to know your patient, you have to know if they are biogenetically predisposed to being addicted, and if you don't know that, then you don't know your patient well enough to be prescribing an addictive drug.

I'm not being critical of anybody here. I'm just saying, surely, this has got to be a new frontier as you've described it, and here we are prescribing addictive drugs of varying degrees of addictivity, as I call it. I think one of our charts shows that roughly 80% of the people who consume nicotine become addicted. Approximately only 20 % of the people who take heroin become addicted. The drug is a major factor, of course, in its addictivity, but the other piece of it, maybe the bigger piece, the piece that is driving all the drug diversion is buried in that statement. The biogenetically predisposed person is what's driving this whole thing, this multi-billion dollar black market drug industry.

So can you tell us, because you're probably as close to this as anyone, how far we are along in recognizing, in measuring, in identifying the biogenetically predisposed individual, so that he or she can know early on in life that they are biogenetically predisposed, so the doctor can know, and so we can start dealing with that as a society?

Â (1215)

Dr. Roman Jovey: Further also, to look at that, rather than in a stigmatizing fashion, as an illness. I believe addiction is an illness, much as diabetes is, much as high blood pressure is. Unfortunately, the fact of the matter is, we don't have an easy tool to diagnose those patients. There are very exciting developments in the addiction world that parallel our increasing knowledge in the pain world, because both involve the brain, so it's quite possible that within the next five years we may have better techniques.

For example, there's a tool called functional MRI. Everybody knows what an MRI scanner is, but you can manipulate an MRI scanner and plug people into an MRI scanner who don't have pain, inflict pain on them, and look at what parts of the brain light up. You can, similarly, take a patient with a chronic pain, for example, an arm pain, plug them in the scanner, see what parts of the brain light up on this scan, block the pain by doing a nerve block at the shoulder or the neck, put them back in and see what places turn off. It's very exciting technology, and it may be able to answer the age-old question that torments physicians: is this a legitimate pain or not? That's a whole other discussion we don't have time for, but it also may eventually help us to diagnose those patients who may be at risk for addiction, because in those patients it appears that other brain areas might be involved.

This is five or ten years in the future. The only tool we have right now, unfortunately, is asking questions. That's it.

Mr. Derek Lee: On the issue of diversion of legitimate drugs into non-medical use, we've just heard from the pharmacists. They see their part of it, the chain of command, but they don't see themselves being in control. I don't think the pharmaceutical companies are going to be around very long if they are selling their drugs illegally out by the back door, so they are probably not the problem.

You are a physician. Is the biggest piece of the problem of diversion the physicians with over-prescription, or duplicate prescription, or the scam prescription, or the sloppy prescription? Is it the physicians? I'm not blaming the whole medical doctor community here, I'm just saying that if we have to identify the weakest link here or the area of problem we should be focusing on, is it the physician's management of the prescription process that we should be looking at?

Dr. Roman Jovey: I'm not up-to-date on the statistics between stolen, diverted en route, versus physician-prescribed diverted. My guess would be it's the latter, but pharmacists can't simply excuse themselves by saying they have no power here. A pharmacist can, of course, refuse to fill a script.

My problem, as a physician treating pain, is more often that I spend time educating the patient about the risks and benefits of opioids. They see a pharmacist who does the “over the glasses” look at the patient and dissuades them from doing it. In fact, in that way they do harm. The pharmacist may pat themselves on the head saying, great, I talked another patient out of opioids, but in fact, what they've done is harm. They have to be part of the team, part of the solution, because they do have a key role to play.

Nurses have to be part of the solution, and for sure, physicians need more education. In the years I've been speaking I think we've touched 6,000 physicians across Canada. That's still a small percentage, so ongoing education is required.

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Mr. Andrew Darke: Just to add to that, one of the things that you asked concerned the distribution of the problem. Is it here or is it there? To go back to one of our earlier comments, we don't have information on the drugs and the quantity of individual drugs there ending up with the end abuser. The best information we have, I think, relating to diversion and abuse is the data maintained by law enforcement in collaboration with the office of controlled substances, where they do track forgeries and thefts, and lawsuits. I don't think we know how that relates quantitatively to drugs that are perhaps legitimately prescribed to a patient, but end up being diverted to abusers.

Mr. Derek Lee: Thank you.

The Chair: Mr. Sorenson.

Mr. Kevin Sorenson (Crowfoot, Canadian Alliance): Again, I want to thank you for coming. It's been kind of an education for me. I have never so much thought of the role of the physician and the role of pharmacists in not only our drug strategy, but perhaps certain parts of our drug pain. My wife is a registered nurse, and sometimes she and I will have difference of opinion. There's a doctor who maybe just doesn't believe in giving pain medication, and she sees the person suffering, while the other side of it is the family that says, listen, they may be a palliative patient, but we would still like them to be able to visit with us and not be strung out on drugs or have their mind altered by the effects of the drugs.

I'm not sure if you're the right folks to ask or not, but what role do the pharmaceutical companies play in addressing some of the problems or the concerns their drugs create? Is there a role that some of these pharmaceutical companies already play? We've talked with the pharmacies about the role of government. The federal investigator, the guy who would go around to the pharmacies, isn't there any more, a federal individual touring the pharmacies, questioning, looking at their inventories. Is there a role pharmaceutical companies could play that they aren't playing now in addressing some of the addiction problems, some of the concerns with what these drugs are maybe doing?

Mr. Andrew Darke: We look at a whole range of possible activities that we now undertake or would undertake in the future, a wide range of initiatives. I won't repeat what Kathryn has said about our educational activities, but I think that is actually one of the keys. If one of the routes for drugs entering the diversion channels is by inappropriate prescribing or ongoing distribution from legitimate patients to abusers, I think that is addressed within the context of educational activities and messages.

At another end of the problem, obviously, we deal with security issues relative to our products in a way that essentially minimizes the possibility that within our hands these drugs are going to become accessible to diversion channels.

With law enforcement activities, one of the things we have done is collaborate with the U.S., for example, in identifying OxyContin tablets as different from the ones that are marketed in the U.S. So law enforcement efforts to determine the source of diverted drugs is facilitated.

We have also talked about research activities, and as I mentioned, we are involved with discussing approaches to the management of patients using techniques or approaches that will reduce the probability that they will either divert or abuse their own drugs.

Those are four areas where we can say companies such as ours are active. The problem, as everyone probably recognizes, is one of the person who chooses to abuse. How we get to that person as a company, how we would influence decisions made by that person, is much more difficult to determine, unless it be through the intermediation of the health care professional, the physicians, and so forth.

Â (1225)

Mr. Kevin Sorenson: I think that's all.

Maybe my view on some of this is wrong. I'm more concerned about the abuser who is taking drugs for euphoria, who wants to enhance his or her state, how he or she feels. For Grandma or Aunt Beatrice who is strung out on sleeping pills maybe the cost is huge as well. Maybe we don't measure addiction, but our focus, I think, is on the euphoric--at least, I feel that is what it should be. Maybe that's not what the highest cost is. Maybe there is a higher cost in productivity and everything else through individuals who are not recognizing that they have a problem. The person who is trying to cheat the system or cheat health care or double-doctor and all those things is a major problem, but perhaps the person who doesn't realize he or she has the problem is, again, one we need to address as well.

That is more of a comment, not a question.

The Chair: Thank you.

Madame Allard.

[Translation]

Ms. Carole-Marie Allard: Madam Chair, I find that the graph presented by the witnesses regarding opiate prescriptions in Canada is very revealing, and I ask myself where does this data we are seeing come from.

[English]

Mr. Andrew Darke: If we take the last report by a company called IMS Health, the data are available to companies that wish to purchase this information, but it can also be made available to other agencies, perhaps at low cost or no cost outside the for-profit sector.

[Translation]

Ms. Carole-Marie Allard: It would be interesting to look at previous years to try to find at what point consumption started to grow in this field.

Doctor Jovey, you have published an excellent book. Congratulations. Like my colleague here, I had targeted bio genetic predisposition.

This morning we heard from the pharmacists and now you are appearing before us. You seem to claim that the doctor really holds the key to the solution. I find it worrisome when you state that 20 years ago, little training was given regarding opiates and pain treatment, one being linked to the other. You also mention the small test here.

Given that technology now makes it possible, would you be in favour of obliging the doctor who is prescribing opiates to have the patient's medical history - I am getting back to what I said this morning - on a smart card.

Aren't we headed in this direction precisely to avoid substance abuse by Canadians? Is there not another way to establish a means whereby an electronic medical file could be created, allowing the doctor to know about the patient's history?

Â (1230)

[English]

Dr. Roman Jovey: As a practising physician, I welcome all additional information I can obtain on a given patient, because sometimes it takes months for bits of information to filter in from a family doctor or from a previous treating doctor if the the patient has moved from Vancouver. From my perspective as a health care professional, I'm all for what you are suggesting. I understand the concern with privacy, but I think it would certainly eliminate some inefficiencies in the system, for example, duplicate testing, duplicate investigation. It may help the problem of patients who go from city to city and purposely divert drugs for profit, but I have no idea of the cost of such a thing. If it were huge, we would, as a society, have to accept that this is worthwhile. Second, how do we address the privacy concerns? I'm all for it. I support what you are suggesting.

The Chair: First, let me thank you for coming before us. Certainly, the companies that produce the products that enhance our quality of life and help us deal with these issues are really an important piece of the puzzle. We all want the products to continue to be available for those people who need them. It's been really helpful for you to come before us and be so willing, unlike some companies that were a little less than willing. We'll be talking to the over-the-counter people as well, because that's another piece of the puzzle.

I just want to clarify one thing. When you talk about addiction, you are being very specific, I think. It's a very tight description. And you mentioned the differences between addiction, abuse, dependence, and tolerance. A part of me appreciates all those scientific differences or details, but another part of me says it doesn't really matter, because the people who are in any of those four categories are creating some problems for themselves and their families and could ultimately create some issues for us all as a society. So the kid who got Dilaudid in Nova Scotia maybe just liked the euphoria, maybe was an addict, maybe was developing some tolerance, but started to inject the product to keep the cost down and now has hepatitis C, is all of our problem. There may be some biogenetic work done in the next five years to figure out how to predict that this kid shouldn't have been given that substance, but that's too long for a lot of the people who end up in this cycle.

I wondered if you could comment on that and the appropriate product or the appropriate therapy at the right time. Mr. White described what most people probably go through when they get back pain, but some of those things may be the end point. Maybe it is massage therapy that makes people deal with the stress, and that's enough, or physiotherapy. It may not solve the problem in the long term, but it could be enough, if the regime is continued, that they will not need other interventions. So that's great. It may not solve it if they stop it.

How do we make sure more physicians and nurses and pharmacists and people involved in the health care system help integrate this information and support each other in making sure the right people get the right information? Certainly, an electronic data system would be helpful. But there are other ways we need to talk about with this issue I think.

Â (1235)

Dr. Roman Jovey: I asked how long this committee had been serving because I wondered if you're rookies or whether you've already accumulated some information, but I heard a question asked this morning that clearly told me there is confusion about terminology. If you read no other part of the book, appendixes A1 and A2 are short, they're two pages, and they specifically deal with this difference in terminology. It is important.

I was just reading on the airplane coming here a case example of a patient who was inappropriately labelled as addicted, was taken off his opioid painkiller, and blew his head off--this was an American. So who's responsible in that case? That's the other side of this question. Thus the terminology is very important. It is very important to differentiate between physically dependent and addicted. The physically dependent person is a relatively easy problem to solve, the addicted person is a much more challenging problem.

So terminology is important, and these people do not have equal impact on society. It's the sort of diverters who are in it for profit or the truly addicted people or the people abusing for euphoric effect who probably create the biggest burden of adverse effect to society.

For example, I just saw a month ago a Chinese gentleman who had had a cancer successfully treated, which resulted in some leg pain. He had been put on an opioid. In fact, he was put on OxyContin. His pain was well managed, but his cancer was cured and he tried to stop his OxyContin and was unable to do so. He was referred to me by his family physician with the question, is this man addicted to his opioid? In fact, he was not, he was physically dependent--big difference. To take him off the opioid simply required some low-level expertise and technique. I just saw him yesterday, and he is totally off his opioids; although he had some mild withdrawal symptoms, he's finished. So it is important. Physical dependence is not addiction.

The Chair: Clearly, there is a difference in how you take him off. Someone who is diabetic is physically dependent on insulin, we don't need to take them off, that's fine. But if the product or the drug is not performing.... It could be prescription drugs, over-the-counter drug, illicit drugs, St. John's Wort, that whole category of products. Maybe the product is allowing them to be the best they can be, but we have to make sure the right product is being given to the right person with the right regime, whether that's getting an endorphin rush or running.

So there are some important differences in what you're going to do as a doctor for that person, but the concern among communities is, sure, Halifax doesn't have a heroin problem, but it's got a hell of a prescription drug misuse problem and it's creating other health impacts. So it may be the grandmother who is creating all kinds of health care issues, because no one is really dealing with her dependence or her pain tolerance or her addiction, but she is going to break her hip and she's not just strung out. There are implications in that. It could be the 22-year-old who just had surgery and was given the wrong drug. It matters to you, but does it really matter to us which of those four definitions?

Dr. Roman Jovey: Oh, absolutely. Medicine is about risk and benefit, and every day I'm in practice I have to weigh risk and benefit. For example, many physicians who are opiophobic, fearful of opioids, because of the regulatory environment, because of fears of addiction, will keep people on anti-inflammatory drugs for decades. In fact, in Canada last year almost 2000 people died of adverse effects from anti-inflammatories. So where is the parliamentary committee to study that problem?

What I can tell you is that approximately 400 heroin addicts died of overdose, at the most. I understand there are other implications of being addicted to heroin, but let us keep things in perspective, keep a balanced view here about inadequate pain management over decades, really over centuries, versus this problem of diversion addiction, which is small. It doesn't mean it's insignificant, but where are we going to put the resources?

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The Chair: Right. Probably it's about getting the right product, whether it's an anti-inflammatory or an opiate, to the right person at the right time, and clearly, Ms. Raymond's work is trying to make sure that does occur. We do appreciate that, and obviously, the pharmaceutical companies play an important role in making sure the right product gets to the right individual.

Ms. Kathryn Raymond: The other thing that's important--and I alluded to it in the presentation--is educating the family that the patient will become physically dependent when they take an opiate for a while, but they are not addicted. They are being helped by the drug, and this is a natural progression of taking the product. They may become tolerant to it. At that point they need to be reassessed by the physician and their medication, the dose they're taking, whatever, needs to be reassessed to make sure they are getting the best treatment. Those are very important things to educate not only the family on, but the patient, so they recognize their own symptoms and can work with you as a physician. That's very important, and we do cover that in our education as well, educating the family as well as the patient, the pharmacist, the nurses. It's a team effort, and we are now starting to pull teams together, to educate them together, so that they are all on the same page.

The Chair: It's something I would be surprised if this committee didn't recommend. Better discussion about substances and their appropriate role within our communities and how to make people better able to educate themselves, so that they are able to ask the right questions and to discuss issues, would be helpful right across the country When the poor first person raised prescription drugs to us, we were all saying, prescription drugs? We're dealing with heroin and the social disorder with all these things. It's not an issue, but it really has become an issue as we have gone to different parts of the country.

That reminded me of one other question. Do you track different pockets of the country where you are seeing a spike in sales that may be questionable and wouldn't fit with the national averages?

Mr. Andrew Darke: We do look at data on a provincial basis. So we are able to determine as a rough approximation the provinces that have higher utilization than others. The problem with those data as an index or predictor of diversion and abuse, which is really where we would want to be able to use such information, is that they're heavily influenced by provincial reimbursement programs, for one thing. So they become very difficult to use, particularly at the provincial level, where there could be any number of factors that would affect utilization, to actually identify provinces where there is an abuse problem based on sales that are actually sales into a legitimate market.

The Chair: Right. We'll leave the province out and the product out, but it would seem that because it's a generic product, they're choosing that product to manage pain when there could be other things that would work better and create less exposure to those who are biogentically predisposed, because there's a cost issue and the province is dealing with its budget rather than with its patients. That's a concern as well.

Thank you very much, on behalf of the committee. I forgot to say that to the other group. We're in the final stages, but if there's anything else you want to forward to us or you see in your travels, Dr. Jovey, that you think we need to have as we write our report, please let us know. We are intending to report in November. You're always welcome to contact us if you have more information or ideas, and we appreciate that.

Colleagues, we'll adjourn until 2:30. Thank you.